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Umbilical cord antiseptics for preventing sepsis and death among newborns
Abstract
Background:
The umbilical cord is a structure made of blood vessels and connective tissue that connects the baby and placenta in utero. The umbilical cord is cut after birth, which separates the mother and her baby both physically and symbolically. Omphalitis is defined as infection of the umbilical cord stump. Tracking of bacteria along the umbilical vessels may lead to septicaemia that can result in neonatal morbidity and mortality, especially in developing countries.
Objectives:
To determine the effect of application of antimicrobials on newborn's umbilical cord versus routine care for prevention of morbidity and mortality in hospital and community settings.
Search methods:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 October 2012). In addition, we also searched LILACS (1982 to 11 October 2012) and HERDIN NeON (October 2012)
Selection criteria:
We included randomized, cluster-randomized and quasi-randomized controlled trials of topical cord care compared with no topical care, and comparisons between different forms of care.
Data collection and analysis:
Two review authors independently assessed trials for inclusion, trial quality and subsequently extracted data. Data were checked for accuracy.
Main results:
The search identified 77 trials. We included 34 trials in the review involving 69,338 babies, five studies are awaiting classification and there are two ongoing community trials. Included studies were conducted in both developed and developing countries. Among the 34 included trials, three were large, cluster-randomized trials conducted in community settings in developing countries and 31 studies were conducted in hospital settings mostly in developed countries. Data for community and hospital studies were analyzed separately. The three trials conducted in community settings contributed 78% of the total number of children included in this review. Of the trials conducted in hospital settings, the majority had small sample sizes. There were 22 different interventions studied across the included trials and the most commonly studied antiseptics were 70% alcohol, triple dye and chlorhexidine.Only one antiseptic, chlorhexidine was studied in community settings for umbilical cord care. Three community trials reported data on all-cause mortality that comprised 1325 deaths in 54,624 participants and combined results showed a reduction of 23% (average risk ratio (RR) 0.77, 95% confidence interval (CI) 0.63 to 0.94, random-effects, T² = 0.02, I² = 50%) in the chlorhexidine group compared with control. The reduction in omphalitis ranged from 27% to 56% depending on the severity of infection. Cord separation time was increased by 1.7 days in the chlorhexidine group compared with dry cord care (mean difference (MD) 1.75 days, 95% CI 0.44 to 3.05, random-effects, T² = 0.88, I² = 100%). Washing of umbilical cord with soap and water was not advantageous compared with dry cord care in community settings.Among studies conducted in hospital settings, no study reported data for mortality or tetanus. No antiseptic was advantageous to reduce the incidence of omphalitis compared with dry cord care in hospital settings. Topical triple dye application reduced bacterial colonization with Staphylococcus aureus compared with dry cord care (average RR 0.15, 95% CI 0.10 to 0.22, four studies, n = 1319, random-effects, T² = 0.04, I² = 24%) or alcohol application (average RR 0.45, 95% CI 0.25 to 0.80, two studies, n = 487, random-effects, T² = 0.00, I² = 0%). There was no advantage of application of alcohol and triple dye for reduction of colonization with streptococcus. Topical alcohol application was advantageous in reduction of colonization with Enterococcus coli compared with dry cord care (average RR 0.73, 95% CI 0.58 to 0.92, two studies, n = 432, random-effects, T² = 0.00, I² = 0%) and in a separate analysis, triple dye increased the risk of colonization compared with alcohol (RR 3.44, 95% CI 2.10 to 5.64, one study, n = 373). Cord separation time was significantly increased with topical application of alcohol (MD 1.76 days, 95% CI 0.03 to 3.48, nine studies, n = 2921, random-effects, T² = 6.54, I² = 97%) and triple dye (MD 4.10 days, 95% CI 3.07 to 5.13, one study, n = 372) compared with dry cord care in hospital settings. The number of studies was insufficient to make any inference about the efficacy of other antiseptics.
