Topical umbilical cord care for prevention of infection and neonatal mortality

Home-based care for umbilical cords of neonates by family caregivers in Mpumalanga province, South Africa

Background

Multiple substances have been applied to neonates' umbilical cords and have yielded detrimental results on neonates' health status.

Aim

The study aimed to explore and describe home-based care for umbilical cords of neonates by family caregivers.

Setting

The study was conducted at Waterval community, a village under Dr J.S Moroka local municipality in Nkangala district in the Mpumalanga province.

Methods

A qualitative exploratory, descriptive research study design was used to explore home-based care for neonates' umbilical cords. The target population was family caregivers who had been caring for the umbilical cords of neonates at home. Non-probability and purposive sampling were done, and individual in-depth interviews were used for data collection. The sample size of 18 participants was determined by data saturation. Thematic analysis was utilised to analyse the data.

Results

The following main themes emerged during data analysis: substances applied on the umbilical cord, beliefs associated with umbilical cord care, the effectiveness of health education provided on discharge from the community health centre and the healing process.

Conclusion

The findings of the study revealed that various harmful substances were applied to the umbilical cords of neonates, and these practices were influenced by cultural beliefs.

Contribution

The findings of the study brought to light that indeed, the application of substances that have not been recommended by the South African guidelines on neonates' umbilical cord does lead to delayed umbilical cord separation and healing and has the potential to cause neonatal infections.

Harmful newborn cord care practices and associated factors among mothers who gave birth in the last six months in Chencha town, Southern Ethiopia: a mixed-methods study

Background

Harmful substance-related infections that cause neonatal deaths on the umbilical stump continue to be a major cause of worry, accounting for a large portion of the yearly mortality toll in developing nations such as Ethiopia. In our study region, there is, however, little data regarding these issues. In Chencha town, Southern Ethiopia, mothers who gave birth in the last six months were the subjects of this study.

Methods

A community-based cross-sectional mixed study design was conducted among mothers who gave birth within the past six months, from April to May 2023. Quantitative data was collected through structured interview questionnaires from 312 randomly selected mothers. The collected data was coded, cleaned, and entered into Epi-info version 7.2.5.0, and analyzed using SPSS version 26. Binary logistic regression analysis was used to identify associated factors, and the strength of association was measured by odds ratios with a 95% confidence interval at a p-value of <0.05. The audio-recorded qualitative data were transcribed in Amharic language and then translated into English and entered into Open Code software version 3.6.2 for analysis using the thematic content analysis method.

Results

Harmful newborn cord care practice was prevalent among 55.8% (95% CI: 50.1, 61.4) of the mothers. Factors such as husband's educational status (AOR = 3.09, 95% CI: 1.11, 8.67), communication on cord care within the community (AOR = 10.24, 95% CI: 5.44, 19.28), and discussions with health workers regarding cord care (AOR = 7.26, 95% CI: 3.59, 14.64) demonstrated significant associations with harmful newborn cord care practice (p < 0.05). In the qualitative analysis, four themes emerged such as substance applied (butter, Vaseline, and ointment). The reasons for application were moisturizing the cord, facilitating its separation, and promoting its healing. The sources of advice on cord care were relatives, neighbors, and HCW.

Conclusion

This study revealed that harmful newborn cord care practice was prevalent among 55.8% [95% CI (50.1, 61.4)] of mothers who gave birth in the last six months. The present study identified husbands' educational status, exposure to cord care messages through interpersonal communication in the community, and mothers who didn't ever engage in discussion with health workers about cord care as significant factors.

Incidence and risk factors for clinical omphalitis among neonates in Eastern Uganda using chlorhexidine gel for cord care: a community-cohort study

BACKGROUND

Omphalitis is a bacterial infection of the umbilicus and/or surrounding tissues, occurring primarily in the neonatal period. Whereas it is known to be a major route of localized and often systemic infection, studies describing incidence and risk factors remain scanty, especially in resource limited settings where the condition is thought to be common. We assessed the incidence and risk factors for omphalitis among neonates born to women who received a birth kit containing chlorhexidine for umbilical cord care after birth in Eastern Uganda.

TRIAL REGISTRATION FOR THE PARENT STUDY

The BabyGel trial was registered in the Pan African Clinical Trial Registry -(PACTR202004705649428 Registered 1 April 2020, https://pactr.samrc.ac.za/ ).

METHODS

We conducted a community-based cohort study between January 2021 and June 2023. This study was nested within the BabyGel trial. Our outcome of interest was clinical omphalitis, defined as purulent discharge from the umbilical cord stump within the first twenty-eight days of life as witnessed by a study midwife. Data were analyzed using Stata version 17.0. Bivariable and multivariable analyses were conducted using Cox proportional hazard regression models to estimate hazard ratios (HR) of selected exposures and time to omphalitis.

RESULTS

A total of 2052 neonates were enrolled; half of which were female (51.1%). The incidence of omphalitis was 3.0% (62/2052; 95% confidence interval (CI): 1.9%, 4.4%). The incidence rate of omphalitis was 1.6 cases per 1000 person days (95% CI: 1.1, 2.3). Neonates born at home were twice as likely to develop omphalitis as those born in a health facility (adjusted hazards ratio (AHR) 1.99; 95% CI: 1.01, 3.9).

CONCLUSION

The incidence of omphalitis among neonates in Eastern Uganda was low. Home births carried twice the risk for omphalitis. Use of chlorhexidine coupled with close follow-up of neonates in the community by health workers and community health workers might have reduced the risk of omphalitis.

A qualitative systematic review of umbilical cord care practices in Nigeria

BACKGROUND

Umbilical cord care is an important aspect of newborn health, and different practices exist around the world, often influenced by cultural, healthcare infrastructure, and socioeconomic factors. The objective of this systematic review is to synthesize current literature on umbilical cord care practices in Nigeria, with an emphasis on the impact of cultural beliefs, healthcare infrastructure, and socioeconomic factors.

METHODS

A comprehensive search for literature was performed across PubMED, MEDLINE and Google scholar for studies published between 2010 and 2023. The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines was followed for the execution of this study. Eligibility criteria included only English studies investigating umbilical cord care practices in Nigeria, with outcomes connected to cultural, healthcare, or socioeconomic factors. Critical Appraisal Skills Programme (CASP) checklist was used to critically appraise the quality and rigor of selected studies. Due to the heterogeneity of the studies (qualitative and quantitative), qualitative narrative synthesis was used to synthesize the studies in a textual format for comprehensive understanding.

RESULTS

A total of 11 included studies were found out of 1532 studies. The findings reveal a range of cord care practices, emphasizing the use of various methods such as methylated spirit, hot compresses, and indigenous substances. Cultural beliefs, a lack of healthcare infrastructure, and socioeconomic circumstances all have a big impact on cord care decisions. Disparities in knowledge and adherence to evidence-based procedures are noticeable, particularly in the use of chlorhexidine gel. Infections continue to be a problem, highlighting the significance of appropriate therapies.

CONCLUSION

This systematic review offers a comprehensive perspective of Nigerian umbilical cord care practices, emphasizing the importance of culturally responsive educational interventions, enhanced healthcare infrastructure, and targeted legislative measures. Despite its limitations, the study is an important resource for guiding future research, policy creation, and interventions to improve maternal and newborn health outcomes in Nigeria.

Use of chlorhexidine digluconate 7.1% gel for umbilical cord care in selected regions in Northern Ghana: qualitative perspectives of key stakeholders

BACKGROUND

The Government of Ghana in 2017 included chlorhexidine (CHX) digluconate 7.1% gel in the essential medicines list to replace methylated spirit for umbilical cord care. However, there are limited studies around the use of the CHX gel. This paper explores the perspectives of stakeholders in childcare regarding the use of the gel for umbilical cord care in selected regions in Northern Ghana.

METHODS

Data for the study were from 42 in-depth interviews and 12 focus group discussions conducted among mothers, caregivers, fathers, traditional birth attendants, and health care providers (including pharmacists and over the counter medicine sellers). The transcribed data was analysed and organized into themes and sub-themes using thematic analysis approach. The data analysis was conducted using NVIVO version 12 analytical software.

