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Trends in umbilical cord care: Scientific evidence for practice
CLINICAL PRACTICE
Abstract To provide an increasing body of knowledge related to umbilical cord care, a literature review was conducted to study the evolution of umbilical cord care, to evaluate the scientific evidence used to guide practice changes, and to make recommendations for current practice. Historically, there has been a wide range of inconsistent practices related to umbilical cord care that have included a variety of cleansing agents and techniques. The findings of this literature review indicate that the current standard of umbilical cord care may be based on historic practices and traditions rather than scientific investigation and justification. There appears to be little support for continued alcohol use. Yet, insufficient evidence is available to support an immediate change in the standard of care from topical antimicrobial treatment of the umbilical cord to natural healing. Further research is recommended to evaluate natural healing and to establish evidence-based recommendations for practice. © 2004 Elsevier Inc. All rights reserved.
From the Greenville Technical College, School of Nursing, Greenville, SC; Clemson University, School of Nursing, Clemson, SC; and Public Health Sciences, Clemson University, Clemson, SC. Address reprint requests to Tammy P. McConnell, MSN, RN, Nursing Instructor, 331 Ruth A. Nicholson, Nursing/Science Building, Greenville Technical College, School of Nursing, Greenville, SC. 29606 © 2004 Elsevier Inc. All rights reserved. 1527-3369/04/0404-0000$30.00/0 doi:10.1053/j.nainr.2004.09.004
Trends in Umbilical Cord Care: Scientific Evidence for Practice By Tammy P. McConnell, MSN, RN, Connie W. Lee, EdD, ARNP, IBCLC, Mary Couillard, PhD, RN, CS, FNP, and Windsor Westbrook Sherrill, PhD, MBA, MHA
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here is considerable debate among health care professionals about the most effective newborn umbilical cord care. Historically, there has been a wide range of recommended practices related to umbilical cord care that have included a variety of cleansing agents and techniques. Recent research has indicated that, in the context of modern infection control policies, the current standard of umbilical cord care may be based on historic practices and traditions rather than scientific investigation and justification. These studies recommend abandoning the traditional use of antimicrobials for soap and water or natural healing.1,2 Originally, cord care addressed concerns for bacterial colonization and subsequent infection; however, the relationship between umbilical colonization and infection was unclear. Delayed cord separation has also been proposed to increase the incidence of infection.1–3 The use of antimicrobial umbilical cord treatment such as isopropyl alcohol (alcohol) has consistently been proven to lengthen the time of cord separation.1,2,4 Yet, alcohol continues to be routinely used as an antimicrobial agent for the purpose of cord drying and is recommended by health care providers as an agent to hasten cord separation.4 Despite many studies of different cord care regimens, the treatment options recommended and practiced in the United States currently continue to vary from hospital to hospital and may include triple dye, isopropyl alcohol (alcohol), povidone-iodine (Betadine), antibiotic ointments, soap and water, or no treatment at all. The purposes of this article are to examine: 1) the history of umbilical cord care and its evolution over time; 2) the current cord care practices and the evidence that these practices are derived from; 3) the benefits and risks of the various cleansing agents used; 4) the relationship between bacterial colonization and infection; 5) the effects of umbilical cord care on cord separation; and 6) clinical significance. Finally, the appropriateness of current cord care practices and implications for changing the practice of cord care will be discussed.
Newborn and Infant Nursing Reviews, Vol 4, No 4 (December), 2004: pp 211–222
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The History of Umbilical Cord Care
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n the 1950s, frequent epidemic outbreaks of staphylococcus in newborn nurseries were occurring. There were cited cases of mastitis, pyoderma, septicemia, osteomyelitis, pneumonia, omphalitis, and fetal death related to these epidemics.5 During this era, it was typical for an infant to be in the nursery at least 10 days before discharge. “Rooming in” was not the standard of care. Nursery personnel were scrubbing, wearing scrubs, gowning, wearing caps, wearing masks, and washing hands between infants. The use of clean gloves was not a standard of care. The “no bathing technique” was a standard of care. Most infants were not bathed after delivery until discharge, which was usually day 10.5 As a reaction to these epidemic outbreaks, studies were conducted to address effectiveness of skin care, staff infection control practices, comparisons of umbilical cord care, maternal carrier states, maternal and infant colonization, and environmental contamination.5-15 Some studies concluded that the use of hexachlorophane wash (eg, pHisoHex®, GlaxoSmithKlein, Triangle Park, NC) or powder (Ster-zac®, SSL, Western Australia) as a skin cleansing agent substantially reduced staphylococcal colonization.5–7,9,11,14,15 In the 1960s, hexachlorophane wash or powders became a standard of care in newborn nurseries around the country. In 1969, a six and a half year study of hexachlorophane baths substantiated its effectiveness in eliminating staphylococcal infections and resulted in recommendations for major changes in the standard of care for newborns.15 These recommendations eliminated certain traditional elements of nursery routine. The use of caps and masks, deferring initial baths until thermal homeostasis, the use of hairnets, admission of students and parents into the nursery, and the use of gowning were no longer a part of routine nursery care. In late 1971, the Food and Drug Administration (FDA) and the American Academy of Pediatrics (AAP) recommended the discontinuance of routine infant bathing with hexachlorophane due to studies that revealed potential toxic effects of the cleansing agent.16 Within a month, some facilities experienced an increase in staphylococcal colonization and staphylococcal disease.17 This instigated immediate studies to determine a safe alternative for skin and cord care.16 –19 These studies evaluated triple dye compared with other cleansing agents. All studies found that triple dye was able to significantly reduce staphylococcal colonization, even with a one-time application. Triple dye became an alternative umbilical cord treatment for hexachlorophane. Other topical antimicrobials such as povidone-iodine (Betadine) and antibiotic ointments also
significantly reduced staphylococcal colonization. Thus, variance in standards of care was often based on physician and staff preference.20 Since the 1970s, it has been widely accepted to use some form of topical antimicrobial to treat the umbilical cord. Other accepted cord care practices include assessment of the cord for signs of infection, good hand washing between infants, folding down the diaper to avoid unnecessary friction or soiling, avoidance of tub baths until separation of the cord occurs, and avoiding the use of oils, lotions, and creams on the cord.20 In the 1980s, the use of clean gloves between patients became an infection control standard. Since the 1980s, studies have continued to evaluate differences in cord care regimens and staphylococcal colonization and infection and cord separation times.1– 4,20-27 Recent literature describes current cord care practices as being based on the assumptions of historic health care routines instead of research evidence.1,4,23
Current Cord Practice
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oday, cord care practices vary greatly from institution to institution in the United States. According to the AAP, no single method of cord care has proven superior in limiting bacterial colonization and disease.20 Methods of cord care that are currently used include triple dye, alcohol, antibiotic ointments, povidone-iodine (Betadine), soap and water, or no treatment at all.4 In general, the umbilical stump is expected to be kept clean and uncovered to promote healing, drying, and cord separation.20 For decades, the use of alcohol daily and as often as each diaper change has been recommended to decrease infection and shorten cord separation time. However, there is an absence of studies that show the benefits of using alcohol.4 It is important to note that the exposed necrotic tissue of the umbilical stump is readily colonized and infected by pathogenic bacteria. Ready access of the bacteria into the systemic circulation places neonates at high risk for infection. In developing countries, hygienic umbilical care is believed to reduce umbilical colonization, infection, tetanus, and sepsis, but the role of antiseptic cord care in reducing infections is unclear. Although studies in these less developed countries addressing cord care are lacking, historical controls and studies have demonstrated the decrease in infection during epidemic outbreaks in the 1950s. Recurrent epidemics of streptococcal infections have also been reported with the use of dry treatment or the use of alcohol alone, suggesting these regimens are insufficient.28 In the United States, the incidence of omphalitis (inflammation or infection of the umbilical stump) is rare.2 This has been assumed to be related to hand washing,
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Table 1. Comparison of Cleansing Agents and Usage Recommendations Issues of Concern Alcohol
Triple Dye
Povidone-Iodine (Betadine)
Topical Antibiotics: Bacitracin, Silver Sulfadiazine (Silvadene), Neomycin, Gentamycin
Natural Healing
standard precautions, knowledge of transmission, and antiseptic treatments of the umbilical stump.1 The thought that bacterial colonization of the umbilical stump is beneficial to the healing process and cannot necessarily be correlated with infection is also being explored by some investigators.1,2,4 These investigators have compared cleaning solutions and natural healing, and all recommend that no treatment at all may be more beneficial than the routine and historic use of topical antimicrobials.1,2,4
Benefits and Risks of Cleansing Agents
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opical cleansing agents have been used for neonatal baths and umbilical cord care. Table 1 provides a comparison of cleansing agents and usage recommendations. It is imperative to remember that topical use does not guarantee safety, as demonstrated by the widespread use and associated toxicity of hexachlorophane baths in the 1950s and 1960s. Other than systemic absorption and toxicity, risks of topical antimicrobials range from local
Recommendations Sufficient evidence exists to support a discontinuance of the use of alcohol for routine cord care. It has been proven to prolong cord separation. It has not been proven to be beneficial for decreasing bacterial colonization or infection. Insufficient evidence is available to support a discontinuance of triple dye for routine cord care. Enough evidence for natural healing is available to support an investigation of the risks and benefits of discontinuing triple dye use. Further research is recommended to evaluate the continued use of triple dye. Sufficient evidence exists to support a discontinuance of the use of Betadine for routine cord care. Triple dye has been proven to be superior in decreasing bacterial colonization or infection. Betadine has been associated with more serious toxic effects than triple dye. Sufficient evidence exists to support a discontinuance of the use of topical antibiotics for routine cord care. Triple dye has been proven to be superior in decreasing bacterial colonization or infection. Topical antimicrobials have been associated with emergence of bacterial resistance and allergic contact dermatitis. Insufficient evidence is available to support an immediate change in the standard of care from topical antimicrobial treatment of the umbilical cord to natural healing. Significant research is available, but more research is indicated before these results can be generalized to infants born in the United States. Further research is recommended to evaluate natural healing of the umbilical cord and to establish evidence-based recommendations for practice.