Authors' conclusions:
There is significant evidence to suggest that topical application of chlorhexidine to umbilical cord reduces neonatal mortality and omphalitis in community and primary care settings in developing countries. It may increase cord separation time however, there is no evidence that it increases risk of subsequent morbidity or infection.There is insufficient evidence to support the application of an antiseptic to umbilical cord in hospital settings compared with dry cord care in developed countries.
... [1][2][3] Colonization of bacteria in umbilical vessels and omphalitis, an infection of the umbilical cord, leads to septicemia, which is one of the main causes of neonatal morbidity and mortality. 4 Globally, neonatal mortality, defined as death occurring within the first 28 days of life, represented 45.1% of all child deaths in 2015, a 15% increase over a span of 15 years. 5 The World Health Organization (WHO) estimates that one-fourth of the world's neonatal deaths are mainly due to infection, three-fourths of which occur in the first week of life, and the umbilical cord was found to be the main means of entry. ...
Purpose:
Globally, the cord care practices contribute to neonatal infections and account for a large proportion of neonatal deaths annually, especially in low-income countries. This study has been provoked by the absence of previous similar research in this locality. The study aimed at exploring and highlighting the factors and practices in the community that influence umbilical cord care to identify the areas of intervention.
Methods:
This was a cross-sectional study conducted among mothers of neonates in Edaga Hamus community who had given birth a month prior to the study. The research team prepared a questionnaire used for data collection on a face-to-face interview, which lasted for 15 minutes for each participant. SPSS version 22 was used for quantitative analyses. Descriptive statistics were presented in frequencies and percentages, and bivariate correlations were used to analyze the association between independent and dependent variables.
Results:
One hundred and seventy-five women participated in this study, with an age range of (19 to 43) years (28.5 ± 5.1 years) of whom (84.5%) used the dry care method, whereas (19%) of the total cord infections were related to different traditional practices. A higher proportion of women (90%) expressed fear and depression once the cord became infected. A greater number of women followed the advice given by nurses, and this finding was significant (p value = 0.008).
Conclusion:
Majority of the participants in this study acknowledged the importance of using the dry care method as recommended by World Health Organization. Those neonates whose cords were exposed to unwarranted practices had delayed detachment. This study confirmed that health promotion in cord care practices should involve family members and the community to achieve successful outcomes.
... As mentioned above, the protocol recommended the use of normal saline solution once daily for HU as an alternative to dry UC care. The main purpose of this recommendation was to abandon the use of disinfectants for HU care as they are unnecessary, potentially locally toxic, especially in preterm newborns, and as they prolong the UC separation time, yet without increasing the risk of infection, probably due to their antiseptic effect (9). The following effect was evident as the use of the normal saline solution for HU care increased by almost 30% and the use ethanol solution decreased by nearly 40%. ...
Objectives −To analyze the current umbilical cord (UC) care practice in Slovenia and to evaluate the impact of national UC care recommendations by comparing the UC care practice before and after their introduction.Materials and Methods − A questionnaire covering the complete UC care was sent to medical nurses and midwifes involved in UC care in primary-level pediatric centers, health visiting and parent education services (outpatient group) and secondary and tertiary-level pediatric centers (inpatient care group) in Slovenia. Three different clinical conditions of the newborn’s umbilicus, i.e. healthy umbilicus (HU), umbilicus at risk (RU) and unhealthy umbilicus (UU) were used. The inpatient and outpatient groups and UC care in 2013 and 2021 were compared.Results − The sample included 396 respondents from all Slovenian regions. The odds for using UC care protocol in 2021 were 2.6 times higher compared to 2013 (P<0.001). The UC care of HU changed: the dry UC care became less frequent (P<0,001), the use of normal saline solution increased and the use of ethanol solution decreased (P<0.001). The use of ethanol solution for UU decreased (P<0.001) and the use of octenidine increased more than 200 times (P<0.001). Conclusions − The implementation of national recommendations significantly influenced the UC care in Slovenia. The current UC care practice is more unified and consistent with international recommendations. The adjusted UC care, depending on the clinical condition of the newborn’s umbilicus, puts additional value to these recommendations. Further refinements of the UC care protocol should emphasize the use of dry UC care.
