As you work on your list of questions for your twins' one-year check-up with their pediatrician, you're likely giving both of your sweet children thorough once-overs to think of anything you want to ask their doctor about.
I did the same during the weeks before and after our guys' first birthday, going from head to foot.
And when I got to the bottom of Baby A's foot, I noticed a strange white bump on his heel. It was hard and rock-like.
...when I got to the bottom of Baby A's foot, I noticed a strange white bump on his heel. It was hard and rock-like.
I hadn't noticed it the week before, but I don't give my babies' incredibly thorough exams every single day, so it may have been there for a while before it became big enough to see or feel.
I gently investigated it, and that baby (read: the nodule, not the actual baby) wasn't going anywhere; it was firmly attached. It didn't seem to be bothering him in any way, so that was a relief.
I was glad to have noticed this anomaly right before our pediatrician appointment. I took a picture of my son's foot, and even though it was only a day or two away, curiosity got the better of me, so I searched for possible answers.
Preemie prevalence
From what I could find, these hard white nodules are known as heel-stick calcinosis and are commonly seen in premature babies (read: twins, more often than not) who spend time in the neonatal intensive care unit (NICU) and require repeated heel pricks for blood testing and monitoring (though, some rare cases have been seen after only one heel prick).
According to an article by Matthew Galas and Joseph M. Lam in the Canadian Medical Association Journal, they are "calcium deposits in the skin seen most often in infants with multiple heel sticks. Although the injury occurs in the neonatal period, the lesions do not appear until later—usually between four and 12 months of age."
An article by Keshavmurthy A. Adya and Arun C. Inamadar and shared by the National Institutes of Health says the condition is benign and usually self-resolving, but that parents can be concerned upon discovering the lesions.
The article goes on to explain that the "release of alkaline phosphate by injured tissue elevates the local pH, favoring calcium deposition. The lesions can be solitary or multiple discrete, yellow-white papules or nodules and keratotic lesions, which may be seen extruding through the epidermis. The lesions usually regress within about two to three years of age."
While most cases see the nodule resolve and work its way out of the heel, there are some cases that require surgical excision to remove the lesion(s).
Both twins may not have it
While both of my twins had several heel sticks during their stay at the NICU, only one of them had a nodule from the condition, and it didn't show up until just before their first birthday. Interestingly, it was the twin who had the shorter NICU stay that got the lesion; I'd assume chances would be in Baby B's favor, since he had two extra weeks worth of time in the NICU, but there you have it.
I did notice Baby B had a small, white dot on his heel in about the same location as his brother, but the spot never grew, got firm, nor pushed itself out of the skin. It just sort of faded and went away shortly thereafter.
It's not a well-known condition
Obviously, if you have any concerns about anything you see on your babies' bodies, bring it up with your pediatrician and ask for their thoughts and advice. We had an appointment coming up within a day or two, so since it wasn't urgent, I waited, but if we hadn't had one coming up, I'd have taken them in for a check-up.
When I showed the pediatrician the photo of Baby A's foot and explained what I thought it might be, they didn't think it was from heel pricks in the NICU and said to just monitor it for any changes.
My gut told me it was what I had read about, but since it didn't seem to be causing any discomfort, wasn't bothering my toddler's foot in any way, and seemed to have no ill affect on his ability to walk, I left it at that.
The next time I saw my sister, who's been a nurse in the NICU for nearly two decades, she looked into my suggestion and agreed that's likely what it was. And she'd never heard of it before, either.
...there's a lack of awareness of this condition. This is because of the prolonged delay (months, or even up to a year) between tissue injury and the eventual papule presentation.
The article by the National Institutes of Health goes on to explain that there's a lack of awareness of this condition. This is because of the prolonged delay (months, or even up to a year) between tissue injury and the eventual papule presentation.
We kept an eye on it, and it never changed in appearance, except to be visibly working its way out of the heel, which is what we had expected and were waiting for.
As the months went by, the nodule got looser as it was making its way out of the skin.
What had shown up right around the 12-month mark (less than a week after their first birthday) had resolved itself just before their 18-month check-up, leaving a tiny little "ball-shaped" indent where the calcium deposit had pushed itself out of my baby's foot.
And that indent then, of course, went back to normal after a very short period of time.
We told the pediatrician that the lesion had resolved itself just before that appointment, and so he made note of that on the file, and that was the end of it.
Always monitor anything you're unsure of
This is not to say that the hard white bump you see on your own child's heel is definitely, without a doubt, heel-stick calcinosis.
Could it be something else? Of course.
Always take pictures of things that concern you and discuss them with your pediatrician as soon as you can.
Ask about tests to rule out other diagnoses with similar symptoms, like porokeratotic eccrine ostial and dermal duct nevus or milia-like idiopathic calcinosis cutis, which is mostly associated with Down syndrome and exhibits features on the skin similar to heel-stick calcinosis.
If you find someting on your child's body that you aren't sure of and want more information about, book an appointment with your twins' pediatrician and ask for their expertise.
If your gut tells you there's more to it, do some additional research, ask more questions, request tests or other opinions, and monitor things closely.
Parents know their babies best, so they're most likely to know when something needs further investigation. It's up to you to bring it to the doctor's attention.
Did either of your twins have heel-stick calcinosis? When did you discover it? And did it resolve itself or was surgery required? Let us know in the Comments section below.
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