The study on the prevalence of Mongolian spots in the neonates

ABSTRACT

Background:

Mongolian Spots (MS) generally exist at the time or under the first few weeks of the neonate life-cycle, often considered a birthmark, characterized by hyper-pigmented marks especially bluish-black hue that cannot vanish easily and are generally found on the lumbosacral region. As this MS is reminiscent of bruises and appears to be caused by abuse, this may raise questions about the possibility of abuse. Hence, it is significant to identify MS bruises. The objective of the study was to assess the prevalence of MS in neonates by using the parameters like location, method of delivery, gestational age, and, weight at birth.

Methodology:

500 neonates were enrolled in the study for the evaluation of the prevalence of Mongolian spots. The study design was cross-sectional, observational, and conducted for two and a half years. The neonate’s whole skin surface, including the hand palms, scalps and soles, mucous membranes, genitalia, hair, and nails, was inspected in adequate light. The changes were seen (physiological and pathological) over the skin, so the details were reviewed, analyzed, and documented. Photographic records were kept to document the study. Descriptive statistics were analyzed by t-test and Chi-square test and the inferential statistics were analyzed by proportions and Chi-square test.

Results:

From the 500 neonates, 408 (81.6%) were reported to have Mongolian spots. Based on the site of locations 337 (82.60%) neonates were found with spots maximum on the sacrococcygeal area and rarely on the extremities 4 (0.98%). 221 (54.1%) were found with normal vaginal delivery, and males have more predominance 247 (60%). Based on the gestational age full term was 366 (89.71%), with the birth at a weight of more than 2.5 kg found in 349 (85.54%).

Conclusion:

The study concluded that the maximum number of neonates had been found with Mongolian spots and it is very common among neonates. This study will enlighten the awareness of the physician to distinguish the other lesions from other cutaneous skin conditions. The only drawbacks of this research study are a smaller sample size and limited study duration. The study of diameter, size, and dimensions of spots are not included. More intervention studies are required to compare MS with other skin conditions and their therapies. Further research is required for the study of the dimensions of marks on the neonate’s body.

Introduction

Mongolian Spots (MS) generally exist at the time or under the first few weeks of the neonate life-cycle, are often considered a birthmark, characterized by hyper-pigmented marks especially bluish-black hue that cannot vanish easily, and are generally found on the lumbosacral region. At the beginning of neonate life, these patches are most conspicuous and started disappearing till early childhood. It is previously called dermal melanocytosis and is non-cancerous and not related to the disease.[1,2]

The location of MS is usually found on the backward area, butt, spinal cord base, shoulders, or other different body areas. The colors of MS are found as blue or bluish gray spots, with flat and irregular sizes and dimensions, and obscure circumferences, 2 to 8 centimeters wide or larger. This disease is seen in both genders equally. The prevalence of MS can vary and depends on race and ethnicity, and, is most generally found in Asians race and Africans race, and is hardly seen in Caucasians people.[3,4]

The phenomenon, in which light is dispersed by molecules that come in the path, is the Tyndall phenomenon, and the formation of blue marks is based on it. As the pigmentation has smaller wavelengths and is directed at the body, it resembles various shades of gray (bluish gray, blackish gray).[1] Due to their longer wavelengths, colors like orange, red, and yellow penetrated deeper into the skin. The number and melanin of melanocytes and their deepness in the skin are significant factors for color.[5,6]

Previously, MS has been considered benign and usually fades away with time, but current studies have proposed that it is related to different disorders such as inborn errors of metabolism (IRM) and neurocristopathies. The disorder “neurocristopathy” is characterized by deformities in neural crest location, differentiation, and growth. Because of the common emergence of melanocytes and the central nervous system from the neural crest, they have intact relation, this elucidates the reason for the occurrence of these disorders at the same time and together.[7]

Furthermore, association of MS with lysosomal storage disorders like Niemann-Pick disease, Hurler’s disease, Hunter’s syndrome and mannosidosis as well as non-involuting congenital hemangioma, Sturge-Weber syndrome, cutis marmorata telangiectatica congenita, segmental café-au-laitmacules and Klippel-Trenaunay syndrome. Therefore early detection of these serious disorders related to MS can help medical professionals treat patients with extensive MS.[1]

Moreover, MS is reminiscent of bruises and appears to be caused by abuse, this may raise questions about the possibility of abuse. Hence, it is significant to identify the MS bruises and create a proper ecosystem for children and their guardians for reporting the dermal condition of neonates.[3] As dermal conditions will create psychological stress among the parents and they need medical guidance for such diseases. The objective of the study was to assess the prevalence of Mongolian spots on neonates by using the parameters like the site of Mongolian spots, method of delivery, gestational age, and, weight at birth.[8]

