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Structural Anomalies in Children
Essentials
- None of the structural anomalies listed below requires systematic screening in primary (with the exception of malpositions of the foot).
- Most of the anomalies are age-related normal variations associated with the growth and development of a child. The child does not complain of any symptoms, and the anomalies usually are irrelevant as regards the child's health in adulthood.
Structural anomalies of the extremities
- Metatarsus adductus is characterised by internal rotation of the forefoot, and it causes an inverted curvature of the medial side of the forefoot.
- A cast, plaster or surgery may sometimes be needed.
- Flat footPainful Conditions of the Ankle and Foot in Children and Adolescents is an innocent finding if the forefoot can be freely mobilised into inversion and eversion, and the valgus angle of the heel disappears when the child stands on his/her toes.
- There is no causal relationship between the shape of the foot and ”growing pains” experienced at rest.
- A flat foot is likely to be pathological if it is unilateral, rigid or painful when manipulated or when weight bearing.
- In-toeing and out-toeing gait (feet rotated externally or internally) is a normal condition that does not need treatment. The condition is usually attributable to the age-related change in the position of the hip joint.
- Genu varum (bow legs) is a normal condition in all infants and also in most toddlers.
- Genu varum is an indication for specialist consultation if the condition is asymmetrical or becomes worse after the second year of life.
- Symmetric genu valgum (knock-knees) is a normal age-related condition and is usually most evident around the age of 3 years.
- Unilateral or significant (malleolar gap more than 10 cm) genu valgum is an indication for specialist consultation as is genu valgum that continues to progress at school age.
- Overlapping toes are caused by an overtight flexor tendon in the toe lying underneath. The condition causes no functional impairment.
- Surgical correction (excision of the tendon) is only indicated for aesthetic reasons.
- Syndactyly (webbing) of the fingers should be evaluated by a paediatric surgeon or hand surgeon in infancy. In most cases surgery is indicated and its timing is decided case by case. Usually, surgical treatment is performed, the latest, at preschool age.
- Surgical correction of syndactyly of the toes is only indicated for aesthetic reasons.
Anomalies of the trunk
- Phimosis is normal in boys before puberty.
- Obstructing balanitis (balanitis xerotica obliterans; pictures1 2) is the only absolute indication for circumcision.
- Relative indications for circumcision include recurrent purulent balanitis and paraphimosis (the foreskin becomes trapped behind the glans). Bulging of the foreskin during urination alone is not an indication for surgery.
- Acute balanitis Posthitis (Balanoposthitis) in a Child is treated by bathing the area and applying an antibiotic eye ointment under the foreskin.
- An umbilical hernia Hernias in Children disappears in most children spontaneously during the first years of life and does not require surgical repair.
- All children aged 4 years or over with an umbilical hernia should be referred to a paediatric surgeon for an evaluation of the need for surgery.
- An inguinal hernia is always an indication for referral.
- The parents should be told that a bulging hernia in itself is not dangerous. The parents should also be instructed how to reduce the hernia and advised to consult their doctor if the hernia cannot be reduced and the child remains in obvious discomfort.
- An inguinal hernia in a child less than 6 months of age becomes easily incarcerated, and it should be operated on within a few weeks.
- A hydrocoele need not be operated on before the age of 4 years. In younger children it can be monitored in primary care Enlarged Scrotum or Palpable Mass in Scrotum. A hydrocoele that is painful or of considerable size or that appears after early childhood is operated on earlier, as necessary.
- Pigmented spots are usually harmless (picture 3).
- A haemangioma (infantile) is small at birth and typically increases in size during the first 6 months of life. Most haemangiomas disappear spontaneously by the school age (picture 4).
- The size of a complicated haemangioma with ulceration or in a cosmetically central area can be reduced with propranolol Propranolol for Infantile Hemangiomas. The treatment and follow-up take place in specialized care. Typically pharmacotherapy is started at the age of a few months and it is continued until the age of 12 months.
- Infant torticollis (a "pseudotumour" of the sternocleidomastoid muscle) can be treated with positional and physical therapy.
- If the muscle remains contracted, surgery may be indicated at the age of 12 months.
- Pectus carinatum (pigeon chest) is not an indication for surgery. Severe pectus excavatum (funnel chest) may require surgical correction because of cosmetic problem.
- A shortened frenulum of the tongue does not require surgery unless it prevents the normal movement of the tongue. In infancy, a short frenulum may interfere with the baby's ability to latch and suckle at the breast. In preschool age or thereafter, cutting the frenulum may be indicated due to speech sound errors.
- Cutting the membrane-like frenulum of a newborn infant is possibly to perform without anaesthesia soon after birth. When performed at a later stage, it is usually done by an ENT specialist under general anaesthesia.
Abnormal head shape
- Different types of aberrations in the shape of the head are common. The majority of them are mild and only a small share requires treatment.
- Continuous growth of the head is more important than following a specific curve. If the growth stops for a prolonged time and there is a drop in the growth curve, a referral to further investigations is warranted.
- Fontanelle size has no practical meaning as long as the child is healthy. The (anterior) fontanelle size varies greatly and in some children it does not close before the age of 4 years.
- Metopic ridge at the middle of the forehead (picture 7) is a clinically insignificant finding if the head shape is otherwise normal. There is no need for treatment or follow-up. If the forehead is keel-shaped and narrow and clearly looks abnormal, it may be because of the rare trigonocephaly. It is caused by synostosis of the metopic suture and and requires an assessment by a specialist.
- Scaphocephaly is the most common type of craniosynostosis. It is caused by premature closing of the sagittal suture which results in a long head form. The head shape varies depending on the location and length of the synostosis in the suture, but typical features are usually clearly visible right after birth. The child should be referred to specialized care for an assessment already during the first months of life, since surgical therapy is usually performed at 4-6 months of age. See picture 8.
- Skull asymmetry is usually most marked in the occipital area and it is corrected as the child grows (deformational posterior plagiocephaly; picture 8). If a child's skull is mildly asymmetric, his/her growth and development should be monitored in a child health clinic until about the age of one year. If the form of the skull begins to normalize and the child has no neurological or other abnormal findings, there is no indication for a referral.