Umbilical granuloma is the most common umbilical abnormality in newborn children or neonates, causing inflammation and drainage.[1][2][3] It may appear in the first few weeks of newborn infants during the healing process of the umbilical cord due to an umbilical mass.[4] It is the overgrowth of the umbilical tissue.[5] It develops in about 1 out of 500 newborns.[6] With appropriate treatment, it is expected to heal in 1~2 weeks.[7]

Causes

Following umbilical cord clamping during delivery, the umbilicus base will spontaneously separate within 7-15 days. With routine cord care and proper hygienic conditions, the remaining umbilical base will heal and new skin tissue will form. In some instances, a mass of tissue, or granuloma, will form at the base.[8][9]

Umbilical granulomas occur after umbilical cord removal when the remaining ring of the umbilicus undergoes incomplete wound healing and there is excessive healing tissue, also known as granulation tissue.[10]

Delayed cord separation, mild infections and hygienic conditions are all factors which may contribute to the incidence of umbilical granuloma.[11] Although the exact cause of umbilical granulomas is unknown, it is hypothesized that inflammation of the remaining umbilical stump drives skin cell division, resulting in a tissue mass, rather than proper healing at the site.[11]

Histophysiology

An umbilical granuloma is a physiological response which surpasses the normal processes of skin restoration following umbilical cord clamping.[12][13] Once the skin lesion is formed, there is an excess of fibroblast production. These fibroblasts, or connective tissue cells, are responsible for the production of collagen and additional fibers, resulting in the excess tissue mass found in the granuloma.[13][14] Additional histological studies reveal an increase of cell division of vascular endothelial cells.[13][14] These cells line our blood vessels and are further responsible for the growth and development of tissue and the formation of new blood vessels within the granuloma.[13][14]

Pathophysiology

Inflammatory saprophytic microorganisms, involved with decomposition, may delay the healing process, and can lead to overproduction of fibroblasts that are involved in normal skin restoration. These microorganisms can interfere with the skin’s normal flora, and lead to increased pathogenic inflammation that leads to delayed epithelialization and the formation of granulomas with excessive blood vessels, fibroblasts, and mucus.[15]

Signs and symptoms

Umbilical granulomas appear as round, pink lumps found at the base of the umbilicus after the removal of the umbilical cord. It appears small, pink/red, and moist due to cord separation. They are usually 1-10 mm in size, however grow in size if they are not treated. Umbilical granulomas are also painless since they do not contain nerve fibers. In some cases, they may contain an odorless discharge, or may be covered in a clear mucus. The surrounding skin of the infant's umbilicus site will appear normal. [16]

Umbilical granulomas can become entry points for infectious agents. Symptoms such as edema, redness around the umbilical site, pain or discomfort when the area is touched, accompanied by a fever and purulent discharge, may indicate sepsis or a serious infection at the umbilicus site.[15]

Diagnosis

Umbilical granuloma can be diagnosed from physical examination. If there is a discharge around the navel and the granulation tissue is large enough to be visible with the open eye, umbilical granuloma is the first to be suspected. Open eye inspection and/or dermoscopy is commonly used to recognize the granular tissue at the site. If the granuloma is not visible with the open eye, gentle pressure on the surrounding site or a surgical tweezer can be used to expose the small granuloma hidden within the umbilical pit. An otoscope may also be used by physicians in order to expose a small, sessile granuloma. Other additional tests are usually not required, but if continued, ultrasonography (US) can be used for initial diagnosis of umbilical lesions.[17]

Treatment

Topical

Although there is no singular method of treatment for umbilical granulomas, some treatment options available include common salt, silver nitrate, corticosteroids, and cleaning with alcohol.[18] Home care following treatments include gentle cleaning the navel area with soap and sterile water, followed by open exposure of the belly button to air.[19]

Silver nitrate

Silver nitrate is the most common treatment and practiced worldwide. Neonatology textbooks suggest silver nitrate as a first-line treatment option.[20] The application of silver nitrate to granulomas was first noted in early 1800s as a cauterizing agent.[20]

