Saturday, May 7, 2011

Andie's DDH Story

Andie is my niece.  The daughter of my only sister, Jaja.  She was born one August day in the year 2007.  The first grandchild on both her father's and mother's sides of the family, everyone was just dying to meet her on the day of her birth.  I remember being in the labor room with my sister, and seeing Andie just minutes after she was born.  I fell in love with her right then and there.  My first full-blooded niece!

Boundless Life and Energy
Andie was such a wacky and intelligent baby!  I could tell from the start that she is a very special child.  So full of life!  So bright!  So smart!  Highly perceptive.  Very talkative!  Really sociable and friendly.  Sometimes, Andie can also get really naughty and feisty with everyone, but never with me! (Smile!)  Her energy seemed to have doubled when she became a toddler.  And was like a speeding bullet in the way she zoomed from one area to the next.  She ran around everywhere while screaming with delight.  She hopped and skipped to nursery songs, and danced and twirled like a ballerina in her pink tutu.  I can't anymore remember how many times she's announced to everyone that she wanted to dance the ballet like her mom.

There was this incident a couple years back when Andie just turned 2 years old.  She was jumping on the bed and then fell, head first, on the floor.  I remember the horror on her parents' face, the shock we all felt seeing the dark purple bump on her forehead, which was the size of a golf-ball!  It was off to the E.R., as you can imagine.  Thankfully, nothing serious came up from that.  Those were the times when Jaja and Mark were all-eyes on Andie because she was figuring into too many accidents.

The Signs
I don't exactly remember who noticed it first; and when anyone really started to observe it.  But one day, I observed the way Andie's left foot always "tip-toed" whenever she walked.  I remember always reminding Andie to stop and walk slowly.  I'd tell her things like:  "Walk properly." "Place your foot down - first with your heel, then with your toe."   Or "Andie? Heel. Toe."  She would obey.  But just soon after (not even a minute), perhaps because it really didn't feel "natural" to her, she would go back to tip-toeing, but just her left foot.  So I initially thought that maybe it was the way that her one of her former yayas "trained" her to walk.  Maybe they used to lift her left arm/body too high when they felt she was "slacking" as they were teaching her to walk when she was a baby.

And like I said, others noticed it too.  We all saw, but never really thought of "investigating further".  As Andie grew, her "unbalanced" gait was becoming more pronounced.  But like most parents, grandparents, uncles, and aunts...we all thought it was nothing really serious and that it was only a matter of "correcting" Andie on how to walk properly and re-training her.  I, personally, thought that it was only as simple as that.  How are we to know that something as simple as a tip-toe can mean something deeper?

The Discovery
While on a month-long vacation in the U.S., and enjoying Disneyland in Anaheim last November...a stranger approached my sister and suggested that she have Andie's legs checked.  Apparently, the man was a surgeon.

It was the start of a series of appointments and consultations with different specialists and surgeons, from that time on.  They discovered that the problem was not Andie's left foot at all.  Nor her left leg, per se.  Rather, it was the joint between the upper part of her left thigh bone and hip or pelvis.  Specifically, Andie has a case of Developmental Dysplasia of the Hip (DDH).  They got a second, and a third opinion.  They were all the same.  Jaja asked Andie's pediatric-orthopedic surgeon whether or not the condition is painful.  The doctor mentioned that such case is not painful for kids in the beginning.  But without surgery, and by the time Andie turns 6 or 7 years old, her unbalanced walk will get even more pronounced, and she WILL start to feel pain.  The pain will even get physically debilitating as years go on.  Depending on the particular condition of her DDH, the doctor said that Andie herself will be the one to ask her parents for a hip surgery.  She also informed that ALL persons with DDH, but more so those who didn't opt for any form of treatment, will have early osteoarthritis at around 40 years of age.  So given these facts, coupled with Jaja's own research over the internet, they had no choice but to push through with the operation.

I was shocked when Jaja first told me.  I've never heard anything like it.  I was never aware of such a condition until that day.  It was all very surreal to everyone of us.  Jaja was bawling.  My heart fell seeing her that way.  I was especially concerned for the little one in her tummy.  Did I mention already that my sister was 2 months pregnant at the time?  Yes, still in her 1st trimester.  I feared that the stress might get to her and the baby.  I don't know what I would do if I was in her situation.

DDH Principles
Following are just some of the data I gathered from different websites, to give you an idea on what DDH is:

The hip is a 'ball and socket' joint. The top of the thigh bone (femur) is shaped like a ball and fits into a matching cup (acetabulum) on the outer side of the pelvis. Various problems can affect the baby's hip as it develops. Sometimes the ball does not lie safely in the socket and is displaced from it: this is what is meant by dislocation. Sometimes, although the ball is in the socket it can slip in and out of place. This is what is meant by the hip being dislocatable. Sometimes although the hip is in the socket it is not deeply in place and we call this hip 'subluxated.' Finally in some children although the hip is in the right place the socket does not grow properly and is too shallow. If the hip socket is shallow this may allow the ball to move from the position it should occupy.

