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Pediatrics International (2013) 55, 6064 doi: 10.1111/j.1442-200X.2012.03738.x

Original Article

Neonatal suppurative parotitis over the last 4 decades: Report of three

new cases and review

Essam A Ismail, Tarek M Seoudi, Mohamad Al-Amir and Ahmad A Al-Esnawy

Paediatric Department, Farwaniya Hospital, Kuwait

Abstract Background: Neonatal suppurative parotitis is a rare disease. Only 32 cases were reported in the English-language
literature between 1970 and 2004.
Methods: We searched Medline for acute, neonatal, bacterial, suppurative, parotitis, facial, preauricular swelling
starting from 1970, limiting our search to the English-language literature. We reviewed all the reported cases together
with three more managed in our department.
Results: We identified nine new cases since 2004. The total number of patients reviewed was 44, including our patients.
Most of them were male (77%). The majority developed unilateral inflamed parotid swelling (77%) and exuded pus from
the ipsilateral Stensen duct. Fever was seen in fewer than half of them (47%). Premature babies constituted a third of the
patients. Staphylococcus aureus was the leading causative agent (61%). Most patients responded well to conservative
treatment with antibiotics (77%). The most frequently used combination of antibiotics was an anti-staphylococcal agent
with either an aminoglycoside or a third-generation cephalosporin. A minority required surgical drainage. No deaths
were reported in the group studied after 1970.
Conclusion: Neonatal suppurative parotitis is rare but easy to diagnose and if readily treated with appropriate antibiotics
the outcome is excellent.

Key words bacterial, neonatal, parotitis, preauricular, suppurative.

Neonatal suppurative parotitis (NSP) is rare; fewer than 90 cases
were reported before 1970.1
Spiegel et al.2 reviewed 32 cases of NSP reported in the
English-language literature between 1970 and 2004. Most of
them appeared as single case reports. NSP commonly presented
with irritability, swelling, erythema and tenderness over the
affected parotid gland in the presence or absence of fever. Pus
exuding from the Stensen duct or aspirated from the affected
gland was considered pathognomonic. Staphylococcus aureus
was the most frequent offending organism, but other Gram-
positive, Gram-negative and anaerobic organisms were also iso-
lated.2 It is thought that they get access to the gland by either
ascending through the Stensen duct or, less commonly, by the
hematogenous route.
Most cases were treated only with antibiotics, but few patients
needed surgical drainage.
We reviewed the English-language literature from 2004 to
identify any additional cases of NSP. We found only nine new
reports, each describing a single case.311
We describe three more cases managed in our department over
the last year and review them together with those studied by
Correspondence: Essam A Ismail, MRCP (UK), Paediatric Depart-
ment, Farwaniya Hospital, PO Box 936, Salmiya 22010, Kuwait.
Email: rsessam@hotmail.com
Received 22 April 2012; revised 4 September 2012; accepted 5
September 2012.
Spiegel et al.2 and the nine reported since 2004 (totaling 44
cases).
Case reports
Case 1
A 9-day-old breast-fed boy presented with a 1-day history of
fever, irritability, poor sucking and left pre-auricular swelling. He
was born at term by cesarean section after an uneventful preg-
nancy. Birthweight was 3850 g. On admission the baby was irri-
table and looked unwell. His weight was 4300 g, and rectal
temperature was 39.2C. Examination revealed a swelling and
redness over the left parotid gland. Pus exuded from the left
Stensen duct when pressure was applied to the gland. The rest of
the physical examination was unremarkable.
Laboratory tests revealed a hemoglobin of 15.9 g/dL; white
blood cell (WBC) count 20 500/mm3, 72.5% were neutrophils;
erythrocyte sedimentation rate (ESR) 19 mm/h; and serum
amylase concentration 35 U/L (normal range, 25125 U/L).
Serum electrolytes were as follows: urea 9 mg/dL; sodium
136 mmol/L; potassium 4.8 mmol/L; and chloride 103 mmol/L.
The parents declined lumbar puncture. Ultrasound examination
of the parotid glands demonstrated enlarged left parotid gland
with diffuse hypoechogenicity of the parenchyma, compatible
with parotitis (Fig. 1). Computed tomography (CT) scan con-
firmed the same findings. Treatment with i.v. fluid, cloxacillin
200 mg/kg/day and cefotaxime 200 mg/kg/day (each divided

