Emma came in for her newborn examination at twelve days of age. She was a beautiful baby, and her parents were filled with joy. She was nice and pink without a trace of jaundice. And she was four ounces above her birth weight which assured her first-time mom that the breast-feeding was a success. The umbilical stump was hanging on by a thread. I instructed them to continue sponge bathing the baby until the stump fell off. Once that occurred they could give her a tub bath provided the remaining area was clean and dry. For assurance sake they should wait a day or so. Since Emma was doing so well, and the breast-feeding was adequately established, I would see her back for her two month well visit.
Emma came back ten days later, the parents being quite worried. Her umbilical stump had fallen off two days after her last visit, just as we had expected. But the area where the stump was looked awful. It had a raised, red growth protruding from it, and there was a yellowish lump at the base. It was moist and oozed a clear fluid. The surrounding skin was red and irritated.
“We have been waiting for the area to be dry so that we could give her a bath, but it just got worse,” they said in a concerned voice. “Now the area looks infected. We looked on-line and found some articles on omphalitis which is a serious infection. Did we wait too long?” they queried anxiously.
Their concerns were legitimate. But after examining the baby I was certain that this was not a problem. Her temperature was normal, and she did not look ill or toxic. Her exam was completely normal as was the review of systems. The area of the umbilicus did in fact have a growth that was polypoid and pinkish in color. At the base was a yellow area that glistened because it was moist and wet. The surrounding skin was red and macerated, not because of infection, but because it was constantly moist. I assured them that Emma would be just fine, that she had an umbilical granuloma, which was very common in newborns. They let out a sigh of relief.
Once the umbilical cord is cut in the delivery room the baby’s body now recognizes the stump as a foreign body. It sends white blood cells to the area to expel the stump. The cord usually falls off in one-to-three weeks. Shortly thereafter, the raw area is covered with normal skin cells. Scar tissue is formed and healed. In some cases skin bacteria is present that delays the healing process and causes the area to remain moist. This promotes the formation of excess granulation tissue. This redundant tissue is what causes the umbilical granuloma. In Emma’s case, the surrounding tissue was red and irritated because of the wet, moist environment.
If not treated the granuloma can persist, but rarely cause any problems other than cosmetic. The treatment is simple. The pediatrician can cauterize the granuloma with silver nitrate that allows the area to dry and heal. This is done in the office with a silver nitrate stick. It has a solid ball of silver nitrate at one end and resembles a Q-tip. The granuloma is gently rubbed with the silver nitrate which cauterizes the granuloma and dries it out immediately. Some cases require a second or even a third application, depending on how large the granuloma is. It is not painful for the baby, as the granuloma has no nerve supply. One or two days after it is cauterized, if the area remains clean and dry, the baby may be given a tub bath.
Silver nitrate is a chemical that can stain normal skin a dark charcoal color. If you get it on your fingers within a few hours there will be a dark smudge where it came in contact with the skin. This will fade away in a few days. Often times after the granuloma is cauterized, the normal skin around the umbilical area may have this dark charcoal color from the silver nitrate that inadvertently came into contact with it. This, too, will fade away in a matter of days and is of no consequence.
Emma’s parents raised the question of “omphalitis” which is a serious and truly life-threatening infection of the newborn that carries a high mortality rate. This is a true bacterial infection of the umbilical cord that moves very fast and leads to septic shock. These babies are critically ill and have a cellulitis around the umbilical area. This is an intense redness from infection that is red and warm, and rapidly expanding. This is quite different from simple irritation. Omphalitis is a medical emergency. It must be recognized as early as possible and treated in the neonatal intensive care unit.
Emma’s parents were relieved as I assured them that she would be fine. After I cauterized her granuloma I told them if it was not dry within a few days I would re-cauterize it. A follow-up appointment was made for three days. Two days later they called to inform me that it was dry, looked great, and that Emma had just experienced her first true bath. All were pleased.