Sections

Omphalitis

Workup

Laboratory Studies

Routinely obtain specimens from umbilical infection and submit specimens for Gram stain and culture for aerobic and anaerobic organisms. If myonecrosis is suspected, obtain specimens from the involved muscle rather than the wound surface.

Obtain blood cultures for aerobic and anaerobic organisms.

Obtain a complete blood cell (CBC) count with manual differential. Neutrophilia or neutropenia may be present in acute infection. An immature-to-total neutrophil ratio greater than 0.2 may be a useful indicator of systemic bacterial infection in the first few days of life. Thrombocytopenia may be present.

Other nonspecific laboratory tests, either alone or in combination with a defined scoring system, have been evaluated for their usefulness in rapid detection of bacterial infection in neonates, although none has demonstrated sensitivity or specificity sufficiently high to dictate clinical care. The tests include the following:

C-reactive protein levels
Procalcitonin
Erythrocyte sedimentation rate
Neutrophil CD64

The following laboratory studies are suggested in neonates in whom sepsis and disseminated intravascular coagulation (DIC) are suspected:

Peripheral blood smear
Prothrombin time
Activated partial thromboplastin time
Fibrinogen
Fibrinogen split products or D-dimer

Other abnormalities associated with serious systemic infection include the following:

Hypoglycemia
Hypocalcemia (often related to saponification with fatty acids released by bacterial lipases in subcutaneous tissue)
Metabolic acidosis

Other studies and/or procedures

Analysis of biopsy specimens may reveal necrotizing fasciitis, which is an acute inflammatory infiltrate found in subcutaneous fat and connective tissue, or myonecrosis, which is an acute inflammatory process surrounding muscle bundles, many of which are no longer viable.

Lumbar puncture may be warranted in infants in whom sepsis is suspected.

Imaging Studies

The following imaging studies may be indicated:

Abdominal radiography may reveal intra-abdominal wall gas.
Ultrasonography may reveal fascial thickening and fluid accumulation between subcutaneous fat and muscle in cases with fascial involvement. It may also be useful in the detection of anatomic abnormalities.
Computed tomography scanning of the abdomen may determine the presence and extent of muscle and/or fascial involvement and potentially aid in detection of anatomic abnormalities.

Staging

Staging of neonatal omphalitis is as follows^[48]:

Grade 1: Funisitis with purulent umbilical discharge that may be malodorous
Grade 2: Funisitis with purulent umbilical discharge that may be malodorous with periumbilical abdominal wall cellulitis
Grade 3: Funisitis with purulent umbilical discharge that may be malodorous, the presence of periumbilical abdominal wall cellulitis, and systemic involvement, including sepsis, shock, disseminated intravascular coagulation, multiple organ dysfunction
Grade 4: Funisitis with purulent umbilical discharge that may be malodorous; the presence of periumbilical abdominal wall cellulitis, ecchymosis, crepitus, bullae; with evidence of involvement of superficial and deep fascia and associated muscle; and with systemic involvement, including sepsis, shock, disseminated intravascular coagulation, multiple organ dysfunction