irritation, chemical burns, sensitization and allergic contact dermatitis, and accidental ingestion and poisoning.29 The dangers of percutaneous absorption in children are well documented. There have been numerous reports describing toxic side effects from systemic absorption of topically applied agents in infants.23,30 Although the structure of the epidermal barrier in full-term infants is mature, its thickness is 40 to 60% less than that found in an adult,4 some risk for percutaneous toxicity still remains.30 Several unique pediatric features help to explain this, such as the increased ratio of skin surface area to body weight; immature hepatic and renal function, which impairs drug metabolism and excretion; and decreased plasma protein binding that allows toxicity at lower drug doses.4,28 –30 Immature epidermal barriers as seen in preterm infants place them at even greater risk for percutaneous toxicity.30 The skin barrier function of infants of 25 weeks’ gestation and less may take 4 to 8 weeks to mature. This delay in skin maturation also increases the risk for secondary problems such as opportunistic infection, mechanical fragility,
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and absorption of topical agents.4,23,28 A conservative approach is mandated due to the increased permeability of neonatal skin. The use of topical preparations should be limited to only essential compounds and washing them off should further minimize exposure as soon as their purpose has been accomplished.28 Observation of the umbilical area may be more appropriate than cleaning.2 Isopropyl alcohol (alcohol) is widely used for cord care. It usually evaporates before it is absorbed by normal skin. Cases of acute alcohol toxicity in infants up to 21 days old have been reported after generous applications of alcohol to the umbilical stump and one case where the parents placed a dressing of alcohol under an occlusive barrier (occlusion) over the umbilical stump.29 Toxicities from alcohol absorption include hemorrhagic skin necrosis, dysfunction of the central nervous system, metabolic acidosis, and hypoglycemia.30 Physicians and nurse practitioners should limit or avoid the use of alcohol for cord care if possible despite its comfortable familiarity.29,30 In one study of an alcohol cord care regimen, umbilical cord cultures showed a dramatic increase in bacterial colonization almost immediately after a perinatal unit initiated the new alcohol cord care regimen. Approximately 6 months after implementation of the new alcohol cord care regimen, physicians in the community, who were unaware of the change in hospital practices, reported an increase in the number of infant skin infections. All cases cultured positive for Staphylococcus aureus.24 Povidone-iodine (Betadine) is another common topical antimicrobial used for umbilical cord care. When absorbed in significant amounts, this agent has increased serum iodine levels enough to stimulate neonatal hypothyroidism. Disturbance of thyroid function can be associated with intraventricular hemorrhage, cognitive abnormalities, growth and motor retardation, and death.29 Studies indicate that preterm and low-birth-weight infants are at greatest risk for significant iodine absorption.30 Some dispute the significant risks of these events in the United States, because this phenomenon occurs primarily in countries with relative iodine deficiency.29 If iodinated compounds are used, application should be brief, followed by a thorough rinsing, and never under occlusion.30 Topical antibacterial agents such as Bacitracin (Pharmaraia & Upjohn Company, Kalamazoo, MI), neomycin, gentamicin, and silver sulfadiazine (Silvadene) are also used to treat the umbilical stump. Safety depends on avoidance of systemic absorption, local irritation and tissue destruction, and hypersensitivity. Toxicities from topical antimicrobials include allergic contact dermatitis, anaphylaxis (rare), and neural deafness (rare). Emergence of bacterial resistance has also been seen with topical use of antibiotics that are used systemically. Therefore it is recommended to avoid their use if possible.29 It has also been
documented that antimicrobial ointment exposure can sensitize the skin to allergic reactions later in life.22 Hexachlorophane (pHisohex®, GlaxoSmithKlein, Research Triangle Park, NC) and chlorhexidine (Hibiscrub® or Hibiclens®, 3 Com, Marlborough, MA) are broadspectrum antimicrobials against gram-positive and -negative bacteria, and some yeast. Due to past problems with hexachlorophane, chlorhexidine was introduced as an effective and safe alternative. Now it is accepted that hexachlorophane is safe when properly used and has been reintroduced.26 Both agents are generally safe when used appropriately as topical preparations without occlusion on term infants. Some local reactions and systemic absorption has been noted in preterm infants. If alcohol is used as a vehicle for either of these agents, its toxicities should be considered as well.29 Triple dye, an agent bactericidal to both gram-positive and -negative bacteria, contains three ingredients: brilliant green, crystal violet, and proflavine hemisulfate. It was widely used in the 1950s until the popularity of hexachlorophane baths. In 1971, when hexachlorophene baths were not recommended, triple dye was reappraised. Since the early 1970s, triple dye has been used commonly for umbilical cord care.20 Toxicity of triple dye is rare. It can cause skin necrosis if it is inadvertently applied to the skin surrounding the umbilical stump. Prolonged use of gentian violet in adults may also cause nausea, vomiting, diarrhea, and mucosal ulceration. It is reasonable to surmise that prolonged use of triple dye could cause the same adverse effects in neonates. When applying to the cord, inadvertent applications or leakage onto the abdominal wall should be avoided if possible and washed off if necessary.28 Many studies have compared topical antimicrobial treatments of the umbilical stump. Table 2 provides an overview of recent studies regarding umbilical cord care and Table 3 provides an overview of the substantiated evidence and the fittedness and feasibility of these recent studies. In several studies, triple dye was found to be significantly better than castile soap, hexachlorophane (pHisoHex®, GlaxoSmithKlein, Triangle Park, NC), alcohol, povidone iodine, silver sulfanazine (Silvadene), and Bacitracin® (Pharmaraia & Upjohn Company, Kalamazoo, MI) in reducing cord colonization.17,18,21,24 These studies were different from the 1957 study of triple dye because they limited triple dye application to one-time application instead of daily application.13 It should be noted that some studies dispute the efficacy of triple dye on gram-negative bacteria.18 Although it is unclear which antimicrobial is the most beneficial for cord care treatment, many researchers recommend their use as a result of their studies. Others argue that the role of decreasing bacterial colonization has an uncertain relationship with the development of infection.
Table 2. Overview of Recent Umbilical Cord Care Studies Reference
Dore et al (1998)
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Medves and O’Brien Paes and Jones (1987) Stark and Harrisson (1992) Verber and Pagan (1993) Watkinson and Dyas (1997) (1992) Purpose To compare alcohol cleaning To evaluate differences To compare triple dye vs alcohol To determine the incidence To compare the colonization To compare colonization and natural drying of in time of cord in preventing bacterial and level of rate and length of cord rate and length of newborn umbilical cords. separation and colonization. Staphylococcus aureus separation with cords cord separation bacterial colonization in newborn treated with between treatment colonization with infants and its hexachlorophane, with alcohol and alcohol vs water. relationship to incidence chlorhexidine, early bath, 0.33% of infection. or dry cord care. hexachlorophane powder with tap water and dry care. Subjects 1,876 singleton full-term 148 term infants born 1,545 newborns born in a 340 newborns born in a 630 of all newborns born in 102 neonates born in a newborns enrolled from a at a tertiary hospital Canadian level II hospital that UK hospital. a UK hospital. UK hospital, tertiary level teaching in western Canada were not discharged prior to excluding those with hospital and a level II were included in the umbilical cultures taken on early PROM community hospital in study. 136 day 4. (premature rupture of Canada. 1,811 completed completed the study. membranes ⬎24 the study. hours) and those admitted to NICU Findings No newborn in either group Cords cleaned with Significant differences were Infants with level 5 Significant decrease in Infants without treatment was identified with an sterile water found in colonization with the colonization (heavy) colonization with showed a 1.75 infection. significantly use of triple dye and alcohol were significantly more chlorhexidine; modestly significant increase in There was a statistical separated 2-3 days for all bacteria, likely to develop an significant decrease with colonization. difference, with the faster than those Staphylococcus aureus, Group infection. chlorohexaphane and no No significant difference natural drying group treated with alcohol B streptococcus, and GramNo significant difference significant decrease with between groups with having shorter cord No statistical negative bacteria. with colonization related early bath. Significant signs of infection. separation by 1.7 days. difference between to location of infant at difference in length of Significantly greater No significant difference in colonization rates of time of culture. cord separation with proportion of cords maternal comfort with either group. chlorhexidine. with no treatment cord care/separation. No significant difference in separated before day 7. length of cord separation The modal day of with hexachlorophane separation was day 6 with no treatment and day 7 with treatment. No differences in ranges (no treatment ⫽ 3-12 days, treatment ⫽ 3-13 days) Recommendations Evidence does not support Cleaning with alcohol Total bacterial colonization was Showed the risk of The use of dry cord care Recommend use of continued use of alcohol will increase the reduced with triple dye. postdischarge disease was alone will lead to an antimicrobial for cord care. length of time from Colonization was related to related to the degree of unacceptably high treatment of the cord. Health providers should birth to cord infection by an increased predischarge colonization. colonization rate of Researchers feel those explain the normal process separation by 2-3 incidence of reported Neonates with level 5 Staphylococcus aureus. advocating no of cord separation days but will not infections by general colonization (heavy) at 48 Recommend use of treatment have not including appearance and prevent colonization practitioners and pediatricians hours were of greater risk antiseptic treatment of the presented a balanced possible odor. of the umbilical while alcohol was being used. of developing infection cord to reduce equation and Heath care providers should area. No infections occurred with than neonates with lower colonization. argument to include continue to develop triple dye use. level or no colonization. the considerable cost evidence to support or 44 infants (12%) of both sporadic cases eliminate historic health developed an infection. and outbreaks of care practices. Recommended reducing Staphylococcal colonization to reduce infections. postdischarge infection.
Dore et al (1998)
Substantiated Sample size, sensitivity/specificity Evidence of statistical tools adequate/appropriate. Outcomes were physiologic measures of length of time for cord separation and signs of umbilical infection previously established by the hospital of study. Significant differences were found with length of cord separation with natural drying 1.7 days shorter (t ⫽ 8.9, P ⫽ 0.001). No statistical difference in incidence of infection. Neither group experienced infection.
Fittedness
Medves and O’Brien (1997)
Paes and Jones (1987)
Sample size, sensitivity/specificity Sample size, sensitivity/ of statistical tools adequate/ specificity of appropriate. Outcomes were statistical tools physiologic measures of length adequate/ appropriate. of cord separation and Outcomes were colonization from consistently physiologic measures obtained cultures. Significant of colonization from differences were found with consistently obtained length of cord separation with cultures. Significant sterile water being 2-3 days differences were shorter than alcohol (t ⫽ 3.15, found with P ⬍ 0.002). No statistical colonization being differences in colonization higher with alcohol were found between the two than with triple dye groups (F ⫽ 1.59, df ⫽ 2, cord care. P ⫽ 0.205). All bacteria 2 ⫽ 247.01, P ⬍ 0.00001. S. aureus 2 ⫽ 346.51, P ⬍ 0.00001. Group Bstrep 2 ⫽ 41.17, P ⬍ 0.00001. Gram neg bact. 2 ⫽ 7.2, P ⬍ 0.027.
