UMEM Educational Pearls - Pediatrics

Epidemiology:

Trampoline injuries doubled between 1991 and 1996, increasing from 39,000 injuries per year to more then 83,000 injuries per year.  Injury rates and trampoline sales peaked in 2004 and have been decreasing since; however, hospitalization rates are still between 3% and 14%.

Risk Factors:

¾ of injuries occur when multiple people are on the trampoline at once

Smaller participants were 14x more likely to be injured then their heavier playmates

Falls account for 27-39% of all injuries

Springs and frames account for 20% of injuries

Up to ½ of injuries occur despite adult supervision

Injury types:

Lower extremity injuries are more common than upper extremity

Head and neck injuries accounted for 10-17% of trampoline injuries

Unique Injuries:

Proximal tibial fractures

Manubriosternal dislocations and sternal injuries

Vertebral artery dissection

Atlanto-axial subluxation

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Category: Pediatrics

Title: Fever and neck pain (submitted by Connor Lundy, MD)

Keywords: meningitis, neck pain, retropharyngeal abscess (PubMed Search)

Posted: 11/16/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Question

A 1 year old gets sent from their pediatrician’s office for rule out meningitis. They presented with fever for 2 days and neck rigidity. Your LP results are normal. What additional test should you consider?
 

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Conventional pediatric nasal cannula can safely deliver up to 4 lpm but are limited by cooling and drying of the airway. This leads to decreased airway patency, nasal mucosal injury, bleeding and possibly increase in coagulase negative staph infections.

HFNC delivers flow up to 40 lpm with 95-100% relative humidity at a controlled temperature. In infants, the initial flow rate is set between 2-4 lpm and can be increased to 8 lpm. Older children and can be started at 10 lpm and increased as high as 40 lpm. Oxygen is also adjustable.

Studies have shown improved comfort, respiratory rate and oxygenation compared to nasal CPAP.

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- If child is <6 months think: laryngomalacia and if >6y-3y/o think croup
- The differential of child with stridor <6m:
Ø  laryngomalacia
Ø  vocal cord paralysis
Ø  subglottic stenosis
Ø  vascular ring structures
- Other causes of stridor: tracheitis, epiglottitis, trauma, foreign body, deep neck space infection
- Tips for the treatment of croup:
Ø  Dexmethasone is superior to prednisolone. Start dexmethasone  at 0.15-0.6 mgkg. Typically one time dosing is sufficient. PO/IM forms are considered equivalent.
Ø  A 2011 Cochrane review found no difference in the type of nebulized epinephrine used.
Ø  If regular epinephrine dosing is 0.5 ml/kg of 1:1000. If 2.25% racemic epinephrine, give 0.05 ml/kg.
 
http://www.youtube.com/watch?v=1Enq2BvX9aw&feature=fvwrel
 
References
Donaldson D, et al. Intramuscular versus oral dexamethasone for the treatment of moderate-to-severe croup: a randomized, double-blind trial. Acad Emerg Med. 2003 Jan;10(1):16-21.
Leung AKC, Cho H. Diagnosis of stridor in children. Am Fam Physician. 1999 Nov 15;60(8):2289-2296.
Sparrow A, Geelohoed G.  Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. 2006 Jul;91(7):580-3.

Category: Pediatrics

Title: Pediatric Cerebral Edema in DKA

Posted: 10/12/2012 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • approximately 1% of children in DKA have some degree of cerebral edema, and up to 25% of them may die
  • known risk factors include the following:
  1. younger children (especially <5 years)
  2. new onset or newly diagnosed
  3. increased BUN at presentation
  4. severity of acidosis at presentation
  5. bicarbonate therapy use
  6. failure of sodium to improve following therapy

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Category: Pediatrics

Title: Vaccines in children less then 1 year

Keywords: Vaccines (PubMed Search)

Posted: 10/5/2012 by Jenny Guyther, MD (Updated: 12/8/2022)
Click here to contact Jenny Guyther, MD

We often ask our pediatric patients if there vaccines are up to date, but what does this mean?

Hepatitis B: birth, 2 and 6 months

Diphtheria/Tetanus and Acellular Pertussis: 2, 4 and 6 months

Pneumococcal vaccine: 2, 4 and 6 months

Haemophilus influenzae B : 2, 4 and 6 months

Polio: 2, 4 and 6 months

Rotavirus: 2 and 4 months or 2, 4 and 6 months depending on the brand. 

