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Should you be concerned about erythema around the umbilical stump?!
Yes!
Often parents will bring their neonate to the ED with concerns about the umbilical cord and it is just a simple granuloma or normal detachment. But is it omphalitis???
Omphalitis incidence is low in developed countries, but that means it’s easier, and no less catastrophic, to miss!
Omphalitis is a superficial cellulitis of the umbilical cord, but 10-16% progress to necrotizing fasciitis of the abdominal wall!!!
Always ADMIT and consider consulting surgery early in case of rapid progression…
Most often polymicrobial and should be treated with:
- Anti-staphylococcal PCN, Vanc, & an Aminoglycoside
- Also consider adding Metronidazole or Clindamycin for anaerobic coverage
- Anti-pseudomonal coverage if toxic
Should notice improvement within 12-24 hours, so if don’t or begin to observe
- Fever
- Induration
- Peau d’orange tisse
- Tenderness
- Violaceous discoloration
- Crepitace
- Increased erythema
- Systemic signs of toxicity/shock
CONSULT SURERY for concern of necrotizing fasciitis which has a mortality rate of close to 60%!!!
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Definition: An episode that is characterized by some combination of apnea, color change, change in muscle tone, choking, gagging, or a fear in the observer that the infant has died.
DDx: VAST!
- GERD is by far the most common underlying etiology
- Do NOT forget about child abuse
Workup: Dependent on your Hx/PE (Take into account the child’s age (<30 days or h/o prematurity), existence of prior ALTE episodes, general appearance, etc.)
One study showed the concordance of initial working to discharge diagnosis of GERD was 96%, and non-concordant diagnoses evolved within 24 hours
Dispo: The easy part! ADMIT!
Even well-appearing children with a “benign” diagnosis like GERD have been shown to benefit from admission. And there is a high likelihood that ALTE’s from a serious cause are likely to recur within 24hours.
A recent study looked at 176 infants who presented to the ED with an ALTE over a 5 year period. Essentially all were admitted.
- Blood cultures were obtained in 63% and CSF cultures were obtained in 37% and no pathogens were identified in either
- CXRs were obtained in 115 (65%) patients and 12 had infiltrates
- RSV nasal washing were obtained in 32% and positive in 9 patients
- At the time of follow up, 2 patients had died, both after hospital discharge and within 2 weeks of ED visit and both of pneumonia. Both had a negative diagnostic evaluation in the ED.
Conclusion: The risk of subsequent mortality in infants presenting ALTE is substantial, and we should consider routine admission for all of these patients.