What to Expect from Polycystic Ovary Syndrome in Teens

By Marc Dadios, pediatric resident at CHOC Children’s

It’s normal for adolescents to go through physical and behavioral changes during puberty, but it can be difficult for parents to know when something may be cause for concern. Teen girls who experience irregular or missed periods may be suffering from Polycystic Ovary Syndrome (PCOS), a condition where a woman’s hormones become out of balance.

With PCOS, ovaries produce higher than normal amounts of hormones causing small cysts to form on the ovaries. These are generally not cancerous and don’t need to be surgically removed. Side effects include hair overgrowth and acne outbreaks.  This condition frequently manifests during adolescence and can be associated with obesity. Women with PCOS may have an increased risk of developing type 2 diabetes, metabolic syndromes, cardiovascular disease and endometrial carcinoma. It is the most common cause of infertility in women.

What to expect during your doctor’s visit

If your doctor is concerned about your child developing PCOS, your doctor will order blood work to be checked before your next visit. Some of the blood work that your doctor will check are testosterone levels, estrogen levels, hormone precursors called DHEA levels, glucose levels, lipid levels, and cholesterol levels. Your child will also be asked to provide a urine sample as pregnancy, like PCOs, can be the cause of irregular or absent periods.

PCOS Treatment

A treatment plan for PCOS includes management of the underlying metabolic abnormalities as well as reducing the risk factors for type 2 diabetes and cardiovascular disease. Diet and exercise changes for weight reduction will be recommended in cases associated with obesity, to prevent diabetes and help control hormonal imbalances in your child’s body. Hormonal therapy can help control hormonal imbalances caused by PCOS. Hormonal therapy is also known as oral contraceptives or birth control pills but those names can be misleading for the purpose of using these pills. The importance of using hormonal therapy is to normalize your child’s periods to prevent the development of endometrial cancer. Women who do not have periods for a long period of time are at increased risk of developing endometrial cancer.

What to expect next

If your child’s blood work shows evidence of hormonal imbalances concerning for PCOS your doctor will recommend diet, exercise, hormonal therapy, and close follow up. While PCOS can be a scary diagnosis to face, this condition can be effectively managed with a team effort between yourself and your doctor. Your pediatrician may refer your child to a pediatric endocrinologist for further specialty care.

Learn more about adolescent medicine at CHOC.

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Landon’s Life-Saving Jejunal Atresia Surgery

Lizette Lough, experiencing a seemingly normal pregnancy, was making final preparations to welcome her first baby, when her water unexpectedly broke at 33 weeks. She was rushed to San Antonio Regional Hospital in Upland, close to home, where her son Landon was born early on May 3, 2016.

After a few days in the hospital, Lizette and her husband Sean noticed the baby had not made a bowel movement. Tests revealed that Landon had an obstruction in his intestine. His physician recommended Landon be transferred immediately to CHOC for an emergency surgery with Dr. Peter Yu, a pediatric general and thoracic surgeon.

“My husband and I lost it,” Lizette says. “Our baby was only three days old and weighed about 4 pounds. The thought of surgery was beyond frightening.”

Upon arrival at CHOC, the Loughs were immediately made to feel at home by the staff, who helped them find a nearby hotel. Dr. Yu explained every scenario of the complex surgery in a compassionate and confident manner, the Loughs recall.

Jejunal atresia
Landon was born at 33 weeks and diagnosed with jejunal atresia, despite prenatal genetic testing and a healthy pregnancy.

“Landon was in stable condition when he arrived at CHOC, and I’m very pleased that our expert transport team was able to get him here quickly and safely. If there had been a delay in transfer, Landon could have become very sick and it’s very possible that more of his intestine could have died. If that would’ve happened, he may not have had enough bowel to adequately digest food, which can be incompatible with life,” Dr. Yu says.

Landon was diagnosed with jejunal atresia, a rare condition – approximately 1 in 5,000 births – in which the small intestine is incompletely developed, leading to one or more gaps, or blockages, in the intestinal tract.

Lizette had gone through the required genetic tests prior to Landon’s birth, and jejunal atresia – often diagnosed prenatally – was not detected.

Additionally, Landon had malrotation of his intestines, which failed to coil in the proper position in the abdomen. This led to twisting of his bowel. If surgery had been delayed for longer, Landon could have died.

Landon’s surgery involved making an incision on his abdomen, examining the entire length of his intestine and untwisting it, removing the dead bowel, stitching together his small intestine, and performing a Ladd’s procedure. A Ladd’s procedure places the intestines back into the abdomen in a safe configuration to prevent future twisting of the bowel.

jejunal atresia
Landon and his dad Sean in the surgical NICU at CHOC after Landon’s jejunal atresia surgery

Sean, who works as a law enforcement officer, recalls how traumatic this was for his family. “I’m used to working in stressful situations, but this was a different kind of stress,” he says. “We were so happy that our baby had a successful surgery and that he was better. However, we were still waiting for him to have his first bowel movement. We were trying to stay positive.”