RESULTS

CHX gel was used side-by-side with methylated spirit for umbilical cord care in the study areas. Use of methylated spirit for umbilical cord care was found to be common, and in the home setting there was evidence of use of traditional substances such as shea butter, toothpaste, cow dung, herbs and chalk. However, shea butter was regarded as the "golden standard" for cord care among non-health professionals. Co-use of traditional and orthodox cord care substances was also rife. The limited use of the CHX gel was attributable to the fact that some participants, especially health providers were convinced that the gel and methylated spirit were both effective; hence they continued prescribing methylated spirit over the gel for cord care. Evidence on the efficacy of the gel was mixed perhaps a reflection of the limited awareness and knowledge about the CHX gel, and the limited use behaviour / use skills. Additionally, awareness of the inclusion of the CHX gel in the national health insurance was also mixed.

CONCLUSIONS

The CHX gel is yet to replace other cord care substances as the use of methylated spirit and traditional substances were still prevalent. Hence, a comprehensive strategy is needed to create awareness and educate providers, significant others, and the community about the gel and its efficacy if it is to replace methylated spirit as the cord care substance.

Postnatal cord care practices and associated factors in Arba Minch town, southern Ethiopia

BACKGROUND

Cord care is one component of essential newborn care that reduces newborn morbidity and mortality. Poor cord care practice leads to a large amount of neonatal death due to infection. In Ethiopia, many women give birth at home, where neonates are exposed to unclean cord care practices or application of different traditional substances. Despite the severity of the problem, studies related to postnatal cord care practice are scarce. Hence, this study is aimed to assess umbilical cord care practices and associated factors in the postnatal period in Arba Minch town.

OBJECTIVE

To assess postnatal cord care practices and associated factors among mothers who gave birth in the last six months in Arba Minch Town, southern Ethiopia, 2019.

METHODS

Cross-sectional study design was conducted and using simple random sampling method 423 mothers who gave birth with in the last six months in Arba Minch town from November 11 to December 02, 2019, were selected. Data was collected using structured questionnaire administered by the interviewer. EpiData version 4.4 was used for data entry and SPSS version 25 was used for data analysis. Variables with p ≤ 0.25 in bivarible logistic regressions were considered as potential candidates for multivariable logistic regression analysis to control confounders. Adjusted Odds Ratio with 95% confidence interval was applied in multivariable logistic regression models, to identify variable, which has significant association.

RESULTS

The overall proportion of women who had good postnatal cord care was 67.1%. The maternal age group of 25 to 29 years (AOR = 2.51; 95% CI: 1.35-4.68), maternal educational status of secondary school and above (AOR = 4.19; 95% CI: 2.05-8.54), mothers with good knowledge of cord care (AOR = 1.77; 95% CI: 1.03-3.05), and health facility delivery (AOR = 2.60; 95%CI: 1.05-6.41) were independent factors associated with good cord care.

CONCLUSIONS

The proportion of good cord-care practice reported in this study was relatively worthy. Maternal age group of 25-29 years, maternal educational status of secondary school and above, having good knowledge of cord care, and delivering at health facility were factors that increased good postnatal cord care practice. Therefore, investing in improving these factors would positively affect maternal postnatal cord care practice. In order to reduce neonatal morbidity and mortality, routine counseling of cord care practice to mothers would attain good knowledge about postnatal cord care practices. Community health education would also increase awareness and practice of postnatal cord care.

The nexus between maternal antenatal care attendance, newborn postnatal care and neonatal mortality in India: a matched case-control study

INTRODUCTION

Our study examines the relationship between newborn postnatal care and neonatal mortality stratified by maternal antenatal care attendance under a matched case-control framework.

METHODS

Data from the fifth round of the National Family Health Survey was used. A total of 172,079 recent births to eligible women (15-49 years) in five years preceding the survey were included in the study. We used the conditional logistic regression model, a commonly used regression model to fit matched case-control data to examine the effects of newborn postnatal care on neonatal mortality. The mother's age at birth of the newborn, previous birth intervals, birth order of the newborn, and birthsize of the newborn were included as the matching variables.

RESULTS

Newborns receiving postnatal care within two days or more than two days of birth are less likely to die during the neonatal period. Preferences for newborn postnatal care were also observed to increase with more maternal antenatal care visits. Our study also found a lower risk of neonatal mortality among those newborns whose umbilical cord was examined within two days of birth, regardless of the number of maternal antenatal care visits. Similarly, the risk of newborn deaths was lower among babies whose body temperature was measured within two days of birth. The tendency to breastfeed their newborns within an hour after delivery was considerably higher among those births that occurred to mothers who had a higher number of maternal antenatal care visits. The risk of newborn deaths was also observed to be lower among those born in public or private healthcare facilities.

CONCLUSION

Considering the cohesive nature of the relationship between neonatal mortality and maternal and child healthcare utilisation, strategic planning and management of the existing policies and programmes related to accessibility, availability, and affordability of maternal and child healthcare services is needed to achieve goal 3.2 of the Sustainable Development Goals. Promoting cost-effective measures such as continuous monitoring of the baby's body temperature and umbilical cord care could also effectively help reduce neonatal mortality.

An update on factors affecting umbilical cord care among mothers: A review

Umbilical cord care remains a critical aspect of newborn health, yet practices vary significantly across different cultures and healthcare settings. This paper aims to provide an updated synthesis of the factors influencing umbilical cord care among mothers. The umbilical cord is a vital link between the fetus and the placenta during pregnancy, but after birth, it requires proper care to prevent infections. Numerous factors influence a mother's approach to umbilical cord care, including cultural beliefs, socio-economic status, access to healthcare information, and traditional practices passed down through generations. Understanding these factors is crucial for healthcare providers to offer tailored guidance and support to mothers, ensuring the optimal care for newborns. This paper examines recent research and literature encompassing diverse cultural perspectives, socio-economic considerations, healthcare access, and educational interventions related to umbilical cord care. It also highlights the impact of technological advancements, such as telemedicine and digital health platforms, in disseminating crucial information to mothers, especially in remote or underserved areas. Moreover, the review delves into the role of healthcare professionals in promoting evidence-based practices and addressing misconceptions regarding umbilical cord care. It emphasizes the importance of culturally sensitive and context-specific interventions in enhancing maternal knowledge and practices related to neonatal care. In conclusion, this review presents an updated overview of the multifactorial influences on umbilical cord care among mothers. It calls for continued research and concerted efforts to bridge gaps in knowledge, cultural beliefs, and healthcare access, ultimately contributing to the promotion of optimal newborn health outcomes.

Harmful Traditional Practices of Umbilical Cord in Edaga Hamus Community, Asmara, Eritrea

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.

COMPARISON OF THE EFFECTIVENESS OF BREAST MILK, DRY-KEEPING, AND USE OF CHLORHEXIDINE IN UMBILICAL CORD CARE

This research was conducted as a randomized study with the objective of determining the effects of breast milk, dry-keeping, and chlorhexidine methods used in umbilical cord care on the time of umbilical cord separation and on omphalitis and bacterial flora development. The study was carried out in 97 newborns divided into three groups, as follows: breast milk was used for umbilical cord care in group 1 of 32 newborns, dry-keeping was applied in group 2 of 35 newborns, and chlorhexidine was applied in group 3 of 30 newborns. Infants were assigned to three subgroups through randomization performed using a computer program. Swabs for culture were obtained from umbilical cord on postnatal day 2 and day 5. While difference in the results of the care methods applied was not significant on day 2, significant difference in the results was found on day 5. It was determined that there was no bacterial growth in 46.7% of the chlorhexidine group, while maximum bacterial growth was recorded in the dry-keeping group. In the chlorhexidine group, timing of umbilical cord separation was significantly shorter than in other groups. Study results indicated that the most effective method was the use of chlorhexidine. Dry-keeping can be risky since it was inefficient in preventing umbilical colonization, and in cases where the cost of chlorhexidine is an issue, the use of breast milk can be recommended.

To adopt or adapt an existing neonatal core outcome set in Kenya: a study protocol

BACKGROUND

Development and use of core outcome set(s) (COS) in research can reduce research wastage by ensuring that a minimum set of outcomes are always reported on. Neonatal morbidity and mortality are a big burden in low- and middle-income countries (LMICs). Research is continuously being undertaken to reduce this burden. Currently, there is no COS for neonatal research in LMICs but there exists one for neonatal research in high-income countries (HICs).