Influenza: 6 months and older

Children less than 8 years old should receive 2 doses of flu vaccine at least 4 weeks apart during the first flu season that they are immunized.  Children older than 2 years are eligible for the nasal vaccine if they do not have asthma, wheezing in the past 12 months or other medical conditions that predispose them to flu complications.

To see the full vaccine schedule including exact time frames between doses and catch up schedules, see: http://www.cdc.gov/vaccines/schedules/downloads/child/0-6yrs-schedule-pr.pdf

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The incidence of pediatric syncope is common with 15%-25% of children and adolescents experiencing at least one episode of syncope before adulthood. Incidence peaks between the ages of 15 and 19 years for both sexes.

Although most causes of pediatric syncope are benign, an appropriate evaluation must be performed to exclude rare life-threatening disorders. In contrast to adults, vasodepressor syncope (also known as vasovagal) is the most frequent cause of pediatric syncope (61%–80%).  Cardiac disorders only represent 2% to 6% of pediatric cases but account for 85% of sudden death in children and adolescent athletes.  17% of young athletes with sudden death have a history of syncope.

Key features on history and physical examination for identifying high-risk patients include exercise-related symptoms, a family history of sudden death, a history of cardiac disease, an abnormal cardiac examination, or an abnormal ECG.

Pediatric Dysrhythmias that can cause syncope in children:
- Congenital long QT
- Brugada syndrome
- Catecholaminergic polymorphic VT
- Wolff-Parkinson-White syndrome (WPW)
- Congenital short QT
- Hypertrophic Cardiomyopathy (HCM)
- Arrythmogenic RV dysplasia.
 
 
Reference:
Fischer JW, Cho CS. Pediatric syncope: cases from the emergency department. Emerg Med Clin North Am. 2010 Aug; 28(3):501-16.

Category: Pediatrics

Title: Pediatric intubation (submitted by Danya Khoujah, MBBS)

Keywords: premedication, RSI, ventilator, high flow nasal cannula (PubMed Search)

Posted: 9/21/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

When intubating an infant, a few key points need to be kept in mind:
- Remember that the narrowest point is the cricoid, so even if the ETT passes the cords it might still not pass through the cricoid itself.
- Remember premedication with atropine is recommended in all children less that 1 year old and in those less than 5 years old when using succinylcholine. It is used to prevent reflex bradycardia and high ICP and to decrease secretions. The dose is 0.02 mg/kg IV, with a minimum of 0.1 mg and a max of 0.5 mg. Give it 2 full minutes before the start of intubation.
- Remember that succinylcholine is contraindicated in neuromuscular disease (including an undiagnosed myopathy). A slightly higher dose (2mg/kg) may need to be used in infants (compared to 1-1.5mg/kg in adults and older children).  
- Pressure control mode is preferred over volume control (VC) setting in peds, because VC tends to overestimate how much volume it's delivering, therefore delivering inadequate ventilation.
- Remember your alternatives: High Flow Nasal cannula (HFNC) can be used in infants with respiratory distress to avoid intbation. One study showed that is decreased intubation rates by 68% in respiratory distress due to bronchiolitis
 
References:
1. Santillanes G, Gausche-Hill M. Pediatric Airway Management. Emerg Med Clin N Am 26 (2008) 961–975
2. Bledsoe G H, Schexnayder S M. Pediatric Rapid Sequence Intubation A Review. Ped Emerg Care 20 (2004) 339-344

Category: Pediatrics

Title: Night Terrors

Posted: 9/15/2012 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • sleep disruption silimar to a nightmare, but much more dramatic most often between 4-12 years
  • sudden fear reaction which occurs during the transition to and from deep non-REM sleep while nightmares occur during REM sleep
  • occurs 2-3 hours after falling asleep when the child suddenly awakens in distress and may thrash about, scream, cry
  • child returns to sleep with no memory of the event the following morning
  • often occurs when a child is stressed, overtired, on new medication, or sleeping in a new environment
  • do not awaken the child during the event but rather allow them to calm on their own

Category: Pediatrics

Title: Evaluating the Cervical Spine in Pediatric Trauma

Keywords: cervical spine, trauma, pediatrics (PubMed Search)

Posted: 9/7/2012 by Lauren Rice, MD
Click here to contact Lauren Rice, MD

 

 

Ligamentous laxity is increased in children and ligamentous injury is more common than fractures.

