A 7-year-old boy is brought to the pediatric clinic by his mother who noticed irregular red patches on his tongue that seem to change shape every few days. On examination, the tongue shows red atrophic areas with white serpentine borders. The child is otherwise asymptomatic and systemically well. The feature marked **C** in the diagram (migratory pattern of lesions) is the key distinguishing characteristic. Which of the following is the most appropriate management for this child?

Explanation

## Why "Reassurance and observation; avoid spicy/acidic foods if symptomatic" is right Geographic tongue (benign migratory glossitis) is a common benign condition affecting 1–3% of the population, characterized by red atrophic patches with white serpentine borders that **migrate and change pattern day-to-day** — this migratory feature (marked **C**) is the key distinguishing characteristic. Most patients are asymptomatic, and the condition requires no treatment. The most important intervention is reassurance to the parents and avoidance of spicy/acidic foods if the child reports any mild burning or sensitivity. The condition is idiopathic and self-limiting, and no investigations or systemic therapy are needed for asymptomatic cases. [Hutchison's Clinical Methods] ## Why each distractor is wrong - **Immediate antifungal therapy with nystatin suspension**: Geographic tongue is NOT infectious and is NOT caused by Candida. Antifungal therapy is unnecessary and may delay appropriate reassurance. Median rhomboid glossitis (which may be related to chronic candidiasis) presents as a central rhomboid patch, not migratory lesions. - **Referral for esophageal endoscopy to rule out Plummer-Vinson syndrome**: Plummer-Vinson syndrome is associated with iron deficiency anemia and presents with atrophic glossitis, angular cheilitis, and dysphagia — not with the characteristic migratory pattern seen in geographic tongue. Endoscopy is not indicated in this asymptomatic child with a benign migratory pattern. - **Empirical iron supplementation and hematologic workup**: While iron deficiency can cause atrophic glossitis, it does not produce the migratory pattern characteristic of geographic tongue. Iron deficiency glossitis is typically painful, smooth, and non-migratory. Unnecessary investigations and supplementation would be inappropriate without evidence of deficiency. **High-Yield:** Geographic tongue's **migratory pattern** (lesions change day-to-day) is the key distinguishing feature — most patients are asymptomatic and require only reassurance and dietary advice; no treatment is needed. [cite: Hutchison's Clinical Methods]