After his first bowel movement indicated that his intestines were recovering well, and spending about a month in CHOC’s surgical NICU, Landon was finally able to go home with his family.

jejunal atresia
Landon and his mom Lizette during his first feeding, which took place in the surgical NICU at CHOC after his jejunal atresia surgery

“It takes a team to successfully care for sick babies and complex patients,” Dr. Yu explains. “Landon would not have had the excellent outcome that he had without our wonderful neonatologists, experienced and skilled pediatric anesthesiologists, Melissa Powell, our dedicated surgical neonatal nurse practitioner, and the outstanding NICU nurses who have dedicated their lives to taking care of newborn babies such as Landon and countless others. Together, we have the only dedicated surgical NICU in the area, with a special focus on taking care of newborns with surgical problems.”

Thanks to the expert multidisciplinary care provided at CHOC, today Landon is a happy baby, meeting all his milestones. The Loughs are enjoying their brave little boy, and look forward to his first birthday next month.

jejunal atresia
Landon is looking forward to celebrating his first birthday at home with his parents.

“Dr. Yu and the nurses in the NICU were so empathetic and amazing. They saw us through so much throughout our stay and we will forever be thankful,” Lizette says.

Find a CHOC pediatric surgeon

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Three CHOC Caretakers Shave Heads, Raise Awareness for Pediatric Cancer

Meet three members of the CHOC Children’s care team who recently shaved their heads to raise awareness and research funds for pediatric cancer.

Erika Crawford, RN, Oncology

pediatric cancer

“I used to work in Portland, Oregon as a pediatric hematology/oncology nurse and it was just part of the nursing culture there to at least participate once in this process. As the clippers were shaving my head in 2010, I found that it was a very emotional experience. I imagined the many patients I had taken care of that had experienced the same thing. At work, the patients and parents verbalized gratitude and some parents were inspired to shave their own heads for their children. I told myself then, that I would like to participate in another head shaving event once again in my lifetime.

Not only is it a great way to raise awareness and much-needed funds for pediatric cancer research, but it’s a way for nurses to participate in their patient’s journey. Our patients don’t get a choice in losing their hair (which is a very difficult thing to experience), but as a nurse we can choose to join them in a small way on their journey by choosing to experience being bald.

Even though I have been down this road before, I still struggle internally with my approaching baldness. However, those same insecurities, feelings and fears are experienced by our young patients. I think it’s important to walk with them on this journey in some way shape or form.”

Karen DeAnda, RN, CN Oncology

pediatric cancer
Inspired by the oncology patients they care for at CHOC Children’s, registered nurse Erika Crawford, charge nurse Karen DeAnda, and clinical associate Viri Harris recently shaved their heads to raise awareness and research funds for pediatric cancer.

“When I first met Erika, she had a cute bald noggin. She had just participated in another head shaving event to raise money for childhood cancer research. Over the years I have thought it would be something I’d like to do. When Erika told me she was participating again this year I decided it was now or never. As Erika has expressed, it is a very emotional process. When I tell people what I am doing they are absolutely amazed and shocked that I would do such a thing. This is a very small way that we can show our patients our respect for the difficult road they travel. I can honestly say that I am terrified, but also extremely proud and committed to this process. I love my job and this small gesture is one way I can give back to the wonderful children I have had the privilege of caring for here at CHOC.

I am fortunate to work with some amazing nurses who have been so generous with their donations and emotional support. My family has been fundraising on my behalf as well, and the response has just been phenomenal.”

Viri Harris, clinical associate, Outpatient Infusion Center

pediatric cancer

“I have been at CHOC for 18 months, and this is the second time shaving my head as a form of honoring the children we serve. I wanted to do something to show my love for them and to show gratitude for the way they and their families have inspired me on a daily basis. To be completely honest, I was nervous about how my head would look bald- I had an intense fear that my head would be oddly shaped. But, then I thought about how I wanted to come alongside these beautiful kids, and my nervousness went away. We witness these kids and their families struggle on a daily basis and this has inspired me to support them in any way I can. If that means shaving my head to bring awareness and raise funds, that is what I will do- it is the least I can do.”

Have you had a special nurse at CHOC? Nominate them for the Daisy Award

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Lifelong Pediatrician Becomes CHOC Volunteer

Each year, nearly 1,000 CHOC Children’s volunteers provide more than 100,000 hours of service. Every day, they graciously donate their time and talents to help CHOC provide the very best pediatric services in Orange County. This week, CHOC celebrates National Volunteer Appreciation Week, and we salute our dedicated and enthusiastic team of volunteers.

Volunteers come to CHOC for a variety of reasons: some wish to donate their time as a way to give back to a hospital that cared for their child, while others have an interest in medicine.

Jack Bruno is the latter. Having spent 39 years as a pediatrician and nearly 20 of those as vice president of medical affairs at an east coast hospital, Dr. Bruno has cared for thousands of children and their families. After retiring to sunny Southern California with his wife to be closer to his grown children, he decided to give back by volunteering his time at CHOC.

choc volunteer
Dr. Jack Bruno, a CHOC volunteer

“When I moved to California, aside from family, I didn’t know too many people, and I knew that I wanted to have some contact within a pediatric hospital system,” says Dr. Bruno. “So much of my adult life had been engaged in health care, and since I had the time, I decided to volunteer. From living in Orange County I knew about CHOC and I thought I would apply to volunteer.”

