Pediatrics

Discovering a metopic ridge in your child yourself or being told by your doctor that she or he has a concern can be an alarming time for you as a parent. Is there something wrong with my child? How did I not notice this before? What does this mean? This can be even harder when you are told you need to see a craniofacial surgeon.

What is a cranial suture?
Babies are born with five major bones of the skull: two frontal bones, two parietal bones, and one occipital bone. Where these bones meet are called sutures. Cranial sutures are special joints of the skull bones that play several important roles in the growing child. First, sutures allow the skull bones to move during birth to allow the head to fit through the birth canal. Second, sutures allow the skull to grow quickly during the first few years of life in response to the rapidly growing brain

When does the Metopic Suture fuse?
The Metopic suture is the name for the suture that separates the two frontal bones in the middle of your child’s forehead. It is different from all the other major sutures of the skull. The other sutures fuse in the second or third decade of life. In contrast, the metopic suture normally fuses in the first year of life – between 3 and 9 months of age usually. When the metopic suture fuses, the bone next to the suture will often thicken, creating a metopic ridge. The ridge may be subtle or obvious, but it is normal and usually goes away after a few years.

What is Craniosynostosis?
Craniosynostosis is an abnormal condition when a cranial suture fuses too early. Most babies with craniosynostosis are born with a fused suture, but occasionally, children may develop craniosynostosis after birth. Craniosynostosis leads to two major problems. First, skull growth is limited at the site of a fused suture. The remaining open sutures will attempt to compensate by growing faster. This can lead to an abnormal head shape that takes on a specific pattern depending on the suture that is fused. Second, because sutures are important sites of skull growth in the first few years of life, premature fusion of a cranial suture can increase a child’s risk of developing increased pressure inside the skull (intracranial hypertension). This can lead to headaches, developmental delay, and even blindness.

What is Metopic Craniosynostosis?
Metopic craniosynostosis occurs when the metopic suture fuses prematurely. Babies usually with this condition have an abnormally shaped head referred to as trigonocephaly. There is a ridge at the metopic suture, the forehead is angled instead of flat, like the front of a boat, and the eyebrow bones (supra-orbital rims) are pulled back. The eyes can also appear close together. The best way to see this abnormal shape is by looking at your child from the top where the head will appear triangular, or tear drop shaped.

How do we treat Metopic Craniosynostosis?
There are several different interventions that may be recommended to treat a child with metopic craniosynostosis. These will vary depending on the child’s age, the severity of the deformity, and the philosophy of the treating surgeon. Most surgeons treat metopic craniosynostosis with an open surgery, sometimes called a cranial vault remodeling (CVR) or fronto-orbital advancement (FOA). These are two names for the same operation which involves reshaping the front of the skull including the forehead and upper portion of the eye socket to create space for the brain to grow and improve the shape of the head. These operations are typically done between 9-18 months of age and involve an ear-to-ear incision and a multi-hour operation.

What do you do if you want more information?
If you have questions or comments, or would like to learn more about craniosynostosis, please contact our office. You can schedule an appointment or send an email with questions.

The Pediatric Brachial Plexus Clinic provides multidisciplinary evaluation and treatment of children with all types of brachial plexus and peripheral nerve injuries. Members of the center’s multidisciplinary team include specialists in the following fields:

• Plastic surgery
• Physical and occupational therapy
• Clinical social work
• Pathology
• Anesthesiology
• Neurosurgery
• Hand surgery
• Neuroradiology
• Neurology
• Orthopaedic surgery

Referral Requirements
Referrals are required from primary care physicians or other Children’s Hospital specialty services. Referrals for patients enrolled in managed care insurance plans also may require authorization from the insurance provider and primary care physician. All necessary referral and authorization forms must be received before the patient’s visit. For accurate provider numbers or more information, please call 412-692-3433.

