Umbilical cord care. A study of bacitracin ointment vs. triple dye

Anomalies, abnormalities, and care of the umbilicus

This article discusses various anomalies and abnormalities of the umbilical cord and issues related to cord care. The issue of screening newborns with an isolated single umbilical artery for renal abnormalities is addressed. The clinical presentation of infants with omphalomesenteric and urachal duct remants along with the more common umbilical granuloma is reviewed. All three of these abnormalities can present with a wet or draining cord. The need for umbilical cord treatment with antimicrobial/antiseptic agents versus dry cord care is discussed, as are serious infections that involve the cord.

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

OBJECTIVE

The purpose of the present study was to compare alcohol versus natural drying for umbilical cord care in preterm infants and to examine its effects on bacterial colonization and cord detachment.

STUDY DESIGN AND METHODS

Eligible infants <34 weeks gestation admitted to the NICU were randomized to receive either umbilical cleansing with 70% isopropyl alcohol at each diaper change or natural drying. Umbilical stump cultures were performed at 12 to 24 hours, 72 hours, 7 days, and 14 days of age.

RESULTS

A total of 109 infants were enrolled; 102 completed the study. Analyses revealed that the median cord detachment time was significantly shorter in the natural drying group compared to the alcohol group (13.0 versus 16.0 days; p=0.003). There were no cases of local umbilical infection in either group.

CONCLUSION

Based on the present study, it appears that natural drying is a safe and effective means of umbilical cord care in preterm infants.

Neonatal skin care

The relative importance of neonatal health and neonatal skin care has been highlighted in recent years as infant mortality rates have decreased while death rates during the neonatal period remain unacceptably high in many areas of the world. During the neonatal period, many newborns develop preventable, clinically apparent skin problems, and many more, especially preterm neonates, experience morbidity caused by compromised skin barrier integrity. Several strategies are available for protecting the integrity and promoting the hygiene of the skin and augmenting its function as a barrier to TEWL and heat loss and the entrance of infectious or toxic agents. Research defining optimal applications of many of these strategies, however, and the development of new approaches in skin care is one of the greatest challenges in pediatric dermatology and holds promise for improving neonatal outcome in the future. The ability to modulate epidermal barrier function and integrity relies largely on the topical use of protective materials and substances and manipulation of the external environment. As understanding of epidermal barrier development advances, perhaps pharmacologic manipulation of barrier development, as now practiced for augmentation of neonatal lung maturity, will become a reality. In the meantime, greater awareness among neonatal health care practitioners of state-of-the-art strategies for optimizing skin integrity in neonates is an important step toward improving neonatal health.

Neonatal skin care: the scientific basis for practice

OBJECTIVE

To review the literature addressing the care of neonatal skin.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review.

DATA EXTRACTION

Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown.

DATA SYNTHESIS

Newborns' skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin's immature barrier function, and promoting skin integrity.

CONCLUSIONS

This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

Neonatal skin care: the scientific basis for practice

OBJECTIVE

To review the literature addressing the care of neonatal skin.

DATA SOURCES

Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included neonatal skin differences; neonatal skin and care practices for skin integrity; neonatal skin and toxicity; permeability; and contact irritant sensitization.

STUDY SELECTION

Articles and comprehensive works relevant to key concepts and published after 1963, with an emphasis on new findings from 1993 to 1999. One hundred two citations were identified as useful to this review.

DATA EXTRACTION

Data were extracted and organized under the following headings: anatomy and physiology of the skin; physiologic and anatomic differences in neonatal skin; nutritional deficiencies; skin care practices; and care of skin breakdown.

DATA SYNTHESIS

Newborns' skin is at risk for disruption of normal barrier function because of trauma. In light of available evidence about differences in neonatal skin development, clinical practice guidelines are suggested for baths, lubrication, antimicrobial skin disinfection, and adhesive removal. In addition, basic care practices are suggested for maintaining skin integrity, reducing exposure to potentially toxic substances, and promoting skin health beyond the neonatal period. Preventive care recommendations are made for reducing trauma, protecting the skin's immature barrier function, and promoting skin integrity.

CONCLUSIONS

This review generated evidence with which to create a new and comprehensive practice guideline for clinicians. Evaluation of the guideline is under way at 58 U.S. sites.

Neonatal skin and skin care

Infant skin differs from adult skin in several ways. These important differences place infants at increased risk for fluid electrolyte imbalance, thermal instability, skin damage, percutaneous infection, and percutaneous toxicity from topically applied agents. This article includes a review of skin development, as well as the details of current skin care practices in the neonatal nursery. A better understanding of the principles of infant skin care and a more uniform approach to skin care in the neonatal nursery can minimize risks and costs to this special population of patients.

Cleaning solutions and bacterial colonization in promoting healing and early separation of the umbilical cord in healthy newborns

The efficacy of alcohol or water in promoting umbilical cord separation was compared in a randomized controlled trial. Rates of skin colonization between groups were also evaluated on three occasions. Time to cord separation, rates of colonization, and species of organisms that colonized were compared between groups. Of 148 participants, 136 (92%) completed the protocol. Cords that were cleaned with sterile water separated more quickly than those cleaned with alcohol (t = 3.15, p = 0.002). Between-group differences in colonization rates were not found (F = 1.59, df = 2, p = 0.205). Umbilical or other infections did not occur. Bacterial colonization of the umbilical area and surrounding skin occurs over time in healthy term neonates. Cleaning with alcohol will increase the length of time from birth to cord separation but will not prevent colonization of the umbilical area.

A prolonged outbreak of exfoliative toxin A-producing Staphylococcus aureus in a newborn nursery

An outbreak of erythromycin-resistant, exfoliative toxin-producing Staphylococcus aureus infection in a neonatal unit is described. The organism was coagulase positive but staphyloslide negative, and this unusual phenotype facilitated early recognition of the organism in the routine laboratory. In the initial outbreak there were 77 probable or confirmed cases, with a peak attack rate of 66%. Increased infection control measures were put in place and attempts were made to identify a staff carrier. No carriers were found and the major outbreak subsided. Sporadic cases occurred over the following 10 months, until May 1992, when a colonized staffperson was discovered. She was treated and no further cases occurred. The causative organism was subjected to typing by phage, enterobacterial repetitive intergenic consensus sequence polymerase chain reaction, and pulsed-field gel electrophoresis with two separate enzymes. The phage typing and genomic tests confirmed the presence of the same clone in the unit for 9 months. The organism possessed genes encoding exfoliative toxin A as determined by polymerase chain reaction.

Time of separation of the umbilical cord: a comparative study of treatment with alcohol and Rikospray

The time of cord separation and the umbilical changes post cord falling were studied in 394 infants, 35 to 42 weeks gestation, 1900 to 4500 g birth weight. Two methods of treatment; alcohol 70% with 0.5% chlorhexidine, and Rikospray were compared. The mean +/- SD age of cord separation was 6.36 +/- 2.64 days (range 3-20 days) in all infants studied. The time of cord separation and post fall umbilical complications were similar in the two treated groups. The only point of difference was the repulsive odor in the alcohol-treated group, making handling of the infants very unpleasant.

Randomized study of six umbilical cord care regimens. Comparing length of attachment, microbial control, and satisfaction

Two hundred and seventy one infants were enrolled in a study to compare six different methods of treating the umbilical cord. Antimicrobial control was equal for all methods. Repeated triple dye application was considered least acceptable by staff and parents and had the longest attachment time. Povidone-iodine was associated with the shortest attachment time and was most liked. If there is no special need to treat a specific nosocomial outbreak, duration of cord attachment and satisfaction of staff and parents can help clinicians decide on a cord care regimen.