Abstract
A 21-month-old male presented with a suction blister on his thumb caused by the thumb being caught in a pacifier overnight. This rare presentation highlights the need for careful monitoring of pacifier use in young children to prevent similar injuries and underscores the importance of considering uncommon causes in the differential diagnosis of blisters.
Educational objectives
Recognize uncommon causes of pediatric blisters, including pacifier-induced suction blisters, and incorporate these into the differential diagnosis when assessing similar presentations.
Understand the importance of educating caregivers about the potential risks associated with pacifier use and implement appropriate anticipatory guidance to prevent pacifier-related injuries in young children.
Introduction
Blisters in children are often caused by impetigo, herpes-zoster, burns and scalds, sunburn, friction, contact dermatitis, bug bites, and thumb-sucking. One of the most common causes of blisters is friction. Friction blisters occur when the epidermis is injured by shearing forces and most commonly are found on the feet and toes as a result of friction from shoes during walking or running. Friction blisters are uncommon on the fingertips of children. 1 These blisters typically present with tense vesicles or bullae, a history of rubbing at the site, and minimal or absent pruritus. Suction blisters are a type of friction blister that form when constant negative pressure is applied to a specific area of the skin for a prolonged period. The pressure causes hemidesmosomes to detach from the basement membrane, separating the dermis and epidermis, allowing fluid to accumulate. In young children, suction blisters due to pacifiers can occur on the mouth and lips. Suction blisters are not to be confused with sucking blisters, which appear as unilateral or bilateral vesicles or bullae on the distal extremities due to the neonatal sucking reflex in utero. 2 While suction blisters from finger sucking are reported, there are no published reports of suction blisters on the fingers caused by pacifiers. Monitoring the use of pacifiers is essential to avoid such injuries. The aim of our case report is to review the clinical presentation of digit blisters in pediatric populations and emphasize uncommon pacifier injury to include in the differential diagnosis.
Case description
The patient was a 21-month-old male with no significant past medical history. Father provided history. The patient woke in the crib with irritable crying. Upon inspection by parents, the pacifier was found suctioned over the left thumb. Parents removed the pacifier and noted that the skin on the thumb from the proximal interphalangeal (PIP) joint was circumferentially pale, extending to the distal thumb. The volar thumb pad had an intact, oval bulla with clear fluid consistent with a friction blister. Upon removal of the pacifier, return of perfusion resulted in the skin surrounding the bulla changing from pallor to erythema (Figure 1). Due to perceived pain, the patient was treated with ibuprofen and transported to the clinic.
(a) Thumb bulla: palmar (left), dorsal (middle), and lateral (right) views. (b) Pacifier that caused the injury that led to suction blister. (c) Multiple angles of stock pacifier. (d) Comparison of sucking blister (left) and suction blister (right) generated by Craiyon using published image. 2
During the interview, the father reported that the patient had gone to bed with a pacifier and woke up the next morning with a blister on his left thumb. The thumb had been caught in the pacifier overnight, leading to a suction blister. On physical examination, a bulla was located on the distal thumb. It was intact, filled with clear fluid, and ~8 mm in diameter. The surrounding skin was erythematous from the PIP to the end of the thumb without edema or associated warmth. The nail plate appeared smooth without pits, grooves, or bruising. There was no sign of infection or other complications. The child was otherwise healthy and exhibited no other symptoms. The pacifier is one-piece silicone polypropylene, measuring at 1.5 inches in height (3.8 cm) × 2.25 inches in width (5.7 cm) × 2 inches in diameter (5 cm; Figure 1).
Management and outcome
The blister was managed conservatively. The parents were advised to keep the area clean with soap and water and to avoid puncturing the blister to prevent infection. Anticipatory guidance on how to care for the blister once broken was discussed. Parents were instructed to let the open blister drain and leave the superficial skin flap in place. The parents decided to discontinue pacifier use. The digit was examined at routine follow-up 3 months later with complete resolution without residual scarring or pigment change. No occurrence has occurred over 1 year after initial presentation.
Discussion
Pacifiers are nearly ubiquitous among children in the United States, and although safety regulations exist, the responsibility to choose and maintain a safe pacifier generally falls on the caregivers, many of whom are unaware of potential hazards. Pacifiers, while useful for soothing young children, can cause injuries such as suction blisters. Suction blisters result from sustained negative pressure applied to the skin. To our knowledge, this is the first case report of a suction blister caused by pacifier use. This case underscores the importance of parental vigilance when using pacifiers. Educating parents about the potential risks and providing recommendations for pacifiers can prevent similar incidents.