Additional Resources
Brachial Plexus Palsy Foundation
The National Brachial Plexus/Erb’s Palsy Association, Inc.
United Brachial Plexus Network (UBPN)
Outreach- A United Brachial Plexus Network publication
Brachial Plexus Clinic Brochure (PDF)

What is cleft lip?

Cleft lip is a treatable birth defect. It happens when the tissues of the upper jaw and nose don’t join as expected during fetal development. This causes a split (cleft) in the lip.

A cleft lip may be complete or incomplete. With either type, it may involve one or both sides of the upper lip and rarely occurs in the lower lip. Cleft lip often occurs with cleft palate. Cleft palate and cleft lip are the most common birth defects of the head and neck.

A cleft lip usually doesn’t cause health problems. Surgery can be done to fix the split and improve the appearance of the mouth and nose.

What causes cleft lip?

Doctors don’t know what all of the causes are. But your baby may be more likely to have a cleft lip if:

• You use certain medicines while you’re pregnant.
• You use alcohol or illegal drugs while you’re pregnant.
• You or a household member smokes while you’re pregnant.
• You are exposed to radiation or infections while you’re pregnant.
• You or your baby’s father have a family history of cleft lip.

It’s important to take good care of yourself before and during your pregnancy so that your baby will be as healthy as possible.
People who have a family history of cleft lip may want to think about genetic counseling. It can help you understand your chances of having a child with a cleft lip.

What are the symptoms?

You’ll notice a split in the baby’s lip. It’s easy to see right at birth.
A baby with a cleft lip typically doesn’t have any problems feeding. But a baby who has both a cleft lip and a cleft palate may have feeding problems.

How is a cleft lip diagnosed?

A cleft lip is usually diagnosed at birth. Shortly after birth, the baby will have a physical exam. The doctor will look inside your baby’s mouth to see whether there is also a cleft palate.
Sometimes a fetal ultrasound during pregnancy can detect a cleft lip. But an ultrasound doesn’t always find the problem, so doctors can’t always rely on it to diagnose a cleft lip.

How is it treated?

Surgery can fix a cleft lip. Before surgery, a baby may wear a mouth support (such as a dental splint) or a soft dental molding insert along with medical adhesive tape.

Most doctors suggest that surgery be done by the time a baby is 6 months old. But the timing of the surgery depends on a few things, such as how severe the split is and the health of the baby.

As your child grows, he or she will probably need more than one operation. For example, if your baby’s nose has an odd shape, surgery may help fix it. Your child may need other treatment, such as speech therapy if he or she has a hard time pronouncing words.

What can you do at home to help your child and yourself?

As your child grows, pay special attention to dental care and any speech problems. Support your child’s self-esteem. Explain how cleft lips form and how having one has been a part of making your child strong. This will help your child know how to answer questions from other children and adults. You can also ask your doctor what treatments can make the scar less noticeable.

Caring for your child who has a cleft lip can take time and patience. Seek support from friends and family. You can join a support group to meet others who are going through similar challenges.

What is cleft palate?

Cleft palate is a treatable birth defect. It happens when the roof of the baby’s mouth (palate) doesn’t develop normally during pregnancy, leaving an opening (cleft) in the palate that may go through to the nasal cavity. A cleft can form on any part of the palate, including the front part of the roof of the mouth (hard palate) or the small flap of tissue that hangs down from the soft palate (uvula). It may appear by itself or along with other birth defects of the face and skull, such as a cleft lip.

Cleft palate and cleft lip are the most common birth defects of the head and neck. Until a cleft palate is treated with surgery, it can cause problems with feeding, speech, and hearing.

What causes cleft palate?

Doctors aren’t sure what causes it. But your baby may be more likely to have a cleft palate if you:

• Use certain medicines while you’re pregnant.
• Use alcohol or illegal drugs while you’re pregnant.
• Smoke while you’re pregnant.
• Are exposed to radiation or infections while you’re pregnant.
• Have a family history of cleft palate.