Treatment & Management

Cushing AH. Omphalitis: a review. Pediatr Infect Dis. 1985 May-Jun. 4(3):282-5. [QxMD MEDLINE Link].
Airede AI. Pathogens in neonatal omphalitis. J Trop Pediatr. 1992 Jun. 38(3):129-31. [QxMD MEDLINE Link].
Brook I. Microbiology of necrotizing fasciitis associated with omphalitis in the newborn infant. J Perinatol. 1998 Jan-Feb. 18(1):28-30. [QxMD MEDLINE Link].
Mason WH, Andrews R, Ross LA, Wright HT Jr. Omphalitis in the newborn infant. Pediatr Infect Dis J. 1989 Aug. 8(8):521-5. [QxMD MEDLINE Link].
Sawardekar KP. Changing spectrum of neonatal omphalitis. Pediatr Infect Dis J. 2004 Jan. 23(1):22-6. [QxMD MEDLINE Link].
Sengupta M, Banerjee S, Banerjee P, Guchhait P. Outstanding prevalence of methicillin resistant Staphylococcus aureus in neonatal omphalitis. J Clin Diagn Res. 2016 Sep. 10(9):DM01-3. [QxMD MEDLINE Link]. [Full Text].
Brook I. Anaerobic infections in children. Adv Exp Med Biol. 2011. 697:117-52. [QxMD MEDLINE Link].
[Guideline] Liljestrand J, Zupan J, et al, for the World Health Organization, Department of Reproductive Health and Research. Childbirth – labour, delivery and immediate postpartum care. Mattock N, Casna R, eds. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. 3rd ed. Luxembourg: WHO Press; 2015. [Full Text].
Stewart D, Benitz W, for the Committee on Fetus and Newborn. Umbilical cord care in the newborn infant. Pediatrics. 2016 Sep. 138(3):[QxMD MEDLINE Link]. [Full Text].
Hung CH, Cheng SN, Hua YM, et al. Leukocyte adhesion deficiency disorder: report of one case. Acta Paediatr Taiwan. 1999 Mar-Apr. 40(2):128-31. [QxMD MEDLINE Link].
Mogica-Martinez MD, Lopez-Duran JL, Canseco-Raymundo MR, Becerril Angeles M. [Leukocyte adhesion deficiency syndrome: case report] [Spanish]. Rev Alerg Mex. 1999 Sep-Oct. 46 (5):140-4. [QxMD MEDLINE Link].
van Vliet DN, Brandsma AE, Hartwig NG. [Leukocyte-adhesion deficiency: a rare disorder of inflammation] [Dutch]. Ned Tijdschr Geneeskd. 2004 Dec 11. 148(50):2496-500. [QxMD MEDLINE Link].
Alizadeh P, Rahbarimanesh AA, Bahram MG, Salmasian H. Leukocyte adhesion deficiency type 1 presenting as leukemoid reaction. Indian J Pediatr. 2007 Dec. 74(12):1121-3. [QxMD MEDLINE Link].
Parvaneh N, Mamishi S, Rezaei A, et al. Characterization of 11 new cases of leukocyte adhesion deficiency type 1 with seven novel mutations in the ITGB2 gene. J Clin Immunol. 2010 Sep. 30(5):756-60. [QxMD MEDLINE Link].
Deshpande P, Kathirvel K, Alex AA, et al. Leukocyte adhesion deficiency-I: clinical and molecular characterization in an Indian population. Indian J Pediatr. 2016 Aug. 83(8):799-804. [QxMD MEDLINE Link].
Jasani BB, Nanavati R, Kabra N. Unusual neonatal presentation of type I leukocyte adhesion deficiency. J Clin Neonatol. 2014 Apr. 3(2):109-11. [QxMD MEDLINE Link].
Hagimoto R, Koike K, Sakashita K, et al. A possible role for maternal HLA antibody in a case of alloimmune neonatal neutropenia. Transfusion. 2001 May. 41(5):615-20. [QxMD MEDLINE Link].
Rezaei N, Moin M, Pourpak Z, et al. The clinical, immunohematological, and molecular study of Iranian patients with severe congenital neutropenia. J Clin Immunol. 2007 Sep. 27(5):525-33. [QxMD MEDLINE Link].
Shim YJ, Kim HJ, Suh JS, Lee KS. Novel ELANE gene mutation in a Korean girl with severe congenital neutropenia. J Korean Med Sci. 2011 Dec. 26(12):1646-9. [QxMD MEDLINE Link].
Donadieu J, Fenneteau O, Beaupain B, Mahlaoui N, Chantelot CB. Congenital neutropenia: diagnosis, molecular bases and patient management. Orphanet J Rare Dis. 2011 May 19. 6:26. [QxMD MEDLINE Link]. [Full Text].
van den Tooren-de Groot R, Ottink M, Huiskes E, et al. Management and outcome of 35 cases with foetal/neonatal alloimmune neutropenia. Acta Paediatr. 2014 Nov. 103(11):e467-74. [QxMD MEDLINE Link].
Porcelijn L, de Haas M. Neonatal alloimmune neutropenia. Transfus Med Hemother. 2018 Oct. 45(5):311-6. [QxMD MEDLINE Link]. [Full Text].
Skokowa J, Dale DC, Touw IP, Zeidler C, Welte K. Severe congenital neutropenias. Nat Rev Dis Primers. 2017 Jun 8. 3:17032. [QxMD MEDLINE Link].
Elhassani SB. The umbilical cord: care, anomalies, and diseases. South Med J. 1984 Jun. 77(6):730-6. [QxMD MEDLINE Link].
Boyle G, Rosenberg HK, O'Neill J. An unusual presentation of an infected urachal cyst. Review of urachal anomalies. Clin Pediatr (Phila). 1988 Mar. 27(3):130-4. [QxMD MEDLINE Link].