Sample population has limited Same as Fittedness of Dore et al. generalizability to healthy full-term infants born in Canada being discharged between 48 and 96 hours after birth. Results may not apply to other countries/regions without further investigation with a more generalizable population. Especially in the United States where evidence has shown a lengthened cord separation time (compared to other countries) ranging from 9.8-15 days. Factors may include frequency of care, LOS, and humidity, which may vary from Canada (Medves and O’Brien, 1997). Other more effective antimicrobials were also not addressed such as triple dye, which has been shown to be superior to alcohol at decreasing colonization (Paes and Jones, 1987). May not be generalizable to out of hospital deliveries. Does not correlate colonization with infection because infection did not occur in any group studied.
Sample has generalizability to all newborns born in a Level II Canadian hospital who were not transferred to a tertiary hospital (NICU) or with early discharge prior to day 4. Other comments previously made for US considerations apply here also. Authors only relate colonization with infections seen at the facility of study when alcohol was a standard of care.
Stark and Harrisson (1992) Sample size, sensitivity/ specificity of statistical tools adequate/ appropriate. Outcomes were physiologic measures of colonization from consistently obtained cultures. Significant differences were found with level of colonization and infection rate with Level 5 colonization more likely to develop into postdischarge infection (2 test; P ⬍ 0.001).
Verber and Pagan (1993) Watkinson and Dyas (1992) Sample size, sensitivity/ Sample size, sensitivity/ specificity of specificity of statistical tools statistical tools adequate/ appropriate. adequate/ appropriate. Outcomes were Outcomes were physiologic measures physiologic measures of colonization from of colonization from consistently obtained consistently obtained cultures and length of cultures and length of cord separation. cord separation Significant differences measured by midwife were found when using home visits. antiseptic cord care in Significant differences decreasing colonization were found with vs dry cord care using incidence of Chi-square test. colonization. With no Chlorhexidine treatment ⫽ 1.75 (P ⬍ 0.001). times greater chance Hexachlorophane of colonization. (OR (P ⬍ 0.025). ⫽ 1.75; 95% CI, Significant differences 1.08, 2.85). were found with length Significant difference of cord separation in cord separation being longer with before day 7 (OR ⫽ chlorhexidine (P ⬍ 1.78;95% CI, 1.04, 0.001) than dry care. 3.05) and no No significant differences significant difference with length of cord in range of separation with separation. hexachlorophane vs dry care. Sample only has Sample has Sample only has generalizability with generalizability to all generalizability to all all newborns born in newborns born in an newborns born in a a UK hospital of UK hospital of UK hospital of similar characteristics similar characteristics similar characteristics as hospital of study. of the hospital of as the hospital of Comments previously study. Does not relate study. Does not make made for US colonization with any correlation considerations apply infection, but cites between colonization here also. Stark and Harrison’s and infection. correlation between colonization and infection.
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Table 3. Overview of Substantiated Evidence, Fittedness, and Feasibility of Recent Umbilical Cord Care Studies
Feasibility
Risks: Include possible increased incidence of neonatal infection and morbidity.
Benefits: Eliminate possibly historical medical practices and replace with evidence-based practice. Resources: Readily available (natural healing does not require additional resources). Costs: Cost of antimicrobials at $0.52-1.90 are potentially saved. Yet, if infection occurs, the cost are substantially greater that the cost of the antimicrobial. Readiness: Healthcare is now embracing evidence-based practice and motivation is present to eliminate ungrounded historical practices if substantiated by evidence.
Same as Feasibility of Dore et al.
Risks: May be Same as Feasibility of reinforcing historical Peas and Jones. practices of cord care and discouraging further studies toward evidence-based practice concerning cord care. Benefits: Eliminating/ reducing colonization of S. aureus and potentially limiting infection if the two are truly related.
Risks: May be Same as Feasibility of reinforcing historical Verber and Pagan. practices of cord care and discouraging further studies toward evidenced based practice concerning cord care. Benefits: Eliminating/ reducing colonization of S. aureus and potentially limiting infection if the two are truly related.
Costs: Insignificant differences in cost between triple dye and alcohol.
Costs: Insignificant differences.
Readiness: Some agencies already employ these measures; other agencies are investigating evidence-based research that supports natural healing.
Readiness: Some agencies already employ similar antimicrobial treatment of the cord; other agencies are investigating evidence-based research that supports natural healing.
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If topical antimicrobials are going to be used in the prophylactic treatment of infection in newborns, it is important to realize the potential for adverse local and systemic reactions.
Relationship Between Bacterial Colonization and Infection
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he role of bacterial colonization and how it relates to neonatal infection has been disputed greatly by researchers. Some researchers report a positive relationship between colonization and infection.5,7–10,15,17,24,25,27 Others report an unclear relationship between colonization and infection.6,13,28 Lastly, some researchers report that there is no significant relationship between colonization and infection.1,2,4,16,21 Research findings have shown no relationship between a maternal carrier state and an increased colonization of newborns.6 Research findings also demonstrate no relationship between staff carrier state, maternal carrier state, or environmental contamination with increased infant colonization. In fact the research that demonstrated this was done during a transition into a newly built nursery and was able to present findings that indicated that the cross-contamination was coming from the infants themselves.12 Another study was also able to relate an increase in colonization with an increase in length of maternal or neonatal hospital stay.11 Three studies of particular interest discussed bacterial colonization and the development of disease as they attempted to adopt cord care techniques that did not treat the cord at all. Curiously, these studies were not cited in the current and most recent literature that recommends no cord care or natural healing. Although there are several pathogens such as S. aureus, S. epidermidis, and B-hemolytic streptococcus that may colonize the umbilical stump, S. aureus was the major pathogen associated with the infectious outbreaks and infant mortality in maternity and neonatal units in the 1950s and 1960s when antimicrobial treatment of umbilical cords was initially instituted.21,27 Due to this knowledge, the studies of interest represented in this article are those that examined S. aureus colonization in particular.25,27 Studies The first study was conducted in 1992 due to concern over reported drug toxicity to nervous tissue such as nerves and nerve cells, prolonged cord separation and healing, and staff questioning the need to treat the cord at all (based on recent literature recommendations). This study was undertaken to explore the possibility of aban-
doning antimicrobial treatment of umbilical cords.27 The study was a prospective study using a convenience sample of 102 neonates born in a UK hospital excluding those with early premature rupture of membranes (⬎24 hours) and those admitted to NICU. The study compared the colonization rate and length of cord separation between treatment with alcohol and 0.33% hexachlorophane powder with tap water and dry care. Cultures were taken from the umbilical stump on the fifth day of life and colonization and length of time for cord separation were compared using odds ratio (OR) and 95% confidence interval (CI). The study showed that those babies whose umbilical cords were untreated had a colonization rate 1.75 times greater than those treated (OR ⫽ 1.75; 95% CI, 1.08, 2.85). It also showed that cord separation time is shorter with no cord treatment (OR ⫽ 1.78; 95% CI, 1.04, 3.05). The study was conducted under the premise that prevention of infection is the primary objective of cord care. Although prolonged cord attachment is also an issue, in this study it was not the primary purpose of cord care because there are fewer complications with prolonged cord attachment than the complications associated with umbilical and neonatal infection. The study demonstrated that colonization quickly increased once antiseptic practices were modified. The researchers feel that those advocating no treatment have not presented a balanced equation and argument to include the considerable cost and consequences of sporadic cases and outbreaks of staphylococcal infection. They suggest that this perspective may be related to the fact that this new generation of health care providers have not worked or experienced the decades when S. aureus was a major perinatal pathogen. They feel that, without further evidence, antiseptic use should be continued in cord treatment. They regard limiting staphylococcal colonization as the single most important aim in cord care.27 The second study was conducted in 1992 in a hospital where routine cord care consisted of leaving the umbilical area dry without applications of any kind. The convenience sample consisted of 370 newborn infants born at a UK hospital. The incidence of S. aureus colonization and its relationship to infection was examined. Cultures of the umbilical stump were obtained regardless of infant location at 48 hours and at 8 to 9 days after birth. The level of colonization was compared with the incidence of infection using the Chi-square test. Differences in infant location at time of collection were compared using ANOVA. Changes of colonization and differences between locations were compared using ANCOVA. The findings demonstrated that the incidence of colonization was significantly higher with no cord treatment (68% of infants at 48 hours). Forty-nine percent (171 neonates) of the colonized infants were heavily colonized. They were able to significantly show that neonates with heavy colonization at 48 hours
Umbilical Cord Care
were at a greater risk to develop an infection (P ⬍ 0.001). Twenty-eight percent of this group (44 infants) developed a staphylococcal infection (12% of the entire sample size). In view of these findings, the researchers believe that reducing colonization rates from time of delivery might also lead to a reduction in postdischarge infection.25 The third study was conducted due to doubts regarding the need for antiseptic treatment of the cord by some researchers. The 1992 six-month prospective study was conducted in a UK hospital that had been using dry cord care. The study compared colonization rate and length of cord separation (using Chi-square) with cords treated with hexachlorophane, chlorhexidine, and early bath or dry cord care. A convenience sample of 630 newborns was cultured at the umbilicus on the morning of the 3rd day of life and a second swab was obtained at discharge if the infant stayed longer than 3 days. A significant decrease in colonization was seen with chlorhexidine (P ⬍ 0.001), a modest significant decrease was seen with chlorohexaphane (P ⬍ 0.025), and no significant decrease was seen with an early bath (P ⫽ 0.9). The study revealed a high colonization rate along with intermittent outbreaks of pemphigus neonatorum in association with dry cord care. The investigators feel the study confirms that the use of dry cord care alone will lead to an unacceptably high colonization rate with S. aureus. They also feel that the relationship between cord colonization and infection is well established and that many health care providers that are promoting dry cord care are not aware of the actual occurrences of postdischarge infections. They recommend the use of antiseptic treatment for umbilical cords because cross-infection happened principally when no antiseptic was used on cords.26 Effects of Umbilical Cord Care on Cord Separation Other studies exploring natural healing and the effects of antimicrobials on the length of time for cord separation are not convinced that colonization correlates with infection. Some researchers believe that cord separation is most likely mediated through leukocyte infiltration and subsequent digestion of the umbilical cord. Interventions such as antimicrobials will impede or inhibit migration and activity of leukocytes.3 The presence of bacteria in wounds does not necessarily have to be associated with detrimental outcomes. The stimulatory effect of bacteria on wound healing has long been recognized. All wounds are colonized, but not all wounds are infected. Therefore, colonization does not necessarily lead to infection. Bacteria are believed to help initiate the inflammatory or first stage of wound healing. Some of the major functions of
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this stage include removal of cellular debris and the attack and removal of infectious agents. Chemical mediators and chemoattractants are considered important to guide the neutrophils and macrophages to the site.31 Body of Knowledge Regarding Cord Care Based on this body of knowledge the cessation of routine antimicrobial treatment of the umbilical cord can be recommended. One study conducted from 1995 to 1996 compared alcohol cleaning with natural drying. The study consisted of 1,811 newborns. The study found that there were statistically significant differences in cord separation time. The natural drying group time was shorter by 1.7 days. No infections occurred with either treatment. Based on this study, the researchers recommend discontinuing the use of alcohol for newborn cord care.1 Another study conducted in 1996 was a randomized trial to evaluate the difference in alcohol and water in promoting umbilical cord separation. The sample size consisted of 148 term, healthy newborns. The findings supported the hypothesis that treating the cord prolonged the time for cord separation. The time was lengthened by a mean of 2 to 3 days. Colonization studies supported the hypothesis that there was an insignificant difference in colonization with the two methods of treatment. The authors speculate that there is no reason to suspect that this would not be the case with any antimicrobial solution. They suggest that there is no evidence to continue the use of alcohol as routine umbilical cord treatment.2 The research proposing the benefits of natural healing is limited because it has only examined the use of alcohol compared with natural healing and did not include other agents. It is difficult to surmise if similar findings would be attainable if comparisons were made with the other antimicrobials currently used. These studies were also conducted in Canada. It is unclear whether these findings could be duplicated in the United States. Evidence has shown an unexplained lengthened cord separation time for infants in this country compared with other developed countries. The time of separation ranging from 9.8 days to 15 days has been attributed to variances in frequency of cord care, length of hospital stay, and environmental factors such as humidity.2 These explanations have been based on speculation and are yet to be proven. Before generalizing the findings of the Canadian studies, more research comparing outcomes with natural healing and antimicrobials other than alcohol would be beneficial. It is also imperative to conduct this research using a population that demonstrates characteristics that would allow it to be generalized to infants in the United States.