It’s important to take good care of yourself before and during your pregnancy so that your baby will be as healthy as possible.
If someone in your family was born with a cleft palate, you may want to think about genetic counseling. It can help you understand your chances of having a child with a cleft palate.

What are the symptoms?

Some forms of cleft palate are easy to see when the child is born. But even if the cleft palate doesn’t affect how the baby’s face looks, it can usually be seen inside the mouth.

The location of the cleft matters more than how it looks. A small cleft in the soft palate may cause more problems-because of its effect on speech-than a large cleft that is easy to see.

A baby with a cleft palate often has feeding problems, because he or she isn’t able to suck and swallow normally. But this doesn’t always last, especially with treatment.

How is a cleft palate diagnosed?

A doctor can diagnose a cleft palate by doing a physical exam of the baby’s mouth shortly after birth.
Fetal ultrasound can sometimes find cleft palate as early as 14 to 16 weeks into pregnancy, especially if the cleft palate is severe and occurs along with a cleft lip. But ultrasound doesn’t always find the problem, so doctors can’t always rely on it to diagnose a cleft palate.

How is it treated?

Treatment involves a team of health care providers. The type of treatment depends on how severe the problem is.
Surgery is the most common treatment for a cleft palate. For the most part, it’s done before a child is 12 months old. Before surgery, your baby may need treatment for breathing or feeding problems. He or she may also wear a mouth support (such as a dental splint) or a soft dental molding insert along with medical adhesive tape.

As your child grows, he or she will probably need more than one operation. But the problem is normally fixed by the time a child is a teen. Although surgery often leaves scars, the palate usually heals well and leaves few signs of the cleft. A child’s facial bones most often grow normally, and the child speaks more clearly.

Some children who have a cleft palate need more treatment for other problems, such as speech, hearing, or teeth problems; sinus and ear infections; and problems from surgery.

What can you do at home to help your child and yourself?

If your baby is born with a cleft palate, get help with feeding. A nurse can guide you on feeding techniques. Watch for infections and hearing or teeth problems too.

As your child grows, pay special attention to dental care, hearing, and speech. You can also support your child’s self-esteem. Explain how a cleft palate forms and how having one has been a part of making your child strong.
Caring for a child who has a cleft palate can take a lot of time and patience. Seek support from friends and family. You can join a support group to meet others who are going through similar challenges.

What is a congenital limb difference?

Congenital limb differences are treatable birth defects that affect the patient’s upper or lower extremities. They frequently affect the hands and may appear as an isolated finding or along with other birth defects.

These differences may be as simple as an extra digit or as complex as a missing thumb and are frequently treatable problems. An evaluation by an experienced pediatric hand surgeon is the best choice for your child in order to determine the best course of treatment.

Examples of congenital limb differences include:

• Polydactyly (extra fingers or toes)
• Thumb duplications
• Thumb hypoplasia (small or absent thumb)
• Syndactyly (fused fingers)
• Cleft hand (divided hand)
• Radial longitudinal deficiency
• Ulnar longitudinal deficiency
• Brachydactyly (short digits)
• Symbrachydactyly (missing digits / limb)
• Macrodactyly (large digits)
• Arthrogryposis
• Joint contractures

What causes a congenital limb difference?

Congenital limb differences typically occur between 8 and 12 weeks of gestation, when the limb buds are forming in the embryo. There are a variety of known factors that can affect limb growth, but not all congenital limb differences come from known causes.

Some of the notable causes of a congenital limb difference are genetic syndromes, such as Apert syndrome, Holt-Oram syndrome, and Greig cephalopolysyndactyly, but not all children with a congenital limb difference have an underlying syndromic cause.

Genetic counseling is often helpful for patients with more complex differences, because they can help determine if there are other factors that need to be evaluated so that the patient may grow and develop safely. Your pediatric hand surgeon will discuss these considerations with you in detail at your consultation.