As a lead patient hospitality volunteer, Dr. Bruno assists families during the discharge process and ensures they get safely from their hospital room to their car, and that nothing gets left behind. He also makes rounds on various units in the hospital, checking in with parents to see if there’s anything they need, even just a cup of coffee or break to have an adult conversation that’s non-medical. Even when his volunteer services are needed as a patient buddy, keeping a little one company and playing games while their parent has to run an errand, it’s rare that a family finds out that he was a pediatrician for nearly four decades.

“I don’t generally volunteer my background as a pediatrician and hospital executive since I am not in the room to provide medical advice. I leave that up to the excellent medical staff at CHOC,” Dr. Bruno says. “A couple of times it has come up when talking to a family, but hospitality volunteers are mainly there to provide companionship and some assistance.”

Dr. Bruno says that many of qualities he admired about his own patients he also sees in children and families at CHOC.

“One of the things I learned from years of practicing medicine and what I see again is a sense of fulfillment. Families are so strong. They often have various serious illnesses to battle, they might be in and out of the hospital frequently, but I draw strength from how they handle their situation,” Dr. Bruno says. “When you have a sick child, even if they will likely make a full recovery, it’s still a stressful experience for the parents and siblings. Part of the reason I like to volunteer is to see if I can help relieve some of that stress.”

Current volunteer opportunities at CHOC

Volunteers are special group at CHOC that provides vital assistance in all hospital departments, as well as at CHOC Children’s at Mission Hospital.

Currently, our highest needs are weekday shifts from 8 a.m. – 4 p.m. Night and weekend opportunities are limited. Assignments ae based on a combination of the current needs of the patient population, as well as the interests and skill sets of the volunteer.

Some of our CHOC volunteers:

  • Greet visitors as they arrive
  • Escort families around the hospital
  • Help visitors and families in the Family Resource Center
  • Organize coloring and reading activities for patients in our waiting areas
  • Assist our child life specialists in playrooms

choc volunteer

Another aspect of our robust volunteer program is pet therapy, an opportunity for volunteers with dogs who are certified by Pet Partners, a non-profit that registers therapy animals. Pet therapy can play an important part of a patient’s treatment by minimizing stress associated with a hospitalization, offering normal-life experiences, offering a distraction from pain, and encouraging patients to complete treatment goals like walking. The pet therapy program at CHOC Children’s at Mission Hospital is currenty accepting volunteers. For more information, please email volunteers@choc.org.

Learn more about becoming a CHOC volunteer.
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10 Questions to Ask Your Child’s Anesthesiologist

By Dr. Eric Ontiveros,  chair of pediatric anesthesiology at CHOC Children’s

You want to know your child who needs surgery is in the best hands. Kids’ bodies are completely different inside, and pediatric specialists know the difference. Pediatric anesthesiologists at CHOC Children’s, who lead your child’s surgery team, have compiled a list of questions commonly asked before surgery. Any question about your child is a good question. If there is ever anything you do not understand, ask your child’s surgery team.  They are there to help.

Am I allowed to be with my child before surgery? If so, for how long?

Before surgery, you and your child will be taken to the pre-operative unit, or “pre-op.”  A nurse will review the information needed to safely perform the child’s procedure. The surgeon and the anesthesiologist will evaluate your child and answer any questions you have. You will be asked to sign any necessary paperwork and then accompany the child to the operating room doors. After another hug and kiss, the team will assume care of your child.

Am I allowed to be with my child while anesthesia is being given?

You child’s safety is our biggest priority. Having a parent in the operating room can distract the team’s focus away from your child. To ensure the safest environment possible for your child, you will be taken to the waiting room.

Will my child have pain when getting an IV?

Depending on the child’s age and planned procedure, we may start an IV in the pre-op unit. An IV is a small plastic tube inserted into the vein and  used to deliver medication. Depending on the age of your child, a small amount of anti-anxiety medicine may be given orally before placement of the IV. The staff will also use special numbing medicine to reduce the discomfort of IV insertion. A child life specialist will provide age-appropriate distractions such as books, games, or bubbles to aid in the process.

What kind of anesthesia will my child be given?

Anesthesia is broken down into three main categories: General, Regional, and Local.

General anesthesia makes and keeps a person completely unconscious (or “asleep”) during the operation. It can be administered through an IV, or by inhaling an anesthesia gas delivered by mask.

Regional anesthesia is when a drug is injected near the spinal cord, numbing a large area of the body. An example is an epidural. It is often combined with general anesthesia in kids and used for pain control after the surgery.

Local anesthesia numbs a small, specific area of the body- for example, a foot, hand or patch of skin. It can be given as a shot, spray or ointment. Local anesthesia is often used to reduce the pain after surgery.

The anesthesia your child receives is tailored to their needs and depends on factors including:

  • The type of surgery
  • The location of the surgery (hospital, outpatient surgery center or doctor’s office)
  • How long the surgery will take
  • Current and previous medical condition
  • Previous reactions to anesthesia (in your child or family members)
  • Medications your child is currently taking
  • Age, height and weight

No matter which type of anesthesia your child receives, your anesthesiologist will be available before, during and after the operation to monitor the medications your child receives and ensure they are receiving the right amounts.

Will my child be sedated before anesthesia is given?

