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.

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