Pediatric emergency medicine trisk 640

The umbilical cord remnant necroses and separates from the body at 1 to 3 weeks
of age. It is not unusual to have a small amount of moisture at the base. A slight
foul odor is also not unusual as long as there are no other local or systemic signs
of infection. The odor will generally improve with local care.
Omphalitis
Omphalitis is an infection of the umbilical cord that presents with purulent or
serosanguinous drainage from the umbilical stump. Complications can include
life-threatening necrotizing fasciitis, ascending infection to the liver and systemic
circulation, and staphylococcal scalded skin syndrome. In nonsterile births, there
is also the risk of tetanus contaminating the umbilical stump. Infection may
spread through the umbilical artery and contaminate the peritoneum, causing
infectious peritonitis, or may spread through the arterial system, causing loculated
infections along the iliac or femoral arteries. Signs include purulent and/or foulsmelling discharge from the umbilical stump. There may be associated
periumbilical edema, erythema, or induration in more extensive disease.
Parenteral antibiotics are required. Infants with necrotizing fasciitis may also
need surgical resection of the affected area.
Granuloma
The most common cause of umbilical discharge or moisture is a granuloma. It
typically presents after the cord has separated, and represents granulation tissue
that has not yet epithelized. A benign diagnosis, it must be distinguished from the
less common but more serious lesions of urachal or omphalomesenteric duct
anomalies. Treatment consists of local wound care and cauterization, most often
with silver nitrate. Caution is necessary when applying silver nitrate to avoid
surrounding skin, as it can burn the surrounding tissue. Persistent drainage after
cauterization should increase suspicion for other umbilical abnormalities.
Urachal Anomalies
Urachal anomalies can present at any age, although the neonatal period is the
most common age of presentation for a patent urachus. In this population, typical
presentation includes persistent, active serous drainage of the umbilical stump,
which may ultimately lead to redness and irritation. A patent urachus can be
complicated by urinary tract infections (UTIs). It can be confirmed by US or

voiding cystourethrogram. Symptomatic urachal anomalies are treated surgically
once any active infection has cleared. There is some controversy regarding the
management of asymptomatic anomalies; there may be increased risk of


malignant transformation, although the true incidence of this complication
remains unknown. Patients with urachal anomalies are also at higher risk for
additional genitourinary anomalies, particularly vesicoureteral reflux (VUR),
which can be further evaluated as an outpatient.
Omphalomesenteric Duct Remnants
Omphalomesenteric duct remnants also can present at any age. In the neonatal
period these usually present with persistent discharge from the umbilicus or
stump—the discharge may be clear or bilious. Because omphalomesenteric duct
remnants typically are composed of gastric mucosa, the discharge is often acidic
and can cause local dermatitis. It can also be confirmed by US, and is treated by
surgical excision.

Abnormal Stool
Goals of Treatment
The goal of treatment is to distinguish between benign variations in stool
frequency or color and changes that require urgent evaluation. In the first month
of life, infant stool varies from thick, dark meconium, to green-colored
transitional stool, and eventually yellow, seedy breast-milk stool. Texture may
vary from thick, paste-like stool to a much looser stool. These variations may be
worrisome to a new parent, but rarely reflect any pathology in the infant. This is
in contrast to bloody or acholic stools, as well as chronic watery diarrhea, all of
which require a much more detailed evaluation.
CLINICAL PEARLS AND PITFALLS
Bloody stool is a nonspecific finding that may be benign or lifethreatening in nature.
Acholic stool in a neonate may represent biliary atresia, a condition that

requires urgent diagnosis and intervention and may not present until
several weeks of life.
Hematochezia and Melena
Bloody stool in infants can be relatively benign, caused by anorectal fissures,
swallowed blood from cracked nipples, or a food-protein allergy. In more severe
cases, it can represent life-threatening intestinal ischemia and necrosis, as in
volvulus or enterocolitis. Detailed history and physical examination is necessary
to distinguish benign and worrisome causes of GI bleeding, including feeding and