1 to 2 in 1,000 babies born may have a hip that is dislocated at birth. A slightly larger group of children have hips which are not safely in the socket or in whom the socket is shallower than it should be. In general girls are more likely to be affected that boys. The left hip is more often affected than the right.

What are the symptoms?
The condition is not painful and there are no definite signs that a child may have a problem with hip development, but the following are associated with the condition:
  • One leg appears shorter than the other;
  • One hip joint moves differently from the other and the knee may appear to face outwards;
  • When a baby's nappy is changed one leg does not seem to move outwards as fully as the other one;
  • The child crawls with one leg dragging.
After walking age it may be noticed that:
  • a child stands and walks with one foot on tiptoes with the heel up off the floor. (The child walks this way in an attempt to accommodate the difference in leg length);
  • the child walks with a limp (or waddling gait if both hips are affected).

Signs and Symptoms
Infants often don't show signs that they have DDH, and there may be no signs at all. Still, doctors look for these indicators:
  • at birth, an inability to move the thigh outward at the hip as far as possible
  • an audible "click" during routine post-natal checkups
  • asymmetry in the fat folds of the thigh around the groin or buttocks
  • in older kids, an exaggeration in the spinal curvature that may develop to compensate for the abnormally developed hip
  • limping in older children
Treatment for DDH depends on the age of the child and the severity of the condition. Mild cases may correct themselves in the first few weeks of life.

If an unstable hip is seen in newborns, the hip may be held in position with a Pavlik harness. This device keeps the femoral head in its socket by holding the knee up toward the child's head. A shoulder harness attaches to foot stirrups to keep the leg elevated. The goal is to tighten the ligaments in the area and stimulate normal forming of the hip socket. Treatment with the Pavlik harness lasts about 6 to 12 weeks, and continues until the hip is stable and ultrasound exams are normal.

After a child reaches 6 months of age the Pavlik harness will be ineffective. Older kids will need to undergo one of the following treatments:
  • Closed reduction. The bone is manually put back into place after the child is put under anesthesia. This treatment is usually preferred in children younger than 18 months.
  • Open reduction. The hip is realigned and the thighbone is placed back into the hip socket through surgery. During the procedure, tight muscles and tissues surrounding the hip joint are loosened and then later tightened up once the hip is back in place. This is the procedure of choice for kids older than 18 months.
After reaching age 2 or 3, a child might need surgery on the pelvis to deepen the hip socket (if it's too shallow) or to shorten the thighbone or realign it. Following surgery, the child is put in a hip spica (body cast). About 1 in 20 babies with DDH needs more than the Pavlik harness to correct the condition.

Caring for Your Child
DDH can't be prevented, but if it's recognized early and treated appropriately, most children will develop normally and have no related problems. DDH does not cause pain initially, but if left untreated it can result in significant impairment of function.

Kids with untreated DDH will have legs of uneven lengths in adulthood, which can lead to a limp or waddling gait, back and hip pain, and overall decreased agility.

Developmental dysplasia of the hip (DDH) is a dislocation of the hip joint that is present at birth. The condition is found in babies or young children.

Causes And Risk Factors
The cause is unknown, but genetic factors may play a role. Low levels of amniotic fluid in the womb during pregnancy can increase a baby's risk of DDH. Other risk factors include:
  • Being the first child
  • Being female
  • Breech delivery
  • Family history of the disorder
Signs And Tests
Pediatric health care providers routinely screen all newborns and infants for hip dysplasia. There are several methods to detect a dislocated hip or a hip that is able to be dislocated.

The most common method of identifying the condition is a physical exam of the hips, which involves applying pressure while moving the hips. The health care provider listens for any clicks, clunks, or pops.

Ultrasound of the hip is used to confirm the problem. An x-ray of the hip joint may help diagnose the condition in older infants and children.

A hip that is truly dislocated in an infant should be detected at birth, but some cases are mild and symptoms may not develop until after birth, which is why multiple exams are recommended. Some mild cases are silent and cannot be found during a physical exam.

Expectations (Prognosis)
If hip dysplasia is identified in the first few months of life, it can almost always be treated successfully with a positioning device (bracing). In a few cases, surgery is necessary to put the hip back in joint.

Hip dysplasia identified after early infancy may be associated with a worse outcome and may require more complex surgery to repair the problem.

Differences in the lengths of the legs may persist despite appropriate treatment.

Untreated, hip dysplasia will lead to arthritis and deterioration of the hip, which can be severely debilitating.