... Staphylococcus aureus (S. aureus) is a gram-positive, coagulase-positive and facultative anaerobic organism [1]. S. aureus is distributed widely in nature, and it is the main pathogen in host, which mostly colonized in the nasal vestibular mucosa [2], groin [3] and perineum [4] or umbilical cord of the newborn [5]. Through the production of various extracellular secretions including multi-hemolytic toxins, enterotoxins and plasma coagulase, S. aureus cause the suppurative inflammations in respiratory tract, urinary tract and surgical site infections [6]. ...
Objective
Staphylococcus aureus (S. aureus), especially Methicillin resistant S. aureus (MRSA), has been disseminated across communities and hospitals, associated with severe infections and organ failure. In order to understand the clinical epidemiological characteristics of S. aureus stains in the First Affiliated Hospital of Wenzhou Medical University in 2018, the prevalence and the drug resistance of S. aureus stains were investigated, for improving the clinical effective prevention and control of S. aureus infection.
Methods
A total of 105 S. aureus isolates were separated from wound infection of inpatients in the First Affiliated Hospital of Wenzhou Medical University in 2018, and the department distributions and drug resistance of the isolates were analyzed. The genotyping homology analysis was conducted through the random amplified polymorphic DNA typing (RAPD-PCR) coupled with NTSYS cluster analysis.
Results
Among the 105 strains of S. aureus, 31 isolates were MRSA. The prevalence of MRSA among inpatients in the Departments of Burn, Trauma, Orthopedics, Nephrology and Neurosurgery were 35.48%, 19.35%, 9.68%, 6.45%, and 29.03%, respectively. Among the 105 strains, 35.24% strains were the hospital-acquired infections (HAI) and 64.76% strains were community-acquired infections (CAI). DNA genotyping of the 105 S. aureus strains showed seventeen different groups, most of which were type I, type VII, type IX, and type VII, the others were scattered.
Conclusion
This study highlights the prevalence of S. aureus strains in the First Affiliated Hospital of Wenzhou Medical University in 2018. The emergence and mutation of the strains should be closely monitored for the prevention and control of the S. aureus infection and transmission in the nosocomial settings.
This chapter provides an overview of neonatal skin function and intrauterine skin development. The impact on the skin of gestational age at birth is discussed along with cutaneous complications arising from prematurity and neonatal medical procedures. Skin care practices and considerations for neonates are summarised and physiological appearances and changes are described. On overview of disordered skin in neonates is provided, including pustular eruptions, atrophic skin lesions, disorders of neonatal fat, colloidion baby, blueberry muffin baby, purpura fulminans and common neonatal dermatosis. The clinical manifestions in a neonate of transplacental transfer of maternal autoantibodies is evaluated, including in conditions such as pemphigus vulgaris, pemphigus foliaceus, herpes gestationis, lupus erythematosus and maternal malignancy. Finally, on overview of infective skin pathologies and clinical manifestations in neonates is provided including viral, bacterial and fungal pathogens.
Rashes in the first 4 weeks of life are common and can be alarming for both parents and medical staff. Many of these are entirely innocent and resolve spontaneously and reassurance of the parents is all that is required. It is important to be aware of such ‘benign’ rashes (as well as the appearance of preterm and post‐term skin) when assessing genuine pathology in the neonate. Pathological dermatoses may arise by a number of different mechanisms. Iatrogenic causes (medical procedures) can cause rashes/lesions both in utero and in the neonatal period. Transplacental transfer of antibodies, infection or malignant cells from mother to child is another mechanism for causing neonatal rashes. Infection can also be passed on from attendant medical staff. Finally, primary dermatoses may present early in the neonatal period, especially genodermatoses such as collodion baby and epidermolysis bullosa.
