Umbilical Cord Care in the Newborn Infant Dan Stewart, MD, FAAP, William Benitz, MD, FAAP, COMMITTEE on FETUS and NEWBORN

CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care

Umbilical Cord Care in the Newborn Infant Dan Stewart, MD, FAAP, William Benitz, MD, FAAP, COMMITTEE ON FETUS AND NEWBORN

Postpartum infections remain a leading cause of neonatal morbidity and abstract mortality worldwide. A high percentage of these infections may stem from bacterial colonization of the umbilicus, because cord care practices vary in refl ection of cultural traditions within communities and disparities in health care practices globally. After birth, the devitalized umbilical cord often proves to be an ideal substrate for bacterial growth and also provides direct access to the bloodstream of the neonate. Bacterial colonization of the This document is copyrighted and is property of the American cord not infrequently leads to omphalitis and associated thrombophlebitis, Academy of Pediatrics and its Board of Directors. All authors have fi led confl ict of interest statements with the American Academy cellulitis, or necrotizing fasciitis. Various topical substances continue to be of Pediatrics. Any confl icts have been resolved through a process approved by the Board of Directors. The American Academy of used for cord care around the world to mitigate the risk of serious infection. Pediatrics has neither solicited nor accepted any commercial More recently, particularly in high-resource countries, the treatment involvement in the development of the content of this publication. paradigm has shifted toward dry umbilical cord care. This clinical report Clinical reports from the American Academy of Pediatrics benefi t from expertise and resources of liaisons and internal (AAP) and external reviews the evidence underlying recommendations for care of the umbilical reviewers. However, clinical reports from the American Academy of cord in different clinical settings. Pediatrics may not refl ect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

INTRODUCTION All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffi rmed, Despite significant global progress in recent decades, 1 bacterial revised, or retired at or before that time. infections (sepsis, meningitis, and pneumonia) continue to account for DOI: 10.1542/peds.2016-2149 approximately 700 000 neonatal deaths each year, or nearly one-quarter PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). of the 3 million neonatal deaths that occur worldwide. 1, 2 Although the magnitude of its contribution to these deaths remains uncertain, the Copyright © 2016 by the American Academy of Pediatrics umbilical cord may be a common portal of entry for invasive pathogenic FINANCIAL DISCLOSURE: The authors have indicated they bacteria, 3 with or without clinical signs of omphalitis. Neonatal mortality do not have a fi nancial relationship relevant to this article associated with bacterial contamination of the umbilical stump may to disclose. therefore rank among the greatest public health opportunities of the 21st FUNDING: No external funding. century. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to Common risk factors for the development of neonatal omphalitis include disclose. unplanned home birth or septic delivery, low birth weight, prolonged rupture of membranes, umbilical catheterization, and chorioamnionitis. 4, 5 In countries with limited resources, the risk of omphalitis may be 6 To cite: Stewart D, Benitz W, AAP COMMITTEE ON FETUS times greater for infants delivered at home than for hospital births. 6 AND NEWBORN. Umbilical Cord Care in the Newborn Infant. Pediatrics. 2016;138(3):e20162149 Multiple studies have delineated the susceptibility of the umbilical