OBJECTIVES

To determine outcomes that are useful for neonatal care in Kenya to inform whether an existing COS should be adopted or adapted. To assess the feasibility of a routine data collection system to collect data of the agreed-on COS.

METHODS

A review of existing literature on neonatal research in LMICs followed by a qualitative study of key stakeholders in neonatal care. To explore whether to adapt or adopt, in two hospitals, two focus group discussions with 6-8 parents/caregivers will be undertaken (one each in two hospitals). Key informant interviews will also be conducted with 6 health care providers in each of the hospitals. At the policy-making level, we will conduct 10 key informant interviews. Qualitative data will be analyzed thematically. A consensus meeting will be undertaken with key stakeholders, who will be presented with an overview of the COS developed for HICs, key findings from the literature, and the qualitative study to determine context-appropriate COS. The agreed-on outcomes will be counterchecked against the case records in the two hospitals. The feasibility of collecting the outcomes on a routine electronic research database, the Clinical Information Network that collects standardized data at admission and discharge, will be explored. The congruence (or not) of the outcomes will be documented and be used to enrich the discussion and provide a snapshot of the feasibility of the health information system to collect routine data on the COS.

CONCLUSIONS

A COS for use in neonatal care in Kenya will help enhance outcome measurements and reporting not just in research but also in routine practice. This will enhance the comparability of interventions in trials and routine settings leading to reduced research wastage and likely improved quality of care. Additionally, the methodology used for this work can be adopted in other settings as a means of adopting or adapting an existing COS.

Quantitative assessment of umbilical cord care practices amongst mothers in Jos, Plateau State, Nigeria

Introduction

A newly cut neonatal umbilical stump is a potential portal of pathogen entry leading to omphalitis. Neonatal sepsis can complicate omphalitis, but good cord care practices can reduce this risk.

Objective

The objective of this study was to assess umbilical cord care practices in tertiary-, secondary- and primary-level healthcare facilities in Jos, Nigeria.

Methods

A multi-centre, cross-sectional study of 284 mothers of infants aged 3-6 weeks old attending immunisation clinics in the three-level healthcare facilities using multistage sampling technique between April and September 2019. Data were analysed using SPSS version 23.0. Pearson's Chi-squared test was used to compare categorical variables. Adjusted odds ratios (AORs) and 95% confidence interval (CI) were used as point and interval estimates, respectively. P < 0.05 was adjudged to be statistically significant.

Results

The mean age of the mothers and infants was 25 ± 6 years and 5 ± 1 week, respectively. Only 2.2% of mothers used chlorhexidine (CHX) gel for cord care. Mothers showed good knowledge but poor practice of cord care. A significant positive relationship was observed between quality of cord care practices and level of healthcare facility (χ2 = 15.213; df = 2; P < 0.001). Good cord care practices were predicted by mothers' age 30-46 (AOR = 3.6; CI: 1.4-9.1) and good knowledge of cord care (AOR = 4.7; 95% CI: 2.2-9.9).

Conclusions

The study has highlighted the good knowledge but poor practices of cord care by mothers and the need to scale up the uptake of CHX gel in Jos. Mother's age and good knowledge of cord care are predictors of good cord care practices.

The impact of umbilical cord care education given to Primiparous mothers on cord separation time: A randomized controlled study

PURPOSE

This study aims to determine the impact of umbilical cord care education given to primiparous mothers on cord separation time.

DESIGN AND METHODS

This randomized controlled trial was conducted according to the Consolidated Standards of Reporting Trials (CONSORT) guidelines. The mothers constituting the research sample were divided into two groups, the control group and the education group, and cord care and cord separation times were measured.

RESULTS

The mean age of the mothers was 28.72 ± 4.86 years (min. 20 years, max. 40 years). There was no difference in age, gestational week of the baby, birth weight of the baby, gender of the baby and mode of delivery of the mother between the mothers in the control and education groups. While the cord separation time was 10.97 ± 0.320 days in the babies in the control group, it was 6.60 ± 0.177 days in the babies in the education group. A statistically significant difference was found between the duration of cord separation of the babies in the control and education groups.

CONCLUSIONS

This study showed that giving umbilical cord care education to primiparous mothers reduces umbilical cord separation time.

PRACTICE IMPLICATIONS

It is recommended that pediatric nurses provide education on umbilical cord care and the goals and methods of application of care practices, especially to primiparous mothers.

CLINICAL REGISTRATION

This study was registered at the U.S. National Library of Medicine Clinical Trials (code: NCT05573737).

Mothers' cord care practices in an academic hospital in Kenya

Background

Nearly 99% of neonatal deaths globally occur in low- and middle-income countries with about three-quarters of the neonatal deaths resulting from sepsis including those arising from cord infections. Thus, good cord care practices have the potential to reduce the neonatal deaths in low and middle-income countries such as Kenya.

Objective

Describe cord care practices of mothers in an academic hospital in Kenya.

Methods

A questionnaire was administered to 114 mothers attending child welfare clinic at 6 weeks in an academic hospital in Western Kenya. Descriptive statistics were computed for continuous variables while frequencies were computed for categorical variables. Parametric and non-parametric tests were used to check for association between maternal variables and cord care practices.

Results

Most mothers applied chlorhexidine (n =73, 64%) or practiced dry cord care (n = 17, 14.9%). Some mothers (12.9%) applied potentially harmful substances including saliva, ash and soil. Mothers who attended at least three antenatal clinic visits practiced the recommended cord care (χ2 =16.02, p. = 0.03).

Conclusions

Although mothers predominantly practiced the recommended cord care, some potentially deleterious practices were reported. There is need to encourage attendance to antenatal clinic in order to optimize umbilical cord care practices.

Omphalitis: Clinical Presentation and Approach to Evaluation and Management

ABSTRACT

Omphalitis is an uncommon but potentially serious infection in neonates. Findings include erythema and induration around the umbilical stump, and purulent drainage may be present. Fever and signs of systemic illness may occur, or there may only be signs of localized soft tissue infection. Until recently, there have been very few cohort studies of omphalitis in high-income countries, and no literature was available regarding the incidence of concurrent serious bacterial infection such as meningitis or urinary tract infection. A recent large, multicenter study suggests that most omphalitis presents as localized soft tissue infection, with very low rates of concurrent serious bacterial infection or adverse outcomes. Underlying urachal abnormalities should be considered in the infant with umbilical drainage. Treatment of omphalitis consists primarily of antibiotic administration, with surgical intervention rarely needed. Although antibiotics are typically administered intravenously, there may be a role for oral antibiotics in some lower risk infants with omphalitis.

Cost and consequences of using 7.1 % chlorhexidine gel for newborn umbilical cord care in Kenya

Background

Omphalitis is an important contributor to neonatal mortality in Kenya. Chlorhexidine digluconate 7.1 % w/w (CHX; equivalent to 4 % w/w chlorhexidine) was identified as a life-saving commodity for newborn cord care by the United Nations and is included on World Health Organization and Kenyan Essential Medicines Lists. This pilot study assessed the potential resource savings and breakeven price of implementing CHX for neonatal umbilical cord care versus dry cord care (DCC) in Kenya.

Methods

We employed a cost-consequence model in a Kenyan birth cohort. Firstly, the number of omphalitis cases and cases avoided by healthcare sector were estimated. Incidence rates and treatment effect inputs were calculated from a Cochrane meta-analysis of randomised clinical trials (RCTs) (base case) and 2 other RCTs. Economic outcomes associated with omphalitis cases avoided were determined, including direct, indirect and total cost of care associated with omphalitis, resource use (outpatient visits and bed days) and societal impact (caregiver workdays lost). Costs and other inputs were sourced from literature and supplemented by expert clinical opinion/informed inputs, making necessary assumptions.