I'm also posting the following images on DDH for better understanding:

Image from OrthoPediatrics

(Left image from Steps Charity) Uneven folds and creases on the legs
(Right image from Pediatric-Orthopedics) Uneven legs

The last 3 photos shown on top are, from my understanding,
what they did to my niece during her hip operation.
Images from OrthoPediatrics
So in short, DDH is a deformity in the bones where the hips are, which eventually results in hip dislocation and eventually an abnormal walk.  Cases go from mild (involving braces and therapy) to really severe ones (involving open surgery and possible therapy).  If "discovered" at birth or only a few months after it, chances for fully correcting it are high and surgery may not even be needed.  To note, my niece Andie was diagnosed at 3 years old.

The Operation
It took about 4 months, from the time that a stranger in Disneyland took my sister aside, to the time Andie was finally scheduled and operated on for her DDH.  If it was up to my sister, she would have wanted the operation sooner.  But their surgeon had prior professional commitments, and (apparently) other kid-patients who were already scheduled long before Andie. do you react to that?

The day before the operation, when the hospital staff was performing a series of required tests on her (poking and sticking things at her, taking blood samples, doing x-rays, etc.), she started to cry like any child would.  But soon enough, she "braved up" to the many nurses, nurse aides, and medical technicians around her.  I can imagine how very traumatic every thing was for her.

On the day of the operation, she was wheeled inside the O.R. with her mom in tow.  My sister said she could tell how very scared Andie was but that she still put on a "brave face" for everyone anyway.  How very Andie I must say!  She smiled at her mom as they placed the oxygen mask over her nose and mouth, and then immediately dozed off to sleep.  The operation took more than 12 hours to finish.  I learned later on how the nurses proudly reported that when Andie came to, alone in the recovery room, she didn't even cry.  See?  What did I tell you?  Very brave huh!

The following is a photo of Andie (in her cast) and her mom (my sister) Jaja.  It was taken in March of this year, just 2 weeks after the operation.

Brave little Andie.  Do you see her sweet smile? :)
The cast is almost all over her body, leaving only a few parts of her exposed (from her chest up to her face; from her right knee down to her foot; her privates; and the toes of her left foot).  It's supposed to be on for only 2 months, and then Andie should graduate into wearing steel braces or something.  The follow-up check-ups and x-rays showed nothing to worry about.

The Unexpected
On the 7th week (just a week short of finally taking the cast off her), the doctor saw a new gap in Andie's hip.  Apparently her hip is an unstable one.  And they said that it's a sign that Andie might experience even more hip dislocations and operations in the future.  I'm hoping and really praying that they are wrong about this...and that a miracle will happen in Andie's favor.

All this was just too much for my brother-in-law and my pregnant sister, and it left them feeling really sad.  Mark, I heard, cried and felt really down when they left the doctor's office.  Jaja was emotional over the phone.  I was trying really hard to console her and tell her to be strong for Andie and the little one still in her womb.  To have faith and never lose hope.  I feel for them, really.  No parent can stand to see their little one suffering or in pain.  I personally couldn't stop crying when I heard about it and thought about Andie and how all this is affecting her physically, emotionally, and mentally.  How overwhelming all this might be for her young and innocent mind.

Lessons Learned
Situations like these sometimes make people start to question life in general, and God in particular.  They start to ask what His purpose is for their life.  But all one can really do is trust.  Fully-surrender to God and trust that all these things are happening for a reason.  To have faith in the Lord and all his works.  Faith in the God-given talents of people, medical professionals, specialists.  To teach us to appreciate people for their uniqueness, character, individual strengths, kindness, and inner beauty.  To pay no attention to what other people think.  To stop blaming one's self and move forward.  Take action.  To learn to count one's blessings.  To make the most of everything.  To hope for the best.  And last but not least, to pray.  Yes, prayer is best.

Andie was just operated on, a second time, just last Monday.  As of this writing, she is recuperating from home.  And I know for sure that Andie will be alright because so many people are praying for her and her full recovery.  Just knowing that so many people are behind your child and supporting him or her through prayer gives comfort to any parent.  So hang in there Mark and Jaja.  Hang in there, Andie-girl.  Your lolos, lolas, titos, titas, and cousins are all behind you.

Mama Mia, Tito Poof, and Maia are (and will always be) here for you.  Always know that we love you no matter what!  God will soon answer all our prayers, just you wait.  Everything will be alright.  Get well soon and God bless you always and forever!

Mama Mia is a 30-something wife; stay-at-home mom to one; blogger; and author of Online Confessions of a Stay-at-Home Mom (OCSAHM). Learn more about Mia here, or contact her via this page. You can also get instant updates on this blog by following Mia on Twitter @miadsoriano; by "Liking" the official OCSAHM Facebook page; or by subscribing via Email or RSS.
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