Umbilical granulomas are often an incidental finding on physical exam, but can be the reason a patient presents to the ED. These fleshy pink masses represent incomplete epithelialization of tissue that persists after the cord separates. It has the honor of being the #1 belly button mass in newborns. On exam they are soft, wet and pink and can be friable (bleed easily with friction). The chief complaint may be “bleeding belly button.”

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The differential diagnosis includes:

Umbilical polyps

Usually more firm with mucoid secretions

Omphalitis

Infection of the umbilicus and surrounding structures. Babies with this diagnosis can be febrile and are generally ill appearing. Abdominal wall cellulitis or peritonitis can ensue and neonates need a complete sepsis workup with inpatient admission and empiric broad-spectrum parenteral antibiotics.

Management

Though parents are often worried, reassurance is often all that is necessary. They should be advised to keep it dry and exposed to the air. They may have heard from a relative that alcohol should be applied to the base of the cord to help it dry out. This is not recommended and may lead to irritation. In granulomas that are particularly large or friable you can apply silver nitrate to cauterize. The steps for this procedure are as follows:

  1. Clean the local area
  2. Protect surrounding skin with petrolatum jelly or antibiotic ointment
  3. If the granuloma is dry, apply tap water to moisten it before application, as the silver nitrate sticks require moisture to activate
  4. Hold the 75% silver nitrate stick against the granuloma for 2-3 seconds until the tissue turns from red to grey or black

Avoid touching or splashing it onto adjacent skin, as this can cause irritation and staining.

Tell the parents that the cauterization may need to be repeated at 3-day intervals if drainage persists. This can almost certainly be done at the PMDs office.