Results

The model estimated that, over 1 year, ~ 23,000 omphalitis cases per 500,000 births could be avoided through CHX application versus DCC, circumventing ~ 13,000 outpatient visits, ~ 43,000 bed days and preserving ~ 114,000 workdays. CHX was associated with annual direct cost savings of ~ 590,000 US dollars (USD) versus DCC (not including drug-acquisition cost), increasing to ~ 2.5 million USD after including indirect costs (productivity, notional salary loss). The most-influential model parameter was relative risk of omphalitis with CHX versus DCC. Breakeven analysis identified a budget-neutral price for CHX use of 1.18 USD/course when accounting for direct cost savings only, and 5.43 USD/course when including indirect cost savings. The estimated breakeven price was robust to parameter input changes. DCC does not necessarily represent standard of care in Kenya; other, potentially harmful, approaches may be used, meaning cost savings may be understated.

Conclusions

Estimated healthcare cost savings and potential health benefits provide compelling evidence to implement CHX for umbilical cord care in Kenya. We encourage comprehensive data collection to make future models and estimates of impacts of upscaling CHX use more robust.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06971-7.

Effect of a supportive-educative nursing intervention programme on knowledge of chlorhexidine gel for umbilical cord management amongst mothers in Cross River State, Nigeria

BACKGROUND

Umbilical cord infection contributes significantly to neonatal mortality rate in sub-Saharan Africa. Studies have shown low knowledge of chlorhexidine (CHX) gel for umbilical cord management amongst mothers in low-resource settings, including Nigeria.

OBJECTIVE

The objective of this study was to assess the effectiveness of a supportive-educative nursing intervention programme on knowledge of CHX gel amongst mothers in Cross River State, Nigeria.

METHODS

A quasi-experimental study design was used, and study participants comprised 168 expectant mothers, who were purposely selected and assigned to randomised control and intervention groups. The instrument for data collection was a researcher-developed structured questionnaire. The data were analysed using Statistical Package for Social Sciences version 23 for descriptive and inferential statistics at significant level was set at p 0.05.

RESULTS

The result showed that at post-test the knowledge score of mothers on CHX gel improved significantly in the intervention group (t 77 = 24.394; p 0.05). The result showed no significant difference between mothers' demographic variables and knowledge of CHX gel.

CONCLUSION

A supportive-educative nursing intervention programme could effectively improve knowledge of CHX gel for umbilical cord management amongst mothers. This underscores the need to improve mothers' knowledge of CHX gel by healthcare personnel.

Correlations between the Status of the Umbilical Cord and Neonatal Health Status

Purpose: This study aimed to identify correlations between the status of the umbilical cord and neonatal health status.Methods: In total, 172 newborns were enrolled who were admitted to the newborn nursery with a gestational age of 35 weeks or older and a body weight of 2 kg or above. Data were collected on the basic personal information of the newborns, the diameter and soft tissue status of the umbilical cord, and neonatal health status after birth. Analyses were performed using t-test, analysis of variance, <i>x</i>² test, and Fisher exact test.Results: Umbilical cord diameter exhibited a statistically significant difference by sex (t=2.71, <i>p</i>=.007). A thin umbilical cord diameter was associated with a 1-minute Apgar score less than 8 points (t=2.47, <i>p</i>=.015) and with being transferred to the intensive care unit (t=2.45, p=.015). Poor soft tissue status of the umbilical cord was associated with a 1-minute Apgar score of less than 8 points (<i>x</i>²=16.68, <i>p</i><.001) and with oxygen being supplied (<i>x</i>²=4.81, <i>p</i>=.028).Conclusion: Assessing the umbilical cord diameter and status in newborns is an important tool for evaluating neonatal health status after birth, and this point also underscores the importance of professionals' careful observations in the newborn nursery.

Association between birth attendant and early newborn care in Senegal

OBJECTIVE

To examine the association between type of birth attendant and early newborn care in Senegal.

DESIGN

This was a secondary analysis of cross-sectional data from the 2017 Continuous Demographic and Health Survey.

PARTICIPANTS

The study included data on 6328 women with live births in the three years preceding the survey.

MEASUREMENTS

The main exposure was the type of birth attendant (doctor, nurse/midwife, auxiliary midwife/matrone, traditional birth attendant, or "others (friend, relative, or no one)). We assessed three outcomes: 1) early initiation of breastfeeding, 2) breastfeeding support, and 3) cord examination. We used multivariable logistic regression to estimate the odds ratios and 95% confidence intervals of early newborn care after adjusting for potential confounders.

FINDINGS

The coverage of all three newborn care indicators of interest was low. In the adjusted regression models, women whose births were assisted by a nurse/midwife were nearly twice as likely to initiate breastfeeding early compared to those assisted by doctors (odds ratio: 1.87, 95% confidence interval: 1.00-3.45). Women assisted at birth by doctors were significantly more likely to report breastfeeding support and newborn cord examination than those assisted by other types of birth attendants.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Although most recent births were facility-based and assisted by skilled birth attendants, the prevalence of early newborn care was suboptimal. This presents a missed opportunity to improve neonatal outcomes. Training and supporting skilled birth attendants may bridge the gap between opportunity and practice, and lead to improved coverage and quality of newborn care in Senegal.

Umbilical cord separation time, predictors and healing complications in newborns with dry care

Objective

The objective of this study was to explore the umbilical cord separation time, predictors, and healing complications from birth until the newborn was one month old.

Design

A quantitative longitudinal observational analytical study by stratified random sample was adopted.

Setting

Public health system hospitals in southern Spain and at newborns’ homes.

Participants

Between April 2016 and December 2017, the study included 106 neonates born after 35–42 weeks of gestation whose umbilical cord was cured with water and soap and dried later as well as newborns without umbilical canalisation whose mothers enjoyed a low-risk pregnancy.

Methods

The data collection procedure comprised two blocks: from birth to the time of separation of the umbilical cord and from cord separation to the first month of life of the newborn. Umbilical cord separation time was measured in minutes; socio-demographic and clinical characteristics were measured by means of questionnaires, and the external diameter of the umbilical cord was measured using an electronic stainless-steel calliper and trailing roller.

Results

The mean umbilical separation time: 6.61 days (±2.33, IC 95%:6.16–7.05). Incidence of omphalitis was 3.7%; granuloma was 8.6%. Separation time predictors were wetting recurrence, birth weight, intrapartum antibiotics, birth season, and Apgar < 9 (R² = 0.439 F: 15.361, p <0.01).

Conclusion

The findings support the World Health Organization recommendations: dry umbilical cord cares is a safe practice that soon detaches the umbilical cord, taking into account the factors studied that will vary the length of time until the umbilical cord is separated.

Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: a case-control study

Background: Three-quarters of all annual neonatal deaths in developing countries are attributable to neonatal sepsis. In primary care settings, poor cord hygiene due to improper handling of the infant's cord is a major contributor to the occurrence of neonatal sepsis. The objective of this study was to describe the umbilical cord practices among mothers attending a primary care facility, assess the relationship between umbilical cord hygiene and neonatal sepsis, its impact on the population, as well as the influence of other neonatal and maternal factors on this relationship. Methods: A case-control study was conducted to assess the umbilical cord hygiene-neonatal sepsis relationship among neonates attending a primary care facility between August and October 2018. All cases were selected, while controls were systematically random sampled, as per study eligibility criteria. Exposure variables were summarized using descriptive statistics. A multivariable logistic regression model was fitted to evaluate the association between umbilical cord hygiene and neonatal sepsis adjusting for the effect of potential confounders. Subsequently, a population attributable fraction (PAF) was estimated. Results: The proportion of mothers with improper hygiene was 35.3%: 72.1% among the cases and 16.3% among the controls' caregivers. The odds of neonatal sepsis were 13 times higher (OR=13.24; 95% CI: [7.5; 23.4]) among infants whose caregivers had improper hygiene compared to those who had proper hygiene. None of the neonatal and maternal covariates confounded the umbilical cord hygiene-neonatal sepsis association. This odds ratio gave a PAF of 66.7% (95% CI: 62.5; 69.03). Conclusions: Improper cord hygiene is prevalent in this low resource setting. Improper cord hygiene has a strong positive association with neonatal sepsis. Observing good cord care practices could avert up to 67% of newborn infections. This calls for inclusion of good cord care practices in the antenatal care educational package.