Methodology

This research was carried out only after approval from the Institutional ethics committee (IEC) with reference number DMIMS (DU)/IEC/2014-15/827. The cross-sectional observational study was carried out in association with the Department of Pediatrics and Obstetrics and Gynecology on neonates that were admitted to the neonatal intensive care (NICU) and Post Natal Care unit (PNC) of the hospital for the span of 2 and a half years after receiving written informed consent. The inclusion criteria were depended on neonates under the first four weeks of age, gender, method of delivery, body weight, and gestational period. The critically ill neonates on ventilators support were not considered. The sample size estimation was undertaken from the references that have the least prevalent cutaneous dermatosis which are hypertrichosis desquamation, napkin dermatosis, CMN, etc. are reported to be prevalent to the extent of 0.1%. Considering the same minimal prevalence of cutaneous neonatal dermatosis, the sample size was calculated with 20% relative precision and 95% confidence level. The calculated sample size was neonates. Therefore, neonates were considered by including dropouts. A total of around 500 neonates were included in the study. The guardian’s informed consent was documented. Following consideration of inclusion, and exclusion criteria all newborns were included. In the proforma relevant information about the newborns such as age, weight, sex birth and, mother involving mother’s parity, consanguinity, type of delivery, and maternal illness details at the time of pregnancy was noted and recorded. The neonate’s whole skin surface, including the hand palms, scalps and soles, mucous membranes, genitalia, hair and nails, was inspected in adequate light. The changes were seen (physiological and pathological) over the skin, so the details were reviewed, analyzed, and documented. Photographic records were kept to document the study. Non-invasive tests such as KOH examination and culture of scrapings for fungal infections, pus swabs for Gram staining and bacterial culture, Tzanck smear, and biopsy were performed as necessary.

Descriptive statistics were analyzed by t-test and Chi-square test and the inferential statistics were analyzed by proportions and Chi-square test. The entire data was accessed in Microsoft Excel in 2013 and checked for duplicates and incomplete entries. The data were subjected to statistical analysis using SPSS (22.0, IBM Analytics, New York, U.S.A). A Chi-square test was performed to associate the type of dermatosis with the parameters of age, gender, delivery type, and birth weight. All P values not more than 0.05 was regarded to be statistically significant.

Results

Table 1 showed that the common location of involvement for Mongolian spots was sacrococcygeal region seen in 337 (82.6%) neonates followed by buttocks (11.03%), trunk (3.92%), shoulder (1.47%) and extremities (0.98%).

Table 1.

Allocation of Mongolian spot as per the site of involvement

Site of involvement	Number of neonates with Mongolian spot	Percentage
Sacrococcygeal	337	82.60%
Buttocks	45	11.03%
Trunk	16	3.92%
Shoulder	6	1.47%
Extremities	4	0.98%
Total	408	100.00%

Table 2 and Graph 1a showed that 221 (54.17%) neonates were born of normal vaginal delivery and 187 (45.83%) were born of cesarean section; with non-significant-value (P = 0.25).

Table 2.

Allocation of neonates with Mongolian spot according to Method of Delivery and Gender

Number of neonates with Mongolian spot	Method of Delivery		Gender
	Normal Vaginal Delivery	Caesarean Section	Male	Female
408	221	187	247	161
Percentage	54.17%	45.83%	60.54%	39.46%
P	1.28 P=0.25, NS		9.68 P=0.01, S

Graph 1.

(a) Allocation of neonates with Mongolian spot according to Mode of Delivery. (b) Allocation of neonates with Mongolian spot according to Gender

Similarly, Table 2 and Graph 1b showed that the maximum number of neonates with Mongolian spot were males that is, 247 (60.54%) and 161 (39.46%) were females; with a significant P value (P = 0.001).

Table 3 showed that the maximum number of neonates with Mongolian spot that is, 366 (89.71%) were full term whereas 36 (8.82%) were post-term and six (1.47%) were preterm; with significant P value (P = 0.0001).

Table 3.