Your child may receive medication to help them remain calm and feel sleepy before the procedure or surgery. This medication is usually given by mouth and before starting the IV. Many children are curious about the operating room and prefer to experience falling asleep in the OR, so they skip the sedative.

Will my child still have an IV in or be hooked up to any monitors or equipment after surgery is over?

Your child will usually wake up with their IV in place. This is helpful as additional medications are sometimes needed to treat pain or nausea. Your child will also wake up with several monitors that help the anesthesiologists and nurses monitor your child’s recovery from anesthesia. These monitor blood pressure, heart rate and oxygen levels. As your child recovers from anesthesia, the IV and monitors will be removed.

How long will it take my child to fully wake up from general anesthesia?

The anesthesiologist will begin to “wake up” your child after the surgery is completed. This amount of time varies from child to child and is dependent on their medical history and type of surgery performed. This can take up to an hour, and most children wake up in the recovery room (also referred to as the post anesthesia care unit, or PACU) in a shorter amount of time. Full recovery can take up to several hours.

How soon after the surgery can I see my child?

After the surgery is completed, the surgeon will speak with you in the Tidwell Procedure Center lobby. It may take an additional 20 to 30 minutes for the nursing staff and anesthesiologist to recover your child from anesthesia before having you enter the recovery room (PACU).

How soon after the surgery can my child eat, drink, go to school, or drive [if you have a teen]?

If your child is going home after surgery, the nurse will offer your child a snack and drink in the recovery room. No driving for teens the day of surgery. The surgeon will provide a school note if time off is required. If a hospital stay is required, and depending on the procedure, the surgeon will order the appropriate diet.

How soon after the surgery can my child go home?

Children usually spend 30-90 minutes in the recovery room. Patients heading home will be provided a discharge plan. This plan may include instructions on how to take care of the operative site, what medications to take, what your child should eat that day, and what activities the child may participate in. It will also have instructions on what to look out for and when to call the doctor. Download a copy of the discharge questions worksheet.

You will receive a phone call from a CHOC nurse within 72 hours of the patient’s discharge from the hospital. Our nurse will ask about how the child is feeling and will be able to answer any additional questions you may have.

Download these questions and answers.

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A Road Map to Surgery at CHOC Children’s

Having surgery at a hospital can be a scary thought for children and parents, alike.  Knowing what to expect can help alleviate fear and anxiety.  The photos below highlight some key aspects of the patient and family journey through the Tidwell Procedure Center at CHOC Children’s Hospital.

surgery at choc

Welcome to CHOC Children’s Hospital – a hospital for children and teens, only. When a child requires surgery, his needs are different than an adult. CHOC has specialized in pediatric surgery since we welcomed our first patient in 1964. Today, our nationally recognized surgeons perform the latest procedures using equipment customized to pediatric patients, from newborns to adolescents.

surgery at choc

After checking in at our first floor lobby, surgical patients and their families are directed to our Tidwell Procedure Center, which includes seven operating rooms, five procedure rooms and two cardiac catheterization labs. The Center boasts leading-edge technology and safety features, as well as a calm, healing environment. Here’s the Center’s bright, colorful lobby, featuring natural light, bubble columns and interesting artwork. There’s also a family room and playroom.

surgery at choc

We want our patients and their siblings to still have the opportunity to act like kids while facing the adult issues of surgery. In addition to a playroom in the lobby, we have an area for play, stocked with books and toys in pre-op. Dedicated child life specialists help normalize the experience by making the environment less strange. Providing distraction and developmentally appropriate education, child life specialists are important members of the surgical team.

surgery at choc

Child life specialists are at the bedside to provide developmentally appropriate education. Patients are able to see pictures of the operating rooms on iPads, which helps to limit stress and anxiety without the use of medication.

surgery at choc

Before heading into the operating room, patients stop at what is affectionately called the “kissing spot.” Here’s where they can say “see you later” to their loved ones before “taking a nap” for surgery.

surgery at choc

Child life specialists escort patients into the operating rooms and to provide distraction and emotional support while pediatric anesthesiologists and other staff members prepare patients for surgery.

surgery at choc

Following surgery, patients recover in our PACU (post anesthesia care unit). As soon as the patient is stabilized, parents/legal guardians are escorted into the area. During this time, patients need as much rest as possible to help their bodies heal and give pain medication time to take effect. The environment is kept calm and quiet. From here, the patient will either be taken to a hospital room, or discharged home.

Our physicians, nurses and staff are dedicated to getting kids better and back to their normal activities as quickly as possible. Patients and families are our partners in this effort; knowing what to expect before, during and after surgery can make a big difference on the experience and recovery. For more information, visit www.choc.org/surgery.

Take a virtual tour of the Tidwell Procedure Center

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Prevent Nursery Product-Related Injuries by Babyproofing the Nursery

When preparing for a new baby, most parents consider baby proofing their home, but the nursery is often overlooked. Children’s products are recalled more than any other type, says Amy Frias, community educator at CHOC Children’s and Safe Kids Orange County coordinator.

“Accidents are going to happen. Parents just need to do what they can to prevent serious injuries,” says Frias. “Nobody thinks a major accident in the home is going to happen to them.”

Frias offers the following tips for baby proofing the nursery. These “babyproofing” rules apply not only to your home, but anywhere else your baby may spend time, such as a grandparent or babysitter’s house or daycare.