If fractures occur, they are more likely to be in the upper cervical spine in infants and the lower cervical spine in older children.

Pseudosubluxation:  physiologic subluxation between C2-3 and C3-4 may exist until age 16 years

 

 

Screening Assessment/Clearance for Verbal Children

-Midline C-spine tenderness?

-Pain with active motion?

-Altered level of alertness?

-Evidence of intoxication?

-Focal neurological deficit?

-Distracting painful injury?

-High impact injury?

 

Screening Assessment/Clearance for Pre-Verbal Children

-Neurological assessment of basic reflexes

-Response to painful stimuli

-Equal movements of all extremities

-Response to sound (eye tracking)

-Extremity strength and resistance

-Palpate posterior C-spine (observe for facial grimace)

-Feel for step-offs, deformities

-Verify full range of motion of neck (may need to be creative) 

-Repeat neurological assessment 

 

If concern arises on screening assessment, keep child in hard cervical collar and image (may start with x-ray and progress to CT if still concerned and x-rays negative).

If imaging negative, but persistent suspicion based on neurological deficits consider SCIWORA (Spinal Cord Injury WithOut Radiographic Abnormality) which exists in up to 50% of children with cervical cord injury, and may require MRI to further identify injury.


The mortality from septic shock and severe sepsis ranges between 10-12%.

The PALS algorithm includes 5 points in management.  The first two points are optimally reached within one hour:
1) Recognition of sepsis and vascular access
2) 20ml/kg IVF X 3 within 1 hour or 60ml/kg IVFs within 15 minutes and antibiotic administration
3) Determine if fluid responsive
4) ICU monitoring and/or
5) Vasoactive medications

A recent study at a tertiary care children's hospital retrospectively reviewed 126 patients diagnosed with sepsis. Their findings:

- 37% received 60ml/kg in 60 minutes
- 11% received 60ml/kg in 15 minutes
- 70% received antibiotics in 60 minutes
- In 49% of cases fluids were delivered via IV infusion pump versus manual or pressure bag
- There was a 57% shorter overall hospital stay and 42% shorter ICU stay in patients that received 60ml/kg IVFs within 60 minutes.
- Similarly adherence to the algorithm resulted in decrease hospital stay.
- Liver enzymes, coagulation profiles, and lactic acid levels were obtained in "few" patients.

Conclusions:
Suboptimal fluid resuscitation in sepsis is linked to longer hospital stays. Knowledge of PALS guideline and faster administration of fluid were thought to have been causes of poor adherence.

Additionally, parameters measured in sepsis including lactic acid, coagulation studies, and liver enzymes were not routinely collected. The authors concluded this came from a lack of knowledge of their utility in sepsis.


References:
Paul R, et al. "Adherence to PALS Sepsis Guidelines and Hospital Length of Stay." Pediatrics: 2012 Jul 2 [epub adhead of print].

Types:
- Uniphasic anaphylaxis: occuring immediately after exposure to allergen, resolves over minutes to hours and does not recur
- Biphasic anaphylaxis: occuring after apparent resolution of symptoms typically 8 hours after the first reaction. Occur in up to 23% of adults and up to 11% of children with anaphylaxis

Treatment:
1. First line: IM epinephrine 1:1000 solution
   - vasoconstrictor effects on hypotension and peripheral vasodilation; bronchodilator effects on upper respiratory obstruction
   - NO absolute contraindication for use in anaphylaxis
   - Dosage: Adult: 0.3 - 0.5mg; Peds: 0.01mg/kg (max 0.3mg)
   - can be repeated every 5-15 minutes
2. Adjunctive therapy:
   - H1 Blocker: diphenhydramine 1-2mg/kg up to 50mg IV
   - H2 Blocker: ranitidine 1-2mg/kg
   - Corticosteroid: 1-2 mg/kg for prevention of biphasic reactions
   - Bronchodilator: Albuterol for bronchospasm
   - Glucagon: for refractory hypotension or if patient is on beta blocker
          - Dosage: Adult: 1-5 mg; Peds 20-30microgm/kg
          - Dose may be repeated or followed by infusion of 5-15 mg/min
   - place patient in recumbent position if tolerated with lower extremities elevated
   - supplemental O2
   - IV fluids for hypotension

