Does umbilical cord care in preterm infants influence cord bacterial colonization or detachment?

Breast Milk Application as a Natural Method for Umbilical Cord Care: A Community-Label 3-Arm Pilot Clinical Trial

Objective

To compare the effects of human breast milk with those of chlorhexidine and the dry method on umbilical cord separation in Ethiopia.

Methods

This open-label 3-arm nonrandomized pilot clinical trial was conducted among 45 neonates (15 in each arm) with more than 630 home visits. After a standard cord cut, human breast milk, chlorhexidine, or nothing was applied once per day for 7 days. The primary outcome was the duration of cord separation, while the secondary outcomes were umbilical cord infection, neonatal fever, jaundice, feeding and breathing difficulty, and persistent crying.

Results

There were statistically significant differences in the time-to-cord separation between the human breast milk group and the chlorhexidine (P < 0.001) and dry alone (P = 0.038) groups. Compared to those of chlorhexidine, the rates of cord separation among human breast milk and the dry-alone group were 16.02, with 95% confidence intervals (3.81, 37.43; P < 0.001) and 3.15 (0.99, 10.00; P = 0.052), respectively. One (6.7%) cord site infection was observed in the dry-alone groups only.

Conclusion

This community-label study indicated that human breast milk application significantly shortened the length of umbilical cord separation time compared to chlorhexidine and dry methods. A large-scale randomized controlled trial is needed to confirm these results.

Registration

PACTR202310902873290; https://pactr.samrc.ac.za.

Umbilical Cord Separation Time and Influencing Factors in Very-Low-Birth-Weight Preterm Neonates

OBJECTIVE

The average time for umbilical cord separation in term neonates is 7 to 10 days. Prematurity, phototherapy, prolonged duration of antibiotic treatment, and parenteral nutrition are other factors which were demonstrated to delay cord separation. In the previous studies including greater premature infants, the time of separation of the umbilical cord was shown to vary 2 to 3 weeks. We aimed to determine the cord separation time and associated factors in very-low-birth-weight (VLBW) infants.

STUDY DESIGN

In this retrospective study, VLBW infants (birth weight [BW] <1,500 g, gestational age [GA] < 32 weeks) without umbilical catheterization were included. Specific cord care was not applied. The cord separation time, gender, mode of delivery, presence of sepsis, duration of antibiotic treatment, serum free thyroxine, free triiodothyronine (FT3), thyroid-stimulating hormone, lowest leukocyte, polymorphonuclear leukocytes (PMNLs), and platelet counts were recorded.

RESULTS

The study included 130 infants (GA: 29 ± 2 weeks, BW: 1,196 ± 243 g). Mean cord separation time was 14 ± 5 days, while 95th percentile was 22nd day of life. A positive correlation was demonstrated between duration of antibiotic treatment and cord separation time (p < 0.001, r: 0.505). Cord separation time did not differ regarding gender or mode of delivery. Corrected leukocyte count (p = 0.031, r: -0.190) and PMNL count (p = 0.022, r: -0.201), and serum FT3 level (p = 0.003, r: -0.261) were found to be negatively correlated with cord separation time. The cord separation time was found to be delayed in the presence of sepsis (with sepsis: 18 ± 7 days and without sepsis: 13 ± 3 days; p = 0.008). Sepsis was found to delay the cord separation time beyond second week (odds ratio = 6.30 [95% confidence interval: 2.37-15.62], p < 0.001).

CONCLUSION

The 95th percentile for cord separation time was 22nd day. Sepsis might be either the reason or the consequence of delayed cord detachment. The exact contribution of low serum FT3 levels to the process of cord separation should be investigated in further studies.

KEY POINTS

· Mean cord separation time was 14 ± 5 days, while 95th percentile was 22nd day, in VLBW infants.. · Sepsis was found to delay the cord separation time by sixfold beyond second week.. · Serum free triiodothyronine level was negatively correlated with cord separation time..