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 :e 20162149 FROM THE AMERICAN ACADEMY OF PEDIATRICS cord to bacterial colonization. The discharge), (3) omphalitis with somewhat controversial and variable, method of caring for the umbilical systemic signs of infection, and (4) even in high-resource countries cord after birth affects both bacterial omphalitis with necrotizing fasciitis with relatively aseptic conditions colonization and time to cord (umbilical necrosis with periumbilical at the time of delivery. In resource- separation. 7 – 10 The devitalized ecchymosis, crepitus, bullae, and limited countries, in accordance umbilical cord provides an ideal evidence of involvement of superficial with cultural traditions, unhygienic medium for bacterial growth. and deep fascia; frequently associated substances continue to be applied Sources of potentially pathogenic with signs and symptoms of to the umbilicus, creating a milieu bacteria that colonize the umbilical overwhelming sepsis and shock).6 ideal for the development neonatal cord include the mother’s birth omphalitis. To achieve the goal of The incidence of omphalitis reported canal and various local bacterial preventing omphalitis worldwide, in different communities varies sources at the site of delivery, most deliveries must be clean and greatly, depending on prenatal prominently the nonsterile hands umbilical cord care must be hygienic. and perinatal practices, cultural of any person assisting with the The cord should be cut with a sterile variations in cord care, and delivery delivery. 11 Staphylococcus aureus blade or scissors, preferably using venue (home versus hospital). remains the most frequently reported sterile gloves, to prevent bacterial Reliable current data on rates in organism. 5– 7, 12 Other common contamination leading to omphalitis untreated infants are surprisingly pathogens include group A and group or neonatal tetanus. As discussed scant. In high-resource countries, B Streptococci and Gram-negative later, dry cord care without the neonatal omphalitis now is rare, bacilli including Escherichia coli, application of topical substances is with an estimated incidence of Klebsiella species, and Pseudomonas preferable under most circumstances approximately 1 per 1000 infants species. Rarely, anaerobic and in high-resource countries and for managed with dry cord care (eg, a polymicrobial infections also may in-hospital births elsewhere; the total of 3 cases among 3518 infants occur. In addition to omphalitis, application of topical chlorhexidine described in 2 reports from Canada17, 18). tetanus in neonates can result is recommended for infants born In low-income communities, from umbilical cord colonization, outside the hospital setting in omphalitis occurs in up to 8% of particularly in countries with limited communities with high neonatal infants born in hospitals and in resources. This infection results mortality rates. 20 as many as 22% of infants born from contamination of the umbilical at home, in whom omphalitis is separation site by Clostridium tetani Methods of umbilical cord care moderate to severe in 17% and acquired from a nonsterile device have been the subject of 4 recent associated with sepsis in 2%. 19 used to separate the umbilical cord meta-analyses, 21 – 24 including 2 Depending on how omphalitis is during the peripartum period or from Cochrane reviews.23, 24 Although defined, case-fatality rates as high application of unhygienic substances the scope and methodologies as 13% have been reported. 4 The to the cord stump. of these reviews differed, all 4 development of necrotizing fasciitis, stratified results according to the with predictable complications from Multiple complications can occur study setting, distinguishing results septic shock, is associated with much from bacterial colonization and reported from communities with higher case-mortality rates.5 These infection of the umbilical cord high proportions of births at home disparate observations in different because of its direct access and high neonatal mortality rates settings have resulted in divergent to the bloodstream. These from those obtained in hospitals recommendations for cord care complications include the and settings with low neonatal by the World Health Organization development of intraabdominal mortality rates. These analyses (WHO), which advocates dry cord abscesses, periumbilical cellulitis, concluded that 3 studies (including care for infants born in a hospital or thrombophlebitis in the portal and/or >44 000 subjects) in community in settings of low neonatal mortality umbilical veins, peritonitis, and bowel settings in South Asia with a high and application of chlorhexidine ischemia.13 – 16 Neonatal omphalitis neonatal mortality rate 3, 25, 26 support solution or gel for infants born at may present at 4 grades of severity: the effectiveness of application of home or in settings of high neonatal (1) funisitis/umbilical discharge 4% chlorhexidine solution or gel mortality. 20 (an unhealthy-appearing cord with to the umbilical cord stump within purulent, malodorous discharge), 24 hours after birth, which results (2) omphalitis with abdominal wall in a significant reduction in both EVIDENCE-BASED PRACTICE cellulitis (periumbilical erythema omphalitis (relative risk [RR]: and tenderness in addition to an Best practices for antisepsis of the 0.48; 95% confidence interval [CI]: unhealthy-appearing cord with umbilical cord continue to remain 0.40–0.57) and neonatal mortality