Fatalities: typically seen with peanut or treenut ingestions from cardiopulmonary arrest. Associated with delayed or inappropriate epinephrine dosing

Disposition:
   - Mild reaction with symptom resolution: observe for 4-6 hrs (ACEP, AAP)
   - Recurrent symptoms or incomplete resolution: admit

Bonus pearl:
(For children) Follow the "Rule of 2's":
2 system involvement,
2 mg/ kg diphenhydramine
2 mg/kg ranitidine
2 mg/kg solumedrol
2 types of epi-pens available: 0.15 mg and 0.3 mg .... weight-based!


Reference:
1. World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis, Feb 2011
2. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID-Sponsored Expert Panel Oct 2010


Category: Pediatrics

Title: Pertussis (submitted by Andy Windsor, MD)

Keywords: vaccination, whooping cough (PubMed Search)

Posted: 8/17/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

If you have a patient who meets (or has had close exposure to someone meeting) the clinical case definition of pertussis (a cough lasting at least 2 weeks with one of the following: paroxysms of coughing, inspiratory “whoop,” or post-tussive vomiting) here are some important points to keep in mind:

Vaccination

  • Be wary that children younger than 7 might not be “up to date” for pertussis vaccination.
    • The recommended schedule is four primary doses of DTap at 2, 4, 6 and 15-18 months, and a fifth DTap booster at 4- 6 years old. ACIP now recommends kids 7 and older get a Tdap booster if their immunizations were previously incomplete.

Testing

  • The available testing modalities for routine surveillance are culture and/or PCR (from a posterior nasopharyngeal swab or aspirate) and serologic testing.
    • Serologic results are not currently accepted as laboratory confirmation for purposes of national surveillance, but may be more useful for testing patients in the convalescent stage.

Treatment

  • The CDC recommends treatment of clinical or confirmed cases with one of these regimens:
    • Azithromycin daily x 5 days
    • Clarithromycin BID x 7 days
    • Erythromycin QID x 14 days
    • Trimethoprim/sulfamethoxazole (Bactrim) BID x 14 days if resistance or allergy to macrolides
      • However, a 2011-updated Cochrane review showed that short-term antibiotics (azithromycin for 3-5 days, or clarithromycin or erythromycin for 7 days) were as effective as long-term (erythromycin for 10-14 days)  (RR 1.01) (95% CI  0.98-1.04). Trimethoprim/sulfamethoxazole for seven days was also effective.
  • Insufficient evidence to decide whether there is clear benefit for treating healthy contacts, but the CDC does recommend prophylactic treatment of close contacts and family members.

 

References:

Altunaiji SM, Kukuruzovic RH, Curtis NC, Massie J. Antibiotics for whooping cough (pertussis). Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004404. DOI: 10.1002/14651858.CD004404.pub3

http://www.cdc.gov/vaccines/pubs/surv-manual/chpt10-pertussis.html


  • small growth of grainy pink/redish tissue that forms on an area of the umbilical stump which is inflamed and produces a sticky mucous dishcarge not allowing normal tissue to grow on top of it
  • caused by abnormal tissue healing after the remaining umbilical cord dries up and falls off
  • treatment is painless as the granuloma lacks innervation, and requires applying chemical silver nitrate directly to the granumloma to burn the tissue off
  • although rare, careful examination of the tissue is needed to enssure the tissue is not intestinal or bladder in origin

Category: Pediatrics

Title: Henoch-Schonlein Purpura

Posted: 8/3/2012 by Lauren Rice, MD (Updated: 12/8/2022)
Click here to contact Lauren Rice, MD

 

Henoch-Schonlein Purpura (aka. Anaphylactoid purpura) is a small vessel vasculitis.

