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Umbilical swelling and drainage in a newborn



THE CASE

The mother of a 17-day-old boy with Down syndrome calls you over the weekend worried about increasing swelling, redness, warmth, and yellowish-brown drainage from the umbilicus over the last 8 hours. She used soap and water each morning to clean the cord in addition to applying rubbing alcohol each evening. She pulled the dried, blackened umbilical stump off 2 hours before calling you because of her concern for the spreading redness. You ask the mother to meet you in the pediatric emergency department with the baby.

DIAGNOSIS: Omphalitis with abdominal wall cellulitis

CLINICAL FINDINGS


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This infant presented with signs of inflammation in the umbilical area as well as purulent umbilical discharge. The area of erythema was marked, and serial abdominal examinations were performed. His radiographic imaging offered reassurance that there was no portal gas or subcutaneous air. An ultrasound confirmed limitation of the infection to the superficial abdominal wall without the presence of embryologic abnormalities or evidence of underlying fluid collections.

Risk factors for the development of an infection of the umbilical cord include protracted labor, septic delivery, prematurity, low birth weight, and umbilical catheters.1 A risk factor unique for some patients includes Trisomy 21, because of possible neutrophil dysfunction despite normal neutrophil quantity.2 In healthy newborns, the cord usually separates from the umbilicus approximately 10 days after delivery.3 Delay of umbilical cord separation beyond 1 month warrants immunologic evaluation because of concern for leukocyte adhesion deficiency.

A seemingly minor umbilical infection has the potential to lead to rare but serious complications.1 Serious complications of omphalitis include septicemia, necrotizing fasciitis, abscesses, peritonitis, adhesive small bowel obstruction, and hepatic vein thrombosis.

ETIOLOGY

The most commonly involved microorganisms in omphalitis are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Enterococci.4 Studies from the first half of the 20th century reported gram-positive organisms as the predominant pathogens. However, the reported incidence of anaerobic and gram-negative organisms has increased over the past 2 decades, with speculation that routine antistaphylococcal cord care has shifted the epidemiologic flora findings.

Reduction in neonatal omphalitis has been achieved in developing nations through umbilical cord care packs and health education about hygienic cord care.1,5,6 A Cochrane review concluded that there is a lack of evidence that applying topical antiseptic sprays, creams, or powders is any better than keeping the baby's cord clean and dry.7

TREATMENT

Infants with omphalitis should be admitted for close monitoring and for empiric intravenous antibiotics for initial coverage of gram-positive, gram-negative, and anaerobic organisms. Antimicrobials can be narrowed once culture yields sensitivity and susceptibility of the offending pathogen.

In the event of concern for necrotizing fasciitis, an urgent abdominal computed tomography scan or magnetic resonance image would assist in delineating tissue involvement.8 An abdominal ultrasound should be done to detect any congenital abnormalities.


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