The Use of Alcohol versus Dry Care for the Umbilical Cord in Newborns: A Systematic Review and Meta-analysis of Randomized and Non-randomized Studies

Inadequate cord care in neonates is an important modifiable risk factor of cord stump infection, sepsis, and neonatal death, particularly in countries with limited resources. Dry cord care and alcohol 70% are commonly used in multiple developing countries. There is a need to investigate the efficacy and safety of both the cord care to achieve the best outcomes in neonates during this critical period of life. The objective of the study was to compare between dry cord care and topical application of alcohol 70% for cord care in newborn infants in terms of cord separation time (CST) as well as the incidence of omphalitis, sepsis, and neonatal mortality. The analysis was conducted up to April 2019 in MEDLINE, Cochrane Library, Embase, Scopus, and Google Scholar to include randomized clinical trials (RCTs) and quasi-experiments which investigated at least two infant groups receiving either dry cord care or alcohol 70%. Mean differences (MDs) and 95% confidence intervals (CIs) were used to analyze continuous data, while risk ratios (RRs) and 95% CIs were used to analyze dichotomous variables. A total of 13 articles were included (4967 infants, 50.35% females, six RCTs). Alcohol application was significantly associated with longer CST (MD = 1.93 days, 95% CI: 0.80, 3.06) with significant heterogeneity among studies (I2 = 97%) while no significant differences were found in the risk of omphalitis. On the other hand, dry cord care was associated with the risk of foul odor at the cord/surrounding tissues (RR = 0.49, 95% CI: 0.28, 0.85) and increased risk of E-coli colonization (RR = 0.75, 95% CI: 0.57, 0.98). Dry cord care is a simple and effective way to shorten CST, particularly in countries with limited resources. However, in light of the limitations of the included studies, future RCTs with higher methodological quality are warranted. The significant heterogeneity among studies is the limitations of the included studies.

[Recommendations for the care of the umbilical cord in the newborn]

The care of the umbilical cord until its detachment still remains controversial. The latest updated recommendations by the World Health Organisation advocate dry cord care in those countries with adequate obstetric care and low neonatal mortality rate. In recent years, new studies and reviews attribute some benefit to applying chlorhexidine on the umbilical stump. An analysis is presented here of the available evidence and results in the advisability of still recommending the dry cord care in the newborns in our setting.

Newborn Skin Care

The skin serves as a unique barrier from the outside world and undergoes critical changes during its development and maturation. This article reviews evidence-based recommendations for the routine care of newborn skin that should be integrated into the pediatrician's practice. [Pediatr Ann. 2019;48(1):e11-e15.].

Evidence-based skin care in preterm infants

Most guidelines on neonatal skin care emphasize issues pertaining to healthy, term infants. Few address the complex task of skin barrier maintenance in preterm, very preterm, and extremely preterm infants. Here, we provide an evidence-based review of the literature on skin care of preterm neonates. Interestingly, the stratum corneum does not fully develop until late in the third trimester, and as such, the barrier function of preterm skin is significantly compromised. Numerous interventions are available to augment the weak skin barrier of neonates. Plastic wraps reduce the incidence of hypothermia while semipermeable and transparent adhesive dressings improve skin quality and decrease the incidence of electrolyte abnormalities. Tub bathing causes less body temperature variability than sponge bathing and can be performed as infrequently as once every four days without increasing bacterial colonization of the skin. Topical emollients, particularly sunflower seed oil, appear to reduce the incidence of skin infections in premature neonates-but only in developing countries. In developed countries, studies indicate that topical petrolatum ointment increases the risk of candidemia and coagulase-negative Staphylococcus infection in the preterm population, perhaps by creating a milieu similar to occlusive dressings. For preterm infants with catheters, povidone-iodine and chlorhexidine are comparably effective at preventing catheter colonization. Further studies are necessary to examine the safety and efficacy of various skin care interventions in premature infants with an emphasis placed on subclassifying the patient population. In the interim, it may be beneficial to develop guidelines based on the current body of evidence.

Two methods of cord care in high-risk newborns: their effects on hydration, temperature, pH, and floras of the cord area

This randomized clinical study explored the effects of two cord care methods on hydration, temperature, pH, and floras at the cord area in high-risk newborns. One group used the water method; and the other group used the alcohol method. Seventy-two newborns, including premature newborns, in the neonatal intensive care unit (NICU) of a university-affiliated hospital in South Korea were enrolled from August 2011 to May 2012. Hydration, temperature, pH, and floras were measured daily until the cords fell off. The results showed no difference between the groups in hydration, temperature, pH, and the colonization of floras, but cord detachment in the alcohol group took 2 days longer (12.8 [5.7] days) than in the water group (10.9 [4.1] days). Our findings suggest that the clean-and-dry method of cord care, which uses water, could be sufficient, possibly even better than alcohol in maintaining the physiologic surface milieu of the cord area with less chance of infection and manipulation in NICUs with optimal infection control.