Background:

  • most commonly diagnosed vasculitide in childhood
  • age range 3-15 years, mean age 4yo, mostly <7yo (75% cases)
  • more cases in Winter and Spring months
  • boys more commonly than girls (2:1)
  • IgA-mediated leukoclastic vasculitis

Clinical Features:

  • Rash: progresses to petechiae, purpura; occurs on lower extremities and buttocks in dependent areas
  • Joints: arthritis/arthralgia mainly of large joints (knees, ankles)
  • GI: colicky abdominal pain, may occur with melena (33%) or less likely, hematemesis; ultrasound for intussusception (2-14%)
  • Renal: microscopic hematuria with/without proteinuria; usually transient but may lead to progressive renal disease in patients with more severe, persistent symptoms
  • Orchitis and/or angioedema may also occur

Etiology:

  • unknown
  • preceding URI (50%)
  • associated with bacteria (Strep pyogenes, Legionella, Mycoplasma), viruses (EBV, CMV, parvovirus), drugs (penicillin, cephalosporins), and insect bites

Diagnosis:

  • clinical features
  • lab studies that are helpful but nonspecific: high WBC, high ESR, high IgA, normal platelet and coagulation studies

Treatment:

  • supportive care, may last up to 4 weeks
  • steroids may be helpful but evidence has not shown true benefit
  • recurrence happens in 40% of cases

Category: Pediatrics

Title: Neonatal jaundice (submitted by Adam Brenner, MD)

Keywords: hemolysis, bilirubin, kernicterus, jaundice (PubMed Search)

Posted: 7/27/2012 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Emergency physicians must be comfortable evaluating the neonate, and be able to manage, offer guidance to parents, and interpret and discuss bilirubin levels with pediatricians to prevent development of kernicterus
 
1 ) The key is the history, which allows you to risk stratify your patient; Risk factors for rising bilirubin levels include:
- isoimmune hemolytic disease
- G6PD deficiency
- Asphyxia
- Lethergy
- Sepsis
- Albumin < 3.0
Always ask parents about;
- Time of birth (hours matter)
- Maternal and fetal blood type
- Birth hx: term or preterm, GBS, TORCH infections
- Fever
- Poor feeding/ feeding patterns, including whether mom feels engorged and if latching is successful
- Stool color (yellow, acholic)
- Timing of first stool
- Timing of jaundice (jaundice at Day 1 of life is not physiologic)
 
2) Determine direct and total bilirubin level (direct bilirubinemia is always pathologic, and may indicate biliary atresia or hepatitis)
 
3) Determine need for observation, phototherapy, or exchange transfusion- Plot total bilirubin level on bilirubin nomogram- Nomograms can be referenced online or in Harriet- Lane handbook (separate nomograms exist for guidelines regarding phototherapy and exchange transfusion)
 
4) If safe for discharge, arrange for followup, and if no follow up available, the patient should return to the ED for a repeat bilirubin check in 12-24 hrs
 

Bonus pearl:  Types of Jaundice by Age

- < 24 hrs: hemolyis, TORCH, bruising from birth trauma (ie- cephalohematoma), acquired infection
- Day 2-3: Physiologic
- Day 3-7: infection, congenital diseases, TORCH
- >1 week: Breast Milk Jaundice, breast feeding jaundice, drug hemolysis, hypothyroidism, biliary atresia, hepatitis, red cell membrane disorders (SS, HS, G6PD deficiency)

 


Category: Pediatrics

Title: Childhood cancer (submitted by Semhar Tewelde, MD)

Keywords: leukemia, back pain, cancer (PubMed Search)

Posted: 6/29/2012 by Mimi Lu, MD (Emailed: 7/20/2012) (Updated: 7/20/2012)
Click here to contact Mimi Lu, MD

ED Presentations of Childhood Cancers

Approximately 12,000 children are diagnosed with malignancies in the USA each year.  Cancer is the second leading cause of death in children in the USA. Acute leukemias are the most common type of cancer, 26% of all cancer diagnosis.  Brain tumors and lymphomas are the next most common categories of neoplasm in children.
 
Initial symptoms in children who are diagnosed with cancer often mimic those of other, more common childhood illnesses; fever, vomiting, weight loss, fatigue, and malaise.  Particular attention should be paid to the patient who makes repeated visits for a persistent complaint that has not been fully evaluated.
 