What are the symptoms?

Children with congenital limb differences will usually have visible differences, but not all differences are immediately noticeable. A good example of this are patients who have extra fingers or toes. To the casual observer, these may not be readily apparent, and sometimes are not diagnosed immediately after birth. Other patients may have immediately recognizable differences that affect limb function and appearance noticeably.

Your pediatric hand surgeon will evaluate the patient to determine if their congenital limb difference is associated with a functional issue or stigmatizing appearance and discuss the options for treatment.

How is a congenital limb difference diagnosed?

In many cases, the diagnosis of a congenital limb difference is made by prenatal ultrasound, but not all differences are immediately detectable with this test. If your child has a prenatal diagnosis made, you may be referred for a prenatal consultation with a pediatric hand surgeon to discuss the findings and possible treatment plans.

Often, the congenital limb difference is only detected at birth, when the pediatrician examines the baby for the first time. The pediatric team will often make the referral to the pediatric hand surgeon shortly thereafter so that your child may be further evaluated and treated.
How are congenital limb differences treated?

Treatments for congenital limb differences may vary widely, and are often dependent upon the overall functionality of the limb and the specific structures involved. Some patients only require simple treatments, like splinting, in order to maximize appearance and function, while other patients may require several surgeries over time to achieve a good result. It is important to seek an evaluation with an experienced pediatric hand surgeon in order for the patient to be fully evaluated and have an open discussion with the team regarding the best choices for your child.
What can you do to at home to help the child with the congenital limb difference and yourself?

If your baby is born with a congenital limb difference, your pediatrician will usually make the diagnosis shortly after the patient is born. They can then make the referral so your child can be seen by a specialist who has experience in treating patients with congenital limb differences, usually a pediatric hand surgeon.

Once you have seen the pediatric hand surgeon, they will make recommendations about how the child may be treated. Sometimes, this is as simple as wearing a splint, and other times, the condition may best be treated with surgery. It is important to ask questions about the options and how the child may be affected by each approach. Once a treatment plan is agreed upon, your caregiver will see the patient as he or she grows in order to follow their progress. It is important for you to pay special attention to how the patient uses his or her hands for activities of daily living, such as brushing their hair, eating, writing, or even playing. These details will help your pediatric hand surgeon to make informed, personalized choices with you regarding any treatment that may be helpful.

As your child grows, we can also assist you in supporting your child’s self-esteem, explaining how a congenital limb difference forms, how theirs was treated, and answer any questions your child may have as he or she grows up. We want to empower you to be able to handle these questions your child and others may have, in order to help improve understanding and acceptance.

Caring for a child who has a congenital limb difference can be a demanding task, requiring time and patience. It is normal to feel somewhat overwhelmed, especially in the beginning, and we are happy to help. It is also important for you to seek support from your friends and family. You may even join a support group to meet other parents and patients who may have gone through similar challenges. You are not alone.
Our pediatric hand surgery team is available to help support you and your family through this process so that you and your child may enjoy life to the fullest, with the best possible result for their future.

What is hand trauma?

Hand trauma is a term that refers to a group of injuries that affect the patient’s upper extremities. These injuries may be as simple as sprain, where rest and taping are helpful, or as complex as amputations. An evaluation by an experienced pediatric hand surgeon is the best choice for your child in order to determine the best course of treatment.

Examples of common hand trauma include:

• Sprains of the wrist, hand, and fingers
• Fractures (broken bones):
• Carpal bone fractures
• Metacarpal fractures
• Phalangeal fractures
• Lacerations (cuts) of the skin and soft tissues of the forearm, hand, or fingers
• Tendon lacerations (cut tendons)
• Nerve injuries
• Blood vessel injuries
• Crush injuries, including door slam injuries to the fingers
• Finger or hand amputations

What causes hand trauma?