Falls

Since children up to age 5 spend most of their time at home, they are more likely to be injured in the home than anywhere else. Most injuries children experience in the home are due to falls.

“If a product for your child comes with a strap, use it. Don’t assume the baby is safe without a strap,” says Frias. “Babies don’t tell you when they’ve learned a new trick like how to roll over and in this case off the changing table. You don’t know what they can do until they do it.”

Lower your crib mattress once your baby is able to sit up. Lower it again once the baby begins to pull themselves up.

Before a baby learns to crawl, secure furniture to the wall, especially heavy items such as tall dresses and changing tables to prevent them from tipping over.

Parents are not immune to falls, so when using a baby carrier, be aware of your surroundings when wearing your baby,” says Frias.

Safe sleep for babies

Although it’s safe for babies to room share with their parents, they need their own sleep surface. Remember the ABC’s of safe sleep: babies should sleep ALONE, on their BACK, in their own CRIB (or other sleep surface).

Remember that a baby’s sleep surface should be naked. Remove any blankets, stuffed animals or other items from their crib.

The biggest risk factors in nurseries are tied to suffocation, strangulation and entrapment, says Frias:

  • Suffocation: don’t keep bumpers, blankets, stuffed animals, or anything else besides a mattress and fitted sheet in the baby’s crib.
  • Strangulation: avoid using mobiles. Furniture should be kept away from windows that have cords, since baby can pull themselves up and become entangled in the cords.
  • Entrapment: there should be no gaps larger than two fingers between the crib side and mattress. The crib mattress should be firm and fit well in the crib. It is important that parents only use a Consumer Product Safety Commission approved crib. Cribs with drop sides do not meet the current standards, are not safe, and should not be used. If your child will be in a used crib make sure it does not have a drop side. Do not use infant positioners such as wedges or pillows due to risk of suffocation and entrapment. Avoid using crib bumpers.

The dangers of baby walkers

Walkers are safer now than they used to be, but the risks outweigh any perceived benefits, says Frias. “Research shows that baby walkers are not developmentally helpful for children as they learn to walk.”

Using baby walkers can calm and entertain a baby while a parent needs their hands free, but it allows babies to move faster than they can on their own— often faster than a parent’s reaction time, she says.

They also give babies a boost to reach hot, heavy or poisonous objects.

“Even though some walkers come with locking wheels that prevent a spill down the stairs, they can fit through a lot of doorways you wouldn’t expect them to,” Frias says. “It’s best not to have them in the house, especially if you have stairs.”

The American Academy of Pediatrics has recommended a ban on the manufacture and sale of baby walkers in the United States. Canada banned the sale, advertising and import of baby walkers in 2004.

Research baby products carefully

Before making a purchase, research the product via the United States Consumer Product Safety Commission, which offers specific product-related information on recalls, research and safety standards.

Used products should be researched the same way, if not more stringently than new products.

Remember to register your products with the manufacturer to ensure that you will be notified in the event of a recall.

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Sign up for our KidsHealth e-newsletter.

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A Day in the Life of Pediatric Surgeon Dr. Peter Yu

By Dr. Peter T. Yu, pediatric general and thoracic surgeon at CHOC Children’s

5:00 a.m.: Alarm rings. I hit snooze once, for an additional 9 minutes of peace. Then it is time to get up and at ’em. In the dark, I attempt to avoid injuring myself on the various toys that are strewn about the house–one of the hazards that comes with raising young children. I start the coffee maker, brush my teeth, shave, get dressed and kiss my slumbering family good-bye. Then it is off to swim practice.

7 a.m.: Swim practice is over. Fatigued but happy, I shower and joke with the teammates on my masters swim team. I am grateful for my health and momentarily enjoy the small personal accomplishment of having completed my workout for the day.

7:30 a.m.: After navigating moderate traffic and enjoying NPR, I arrive at CHOC. I meet with the very kind family of my first patient, a 5-year-old boy who is having inguinal hernia/hydrocele surgery today. In children, an inguinal hernia is a small, congenital opening in the groin that allows communication between the abdomen and the scrotum in boys and the labia in girls. Thus, things like fluid, fat, omentum or intestines can pass through this opening, creating a bulge and sometimes causing pain. A hydrocele is related to an inguinal hernia and is due to fluid that has passed from the abdomen, through the opening, and into the scrotum. Inguinal hernias occur in about 1-5 percent of all children. Hernia and hydrocele surgery are routine operations for all pediatric general and thoracic surgeons and, as expected, the operation goes smoothly.

9:00 a.m.: For my second operation of the day, Dr. Mustafa Kabeer, a fellow pediatric general and thoracic surgeon, and I perform a minimally invasive Nuss procedure on a teen athlete. This patient, who hopes to earn a college scholarship, has pectus excavatum or sunken chest, the most common congenital chest wall abnormality in children. For many, this is far more than a cosmetic problem. Using small incisions that will ultimately be well-hidden in this patient’s armpits, we are able to insert a metal bar between his heart and his chest wall that helps to pop the sternum out into normal position. This bar will stay in place for three years, before it is removed in an outpatient procedure. Our operation today took only 2 small incisions and 45 minutes of operating time. We prefer the minimally invasive Nuss procedure to the older, more invasive Ravitch procedure since it achieves a wonderful outcome with less pain, minimal blood loss and only tiny, hidden scars.