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References
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Andrich and Golden Baldwin et al Barrett et al Corner et al Czarlinsky et al Darmstadt and Dinulos DeLoache et al Dore et al Gillespie et al Gladstone et al Gluck and Wood Gluck et al Hardyment et al Howard Hurst Jellard Lund et al Medves and O’Brien Mendenhall and Eichenfield Novack et al Paes and Jones Perry Pildes et al Shaffer et al Simon et al Spray and Siefried Stark and Harrisson Taquino Verber and Pagan Watkinson and Dyas Williams and Oliver
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Type Coding: Clinical Research (CR), Research Utilization (RU), and Literature Review (LR). Relevance Coding: Historical (H) and Current Issues/Concern (C). ‡ Issues and Population Addressed Coding: Included (⫹), if not included no mark will appear. †
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Table 4. Summary of Research
Umbilical Cord Care
Clinical Significance The hospital costs of umbilical cord treatment vary with the method of application and length of hospital stay. One study estimates the monetary costs of 10 minutes to teach cord care at $20/hr to be approximately $16,000 at a hospital with 4,800 births per year.2 Another study cites the specific costs of alcohol application to be from $0.52 to $2.74 per newborn depending on application method and length of hospital stay.1 No references were found estimating the cost of other antimicrobials. Although there was no cost of natural drying, costs could be increased due to expensive cultures obtained because of concerns of health care providers. More than three times more cultures were done on infants attempting natural healing than those using alcohol. The use of cultures could potentially be decreased with proper education and increased awareness on the natural process of cord separation involving odor and an infected appearance.1
Discussion
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ven though there are a multitude of studies regarding cord care, it is clear that many of the historical practice decisions were based on reactionary responses to epidemics rather than evidence-based research. Due to the reactionary nature of these studies, most have focused on individual facets of the technique and it is unclear which technique is the most beneficial. Table 4 summarizes the type of research, issues addressed, population addressed, and relevance of the literature reviewed. Of the current cleansing agents, a one-time application of triple dye seems to have the fewest adverse reactions and is associated with a significant decrease in staphylococcal colonization. Alcohol, on the other hand, seems to offer more adverse effects than benefits. Several studies demonstrated it as inferior with regard to decreasing colonization. Some studies could not even demonstrate a significant difference in alcohol and water or no treatment. Alcohol was also significantly proven to prolong cord separation time. In light of alcohol’s limited effect on decreasing colonization, and its deleterious effect of prolonging cord separation time, it is not recommended as a routine treatment for umbilical cord care. While some researchers have proposed that the minimal benefits of alcohol on colonization can be generalized to other antimicrobials,2 other studies demonstrated a significant difference in a variety of other topical treatments and the effect of umbilical colonization. It is difficult to equate alcohol with all other antimicrobials when it was shown to be inferior many times.
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Alcohol has been proven to prolong the length of cord attachment. It is also reasonable to generalize that other antimicrobials lengthen the time of cord attachment. Further research in this area would also be beneficial, although it is not as difficult to believe that findings would be similar to those with alcohol. Despite the fact that several researchers recommend natural healing over antimicrobial treatment of the umbilical stump,1,2 it is important to be certain that the risks of not using prophylactic treatment for infection are not forgotten. At this time, it seems premature to completely abandon the use of all antimicrobials without further research. Yet, it is imperative to be sure that current practices are based on evidence rather than historical practice. Many aspects of the health care setting have changed since the practice of umbilical cord care was established in the 1950s. Regardless of the current cord care practice in use, it is important to educate clients on the proper topical application and care of the umbilical stump, as well as the risks and benefits of any cleansing agent used and symptoms of adverse or toxic effects associated with the cleansing agent. Teaching should also include education regarding the normal appearance of the umbilical stump (especially if a “drying” agent is not utilized), local and general signs and symptoms of infection, and expected length of time for cord separation to occur. To provide evidence-based evaluation of practices related to umbilical cord care, additional research is recommended to include comparisons of current cord care practices, natural healing, as well as outcome studies following implementation of teaching strategies.
References 1. Dore S, Buchan D, Coulas S, et al: Alcohol versus natural drying for newborn cord care. JOGNN 27:621– 627, 1998 2. Medves JM, O’Brien BAC: Cleaning solutions and bacterial colonization in promoting healing and early separation of the umbilical cord in healthy newborns. Can J Public Health 88:380 –382, 1997 3. Novack AH, Mueller B, Ochs H: Umbilical cord separation in the normal newborn. Am J Dis Child 142:220 –223, 1988 4. Mendenhall AK, Eichenfield LF: Back to basics: Caring for the newborn’s skin. Contemp Pediatr 17:98 –114, 2000 5. Shaffer TE, Baldwin JN, Rheins MS, et al: Staphylococcal infections in newborn infants: I. Study of an epidemic among infants and nursing mothers. Pediatrics 18:750 –761, 1956 6. Baldwin JN, Rheins MS, Sylvester RF, et al: Staphylococcal infections in newborn infants: III. Colonization of newborn infants by staphylococcus pyogenes. Am J Dis Child 94:107–116, 1957 7. Corner BD, Crowther ST, Eades SM: Control of staphylococcal infection in a maternity hospital: Clinical survey of the prophylactic use of hexachlorophane. Br Med J 1:1927–1929, 1960 8. Gillespie WA, Simpson K, Tozer R: Staphylococcal infection in a maternity hospital: Epidemiology and control. Lancet ii:1075–1084, 1958 9. Gluck L, Simon HJ, Yaffe SJ, et al: Effective control of staphylococci in nurseries. Am J Dis Child 102:737–739, 1961 10. Gluck L, Wood H: Effect of an antiseptic skin-care regimen in
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reducing staphylococcal colonization in newborn infants. N Engl J Med 265:1177–1181, 1961 11. Hardyment AF, Wilson RA, Cockcroft W, et al: Observations on the bacteriology and epidemiology of nursery infections. Pediatrics 25: 907–918, 1960 12. Hurst V: Transmission of hospital staphylococci among newborn infants: I. Observations on the contamination of a new nursery. Pediatrics 25:11–20, 1960 13. Jellard J: Umbilical cord as reservoir of infection in a maternity hospital. Br Med J 1:925–928, 1957 14. Simon HJ, Yaffe SJ, Gluck L: Effective control of staphylococci in a nursery. N Engl J Med 265:1171–1176, 1961 15. Williams CPS, Oliver TK: Nursery routines and staphylococcal colonization of the newborn. Pediatrics 44:640 – 646, 1969 16. Czarlinsky DK, Hall RT, Barnes WG, et al: Staphylococcal colonization in a newborn nursery, 1971-1976. Am J Epidemiol 109: 218 –225, 1979 17. Pildes RS, Ramamurthy RS, Vidyasagar D: Effect of triple dye on staphylococcal colonization in the newborn infant. J Pediatr 82:987– 990, 1973 18. Barrett FF, Mason EO, Fleming D: Brief clinical and laboratory observations: The effect of three cord-care regimens on bacterial colonization of normal newborn infants. J Pediatr 94:796 – 800, 1979 19. DeLoache WR, Cantrell HF, Reubish GK: Prophylactic treatment of umbilical stump: Comparison of techniques. South Med J 69: 627– 628, 1976
20. Perry DS: The umbilical cord: Transcultural care and customs. J Nurse Midwifery 27:25–30, 1982 21. Andrich MP, Golden SM: Umbilical cord care: A study of bacitracin ointment vs. triple dye. Clin Pediatr 23:342–344, 1984 22. Gladstone IM, Clapper L, Thorp JW, et al: Randomized study of six umbilical cord care regimens: Comparing length of attachment, microbial control, and satisfaction. Clin Pediatr 27:127–129, 1988 23. Lund C, Kuller J, Lane A, et al: Neonatal skin care: The scientific basis for practice. JOGNN 28:241–254, 1999 24. Paes B, Jones CC: An audit of the effect of two cord-care regimens on bacterial colonization in newborn infants. Qual Rev Bull 13:109 –113, 1987 25. Stark V, Harrisson SP: Staphylococcus aureus colonization of the newborn in a Darlington hospital. J Hos Infect 21:205–211, 1992 26. Verber IG, Pagan FS: What cord care: If any? Arch Dis Child 68:594 –596, 1993 27. Watkinson M, Dyas A: Staphylococcus aureus still colonizes the untreated neonatal umbilicus. J Hos Infect 21:131–135, 1992 28. Darmstadt GL, Dinulos JG: Neonatal skin care. Pediatr Clin North Am 47:757–782, 2000 29. Howard R: The appropriate use of topical antimicrobials and antiseptics in children. Pediatr Ann 30:219 –224, 2001 30. Spray A, Siegfried E: Dermatologic toxicology in children. Pediatr Ann 30:197–202, 2001 31. Taquino LT: Promoting wound healing in the neonatal setting: Process versus protocol. J Perinat Neonat Nurs 14:104 –115, 2000
Abstract To provide an increasing body of knowledge related to umbilical cord care, a literature review was conducted to study the evolution of umbilical cord care, to evaluate the scientific evidence used to guide practice changes, and to make recommendations for current practice. Historically, there has been a wide range of inconsistent practices related to umbilical cord care that have included a variety of cleansing agents and techniques. The findings of this literature review indicate that the current standard of umbilical cord care may be based on historic practices and traditions rather than scientific investigation and justification. There appears to be little support for continued alcohol use. Yet, insufficient evidence is available to support an immediate change in the standard of care from topical antimicrobial treatment of the umbilical cord to natural healing. Further research is recommended to evaluate natural healing and to establish evidence-based recommendations for practice. © 2004 Elsevier Inc. All rights reserved.