In Denmark, a Pure Pork concept for raising pigs without antibiotics was initiated in 2015 by the Danish Crown slaughterhouse cooperative. Pure Pork herds are characterised by minimal use of antibiotics and pigs are mainly treated individually. An increased prevalence of pigs suffering from umbilical outpouchings (UO) is a considerable challenge for Pure Pork producers. Umbilical outpouchings in pigs are challenging due to reduced welfare and increased workload and cost for the farmer. Therefore, Pure Pork producers require means other than antibiotic treatment to prevent UO. The primary objective of this study was therefore to evaluate the effect of autogenous sow vaccines based on bacteria isolated from the inflamed umbilici of piglets and a 7% iodine treatment at birth on the risk of pigs developing UO during the first 12 weeks of life. In addition, umbilical clinical and necropsy findings were presented, including variation over time and an identification of risk factors. A total of 5852 live-born piglets were included at birth from two Pure Pork herds. In this study, UO was defined as the presence of a rounded outpouching and/or a small firm protrusion at the umbilical area. Among 5614 pigs examined at weeks 5 and 12 and/or at death a total of 534 (9.5%) pigs were recorded with UO. The incidence of outpouchings was 10.2% for Herd A and 8.8% for Herd B. In the present field trial, neither autogenous vaccination of sows nor a 7% iodine spray on the umbilical area of new-born piglets had a statistically significant effect on the incidence of UO, but there was a tendency for a lower risk of UO in pigs treated with iodine spray at birth in one herd (OR = 0.7, p = 0.07), which might be worth investigating further. The risk factors for UO identified in this study included sow parity in one herd with more UO pigs from second parity sows and older compared to gilts (OR = 2.0, p = 0.02), batch in the second herd, and sex in both herds with male pigs at lower risk of UO development compared to female pigs (OR = 0.8, p = 0.006). Furthermore, antibiotic treatment as an indicator of the presence of other diseases resulted in a higher risk of UO compared to untreated pigs (OR = 1.9, p<0.0001). The presence of UO in one pig varied over time; For UO pigs examined alive at both week 5 and 12, 136 pigs (2.4%) had an UO record at week 5 but not at week 12 and 179 pigs (3.2%) did not have an UO at week 5 but a UO record at week 12. For 115 pigs (2.0%) an UO was recorded both at week 5 and week 12.
Objective: To compare cord bacterial, colonization and cord separation time among newborns whose cords were treated with Alcohol 70% versus dry cord care. Methodology: The participating neonates in the two hospitals affiliated to Shaheed Beheshti University of Medical Sciences of Iran were randomly assigned to two groups. Group 1, had 36 neonates and Group had 41 neonates, who were treated with dry cord care and Alcohol 70% methods respectively. Results: In the dry cord care group infant were significantly colonized with group B Streptococcus (58.3% vs 35% p=0.042), Staphylococcus epidermidis (86.7% vs 61 % p=0.020) and Escherichia coli (88.9% vs 67.5% p=0.025). There were no cases of local umbilical infection in either group. There was no significant correlation between separation time of umbilical cord and the two methods of the care. Conclusion: Based on the present study, bacterial colonization was higher in dry cord care group. There is, therefore, potential risk in discontinuing bacterial treatment of the umbilical cord stump.
Objective: To compare the effects of two care regimens with merbromin (one daily application versus three) on umbilical cord detachment time. Method: Two hundred eighty-five newborns were randomly assigned to one of the two study groups. Complete information was obtained on 280 newborns (145 in the group receiving three applications a day and 135 in the group receiving one a day). The following variables were collected: type of delivery, birth weight and Apgar score of the newborn child, time to umbilical cord detachment, adverse effects, difficulty in care and parental concern. Results: In the group receiving three applications, the mean umbilical cord detachment time was 10.8±6.1 days, while in the group undergoing one application it was 8.8±3.9 days (p < 0.001). There were no cases of omphalitis or allergic reactions. Six newborns in the group receiving three applications (4.1%) developed granuloma, versus 5 (3.7%) in the single application group, a difference that was not statistically significant. Conclusions: Umbilical care consisting of one daily application of merbromin has a good healing effect and is associated with a shorter umbillical cord detachment time, lower cost and greater tranquilit for parents.
