• 
• 

Three Part Question

In [a well two week old neonate, with an umbilical granuloma] is [silver nitrate cauterization preferable to conservative treatment] in order to [facilitate safe resolution of the granuloma]?

Clinical Scenario

A mother brings her two-week-old baby to your clinic. The child has a small umbilical granuloma but is otherwise well. Should you use silver nitrate to cauterize the granuloma?

Search Strategy

Medline 1966-2001, using the OVID interface
[Silver nitrate.mp.] LIMIT to [Clinical Trial.pt.] 36 papers of which nil were relevant. [Umbilic$.mp.] AND [Silver nitrate.mp.] found 10 papers, 1 highlighting complications, 1 was a comment on this paper, 1discussing the use of salt, 7 were irrelevant. Secondary searches – Cochrane, Clinical evidence - none

Search Outcome

10 papers, 1 highlighting complications, 1 was a comment on this paper, 1 discussing the use of salt, 7 were irrelevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kesaree et al 1983, India.	>100 babies with umbilical granuloma all treated with salt	Prospective cohort (level 2b)	Resolution of umbilical granuloma	100% clearance of granuloma (95% CI 96.38% to 100%)	Used salt crystals held in place with a swab for 5-10 minutes. No controls.
Chamberlain et al 1992, USA.	3 infants treated with silver nitrate for an umbilical granuloma	Case study (level 4)	Adverse effects	Silver nitrate caused chemical burns to periumbilical area causing a visit to an emergency department	No denominator

Comment(s)

The above papers suggest umbilical granulomas may be self-limiting and resolve with conservative management such as the application of salt. They also suggest that application of silver nitrate is not without risk. Anecdotal evidence suggests that cleaning with Steret alcoholic wipes may be as effective as salt. If they are used then they should be applied at each nappy change. It may also be beneficial to fold the front of the nappy to expose the umbilicus. There is no randomized controlled trial (RCT) that shows that conservative management is as effective as silver nitrate. A RCT to investigate this is being planned.

Clinical Bottom Line

Silver nitrate may be dangerous – it can cause burns. Conservative management involving salt may be just as successful.

References

1. Kesaree N, Babu PS, Banapurmath CR, Krishnamurthy SN. Umbilical granuloma. Indian Pediatrics. 1983;20(9):690-2.
2. Chamberlain JM, Gorman RL, Young GM. Silver nitrate burns following treatment for umbilical granuloma. Pediatr emerg care. 1992;8(1):29-30.