Umbilicus – Delayed Separation

Umbilicus – Delayed Separation: Excerpt from In A Page: Pediatric Signs and Symptoms

Umbilical cord separation usually occurs between 7 and 14 days of life. Delayed cord separation occurs after 2 weeks of life. Separation of the cord that occurs after 3 weeks of life is considered abnormal. The process of cord separation is chiefly due to the migration of neutrophils into the area, with digestion and necrosis of the umbilical cord.

Differential Diagnosis

• Vigorous use of antiseptics to clean the umbilical cord
  –Probably the most common etiology
  –Inhibits normal colonization of the umbilicus, which otherwise would allow chemotactic infiltration of neutrophils to mediate cord separation

• Immunodeficiencies
  –Leukocyte adhesion defects affecting chemotaxis (LAD I/II)
  –LAD is usually associated with significant systemic (sepsis) or local (omphalitis) infection, recurrent infections, or failure to thrive
  –Sialyl Lewis X antigen deficiency
  –Neonatal alloimmune neutropenia
  –Defective immune (gamma) interferon

• Prematurity
  –Gestational age less than 37 weeks
• Birth via cesarean section
  –Associated with delayed separation, possibly due to decreased bacterial colonization from delivery through a sterile surgical field, resulting in decreased infiltration of neutrophils, which is essential for cord separation
• Neonatal sepsis
• Urachal anomalies
  –More likely to be seen in otherwise healthy infants without signs of local or systemic infection
• Histiocytosis X

Workup and Diagnosis

• History
  –Duration of umbilical cord attachment
  –Risk factors for sepsis
  –Recurrent or severe infections, especially without pus formation or resistance to antibiotic therapy
  –Cleaning techniques for cord care and use of water vs antiseptics (e.g., alcohol, triple dye)
  –Gestational age at birth
  –Vaginal birth vs cesarean section
  –Family history, consanguinity of parents

• Physical exam
  –Signs of generalized neonatal infection/sepsis
  –Omphalitis or other signs of local umbilical infection
  –Drainage from the umbilical stump (seen in urachal anomalies)
• Labs
  –Total and differential white blood cell counts (LADs are characterized by leukocytosis)
  –T and B cell subset determination
  –Testing for leukocyte adhesion molecules; look for abnormal expression of CD18, CD11a, b, and c molecules
  –Functional tests for oxidative burst (zymosan-induced assay)
• Studies
  –Ultrasound, CT, or VCUG to search for urachal or genitourinary anomalies

Treatment

• Decreased use of antiseptics (alcohol) along with the implementation of simple cleaning of the cord with water decreases the length of time to umbilical cord separation without increasing the risk of infection
• Surgical excision of umbilical cord
• Treatment of sepsis and infection with antibiotics
• Transplantation of bone marrow or umbilical blood hematopoietic stem cells to correct LADs
• Surgical repair of any urachal anomalies
• Prevention of transmission of autosomal recessive, inherited conditions (such as LAD) by genetic counseling and testing

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

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