Where to refer an infant with an anal tag?

Referral for an Infant with an Anal Tag

An infant with an anal tag should be referred to a pediatric surgeon for evaluation and management. 1

Understanding Anal Tags in Infants

Anal tags (also called skin tags) are common benign anorectal findings in the pediatric population. They are often associated with:

• Anal fissures (in 58.8% of cases) 2
• Constipation
• Rarely, food protein-induced allergic proctocolitis 3

Most anal tags in children are located at the median line and are typically related to underlying conditions like constipation 2.

Rationale for Pediatric Surgical Referral

The American Academy of Pediatrics guidelines specifically recommend that infants with congenital malformations should be referred to appropriate pediatric surgical specialists 1. While anal tags themselves are often benign, they require:

1. Proper evaluation to rule out underlying conditions
2. Assessment of whether intervention is needed
3. Specialized pediatric surgical expertise if removal is indicated

Evaluation Process

When referring to a pediatric surgeon, the primary care physician should:

• Document the duration of the condition
• Provide specific reason for referral (evaluation, possible surgery)
• Include relevant history such as bowel habits, presence of pain, bleeding, or other symptoms 1
• Note any associated conditions that might require concomitant management

Management Considerations

The pediatric surgeon will determine the appropriate course of action:

• Conservative management: Most anal tags in infants may be observed if asymptomatic

• Medical management: If associated with fissures, treatment may include:

  • Increased fiber and fluid intake
  • Stool softeners
  • Topical treatments if indicated 4

• Surgical removal: Only considered if the tag:

  • Causes persistent symptoms
  • Creates hygiene issues
  • Shows signs of inflammation or bleeding
  • Is associated with other conditions requiring intervention

Important Caveats

1. Differential diagnosis: The surgeon will need to distinguish between:

   • Simple anal tag
   • Sentinel tag associated with anal fissure
   • Other perianal lesions requiring different management

2. Examination technique: Digital rectal examination should be performed carefully, and in some cases, may be done after imaging to prevent injury if there's concern for other conditions 1

3. Avoid unnecessary procedures: Manual anal dilatation is strongly discouraged in pediatric patients 4

4. Consider non-surgical approaches first: Surgical intervention should be reserved for cases that don't respond to conservative management or have specific indications for removal

By referring an infant with an anal tag to a pediatric surgeon, you ensure proper evaluation, appropriate management decisions, and specialized care if intervention is needed.