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Pediatrics International 2012 Japan Pediatric Society
 Neonatal parotitis 61

ebrospinal fluid cultures were sterile. The antibiotic treatment

was changed to i.v. vancomycin (40 mg/kg/day) and gentamicin
(5 mg/kg/day). The left parotid abscess was surgically drained on
the next day and the patient showed gradual improvement. The
treatment was continued for 14 days with complete recovery. The
patient did not show on follow up.
Case 3
A 16-day-old breast-fed girl was admitted because of left parotid
gland inflammation 2 days before admission. She was born at
37 weeks by normal vaginal delivery and her birthweight was
3250 g. On examination she appeared irritable and dehydrated
and her weight was 2900 g. Her temperature was 37.2C. Pus
exuded from the left Stensen duct opening. Systemic examina-
tion was otherwise unremarkable. Total WBC count was 28.1
103/mm3. The hemoglobin, serum C-reactive protein, and ESR
levels were 15.5 g/dL, 6.2 mg/dL, and 2 mm/hr, respectively.
Serum urea was 5 mg/dL; sodium 139 mmol/L; potassium 4.5
mmol/L; and chloride 109 mmol/L.
Fig. 1 Ultrasound color Doppler picture showing the enlarged left
Ultrasound findings were similar to Case 1. She was started on
parotid gland of case 1 and displaying hypoechoic edematous texture
with congestion (arrow). i.v. fluids for rehydration, vancomycin (40 mg/kg per day) and
gentamicin (5 mg/kg per day in two divided doses). Culture of
the purulent exudates from left Stensen duct and blood revealed
6-hourly) was started. The parotid pus, nasal swab and urine S. aureus while the urine and cerebrospinal fluid were sterile. The
cultures, but not the blood, grew methicillin-resistant S. aureus parotid swelling disappeared within 3 days but the antibiotic
(MRSA) on the third day after admission. Despite clinical therapy was continued for 14 days. The patient did very well on
improvement and based on culture, the antibiotic treatment was follow up after 3 months.
switched to vancomycin 40 mg/kg/day, divided every 6 h, for 10
more days. The patient was discharged well but did not appear on Discussion
follow up. The three patients reported here are similar to those reported
before. All neonates showed parotid gland swelling with varying
Case 2
An 11-day-old bottle-fed boy presented with 8 days history of
right pre-auricular swelling followed 2 days later by swelling on
the left side. Pregnancy and delivery at term were uneventful.
Birthweight was 2200 g and there were no perinatal problems.
On admission, the baby was irritable but not in a critical
condition and clinically well-hydrated. His weight was 2320 g
and rectal temperature was 38.5C. Both parotid glands showed
signs of inflammation. Pus exuded from the Stensen duct of the
right gland on the fourth day of admission. The remainder of the
physical examination was unremarkable. Laboratory results were
as follows: hemoglobin 15.2 g/dL; WBC count 8.7 103/mm3;
C-reactive protein 23.4 mg/L (reference range is less than 8);
serum amylase concentration 5 U/L; urea 4.5 mg/dL; sodium
144 mmol/L; potassium 5.6 mmol/L; and chloride 110 mmol/L.
Ultrasound examination demonstrated enlarged superficial and
deep parts of both parotid glands, displaying hypoechoic texture
with massive edema. Few pockets of thick pus were noted
(Fig. 2). CT scan of the parotid glands confirmed the same
findings.
Intravenous cloxacillin (100 mg/kg/day) and cefotaxime
(100 mg/kg/day) were commenced. The fever resolved within 6 h
after admission but the local signs of inflammation did not Fig. 2 Ultrasound picture of case 2 demonstrating the enlarged
improve. The right Stensen duct pus yielded growth of right parotid gland with pockets of thick turbid fluid (arrow) display-
methicillin-resistant S. aureus (MRSA), but the urine and cer- ing posterior acoustic enhancement.

