The Rate of Oral Lesions in Infants and Neonates Attend Maternity and Pediatric Teaching Hospital in Sulaymaniyah City

Background: The prevalence of oral mucosal lesions in infants and neonates is still a matter of debate. Objective: To find the frequency of oral mucosal lesions in children from Sulaymaniyah city. Patients and Methods: A cross-sectional study was performed in Maternity and Pediatrics Teaching Hospitals in Sulaymaniyah city. Twohundred children aged from birth to two years old were randomly selected. Demographic features, mode of delivery, pattern of feeding, and type and site of oral mucosal lesions, were recorded. Results: Male: female ratio was 1.06:1, and 64% were delivered by cesarean section. Significant differences were present between breastfeeding with the mode of delivery and age of the infants. Oral mucosal lesions were observed in 64.5% of children at 141 sites. 30% of lesions are located at median palatine raphe. The diagnosis of 30% of oral mucosal lesions was Epstein pearls, and 16% were Bohn’s nodule. The oral mucosal lesions were more frequently seen in children within the first week. Conclusion: About three-quarters of children was afflicted with oral mucosal lesions. Besides, Epstein pearls and Bohn’s nodule were among the most frequent diagnosis. Further, ages of a week or less afflicted more with congenital oral mucosal lesions.


Introduction
The oral cavity is a gateway into the digestive system, and the mucous membrane of the oral cavity is considered a mirror for general health [1]. Besides, oral mucosal lesions (OMLs) were not adequately studied in children, and they associate with their growth and development; therefore, it is an important issue that needs to be considered well.
The OMLs in pediatric age groups is a rare topic. They are of interest to pediatricians, dentists, and dermatologists [2]. Until now, the incidence and classifications of OMLs for children aged less than two years old are not well established. This fact is because most of the authors studied these lesions in children having more than two years, and only a few researchers examined a group of children aged from birth up to five years old (2)(3). Besides, the considerable sociodemographic heterogeneity, geographical extensions, and differences in the epidemiology of OMLs are other reasons for not well establishing its classification [3]. Therefore, the prevalence and incidence of OMLs are still a matter of debate in infants and neonates. It has been reported to range from 2.3-24.9% in children aged from birth to five years (2)(3). While in the study of Espinosa-Zapata et al. [4] in Mexico, which enrolled children aged from one year to 16 years old, the OMLs incidence was 7.4%, and the study of Abdulla et al. [5]in Iraq which enrolled children aged from birth to 15 years old, its incidence was 12%.
The OMLs can be caused by; local microorganisms, systemic diseases, drug reactions, developmental lesions (e.g., cysts), and lifestyle factors such as nutritional status and feeding [3,6]. The clinical features of OMLs can be asymptomatic or associated with pain and discomfort [3]. They may interfere with chewing, sucking, and swallowing and may produce halitosis [3]. Moreover, the treatment of OMLs depends on the cause(s); therefore, knowledge about the type and distribution of lesions in the oral cavity is mandatory for successful treatment [1].
The current study aimed to determine the frequency of oral lesions in neonates and children in Sulaymaniyah city. It also aimed to identify their association with the route of delivery, the age, gender, and feeding process of those children.

Patients and Methods
A cross-sectional study was conducted for five months from October 2019 through February 2020. The study was held at the Maternity and Pediatrics Teaching Hospitals in Sulaymaniyah city. Two hundred randomly selected neonates and children (aged from birth to two years old) were included after obtaining their parents' acceptance and signing a consent form. The Research Ethical Committee of the Kurdistan Board of Medical Specialties (KBMS) approved the study proposal, and a formal acceptance letter was obtained from the hospitals before starting the study.
The age, gender, bodyweight of the baby, and parental consanguinity and residency were recorded. Besides, the history of the mode of delivery and the manner of baby feeding were also recorded. For intraoral examination, all the children and neonates were examined by the oral medicine specialist under standardized conditions Frequency and percentage were measured for non-parametric variables. The age was presented as mean ± standard deviation (SD). Mann-Whitney U test was used to ascertain the significance of differences between the groups.

Statistical analysis
Data analyzed using IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp. Statistical significant results were considered at a p-value of less than 0.05.