From the Greenville Technical College, School of Nursing, Greenville, SC; Clemson University, School of Nursing, Clemson, SC; and Public Health Sciences, Clemson University, Clemson, SC. Address reprint requests to Tammy P. McConnell, MSN, RN, Nursing Instructor, 331 Ruth A. Nicholson, Nursing/Science Building, Greenville Technical College, School of Nursing, Greenville, SC. 29606 © 2004 Elsevier Inc. All rights reserved. 1527-3369/04/0404-0000$30.00/0 doi:10.1053/j.nainr.2004.09.004
Trends in Umbilical Cord Care: Scientific Evidence for Practice By Tammy P. McConnell, MSN, RN, Connie W. Lee, EdD, ARNP, IBCLC, Mary Couillard, PhD, RN, CS, FNP, and Windsor Westbrook Sherrill, PhD, MBA, MHA
T
here is considerable debate among health care professionals about the most effective newborn umbilical cord care. Historically, there has been a wide range of recommended practices related to umbilical cord care that have included a variety of cleansing agents and techniques. Recent research has indicated that, in the context of modern infection control policies, the current standard of umbilical cord care may be based on historic practices and traditions rather than scientific investigation and justification. These studies recommend abandoning the traditional use of antimicrobials for soap and water or natural healing.1,2 Originally, cord care addressed concerns for bacterial colonization and subsequent infection; however, the relationship between umbilical colonization and infection was unclear. Delayed cord separation has also been proposed to increase the incidence of infection.1–3 The use of antimicrobial umbilical cord treatment such as isopropyl alcohol (alcohol) has consistently been proven to lengthen the time of cord separation.1,2,4 Yet, alcohol continues to be routinely used as an antimicrobial agent for the purpose of cord drying and is recommended by health care providers as an agent to hasten cord separation.4 Despite many studies of different cord care regimens, the treatment options recommended and practiced in the United States currently continue to vary from hospital to hospital and may include triple dye, isopropyl alcohol (alcohol), povidone-iodine (Betadine), antibiotic ointments, soap and water, or no treatment at all. The purposes of this article are to examine: 1) the history of umbilical cord care and its evolution over time; 2) the current cord care practices and the evidence that these practices are derived from; 3) the benefits and risks of the various cleansing agents used; 4) the relationship between bacterial colonization and infection; 5) the effects of umbilical cord care on cord separation; and 6) clinical significance. Finally, the appropriateness of current cord care practices and implications for changing the practice of cord care will be discussed.
Newborn and Infant Nursing Reviews, Vol 4, No 4 (December), 2004: pp 211–222
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The History of Umbilical Cord Care
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n the 1950s, frequent epidemic outbreaks of staphylococcus in newborn nurseries were occurring. There were cited cases of mastitis, pyoderma, septicemia, osteomyelitis, pneumonia, omphalitis, and fetal death related to these epidemics.5 During this era, it was typical for an infant to be in the nursery at least 10 days before discharge. “Rooming in” was not the standard of care. Nursery personnel were scrubbing, wearing scrubs, gowning, wearing caps, wearing masks, and washing hands between infants. The use of clean gloves was not a standard of care. The “no bathing technique” was a standard of care. Most infants were not bathed after delivery until discharge, which was usually day 10.5 As a reaction to these epidemic outbreaks, studies were conducted to address effectiveness of skin care, staff infection control practices, comparisons of umbilical cord care, maternal carrier states, maternal and infant colonization, and environmental contamination.5-15 Some studies concluded that the use of hexachlorophane wash (eg, pHisoHex®, GlaxoSmithKlein, Triangle Park, NC) or powder (Ster-zac®, SSL, Western Australia) as a skin cleansing agent substantially reduced staphylococcal colonization.5–7,9,11,14,15 In the 1960s, hexachlorophane wash or powders became a standard of care in newborn nurseries around the country. In 1969, a six and a half year study of hexachlorophane baths substantiated its effectiveness in eliminating staphylococcal infections and resulted in recommendations for major changes in the standard of care for newborns.15 These recommendations eliminated certain traditional elements of nursery routine. The use of caps and masks, deferring initial baths until thermal homeostasis, the use of hairnets, admission of students and parents into the nursery, and the use of gowning were no longer a part of routine nursery care. In late 1971, the Food and Drug Administration (FDA) and the American Academy of Pediatrics (AAP) recommended the discontinuance of routine infant bathing with hexachlorophane due to studies that revealed potential toxic effects of the cleansing agent.16 Within a month, some facilities experienced an increase in staphylococcal colonization and staphylococcal disease.17 This instigated immediate studies to determine a safe alternative for skin and cord care.16 –19 These studies evaluated triple dye compared with other cleansing agents. All studies found that triple dye was able to significantly reduce staphylococcal colonization, even with a one-time application. Triple dye became an alternative umbilical cord treatment for hexachlorophane. Other topical antimicrobials such as povidone-iodine (Betadine) and antibiotic ointments also
significantly reduced staphylococcal colonization. Thus, variance in standards of care was often based on physician and staff preference.20 Since the 1970s, it has been widely accepted to use some form of topical antimicrobial to treat the umbilical cord. Other accepted cord care practices include assessment of the cord for signs of infection, good hand washing between infants, folding down the diaper to avoid unnecessary friction or soiling, avoidance of tub baths until separation of the cord occurs, and avoiding the use of oils, lotions, and creams on the cord.20 In the 1980s, the use of clean gloves between patients became an infection control standard. Since the 1980s, studies have continued to evaluate differences in cord care regimens and staphylococcal colonization and infection and cord separation times.1– 4,20-27 Recent literature describes current cord care practices as being based on the assumptions of historic health care routines instead of research evidence.1,4,23
Current Cord Practice
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oday, cord care practices vary greatly from institution to institution in the United States. According to the AAP, no single method of cord care has proven superior in limiting bacterial colonization and disease.20 Methods of cord care that are currently used include triple dye, alcohol, antibiotic ointments, povidone-iodine (Betadine), soap and water, or no treatment at all.4 In general, the umbilical stump is expected to be kept clean and uncovered to promote healing, drying, and cord separation.20 For decades, the use of alcohol daily and as often as each diaper change has been recommended to decrease infection and shorten cord separation time. However, there is an absence of studies that show the benefits of using alcohol.4 It is important to note that the exposed necrotic tissue of the umbilical stump is readily colonized and infected by pathogenic bacteria. Ready access of the bacteria into the systemic circulation places neonates at high risk for infection. In developing countries, hygienic umbilical care is believed to reduce umbilical colonization, infection, tetanus, and sepsis, but the role of antiseptic cord care in reducing infections is unclear. Although studies in these less developed countries addressing cord care are lacking, historical controls and studies have demonstrated the decrease in infection during epidemic outbreaks in the 1950s. Recurrent epidemics of streptococcal infections have also been reported with the use of dry treatment or the use of alcohol alone, suggesting these regimens are insufficient.28 In the United States, the incidence of omphalitis (inflammation or infection of the umbilical stump) is rare.2 This has been assumed to be related to hand washing,
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Table 1. Comparison of Cleansing Agents and Usage Recommendations Issues of Concern Alcohol
Triple Dye
Povidone-Iodine (Betadine)
Topical Antibiotics: Bacitracin, Silver Sulfadiazine (Silvadene), Neomycin, Gentamycin
Natural Healing
standard precautions, knowledge of transmission, and antiseptic treatments of the umbilical stump.1 The thought that bacterial colonization of the umbilical stump is beneficial to the healing process and cannot necessarily be correlated with infection is also being explored by some investigators.1,2,4 These investigators have compared cleaning solutions and natural healing, and all recommend that no treatment at all may be more beneficial than the routine and historic use of topical antimicrobials.1,2,4
Benefits and Risks of Cleansing Agents
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opical cleansing agents have been used for neonatal baths and umbilical cord care. Table 1 provides a comparison of cleansing agents and usage recommendations. It is imperative to remember that topical use does not guarantee safety, as demonstrated by the widespread use and associated toxicity of hexachlorophane baths in the 1950s and 1960s. Other than systemic absorption and toxicity, risks of topical antimicrobials range from local
Recommendations Sufficient evidence exists to support a discontinuance of the use of alcohol for routine cord care. It has been proven to prolong cord separation. It has not been proven to be beneficial for decreasing bacterial colonization or infection. Insufficient evidence is available to support a discontinuance of triple dye for routine cord care. Enough evidence for natural healing is available to support an investigation of the risks and benefits of discontinuing triple dye use. Further research is recommended to evaluate the continued use of triple dye. Sufficient evidence exists to support a discontinuance of the use of Betadine for routine cord care. Triple dye has been proven to be superior in decreasing bacterial colonization or infection. Betadine has been associated with more serious toxic effects than triple dye. Sufficient evidence exists to support a discontinuance of the use of topical antibiotics for routine cord care. Triple dye has been proven to be superior in decreasing bacterial colonization or infection. Topical antimicrobials have been associated with emergence of bacterial resistance and allergic contact dermatitis. Insufficient evidence is available to support an immediate change in the standard of care from topical antimicrobial treatment of the umbilical cord to natural healing. Significant research is available, but more research is indicated before these results can be generalized to infants born in the United States. Further research is recommended to evaluate natural healing of the umbilical cord and to establish evidence-based recommendations for practice.