Ward TT, Saltzman E, Chiang S. Infected urachal remnants in the adult: case report and review. Clin Infect Dis. 1993 Jan. 16(1):26-9. [QxMD MEDLINE Link].
Razvi S, Murphy R, Shlasko E, Cunningham-Rundles C. Delayed separation of the umbilical cord attributable to urachal anomalies. Pediatrics. 2001 Aug. 108(2):493-4. [QxMD MEDLINE Link]. [Full Text].
Masuko T, Nakayama H, Aoki N, Kusafuka T, Takayama T. Staged approach to the urachal cyst with infected omphalitis. Int Surg. 2006 Jan-Feb. 91(1):52-6. [QxMD MEDLINE Link].
McKenna H, Johnson D. Bacteria in neonatal omphalitis. Pathology. 1977 Apr. 9(2):111-3. [QxMD MEDLINE Link].
Geil CC, Castle WK, Mortimer EA Jr. Group A streptococcal infections in newborn nurseries. Pediatrics. 1970 Dec. 46(6):849-54. [QxMD MEDLINE Link].
Gezon HM, Schaberg MJ, Klein JO. Concurrent epidemics of Staphylococcus aureus and group A Streptococcus disease in a newborn nursery. Control with penicillin G and hexachlorophene bathing. Pediatrics. 1973 Feb. 51(2):383-90. [QxMD MEDLINE Link].
Nelson JD, Dillon HC Jr, Howard JB. A prolonged nursery epidemic associated with a newly recognized type of group A streptococcus. J Pediatr. 1976 Nov. 89(5):792-6. [QxMD MEDLINE Link].
Sawin RS, Schaller RT, Tapper D, et al. Early recognition of neonatal abdominal wall necrotizing fasciitis. Am J Surg. 1994 May. 167(5):481-4. [QxMD MEDLINE Link].
Ameh EA, Nmadu PT. Major complications of omphalitis in neonates and infants. Pediatr Surg Int. 2002 Sep. 18(5-6):413-6. [QxMD MEDLINE Link].
Feo CF, Dessanti A, Franco B, et al. Retroperitoneal abscess and omphalitis in young infants. Acta Paediatr. 2003. 92(1):122-5. [QxMD MEDLINE Link].
Fraser N, Davies BW, Cusack J. Neonatal omphalitis: a review of its serious complications. Acta Paediatr. 2006 May. 95(5):519-22. [QxMD MEDLINE Link].
Bokka SH, Behera BK, Mohanty MK. Falciform ligament abscess secondary to neonatal omphalitis, a potential complication of home delivery. J Indian Assoc Pediatr Surg. 2015 Jul-Sep. 20(3):160. [QxMD MEDLINE Link]. [Full Text].
Kosloske AM, Cushing AH, Borden TA, et al. Cellulitis and necrotizing fasciitis of the abdominal wall in pediatric patients. J Pediatr Surg. 1981 Jun. 16(3):246-51. [QxMD MEDLINE Link].
Lally KP, Atkinson JB, Woolley MM, Mahour GH. Necrotizing fasciitis. A serious sequela of omphalitis in the newborn. Ann Surg. 1984 Jan. 199(1):101-3. [QxMD MEDLINE Link].
Samuel M, Freeman NV, Vaishnav A, et al. Necrotizing fasciitis: a serious complication of omphalitis in neonates. J Pediatr Surg. 1994 Nov. 29(11):1414-6. [QxMD MEDLINE Link].
Moss RL, Musemeche CA, Kosloske AM. Necrotizing fasciitis in children: prompt recognition and aggressive therapy improve survival. J Pediatr Surg. 1996 Aug. 31(8):1142-6. [QxMD MEDLINE Link].
Weber DM, Freeman NV, Elhag KM. Periumbilical necrotizing fasciitis in the newborn. Eur J Pediatr Surg. 2001 Apr. 11(2):86-91. [QxMD MEDLINE Link].
Nazir Z. Necrotizing fasciitis in neonates. Pediatr Surg Int. 2005 Aug. 21(8):641-4. [QxMD MEDLINE Link].
Bingol-Kologlu M, Yildiz RV, Alper B, et al. Necrotizing fasciitis in children: diagnostic and therapeutic aspects. J Pediatr Surg. 2007 Nov. 42(11):1892-7. [QxMD MEDLINE Link].
O'Brien PH, Meredith HC, Vujic I, Schabel SI. Obstructive jaundice caused by cavernous transformation of the portal vein post neonatal omphalitis. J S C Med Assoc. 1979 May. 75(5):209-10. [QxMD MEDLINE Link].
Perlemuter G, Bejanin H, Fritsch J, et al. Biliary obstruction caused by portal cavernoma: a study of 8 cases. J Hepatol. 1996 Jul. 25(1):58-63. [QxMD MEDLINE Link].
Orloff MJ, Orloff MS, Girard B, Orloff SL. Bleeding esophagogastric varices from extrahepatic portal hypertension: 40 years' experience with portal-systemic shunt. J Am Coll Surg. 2002 Jun. 194(6):717-28; discussion 728-30. [QxMD MEDLINE Link].
Bradley JS, Nizet V. Staphylococcal infections. In: Wilson CB, Nizet V, Maldonado YA, Remington JS, Klein JO, eds. Remington and Klein's Infectious Diseases of the Fetus and Newborn Infant. 8th ed. Philadelphia, PA: Elsevier Saunders; 2016. 487.
Kosloske AM, Bartow SA. Debridement of periumbilical necrotizing fasciitis: importance of excision of the umbilical vessels and urachal remnant. J Pediatr Surg. 1991 Jul. 26(7):808-10. [QxMD MEDLINE Link].
Gras-Le Guen C, Caille A, Launay E, et al. Dry care versus antiseptics for umbilical cord care: a cluster randomized trial. Pediatrics. 2017 Jan. 139(1):[QxMD MEDLINE Link]. [Full Text].