Association between umbilical cord hygiene and neonatal sepsis among neonates presenting to a primary care facility in Nairobi County, Kenya: a case-control study

Background: Three-quarters of all annual neonatal deaths in developing countries are attributable to neonatal sepsis. In primary care settings, poor cord hygiene due to improper handling of the infant's cord is a major contributor to the occurrence of neonatal sepsis. The objective of this study was to describe the umbilical cord practices among mothers attending a primary care facility, assess the relationship between umbilical cord hygiene and neonatal sepsis, its impact on the population, as well as the influence of other neonatal and maternal factors on this relationship. Methods: A case-control study was conducted to assess the umbilical cord hygiene-neonatal sepsis relationship among neonates attending a primary care facility between August and October 2018. All cases were selected, while controls were systematically random sampled, as per study eligibility criteria. Exposure variables were summarized using descriptive statistics. A multivariable logistic regression model was fitted to evaluate the association between umbilical cord hygiene and neonatal sepsis adjusting for the effect of potential confounders. Subsequently, a population attributable fraction (PAF) was estimated. Results: The proportion of mothers with improper hygiene was 35.3%: 72.1% among the cases and 16.3% among the controls' caregivers. The odds of neonatal sepsis were 13 times higher (OR=13.24; 95% CI: [7.5; 23.4]) among infants whose caregivers had improper hygiene compared to those who had proper hygiene. None of the neonatal and maternal covariates confounded the umbilical cord hygiene-neonatal sepsis association. This odds ratio gave a PAF of 66.7% (95% CI: 62.5; 69.0). Conclusions: Improper cord hygiene is prevalent in this low resource setting. Improper cord hygiene has a strong positive association with neonatal sepsis. Observing good cord care practices could avert up to 67% of newborn infections. This calls for inclusion of comprehensive cord care practices in the antenatal care educational package.

Milk Therapy: Unexpected Uses for Human Breast Milk

BACKGROUND

Human breast milk provides a child with complete nutrition but is also a popular therapeutic remedy that has been used in traditional, natural pharmacopeia, and ethnomedicine for many years. The aim of this current review is to summarize studies of non-nutritional uses of mothers' milk.

METHODS

Two databases (PubMed and Google Scholar) were searched with a combination of twelve search terms. We selected articles that were published between 1 January 2010, and 1 January 2019. The language of publication was limited to English.

RESULTS

Fifteen studies were included in the systematic review. Ten of these were randomized controlled trials, one was a quasi-experimental study, two were in vitro studies, and four employed an animal research model.

CONCLUSIONS

Many human milk components have shown promise in preclinical studies and are undergoing active clinical evaluation. The protective and treatment role of fresh breast milk is particularly important in areas where mothers and infants do not have ready access to medicine.

[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.

Comparison of the effectiveness of different umbilical cord care in infants: A protocol for systematic review and network meta-analysis

BACKGROUND

More and more studies were performed to explore the effectiveness of umbilical cord care practices. However, the results remain controversial. Hence, the aim of the review was to evaluate and compare the effectiveness of different umbilical cord care in infants through network meta-analysis.

METHODS

A systematic literature search for relevant articles published in the English language will be conducted in PubMed, EMBASE, the Cochrane library, and Chinese Biomedical Literature Database from their inception to December 2018. Randomized controlled trials (RCTs) that compared the effectiveness of different types of umbilical cord care practices will be included. Cord infection, illness, and death will be used to assess the clinical effect. Risk of bias assessment of the included RCTs will be conducted by the Cochrane risk of bias tool. The WinBUGS 1.4.3 software will be used to perform the network meta-analysis and the result figures will be generated by STATA V.15.0 software. Grading of recommendations assessment, development, and evaluation will be used to assess the quality of evidence.

RESULTS

The results will be published in a peer-reviewed journal.

CONCLUSION

This will be the first network meta-analysis to evaluate and compare the effectiveness of different umbilical cord care in infants. Our study will generate evidence of cord care for infants and provide suggestions for clinical practice or guideline.

PROSPERO REGISTRATION NUMBER

CRD42018118052.

Dry care versus chlorhexidine cord care for prevention of omphalitis. Systematic review with meta-analysis

Objective:

to compare the effect of dry care and the application of chlorhexidine to the umbilical cord of newborns at risk of developing omphalitis.

Method:

systematic review with meta-analysis. Clinical trials comparing dry care with the application of clorexidine to evaluate omphalitis were selected. Methodological quality was evaluated using the Consolidated Standards of Reporting Trials.

Results:

the joint analysis of the studies shows a significant decrease in the risk of omphalitis in the chlorhexidine group compared to the dry care group (RR=0.58, CI: 0.53-0.64). However, in the analysis by subgroups, chlorhexidine umbilical cord care did not reduce the risk of omphalitis in hospital births (RR=0.82, CI: 0.64-1.05), in countries with a low infant mortality rate (RR=0.8, CI: 0.5-1.28), or at chlorhexidine concentrations below 4% (RR=0.55, CI: 0.31-1). Chlorhexidine acted as a protective factor at a concentration of 4% (RR=0.58, CI: 0.53-0.64), when applied in cases of home births (RR=0.57, CI: 0.51-0.62), in countries with a high infant mortality rate (RR=0.57, CI: 0.52-0.63).

Conclusion:

dry cord care is effective in countries with low infant mortality rate and in hospital births. However, 4% chlorhexidine for umbilical cord care protects against omphalitis in home births, in countries with a high infant mortality rate.

The State of Essential Newborn Care by Delivery Location in Bangladesh

Introduction Essential newborn care (ENC) around the time of birth is critical in improving neonatal survival. There is currently a gap in our knowledge of the use of ENC by place of delivery in Bangladesh. This study assesses the provision of ENC and examines the odds of newborns receiving ENC by different levels of delivery care in Bangladesh. Methods Descriptive statistics and logistic regressions were performed on ENC practices from the 2011 Bangladesh Demographic and Health Survey dataset. ENC practices included nonapplication of substances to the cord; application of antiseptic to the cord; drying newborn within 5 min; wrapping newborn within 5 min; delaying first bath until the first 72 h; and breastfeeding within 1 h. Key predictors included home delivery with a lay attendant, delivery with primary healthcare services and delivery with higher-level healthcare services. Results Coverage of ENC practices was low. Women who delivered with primary and higher-level healthcare services generally reported greater odds of their newborns receiving recommended ENC than women who had home delivery with a lay attendant, the referent category. However, the odds of delayed first bath until 72 h and breastfeeding within 1 h were not statistically different for newborns who were delivered with primary healthcare services. Discussion These findings have significant public health implications as primary healthcare facilities are the first point of entry into the healthcare system. Provision of ENC, particularly delayed first bath until 72 h and breastfeeding within 1 h, should be encouraged for all healthy mother-newborn pairs in Bangladesh.

Effectiveness of a campaign to implement chlorhexidine use for newborns in rural Haiti

Background

Chlorhexidine topical cord application is recommended to prevent umbilical cord infections in newborns delivered at home in low-resource settings. A community campaign introducing chlorhexidine for the first time in Haiti was developed. Traditional birth attendants (TBAs) were identified as implementers since they typically cut newborns’ cords. TBAs were trained to apply chlorhexidine to the cord and demonstrate this procedure to the mother. Concurrently TBAs explained reasons for using chlorhexidine exclusively instead of traditional cord care practices. The campaign’s effectiveness was evaluated 7–10 days post-delivery using a survey administered by community health workers (CHWs) to 198 mothers.

Results

Nearly all mothers heard about chlorhexidine use and applied it as instructed. Most mothers did not initially report using traditional cord care practices. With further probing, the majority reported covering the cord but few applied an unhygienic substance. No serious cord infections were reported.

Conclusion

The campaign was highly successful in reaching mothers and achieving chlorhexidine use. In this study, the concomitant use of traditional cloth coverings or bindings of the cord did not appear harmful; however more research is needed in this area. This campaign provides a model for implementing chlorhexidine use, especially where trained TBAs and CHWs are present.