Mongolian spot according to Gestational Age and Birth Weight

Number of neonates with Mongolian Spot	Gestational Age			Birth Weight (kg)
	Pre-term	Term	Post-term	≥2.5 kg	<2.5 kg
408	6	366	36	349	59
Percentage	1.47%	89.71%	8.82%	85.54%	14.46%
P	218.20 P=0.0001, S			103.70, P=0.0001, S

Discussion

Among the 500 neonates, Mongolian spot was the major dermatosis detected in 408 neonates (81.6%) which was more or less similar to the findings of 45% and 50.74% observed by Jain N et al. and Zagne et al. respectively.[9,10] The incidence of Mongolian spots was less that is, 13.2% compared to a study conducted by Gorur DK et al.[11] the incidence was highest that is, 93.5%. This variation could be due to marked racial differences in the prevalence of Mongolian spots. The maximum number of Mongolian spots occurred on the sacrococcygeal area and buttocks and rarely on other sites including the shoulders, back area, and extremities which were also noted by Jain N et al.[9] The appearance of this spots was bluish green color in maximum neonates. The Mongolian spots were found as bluish in color as they were secondary to the Tyndall effect.[1]

Additionally, no relation between Mongolian spot and mode of delivery was found which was almost identical to a study by Sachdeva et al.[12] In the present study number of males with Mongolian spots was more, with a significant value (P = 0.01). But Sadeghzadeh et al. and Gokdemir et al. reported that it was not substantially related to gender. The reason for male predominance might be due to more number of male newborns in the present study.[13,14] Moreover, Mongolian spot was found most commonly in term babies, with a significant P value (P = 0.0001). It also showed that most of the neonates with Mongolian spots were of normal birth weight (≥2.5 kg), with a significant P value (P = 0.0001). It was reported by Basnet S et al. that in early pregnancy, melanocytes are found in the embryo’s dermis, and they wander into the epidermis between 11 and 14 weeks. After the 20^th week, melanocytes do not appear in the dermis. The shifting of melanocytes to the epidermis and their clearance by macrophages was responsible for this. Mongolian spots are caused by the failure of these mechanisms.[15]

There have been cases of MS (a pigmented birthmark) coexisting with vascular birthmarks. Phakomatosis pigmento vascularis (PPV) is characterized by extensive, tenacious, and atypicalnevus flammeus and pigmentary abnormalities.[3] MS hemangiomas, Sturge-Weber syndromes, Klippel-Trenaunay syndromes, cutis marmorata telangiectasia congenita, and café-au-lait macules are also associated with MS.[7] In Medico-legal documentation of MS is important, since they can occasionally be confused with bruises mainly if they are found at atypical locations. The result is an untrue detection of child abuse or battered child syndrome. As a result of features such as being painless, remaining unchanged or not progressing with time, and taking a considerable time to vanish, based on, MS can be differentiated from a bruise.[8]

A co-relation between generalized MS and numerous disorders of storage can be found simultaneously and was first identified by Weissbluth. The major common lysosomal storage disorder related to MS is Hurler’s disease, Niemann-Pick disease, GM1 gangliosidosis, mucolipidosismucopolysaccharidosistypeII (Hunter’s syndrome), and mannosidosis.[16] Broad distribution of lesions in MS in inborn errors of metabolism involving the dorsal, ventral trunk, sacreal area, and extremities. There are chances of progression of the lesion and becoming more resolute with time. In comparison to usual MS, pigmentation is darker and deeper.[5]

Prevalence of MS varies among races as it has been seen that these spots are more common in Asian than in Caucasian neonates, and are a good example of inter-racial differences.[9] Frequency of these bluish green spots was more in the sacrococcygeal area and buttocks. Although there is no substantial relation between the gender of the patient and the occurrence of MS, in the present study male predominance in having MS was seen which may be due to more number of male newborns. Preponderance of MS in full-term babies and those having normal weight was more than in pre-term and underweight or overweight neonates. Such parameters and characteristics of MS as well as its association with various disorders indicate that there is a need for more extensive research for identifying its association with more such disorders as well as comparing MS with other skin conditions. This will help physicians not only identify but also treat various underlying disorders of newborns.

Conclusion

The study concluded that the maximum number of neonates have been identified with Mongolian spots and common skin conditions. Mongolian spots are now differentiated from benign congenital birthmarks. The identification of such comprehensive MS can assist a physician in diagnosing and early recognition of the serious disorder and hence can lead to appropriate palliative care such as stem cell transplantation or enzyme replacement therapy and prevent further complications. This study will enlighten the awareness among the physician to distinguish the spots from other cutaneous skin conditions. The only drawbacks of this research study are a smaller sample size and limited study duration. The study about the diameter, size, and dimensions of spots is not included. More intervention studies are required to compare MS with other skin conditions and their therapies. Further research is required for the study of the dimensions of marks on the neonate’s body.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.