10:00 a.m.: As the anesthesiologist and the operating room staff prepare for my final case of the day, I walk over to the surgical neonatal intensive care unit and medical/surgical unit to make rounds and touch base with my team of excellent, experienced surgical nurse practitioners (NPs). Not a day goes by that I am not thankful for their contributions to the outstanding care of our surgical patients at CHOC. Currently, on the surgical floor, I have patients who have recently had appendectomies, a cholecystectomy (removal of the gallbladder), lysis of adhesions (cutting of intra-abdominal scar tissue) to treat a small bowel obstruction, port placement for chemotherapy, and a Nissen fundoplication for gastroesophageal reflux disease. In the NICU I have one baby with congenital diaphragmatic hernia whom I recently placed on ECMO (extracorporeal membrane oxygenation), state-of-the-art technology that supports the heart and lungs by taking over the heart’s pumping function and the lung’s oxygen exchange. A second patient of mine in the NICU is a baby who recently had esophageal atresia/tracheoesophageal fistula surgery to repair a congenital defect where the trachea, or windpipe, abnormally communicates with the esophagus, or food tube. Fortunately, all patients are doing well, I am able to address the questions of each of my patients and their parents, and the NPs and I come to a consensus on the plan of care for the day for each one.

dr peter yu
Dr. Peter Yu, pediatric general and thoracic surgeon at CHOC Children’s

10:30 a.m.: Once rounds are done, I head back to the operating room for my final case of the day, a thoracoscopic lung lobectomy. This is one of my most favorite operations and is my area of expertise. This 3-month-old patient was diagnosed prenatally when an ultrasound showed a congenital lung lesion, also known as a CPAM (congenital pulmonary airway malformation, formerly known as CCAM). This diagnosis is becoming more and more prevalent, occurring in about 1 in every 5,000 babies. Fortunately, more than 90 percent will be symptom-free during pregnancy and after birth, allowing pediatric general and thoracic surgeon such as myself to hold off on surgery until the infant is a few months old and better able to tolerate the stress of an operation. Even though infants with CPAMs may be asymptomatic, it is still recommended that these lesions be removed because they can often become infected and, in rare instances, may become a cancer later in life. The benefit of operating sometime during the first several months of life is that the CPAM has yet to become infected, making surgery easier and allowing for a minimally invasive removal. Thanks to the patient’s young age, the remaining portion of her healthy lung will grow in size and compensate for the removed lobe.

Thoracoscopic lung lobectomy is extremely technically challenging because the surgeon navigates major blood vessels such as the pulmonary artery and pulmonary vein, and operating time can vary from two to six hours depending on a patient’s particular anatomy. Fortunately, this little baby’s anatomy is favorable and I am able to complete the minimally invasive operation in about 2 hours with minimal blood loss and an excellent outcome. After surgery, I have the privilege of giving her parents good news, which is always the best part of my work day. I anticipate that she will have a two-day hospital stay with minimal pain and no complications, and her tiny scars will ultimately be unnoticeable by others (except for mom! Pediatric surgeons know that moms see everything J).

1:00 p.m.: I have a quick lunch with my NPs and Dr. David Gibbs, another pediatric general and thoracic surgeon at CHOC who is also the medical director of trauma. He has established the excellent trauma program we have here, the only trauma center in Orange County that is exclusively dedicated to children. We take a moment to enjoy each other’s company, get trusted input on current clinical situations, and catch our breaths from this very typical, fast-paced workday.

2:00 p.m.: I participate in a fetal counseling session. Given my special training in fetal surgery, I work closely with community perinatologists (also known as high-risk obstetricians or MFMs–maternal fetal medicine physicians) to counsel expectant mothers and fathers on what to expect when their baby has been diagnosed in utero with a condition that will require surgery.

Today, I meet with parents whose daughter has been prenatally diagnosed with congenital diaphragmatic hernia, or CDH. Simply put, CDH is a hole in the diaphragm, which is the muscle that divides the abdomen from the chest. The diaphragm helps us breathe, and a hole here allows things that are normally in the abdomen, such as the liver or intestines, to pass into the chest. Besides potentially compromising the intestine itself, this can also lead to small lungs (pulmonary hypoplasia) which may not be able to adequately oxygenate the body. Another severe consequence of CDH is pulmonary hypertension, which is abnormally high pressure in the blood vessels of the lungs. This is a problem because a newborn’s heart must work extra hard to pump blood into this abnormal high-pressure system, which can lead to heart failure and death if not appropriately treated.

I go over the diagnosis with mom and dad, and explain to them that, after birth, their baby will require a breathing tube and ventilator to support her small lungs. Special inhaled and intravenous medications will be used to decrease the high blood pressure in the blood vessels in the lungs and to help support her beating heart. If these measures are not enough, we will need to use ECMO. If ECMO is needed, I will perform a surgery to make an incision on her neck to access her carotid artery and jugular vein so that ECMO catheters can be placed.

