Cephalic swelling of the protruding part of the head caused by blood or lymphatic congestion. The swelling usually exceeds all sutures, and decreases within a few days and does not need any further treatment.

Following their behavioral instinct to explore everything by hand and mouth, infants and younger children do suffer such incidents quite frequently. Extraction by minimal invasive techniques (curved forceps, small speculas) is mandatory and possible in the majority of cases, if performed under general anesthesia or deep sedation, gently. In complicated cases ENT specialist’s expertise might be useful.

Cuts of the skull are usually impressive, because of their excessive bleeding. This bleeding is controlled best by firm digital compression on the wound margins**. Frazzled wound margins can be excised. These cuts are usually treated best by deep bite layer sutures* in the galea and skin. A spray glue dressing is preferable to any other dressing because hairs sticking together cause pain during dressing changes and removals. In facial cuts wound margins should never be excised! If in need the margins should be refreshed only by gentle abrasion by a sharp scalpel blade. Suturing in the face should always be intracuticular using fine suture materials. To avoid removal of suture material, whenever possible, absorbable sutures should be used. To minimize scarring, esthetic plastic surgery techniques should be your first preference.

Ingestion – esophagus (i.e., meat piece, button battery, coin); aspiration – trachea (i.e., peanut, pencil rubber, pin): “swallowing” usually happens during play, and since the majority of these patients are less than 6 years of age, every clinician must maintain a high index of suspicion. This is because parents and siblings would have noticed only “something” in the mouth of the children and together they would be able to give only a vague history of the incident. “Excessive salivation”, “wheezing”, and “chocking” are possible symptoms, but quite often the “swallows” are asymptomatic. Thus, if you suspect an ingestion or aspiration of a radio-opaque foreign body, an X-ray study (anteroposterior and lateral view), including the neck and nasopharynx, is recommended to localize it. Esophageal foreign bodies** will mainly be trapped in one of the three esophageal narrowings, while in the trachea-bronchial tree, they will mainly be trapped in the right mainstem bronchus. Especially, if located in the trachea or the bronchial tree, immediate retrieval*** (by rigid/flexible scope) after visualization of the foreign object should be obtained. Aspirated peanuts can germinate and cause mycotic inflammatory reactions, besides hyperinflation, atelectasis, air trapping, shifting, and pneumonia. If the foreign body has already reached the stomach, it will be drained via the natural way in almost all cases. If it is still stuck into the esophagus, the foreign body should either be recovered transorally or gently pushed into the stomach for further “digestion”. Extremely dangerous are retained ingested batteries or magnets since their current or acid leaking out can cause tissue damage like perforation, stricture, or fistulas.

Acids and alkalis from household cleaners are mostly ingested by children <5 years of age or adolescent girls attempting to commit suicide. Strong alkalis tend to injure the proximal pharynx and esophagus and cause lesions with liquid necrosis. Strong acids, on the other hand, cause coagulation necrosis and result in more distal injuries of the esophagus and even stomach wall. More superficial mucosal injuries might resolve without any long-term sequelae. However, deeper lesions always heel by fibrosis and subsequent stricture formation. Every full thickness lesion even has the potential for perforation and fistula formation. Finally, such complications can require esophageal resection or even replacement. If you see a caustic ingestion the first step must be to establish the patency of the airway***! Because the resulting inflammatory swelling of the tissue can rapidly obstruct the airway, making emergency endotracheal intubation or even tracheostomy necessary to save the child. To induce vomiting is strictly contraindicated! This is because the (re-)regurgitation of the caustic substance bears the risk of reinjury to the mucosa and secondary aspiration pneumonia. Endoscopic inspection** is the second step. It is best done very gently within 24–48 h. A common endoscopic grading system is given: 0° = normal, I° = mucosal edema with hyperemia, IIa° = superficial lesion, IIb° = sl + limited areas of deep or circumferential injury, IIIa° = small (scattered) areas of necrosis, IIIb° = extensive necrosis. A contrast study (with water soluble contrast media!!) is usually done 2–3 weeks after the incident to determine the presence and length of strictures. It should be done at first presentation as well, if a perforation is highly suspected. If the study shows free air, or the evidence of contrast media, either in the peritoneal or mediastinal cavity, emergency surgical exploration** is indicated.

Every child has at least one “palpable” cervical lymph node. By definition, any cervical lymph node is considered to be enlarged, if it is more than 1 cm at its longest diameter. Any palpable supraclavicular node is considered as abnormal per definition as well. The assessment of a child with lymphadenopathy requires a thorough history taking and physical examination; especially, the onset and duration of symptoms (e.g., recent animal bites or scratches, contact with infectious diseases, Epstein-Barr, cytomegalovirus, travel abroad, etc.) and the exact numbers of enlarged lymph nodes should be reported. On physical examination, hyperplastic lymph nodes in response to viral infections are small, discrete, mobile, nontender, and bilateral. Usually, they are not accompanied by cellulitis or periadenitis. Pyogenic nodes (caused by Staph aureus, Strept pyogenes infections), on the other hand, tend to be unilaterally large, warm, and tender with surrounding erythema and edema. Nodes associated with malignancy are generally firm or hard, discrete, and nontender. Staph aureus infections are most commonly seen in children between 1 and 4 years of age. Fluctuation occurs in one-fourth of patients. If fluctuation is present, antibiotics are administered and purulence is drained surgically under general anesthesia*. Cat scratch disease (Bartonella species) is usually self-limiting, therefore, a surgical intervention is unnecessary.

