Umbilical Granuloma

Umbilical granuloma is a pink or red, moist, soft mass of granulation tissue at the base of the umbilical cord stump after separation, caused by incomplete epithelialisation. Occurs in about 1 in 500 neonates (about 0.2 percent), more often in the first 2 to 3 weeks.

• Normal cord separation occurs between 5 and 15 days (up to 3 weeks). Granulation tissue persists after separation, secreting serous or mucoid fluid, sometimes causing minor bleeding.
• It is benign, not an infection, and not related to hygiene. Contributing factors: delayed cord separation, use of antiseptics or alcohol, moist environment, mild omphalitis.
• Differentials: umbilical polyp (persistent vitello intestinal duct remnant containing enteric mucosa, or urachal remnant), umbilical hernia, omphalitis, patent urachus, patent omphalomesenteric duct, umbilical cord remnant, pyogenic granuloma, epidermoid cyst, hypertrophic scar, neoplasm.

• A soft, moist, pink red nodule (3 to 10 mm) in the umbilical depression with clear or yellowish discharge, possibly bleeding on touch; the surrounding skin is normal; no fever; the baby is well.
• Granuloma is non-painful and does not cause distress.
• Red flags: periumbilical erythema, swelling, induration, pus, foul smell, warmth, fever, lethargy and poor feeding (omphalitis, which is a medical emergency in neonates); discharge of urine (patent urachus), stool or gas (patent vitello intestinal duct), a firm, bright red mass that does not respond to treatment (umbilical polyp), hernia, bleeding, failure to resolve after 4 weeks, signs of sepsis, delayed cord separation beyond 3 weeks (leucocyte adhesion deficiency), recurrent infections.

• Clinical diagnosis from appearance.
• Abdominal and umbilical ultrasound if the lesion fails to respond to treatment, is persistent, or if there is persistent discharge, suspicion of urachal or omphalomesenteric remnants, or abnormal appearance.
• Swab for culture if infection is suspected; full blood count, CRP and blood culture in suspected omphalitis; fistulogram, if needed.
• Biopsy is rarely needed.

• Keep the area clean and dry; fold the nappy below the umbilicus; avoid immersing in water until healed; keep the umbilicus exposed to air.
• Treatment options (small granulomas heal within 1 to 2 weeks, particularly with simple care):
  • Silver nitrate cautery: apply a 75 percent silver nitrate stick directly to the granuloma for 5 to 10 seconds, avoiding the surrounding normal skin (protect with petroleum jelly), once or twice weekly for up to 3 applications; the area turns grey black and heals in days. Avoid in sensitive skin, avoid excessive application (chemical burns).
  • Table salt: apply a small pinch of salt on the granuloma, cover with a gauze or clean cotton for 10 to 30 minutes, then wipe clean with a damp gauze, once or twice daily for 2 to 3 days (high cure rate; supervision to avoid skin irritation).
  • Topical clobetasol 0.05 percent cream applied twice daily for up to 1 week is a specialist option for granulomas that fail simple measures.
  • Ligation with surgical suture or electrocautery or excision for large or pedunculated granulomas, or when simple measures fail (paediatric surgeon).
• Treat omphalitis urgently: admit, take blood cultures, swab, and give intravenous flucloxacillin 25 to 50 mg/kg every 6 to 12 hours (according to age) plus gentamicin 5 mg/kg once daily (adjust for age and renal function); add metronidazole 7.5 mg/kg every 8 hours if necrotising infection is suspected; surgical review for necrotising fasciitis.
• Umbilical polyp, patent urachus or omphalomesenteric remnant: refer to paediatric surgery for excision.
• Review in 1 to 2 weeks after treatment; refer if no resolution within 4 weeks, recurrence, discharge of urine or stool, or any red flags.