Pediatric Annals

Healthy Baby/Healthy Child 

Neonatal and Prepubertal Gynecologic Concerns

Teri A. Merens, MD

Abstract

The role of the pediatrician in today’s health care environment is one of constant evolution, as specialty care becomes more difficult to access for a growing number of young patients and their families. The primary care doctor will now have to offer more reassurance and follow-up that was once thought to be solely the role of the subspecialist. This article helps to define commonly seen entities in pediatric gynecology and offers the necessary background enabling the practitioner to provide a simple course of treatment, reassurance, or appropriate referral for specialty care. [Pediatr Ann. 2015;44(10):412,414,416–417.]

Abstract

The role of the pediatrician in today’s health care environment is one of constant evolution, as specialty care becomes more difficult to access for a growing number of young patients and their families. The primary care doctor will now have to offer more reassurance and follow-up that was once thought to be solely the role of the subspecialist. This article helps to define commonly seen entities in pediatric gynecology and offers the necessary background enabling the practitioner to provide a simple course of treatment, reassurance, or appropriate referral for specialty care. [Pediatr Ann. 2015;44(10):412,414,416–417.]

The earliest concerns parents may express regarding the reproductive system is that of breast enlargement in the infant, as well as the appearance of vaginal bleeding. Both can be noted in the immediate postnatal period and breast tissue can be seen in boys and girls. Both entities are the result of the effect of maternal hormones on the developing fetus. A brief explanation to the parents stating such will suffice to calm their fears. Noting that these will resolve without intervention (in most cases) should be mentioned. However, any breast enlargement that shows a reddish hue, is warm to the touch, or is associated with a purulent nipple discharge should be brought to the physician’s attention as an infection may be present.

Newborn Gynecologic Irregularities

Neonatal Mastitis

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.

Vaginal Discharge

Vaginal discharge with or without vaginal bleeding, as previously mentioned, is also the result of stimulation of fetal and neonatal tissues by maternal hormones.4 Estradiol causes the secretion of a thickened white mucous that slowly abates as the hormone level falls. Endometrial sloughing causing a blood-tinged discharge may appear as hormone withdrawal occurs. No treatment is needed for either of these physiologic conditions other than gentle cleansing with routine diaper changes.

Labial Adhesions

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.

Premature Thelarche

Although a benign event in the majority of cases, some toddler girls can progress to full precocious puberty. Toddlers who are overweight and not Caucasian are more likely to exhibit premature thelarche than their peers.5 This most often occurs in the first 2 years of life. Without acceleration of linear growth, an abnormal bone age, or the development of other secondary sexual characteristics further evaluation is not warranted. Premature thelarche can also be noted at ages 6 to 8 years and still only careful follow-up is needed if the aforementioned abnormalities are not present. The usual course of the thelarche is innocent, with most instances resolving or progressing quite slowly until true puberty has begun.

Prepubertal Vulvovaginitis

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.

Sexual Abuse

Sexual abuse should be strongly suspected in cases for which there is injury to the posterior fourchette, appearance of new skin lesions, or when the history is inconsistent with the physical findings. Conversely, the absence of trauma on physical examination does not definitively rule out abuse. Although certain infections are nearly always indicative of sexual abuse, some sexually transmitted diseases can also be congenital, passed from the mother to the infant at birth.9 The complete assessment of a child who has been sexually abused is beyond the scope of this article. However, it must be emphasized that great care must be taken in the evaluation of such and referral to those with the appropriate knowledge and expertise should be done in an expeditious fashion.

Concluding Thoughts

Insight into the physiologic development and normal anatomic variation of the infant and prepubertal genitalia is essential for the office clinician. Familiarity with common maladies affecting these structures will allow the pediatrician to provide reassurance, appropriate treatment, or referral for subspecialty care. The ability of the practitioner to provide sensitive, thoughtful, and knowledgeable care will be a great comfort in the ever-changing environment of today’s health care system.

References

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  2. Turbey WJ, Buntain WL, Dudgeon DL. The surgical management of pediatric breast masses. Pediatrics. 1975;56(5):736–739.
  3. Fortunov RM, Hulten KG, Hammerman WA, Mason EO Jr, Kaplan SL. Community acquired Staphylococcus aureus infections in term and near term previously healthy infants. Pediatrics. 2006;118(3):874–881. doi:10.1542/peds.2006-0884 [CrossRef]
  4. Paradise JE. Vaginal bleeding. In Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  5. Freedman DS, Khan LK, Serdula MK, Ogden CL, Dietz WH. Racial and ethnic differences in secular trends for childhood BMI, weight, and height. Obesity (Silver Spring). 2006;14(2):301–308. doi:10.1038/oby.2006.39 [CrossRef]
  6. Paradise JE, Campos JM, Friedman HM, Frishmuth G. Vulvovaginitis in premenarchal girls: clinical features and diagnostic evaluation. Pediatrics. 1982;70(2):193–198.
  7. Laufer MR, Emans SJ. Vulvovaginal complaints in the prepubertal child. http://www.uptodate.com/contents/vulvovaginal-complaints-in-the-prepubertal-child. Accessed September 24, 2015.
  8. Ingram DL, White ST, Lyna PR, et al. Gardnella vaginalis infection and sexual contact in female children. Child Abuse Negl. 1992;16(6):847–853. doi:10.1016/0145-2134(92)90086-7 [CrossRef]
  9. Atabaki S, Paradise JE. The medical evaluation of the sexually abused child: lessons from a decade of research. Pediatrics. 1999;104:178–186.
Authors

Teri A. Merens, MD, is an Assistant Professor of Clinical Pediatrics, Northwestern University Feinberg School of Medicine; and an Attending Physician, General and Academic Medicine, Lurie Children’s Hospital of Chicago.

Address correspondence to Teri A. Merens, MD, 1950 Dempster Street, Evanston, IL 60202; email: TBMKpeds@gmail.com.

Disclosure: The author has no relevant financial relationships to disclose.

 

10.3928/00904481-20151012-03

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