Hand trauma is common in people of all ages, including children, and certain injuries are more common in different age groups. Younger children tend to have injuries like door slam injuries with cuts that affect the fingernails and fingertips, while older children tend to have sports related injuries like broken fingers and sprained joints.

Our pediatric hand center has considerable experience in providing optimal care for children who experience hand trauma, and we offer a wide variety of both non-operative and operative treatments, which are individually selected for the patient’s specific needs.
How is a congenital limb difference diagnosed?

Often, the diagnosis of hand trauma comes at the time of injury, when the patient is brought to an express care facility or emergency room, where an examination and x-rays can be taken to further evaluate the patient. Once the initial evaluation has been completed, our team is often asked to further evaluate and treat these patients.

How are congenital limb differences treated?

Treatments for hand trauma are individualized to the areas affected by the injury and include both non-operative methods, such as casting or splinting, and surgery. The choice of treatment depends on many factors, including mechanism of injury, pattern of injury, age of the patient, potential for improvement, and family wishes. It is important to seek an evaluation with an experienced pediatric hand surgeon in order for the patient to be fully evaluated and have an open discussion with the team regarding the best choices for your child.

What should I expect from a clinic visit for hand trauma?

If your child is diagnosed with hand trauma, the first line caregiver will frequently make the referral to our clinic, usually within the first 1-4 weeks after injury, depending upon the specific injury sustained. We will examine your child, obtain any indicated studies / imaging, and discuss the problem with you openly.

We shall then make recommendations about how your child may be treated. Sometimes, this is as simple as wearing a cast or splint, and at other times, the injury may require surgical treatment. In addition to immobilization or surgery, your pediatric hand surgeon may also make recommendations regarding participation in sports and other activities, in order to allow the injury to heal properly. It is important to follow these directions closely, since excessive activity during the healing process may negatively affect the outcome of the patient.

After treatment is given, the pediatric hand surgeon may also wish to see the patient as he or she grows in order to follow their progress and determine how well they can perform activities of daily living. These details may assist with further treatment, such as pediatric hand therapy, to optimize recovery. Our pediatric hand surgery team is available to help support you and your family through the process of healing.

Parents have many questions when they learn that their child has a breast anomaly. Often this can cause much mental and social stress for both the child and family.

The Breast Anomaly Clinic is part of the Division of Pediatric Plastic Surgery at Children’s Hospital of Pittsburgh of UPMC.
Our plastic surgeon offers complete breast reconstruction care to young people with conditions that include:

• Asymmetry
• Dysphoria
• Underdeveloped or overdeveloped structures
• Missing structures

Treating breast problems in children, teens, and young adults requires careful regard to further growth and development.
At Children’s, our experts take special care to think through all aspects of a diagnosis for you or your child. We assess future growth and the psychosocial welfare for you or your child.

Inborn Breast Conditions We Treat

The Breast Anomaly Clinic at Children’s Hospital provides high-quality care for young people, up to age 25, with:

• Amastia (lack of breast development)
• Amazia
• Accessory nipple
• Breast asymmetry
• Constricted breast deformity
• Gynecomastia (male developing breast tissue abnormally)
• Macromastia (female with excessive breast development)
• Poland syndrome

View patient “before and after” photos from the Congenital Breast Anomaly Clinic (PDF).

The clinical photographs in the linked document contain nudity. Parental discretion is advised.
Contact the Congenital Breast Anomaly Clinic at Children’s Hospital of Pittsburgh
Call 412-692-3433 to make an appointment for your child.

Specialists in the Vascular Anomalies Center at Children’s Hospital of Pittsburgh of UPMC are trained to care for children with a wide spectrum of birthmarks, including hemangiomas and their concomitant complications, as well as vascular malformations such as:

• Venous malformations
• Arterial malformations
• Capillary malformations (port wine stains)
• Lymphatic malformations
• Conditions such as
• CLOVES syndrome
• Klippel-Trenaunay syndrome
• PHACES syndrome
• Sturge Weber syndrome