Ultimately, once their daughter’s heart and lung condition has stabilized—which may take days to weeks after birth—I will repair the congenital diaphragmatic hernia. To do this, I will make an incision on the abdomen, move the intestines and liver from the chest back into the abdomen, and stitch the hole closed.

I am careful to be upfront and honest about the situation: CDH is a serious and frequently life-threatening condition and the national average for survival is approximately 65 percent. Their daughter will likely require a two to three month stay in our NICU and may need to go home with supplemental oxygen and special medications for a period of time. However, I’m able to reassure them as well. Nearly 90 percent of newborns that have this surgery at CHOC survive. At CHOC, we are fully equipped and have the expertise to handle any possible outcome, thanks in part to our surgical NICU, the only one of its kind of the west coast.

Mom and dad are tearful at the gravity of their daughter’s situation but they also express how grateful they are for the opportunity to learn more about CDH, have their questions answered, and leave feeling better prepared for the next steps. They know they can contact us at any time, day or night, and we will be there to address any problem and provide support. They also feel relieved that they will be surrounded by familiar, trusted faces when their daughter is born.

3:00 p.m.: I head back to my office with some precious time to complete some homework—yes, I said homework—and work on research projects. Believe it or not, I have gone back to school to get my Master of Public Health degree from Johns Hopkins University. This is feasible because I am able to complete the majority of my coursework online. I wanted to get this additional degree to gain knowledge and experience in outcomes research, a relatively new branch of public health research that seeks to understand the end results of particular health care practices and interventions. While pursuing this degree, I am simultaneously working on outcomes research projects with my research partner, Dr. Yigit Guner, another pediatric general and thoracic surgeon at CHOC. Together we are utilizing large national databases to create risk calculators that can help better predict CDH outcomes, as well as predict outcomes in other neonatal diseases such as VACTERL (vertebral defects, anal atresia, cardiac defects, trachea-esophageal fistula, renal anomalies, and limb abnormalities).

6:00 p.m.: I head home for the day. En route, I call my mother who lives out-of-state to check in. My father recently passed away after a long struggle with illness and I just want to make sure she’s doing alright. She assures me that she is, and stubbornly resists my suggestions to have her move to Orange County. She is happy and comfortable in her home, which makes me happy as well, but I am concerned that I will be unable to adequately help her in the years to come should her health someday fail.

6:30 p.m.: I’m happy to be home with my family. It’s dinner time and I’m famished. I relish the chance to catch up on the day’s events with my wife and kids. I play with the kids for a bit and then it is time to help my oldest with homework. After that, my wife and I get all the kids ready for bed and tuck them in.

9:00 p.m.: My wife and I finally have a precious moment to ourselves. We watch a favorite TV show together and I barely make it to the end before falling asleep. It feels so good to lie in bed, with the cool night breeze filtering in through my bedroom window. I dream of my family, work and old friends. Tomorrow, I have clinic and then I will spend the remainder of the day and night in the hospital, as I am on call for any pediatric general, thoracic and trauma emergencies that come to CHOC. I feel so blessed to have the family that I have, and to be able to do the meaningful work that I do.

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7 Things You Didn’t Know about Pediatric Anesthesia

By Dr. Eric Ontiveros,  chair of pediatric anesthesiology at CHOC Children’s

Finding out that your child needs surgery can be scary for parents to hear. You want to know that your child is in the best hands possible, and the nationally ranked surgeons and pediatric anesthesiologists at CHOC Children’s specialize in the care of kids. Your child’s pediatric anesthesiologist is not only an important member of your child’s surgery team but also the entire perioperative experience (before, during, and after surgery).

7 things you may not know about pediatric anesthesia:

  1. Before surgery, the preoperative area is the location where you will meet your child’s full surgical team. During this time, questions about your child’s medical and surgical history will be asked and the perioperative plan is adjusted to fit your child’s medical needs.
  2. It is normal for children to feel anxious before surgery. Premedication for anxiety may be administered, either orally or intravenously prior to surgery. This may require the help of a parent. The goal of premedication is to reduce the anxiety and facilitate a smoother transition to general anesthesia. Evidence shows that easing a child’s anxiety prior to heading into surgery may limit the emotional disturbances felt during recovery after surgery. Child life specialists are also available, and may use distraction, video or music therapy to calm an anxious patient.
  3. Anesthesiologists will use a multimodal approach to pain management when appropriate. In addition to pain management during surgery and in the recovery room, a particular child and surgery may qualify for a regional anesthesia procedure or “pain block” that will help control postoperative pain during the days following surgery.
  4. For younger children who meet specified criteria, an inhalational technique may be used to initiate general anesthesia. This technique administers anesthesia through a mask (with a flavor of your child’s choosing) and avoids the placement of an IV until after your child is asleep. For older children, an IV may be placed in the preoperative area after receiving anti-anxiety medicine in oral form.  This allows general anesthesia to be administered in IV form.
  5. You know you’re not supposed to eat or drink anything before surgery. But do you know why? When general anesthesia is administered, your muscles relax, including the muscles in your stomach and esophagus. The body’s reflex to swallow is also briefly suspended during anesthesia. This combination makes the lungs vulnerable to aspiration of food, which can be very dangerous. Abstaining from food for 8 hours prior to surgery is very important for the safety of anesthesia for your children.
  6. Common side effects of general anesthesia include nausea, vomiting, itchiness and something called emergence delirium. Emergence delirium lasts 5-15 minutes and happens during the process of waking up. It usually goes away on its own but can be very concerning for parents because your child may not recognize or respond to you. If your child experiences any of these symptoms after a procedure, their care team will be available to provide appropriate medication to treat those side effects.
  7. Difficulty sleeping may occur for a few nights after a surgical procedure. Night terrors are a common occurrence in children ages 3-6 who have had ear, nose and throat procedures. This difficulty sleeping is often troubling for parents but will typically resolve after a few days and requires no additional treatment. Maintaining a consistent bedtime routine as well as eliminating sources that may interfere with sleep (caffeine, sugar, high energy activities and electronics before bedtime) may help in dealing with these disturbances.

