Omphalitis – Is that a normal umbilical stump or something serious?
Certainly one of the most challenging (and either stimulating or completely terrifying) aspects of emergency medicine is how the seemingly innocuous can belie the sinister and devastating. For example, we examine countless patients for superficial skin infections. We treat most as outpatients without complication, but what about a seemingly mild area of redness surrounding a neonates umbilicus? Is this one of those entities that demands our vigilance?
Umbilical Cord Care
- Do you recall the days of seeing neonates with blue goop on their umbilical stumps? Triple Dye was a mainstay in the delivery room, but no more. In developed countries, it is currently the practice to simple keep the cord clean and dry.
- There is no evidence that any topical dye, antiseptic or antibiotic ointment is better at preventing infection than simply keeping the area clean and dry.
- In developing countries, umbilical cord infections such as Omphalitis, are more common and, thus, topical antimicrobial agents are still advocated.
- Whether the umbilical cord was kept clean and dry or had some antimicrobial agent applied to it, Omphalitis can still occur.
What Parents are Told about the Cord
- Umbilical cord infections are uncommon, but signs of infection should be monitored for.
- Keep the area clean and dry.
- Notify physician (or simply go to the ED… everyone else does) if you note:
- Red skin around the base of the cord
- Fould-smelling discharge from the cord
- Crying when the cord is touched
So, we know that we will be seeing many concerned parents. Fortunately, most of the time it is merely a granuloma that has formed or completely normal process of cord separation. But… your vigilance is needed.
- Incidence of acute omphalitis is low in developed countries… but that means it is easy to miss!
- Omphalitis is superficial cellulitis involving the umbilical cord.
- May present as simple erythema extending beyond the base of the umbilical cord.
- Superficial infection… well, you may think that isn’t a big deal… but it is.
- Reports of 10% – 16% of omphalitis progress to Necrotizing Fasciitis of the Abdominal Wall (that is bad).
- Omphalitis is most often a PolyMicrobial infection
- Gram Positives
- Gram Negatives
- and Anaerobes
- No specific laboratory studies are helpful in diagnosing omphalitis.
- It is a clinical diagnosis.
- There should be no systemic symptoms (tachycardia, tachypnea, etc).
- Labs can be helpful in raising suspicion of an infection that is more progressive than you originally thought (see below).
- If treated appropriately, Omphalitis is able to be resolved without progression.
Necrotizing Fasciitis from Omphalitis
- Nec. Fasc. has a mortality rate of ~60%! Omphalitis should have a mortality rate of ~0%.
- Unlike omphalitis, Nec. Fasc. is a systemic disease.
- The major determinant of survival is early diagnosis and rapid and aggressive surgical debridement.
- Findings that are very concerning for Omphalitis progressing to Necrotizing Fasciitis:
- Peau d/orange tissue or tissue edema
- Violaceous Discoloration
- Rapidly expanding erythema or other changes
- Systemic toxicity and signs of shock
- OF NOTE – they do not need to have severe abdominal wall changes or signs of peritoneal irritation.
- Look for signs of something sinister under the skin – is it Necrotizing Fasciitis (see above)?
- Consult Pediatric Surgery – yep, even for “simple” omphalitis, because in the odd hours of the morning when the “simple” omphalitis turns ugly you don’t have time to consult then.
- AntiStaphylococcal Penicillin, Vancomycin, and Aminoglycoside.
- Many also advocate for Metronidazole or Clindamycin for Anaerobic coverage in all, but definitely this is necessary for any with systemic symptoms.
- Antipseudomonas coverage is also a consideration in the child who is rapidly worsening or toxic appearing.
- Supportive care (goes without saying, but don’t forget it!)
- Simple Omphalitis should improve while on IV antibiotics within the first 12-24 hours. If it doesn’t, it warrants further investigation surgically.
- Maintain a high index of suspicion for the simple omphalitis progressing to necrotizing fasciitis.
Ulloa-Gutierrez R, Rodriguez-Calzada H, Quesada L, Arguello A, Avila-Aguero ML. Is it Acute Omphalitis or Necrotizing Fasciitis? Report of Three Fatal Cases. Pediatric Emergency Care. Sept 2005; 21(9): 600 – 602.
Sawin RS, Schaller RT, Tapper D. Early Recognition of Neonatal Abdominal Wall Necrotizing Fasciitis. American Journal of Surgery. May 1994; 167: 481 – 484.