Dr Mark Butler
Umbilical granulomas are something we see fairly often in acute paediatrics – they occur in about 1 in 500 babies. While they are generally harmless to the baby, they can cause parents a lot of anxiety – parents might worry that the baby has developed an infection, or that the site is painful and irritated, or about the appearance.
The umbilical cord normally dries out and spontaneously falls off at around 5-14 days following delivery (you’ll remember from your membership exams(!) that the rare case of delayed separation of the cord can be an early sign of a leukocyte adhesion disorder). After the cord falls off, the base of the umbilicus rapidly heals and becomes covered with squamous epithelium.
The process by which umbilical granulomas develop is not totally clear – it’s thought that the usual healing process is disrupted and inflammation results in both overgrowth of endothelial cells and inadequate epithelization. What we see is an inflamed, often pinkish fleshy swelling which may secrete an exudate.
The most commonly used treatment for umbilical granulomas has been to use topical silver nitrate to cauterise the area. Since this method involves the risk of chemical burns to the surrounding healthy skin, you need a degree of skill and confidence to do this safely. Paraffin gel (or another skin barrier cream) should always be used to protect the surrounding skin. Often, more than one treatment is required.
Various other treatments have been tried over the years, including surgical excision, electrocautery, cryotherapy, clobetasol or other topical steroids, topical antibiotics and ethanol.
But sometimes the simple methods are the best…
So how about salt? Umbilical granulomas can be treated with topical application of table salt (NaCl, sodium chloride, chip condiment). This option was first used in low resource settings as an alternative where silver nitrate or a healthcare professional were unavailable. After a number of studies have proven the safety and efficacy of using table salt, many areas of the UK have also started to use this approach and several NHS trusts recommend salt as a first line treatment.
The first paper on the use of salt was published in 1983, describing the treatment of over 100 infants with no granuloma recurrence. Several further studies compared salt to conservative treatment, or to topical alcohol, and all have found salt to be safe and effective. Exactly how to apply salt has also been studied – A number of different studies have looked at regimes ranging from 10 minutes to 24 hours salt application. There isn’t any strong evidence to prefer one regimen over another (although there is some evidence that longer treatments are effective more quickly).
Though the risks of silver nitrate are generally low, the potential for significant injury is still there (chemical burns bad enough to need hospital treatment have been reported). Salt therapy has been shown to be safe and effective, it is popular with families and virtually FREE! It is important to be sure that umbilical granuloma has been diagnosed correctly – once the diagnosis has been confirmed by a competent professional then salt treatment can be carried out at home by parents, with medical review only if symptoms do not resolve.
Umbilical granulomas are common. They can cause a lot of distress to parents, but they are not likely to cause significant harm to babies.
Silver nitrate treatment can be associated with serious, though infrequent, complications.
Salt treatment is safe, effective and basically free – and is worth promoting to your colleagues!
Dr Mark Butler – Consultant Paediatrician, Evelina Children’s Hospital, London
An excellent bulletin by Bedfordshire and Luton joint prescribing committee, including a summary of evidence and original references
A parent information leaflet from Royal United Hospitals Bath NHS trust – with a description of the condition and instructions for treatment
Kesaree N, Babu PS, Banapurthamath CR, et al. Umbilical granuloma. Indian Pediatr 1983
Majjiga V, Kumaresan P, & Glass E J. Silver nitrate burns following umbilical granuloma treatment Arch Dis Child 2005