Results
The sample showed slight variation of gender (male: female ratio was 1.06:1) and family residence (inside or outside Sulamaniyah city) distributions. The majority of the children were delivered by cesarean section (64%). The mean age and weight of the children at the time of examination were 3.5 ± 6.17 months and 4.9 ± 2.81 grams, respectively Table (1).

Discussion
Ensuring children's healthy development should be a significant concern for all societies because they represent the future [7]. Further, neonates and infants are vulnerable to many preventable and treatable diseases such as malnutrition and infections [7]. Besides, any oral cavity disease can affect proper feeding, children's growth, and development [1][2][3][4].
The OMLs in children, especially for children aged two years or less, are not well established, and it is a rare topic of interest Hassan et al The Rate of Oral Lesions in Infants and Neonates Attend Maternity and Pediatric Teaching Hospital in Sulaymaniyah City by many researchers [5,[8][9][10]. Published articles showed heterogeneity in the incidence of the OMLs in children because the age ranges were dispersed in different studies [6,10]. Our study focused on children aged two years or less, and their mean age was 3.5 ± 6.17 months. Therefore, this may explain why our patient's demographic features were not the same as other studies' demographic features [2-3, 6, 10-11].
The gender in the current study was almost had equal distribution; the male: female ratio was 1.06:1, which was about the same result as the study of Majorana et al. [11] who selected children from birth to 12 years. Also, the study of Babu et al. [10] showed female predilection. The demographic features, including ages, were not the same in previous literature [6,10]; Majorana et al. [11] selected children from birth to 12 years, while Babu et al. [10] enrolled ages from 1-92 years. Further, 117 (58.5%) children have resided inside the center of Sulaymaniyah city, and this may have affected the parental decision to choose the most accessible mode of delivery for their babies; the majority (64%) of them delivered by caeserian section (C/S). Besides, none consanguinity between the majority of the children's parents in the current study may decrease the possibility of congenital OMLs.
We selected the children from two major public hospitals in Sulaymaniyah city, Maternity and Pediatrics Teaching Hospitals. Although nearly one-third (35.5%) of the sampled children were healthy, hospitalized children are more likely to have OMLs. Also, there is no agreement on unified classification and prevalence for OMLs [11] due to the sample's sociodemographic features, heterogeneity of analysis, and diagnostic criteria differences. Therefore, our sample could represent the entire hospitalized children but not the entire children in our population. Although the ages of the children in the study of Yilmaz et al. [8] done in Turkey were the same as the ages of our children, i.e., two years or less, they had fewer healthy children (21.27%) as compared to our result. Further, this difference may be because we selected hospitalized children from pediatric and obstetrical hospitals; however, Yilmaz et al. [8] enrolled only children from the outpatient clinic of a pediatric hospital.
This study showed that 64.5% of children had clinical findings, predominated at the median palatine raphe followed by the hard and soft palate's junction. Epstein pearls (30%) and Bohn's nodule (16%) were the main clinical findings. Also, twelve children had more than one clinical finding at more than one site. In the current study, most OMLs were congenital (i.e., Epstein pearls and Bohn's nodule). On the contrary, studies performed in Iran [12], Turkey [13], Taiwan [14], Brazil [15], and the United States [16] showed OMLs of inflammatory and reactive types more frequently. However, a study performed in Thailand, partly in agreement with our results, reported cystic lesions, including congenital cysts, more frequently [17]. These differences may be due to age ranges that those studies took compared to the less than two years of age of the children in our study. Therefore, our results showed a statistically significant difference between the location of the OMLs as compared to ages; infants aged a week or less were more afflicted with OMLs. This result may be because the parent focuses early on the congenital lesions of their baby, and the immunity of the infants is not well developed for the acquired lesions.

Conclusions
In conclusion, the majority of children aged less than two years had lesions at the median palatine raphe, followed by the hard and soft palate's junction. Furthermore, the majority of the types of lesions were Epstein pearls, followed by Bohn's nodule. There was a significant difference between the location of the OMLs as compared to ages, and infants of less than a week were more afflicted with OMLs.

Recommendations
We recommend performing new studies on the same topic by either screening all the newly delivered babies, i.e., a very large sample size, or choosing cohort studies, and follow-up children for a longer period to find out the associated risk factors.

Source of funding:
The authors did not receive any funding from any source.
Ethical clearance: The authors had nothing to declare Conflict of interest: Nill.