One study used retrospective analysis to report data from the National Electronic Injury Surveillance System for children <3 years of age treated in emergency departments (1991–2010) for injury associated with a bottle, pacifier, or sippy cup. 3 The authors urged greater efforts to encourage correct usage, ensure product design safety, and increase awareness of the American Academy of Pediatrics’ (AAP) recommendations for discontinuing pacifier use. Although lacerations were the predominant diagnosis across all products, pacifiers were associated with a higher likelihood of soft tissue injuries and dental injuries than bottles or sippy cups. AAP has released pacifier safety information for parents focused on preventing aspiration or ingestion of pacifiers or small pieces and strangulation from pacifier strings. It does not address other types of injuries. Currently, few formal recommendations exist for what age children should discontinue using these pacifiers, and it is unclear whether existing recommendations were developed to prevent these injuries. Recommendations for discontinuing pacifier use focus on preventing otitis media after 12 months of age and preventing changes in the developing orofacial complex of children still using a pacifier after 18 months of age. 4
Improved education of parents through the promotion of information from manufacturing companies and primary care physicians is essential. Parents should be informed of the AAP recommendations and the U.S. Consumer Product Safety Commission requirements to ensure the safe use of pacifiers. Previous case reports have generally focused on rare instances of airway obstruction by nipples, pacifier parts, or whole pacifiers. 3 Product design improvements have been made to address safety concerns, including adding air holes and increasing pacifier size to prevent choking.
Pacifiers come in various materials, including either rubber or silicone. Recommendations from the AAP include obtaining a one-piece model that cannot break into two pieces and ensuring that the shield is at least 1.5 inches (3.8 cm) across and made of firm plastic with air holes to prevent suffocation. Pacifiers should be kept clean; should be sized to the appropriate age and shape; should never be tied to the child or the child’s crib; and should be regularly inspected to be sure that the rubber is unchanged in color and is not torn. 5 Any signs of wear should indicate replacement, and in this case, the manufacturer recommends replacement after 1 month of use. In addition, Consumer Reports recommends silicone over rubber because of material wear and breakdown, and regularly checking consumer recalls to ensure the safety of your child. 3 Thus, frequent inspection of all pacifiers should be encouraged.
The design of the infant pacifier here (Figure 1), sold through a large supermarket chain, would seem to predispose users to suction blisters as it is made entirely of silicone without a firm plastic base. It is important to note that increased rigidity may also promote injury. In one report, a pacifier with a large horizontal dimension and a curved edge to a sharp point led to penetrating eye injury “suggesting that a thicker, rounder edge should be incorporated in any pacifier design to make it more difficult for the pacifier to penetrate the skin.” 6 These reports indicate the need for the manufacturers of infant pacifiers to consider the safety of their products under all situations likely to be encountered by children.
Lastly, there are several differential diagnoses to consider for finger blisters in children under 5 years of age (Table 1). Patient history and clinical exam are crucial for the diagnosis of blisters, particularly friction blisters. Though older patients can report pain or a burning sensation prior to blister formation, younger pediatric patients are unable to provide such explanations. The circular bulla (Figure 1) is highly suggestive for suction blister. Linear bullae are more consistent with sucking blisters. 2 Prominent erythema is often indicative of an infectious cause, such as blistering dactylitis7–10 or contact dermatitis. 11 Though the site was erythematous, alternative diagnoses or secondary infection were unlikely given the quality of history of present illness, acute presentation, and lack of systemic symptoms such as fever. Confluent vesicles can also present similarly to suction blisters, determining if the blister is one lesion versus multiple confluent blisters can aid in diagnosis. 12 Changes in overlying skin are also useful in differential diagnoses, as scales or crusting often represent other etiologies.13,14
Overview of published clinical cases presenting with digit blisters in children under 5 years of age.
Conclusion
Suction blisters can result from mechanical forces applied to the skin, such as those from a pacifier. While pacifiers are commonly used to soothe infants and toddlers, they can pose risks if not monitored properly. The novel presentation of thumb blister secondary to a common soothing device underscores the importance of risk assessment. Educating parents about the potential risks and safe use of pacifiers can prevent similar incidents. Lastly, clinical providers should consider several diagnoses when assessing digit blisters in children under the age of 5 years.
Footnotes
Consent to participate
Written informed consent was obtained from the legally authorized representatives of the subject prior to study initiation for the case report.
Author contributions
Author contributions appear as indicated on the author declaration form.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
No new data was generated during this study. Existing data that support the findings of this study are available from the corresponding author upon reasonable request. Patient data cannot be shared due to ethical/legal restrictions.