The Challenges of Providing Postpartum Education in Dar es Salaam, Tanzania: Narratives of Nurse-Midwives and Obstetricians

Postpartum education can save lives of mothers and babies in developing countries, and the World Health Organization recommends all mothers receive three postpartum consultations. More information is needed to better understand how postpartum education is delivered and ultimately improves postpartum health outcomes. The purpose of this qualitative study was to examine how postpartum care was delivered in three postnatal hospital clinics in Dar es Salaam, Tanzania. Semistructured interviews with 10 nurse-midwives and three obstetricians were conducted. Feminist poststructuralism guided the research process. Postpartum education was seen to be an urgent matter; there was a lack of supportive resources and infrastructure in the hospital clinics, and nurse-midwives and obstetricians had to negotiate conflicting health and traditional discourses using various strategies. Nurse-midwives and obstetricians are well positioned to deliver life-saving postpartum education; however, improvements are required including increased number of nurse-midwives and obstetricians.

Developing guidelines in low-income and middle-income countries: lessons from Kenya

There are few examples of sustained nationally organised, evidence-informed clinical guidelines development processes in Sub-Saharan Africa. We describe the evolution of efforts from 2005 to 2015 to support evidence-informed decision making to guide admission hospital care practices in Kenya. The approach to conduct reviews, present evidence, and structure and promote transparency of consensus-based procedures for making recommendations improved over four distinct rounds of policy making. Efforts to engage important voices extended from government and academia initially to include multiple professional associations, regulators and practitioners. More than 100 people have been engaged in the decision-making process; an increasing number outside the research team has contributed to the conduct of systematic reviews, and 31 clinical policy recommendations has been developed. Recommendations were incorporated into clinical guideline booklets that have been widely disseminated with a popular knowledge and skills training course. Both helped translate evidence into practice. We contend that these efforts have helped improve the use of evidence to inform policy. The systematic reviews, Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches and evidence to decision-making process are well understood by clinicians, and the process has helped create a broad community engaged in evidence translation together with a social or professional norm to use evidence in paediatric care in Kenya. Specific sustained efforts should be made to support capacity and evidence-based decision making in other African settings and clinical disciplines.

Health care providers' perspectives regarding the use of chlorhexidine gel for cord care in neonates in rural Kenya: implications for scale-up

Background

This paper explores the perspectives of health care providers regarding the use of 7.1% Chlorhexidine Digluconate (CHX) gel that releases 4% chlorhexidine for newborn umbilical cord care under a managed access program (MAP) implemented in Bungoma County of Kenya. Understanding the perspectives of providers regarding CHX is important since they play a key role in the health system and the fact that their views could be influenced by prior beliefs and inconsistent practices regarding umbilical cord care.

Methods

Data are from in-depth interviews conducted between April and June 2016 with 39 service providers from 21 facilities that participated in the program. The data were transcribed, typed in Word and analyzed for content. Analysis entailed identifying recurring themes based on the interview guides.

Results

Use of CHX gel for cord care in neonates was acceptable to the health care providers, with all of them supporting scaling up its use throughout the country. Their views were largely influenced by positive outcomes of the medication including fast healing of the cord as reported by mothers, minimal side effects, reduced newborn infections based on what their records showed and mothers’ reports, ease of use that made it simple for them to counsel mothers on how to apply it, positive feedback from mothers which demonstrated satisfaction with the medication, and general acceptance of the medication by the community. They further noted that successful scale-up of the medication required community sensitization, adequate follow-up mechanisms to ensure mothers use the medication correctly, addressing issues of staffing levels and staff training, developing guidelines and protocols for provision of the medication, adopting appropriate service delivery approaches to ensure all groups of mothers are reached, and ensuring constant supply of the medication.

Conclusion

Use of CHX gel for cord care in neonates is likely to be acceptable to health care workers in settings with high prevalence of neonatal morbidity and mortality arising from cord infections. In scaling up the use of the medication in such settings, some of the health systems requirements for successful roll-out can be addressed by programs while others are likely to be a persistent challenge.

Umbilical Cord Care and Infection Rates in Turkey

OBJECTIVE

To compare the efficacy of umbilical cord sponging with 70% alcohol, sponging with 10% povidone-iodine, and dry care on the time to umbilical cord separation and bacterial colonization.

DESIGN

Prospective, interventional experimental study design.

SETTING

Three different family health centers in Istanbul, Turkey.

PARTICIPANTS

In total, 194 newborns were enrolled in one of three study groups: Group 1, 70% alcohol (n = 67); Group 2, 10% povidone-iodine (n = 62); and Group 3, dry care (n = 65).

METHODS

Data were collected between January 2015 and July 2015. Umbilical separation time and umbilical cord bacterial colonization were considered as the study outcomes.

RESULTS

The most commonly isolated bacteria were Staphylococcus aureus, Escherichia coli, and enterococci. There was no significant difference among the groups for umbilical cord separation times (p > .05).

CONCLUSION

Dry care may be perceived as an attractive option because of cost benefits and ease of application.

Umbilical cord-care practices in low- and middle-income countries: a systematic review

Background

Neonatal sepsis is the third leading cause of deaths for infants in their first month of life. The newly cut umbilical cord can be a pathway for bacteria that can cause newborn sepsis and death. Optimal umbilical cord care practices for newborns and during the first week of life, especially in settings with poor hygiene, has the potential to avoid these preventable neonatal deaths. The purpose of this review of cord care practices is to assist in the development of behavior-change strategies to support introduction of novel cord-care regimens, particularly 7.1% chlorhexidine digluconate for umbilical cord care.

Methods

We searched domestic and international databases for articles that were published in English between January 1, 2000, and August 24, 2016. We found 321 articles and reviewed 65 full-text articles using standardized inclusion criteria. The primary criteria for inclusion was a description of substances applied to the umbilical cord stump in the days following birth.

Results

We included 46 articles in this review of umbilical cord-care practices. Articles included data from 15 low- and middle-income countries in sub-Saharan Africa (8 countries), Asia (5 countries), North Africa (1 country), and Latin America and the Caribbean (1 country). Findings from this review suggest that documentation of cord-care practices is not consistent throughout low- and middle-income countries, yet existing literature depicts a firm tradition of umbilical cord care in every culture. Cord-care practices vary by country and by regions or cultural groups within a country and employ a wide range of substances. The desire to promote healing and hasten cord separation are the underlying beliefs related to application of substances to the umbilical cord. The frequency of application of the substance (either the number of days or the number of times per day the substance was applied), and source and cost of products used is not well-characterized.

Conclusions

This desire to actively care for the umbilical cord of a newborn—as noted in the variety of cord care practices and beliefs identified in this review—points toward the need to contextualize any behavior change approach to align with the local culture.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1250-7) contains supplementary material, which is available to authorized users.

TRADITIONAL PRACTICES ADOPTED BY JORDANIAN MOTHERS WHEN CARING FOR THEIR INFANTS IN RURAL AREAS

BACKGROUND

Traditional practices are commonly present within the Jordanian society, especailly those concerned with infant's care. Some of these practices might be harmful and thus health professioanls are required to substitute these practices with safe and healthy ones. The goal of this study is to determine the traditional practices adopted by Jordanian mothers when caring for their infants in rural areas.

MATERIALS AND METHODS

A descriptive study design using qualitative method was utilized in this study. A Purposive sample of 30 mothers was recruited from four rural regions in outskirts of Amman the capital city of Jordan.

RESULTS

Mothers had traditional infant's care practices pertinent to bathing of babies, including the salting, swaddling, care of the umbilical cord and jaundice.

CONCLUSION

Traditional practices are still common in Jordan; some of these behaviors can cause health risks. While health consequences of some of the traditional practices are still not clear, health professianls, especially nurses, are required to intervene by changing policies and education.

TRADITIONAL PRACTICES ADOPTED BY JORDANIAN MOTHERS WHEN CARING FOR THEIR INFANTS IN RURAL AREAS

BACKGROUND

Traditional practices are commonly present within the Jordanian society, especailly those concerned with infant's care. Some of these practices might be harmful and thus health professioanls are required to substitute these practices with safe and healthy ones. The goal of this study is to determine the traditional practices adopted by Jordanian mothers when caring for their infants in rural areas.

MATERIALS AND METHODS

A descriptive study design using qualitative method was utilized in this study. A Purposive sample of 30 mothers was recruited from four rural regions in outskirts of Amman the capital city of Jordan.

