Omphalitis

After birth, the umbilical cord falls off between 2-3 weeks.   The mechanism of sepaparation includes necrosis, granulocyte invasion, infarction, drying, and collangenase activity. On the second day of life, there are usually polymorphonuclear cells and bacteria present on the umbilicus. The PMNs play some role in cord separation and there may be a delay of separation if there are chemotactic defects of these cells.(leukocyte adhesion deficiency LAD) Delay of separation of the cord in healthy neonates may be caused by urachal anomalies 

The cord is colonized by organism from the vagina and caretakers' hands. The organisms most often cultured include:

  1. Staphylococcus aureus and S. epidermidis
  2. Streptococcus pyogenes
  3. Group B strep
  4. Gram negative organisms.
  5. Tetanus in developing countries.
Omphalitis at one time was a common cause of morbidity and mortality in neonates. With the application of hexochlorophene and triple dye to the cord, the incidence has decreased remarkably, especially in industrialized countries. The incidence is between 0.5-2%. The mean age of developing omphalitis is 3.2 days, therefore most cases occur outside the hospital. 

Diagnosis

  1. Presence of inflammation of tissues surrounding the cord associated with redness, swelling, and tenderness.
  2. In certain instances, bullous impetigo lesions may be present as well.
  3. There may be associated systemic symptoms such as fever, lethargy, and poor po intake.
Differential Diagnosis
  1. Normal cord may have accumulation of fluid between the stump and abdominal wall. This may be associated with a bad smell. There is no redness and treatment is to keep clean with alcohol.
  2. Granuloma- Delayed epithelialization of the cord stump may leave a dull grayish-pink granuloma that  oozes fluid. The treatment is to cauterize with silver nitrate stick. The procedure may need to be repeated. After cauterizing, keep the diaper off the cord area temporarily.
Management
  1. Culture of discharge will often reveal normal colonizing bacteria and there are no studies to show the value of aspirating the leading edge of the cellulitis.
  2. Antibioitcs must cover Staph. aureus and Strep. pyogenes.
  3. The route of administration is dependent on how the neonate looks clinically. 
    1. without systemic symptoms, po antibiotics may be started. Awareness of MRSA prevalence in your community may determine which oral agent to start. Careful follow-up must be arranged to check for complications or lack of improvement
    2. If child appears ill, should perform septic workup and start an anti-staph drug combined with an aminoglycoside. If no improvement, consider MRSA as possible etiologic agent.
Complications
  1. Necrotizing fasciitis- Fast growing and may be lethal. First signs may include edema and peau d'orange appearance of the skin around the infection.  Crepitus is unusual and may have  black discoloration. May need debridement
  2. Peritonitis- the umbilical vein is a direct route to the peritoneum.  Requires laparotomy and resection of umbilical vessels.
  3. Portal vein thrombosis- associated with portal hypertension. Watch for development of splenomegaly
  4. Abscesses
  5. Spontaneous bowel evisceration- rare and can result from fascia breakdown.
References
  1. Cushing, Alice. Omphalitis: Still potential for disaster. Contemporary Pediatrics. May 1997
  2. Cushing, Alice. Omphalitis: A Review. Pediatric Infectious Disease May/June 1985
  3. Ravi S. et al.  Delayed Separation of the Umbilical Cord Attributable to Urachal Anomalies.  Pediatrics August 2001
  4. Anderson J, Philip A. Management of the Umbilical Cord Pediatrics in Review NeoReviews April 2004
  5. Fraser N et al.  (2006) Neonatal omphalits: A review of its serious complications.  Acta aediatrica, 95(5) 519-522.