Back pain is a rare complaint in children and should especially concern the ED physician to consider some common childhood tumors i.e. Wilms, Neuroblasoma, Osteosarcoma and Ewing sarcoma, Leukemia and/or Lymphoma

Findings which should prompt further work-up in the ED are: pallor, bleeding: petechiae, purpura, bone pain, limp, painless lymphadenopathy, gingival hyperplasia, abdominal mass, night sweats, pruritis, and unintended weight loss
 
Labs to obtain: CBC with manual differential, peripheral smear, CMP, uric acid, LDH, coagulation profile, and chest radiograph

Category: Pediatrics

Title: Laryngomalacia

Posted: 7/13/2012 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

  • congenital disorder which is the most common cause of stridor in infancy
  • larynx appears disproportionately small, and supporting structures are abnormally soft
  • stridor begins within the first 4 weeks of life, and accentuates with increased ventilation (crying, excitement, URI, etc.)
  • stridor usually resolves by 12 months but may recur with URI until about 3 years of age
  • diagnosis is by fiberoptic bronchoscopy or direct laryngoscopy
  • therapy is usually not needed, but rarely laser therapy of redundant tissue or traceostomy when stridor occurs with failure to thrive or apnea

Show References


Category: Pediatrics

Title: Pediatric Burns

Posted: 6/29/2012 by Rose Chasm, MD (Updated: 12/8/2022)
Click here to contact Rose Chasm, MD

Submitted by Dr. Lauren Rice

The summertime can be full of lots of fun activities (beach, fireworks, cookouts, and campfires) that can put children at risk of burns. 

Burn depth classification:

1. Superficial (first-degree): red and blanching with minor pain, resolves in 5-7 days 

2. Partial thickness (second-degree): red and wet with blisters, very painful, resolves in 2-5 weeks

Treatment: clean with soap and water twice daily, and apply silvadene wrap with gauze, kerlex

3. Full thickness (third-degree): dry and leathery without pain, no resolution after 5-6 weeks, may require graft

Treatment:  wound debridement and dressings as above

Parkland formula: 4ml/kg/%TBSA in 1st 24 hours with 50% of total volume in 1st 8 hours

 Calculate burn surface area:

-SAGE: free computerized burn diagram available at www.sagediagram.com

-Rule of Nines > 14 years old

-Rule of Palm <10 years old

Burn Center Referral

-Extent: partial thickness of >30% TBSA or full thickness of >10-20%

-Site: hands, feet, face, perineum, major joints

-Type: electrical, chemical, inhalation

 

Show References


Category: Pediatrics

Title: Umbilical disease in pediatrics (submitted by Adrea Lee, MD)

Posted: 6/23/2012 by Mimi Lu, MD (Emailed: 6/29/2012) (Updated: 6/29/2012)
Click here to contact Mimi Lu, MD

Pathology at the umbilicus can manifest as inflammation, drainage, a palpable mass, or herniation.

Omphalitis - A cellulitis of the umbilicus. Mild cases often respond to local application of alcohol to clean the area, but due to the possibility of rapid progression and abdominal wall necrotizing fasciitis, admission for observation and IV antibiotics is usually warranted. Cover staph, strep, and GNRs.

Umbilical granuloma - As the umbilical ring closes and the cord sloughs off, granulation tissue formation is a normal part of umbilical epithelialization. There is sometimes an overgrowth of granulation tissue which can be treated once or twice with silver nitrate. Should the tissue not regress after a 1-2 treatments, the patient should be referred to pediatric surgery for excision and evaluation of other pathology (urachal or vitelline remnants).

Umbilical fistula - This is a patent vitelline duct and is characterized by persistent drainage that is bilious or purulent. A fistulogram using a small catheter and radio opaque dye can sometimes be helpful in determining the source of drainage (dye should be seen in the small bowel).

Umbilical polyp - Often confused with an umbilical granuloma with its glistening cherry red appearance, this is actually a vitelline duct remnant and contains small bowel mucosa. It does not regress with silver nitrate.

Vesicoumbilical fistula/sinus - The urachal versions of the umbilical fistula. This are a failure of complete closure of the urachus, resulting in persistent drainage of urine from the umbilicus, and infection (including recurrent UTIs). A fistulogram can be helpful for diagnosis.