Neonatal skin care in tertiary Neonatal Intensive Care Units in Hungary

Introduction: Skin physiology of neonates and preterm infants and evidence-based skin care are not well explored for health care providers. Aim: The aim of our present study was to investigate the skin care methods of the tertiary Neonatal Intensive Care Units in Hungary. Method: A standardized questionnaire was distributed among the 22 tertiary Neonatal Intensive Care Units with questions regarding skin care methods, bathing, emollition, skin disinfection, umbilical cord care, treatment of diaper dermatitis, and use of adhesive tapes. Results: The skin care methods of the centres were similar in several aspects, but there were significant differences between the applied skin care and disinfectant products. Conclusions: The results of this survey facilitate the establishment of a standardized skin care protocol for tertiary Neonatal Intensive Care Units with the cooperation of dermatologists, neonatologists and pharmacists. Orv. Hetil., 2014, 155(28), 1102–1107.

The value of chlorhexidine gluconate wipes and prepacked washcloths to prevent the spread of pathogens--a systematic review

BACKGROUND

Use of chlorhexidine gluconate wipes and pre-packed washcloths has been described for preventing pathogen spread in healthcare settings.

AIM

To assess the impact of chlorhexidine washcloths/wipes in preventing the spread of pathogens.

METHODS

Extensive and structured literature search from studies in Google Academic, Cochrane Library, Web of Science, Pubmed and Cinahl from their inception until November 2012.

FINDINGS

Final analysis included 15 studies, 9 of which were randomised controlled trials. The most frequent setting was the intensive care unit. In intensive care units, a significant reduction of bloodstream infection was associated with intervention and 3 studies revealed a decrease in blood culture contamination. One study showed a decrease in staff and environmental contamination and no increase in chlorhexidine resistance with intervention. Positive blood cultures for multiple pathogens also declined with intervention. In a paediatric intensive care unit, intervention decreased bacteraemia and catheter-associated bloodstream infection. In hospital wards, intervention was associated to a 64% reduction of pathogen transmission. One study had no statistically significant results. Pre-surgical chlorhexidine use significantly decreased bacterial colonisation but had no impact on surgical site infections. Regarding maternal and perinatal setting, one study did not show reduction of early onset neonatal sepsis and pathogen transmission. Another study of vaginal and neonatal decolonisation with chlorhexidine wiping revealed significant reduction in colonisation. One study concluded that single and multiple umbilical cord cleansing reduced the likelihood for a positive swab in 25% and 29%, respectively. Neonatal wiping maintained low levels of skin colonisation for a 24h period, for multiple pathogens.

CONCLUSION

Current evidence supports the usefulness of chlorhexidine washcloths and wipes in an intensive care, hospital and pre-surgical setting. More studies are required to encourage its use for prevention of perinatal and neonatal transmission of pathogens.

Umbilical cord antiseptics for preventing sepsis and death among newborns

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.

Comparative effects of using alcohol, natural drying, and salicylic sugar powder on umbilical stump detachment of neonates

This study compares the effectiveness of alcohol, natural drying, and salicylic sugar powder on umbilical separation time of the neonate in our high-humidity region. From September 2007 to May 2008, a total of 143 neonates in a community hospital were divided into 3 groups according to their birth month in sequence. Each umbilical care regimen was randomly assigned to a 3-month period. Data on occurrence of omphalitis and cord separation time were collected by telephone follow-up until stump separation. The salicylic sugar powder group had the lowest rates of colonization and shortest cord separation time compared with the natural drying and alcohol groups. No omphalitis developed in any of the 3 groups. Natural drying and salicylic sugar powder are safe and effective ways to care for the umbilical cord stump in high-humidity regions. Nursing professionals should consider choosing a more effective umbilical care regimen and provide mothers with thorough instruction.

Efficacy of Arnica Echinacea powder in umbilical cord care in a large cohort study

BACKGROUND

Today healthy newborns are discharged after 48 h-72 h of life until umbilical cord (UC) detachment. Complications due to an inappropriate management are: erythema, edema, bleeding, omphalitis and sepsis. Hence the importance of a safe, effective, easy to do, and cheap method.

AIM

This study tests the effects and the efficacy of arnica echinacea powder by evaluating the time of cord detachment and the risk of side effects in a large cohort of newborns.