RESULTS

Mothers had traditional infant's care practices pertinent to bathing of babies, including the salting, swaddling, care of the umbilical cord and jaundice.

CONCLUSION

Traditional practices are still common in Jordan; some of these behaviors can cause health risks. While health consequences of some of the traditional practices are still not clear, health professianls, especially nurses, are required to intervene by changing policies and education.

Umbilical Cord Care in the Newborn Infant

Postpartum infections remain a leading cause of neonatal morbidity and mortality worldwide. A high percentage of these infections may stem from bacterial colonization of the umbilicus, because cord care practices vary in reflection of cultural traditions within communities and disparities in health care practices globally. After birth, the devitalized umbilical cord often proves to be an ideal substrate for bacterial growth and also provides direct access to the bloodstream of the neonate. Bacterial colonization of the cord not infrequently leads to omphalitis and associated thrombophlebitis, cellulitis, or necrotizing fasciitis. Various topical substances continue to be used for cord care around the world to mitigate the risk of serious infection. More recently, particularly in high-resource countries, the treatment paradigm has shifted toward dry umbilical cord care. This clinical report reviews the evidence underlying recommendations for care of the umbilical cord in different clinical settings.

Dirty and 40 days in the wilderness: Eliciting childbirth and postnatal cultural practices and beliefs in Nepal

Background

Pregnancy and childbirth are socio-cultural events that carry varying meanings across different societies and cultures. These are often translated into social expectations of what a particular society expects women to do (or not to do) during pregnancy, birth and/or the postnatal period. This paper reports a study exploring beliefs around childbirth in Nepal, a low-income country with a largely Hindu population. The paper then sets these findings in the context of the wider global literature around issues such as periods where women are viewed as polluted (or dirty even) after childbirth.

Methods

A qualitative study comprising five in-depth face-to-face interviews and 14 focus group discussions with mainly women, but also men and health service providers. The qualitative findings in Nepal were compared and contrasted with the literature on practices and cultural beliefs related to the pregnancy and childbirth period across the globe and at different times in history.

Results

The themes that emerged from the analysis included: (a) cord cutting & placenta rituals; (b) rest & seclusion; (c) purification, naming & weaning ceremonies and (d) nutrition and breastfeeding. Physiological changes in mother and baby may underpin the various beliefs, ritual and practices in the postnatal period. These practices often mean women do not access postnatal health services.

Conclusions

The cultural practices, taboos and beliefs during pregnancy and around childbirth found in Nepal largely resonate with those reported across the globe. This paper stresses that local people’s beliefs and practices offer both opportunities and barriers to health service providers.

Maternity care providers need to be aware of local values, beliefs and traditions to anticipate and meet the needs of women, gain their trust and work with them.

Neonatal mortality and topical application of chlorhexidine on umbilical cord stump: a meta-analysis of randomized control trials

OBJECTIVE

To examine the efficacy of topical chlorhexidine as an intervention on neonatal umbilical cord stumps and its association with neonatal mortality and omphalitis.

STUDY DESIGN

Meta-analysis of randomized controlled trials (RCTs).

METHOD

PubMed, EMBASE, CINAHL, IMSEAR, Google Scholar, Cochrane Central Register of Controlled Trials, Cochrane Pregnancy and Childbirth Group's Trials Register and Clinicaltrials.gov were screened until September 1, 2015 to identify RCTs that met the inclusion criteria. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated.

RESULTS

Five RCTs, conducted in Italy, Bangladesh, Nepal, Pakistan and India with a total of 55,008 participants were identified. Analysis revealed a significant reduction in the incidence of neonatal mortality among the intervention group as compared to the control group (pooled RR = 0.8; 95% CI: 0.6-1.0; P = 0.04; random effects model, I² = 58%; χ² = 9.5; P = 0.05). Additionally, decreased incidence in omphalitis was seen in the intervention group as compared to the control group (pooled RR = 0.4; 95% CI: 0.3-0.7; P < 0.001; random effects model, I² = 50%; χ² = 8.0; P = 0.09).

CONCLUSIONS

Application of chlorhexidine to newborn umbilical cord stumps, significantly reduce the incidences of both neonatal mortality and omphalitis. However, high-quality trials from different regions and obstetric settings may help form more conclusive judgement on universal application of topical chlorhexidine.

Umbilical cord cleansing with chlorhexidine in neonates: a systematic review

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of chlorhexidine application to the umbilical cord in neonates. We searched MEDLINE and other electronic databases, and included all RCTs that evaluated the effect of single or multiple chlorhexidine cord applications on the neonatal mortality rate (NMR) and/or the incidence of systemic sepsis and omphalitis. A total of six RCTs-four community-based cluster RCTs and two hospital-based trials-were included in the review. Of the four cluster RCTs, three were conducted in South Asia in settings with high rates of home births (>92%) while the fourth, available only as an abstract, was conducted in Africa. Pooled analysis by the 'intention-to-treat' principle showed a significant reduction in NMR after chlorhexidine application (four studies; relative risk (RR) 0.85; 95% confidence interval (CI) 0.76 to 0.95; fixed effects (FE) model). On subgroup analysis, only multiple applications showed a significant effect (four studies; RR 0.88; 95% CI 0.78 to 0.99) whereas a single application did not (one study; RR 0.86; 0.73 to 1.02). Similarly, only the community-based trials showed a significant reduction in NMR (three studies; RR 0.86; 95% CI 0.77 to 0.95), while the hospital-based study did not find any effect (RR 0.11; 0.01 to 2.03). Since all the studies were conducted in high-NMR settings (⩾30 per 1000 live births), we could not determine the effect in settings with low NMRs. Only one study-a hospital-based trial from India-reported the incidence of neonatal sepsis; it did not find a significant reduction in any sepsis (RR 0.67; 95% CI 0.35 to 1.28). Pooled analysis of community-based studies revealed significant reduction in the risk of omphalitis in infants who received the intervention (four studies; RR 0.71; 95% CI 0.62 to 0.81). The hospital-based trial had no instances of omphalitis in either of the two groups. Chlorhexidine application delayed the time to cord separation (four studies; mean difference 2.11 days; 95% CI 2.07 to 2.15; FE model). Chlorhexidine application to the cord reduces the risk of neonatal mortality and omphalitis in infants born at home in high-NMR settings. Routine chlorhexidine application, preferably daily for 7 to 10 days after birth, should therefore be recommended in these infants. Given the paucity of evidence, there is presently no justification for recommending this intervention in infants born in health facilities and/or low-NMR settings.

70% Alcohol Versus Dry Cord Care in the Umbilical Cord Care: A Case-Control Study in Italy

Recently the use of antibacterial agents to clean and dry the stump of the newborns' umbilical cord (UC) after birth has been abandoned by many neonatal units in favor of dry cord care. Aim of this study was to compare the occurrence of adverse events (AEs) and time to cord separation among newborns treated with dry cord care versus 70% alcohol in an Italian Academic Hospital (AH).From December 2014 to March 2015, 239 infants were born at the AH. The number of eligible infants was 200 and they were equally assigned to either case group (dry cord care) or control group (70% alcohol, standard procedure). Standard cord care consisted in 1 application of 70% alcohol at birth followed by other 2 times a day, while experimental dry cord care procedure was executed by the only application of a sterile gauze around the base of the UC at the 1st day of life and after the cord has been exposed to air off the diaper edge. The time to UC separation and any AEs such as local and systemic infections, hemorrhage, and granuloma formation were reported by mothers.We found a significant difference in the mean cord separation time between the 2 groups (dry cord care: 10.1 days [standard deviation, SD = 4.0] vs 70% alcohol: 12.0 days [SD = 4.2]; P < 0.001), while no significant AEs resulted. Incidence rate of granuloma was 0.67 × 1000 days of life in dry cord care group.Dry cord care is an easy, straight-forward, and safe method of handling the UC in healthy newborn infants born in a high-income hospital setting.