The absorption potential of chlorhexidine was investigated in 51 full-term neonates undergoing various wash regimens with a 1:10 aqueous dilution of a commercial 4% chlorhexidine gluconate detergent solution Hibiclens®). No chlorhexidine was detected in the blood of any Hibiclens-treated infant, using a gas-liquid chromatographic method with electron-capture detection (sensitivity limit, 0.1 μg/ml). Significant selective colonization with gram-negative or gram-positive bacteria was not demonstrated in nose, throat and umbilical cultures of infants in the various wash regimens.
In a prospective randomized study different regimens for skin and umbilical disinfection in newborn infants were tested: daily whole body soap wash (control group), daily whole body soap wash and umbilical cleansing with (i) benzine solution, or (ii) 0.05 % chlorhexidine, and daily whole body wash and umbilical cleansing with a 4 % chlorhexidine detergent solution (Hibiscrub®). Bacterial cultures were taken from the nose and umbilical area at discharge. Clinical infections were registered in the nursery, and after discharge until 6 weeks of age. Cultures were taken from infected areas. In the control group a high colonization rate was found for S. aureus (91 %), E. coli (39 %), and group B streptococci (GBS) (20 %). The colonization rates were influenced by the Hibiscrub regimen (colonization rate for S. aureus 59 %, E. coli 23 %, and GBS 10 %), but not by the other regimens. Infections (pemphigus, paronychia, conjunctivitis, umbilical infection) occurred in 12.9 % of the infants, of whom 65 % got infection after discharge from the nursery. 96 % of the infections were caused by S. aureus, and 87 % caused by strains colonizing the infants in the nursery. None of the tested regimens reduced the rate of infections during the first 6 weeks of life.
• We conducted a randomized study to evaluate the effect of gowning by visitors and hospital personnel on a postpartum ward on nose and umbilical colonization and disease in healthy newborn infants. Cultures were obtained in infants assigned to the gowning and nongowning groups within 6 hours of birth from the anterior part of the nares and the base of the umbilicus and at the time of discharge from the nursery. There were 102 infants in the gowning group and 100 infants in the nongowning group. No significant differences were noted between the two groups with respect to sex, length of stay, mode of delivery, weight, or status of nursery admission culture results. The use of gowns on a postpartum ward failed to decrease nose or umbilical colonization when compared with infants in the nongowning group. Seventy (68.6%) of 102 infants in the gowning group and 65 (65%) of 100 infants in the nongowning group had negative umbilical cord cultures on admission to the nursery that became positive at discharge. On followup, no differences were noted between the two groups with respect to their health. Only one infant in each group had an infection develop in the first 4 weeks of life. We conclude that the routine use of cover gowns on postpartum units in healthy full-term infants is ineffective and costly. It may discourage health care providers from examining patients and providing care.
(AJDC. 1990;144:1031-1033)
• A randomized controlled study was undertaken to compare the effectiveness of three umbilical cord treatment regimens in controlling neonatal bacterial colonization. The three regimens studied included castile soap, triple dye, and silver sulfadiazine. The triple dye and silver sulfadiazine application inhibited bacterial colonization. Staphylococcal colonization was inhibited by both treatment regimens but most effectively by triple dye. Group B streptococcal colonization was inhibited most effectively by silver sulfadiazine while triple dye application to the umbilicus promoted colonization with this microorganism. Silver sulfadiazine was more effective in controlling colonization with Gram-negative microorganisms.
(Am J Dis Child 131:1005-1008, 1977)
Summary 1.Flora of the umbilical stump are listed according to the frequency of appearance in our nursery as cultured by two separate laboratories. 2.An incidence of 80+ per cent Staphylococcus aureus, coagulase positive, was found in the umbilical stump by the fourth day of life over a 2 1/2-year period. 3.Two hundred and ten of 211 infants had Staphylococcus aureus, coagulase positive, in the umbilical area on at least one occasion in the first six days of life. 4.Phage types 52/42B/44A/81 were found in 30 per cent (42 of 144) of infants cultured while in the nursery. With over a 90 per cent follow-up, this 30 per cent finding was not associated with an increased incidence of pyoderma.