irritation, chemical burns, sensitization and allergic contact dermatitis, and accidental ingestion and poisoning.29 The dangers of percutaneous absorption in children are well documented. There have been numerous reports describing toxic side effects from systemic absorption of topically applied agents in infants.23,30 Although the structure of the epidermal barrier in full-term infants is mature, its thickness is 40 to 60% less than that found in an adult,4 some risk for percutaneous toxicity still remains.30 Several unique pediatric features help to explain this, such as the increased ratio of skin surface area to body weight; immature hepatic and renal function, which impairs drug metabolism and excretion; and decreased plasma protein binding that allows toxicity at lower drug doses.4,28 –30 Immature epidermal barriers as seen in preterm infants place them at even greater risk for percutaneous toxicity.30 The skin barrier function of infants of 25 weeks’ gestation and less may take 4 to 8 weeks to mature. This delay in skin maturation also increases the risk for secondary problems such as opportunistic infection, mechanical fragility,
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and absorption of topical agents.4,23,28 A conservative approach is mandated due to the increased permeability of neonatal skin. The use of topical preparations should be limited to only essential compounds and washing them off should further minimize exposure as soon as their purpose has been accomplished.28 Observation of the umbilical area may be more appropriate than cleaning.2 Isopropyl alcohol (alcohol) is widely used for cord care. It usually evaporates before it is absorbed by normal skin. Cases of acute alcohol toxicity in infants up to 21 days old have been reported after generous applications of alcohol to the umbilical stump and one case where the parents placed a dressing of alcohol under an occlusive barrier (occlusion) over the umbilical stump.29 Toxicities from alcohol absorption include hemorrhagic skin necrosis, dysfunction of the central nervous system, metabolic acidosis, and hypoglycemia.30 Physicians and nurse practitioners should limit or avoid the use of alcohol for cord care if possible despite its comfortable familiarity.29,30 In one study of an alcohol cord care regimen, umbilical cord cultures showed a dramatic increase in bacterial colonization almost immediately after a perinatal unit initiated the new alcohol cord care regimen. Approximately 6 months after implementation of the new alcohol cord care regimen, physicians in the community, who were unaware of the change in hospital practices, reported an increase in the number of infant skin infections. All cases cultured positive for Staphylococcus aureus.24 Povidone-iodine (Betadine) is another common topical antimicrobial used for umbilical cord care. When absorbed in significant amounts, this agent has increased serum iodine levels enough to stimulate neonatal hypothyroidism. Disturbance of thyroid function can be associated with intraventricular hemorrhage, cognitive abnormalities, growth and motor retardation, and death.29 Studies indicate that preterm and low-birth-weight infants are at greatest risk for significant iodine absorption.30 Some dispute the significant risks of these events in the United States, because this phenomenon occurs primarily in countries with relative iodine deficiency.29 If iodinated compounds are used, application should be brief, followed by a thorough rinsing, and never under occlusion.30 Topical antibacterial agents such as Bacitracin (Pharmaraia & Upjohn Company, Kalamazoo, MI), neomycin, gentamicin, and silver sulfadiazine (Silvadene) are also used to treat the umbilical stump. Safety depends on avoidance of systemic absorption, local irritation and tissue destruction, and hypersensitivity. Toxicities from topical antimicrobials include allergic contact dermatitis, anaphylaxis (rare), and neural deafness (rare). Emergence of bacterial resistance has also been seen with topical use of antibiotics that are used systemically. Therefore it is recommended to avoid their use if possible.29 It has also been
documented that antimicrobial ointment exposure can sensitize the skin to allergic reactions later in life.22 Hexachlorophane (pHisohex®, GlaxoSmithKlein, Research Triangle Park, NC) and chlorhexidine (Hibiscrub® or Hibiclens®, 3 Com, Marlborough, MA) are broadspectrum antimicrobials against gram-positive and -negative bacteria, and some yeast. Due to past problems with hexachlorophane, chlorhexidine was introduced as an effective and safe alternative. Now it is accepted that hexachlorophane is safe when properly used and has been reintroduced.26 Both agents are generally safe when used appropriately as topical preparations without occlusion on term infants. Some local reactions and systemic absorption has been noted in preterm infants. If alcohol is used as a vehicle for either of these agents, its toxicities should be considered as well.29 Triple dye, an agent bactericidal to both gram-positive and -negative bacteria, contains three ingredients: brilliant green, crystal violet, and proflavine hemisulfate. It was widely used in the 1950s until the popularity of hexachlorophane baths. In 1971, when hexachlorophene baths were not recommended, triple dye was reappraised. Since the early 1970s, triple dye has been used commonly for umbilical cord care.20 Toxicity of triple dye is rare. It can cause skin necrosis if it is inadvertently applied to the skin surrounding the umbilical stump. Prolonged use of gentian violet in adults may also cause nausea, vomiting, diarrhea, and mucosal ulceration. It is reasonable to surmise that prolonged use of triple dye could cause the same adverse effects in neonates. When applying to the cord, inadvertent applications or leakage onto the abdominal wall should be avoided if possible and washed off if necessary.28 Many studies have compared topical antimicrobial treatments of the umbilical stump. Table 2 provides an overview of recent studies regarding umbilical cord care and Table 3 provides an overview of the substantiated evidence and the fittedness and feasibility of these recent studies. In several studies, triple dye was found to be significantly better than castile soap, hexachlorophane (pHisoHex®, GlaxoSmithKlein, Triangle Park, NC), alcohol, povidone iodine, silver sulfanazine (Silvadene), and Bacitracin® (Pharmaraia & Upjohn Company, Kalamazoo, MI) in reducing cord colonization.17,18,21,24 These studies were different from the 1957 study of triple dye because they limited triple dye application to one-time application instead of daily application.13 It should be noted that some studies dispute the efficacy of triple dye on gram-negative bacteria.18 Although it is unclear which antimicrobial is the most beneficial for cord care treatment, many researchers recommend their use as a result of their studies. Others argue that the role of decreasing bacterial colonization has an uncertain relationship with the development of infection.
Table 2. Overview of Recent Umbilical Cord Care Studies Reference
Dore et al (1998)
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Medves and O’Brien Paes and Jones (1987) Stark and Harrisson (1992) Verber and Pagan (1993) Watkinson and Dyas (1997) (1992) Purpose To compare alcohol cleaning To evaluate differences To compare triple dye vs alcohol To determine the incidence To compare the colonization To compare colonization and natural drying of in time of cord in preventing bacterial and level of rate and length of cord rate and length of newborn umbilical cords. separation and colonization. Staphylococcus aureus separation with cords cord separation bacterial colonization in newborn treated with between treatment colonization with infants and its hexachlorophane, with alcohol and alcohol vs water. relationship to incidence chlorhexidine, early bath, 0.33% of infection. or dry cord care. hexachlorophane powder with tap water and dry care. Subjects 1,876 singleton full-term 148 term infants born 1,545 newborns born in a 340 newborns born in a 630 of all newborns born in 102 neonates born in a newborns enrolled from a at a tertiary hospital Canadian level II hospital that UK hospital. a UK hospital. UK hospital, tertiary level teaching in western Canada were not discharged prior to excluding those with hospital and a level II were included in the umbilical cultures taken on early PROM community hospital in study. 136 day 4. (premature rupture of Canada. 1,811 completed completed the study. membranes ⬎24 the study. hours) and those admitted to NICU Findings No newborn in either group Cords cleaned with Significant differences were Infants with level 5 Significant decrease in Infants without treatment was identified with an sterile water found in colonization with the colonization (heavy) colonization with showed a 1.75 infection. significantly use of triple dye and alcohol were significantly more chlorhexidine; modestly significant increase in There was a statistical separated 2-3 days for all bacteria, likely to develop an significant decrease with colonization. difference, with the faster than those Staphylococcus aureus, Group infection. chlorohexaphane and no No significant difference natural drying group treated with alcohol B streptococcus, and GramNo significant difference significant decrease with between groups with having shorter cord No statistical negative bacteria. with colonization related early bath. Significant signs of infection. separation by 1.7 days. difference between to location of infant at difference in length of Significantly greater No significant difference in colonization rates of time of culture. cord separation with proportion of cords maternal comfort with either group. chlorhexidine. with no treatment cord care/separation. No significant difference in separated before day 7. length of cord separation The modal day of with hexachlorophane separation was day 6 with no treatment and day 7 with treatment. No differences in ranges (no treatment ⫽ 3-12 days, treatment ⫽ 3-13 days) Recommendations Evidence does not support Cleaning with alcohol Total bacterial colonization was Showed the risk of The use of dry cord care Recommend use of continued use of alcohol will increase the reduced with triple dye. postdischarge disease was alone will lead to an antimicrobial for cord care. length of time from Colonization was related to related to the degree of unacceptably high treatment of the cord. Health providers should birth to cord infection by an increased predischarge colonization. colonization rate of Researchers feel those explain the normal process separation by 2-3 incidence of reported Neonates with level 5 Staphylococcus aureus. advocating no of cord separation days but will not infections by general colonization (heavy) at 48 Recommend use of treatment have not including appearance and prevent colonization practitioners and pediatricians hours were of greater risk antiseptic treatment of the presented a balanced possible odor. of the umbilical while alcohol was being used. of developing infection cord to reduce equation and Heath care providers should area. No infections occurred with than neonates with lower colonization. argument to include continue to develop triple dye use. level or no colonization. the considerable cost evidence to support or 44 infants (12%) of both sporadic cases eliminate historic health developed an infection. and outbreaks of care practices. Recommended reducing Staphylococcal colonization to reduce infections. postdischarge infection.
Dore et al (1998)
Substantiated Sample size, sensitivity/specificity Evidence of statistical tools adequate/appropriate. Outcomes were physiologic measures of length of time for cord separation and signs of umbilical infection previously established by the hospital of study. Significant differences were found with length of cord separation with natural drying 1.7 days shorter (t ⫽ 8.9, P ⫽ 0.001). No statistical difference in incidence of infection. Neither group experienced infection.
Fittedness
Medves and O’Brien (1997)
Paes and Jones (1987)
Sample size, sensitivity/specificity Sample size, sensitivity/ of statistical tools adequate/ specificity of appropriate. Outcomes were statistical tools physiologic measures of length adequate/ appropriate. of cord separation and Outcomes were colonization from consistently physiologic measures obtained cultures. Significant of colonization from differences were found with consistently obtained length of cord separation with cultures. Significant sterile water being 2-3 days differences were shorter than alcohol (t ⫽ 3.15, found with P ⬍ 0.002). No statistical colonization being differences in colonization higher with alcohol were found between the two than with triple dye groups (F ⫽ 1.59, df ⫽ 2, cord care. P ⫽ 0.205). All bacteria 2 ⫽ 247.01, P ⬍ 0.00001. S. aureus 2 ⫽ 346.51, P ⬍ 0.00001. Group Bstrep 2 ⫽ 41.17, P ⬍ 0.00001. Gram neg bact. 2 ⫽ 7.2, P ⬍ 0.027.