Bacteremia in children: epidemiology, clinical diagnosis and antibiotic treatment

The diagnosis of bacteremia in children is important and it can be clinically challenging to recognize the signs and symptoms. The reported rates of bacteremia are higher in young children but with the increasing vaccine coverage, there has been a decrease in bacteremia due to the three vaccine preventable bacteria (Streptococcus pneumoniae, Haemophilus influenzae group b and Neisseria meningitidis). Notably, there have been increases in healthcare-associated bacteremias with a rise in Staphylococcus aureus and Gram negative bacteremias. This review provides a brief overview of the clinical diagnosis of bacteremia in children, focusing on the epidemiology, clinical characteristics, risk factors, antibiotic treatment, outcomes and preventative measures to reduce the incidence of bacteremia and improve morbidity and mortality.

Chlorhexidine skin or cord care for prevention of mortality and infections in neonates

BACKGROUND

Affordable, feasible and efficacious interventions to reduce neonatal infections and improve neonatal survival are needed. Chlorhexidine, a broad spectrum topical antiseptic agent, is active against aerobic and anaerobic organisms and reduces neonatal bacterial colonisation and may reduce infection.

OBJECTIVES

To evaluate the efficacy of neonatal skin or cord care with chlorhexidine versus routine care or no treatment for prevention of infections in late preterm or term newborn infants in hospital and community settings.

SEARCH METHODS

We searched CENTRAL, latest issue of The Cochrane Library, MEDLINE (1966 to November 2013), EMBASE (1980 to November 2013), and CINAHL (1982 to November 2013). Ongoing trials were detected by searching the following databases: www.clinicaltrials.gov and www.controlled-trials.com.

SELECTION CRITERIA

Cluster and individual patient randomised controlled trials of chlorhexidine use (for skin care, or cord care, or both) in term or late preterm neonates in hospital and community settings were eligible for inclusion. Three authors independently screened and selected studies for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data, and assessed study risk of bias. The quality of evidence for each outcome was assessed using GRADE. We calculated pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals (CIs), and presented results using GRADE 'Summary of findings' tables.

MAIN RESULTS

We included 12 trials in this review. There were seven hospital-based and five community-based studies. In four studies maternal vaginal wash with chlorhexidine was done in addition to neonatal skin and cord care. Newborn skin or cord cleansing with chlorhexidine compared to usual care in hospitalsLow-quality evidence from one trial showed that chlorhexidine cord cleansing compared to dry cord care may lead to no difference in neonatal mortality (RR 0.11, 95% CI 0.01 to 2.04). Moderate-quality evidence from two trials showed that chlorhexidine cord cleansing compared to dry cord care probably reduces the risk of omphalitis/infections (RR 0.48, 95% CI 0.28 to 0.84).Low-quality evidence from two trials showed that chlorhexidine skin cleansing compared to dry cord care may lead to no difference in omphalitis/infections (RR 0.88, 95% CI 0.56 to 1.39). None of the studies in this comparison reported effects of the treatments on neonatal mortality. Newborn skin or cord cleansing with chlorhexidine compared to usual care in the communityHigh-quality evidence from three trials showed that chlorhexidine cord cleansing compared to dry cord care reduces neonatal mortality (RR 0.81, 95% CI 0.71 to 0.92) and omphalitis/infections (RR 0.48, 95% CI 0.40 to 0.57).High-quality evidence from one trial showed no difference between chlorhexidine skin cleansing and usual skin care on neonatal mortality (RR 1.03, 95% CI 0.87 to 1.23). None of the studies in this comparison reported effects of the treatments on omphalitis/infections. Maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention (sterile saline solution) in hospitalsModerate-quality evidence from one trial showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on neonatal mortality (RR 0.98, 95% CI 0.67 to 1.42). High-quality evidence from two trials showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on the risk of infections (RR 0.93, 95% CI 0.82 to 1.16).Findings from one trial showed that maternal vaginal cleansing in addition to total body cleansing results in increased risk of hypothermia (RR 1.33, 95% CI 1.19 to 1.49). Maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention (sterile saline solution) in the communityLow-quality evidence from one trial showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on neonatal mortality (RR 0.20, 95% CI 0.01 to 4.03). Moderate-quality evidence from one trial showed that maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention probably reduces the risk of neonatal infections (RR 0.69, 95% CI 0.49 to 0.95). These studies did not report effect on omphalitis.

AUTHORS' CONCLUSIONS

There is some uncertainty as to the effect of chlorhexidine applied to the umbilical cords of newborns in hospital settings on neonatal mortality. The quality of evidence for the effects on infection are moderate for cord application and low for application to skin. There is high-quality evidence that chlorhexidine skin or cord care in the community setting results in a 50% reduction in the incidence of omphalitis and a 12% reduction in neonatal mortality. Maternal vaginal chlorhexidine compared to usual care probably leads to no difference in neonatal mortality in hospital settings. Maternal vaginal chlorhexidine compared to usual care results in no difference in the risk of infections in hospital settings. The uncertainty over the effect of maternal vaginal chlorhexidine on mortality outcomes reflects small sample sizes and low event rates in the community settings.

Proteomics reveals age-related differences in the host immune response to sepsis

Sepsis is commonly caused by community-acquired pneumonia (CAP) and may develop into severe sepsis, characterized by multiple organ failure. The risk of severe sepsis among CAP patients and subsequent mortality increases sharply after the age of 65. The molecular mechanisms associated with this age-related risk are not fully understood. To better understand factors involved with increased incidence and mortality of severe sepsis in the elderly, we used a nested case-control study of patients enrolled in a multicenter observational cohort of 2320 participants with CAP. We identified a total of 39 CAP patients 50-65 and 70-85 years old who did or did not develop severe sepsis. Plasma samples were obtained on presentation to the emergency department and prior to therapeutic interventions. A semiquantitative plasma proteomics workflow was applied which incorporated tandem immunoaffinity depletion, iTRAQ labeling, strong cation exchange fractionation, and nanoflow liquid chromatography coupled to high-resolution mass spectrometry. In total, 772 proteins were identified, of which 58 proteins exhibit statistically significant differences in expression levels among patients with severe sepsis as a function of age. Differentially expressed proteins are involved in pathways such as acute phase response, coagulation signaling, atherosclerosis signaling, lipid metabolism, and production of nitric oxide and reactive oxygen species. This study provides insight into factors that may explain age-related differences in incidence of severe sepsis in the elderly.

The effect of umbilical cord cleansing with chlorhexidine on omphalitis and neonatal mortality in community settings in developing countries: a meta-analysis

Background

There is an increased risk of serious neonatal infection arising through exposure of the umbilical cord to invasive pathogen in home and facility births where hygienic practices are difficult to achieve. The World Health Organization currently recommends ‘dry cord care’ because of insufficient data in favor of or against topical application of an antiseptic. The primary objective of this meta-analysis is to evaluate the effects of application of chlorhexidine (CHX) to the umbilical cord to children born in low income countries on cord infection (omphalitis) and neonatal mortality. Standardized guidelines of Child Health Epidemiology Reference Group (CHERG) were followed to generate estimates of effectiveness of topical chlorhexidine application to umbilical cord for prevention of sepsis specific mortality, for inclusion in the Lives Saved Tool (LiST).

Methods

Systematic review and meta-analysis. Data sources included Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, CINHAL and WHO international clinical trials registry. Only randomized trials were included. Studies of children in hospital settings were excluded. The comparison group received no application to the umbilical cord (dry cord care), no intervention, or a non-CHX intervention. Primary outcomes were omphalitis and all-cause neonatal mortality.

Results

There were three cluster-randomised community trials (total participants 54,624) conducted in Nepal, Bangladesh and Pakistan that assessed impact of CHX application to the newborn umbilical cord for prevention of cord infection and mortality. Application of any CHX to the umbilical cord of the newborn led to a 23% reduction in all-cause neonatal mortality in the intervention group compared to control [RR 0.77, 95 % CI 0.63, 0.94; random effects model, I²=50 %]. The reduction in omphalitis ranged from 27 % to 56 % compared to control group depending on severity of infection. Based on CHERG rules, effect size for all-cause mortality was used for inclusion to LiST model as a proxy for sepsis specific mortality.

Conclusions

Application of CHX to newborn umbilical cord can significantly reduce incidence of umbilical cord infection and all-cause mortality among home births in community settings. This inexpensive and simple intervention can save a significant number of newborn lives in developing countries.