to the patient and booking the anal dilatations under anesthesia once a week. The doctors do that to calm the anxiety of the parents. Under anesthesia, the patient does not complain, and as a consequence, the doctors tend to over-dilate the anus, producing injuries to the suture line. In the following days, the anus is not dilated; the inju­ries tend to heal, producing fi brosis. This is fol­lowed by another traumatic dilatation every week, with more fi brosis. In those cases, we see patients coming to our clinic with severe fi brosis that is impossible to dilate. Because of that, we are very strict about our protocol. In the clinic 2 weeks after surgery, we show the parents how to dilate the anus and we passed a dilator that the baby does not even feel. It is usually a no. 6 or no. 8 Hegar. We do that in order for the mother to gain confi dence performing dilatations. We show the father how to hold the baby with the knees against the chest, to really immobilize him/her in order to avoid showing the mother a “moving tar­get,” which would make the mother more anx­ious. With the baby completely immobilized, the mother passes the dilator well lubricated, leaves the dilator in place for 30 s, and repeats the maneuver twice in the morning and twice at night. We encourage the mother to do the dilata­tion before meals, to avoid the possibility of vomiting and aspiration. We specifi cally tell the parents to increase the size of the dilator by one size per week (1 mm per week) and continue increasing the size until they reach the size that is adequate for the age of the patient. Based on our previous experience, we believe that a normal anal size for a full-term newborn is a no. 12 Hegar dilator, for a 4-month-old baby a no. 13, for an 8-month-old baby a no. 14, and for 1-year­old baby a no. 15 Hegar. Older than that, usually we recommend to go up to no. 16 Hegar dilator (Fig.

which translates in constipation. The constipa­tion is more severe in patients with lower defects (recto-perineal fi stula, rectovestibular fi stula, and imperforate anus with no fi stula); these patients suffer from more constipation than patients with recto-bladder neck fi stulas. We do not know the reason for that. It is important to remember and to be more proactive and aggressive in preventing and managing the constipation of those patients that are at higher risk. When the patients have been with a colostomy, for long periods of time particularly if it is a transverse colostomy, with­out repair of the malformation, they come to us with a severe megarectum and sometimes fecally impacted, they suffer from more severe constipa­tion, and it is important to anticipate that to avoid aggravation of the problem.