Sample population has limited Same as Fittedness of Dore et al. generalizability to healthy full-term infants born in Canada being discharged between 48 and 96 hours after birth. Results may not apply to other countries/regions without further investigation with a more generalizable population. Especially in the United States where evidence has shown a lengthened cord separation time (compared to other countries) ranging from 9.8-15 days. Factors may include frequency of care, LOS, and humidity, which may vary from Canada (Medves and O’Brien, 1997). Other more effective antimicrobials were also not addressed such as triple dye, which has been shown to be superior to alcohol at decreasing colonization (Paes and Jones, 1987). May not be generalizable to out of hospital deliveries. Does not correlate colonization with infection because infection did not occur in any group studied.
Sample has generalizability to all newborns born in a Level II Canadian hospital who were not transferred to a tertiary hospital (NICU) or with early discharge prior to day 4. Other comments previously made for US considerations apply here also. Authors only relate colonization with infections seen at the facility of study when alcohol was a standard of care.
Stark and Harrisson (1992) Sample size, sensitivity/ specificity of statistical tools adequate/ appropriate. Outcomes were physiologic measures of colonization from consistently obtained cultures. Significant differences were found with level of colonization and infection rate with Level 5 colonization more likely to develop into postdischarge infection (2 test; P ⬍ 0.001).
Verber and Pagan (1993) Watkinson and Dyas (1992) Sample size, sensitivity/ Sample size, sensitivity/ specificity of specificity of statistical tools statistical tools adequate/ appropriate. adequate/ appropriate. Outcomes were Outcomes were physiologic measures physiologic measures of colonization from of colonization from consistently obtained consistently obtained cultures and length of cultures and length of cord separation. cord separation Significant differences measured by midwife were found when using home visits. antiseptic cord care in Significant differences decreasing colonization were found with vs dry cord care using incidence of Chi-square test. colonization. With no Chlorhexidine treatment ⫽ 1.75 (P ⬍ 0.001). times greater chance Hexachlorophane of colonization. (OR (P ⬍ 0.025). ⫽ 1.75; 95% CI, Significant differences 1.08, 2.85). were found with length Significant difference of cord separation in cord separation being longer with before day 7 (OR ⫽ chlorhexidine (P ⬍ 1.78;95% CI, 1.04, 0.001) than dry care. 3.05) and no No significant differences significant difference with length of cord in range of separation with separation. hexachlorophane vs dry care. Sample only has Sample has Sample only has generalizability with generalizability to all generalizability to all all newborns born in newborns born in an newborns born in a a UK hospital of UK hospital of UK hospital of similar characteristics similar characteristics similar characteristics as hospital of study. of the hospital of as the hospital of Comments previously study. Does not relate study. Does not make made for US colonization with any correlation considerations apply infection, but cites between colonization here also. Stark and Harrison’s and infection. correlation between colonization and infection.
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Table 3. Overview of Substantiated Evidence, Fittedness, and Feasibility of Recent Umbilical Cord Care Studies
Feasibility
Risks: Include possible increased incidence of neonatal infection and morbidity.
Benefits: Eliminate possibly historical medical practices and replace with evidence-based practice. Resources: Readily available (natural healing does not require additional resources). Costs: Cost of antimicrobials at $0.52-1.90 are potentially saved. Yet, if infection occurs, the cost are substantially greater that the cost of the antimicrobial. Readiness: Healthcare is now embracing evidence-based practice and motivation is present to eliminate ungrounded historical practices if substantiated by evidence.
Same as Feasibility of Dore et al.
Risks: May be Same as Feasibility of reinforcing historical Peas and Jones. practices of cord care and discouraging further studies toward evidence-based practice concerning cord care. Benefits: Eliminating/ reducing colonization of S. aureus and potentially limiting infection if the two are truly related.
Risks: May be Same as Feasibility of reinforcing historical Verber and Pagan. practices of cord care and discouraging further studies toward evidenced based practice concerning cord care. Benefits: Eliminating/ reducing colonization of S. aureus and potentially limiting infection if the two are truly related.
Costs: Insignificant differences in cost between triple dye and alcohol.
Costs: Insignificant differences.
Readiness: Some agencies already employ these measures; other agencies are investigating evidence-based research that supports natural healing.
Readiness: Some agencies already employ similar antimicrobial treatment of the cord; other agencies are investigating evidence-based research that supports natural healing.
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If topical antimicrobials are going to be used in the prophylactic treatment of infection in newborns, it is important to realize the potential for adverse local and systemic reactions.
Relationship Between Bacterial Colonization and Infection
T
he role of bacterial colonization and how it relates to neonatal infection has been disputed greatly by researchers. Some researchers report a positive relationship between colonization and infection.5,7–10,15,17,24,25,27 Others report an unclear relationship between colonization and infection.6,13,28 Lastly, some researchers report that there is no significant relationship between colonization and infection.1,2,4,16,21 Research findings have shown no relationship between a maternal carrier state and an increased colonization of newborns.6 Research findings also demonstrate no relationship between staff carrier state, maternal carrier state, or environmental contamination with increased infant colonization. In fact the research that demonstrated this was done during a transition into a newly built nursery and was able to present findings that indicated that the cross-contamination was coming from the infants themselves.12 Another study was also able to relate an increase in colonization with an increase in length of maternal or neonatal hospital stay.11 Three studies of particular interest discussed bacterial colonization and the development of disease as they attempted to adopt cord care techniques that did not treat the cord at all. Curiously, these studies were not cited in the current and most recent literature that recommends no cord care or natural healing. Although there are several pathogens such as S. aureus, S. epidermidis, and B-hemolytic streptococcus that may colonize the umbilical stump, S. aureus was the major pathogen associated with the infectious outbreaks and infant mortality in maternity and neonatal units in the 1950s and 1960s when antimicrobial treatment of umbilical cords was initially instituted.21,27 Due to this knowledge, the studies of interest represented in this article are those that examined S. aureus colonization in particular.25,27 Studies The first study was conducted in 1992 due to concern over reported drug toxicity to nervous tissue such as nerves and nerve cells, prolonged cord separation and healing, and staff questioning the need to treat the cord at all (based on recent literature recommendations). This study was undertaken to explore the possibility of aban-
doning antimicrobial treatment of umbilical cords.27 The study was a prospective study using a convenience sample of 102 neonates born in a UK hospital excluding those with early premature rupture of membranes (⬎24 hours) and those admitted to NICU. The study compared the colonization rate and length of cord separation between treatment with alcohol and 0.33% hexachlorophane powder with tap water and dry care. Cultures were taken from the umbilical stump on the fifth day of life and colonization and length of time for cord separation were compared using odds ratio (OR) and 95% confidence interval (CI). The study showed that those babies whose umbilical cords were untreated had a colonization rate 1.75 times greater than those treated (OR ⫽ 1.75; 95% CI, 1.08, 2.85). It also showed that cord separation time is shorter with no cord treatment (OR ⫽ 1.78; 95% CI, 1.04, 3.05). The study was conducted under the premise that prevention of infection is the primary objective of cord care. Although prolonged cord attachment is also an issue, in this study it was not the primary purpose of cord care because there are fewer complications with prolonged cord attachment than the complications associated with umbilical and neonatal infection. The study demonstrated that colonization quickly increased once antiseptic practices were modified. The researchers feel that those advocating no treatment have not presented a balanced equation and argument to include the considerable cost and consequences of sporadic cases and outbreaks of staphylococcal infection. They suggest that this perspective may be related to the fact that this new generation of health care providers have not worked or experienced the decades when S. aureus was a major perinatal pathogen. They feel that, without further evidence, antiseptic use should be continued in cord treatment. They regard limiting staphylococcal colonization as the single most important aim in cord care.27 The second study was conducted in 1992 in a hospital where routine cord care consisted of leaving the umbilical area dry without applications of any kind. The convenience sample consisted of 370 newborn infants born at a UK hospital. The incidence of S. aureus colonization and its relationship to infection was examined. Cultures of the umbilical stump were obtained regardless of infant location at 48 hours and at 8 to 9 days after birth. The level of colonization was compared with the incidence of infection using the Chi-square test. Differences in infant location at time of collection were compared using ANOVA. Changes of colonization and differences between locations were compared using ANCOVA. The findings demonstrated that the incidence of colonization was significantly higher with no cord treatment (68% of infants at 48 hours). Forty-nine percent (171 neonates) of the colonized infants were heavily colonized. They were able to significantly show that neonates with heavy colonization at 48 hours
Umbilical Cord Care
were at a greater risk to develop an infection (P ⬍ 0.001). Twenty-eight percent of this group (44 infants) developed a staphylococcal infection (12% of the entire sample size). In view of these findings, the researchers believe that reducing colonization rates from time of delivery might also lead to a reduction in postdischarge infection.25 The third study was conducted due to doubts regarding the need for antiseptic treatment of the cord by some researchers. The 1992 six-month prospective study was conducted in a UK hospital that had been using dry cord care. The study compared colonization rate and length of cord separation (using Chi-square) with cords treated with hexachlorophane, chlorhexidine, and early bath or dry cord care. A convenience sample of 630 newborns was cultured at the umbilicus on the morning of the 3rd day of life and a second swab was obtained at discharge if the infant stayed longer than 3 days. A significant decrease in colonization was seen with chlorhexidine (P ⬍ 0.001), a modest significant decrease was seen with chlorohexaphane (P ⬍ 0.025), and no significant decrease was seen with an early bath (P ⫽ 0.9). The study revealed a high colonization rate along with intermittent outbreaks of pemphigus neonatorum in association with dry cord care. The investigators feel the study confirms that the use of dry cord care alone will lead to an unacceptably high colonization rate with S. aureus. They also feel that the relationship between cord colonization and infection is well established and that many health care providers that are promoting dry cord care are not aware of the actual occurrences of postdischarge infections. They recommend the use of antiseptic treatment for umbilical cords because cross-infection happened principally when no antiseptic was used on cords.26 Effects of Umbilical Cord Care on Cord Separation Other studies exploring natural healing and the effects of antimicrobials on the length of time for cord separation are not convinced that colonization correlates with infection. Some researchers believe that cord separation is most likely mediated through leukocyte infiltration and subsequent digestion of the umbilical cord. Interventions such as antimicrobials will impede or inhibit migration and activity of leukocytes.3 The presence of bacteria in wounds does not necessarily have to be associated with detrimental outcomes. The stimulatory effect of bacteria on wound healing has long been recognized. All wounds are colonized, but not all wounds are infected. Therefore, colonization does not necessarily lead to infection. Bacteria are believed to help initiate the inflammatory or first stage of wound healing. Some of the major functions of
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this stage include removal of cellular debris and the attack and removal of infectious agents. Chemical mediators and chemoattractants are considered important to guide the neutrophils and macrophages to the site.31 Body of Knowledge Regarding Cord Care Based on this body of knowledge the cessation of routine antimicrobial treatment of the umbilical cord can be recommended. One study conducted from 1995 to 1996 compared alcohol cleaning with natural drying. The study consisted of 1,811 newborns. The study found that there were statistically significant differences in cord separation time. The natural drying group time was shorter by 1.7 days. No infections occurred with either treatment. Based on this study, the researchers recommend discontinuing the use of alcohol for newborn cord care.1 Another study conducted in 1996 was a randomized trial to evaluate the difference in alcohol and water in promoting umbilical cord separation. The sample size consisted of 148 term, healthy newborns. The findings supported the hypothesis that treating the cord prolonged the time for cord separation. The time was lengthened by a mean of 2 to 3 days. Colonization studies supported the hypothesis that there was an insignificant difference in colonization with the two methods of treatment. The authors speculate that there is no reason to suspect that this would not be the case with any antimicrobial solution. They suggest that there is no evidence to continue the use of alcohol as routine umbilical cord treatment.2 The research proposing the benefits of natural healing is limited because it has only examined the use of alcohol compared with natural healing and did not include other agents. It is difficult to surmise if similar findings would be attainable if comparisons were made with the other antimicrobials currently used. These studies were also conducted in Canada. It is unclear whether these findings could be duplicated in the United States. Evidence has shown an unexplained lengthened cord separation time for infants in this country compared with other developed countries. The time of separation ranging from 9.8 days to 15 days has been attributed to variances in frequency of cord care, length of hospital stay, and environmental factors such as humidity.2 These explanations have been based on speculation and are yet to be proven. Before generalizing the findings of the Canadian studies, more research comparing outcomes with natural healing and antimicrobials other than alcohol would be beneficial. It is also imperative to conduct this research using a population that demonstrates characteristics that would allow it to be generalized to infants in the United States.
