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Femoral Anteversion

KEY POINTS Excessive femoral anteversion results from medial rotation of the femur after birth. Surgery consisting of femoral derotation osteotomy is usually only contemplated in children older than 8 years with insufficient spontaneous correction, particularly children with diplegic cerebral palsy. Excessive femoral anteversion usually presents as a cause of in-toeing at 3 to 4 years of age, increases in magnitude through 5 to 6 years of…

Tibial Torsion

KEY POINTS Rotational abnormalities of the lower extremities (in-toeing and out-toeing) are common in young children, and abnormal rotation is termed torsion . In-toeing is caused by one of three types of deformities: metatarsus adductus (during the first year), internal tibial torsion (in toddlers), and increased femoral anteversion (in early childhood). Tibial torsion is especially likely with fetal constraint of the legs in a folded and…

Flexible Flatfoot

KEY POINTS Flexible flatfoot is common in children and influenced by age, weight, and gender. This deformity usually becomes evident with weight bearing and is often caused by ligamentous laxity and strongly associated with genetic connective tissue disorders. Treatment of flexible flatfeet is controversial as to whether corrective shoes or orthotics provide demonstrable benefit. Rigid pediatric pes planovalgus can be caused by congenital vertical talus, tarsal…

Deformed Toes

KEY POINTS Constraint of the feet while the legs are in a flexed and folded position can result in medial overlapping of the toes, especially the fifth, fourth, and third toes. Congenital curly toes are relatively common, asymptomatic soft tissue abnormalities of the lateral toes. GENESIS Constraint of the feet while the legs are in a flexed and folded position can result in medial overlapping of…

Talipes Equinovarus (Clubfoot)

KEY POINTS Over the past 25 years there has been a dramatic shift away from extensive surgical releases to manipulative methods with serial casting. The term idiopathic talipes equinovarus is used to describe the most common type of isolated clubfoot that is not part of a syndrome. Structural talipes equinovarus can be either isolated or syndromic (termed complex when there are associated malformations). The forefoot is…

Metatarsus Adductus (Metatarsus Varus)

KEY POINTS Metatarsus adductus is the most common pediatric foot deformation related to intrauterine constraint. The feet turn inward, but the ankle and heel are generally in normal position with a flexible heel cord. In mild and flexible cases, manipulative stretching of the tight medial soft tissues and avoidance of sleeping postures that tend to augment the deformity may be all that are required. When metatarsus…

Calcaneovalgus Feet

KEY POINTS Calcaneovalgus deformation is usually the result of extrinsic deformation. The foot is usually quite flexible and should return to normal without intervention. If not resolved after several months, consider the use of external splints. GENESIS Calcaneovalgus deformation has a reported frequency of 1.1 per 1000 live births, although some authors indicate that more than 30% of newborns have calcaneovalgus deformity of both feet. It…

Clinical Approach to Deformation Problems: Malformations, Deformations, Disruptions, and Dysplasias

KEY POINTS This text is primarily concerned with extrinsic deformations produced by unusual or excessive constraint of an otherwise normal fetus. Individual deformations in this book are presented in an atlas format along with deformation sequences. Deformations are structural defects that represent a normal response of a tissue to an external mechanical force. Deformations are usually attributed to intrauterine molding and termed positional defects . The…

Neonatal hypertension

Introduction First described in the 1970s, awareness of neonatal hypertension has increased over the past several decades. Despite this, there is still uncertainty over which neonates require treatment for hypertension, primarily because of conflicting data on normative blood pressure (BP) values in neonates, and also because few reliable outcome data are available. This chapter will review the existing data on normal neonatal BP and will present…

Urosepsis and uroprophylaxis

Introduction Late-onset sepsis, defined as sepsis occurring after 72 hours of age, is a significant cause of morbidity and mortality in term and preterm neonates. Most of the research on neonatal sepsis has thus far focused on blood and cerebrospinal fluid (CSF) findings, while comparatively little information exists regarding the prevalence and significance of urosepsis and urinary tract infections (UTIs) in this population. The most recent consensus…

