Can aphthous ulcers occur in an 11-month-old infant?

Can Aphthous Ulcers Occur in an 11-Month-Old Infant?

Yes, aphthous ulcers can occur in infants as young as 11 months of age, though they are uncommon in this age group and require careful evaluation to exclude other causes of oral ulceration.

Age-Specific Considerations

• Neonatal aphthous ulcers (Bednar's aphthae) are well-documented in infants from 2 days up to 6 weeks of age, presenting as spontaneously regressing, shallow, symmetrical ulcers on the posterior palate 1

• Aphthous ulcers are among the most common oral mucosal lesions in the general population, but their occurrence in very young infants (under 12 months) is less typical than in older children and adults 2, 3

• In children and adolescents, aphthous stomatitis, infections, and trauma are the most frequent causes of oral ulcerations, making differential diagnosis critical in this age group 4

Critical Differential Diagnoses to Exclude First

Before diagnosing aphthous ulcers in an 11-month-old, you must systematically rule out more common and potentially serious causes:

Infectious Causes (Most Common in Infants)

• Herpes simplex virus is the most common cause of genital and oral ulcers in the United States and should be excluded with HSV culture or PCR testing 5
• Perform serologic testing for syphilis in all patients with ulcers, as recommended by the American Academy of Pediatrics, even though sexually transmitted infections are less likely in this age group 5
• Viral infections, bacterial infections (including acute necrotizing ulcerative gingivitis), and deep fungal infections can all present with oral ulceration 3

Traumatic Causes

• Trauma is one of the three most frequent causes of oral ulcerations in children and should be considered, especially given the developmental stage of an 11-month-old who may be teething or exploring objects orally 4

Inflammatory Bowel Disease

• Aphthous ulceration can be seen in Crohn's disease, with features including "cobblestoning" and aphthous ulceration in the gastrointestinal tract 6
• Children with inflammatory bowel disease may present with oral ulcers as an extraintestinal manifestation, though this is more common in older children 6, 7

Systemic Syndromes

• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenopathy) is a rare childhood disease characterized by abrupt onset of periodic episodes of high fever accompanied by aphthous stomatitis 2
• This syndrome requires systematic oral follow-up to monitor for signs of ulceration and typically presents with recurrent episodes 2

Diagnostic Approach

When evaluating an 11-month-old with oral ulceration:

• Determine if the ulcers are acute (abrupt onset, short duration), recurrent (at least 4 times per year), or chronic (slow onset, insidious progression) 3
• Assess for fever, systemic symptoms, and extraoral manifestations to identify potential systemic diseases 2, 4
• Examine the distribution and characteristics of the lesions: minor aphthous ulcers are typically small and painful, while major aphthous ulcers are larger and may scar 3
• Consider the patient's general condition, comorbidities, and any recent medications as determining factors 4

Common Pitfalls to Avoid

• Do not assume all oral ulcers in infants are benign aphthous ulcers without excluding infectious causes, particularly HSV, which requires specific antiviral treatment 5
• Up to 25% of genital and oral ulcers have no identifiable pathogen even after complete testing, making clinical diagnosis essential, but testing should still be performed first 5
• Failing to recognize PFAPA syndrome due to its periodic nature may lead to delayed diagnosis and unnecessary investigations 2
• Every chronic solitary oral ulcer should be biopsied to rule out malignancy, though this is exceedingly rare in infants 3

Management Considerations

• If true aphthous ulcers are diagnosed after excluding other causes, treatment is palliative and symptomatic 3
• Topical treatments (topical anesthetics, topical steroids, and sucralfate) are first-line therapy for confirmed aphthous ulcers 3
• Bednar's aphthae in young infants typically heal spontaneously within one week and may only require supportive care such as nasogastric feeding to avoid irritation 1
• Recurrent aphthous stomatitis (RAS) is defined by recurrence at least 4 times per year and warrants investigation for underlying conditions including celiac disease, nutritional deficiencies, or immune disorders 3