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Table 1 Clinical features of patients with neonatal suppurative parotitis

Ref. No. of patients Gestation preterm Sex male Unilateral parotid swelling Fever present Surgical drainage
2 32 11 23 26 12 7
3 NR 3 NR
311 9 2 9 6 5 2
1 NR
Current report 3 0 2 2 2 1
Total number (%) 44 13 34 34 19 10
(%) 100% 32% 77% 77% 47% 23%
NR, not reported.

degrees of erythema, warmth and tenderness. Parotid gland
involvement was unilateral in 77% of cases (Table 1). All had pus
exuding from the Stensen duct when pressure was applied exter-
nally to the affected gland or aspirated from it, except in two
cases.6,9 In these two patients, the parotid glands showed all signs
of inflammation and the ultrasound examination of both was
consistent with parotitis. Blood cultures isolated Streptococcus
pyogenes in the first case and Group B Streptococci in the second,
so they were included in the study.6,9 In two other patients, the
exuded pus did not grow any organism12,13 but the blood culture
isolated Staphylococcus epidermidis in one of them.13
Male patients outnumbered female patients (77% were male).
The majority of patients were in fair general condition on pres-
entation except when the organism was isolated from the
blood.1,4,9 Notably, fever was not a universal feature and was
reported in fewer than half of the patients (47%).
The peripheral WBC count was reported to be more than 15
109/L in 71% of patients in a previous study2 and 69% when the
newly studied patients were added. But only 44% of the patients
had elevated WBC if the cut-off count was taken as more than
20 109/L.
Laboratory investigations are generally not very helpful in the
diagnosis of NSP and in fact are not necessary in a typical case.
Serum amylase was high in four out of 16 patients (25%) for
whom the test was done, including our patients.2,3,6,7,9,11
S. aureus was the most frequently isolated pathogen (61%).
MRSA was isolated in two of our three patients and was reported
in one other study.14 This should be considered in the initial
choice of antibiotic guided by the local antibiotic policy and the
sensitivity pattern of local organisms.
Other less frequently encountered bacteria included Gram-
positive cocci constituting about 25% of isolates. Gram-negative
bacilli constituted about 16% of isolates especially from patients
with septicemia who had nosocomial infection.1,2,11 Anaerobic
bacteria were a minority (11%) (Table 2). Two organisms were
recovered simultaneously from the Stensen duct discharge from
each of six patients.1,12,1517
Blood cultures were positive in 11 of 31 patients studied
(35%). The same organism was isolated from the Stensen duct
discharge in all patients except three.6,9,13 There was no discharge
from two.6,9
The causative agents are thought to be derived from the
patients mouth flora. The newborns acquire their first microflora
of the mouth, ear and skin from the mothers birth canal during
normal vaginal delivery.18
Parotid gland infection may take place by one of two routes.
Either ascending through the Stensen duct, and this appears to be
the most common way, or by hematogenous spread as part of
septicemia.1,4,6,9
Ascending infection is thought to be facilitated by dehydra-
tion thereby reducing salivary flow.2 The cause of dehydration
was not clear in the majority of patients.1
About 78% (11 of 14) of the patients with NSP for whom the
type of feeding was reported were breast-fed.2,49,11,14,19 This is
much higher than the 44% breast-feeding initiation rate in the
general population.20 This raises the possibility that insufficient

Table 2 Bacteria cultured from patients with neonatal suppurative parotitis

Ref. No. of Blood culture growth Culture of pus from the affected parotid gland
patients (number of patients) (number of patients)
2 32 SA (4), PsA (1), SA (18), SV (4), SP (2), COS (2), SC (1), E. coli (2), KP (2),
E. coli (1), COS (1) PsA (1), MC (1), Ba (2), Pr (2), PSC (1).
311 9 SA (1), GBS (1), SP (1) SA (6), PsA (1), No discharge (2)
Current report 3 SA (1) MRSA (2), MSSA (1)
Overall 44 11/31 SA: 27 patients (61%)
(%) 35% GP: 11 patients (25%)
GN: 7 patients (16%)
Anaerobic organisms: 5 patients (11%)

Total number of patients reported. Ba, Bacteroides; COS, Coagulase negative staphylococci; E. coli, Escherichia coli; GBS, group B
Streptococci; GN, Gram-negative bacilli; GP, Gram-positive cocci, including blood isolates, other than Staphylococcus aureus; KP, Klebsiella
pneumoniae; MC, Moraxella catarrhalis; MRSA, methicillin-resistant SA; MSSA, methicillin-sensitive SA; Pr, Prevotella; PsA, Pseudomonas
aeruginosa; PSC, Peptostreptococcus; SA, Staphylococcus aureus; SC, Streptococci (unspecified); SP, Streptococcus pyogenes; SV, Streptococcus
viridans.