Renal near-infrared spectroscopy use in the neonate

As bedside monitoring capabilities continue to advance in the neonatal intensive care unit, renal tissue oxygenation monitoring with near-infrared spectroscopy (NIRS) has emerged as a potentially useful tool for clinicians. Renal perfusion and oxygen utilization by the neonatal kidney is impacted by many factors including gestational age, chronological age, hemodynamic status of the infant, fluid balance, and other underlying conditions. Renal tissue oxygen saturation (RrSO 2…

Renal tubular acidosis

Renal acid-base regulation Since birth, the kidney represents the crucial ultimate line of defense against disturbances of acid-base balance, which is performed by the tubular reabsorption of bicarbonate and the excretion of fixed hydrogen ions. The glomerulus contributes to renal acid-base homeostasis by the filtration of urea (the major end-product of protein catabolism) and by providing the filtered load of bicarbonates to the proximal tubule. Up…

Dialysis and kidney transplantation in infancy

Introduction Although the provision of dialysis and the need for a kidney transplant during infancy is rare, medical advancements have led to increased availability and efficacy of these treatments when needed worldwide. Data from the US Renal Data System (USRDS) show that the overall incidence of pediatric end-stage kidney disease (ESKD) requiring dialysis or transplantation has decreased slightly from 12 cases per million people in 2009…

Diagnosis and management of prenatal urinary tract dilatation

Definitions and scope of prenatal urinary tract dilation Abnormal dilation of the fetal urinary tract is a common finding during antenatal screening ultrasound (US) (1%–3% of all pregnancies), second only to cardiac defects. This dilation signifies a spectrum of disease, in some children a transient and physiologic phenomenon and in others an association with significant renal functional impairment. Table 11.1 lists common and impactful causes of…

Effect of preterm birth on renal outcomes

Introduction Preterm birth is estimated to impact 15 million births worldwide annually. Due to advancements in the treatment of preterm infants, survival of these infants has improved, albeit with increased morbidity due to the development of chronic diseases, especially in those born extremely preterm. , The renal consequences of preterm birth are relevant in the short term, during the neonatal intensive care unit (NICU) course, as…

Evidence-based approach to diuretic therapy in the neonate

Introduction Diuretics are commonly used in the neonatal population to treat infants with bronchopulmonary dysplasia (BPD), cardiac disease associated with congestive heart failure, and acute kidney injury (AKI). The relatively high frequency of diuretic use has been documented by several large retrospective cohorts. Laughon et al. utilized the Pediatrix Medical Group data warehouse (1997–2011) to identify that 37% of almost 40,000 infants <32 weeks’ gestation and…

Genetic causes of congenital anomalies of the kidney and urinary tract

Introduction Congenital anomalies of the kidneys and urinary tract (CAKUT) encompass many heterogenous anomalies of the kidney, ureter, bladder, and urethra ( Fig. 8.1 ). CAKUT is the leading cause of kidney disease and of renal failure in children. The prevalence of CAKUT is estimated by population studies to lie between 0.1% and 2%, with higher prevalence in preterm infants. CAKUT has a complex etiology with…

Pathophysiology and management of hyponatremia and hypernatremia in the neonate

Dysnatremias, hyponatremia and hypernatremia, are common in the neonatal intensive care unit. Recent studies indicate that these conditions can result in both short- and long-term morbidity and mortality. This chapter will review the development of renal function with emphasis on the renal handling of water and sodium. We will then discuss the pathophysiology of water and sodium homeostasis that results in hyponatremia and hypernatremia. This will…

Physiological management of fluid and electrolyte therapy in newborns

Introduction Water is critical to the support of all life, and ensuring appropriate balance of fluid and electrolytes is a central aspect of the clinical management of patients. It has been extremely difficult to study and define optimal fluid and electrolyte management in premature infants, despite the fact that this is a population that is essentially completely dependent on what is administered. Study in this area…