Silver nitrate can be used as an antiseptic, an astringent, and as a caustic agent, depending on the indication.[20] It's application requires medical personnel for treatment and may have unfavorable adverse effects if applied improperly.[21] In the treatment of umbilical granulomas, silver nitrate is applied to the umbilical site to burn off the excess tissue.[20] The absence of nerve endings within the granuloma make this a painless treatment for the newborn.[21] While painless, contact of silver nitrate to the adjacent, healthy, normal tissue may result in burns.[21] Silver nitrate application to the infected site should not exceed three applications with an interval of 3-4 days. In this event, alternative treatments should be considered[21] Following treatment with silver nitrate, the granuloma is expected to shrink and resolve within 7 days.[21]

Double-ligature treatment

In cases with deeply located umbilical granulomas, the double-ligature technique can be utilized to ligate the base of the granuloma. The procedure involves prepping and sterilizing the umbilical area with iodine solution, placing a silk suture around the base of the lesion to keep in place, and finally placing a more exact ligature around the granuloma. Much like the normal process of umbilical cord residue healing, the ligated granuloma will necrose due to lack of blood supply and will fall off naturally within 1 to 2 weeks. Minor complications of this technique include minimal bleeding and possibly requiring more ligatures than the original double ligation.[22]

Cryocautery

Cryocautery can be utilized to freeze the umbilical granuloma by using cryogenic nitrous oxide along with other equipment. During cryocautery procedures, the umbilical site is first cleaned. The physician will then hold a cyroprobe with nitrous oxide as a refrigerant directly to the granuloma for 3 minutes. One risk of utilizing this technique is burning the skin surrounding the granuloma. Following the procedure, the naval site is cleansed, left exposed to the air and the infant is discharged.[23] [24]

Cyrocautery is more commonly used for freezing for post hysterectomy granulation tissue. However, though more expensive and complex, cryosurgery is an effective treatment for the indication of umbilical granulomas in infants as well. [23]

Prevention

Newborn naval care

In order to reduce the possibility of an infection or inflammation at the umbilical site, the World Health Organization (WHO) has advocated for the use of dry umbilical cord care in high resource settings. Dry cord care includes keeping the newborn's umbilical area clean and exposed to air or loosely covered by a clean cloth.[25] The remainder of the umbilicus should be cleaned once daily with soap and sterile water. Chlorhexidine is recommended in substitute of sterile water for areas in which infection risks are high.[19]

Diaper positioning can also influence infection risk. Keeping the diaper area clean and reducing moisture at the site can reduce the chance of developing an infection. Aim to position the diaper by rolling the top portion down to sit under the navel, keeping the site open and exposed to air.[25]

Cord clamping technique

The incidence of umbilical granuloma may be influenced by the method of cord clamping. It has been suggested that proximal cord clamping of the umbilical cord for 24 hours reduces the chance of infection at the naval site compared to other cord clamping practices.[26]

Timing

Umbilical cord clamping timing can vary in time intervals.[27] Early clamping is categorized as within the first 60 seconds after birth, whereas late umbilical cord clamping is classified as more than one minute after the birth.[27] There is no evidence indicating that time to umbilical cord clamping has had an effect on umbilical granuloma formation or on additional neonatal morbidity outcomes.[27]

Complications

If an infection occurs, omphalitis may occur.[28]

Recurrence risk

The various treatment modalities of umbilical granuloma result in various recurrence risks.[29] In a systematic review, following infants through weeks 1, 3 and 6 post-treatment for umbilical granuloma, newborns treated with silver nitrate presented with a 9% recurrence risk, whereas newborns treated with common salt presented null recurrence.[29]

