Interviewer: Pectus carinatum is a condition where the chest and the ribcage press outward. It has received over the years the nickname "pigeon chest" because of the way that it presses out, and wanted to find out more information about that today.
And we're with Dr. Stephen Fenton. And I wanted to find out about the condition and about some of the treatments of this condition. So, first of all, what causes it?
Dr. Fenton: That's a great question. It's really unknown. It's a congenital pectus deformity. There are two of them, excavatum and carinatum. And, like you said, carinatum goes outward like a pigeon's chest. It must be some interaction between the costal cartilage, or where the ribs come together with the sternum, and with development of the chest. Those cells push the sternum outward.
It can be symmetric, it can be asymmetric, so it can be to one side versus the other. It can encompass all of the sternum. Sometimes it just encompasses a portion of the sternum. And there's a large range of mild to severe as well. People don't often also recognize something called costal flaring, and that's where the bottom of the ribcage, or what we call the costal margin actually flares out or pushes out as part of this defect.
Interviewer: And is this defect possibly dangerous to a child's health? Because normally you notice it in adolescents.
Dr. Fenton: Correct. I said congenital, meaning the child is born with this defect. But, especially with carinatum, it's usually not noticed until adolescence when the child has gone through puberty and started having growth spurts. And that's when, because the chest is developing one side or the other, starts to push out more. Is it dangerous? That's usually the first question parents want to know. It's not. The chest will be every bit as strong as their peers. And so we don't give any limitations on the child's activities. We want them to play sports, we want them to be active, and certainly don't tell them otherwise.
Interviewer: But I would imagine that that kind of chest deformity can cause some self-esteem issues for a lot of people, especially adolescents where, boy, it's a tough time of life, anyway, right?
Dr. Fenton: That is definitely one of the aspects of these pectus deformities that children often experience. And sometimes it takes the parent by surprise, especially carinatum, which usually isn't seen in the small child. Excavatum can be seen because there's a dip, and so parents oftentimes notice that, especially when the child is young and they're the primary caregiver.
When the child gets older and starts to develop, they often take over their own body. Sometimes they hide their body, if you will, from their parents, they're not taking baths with their parents anymore. And they might be someone who just wants to wear a shirt when they're in the swimming pool, and, lo and behold, oftentimes it's because they don't want others to see what their chest looks like. Obviously, the more mild form of this is much less recognizable than a more severe form and/or kind of an asymmetric form which is going to be the most obvious.
Interviewer: If it's not physically threatening, I guess the treatment would be for cosmetic reasons?
Dr. Fenton: For carinatum, that is usually the case. Now, again, we're talking about the routine kind of run-of-the-mill. In some kids where it's very asymptomatic, deforms the chest quite a bit, that's another story. Even with carinatum, I would say, they should be evaluated and we should determine whether treatment is right for them or not. For most carinatum, though, oftentimes the kids are not symptomatic in another way. So the treatment really is along cosmetic lines.
And it used to be that we would offer this surgically. It required oftentimes a big surgery with a prolonged hospitalization and recovery time. And you can think about the cost and expense of that, and so it wasn't oftentimes pursued. Nowadays, much like correction of teeth with braces, there is bracing that can occur to help correct the chest. We like to do it in kids that have a fairly young body type because their chest is still very malleable, and initiation of bracing usually at that age will allow the chest to correct, and then we, kind of, help them maintain that correction through continued bracing until they've, kind of, finished growing.
Interviewer: What's the earliest point you might consider treatment for a child, and what's the point where you're like, "Well, it might be a little late at this juncture?"
Dr. Fenton: We would like to see the kids, first of all, whenever the diagnosis is suspected. Even if they're young children, we'll see them in clinic, talk to Mom and Dad, and the child about what this is, and then come up with, kind of, a timeline on treatment.
Oftentimes we'll gauge when we should repair based on severity, and based on what the body type is. But, obviously we want to do it not necessarily as soon as it's recognized, but once it's recognized and the child is starting to initiate puberty and growth, because, again, the chest is much more malleable, kids tolerate this a lot better. The older the body type, the older the person, the treatment itself can be much more difficult and not as successful.
Interviewer: And I love the analogy about teeth because we would not hesitate to take our child into the dentist and have their teeth straightened because that's just such a self-esteem thing, and it's so important. This could be very much the same self-esteem thing. It might not necessarily be causing any pain or any other sort of conditions, you know, since it is just a brace. How long would somebody have to wear that brace to make that correction then? And is it like braces that, you know, other people are going to see it?
Dr. Fenton: Most of the braces can be form-fitting. So what I tell parents . . . and we have a list of providers that we've used in the past and parents have been satisfied with what they've had. I tell parents, "First of all, you want the child to wear it." Now, it is a brace. It's not perfect. But, certainly, if it looks like a coat of arms or armor, they're not going to want to wear it. But if, you know, it fits well, it's fairly comfortable, they're going to be more apt to wear it.
Second, you really want the place where you get the brace from to be somewhat convenient. If they're driving from Logan to St. George for fine-tuning of the brace, that's not convenient and probably won't happen. And some kids will have to go in and get adjustments every few months, especially while they're growing in order to make sure that the brace continues to fit. So convenience is the second thing.
And then, thirdly, I tell the kids the amount of time required for correction really depends on how often they wear it. And if it sits in their closet under a pile of clothes, their chest is not going to correct. If they wear it 24 hours a day, sometimes we've seen kids correct in as little as 6 months, that's hard mainly, and it depends on the timing.
So, for example, in the winter, it might be easier for someone to wear a brace to school because they're wearing a hoodie, they're wearing baggy clothing, they might not have gym, etc., whereas in the summer it might be more difficult because they're wearing a T-shirt and shorts. And so I kind of tell the parents and teenager, you know, "You need to gauge it so that you're optimizing your time with the brace. And so, if it's every day after school and all day during the weekend, then great. If during the winter months it's every day, all day long, awesome. You know, if you have to miss the days that you have gym because you don't want to take off your shirt and have a brace on in front of your buddies, that's understandable. You have to do what will actually work." And the more frequent they wear it, the faster it'll correct.
Now, the other caveat with that is, let's say they're very diligent and they wear it every day for six months, and it totally corrects in six months, but they still have a year and a half of growth, there's going to have to be some sort of maintenance. And so, you know, then I usually discuss decreasing the frequency when it's worn, usually wearing it maybe on the weekends, making sure that they're, kind of, self-assessing the chest and seeing if it's starting to come out a little bit more, if it's staying corrected.
And we actually like to see the kids back about six months after they start bracing, and then about every year after that, or when needed to, kind of, help, again, make sure that that bracing is working.
Interviewer: And after the growth period is done, then that's when it, kind of, settles in and it's not going to change anymore, it sounds like?
Dr. Fenton: Correct. I mean, once the cells have stopped really, you know, causing growth to the adult-size chest, it doesn't become more prominent.
Interviewer: Is it an expert such as yourself that parents and the children should go to? Could a general practitioner provide the brace? What would be the process if a parent recognized their children had pectus carinatum?
Dr. Fenton: If it's recognized, we would ask that, you know, you can go and verify it with a general practitioner, or pediatrician, family practice doctor, etc. Most of them will then refer these children to us because the correction does require thoracic surgical expertise, which is what we do. And when we see the child, we can discuss with them and the parents the different options, and decide whether bracing is the right way to go.