Fast hemostasis** in tongue bites is key. Then the wound is closed by interrupted, inverted, and fast absorbable sutures. Besides the hemostasis, the exact reconstruction of the lip vermilion* is essential. In tooth trauma all pieces should be preserved and the child transferred to a dentist.

During the fetal life, most of the blood circulates through the ductus arteriosus into the descending aorta. Postpartal, this circuit is functional and anatomically closed. The neonate with a persistent PDA, therefore, presents with dyspnea, rapid fatigue, intensive sweating as common signs of his/her heart failure. Therapeutic options are closure by indomethacin medication*** or surgical ligation*, via either thoracoscopic or open approach.

Newborns with EA/TEF often have difficulties in clearing their saliva, demonstrate episodes of coughing, chocking, and even cyanosis quite shortly after birth. Attempts to feed the children result in immediate distress. In the clinical setting the diagnosis is confirmed by the failure to pass a firm NGT into the stomach. The classical antenatal sonogram shows the absence of air in the gastric area and the associated polyhydramnion. Postnatally, contrast studies (water-soluble contrast media, careful!), US, and (rigid) bronchoscopy are used to confirm the diagnosis. Common types of esophageal atresia and trachea-esophageal fistula are given: A: proximal esophageal atresia with distal trachea-esophageal fistula (TEF) (85–90 %); B: isolated esophageal atresia (5–7 %); C: TEF without esophageal atresia (2–6 %). Rare forms include atresia with proximal TEF (<1 %) and esophageal atresia with both proximal and distal TEF (<1 %). Associated anomalies (e.g., cardiac 27 %, urogenital 18 %, skeletal 12 %, vertebral 11 %, anorectal 12 %, gastrointestinal, and palate/laryngotracheal 8 %, VACTERL 19 %) are found in approximately half of these newborns. Some of them seem to be quite insignificant; however, a high proportion are even life-threatening and contribute directly to the high morbidity and mortality in this population. As soon as the diagnosis is confirmed, iv fluids and a Replogle tube*** (sump suction catheter device) are administered, and the baby will be nursed in the supine or lateral position. In an otherwise healthy baby, surgery is* performed ideally within the first 24 h*. Most preferable during an “elective” procedure since aspiration (pneumonia) and gastric acid reflux through the lower pouch, TEF are a constant risk. Using the classical approach the baby is positioned in a slightly right lateral elevated position with the right arm raised across the head. The right thoracotomy starts with a curved skin crease incision 1 cm below the angle of the scapula, extending from the anterior axillary line to the lateral margin of the erector spini muscles. After dividing the latissimus, the chest is opened through the fourth intercostal space. The pleura is carefully separated from the ribs to start an extrapleural approach (vs. transpleural approach) towards the TEF. The posterior mediastinal pleura is retracted forward until the azygos vein is visible, at the junction where it enters the superior vena cava. After mobilization the azygos vein is ligated and divided as it enters the cava. Now the fistulous communication between the trachea and distal esophagus is accessible. The distal esophagus and the TEF are identified, the fistula is ligated and cut off. To test TEF repair some N/S is installed into the thorax cavity and the anesthetist asked to exert positive air way pressure to see that no air bubbles leak from the suture line. Be aware, it is quite possible to mobilize the descending aorta in the erroneous impression that this is the distal esophagus!!. To identify the upper pouch the anesthetist is requested to push firmly on the reploge tube. The upper pouch is marked and dissected by bipolar diathermy. Important note: it is a general rule in pediatric surgery to mobilize only the proximal pouch and not the distal one!!. This is because the proximal esophagus can be mobilized better due to its superior intramural blood supply. Mobilizing the distal one instead can disrupt the tenuous bronchial arterial supply and lead to ischemia of the anastomosis. Finally, the two stumps are anastomized directly with fine interrupted polydioxane suture over a NGT placed into the lumen. If the procedure has been strictly extrapleural no chest tube is needed. If the repair has been transpleural or you are in any doubt, it is recommended to place a drain. Long gap EA with distal TEF should undergo cervical esophagostomy and feeding gastrostomy, accepting the need for an esophageal replacement surgery (e.g., extension/expander techniques (Foker), esophagus replacement, or limited (Thal) fundoplication at a later stage). A thoracoscopic approach is nowadays also feasible and safe. Serious complications are recurrent TEF (6–10 %), stenosis/stricture (15 %), dysphagia (10–20 %), GERD (up to 50 %), or anastomosis leak (10 %).

In hypertrophic pyloric stenosis the circular muscle of the pylorus is so hypertrophic that it narrows and elongates the pyloric channel. The usual onset of symptoms occur between 3 and 6 weeks of life. Vomiting, characteristically projectile and free of bile, next to dehydration and weight loss, due to inadequate fluid and caloric intake, soon become apparent. The visible gastric peristalsis and the palpable pyloric tumor are other important clinical findings. Chloride depletion and metabolic alkalosis are concomitant lab findings. The final diagnosis nowadays is made by ultrasonography. If the pylorus presents as a hypoechoic ring with an echogenic center, the pyloric diameter and length are enlarged and the muscle thickness is 4 mm or more, the diagnosis of a hypertrophic pyloric stenosis is confirmed. Preoperative, electrolyte levels, and dehydration need to be corrected*** before Ramstedt’s pylorotomy* (splitting of the pylorus muscle until mucosa bulges into the split incision) by an open, laparoscopic, or Bianchi approach is performed. Complications are duodenal perforation, which is usually the result of excessive tissue separation at the distal end of the pylorus, or the “recurrence” due to the incomplete splitting of the muscle (in up to 8 % of cases).