METHODS

6323 babies were treated with Arnica Echinacea powder twice a day until cord stump detachment. Medications started in hospital ward and continued at home until stump detachment.

RESULTS

The UC stump detachment occurred in 89.09% of newborns during the first 4 days of life. This percentage increase to 96.13% at 6 days.

CONCLUSIONS

Our study demonstrates the efficacy and the safety of arnica echinacea in UC separation. No infections or even bacterial colonizations were found. The use of arnica echinacea reduces hospital costs as a consequence of complications. In addition arnica use is well received by medical staff and parents. In conclusion due to its potential benefits, low cost and feasibility, we recommend the use of arnica echinacea powder as routine procedure in all nurseries.

Impact of umbilical cord cleansing with 4.0% chlorhexidine on time to cord separation among newborns in southern Nepal: a cluster-randomized, community-based trial

OBJECTIVE

Within a community-based, cluster-randomized study of the effects of 4.0% chlorhexidine on omphalitis and mortality risk, we aimed to describe the distribution of times to separation and the impact of topical chlorhexidine treatment on cord-separation times.

METHODS

Between November 2002 and March 2005, 15123 infants were assigned randomly within communities in southern Nepal to receive 1 of the following 3 cord-care regimens: cleansing with 4.0% chlorhexidine, cleansing with soap and water, or dry cord care. In intervention clusters, field workers cleansed the cord in the home on days 1, 2, 3, 4, 6, 8, and 10 after birth. Newborns were monitored throughout the newborn period for signs of omphalitis, and the time to cord separation was noted. Separation times were compared across treatment groups. Cord infection risk and a range of infant and household characteristics were assessed for their relationships to separation time.

RESULTS

The mean separation time was shorter in dry cord care (4.24 days) and soap/water (4.25 days) clusters than in chlorhexidine clusters (5.32 days; mean difference: 1.08 days). Cords of infants who received chlorhexidine were 3.6 times more likely to separate after 7 days. Separation time was not associated with omphalitis. Home-delivered topical antiseptics, facility-based birth, and birth attendant hand-washing were associated with greater likelihoods of cord separation after 7 days of age.

CONCLUSIONS

In this setting, the umbilical cord separated more rapidly than observed in hospital-based studies, and the impact of chlorhexidine cleansing on separation times was negligible. Increased cord-separation time attributable to topical chlorhexidine treatment should not be considered a factor in decision-making in settings where the baseline risk of omphalitis is high and chlorhexidine might reduce infection and mortality risks significantly.

Infections in the Equine Abdomen and Pelvis: Perirectal Abscesses, Umbilical Infections, and Peritonitis

This article addresses the pathophysiology, diagnosis, management, and prognosis of several different infections within the equine abdomen and pelvic region. The latest advances in the diagnosis and treatment of perirectal abscesses, umbilical infections, and local and diffuse peritonitis are discussed. Emphasis is placed on recent advances in diagnostics and therapeutics with reference to human literature that may be useful in equine practice.

Umbilical cord care: a pilot study comparing topical human milk, povidone-iodine, and dry care

OBJECTIVE

To compare the incidence of omphalitis among three groups, each using a different type of newborn cord care: povidone-iodine, dry care, and topical human milk.

DESIGN

Case control.

SETTING

A large urban university hospital in Turkey and participant homes after discharge.

PARTICIPANTS

150 healthy, full-term newborns and their mothers.

INTERVENTIONS

Umbilical cord care consisted of one of three methods: topical application of povidone-iodine twice daily, topical application of mother's milk twice daily, or dry care (keeping the cord dry and clean).

MAIN OUTCOME MEASURE

Outcome was measured in terms of the presence or absence of omphalitis and the number of days elapsed before cord separation. An ongoing questionnaire was administered by telephone every other day after the participants left the hospital. In addition to demographic information, the cord separation day and any signs of omphalitis were recorded in the questionnaire.

RESULTS

There were no significant differences between the three groups in terms of omphalitis occurrence. Two cases of omphalitis were observed (one in the human milk group, one in the povidone-iodine group). Interestingly, babies in the dry care or topical human milk group had shorter cord separation times than those in the povidone-iodine group.

CONCLUSION

The cultural practice of applying human milk to the umbilical cord stump appears to have no adverse effects and is associated with shorter cord separation times than are seen with the use of antiseptics.