Topical Umbilical Cord Care for Prevention of Infection and Neonatal Mortality

Abstract

Umbilical cord care varies often reflecting community or health-worker beliefs. We undertook a review of current evidence on topical umbilical cord care. Study quality was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system, and a metaanalysis was conducted for comparable trials. Available moderate-quality to high-quality evidence indicate that cord cleansing with 4% chlorhexidine may reduce the risk of neonatal mortality and sepsis (omphalitis) in low-resource settings.Keywords cord care; chlorhexidine; neonatal mortality; sepsis; neonates Annually about 3.3 million neonatal deaths occur around the world; 1 of these, more than 30% are caused by infections. 2,3 Some of these infections start as umbilical cord infection. The umbilical cord area supports growth of some innocuous or beneficial microorganisms (commensals) whereas others are harmful (eg, Clostridium tetani). Sources of these bacteria include the mother's birth canal, the environment in which the neonate is delivered and hands of the person assisting with the delivery. Cord infection may be localized to the umbilical cord (omphalitis) or, after entry into the blood stream, become systemic (eg, neonatal sepsis).Data on the incidence of omphalitis in low-income countries is generally scarce, the available data estimate the risk to range between 2 and 77 per 1000 live births in hospital settings, with fatality rates of between 1% and 15% depending on the definition of Copyright © 2012 by Lippincott Williams & Wilkins Address for correspondence: Jamlick Karumbi, BPharm, SIRCLE Collaboration, KEMRI-Wellcome Trust Research Programme, P.O. Box 43640, Nairobi 00100, Kenya. jkarumbi@nairobi.kemri-wellcome.org.. ME conceived the idea for the review. JK and MM conducted the literature searches, NO, JA and JK screened the records for eligibility. NO and JK assessed the quality and synthesized of the results. JK drafted the final review. All the authors reviewed and approved the final draft.Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (www.pidj.com). As cord infections should be preventable in most cases, 8 it is important to identify best cord care practices to reduce neonatal mortality and morbidity and offer an alternative to widespread potentially harmful traditional practices. Examples of such practices include use of traditional herbs mixed with cooking oil or water that has been used to wash an adult woman's genitals (numbati) or application of ash, breast milk, fluid from pumpkin flowers, powder ground from local trees, cow dung, ghee and saliva that may be applied to the cord area and which may be harmful. 9,10 Internationally, the World Health Organization has advocated since 1998 for the use of dry umbilical cord care (keeping the cord clean without application of anything and leaving it exposed to air or loosely covered by a clean cloth, in case it becomes ...

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“…The umbilical cord area supports the growth of some harmless or beneficial microorganisms (i.e., commensals) whereas others are harmful (e.g., Clostridium tetani) (Karumbi et al, 2013). Sources of these bacteria include the mother's birth canal, the environment of delivery and the hands of the person assisting with the delivery (Karumbi, et al, 2013).…”

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“…This is also a missed opportunity because clusterrandomized trials have shown benefits of chlorhexidine application to the baby's cord and associated with decreased mortality (16,17). Use of 4% chlorhexidine has been approved to be more useful if provided to the newborn in 24 , hours of life even to apply it once is effective (18).…”

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“…However, the low mortality rate and the small contribution made by bacterial infection 29 in these settings provide only a small opportunity for a reduction in mortality rates. In 5 such trials 30 -33 analyzed by Karumbi et al, 22 no treatment was found to significantly reduce omphalitis and sepsis when compared against one another, although the sample sizes were small and the evidence was deemed of low quality. 22 The Cochrane review by Imdad et al, 23 which compared a variety of pairs of topical agents, reached similar conclusions.…”

“…In 5 such trials 30 -33 analyzed by Karumbi et al, 22 no treatment was found to significantly reduce omphalitis and sepsis when compared against one another, although the sample sizes were small and the evidence was deemed of low quality. 22 The Cochrane review by Imdad et al, 23 which compared a variety of pairs of topical agents, reached similar conclusions. The most recent meta-analysis, by Sinha et al, 24 considered 2 studies 28, 34 comparing chlorhexidine with dry cord care.…”