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS (RR: 0.81; 95% CI: 0.71–0.92) necrotizing enterocolitis). No cases blood of infants after umbilical cord compared with dry cord care.24 No of umbilical sepsis were reported cleaning. 36, 37 In addition, contact other cord-management strategies in either group, but culture-proven dermatitis has been reported in up have been evaluated systematically sepsis was more common in the to 15% of very low birth weight in such settings, but the application dry cord care group than in the infants after placement of a 0.5% of traditional materials (eg, ash, chlorhexidine group (15 of 70 vs 2 chlorhexidine impregnated dressing herbal or other vegetal poultices, and of 70; P = .002). These observations over a central venous catheter.38 The human milk) may provide a source cannot be generalized to all healthy data on the safety of chlorhexidine of contamination with pathogenic infants born in a hospital. The application are incomplete, and the bacteria, including C tetani.27 In second enrolled 669 subjects, who amount of exposure to chlorhexidine contrast, the meta-analyses found were randomly assigned to receive that can be considered safe is little evidence of benefit from treatment with chlorhexidine powder not known. 24 In addition to the topical treatments for infants born or dry cord care.34 Cord-related incremental increase in the cost of in hospitals. 22 – 24 The meta-analyses adverse events (erosion, irritation, using chlorhexidine, the practice of used different criteria for inclusion lesion, omphalitis, erythema, reducing bacterial colonization may of trials and compared a variety umbilical granuloma, purulence, have the unintended consequences of treatments versus dry cord bleeding, discharge, or weeping of the of selecting more virulent bacterial care or versus one another. Only navel) were more common in the dry strains without demonstrable a single trial28 reported mortality cord care group (29% vs 16%; benefits. 24 Because the incidence data, which did not differ between P = .001), but there were no differences of omphalitis is very low in high- topical chlorhexidine and dry care in serious adverse events (2.1% in resource countries and the severity is (RR: 0.11; 95% CI: 0.01–2.04). both groups) or in the incidence of mild, the preponderance of evidence However, the low mortality rate omphalitis (2.1% vs 0.6%; P = .1). favors dry cord care. and the small contribution made by Although the meta-analysis reported bacterial infection 29 in these settings a significant difference in the pooled provide only a small opportunity for risk of omphalitis (RR: 0.48; 95% PROMOTING NONPATHOGENIC a reduction in mortality rates. In 5 CI: 0.28–0.84), combining culture- COLONIZATION OF THE UMBILICAL CORD such trials 30 –33 analyzed by Karumbi proven sepsis cases28 with omphalitis et al, 22 no treatment was found cases34 is not appropriate. This Promoting colonization of the to significantly reduce omphalitis analysis provides only very weak, or umbilical cord by nonpathogenic and sepsis when compared against perhaps no, evidence for a benefit of bacteria may prevent the one another, although the sample chlorhexidine treatment. development of neonatal omphalitis. sizes were small and the evidence By allowing neonates to “room-in” Since 1998, the WHO has advocated was deemed of low quality. 22 The with their mothers, one can create the use of dry umbilical cord care Cochrane review by Imdad et al, 23 an environment conducive for in high-resource settings. 35 Dry which compared a variety of pairs colonization from less pathogenic cord care includes keeping the cord of topical agents, reached similar bacteria acquired from the mother’s clean and leaving it exposed to air or conclusions. The most recent flora. 39 This type of colonization loosely covered by a clean cloth. If it meta-analysis, by Sinha et al, 24 helps to reduce colonization and becomes soiled, the remnant of the considered 2 studies28, 34 comparing infection from potentially pathogenic cord is cleaned with soap and sterile chlorhexidine with dry cord care. organisms that are ubiquitous water. In situations in which hygienic In the first of these, 140 infants in the hospital environment. conditions are poor and/or infection admitted to the NICU at a hospital in Over time, attempts to decrease rates are high, the WHO recommends north India were randomly assigned bacterial colonization with topical chlorhexidine. 16 to receive cord treatment with antimicrobial agents may actually chlorhexidine solution or dry cord There is some uncertainty as to select for resistant and more care. 28 Enrollment criteria included the effect of chlorhexidine on pathogenic organisms 35 (level of gestational age >32 weeks and birth mortality when applied to the evidence: III). weight >1500 g, but the provided umbilical cords of newborn infants demographic data suggest that the in the hospital setting, but there is infants were predominantly late- moderate evidence for its effects IMPLICATIONS FOR CLINICAL PRACTICE preterm, and they experienced high on infection prevention. 24 Although 1. Application of select antimicrobial rates of complications of prematurity the application of chlorhexidine is agents to the umbilical cord may (including asphyxia, respiratory regarded as safe, 35 trace levels of the be beneficial for infants born distress, mechanical ventilation, and compound have been detected in the at home in resource-limited

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 e3 countries where the risks of Dan L. Stewart, MD, FAAP 6. Sawardekar KP. Changing spectrum of omphalitis and associated Susan W. Aucott, MD, FAAP neonatal omphalitis. Pediatr Infect Dis sequelae are high. Jay P. Goldsmith, MD, FAAP J. 2004;23(1):22–26 Karen M. Puopolo, MD, PhD, FAAP 2. Application of select antimicrobial Kasper S. Wang, MD, FAAP 7. Verber IG, Pagan FS. What cord care— agents to the umbilical cord if any? Arch Dis Child. 1993;68(5 spec LIAISONS no):594–596 does not provide clear benefit in the hospital setting or in Tonse N.K. Raju, MD, DCH, FAAP – National 8. Ronchera-Oms C, Hernández C, high-resource countries, where Institutes of Health Jimémez NV. Antiseptic cord care Wanda D. Barﬁ eld, MD, MPH, FAAP – Centers for reducing bacterial colonization reduces bacterial colonization but Disease Control and Prevention delays cord detachment. 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Updated Information & including high resolution figures, can be found at: Services http://pediatrics.aappublications.org/content/early/2016/08/25/peds.2 016-2149 References This article cites 37 articles, 8 of which you can access for free at: http://pediatrics.aappublications.org/content/early/2016/08/25/peds.2 016-2149#BIBL Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Fetus/Newborn Infant http://www.aappublications.org/cgi/collection/fetus:newborn_infant_ sub Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.aappublications.org/site/misc/Permissions.xhtml Reprints Information about ordering reprints can be found online: http://www.aappublications.org/site/misc/reprints.xhtml

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