See also

References

  1. ↑ Rapini RP, Bolognia JL, Jorizzo JL (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 978-1-4160-2999-1.
  2. ↑ Pomeranz A (June 2004). "Anomalies, abnormalities, and care of the umbilicus". Pediatric Clinics of North America. 51 (3): 819–27, xii. doi:10.1016/j.pcl.2004.01.010. PMID 15157600. S2CID 12607171.
  3. ↑ Nagar H (September 2001). "Umbilical granuloma: a new approach to an old problem". Pediatric Surgery International. 17 (7): 513–514. doi:10.1007/s003830100584. PMID 11666047. S2CID 41675339.
  4. ↑ Haftu H, Gebremichael TG, Kebedom AG (2020). "Salt Treatment for Umbilical Granuloma - An Effective, Cheap, and Available Alternative Treatment Option: Case Report". Pediatric Health, Medicine and Therapeutics. 11: 393–397. doi:10.2147/PHMT.S269114. PMC 7533262. PMID 33061745.
  5. ↑ Tiwari LN, Vijayalaxmi M, Shailaja U, Bhandari M (2021). "Management of umbilical granuloma through chemical cauterization (Ksharakarma)-A case study". Journal of Ayurveda and Integrative Medicine. 12 (1): 169–171. doi:10.1016/j.jaim.2020.10.003. PMC 8039328. PMID 33342647.
  6. ↑ Daruwalla SB, Dhurat RS (August 2020). "A pinch of salt is all it takes! The novel use of table salt for the effective treatment of pyogenic granuloma". Journal of the American Academy of Dermatology. 83 (2): e107–e108. doi:10.1016/j.jaad.2019.12.013. PMID 31838042. S2CID 209385663.
  7. ↑ Haftu H, Gebremichael TG, Kebedom AG (2020). "Salt Treatment for Umbilical Granuloma - An Effective, Cheap, and Available Alternative Treatment Option: Case Report". Pediatric Health, Medicine and Therapeutics. 11: 393–397. doi:10.2147/PHMT.S269114. PMC 7533262. PMID 33061745.
  8. ↑ Pomeranz A (June 2004). "Anomalies, abnormalities, and care of the umbilicus". Pediatric Clinics of North America. 51 (3): 819–27, xii. doi:10.1016/j.pcl.2004.01.010. PMID 15157600. S2CID 12607171.
  9. ↑ Muniraman H, Sardesai T, Sardesai S (July 2018). "Disorders of the Umbilical Cord". Pediatrics in Review. 39 (7): 332–341. doi:10.1542/pir.2017-0202. PMID 29967078. S2CID 49642101.
  10. ↑ Kim DH, Lee HJ, Kim JY, Jung HR (April 2021). "Differential diagnosis of umbilical polyps and granulomas in children: sonographic and pathologic correlations". Ultrasonography. 40 (2): 248–255. doi:10.14366/usg.20020. PMC 7994741. PMID 32660210.
  11. 1 2 Fahmy M (2018). Umbilicus and Umbilical Cord. Springer International Publishing AG. doi:10.1007/978-3-319-62383-2. ISBN 978-3-319-62382-5. S2CID 46822692.
  12. ↑ Brady M, Conway AB, Zaenglein AL, Helm KF (February 2016). "Umbilical Granuloma in a 2-Month-Old Patient: Histopathology of a Common Clinical Entity". The American Journal of Dermatopathology. 38 (2): 133–134. doi:10.1097/DAD.0000000000000429. PMID 26488717. S2CID 24127461.
  13. 1 2 3 4 Jaime TJ, Jaime TJ, Ormiga P, Leal F, Nogueira OM, Rodrigues N (2013). "Umbilical endometriosis: report of a case and its dermoscopic features". Anais Brasileiros de Dermatologia. 88 (1): 121–124. doi:10.1590/S0365-05962013000100019. PMC 3699952. PMID 23539017.
  14. 1 2 3 Ancer-Arellano J, Argenziano G, Villarreal-Martinez A, Cardenas-de la Garza JA, Villarreal-Villarreal CD, Ocampo-Candiani J (May 2019). "Dermoscopic findings of umbilical granuloma". Pediatric Dermatology. 36 (3): 393–394. doi:10.1111/pde.13774. PMID 30811653. S2CID 73472870.
  15. 1 2 Mshelbwala PM, Sabiu L, Chirdan LB, Ameh EA, Nmadu PT (June 2006). "Persistent umbilical discharge in infants and children". Annals of Tropical Paediatrics. 26 (2): 133–135. doi:10.1179/146532806X107485. PMID 16709332. S2CID 32511695.
