Something wrong with baby’s belly button
Umbilical conditions in children.
THE umbilicus, commonly known as the navel or belly button, is an anatomical structure located at the centre of the abdomen. It is a scar which forms after detachment of the umbilical cord after birth.
In utero, the umbilical cord serves as a passage for nutrient and gas exchange between the mother and the foetus. It consists of a few structures, mainly two arteries, one vein, a vitello-intestinal duct and a urachus.
The vi tel lo intestinal duct is a connection between the yolk sac and the primitive gut. The urachus is a connection between the allantois and the bladder.
In birds and reptiles, the yolk sac provides nutrition for the embryo and the allantois functions to collect waste products.
In humans and mammals, these two functions are replaced by the placenta.
By the fifth to seventh week of gestation, the vi tel lo intestinal duct and th eur ac hus will disappear. Persistence of these structures accounts for some of the abnormalities that we see in some children.
In modern practice, umbilical clamping and division is done under aseptic technique in the hospital setting. Dry cord care with routine soap and water bathing with meticulous hand hygiene should be observed during cleaning of the umbilical stump to prevent infection.
Infection of the umbilicus, also known as omphalitis, can be life threatening if not detected and treated early. Cord separation will take place naturally as the cord dries up and falls off.
The average time for cord separation ranges from seven to 14 days. Delay in separation can be caused by infection, persistent umbilical remnants or leukocyte adhesion disorders which warrant further assessment by a paediatric surgeon.
After cord separation, the umbilicus should be cleaned daily during bath and kept dry. A persistently wet and soggy umbilicus should raise suspicion of the following conditions: umbilical granuloma – serous discharge; persistent vi tel lo intestinal fistula– faecal discharge; and persistent urachal fistula – urinary discharge.
Umbilical granuloma
An umbilical granuloma presents as a spot of red granulation tissue at the centre of the umbilicus.
It is believed to be formed due to bacterial colonisation at the base of the umbilical stump after detachment. The raw mucosa constantly secretes serous fluid and can occasionally bleed when rubbed against.
Bleeding is usually self-limiting and stops spontaneously. Umbilical granulomas can be ligated at the stalk or cauterised by application of copper sulfate until epithelization occurs. This lesion is benign and can be treated as a bedside procedure at the outpatient clinic.
Persistent vi tel lo intestinal remnants
Vitellointestinal fistula – This condition is due to failure of closure of the vitelline duct. As a result, a persistent connection is present between the small bowel and the umbilicus.
This is a rare condition. It can be identified by the presence of faecal discharge from the umbilicus. Treatment of this condition consists of surgical excision of the vitelline tract and repair of the small bowel under general anaesthesia.
Vitellointestinal sinus/cyst – Incomplete closure of the vitelline tract leads to formation of a blind ending umbilical pit (sinus) or an enclosed segment with no connection to the skin surface or intestinal lumen (cyst).
Umbilical sinus/cyst often presents with infection. Tenderness, redness and pus discharge around the umbilicus warrants an ultrasound assessment.
Initial drainage and antibiotic therapy is required and excision of the sinus/cyst is done after resolution of the infection.
Vitellointestinal band
This represents a fibrous cord of tissue connecting the deep surface of the umbilicus to the small bowel.
Symptoms occur when a part of small bowel is trapped and twisted around the band, leading to intestinal obstruction. It is also incidentally diagnosed during abdominal surgery for other causes.
Excision of the band will prevent future strangulation of the bowels.
Meckel’s diverticulum
This is an out-pouching in the intestinal wall due to incomplete closure of the vitelline duct. It occurs in about 2% of the general population.
It is two times more common in males, is often symptomatic by two years of age and may contain two types of ectopic mucosa – gastric or pancreatic.
It can get inflamed and present with abdominal pain mimicking acute appendicitis. It can also ulcerate and cause life threatening bleeding.
Bleeding is often sudden in onset with large amounts of fresh blood per rectum. Parents should seek immediate medical attention at the nearest hospital if this happens.
A Meckel’s diverticulum can also cause intussusception, which is invagination of the proximal part of the bowel into the distal part, most often the small bowel telescoping into the large bowel.
Intussusception classically presents between the ages of two months and two years, with intermittent colicky abdominal pain and blood stained stools.
Children with intussusception beyond the age of two years old should be investigated for the presence of a Meckel’s diverticulum.
A Meckel’s scan is helpful in detecting a Meckel’s diverticulum in about 60%-80% of cases. I use a radio nuclear isotope (technetium-99m pertechnate), which is take up by the ectopic gastric mucosa in the diverticulum. The treatment for symptomatic Meckel’s diverticulum is surgical resection.
Persistent urachal stula
This is a persistent connection between the urinary bladder and the umbilicus. Continuous clear discharge from the umbilicus with ammoniac (urinary) rash around the umbilical skin should raise the suspicion of a urachal fistula.
Further investigations should be done to look for lower urinary tract obstruction.
Definitive treatment would be an excision of the urachus and repair of the bladder under general anaesthesia.
Umbilical hernias
Umbilical hernias are common in children. They occur in about 10% of the population. It is due to a delay in the closure of the facial ring, which is a defect in the abdominal wall.
Parents might be alarmed at the size of the swelling, especially during crying or straining, but rest assured that the majority of umbilical hernias undergo spontaneous closure without any complications.
Treatment for this condition would be watchful waiting until the age of three years old. However, large umbilical defects should be inspected carefully to rule out an exomphalos, which is associated with other congenital abnormalities and syndromes.
Take home message
Proper umbilical cord hygiene is important to prevent infection.
Persistent faecal or urinary discharge from the umbilicus warrants further medical attention.
Umbilical hernias are benign and mostly resolve by the age of three years old.
Huge umbilical defects might be associated with other congenital anomalies and will require further assessment by a paediatric surgeon.