Growth and development: In 
pediatrics, everything starts small

In pediatrics, everything starts small.


Babies begin as a zygote, which then divides and subdivides to form the blastocyst. Undifferentiated cells migrate and differentiate into tissues and organs. The organism grows from embryo to fetus. In parturition, the fetus emerges as a neonate.


Infants continue to grow and develop rapidly over the first 2 years of life. By 1 year of age, the previously helpless baby has been transformed into a busy toddler, able to walk on her own and feed herself. By 2 years of age, language has blossomed from holophrastic speech into simple two- and three-word sentences. Gradually, these rudimentary utterances morph into more intricate expressions.


In pediatrics, things start small, then grow and develop.


Like all things in pediatrics, the lesion that appeared on this child's calf had started small as well.


Her mother brought it to my attention at the 9-month well child visit. Small, round, and dark, it had spontaneously appeared on her right lower leg.


"Anybody in the family have freckles or moles?" I asked the mother.


"My husband has a lot," she said. "So does my oldest son—her brother."


I ran the pad of my index finger over the lesion. "At this point it looks okay," I told her. "We'll keep an eye on it."


By her 1-year check up, the lesion had increased in size, taking on a pinkish hue, now a tiny dome on the skin surface. With the exception of a small hemangioma on her left chest, she exhibited no other lesions on the skin.


"It has gotten a bit bigger," I mused, reading the measuring tape. "I think we should ask one of the skin doctors to have a look at it."


I gave the mother the name of a pediatric dermatologist and asked her to call for an appointment.


At the 15-month mark, the mother told me that the skin doctor had seen her daughter and suggested that she consider having the lesion removed. "I didn't want to put my daughter through the trauma of surgery, so we decided to wait. I'll take her back to see the skin doctor in 3 months."


Meantime, I had received a letter from the pediatric dermatologist. The provisional diagnosis was a Spitz nevus. She concurred that the mother had elected to bring the little girl back in 3 months to monitor the development of the lesion.


At 18 months of age, the nevus on the little girl's leg had progressed to 5 mm in diameter. It felt firm, nodular. "What did the skin doctor say?" I asked the mother.


"She thinks it should be removed. I will schedule an appointment with a surgeon that she recommended."


"Good," I said. "The sooner, the better."


After the 18-month well child check, normally we don't see children again until their 2nd birthday. As it turned out, I re-examined the little girl at 22 months of age, when she came in for her pre-op physical.


The surgeon performed an excisional biopsy shortly before her 2nd birthday. Two weeks later, the girl's chart appeared on my desk with the pathology report clipped to the front.


Like everything else in pediatrics, the diagnostic label had grown, from a small insignificant beginning—Spitz nevus—to an expanded description: Spitzoid malignant melanoma.


I reached for the phone to call the surgeon's office, but in the interim he had already placed a call to me.


"Did you get the faxed path report?" he asked.


"Yes, I just finished reading through it. Just for confirmation, the final diagnosis...."


"...is melanoma," he said. "I know. I was shocked as well. I sent out the specimen to New York for a second opinion. They concur with the diagnosis."


"What now?" I asked.


"The only cure for melanoma is wide surgical excision. We have to convince the parents to have this done as soon as possible. The jury's out on the need for a sentinel node biopsy. That would certainly help in the staging—if it has spread. But the margins were clear on the original biopsy. I've spoken to the parents; they seem reticent to proceed. I was wondering if..."


"I'd be happy to speak to them," I said. "I know the mother well."


Understandably, she was still in shock. "I don't want her to have more surgery if the diagnosis is doubtful," she told me. "My daughter didn't do well with the anesthesia."


"I understand your concerns," I said. "If this isn't melanoma, we will have put your daughter through an additional surgery for naught."


"And if it is?"


"There's a good chance we will have saved her life."


In pediatrics, all things start small. Some things grow more quickly than others, and sometimes we have the chance to weed the garden before it's too late.


In the end the parents agreed to have the follow-up surgery done. The wound margins were devoid of malignant cells.


Although she now carries a sizeable scar on her leg, the little girl continues to grow. Like most healthy children, she has an excellent chance of celebrating her next birthday. JAAPA