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References
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Andrich and Golden Baldwin et al Barrett et al Corner et al Czarlinsky et al Darmstadt and Dinulos DeLoache et al Dore et al Gillespie et al Gladstone et al Gluck and Wood Gluck et al Hardyment et al Howard Hurst Jellard Lund et al Medves and O’Brien Mendenhall and Eichenfield Novack et al Paes and Jones Perry Pildes et al Shaffer et al Simon et al Spray and Siefried Stark and Harrisson Taquino Verber and Pagan Watkinson and Dyas Williams and Oliver
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Table 4. Summary of Research
Umbilical Cord Care
Clinical Significance The hospital costs of umbilical cord treatment vary with the method of application and length of hospital stay. One study estimates the monetary costs of 10 minutes to teach cord care at $20/hr to be approximately $16,000 at a hospital with 4,800 births per year.2 Another study cites the specific costs of alcohol application to be from $0.52 to $2.74 per newborn depending on application method and length of hospital stay.1 No references were found estimating the cost of other antimicrobials. Although there was no cost of natural drying, costs could be increased due to expensive cultures obtained because of concerns of health care providers. More than three times more cultures were done on infants attempting natural healing than those using alcohol. The use of cultures could potentially be decreased with proper education and increased awareness on the natural process of cord separation involving odor and an infected appearance.1
Discussion
E
ven though there are a multitude of studies regarding cord care, it is clear that many of the historical practice decisions were based on reactionary responses to epidemics rather than evidence-based research. Due to the reactionary nature of these studies, most have focused on individual facets of the technique and it is unclear which technique is the most beneficial. Table 4 summarizes the type of research, issues addressed, population addressed, and relevance of the literature reviewed. Of the current cleansing agents, a one-time application of triple dye seems to have the fewest adverse reactions and is associated with a significant decrease in staphylococcal colonization. Alcohol, on the other hand, seems to offer more adverse effects than benefits. Several studies demonstrated it as inferior with regard to decreasing colonization. Some studies could not even demonstrate a significant difference in alcohol and water or no treatment. Alcohol was also significantly proven to prolong cord separation time. In light of alcohol’s limited effect on decreasing colonization, and its deleterious effect of prolonging cord separation time, it is not recommended as a routine treatment for umbilical cord care. While some researchers have proposed that the minimal benefits of alcohol on colonization can be generalized to other antimicrobials,2 other studies demonstrated a significant difference in a variety of other topical treatments and the effect of umbilical colonization. It is difficult to equate alcohol with all other antimicrobials when it was shown to be inferior many times.
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Alcohol has been proven to prolong the length of cord attachment. It is also reasonable to generalize that other antimicrobials lengthen the time of cord attachment. Further research in this area would also be beneficial, although it is not as difficult to believe that findings would be similar to those with alcohol. Despite the fact that several researchers recommend natural healing over antimicrobial treatment of the umbilical stump,1,2 it is important to be certain that the risks of not using prophylactic treatment for infection are not forgotten. At this time, it seems premature to completely abandon the use of all antimicrobials without further research. Yet, it is imperative to be sure that current practices are based on evidence rather than historical practice. Many aspects of the health care setting have changed since the practice of umbilical cord care was established in the 1950s. Regardless of the current cord care practice in use, it is important to educate clients on the proper topical application and care of the umbilical stump, as well as the risks and benefits of any cleansing agent used and symptoms of adverse or toxic effects associated with the cleansing agent. Teaching should also include education regarding the normal appearance of the umbilical stump (especially if a “drying” agent is not utilized), local and general signs and symptoms of infection, and expected length of time for cord separation to occur. To provide evidence-based evaluation of practices related to umbilical cord care, additional research is recommended to include comparisons of current cord care practices, natural healing, as well as outcome studies following implementation of teaching strategies.
References 1. Dore S, Buchan D, Coulas S, et al: Alcohol versus natural drying for newborn cord care. JOGNN 27:621– 627, 1998 2. Medves JM, O’Brien BAC: Cleaning solutions and bacterial colonization in promoting healing and early separation of the umbilical cord in healthy newborns. Can J Public Health 88:380 –382, 1997 3. Novack AH, Mueller B, Ochs H: Umbilical cord separation in the normal newborn. Am J Dis Child 142:220 –223, 1988 4. Mendenhall AK, Eichenfield LF: Back to basics: Caring for the newborn’s skin. Contemp Pediatr 17:98 –114, 2000 5. Shaffer TE, Baldwin JN, Rheins MS, et al: Staphylococcal infections in newborn infants: I. Study of an epidemic among infants and nursing mothers. Pediatrics 18:750 –761, 1956 6. Baldwin JN, Rheins MS, Sylvester RF, et al: Staphylococcal infections in newborn infants: III. Colonization of newborn infants by staphylococcus pyogenes. Am J Dis Child 94:107–116, 1957 7. Corner BD, Crowther ST, Eades SM: Control of staphylococcal infection in a maternity hospital: Clinical survey of the prophylactic use of hexachlorophane. Br Med J 1:1927–1929, 1960 8. Gillespie WA, Simpson K, Tozer R: Staphylococcal infection in a maternity hospital: Epidemiology and control. Lancet ii:1075–1084, 1958 9. Gluck L, Simon HJ, Yaffe SJ, et al: Effective control of staphylococci in nurseries. Am J Dis Child 102:737–739, 1961 10. Gluck L, Wood H: Effect of an antiseptic skin-care regimen in
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reducing staphylococcal colonization in newborn infants. N Engl J Med 265:1177–1181, 1961 11. Hardyment AF, Wilson RA, Cockcroft W, et al: Observations on the bacteriology and epidemiology of nursery infections. Pediatrics 25: 907–918, 1960 12. Hurst V: Transmission of hospital staphylococci among newborn infants: I. Observations on the contamination of a new nursery. Pediatrics 25:11–20, 1960 13. Jellard J: Umbilical cord as reservoir of infection in a maternity hospital. Br Med J 1:925–928, 1957 14. Simon HJ, Yaffe SJ, Gluck L: Effective control of staphylococci in a nursery. N Engl J Med 265:1171–1176, 1961 15. Williams CPS, Oliver TK: Nursery routines and staphylococcal colonization of the newborn. Pediatrics 44:640 – 646, 1969 16. Czarlinsky DK, Hall RT, Barnes WG, et al: Staphylococcal colonization in a newborn nursery, 1971-1976. Am J Epidemiol 109: 218 –225, 1979 17. Pildes RS, Ramamurthy RS, Vidyasagar D: Effect of triple dye on staphylococcal colonization in the newborn infant. J Pediatr 82:987– 990, 1973 18. Barrett FF, Mason EO, Fleming D: Brief clinical and laboratory observations: The effect of three cord-care regimens on bacterial colonization of normal newborn infants. J Pediatr 94:796 – 800, 1979 19. DeLoache WR, Cantrell HF, Reubish GK: Prophylactic treatment of umbilical stump: Comparison of techniques. South Med J 69: 627– 628, 1976
20. Perry DS: The umbilical cord: Transcultural care and customs. J Nurse Midwifery 27:25–30, 1982 21. Andrich MP, Golden SM: Umbilical cord care: A study of bacitracin ointment vs. triple dye. Clin Pediatr 23:342–344, 1984 22. Gladstone IM, Clapper L, Thorp JW, et al: Randomized study of six umbilical cord care regimens: Comparing length of attachment, microbial control, and satisfaction. Clin Pediatr 27:127–129, 1988 23. Lund C, Kuller J, Lane A, et al: Neonatal skin care: The scientific basis for practice. JOGNN 28:241–254, 1999 24. Paes B, Jones CC: An audit of the effect of two cord-care regimens on bacterial colonization in newborn infants. Qual Rev Bull 13:109 –113, 1987 25. Stark V, Harrisson SP: Staphylococcus aureus colonization of the newborn in a Darlington hospital. J Hos Infect 21:205–211, 1992 26. Verber IG, Pagan FS: What cord care: If any? Arch Dis Child 68:594 –596, 1993 27. Watkinson M, Dyas A: Staphylococcus aureus still colonizes the untreated neonatal umbilicus. J Hos Infect 21:131–135, 1992 28. Darmstadt GL, Dinulos JG: Neonatal skin care. Pediatr Clin North Am 47:757–782, 2000 29. Howard R: The appropriate use of topical antimicrobials and antiseptics in children. Pediatr Ann 30:219 –224, 2001 30. Spray A, Siegfried E: Dermatologic toxicology in children. Pediatr Ann 30:197–202, 2001 31. Taquino LT: Promoting wound healing in the neonatal setting: Process versus protocol. J Perinat Neonat Nurs 14:104 –115, 2000