THE CASE: Child Protective Services (CPS) has asked you to evaluate a 6-month-old girl with a genital mass. The goal is to determine whether the "weird lump in the baby's private area"--noted while the child's diapers were being changed in day care--was the result of sexual abuse.
The baby's 18-year-old mother brings her to your office. The child is happy and in no distress. She interacts playfully with her mother and is developmentally appropriate. Her mother provides immunization records from the health department and from the urgent care clinic where she has taken her daughter for well-checks and for 2 visits for ear infections. The mother seems appropriately concerned and is able and willing to provide a detailed social history. She, her boyfriend (the baby's father), and the baby had all been staying with her mother (the maternal grandmother) since the patient's birth. The patient's father and grandmother did not get along well; he had moved out 3 weeks earlier, although he was still in contact with them. The mother had to return to work, and the baby had just started day care.
The mother admits that her boyfriend "has a temper," but he has never been violent or sexually aggressive. They have been dating for 3 years and have been "best friends" since childhood. The mother says she has never been sexually abused by her boyfriend and is unaware whether her boyfriend had been subject to sexual abuse. She doubts he would have ever done anything to harm their daughter.
The patient is well nourished (40th percentile for height, 60th percentile for weight). The skin is clear of bruises and marks. The baby moves all extremities with ease, and grabs for the stethoscope when being examined.
The genital examination is performed with the patient in her mother's lap. Gentle traction of the labia majora reveals a circumscribed mass lateral and superior to the right labia minora and clitoral hood (Figure 1). The mass is mildly compressible and rubbery. It is slightly warmer than the surrounding tissue. There is no edema surrounding the area. The remainder of the genitoanal exam is entirely normal.
You are not sure what this mass represents, but you have not seen it previously as a manifestation of sexual abuse. A call to the child abuse specialists in a nearby medical center confirms that such masses are not usually associated with abuse, and after some brainstorming, the possibility of a congenital vascular lesion comes up. You go back and question the mother who says that nothing like this was noted at birth. When the baby had a mild febrile illness at 2 months of age, however, the mother thought the area looked "different": she forgot to point this out at the clinic.
You obtain photos of the area and send them to a pediatric gynecologist. The physician thinks the mass is an infantile hemangioma and confirms this when the child is brought to her office for a visit. You agree to see the baby for monthly follow-up examinations.
The child's home environment is investigated, and a social worker refers the mother to appropriate agencies. Couples and family counseling is offered.
Over the next few months, the lesion grows slightly, but the child remains asymptomatic. The diagnosis of infantile hemangioma appears to be accurate. The child will be observed and photographs will be taken of the mass only at well-child checkups.
At the child's 2-year examination, the mass is no longer grossly visible and is barely palpable. At the 3-year examination, the lesion has resolved without sequelae.
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