Neonatal mastitis may occur in both boys and girls, but is more common in the latter, possibly due to the persistence of the physiologic breast hypertrophy in the female. Parents should be questioned as to the presence of constitutional symptoms such as poor feeding, fever, irritability, or gastrointestinal issues. Although limited studies have been conducted, the use of parenteral antibiotics has been shown to offer the best opportunity for resolution without the need for incision and drainage.1,2 Antibiotic therapy should be directed toward common skin pathogens and enterococci until a definitive causative agent can be identified.3 “Witch’s Milk” is the common name for the clear secretion often noted at the neonatal breast and does not represent infection in the absence of any of the abnormalities described above. The expulsion of this liquid typically resolves after the first few weeks of life without incident.
As the child transitions from newborn to infant, labial adhesions are among the most frequent gynecologic irregularities found in my experience during a routine visit. Their exact incidence is not well known. Most are not of concern to the caretaker as they are generally first noted by the examiner and then shown to the parent. The adhesion may be quite small and transparent or more extensive, with some interference to the urinary stream. Not all lesions need to be treated, but pharmacologic therapy is effective, with few side effects. Topical estrogen cream applied sparingly for at least 2 weeks generally resolves these adhesions. After initial treatment, the application of an ointment, such as petroleum jelly, will prevent a recurrence. If the estrogen cream is applied too generously, breast buds may develop. These resolve when the application of the cream is halted, or when proper technique is employed by applying a minimal amount of the cream directly on the affected tissue. Once resolution has occurred, parents should be instructed to examine the area during diaper changes to detect a recurrence; treatment can then be reinstituted. Although mainly detected in infants and toddlers, adhesions can occur in older prepubertal girls. Therefore, a complete visual inspection of the genitalia is essential at the routine physical examination.
In my experience, prepubertal vulvovaginitis is perhaps the most common gynecologic complaint for which parents seek medical attention. Although most cases of vulvovaginitis are noninfectious and resolve with minimal intervention, it can be quite unsettling and worrisome for caretakers. Etiologies such as local irritation, trauma, foreign body, or improper hygiene are among the more common causes.6 The lack of estrogenization of the prepubertal tissues predisposes this area to injury from these factors. Despite parental concerns regarding infection, antibiotics are rarely indicated because specific care directives will quite likely resolve the discomfort.
As alluded to earlier, most vulvovaginitis in prepubertal girls is of noninfectious origin. Local irritation or trauma is generally caused by constrictive clothing, overuse of bath products, or masturbation.7 Leotards, exercise clothing, tights, wet bathing suits, or layering of undergarments should be avoided or minimized. Parents and caregivers should be encouraged to get children in and out of these types of clothing immediately after related activities when possible. Bathing should be accomplished daily with minimal use of products, and if possible only warm water. Prolonged contact of any product with the genital area should be strictly avoided. Drying the area should be done by gently patting. Bedtime wear should consist of a gown or large tee shirt preferably worn without underwear to promote aeration and prevent friction during sleep. Masturbatory activity that causes irritation or trauma should be addressed in a sensitive and nonjudgmental fashion. A standard emollient, such as petroleum jelly or vitamins A and D ointment, can help relieve the discomfort of local irritation or self-stimulation.
Significant vulvar trauma that involves bleeding or does not correlate with the medical history should be addressed by someone skilled in the gynecologic examination of young children. Straddle injuries from bicycles or playground equipment more often result in trauma to the labial areas; however, injuries to the posterior hymenal area or posterior fourchette may be due to sexual abuse. However, not all sexually abused children show abnormalities upon physical examination. The office clinician should determine the need for further intervention by a surgical specialist by assessing hemostasis, pain control, and the ability to urinate. Adherence to proper protocols for further examination and reporting in suspected cases of abuse is essential.
The presence of a foreign body should be considered in a prepubertal girl whose vulvar complaints do not resolve with the above-mentioned interventions, or when vaginal bleeding is present in the absence of trauma. The most common foreign body is toilet paper and may cause discomfort, dysuria, or malodorous discharge. If noted on examination, the toilet paper may be removed with a swab in a cooperative child. However, general anesthesia may be warranted in a patient that is anxious, fearful, or when another larger foreign body is suspected.
Improper hygiene is another common cause of prepubertal vulvovaginitis. Independent toileting is a much desired goal of parents for their young children; however, the pursuit of this often results in less than optimal hygiene. Parental reminders after toileting that include thorough but gentle front to back wiping, are quite helpful but not always feasible. Daycare centers and busy family life do not always afford caretakers the opportunity to supervise each and every trip taken to the restroom. Nighttime bathing and appropriate sleepwear will go a long way toward correcting daytime mishaps.
Infectious vulvovaginitis is a much less common entity than its noninfectious counterpart. It is usually diagnosed when a purulent discharge is present or other attempts to resolve the problem are ineffective. The vast majority of prepubertal girls who no longer wear diapers do not get yeast infections, despite this being named as an etiology by a parent or health care provider. The unestrogenized vulva is not a favorable environment for the growth of yeast, although occasional cells may be found on a routine urinalysis. These likely represent skin flora and should not be used as a basis for antifungal treatment. In my experience, pinworms, which are common in preschools and daycare centers, are notorious for causing vaginitis associated with nocturnal itching. Careful questioning regarding nighttime awakenings can be a strong indicator of this condition. The in-office tape test, in which a tongue depressor covered with double stick tape is gently touched to the rectum and examined under a microscope for the presence of eggs, can provide a rapid diagnosis. The patient can then be treated with appropriate antihelmintic therapy. Recurrences are common within daycare centers and among family members so completion of all prescribed medication is vital. Treating all family members of the index case as well as keeping the child’s nails well-trimmed can also prevent reinfection. Other agents implicated in infectious vulvovaginitis are Streptococcus pyogenes, Gardnerella vaginalis, and some viruses. S. pyogenes can cause rectal itching and a red rash around the anus, as well as a purulent vaginal discharge. These symptoms readily respond to a course of amoxicillin. Although G. vaginalis was once thought to be only sexually transmitted, some studies have shown that not to be the case.8 In girls who are not suspected to be the victim of sexual abuse, empiric antibiotic treatment with amoxicillin or metronidizole may offer resolution of the symptoms.