  16. ↑ Campbell J, Beasley SW, McMullin N, Hutson JM (November 1986). "Clinical diagnosis of umbilical swellings and discharges in children". The Medical Journal of Australia. 145 (9): 450–453. doi:10.5694/j.1326-5377.1986.tb113871.x. PMID 3773830. S2CID 36026510.
  17. ↑ Kim DH, Lee HJ, Kim JY, Jung HR (April 2021). "Differential diagnosis of umbilical polyps and granulomas in children: sonographic and pathologic correlations". Ultrasonography (published 2020-05-26). 40 (2): 248–255. doi:10.14366/usg.20020. PMC 7994741. PMID 32660210.
  18. ↑ Srinivas Jois R, Rao S (August 2021). "Management of umbilical granuloma in infants: A systematic review of randomised controlled trials". Australian Journal of General Practice. 50 (8): 589–594. doi:10.31128/AJGP-04-20-5371. PMID 34333576. S2CID 236773298.
  19. 1 2 Imdad A, Mullany LC, Baqui AH, El Arifeen S, Tielsch JM, Khatry SK, et al. (2013). "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. 13 (3): S15. doi:10.1186/1471-2458-13-S3-S15. PMC 3847355. PMID 24564621.
  20. 1 2 3 4 Daniels J (November 2001). "Is silver nitrate the best agent for management of umbilical granulomas?". Archives of Disease in Childhood. 85 (5): 432. doi:10.1136/adc.85.5.431. PMC 1718971. PMID 12035816.
  21. 1 2 3 4 5 Majjiga VS, Kumaresan P, Glass EJ (July 2005). "Silver nitrate burns following umbilical granuloma treatment". Archives of Disease in Childhood. 90 (7): 674. doi:10.1136/adc.2004.067918. PMC 1720504. PMID 15970607.
  22. ↑ Lotan G, Klin B, Efrati Y (May 2002). "Double-ligature: a treatment for pedunculated umbilical granulomas in children". American Family Physician. 65 (10): 2067–2068. PMID 12046774.
  23. 1 2 Arutyunyan I, Fatkhudinov T, Sukhikh G (September 2018). "Umbilical cord tissue cryopreservation: a short review". Stem Cell Research & Therapy. 9 (1): 236. doi:10.1186/s13287-018-0992-0. PMC 6138889. PMID 30219095.
  24. ↑ Srinivas Jois R, Rao S (August 2021). "Management of umbilical granuloma in infants: A systematic review of randomised controlled trials". Australian Journal of General Practice. 50 (8): 589–594. doi:10.31128/AJGP-04-20-5371. PMID 34333576. S2CID 236773298.
  25. 1 2 Stewart D, Benitz W (September 2016). "Umbilical Cord Care in the Newborn Infant". Pediatrics. 138 (3): e20162149. doi:10.1542/peds.2016-2149. PMID 27573092. S2CID 25809235.
  26. ↑ Niermeyer S (2015). "A physiologic approach to cord clamping: Clinical issues". Maternal Health, Neonatology and Perinatology. 1: 21. doi:10.1186/s40748-015-0022-5. PMC 4823683. PMID 27057338.
  27. 1 2 3 McDonald SJ, Middleton P, Dowswell T, Morris PS, et al. (Cochrane Pregnancy and Childbirth Group) (July 2013). "Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes". The Cochrane Database of Systematic Reviews. 2015 (7): CD004074. doi:10.1002/14651858.CD004074.pub3. PMC 6544813. PMID 23843134.
  28. ↑ Painter K, Anand S, Philip K (2022). Omphalitis. Treasure Island (FL): StatPearls Publishing. PMID 30020710. Retrieved 2022-07-26. {{cite book}}: |work= ignored (help)
  29. 1 2 Haftu H, Gebremichael TG, Kebedom AG (2020). "Salt Treatment for Umbilical Granuloma - An Effective, Cheap, and Available Alternative Treatment Option: Case Report". Pediatric Health, Medicine and Therapeutics. 11: 393–397. doi:10.2147/PHMT.S269114. PMC 7533262. PMID 33061745.
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