stooling history, level of alertness, associated pain or tenderness, or any systemic
signs such as fever or apnea. Given the variable transit time of the intestine in
newborns, the distinction between hematochezia and melena is not as helpful in
distinguishing between upper and lower gastrointestinal bleeding and so both
should be evaluated similarly. Laboratory evaluation should include complete
blood count to assess for signs of anemia or chronic blood loss, elevated white
blood count, and/or eosinophilia. If infectious colitis is suspected, blood and stool
cultures should be sent prior to the initiation of intravenous antibiotics.
Abdominal radiograph may be warranted if there is suspicion of obstruction,
malrotation, or NEC.
Allergic Enteropathy
Allergic enteropathy can occur in newborns from an exposure to the offending
protein via formula or breast milk. Most common after 2 months of age, it can
present in the immediate neonatal period, most often with painless hematochezia
with or without associated diarrhea. The most common allergy is to cow-milk
protein, which can also affect breast-fed infants whose mothers ingest cow milk.
Up to 40% of infants with cow-milk protein will also have a soy protein allergy,
so that formula-fed infants should be given extensively hydrolyzed formulas.
Breast-fed infants should have mothers avoid both cow milk and soy products in
their diet. The prognosis for allergic enteropathy is overall good, with quick

resolution of symptoms once the offending protein has been removed from the
diet.
Acholic Stool
Acholic or gray-colored stool represents an obstruction to bilirubin excretion and
is always a pathologic finding. It is more often associated with an obstruction to
the biliary tract, as in biliary atresia, but can also be seen in hepatocellular
disease, such as hepatitis. It is accompanied by cholestasis and conjugated
hyperbilirubinemia. Congenital disorders of the hepatobiliary system may not
develop acholic stools until 2 weeks of life or later, so a history of normal
meconium or stool does not exclude hepatobiliary anomalies. Jaundice is covered
in detail in the previous Section: Color Changes.

Abdominal Masses
Goals of Treatment
Most abdominal mass lesions in the newborn are benign lesions or lesions that
can be monitored by the pediatrician in an outpatient setting. The goal of


treatment is to recognize the abdominal mass that requires urgent evaluation and
treatment.
CLINICAL PEARLS AND PITFALLS
Two-thirds of abdominal masses in the neonate are renal in origin.
Infants with suspected renal masses should be monitored for
hypertension.
Renal Masses
Renal lesions are the most common causes of abdominal masses in the neonate.
Cystic masses typically represent hydronephrosis, multicystic dysplasia, or
polycystic disease. Solid masses include renal vein thrombosis, renal ectopic
kidney, or horseshoe kidney. Rarely, renal masses may represent malignant
disease such as mesoblastic nephroma or Wilms tumor. Depending on the size of

the mass, some infants may develop feeding intolerance or respiratory distress in
the setting of profound abdominal distention. Infants with renal masses should be
monitored closely for hypertension, as most causes of hypertension in the neonate
are renal in origin. Evaluation should include US to distinguish cystic from solid
lesions, as well as serum testing for renal function evaluation. Infants with
hydronephrosis may also require voiding cystourethrogram to assess for
comorbid VUR.
Hepatic Masses
Hepatic masses in the neonate are extraordinarily rare, and can represent
significant pathology. Masses may include congenital hemangiomas, hepatic
mesenchymal hamartomas, hemangioendotheliomas, or hepatoblastoma. Because
of the vascular nature of the liver and the relative immaturity of the hepatic
capsule, rapidly enlarging or vascular lesions are prone to bleeding, which when
present can result in significant hemorrhage. This can result in severe anemia and
heart failure, as well as thrombocytopenia caused by consumptive coagulopathy.
Patients with palpable hepatic masses should undergo additional diagnostic
testing with US, as well as serum testing for complete blood count, liver function
tests, coagulation studies, and alpha-fetoprotein.
Adrenal Masses
Suprarenal masses most often represent adrenal hemorrhage, but can also
represent adrenal neuroblastoma or teratoma. Subclinical adrenal hemorrhage is