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Pediatrics International 2012 Japan Pediatric Society

breast-feeding could, at least in part or in some patients, be
responsible for some degree of dehydration in these neonates.
Insufficient breast-feeding has been shown to be frequently
missed but increasingly recognized.21 Unfortunately, relevant
data were not available in the vast majority of previously reported
cases to draw any conclusion. This needs to be looked at in future
studies.
Other risk factors implicated were environmental hot
weather,4 excessive oral suctioning and nasogastric tube-
feeding.13,22 In more recent reports, NSP was linked to maternal
breast abscess in a breast-fed infant4 and in another to cytome-
galovirus parotitis and maternal treatment with methyldopa.3,5
Prematurity was reported in almost one-third of cases (32%)
of NSP. This contrasts with the average worldwide prematurity
rate of 9.6%.23 Prematurity, therefore is a risk factor.
Hematogenous spread was seen less frequently as part of
septicemia either associated with early pneumonia, congenital
malformations,1,13 multiple skin abscesses14,24 or as part of late-
onset neonatal sepsis.6
Ultrasound findings were rather consistent, commonly reveal-
ing enlarged glands with edema, increased vascularity and hyp-
oechoic areas. Some reports demonstrated intraparotid lymph
node enlargement.6,811,19
There is rarely any difficulty in making the diagnosis but the
differential diagnosis may include mandibular osteomyeli-
tis, acute suppurative lymphadenitis, infected hemangioma or
lymphangioma.
The majority of patients were treated successfully with a
combination of antibiotics that included an antistaphylococcal
agent and an aminoglycoside or a third-generation cephalosporin.
Based on the spectrum of bacteria causing NSP (Table 2), we
would advocate the same combination of antibiotics empirically
pending the result of culture and sensitivity. Awareness of the
local sensitivity pattern of the microbial organisms is an impor-
tant asset in the successful management of such small babies. In
responsive patients the fever usually settles down within 24 h and
the swelling within 35 days of starting the antibiotic treatment.
The ideal duration of antibiotic treatment is not known, but the
shortest effective duration reported in treating NSP due to S.
aureus and in the absence of septicemia was 7 days3,5 and the
longest was 21 days with anaerobic organisms.17 Variables like
prematurity, septicemia, other organ involvement and type of
organism might need to be considered in deciding the duration of
treatment. Only 23% needed surgical drainage. This included
patients who came late to medical attention (more than 45 days
from disease onset)4,17 or the organism was resistant to the
empiric antibiotic therapy.5,17
The prognosis seems to be excellent in terms of morbidity and
mortality. Historically, complications included salivary fistula,
facial palsy, mediastinitis, septicemia and meningitis.1 There are
no reported deaths after the early study of Leake and Leake in
1970.1 Also, no serious complications were reported.
In conclusion, NSP is a rare disease that presents classically,
in the majority of patients, with unilateral parotid swelling and
variable degrees of local signs of inflammation. Purulent dis-
charge exuding from the ipsilateral Stensen duct or aspirated
Neonatal parotitis 63
from the affected gland is pathognomonic; however, when there
is no discharge from the Stensen duct, then bacterial growth from
the blood culture in this context is highly suggestive of the
diagnosis. The most common causative agent is S. aureus, but
other Gram-positive, Gram-negative and anaerobic bacteria are
isolated less frequently. Most patients can be treated conserva-
tively, provided that the empiric antibiotic treatment covers the
causative agents according to the local sensitivity pattern and is
started early. The prognosis of the disease is generally excellent.
Acknowledgment
We are indebted to Professor Allie Moosa, visiting consultant
pediatrician Al-Adan Hospital, Kuwait for the critical review of
the manuscript and Dr Ahmad Hassan, from the X-ray Depart-
ment, Farwaniya Hospital for providing us with the ultrasound
images.
Disclosure
The authors declare that they have no conflict of interest.
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