Karumbi J, Mulaku M, Aluvaala J, et al. Topical umbilical cord care for prevention of infection and neonatal mortality. Pediatr Infect Dis J. 2013 Jan. 32(1):78-83. [QxMD MEDLINE Link]. [Full Text].
Imdad A, Bautista RM, Senen KA, et al. Umbilical cord antiseptics for preventing sepsis and death among newborns. Cochrane Database Syst Rev. 2013 May 31. 5:CD008635. [QxMD MEDLINE Link].
Sinha A, Sazawal S, Pradhan A, Ramji S, Opiyo N. Chlorhexidine skin or cord care for prevention of mortality and infections in neonates. Cochrane Database Syst Rev. 2015 Mar 5. 3:CD007835. [QxMD MEDLINE Link].
Leante Castellanos JL, Perez Munuzuri A, Ruiz Campillo CW, et al. [Recommendations for the care of the umbilical cord in the newborn]. An Pediatr (Barc). 2019 Apr 7. [QxMD MEDLINE Link].
Sazawal S, Dhingra U, Ali SM, et al. Efficacy of chlorhexidine application to umbilical cord on neonatal mortality in Pemba, Tanzania: a community-based randomised controlled trial. Lancet Glob Health. 2016 Nov. 4(11):e837-e844. [QxMD MEDLINE Link]. [Full Text].
Mullany LC, Arifeen SE, Khatry SK, et al. Impact of chlorhexidine cord cleansing on mortality, omphalitis and cord separation time among facility-born babies in Nepal and Bangladesh. Pediatr Infect Dis J. 2017 Oct. 36(10):1011-3. [QxMD MEDLINE Link]. [Full Text].
Semrau KE, Herlihy J, Grogan C, et al. Effectiveness of 4% chlorhexidine umbilical cord care on neonatal mortality in Southern Province, Zambia (ZamCAT): a cluster-randomised controlled trial. Lancet Glob Health. 2016 Nov. 4(11):e827-36. [QxMD MEDLINE Link]. [Full Text].
Goldenberg RL, McClure EM, Saleem S. A review of studies with chlorhexidine applied directly to the umbilical cord. Am J Perinatol. 2013 Sep. 30(8):699-701. [QxMD MEDLINE Link]. [Full Text].
Imdad A, Mullany LC, Baqui AH, et al. The effect of umbilical cord cleansing with chlorhexidine on omphalitis and neonatal mortality in community settings in developing countries: a meta-analysis. BMC Public Health. 2013. 13 Suppl 3:S15. [QxMD MEDLINE Link]. [Full Text].
Shariff JA, Lee KC, Leyton A, Abdalal S. Neonatal mortality and topical application of chlorhexidine on umbilical cord stump: a meta-analysis of randomized control trials. Public Health. 2016 Oct. 139:27-35. [QxMD MEDLINE Link].
Sankar MJ, Chandrasekaran A, Ravindranath A, Agarwal R, Paul VK. Umbilical cord cleansing with chlorhexidine in neonates: a systematic review. J Perinatol. 2016 May. 36 Suppl 1:S12-20. [QxMD MEDLINE Link].
Osrin D, Colbourn T. Chlorhexidine and newborn omphalitis and mortality - Authors' reply. Lancet Glob Health. 2017 Mar. 5(3):e272-e273. [QxMD MEDLINE Link]. [Full Text].
Hodgins S. Chlorhexidine and newborn omphalitis and mortality. Lancet Glob Health. 2017 Mar. 5(3):e270-e271. [QxMD MEDLINE Link]. [Full Text].
Osrin D, Colbourn T. No reason to change WHO guidelines on cleansing the umbilical cord. Lancet Glob Health. 2016 Nov. 4(11):e766-e768. [QxMD MEDLINE Link]. [Full Text].
Young TE, Mangum B. Neofax 2008. 21st ed. Montvale, NJ: Thomson Reuters; 2008.
[Guideline] Riley LE, Stark AR, eds. Guidelines for Perinatal Care. 7th ed. Elk Grove Village, IL, and Wash, DC: American Academy of Pediatrics and American College of Obstetricians and Gynecologists; 2012. 302.
Brook I, Dunkle LM. Anaerobic infections. McMillan J, De Angelis CD, Feigin RD, eds. Oski's Pediatrics: Principles and Practice. 3rd ed. Lippincott Williams & Wilkins; 1999. 937-50.
Gormley D. Neonatal anaerobic (clostridial) cellulitis and omphalitis. Arch Dermatol. 1977 May. 113(5):683-4. [QxMD MEDLINE Link].
Karumbi J, Mulaku M, Aluvaala J, English M, Opiyo N. Topical umbilical cord care for prevention of infection and neonatal mortality. Pediatr Infect Dis J. 2013 Jan. 32(1):78-83. [QxMD MEDLINE Link]. [Full Text].
Cosme Jimenez A, Barrio Andres J, Bujanda Fernandez de Pierola L, et al. Clinical characteristics of nonneoplastic cavernomatous transformation of the portal vein at a Gastroenterology Service in Spain. Rev Esp Enferm Dig. 2000 Jul. 92(7):448-57. [QxMD MEDLINE Link].
Painter K, Feldman J. Omphalitis. StatPearls [Internet]. 2019 Jan. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Anatomic relationship between the umbilicus and its embryologic attachments.
A case of omphalitis (left) associated with extensive myonecrosis (right).
A case of omphalitis associated with bullous impetigo due to Staphylococcus aureus.

