Pediatric emergency medicine trisk 640

The umbilical cord remnant necroses and separates from the body at to 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 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 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 ... 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