The more information you have, the calmer you and your child will be prior to surgery. Parents are encouraged to ask as many questions as possible when you meet their child’s anesthesiologist, before or after surgery.

In the video below, a pediatric general and thoracic surgeon answers parents’ most common questions about surgery and anesthesia:

Video: Get answers about anesthesia

 

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Family Medicine Cabinet Essentials

In addition to a first-aid kit, a well-stocked family medicine cabinet can help families contend with a variety of ailments that children of all ages – and adults alike – might experience.

Here, Dr. Jonathan Auth, a CHOC Children’s pediatrician, lists the essential elements of a family’s medicine cabinet.

Family Medicine Cabinet Essentials
Dr. Jonathan Auth, a CHOC Children’s pediatrician, offers tips on family medicine cabinet essentials.

Oral medications

Acetaminophen – Frequently known as Tylenol, this common over-the-counter medication is a first-line defense against fever and pain. He recommends that families stock children’s acetaminophen rather than anything labeled as for infants. Though they used to differ in concentration, formulas are now the same, and children’s versions are typically less expensive than those marketed to infants, Dr. Auth says. Download a parent’s guide to acetaminophen for children to ensure you’re giving your child the right dose.

Ibuprofen – Known in stores as Motrin or Advil, this medication also combats fever and pain. It can also help soothe swelling and other complaints associated with an injury, thanks to its anti-inflammatory properties. Ibuprofen’s effects also last longer than acetaminophen, though it can irritate some children’s stomachs, especially if taken on an empty stomach. Dr. Auth does not recommend it for children younger than 6 months old.

Diphenhydramine – Commonly known as Benadryl, this medication can have multiple purposes, Dr. Auth says. It can help children with mild allergic reactions, as well as those who have seasonal allergies and some cold symptoms. Dr. Auth cautions that it frequently has sedative side effects, and should not be given to children younger than 2 without first consulting a pediatrician.

Calcium carbonate – Known as Tums, these chews can help soothe upset stomachs. Dr. Auth recommends consulting your pediatrician before using them in children younger than 6, however.

Dimenhydrinate – Commonly sold in stores as Dramamine, this medication is good to have on hand for travel with children who are prone to motion sickness.

Topical treatments

Multipurpose antibiotic ointments – Commonly known under the brand names Neosporin or Bacitracin, these topical medications help reduce the risk of possible infections from scrapes and mild skin abrasions, Dr. Auth says.

Hydrocortisone, 1 percent – This low-potency topical steroid cream can help soothe itchy rashes or irritated skin.

Antifungal cream, 1 percent – Commonly known under the brand name Lotrimin, this cream is good for treating yeast diaper rashes, ringworm, and athlete’s foot, Dr. Auth says.

Sunblock – Dr. Auth recommends families keep plenty of sunblock on hand: Barrier forms, which contain compounds like zinc oxide or titanium dioxide and block out the sun are safe at any age. UV A and UV B light absorbers containing PABAs can be used in children after age 6 months old. Dr. Auth also recommends families choose SPFs around 40 or 50. Anything marked higher than that shows minimal additional benefit.

Diaper cream – For families with newborns and young infants, having a diaper cream on hand is valuable, says Dr. Auth, who also recommends choosing a cream containing zinc oxide.

Petroleum-based ointments – These treatments can be helpful as a barrier, Dr. Auth says. For example, they can protect a cut against infection or can lock in moisture on chapped lips or dry hands.

Miscellaneous

Nasal saline solution – Dr. Auth recommends these products to help relieve infants’ stuffy noses or older children’s congestion.

Thermometer – Dr. Auth generally suggests families have a very basic and inexpensive digital thermometer that can be used orally for toddlers and children and rectally for infants.

Nail clippers and files – These are a necessity to keep children’s fingers groomed. When it comes to trimming infants’ nails however, files are safer and less intimidating for new parents, Dr. Auth says.

Bulb suction devices – These products are helpful in removing mucus from newborns, as well as in children who can’t yet blow their noses.

Humidifier – This can be helpful for children suffering colds, Dr. Auth says. However, he cautions families to properly maintain humidifiers to prevent mold production or limescale build-up, which can worsen problems. Also, whether to use a warm or cold mist is generally a matter of preference, Dr. Auth says.

A word of caution

Safely store medications so that they are inaccessible to children.

With any medication, parents should pay special attention and adhere strictly to dosing instructions.

Every household should have the phone number for poison control readily available: 800-222-1222.

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