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Author

Patrick G Gallagher, MD Professor, Departments of Pediatrics, Pathology and Genetics, Division of Neonatal-Perinatal Medicine, Yale University School of Medicine and Yale-New Haven Children's Hospital

Patrick G Gallagher, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Clinical Investigation, American Society of Hematology, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Coauthor(s)

Samir S Shah, MD, MSCE Professor, Department of Pediatrics, University of Cincinnati College of Medicine; Director, Division of Hospital Medicine, James M Ewell Endowed Chair, Attending Physician in Hospital Medicine and Infectious Diseases, Chief Metrics Officer, Cincinnati Children's Hospital Medical Center

Samir S Shah, MD, MSCE is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Society for Pediatric Research, Society of Hospital Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian S Carter, MD, FAAP Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children's Mercy Hospital and Clinics; Faculty, Children's Mercy Bioethics Center

Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization

Disclosure: Nothing to disclose.

Chief Editor

Santina A Zanelli, MD Associate Professor, Department of Pediatrics, Division of Neonatology, University of Virginia Health System

Santina A Zanelli, MD is a member of the following medical societies: American Academy of Pediatrics, American Epilepsy Society, Society for Neuroscience, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Shelley C Springer, JD, MD, MSc, MBA, FAAP Professor, University of Medicine and Health Sciences, St Kitts, West Indies; Clinical Instructor, Department of Pediatrics, University of Vermont College of Medicine; Clinical Instructor, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health

Shelley C Springer, JD, MD, MSc, MBA, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Omphalitis Workup

Laboratory Studies

Other studies and/or procedures

Imaging Studies

Staging

References

Tables

Contributor Information and Disclosures

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