Referral Destination for Pectus Excavatum in a 9-Year-Old

A 9-year-old child with pectus excavatum should be referred to a pediatric surgeon for evaluation and management. 1, 2

Primary Referral Pathway

Pediatric surgeon is the appropriate specialist for pectus excavatum in this age group, as this condition falls under the scope of pediatric general surgery 1, 2
The American Academy of Pediatrics guidelines specify that patients 5 years or younger requiring surgical care must be managed by a pediatric surgeon, and while this patient is older, the complexity of chest wall reconstruction warrants pediatric surgical expertise 1, 2
A pediatric surgeon has completed 5 years of general surgery residency plus 2 years of pediatric surgery fellowship and is certified by the American Board of Surgery 1, 3

Pediatric plastic surgeons are indicated for craniofacial malformations, limb deformities, and soft tissue reconstruction, but pectus excavatum is a thoracic cage deformity requiring expertise in chest wall surgery 1, 4
Pediatric cardiothoracic surgeons focus on congenital heart disease and cardiac surgery, not primary chest wall deformities 1
While some pediatric plastic surgeons may have experience with chest wall reconstruction, the primary expertise for pectus excavatum resides with pediatric surgeons who routinely perform these procedures 1

Concurrent referral to pediatric cardiology is recommended because pectus excavatum patients have significantly higher rates of mitral insufficiency, mitral valve prolapse, tricuspid valve prolapse, cardiac malposition, and congenital heart disease compared to healthy children 5
Cardiac evaluation should occur before surgical planning, as cardiac anomalies may influence operative risk and timing 5
All pectus excavatum patients demonstrate marked cardiac deviation into the left chest on imaging 6

The ideal age for surgical repair is 4-6 years, which allows emotional maturity for a positive hospital experience while avoiding later psychological effects 7
At age 9, this patient is still within an appropriate window for repair, as surgery should ideally be completed before the pubertal growth spurt to allow reversibility of any cardiopulmonary dysfunction 7
Repair in childhood relieves structural compression, allows normal thoracic growth, prevents progressive pulmonary and cardiac dysfunction, and addresses cosmetic concerns that may cause avoidance of sports 7

The pediatric surgeon will obtain imaging (typically CT scan) to calculate the Haller index (chest width divided by distance from posterior sternum to anterior spine) 8, 6
A Haller index >3.2 indicates moderate to severe pectus excavatum and is typically required for insurance authorization of surgical correction 8
Normal chest Haller index is approximately 2.56, while pectus excavatum patients average 4.65 6

Surgical repair achieves excellent long-term results in 95% of patients with only 5% experiencing mild to moderate recurrence 7
Patients with preoperative respiratory symptoms (frequent infections, exercise intolerance, chest pain, asthma) experience improvement after repair 6
Vital capacity increases an average of 11% within 9 months post-operatively 6
Mean hospital stay is approximately 3 days with modern techniques 6

If a pediatric surgeon is not locally available, the primary care physician should contact a pediatric surgeon at a regional pediatric surgical center to discuss whether consultation is necessary 1
Families should weigh the advantages of traveling to a center with pediatric surgical expertise, as outcomes are significantly better when children are operated on by surgeons who preferentially treat pediatric patients 1, 2