Healthy Baby Practical advice for treating newborns and toddlers.

‘Stumped’ by the Newborn Umbilical Cord Stan L. Block, MD, FAAP

he postnatal management for range from daily applications of al- the newborn umbilical cord is cohol, to soap and water washings, to Tsurprisingly controversial. Nu- nontreatment. merous investigators have explored the optimal approach to cord care, whether TREATMENT RATIONALES it is performed during the first 24 hours In the past, most pediatricians were of life, or in the first weeks of life until concerned about bacterial colonization the cord spontaneously separates from of the cord and subsequent increased the body. risk for secondary invasive bacterial The average length of cord retention infection. With its slowly necrotizing varies from 3 to 45 days, with a mean tissue, the umbilical stump is a prime separation time of 13.9 days.1 During source for colonization by gram-nega- past comparative evaluations of several tive bacteria such as Escherichia coli, treatment options of the cord, a few op- Klebsiella, and pseudomonas, along tions have been shown to prolong the with gram-positive bacteria such as A separation of the cord. However, when Staphylococcus aureus and streptococ- compared with dry cord care, most cal species. treatments have been associated with a Secondary infections of the cord/ decreased risk for secondary infections. stump include a commonly encountered Initial options also vary widely from mild purulent discharge some have hospital to hospital; some initially ap- termed “mild funisitis”2 (see Figure 1), ply triple dye, chlorhexidine, or po- occasional impetigo or cellulitis, and vidone iodine, whereas others use no very rare infections such as severe fu- treatment. nisitis, frank omphalitis, and necrotiz- Recommendations for the post- ing fasciitis. hospital management of the cord also Funisitis is an infection of the con- nective tissue of the cord itself, usu- Stan L. Block, MD, FAAP, is Professor of Clinical ally associated with mild malodorous Pediatrics, University of Louisville, and University of discharge from streptococcal species, B Kentucky, Lexington, KY; President, Kentucky Pedi- but also may be associated with a more Figure 1. The bottom (A) and top (B) of the um- atric and Adult Research Inc.; and general pediatri- severe infection of chorioamnionitis, bilical cord base in a 10-day old female whose cian, Bardstown, KY. which is usually seen in stillborns and cord had been left untreated since birth. Lifting 2,3 the cord away from the base of the stump re- Address correspondence to Stan L. Block, MD, preterm infants. vealed the origin of a foul smell — the green and FAAP, via email: [email protected]. Omphalitis is a severe infection of the sanguinous discharge had accumulated since birth. The child was managed with three times Disclosure: Dr. Block has disclosed no relevant entire umbilical stump and surround- daily cotton-tip applications with rubbing alco- financial relationships. ing skin, most often associated with S. hol on both sides of the umbilical base. The cord doi: 10.3928/00904481-20120924-05 aureus.3 discharge resolved rapidly.

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BACTERIAL COLONIZATION OF For example, when a community hos- cords were prospectively evaluated, de- THE UMBILICAL CORD pital in Tampa, FL with 3,000 annual layed cord separation was not associ- Three studies of neonates conducted births instituted a dry cord care policy, ated with an increased risk of infection in the UK during the 1990s evaluated three cases of S. aureus bullous impetigo when compared with dry cord care.1,10 the correlation between S. aureus colo- of the umbilicus were reported within 3 Furthermore, topical applications of nization and infection when the umbili- months of the new policy compared with an antiseptic which may prolong cord cal cord was left untreated. Untreated no cases in the previous years.8 separation cannot create an exceedingly cords in 102 neonates were 1.75 times rare genetic defect. more likely to be colonized with S. au- THE DRY CORD ARGUMENT reus than treated cords.4 Many pediatricians become quite UMBILICAL CORD CARE OPTIONS An untreated cord was associated concerned when spontaneous separation The current treatment options for with a heavy colonization by S. aureus of the cord is delayed beyond the age umbilical cord care usually include:7 in 49% (171 neonates) of patients. More of 3 to 4 weeks. We have been taught • Triple dye (brilliant green, profla- importantly, 12% (44 neonates) of the about the association between delayed vine hemisulfate, and crystal violet). entire sample size developed a staphy- This is considered one of the most effec- lococcal infection.5 When dry cord care tive agents for bacteriocidal prophylax- was compared with hexachlorophane The issue of delayed cord is, particularly for S. aureus, but argu- (which should probably not be used due separation has evolved into ably it also may promote gram-negative to reports of neurotoxicity when used bacteria colonization. Parents complain inappropriately) or chlorhexidine, the a major justification for dry about the purple cord, the inadvertent rate of S. aureus colonization was unac- cord care. purple staining of the surrounding ab- ceptably high. dominal skin, and the brittle nature of Dry cord care has also been asso- the cord at home. One or two applica- ciated with intermittent outbreaks of cord separation and genetic defect of tions have not been shown to be toxic. neonatal bullous impetigo.6 Another diminished neutrophil mobility/severe • Isopropyl alcohol. By itself, this randomized trial of 766 newborns in recurrent bacterial infections.9 may have the least antibacterial activity British Columbia compared dry cord This phenomenon is usually caused of all agents. It also dries out and may care with a treatment regimen of two by a severe autoimmune, autosomal irritate the periumbilical skin. Many applications of triple dye on the day recessive disorder known as type 1 leu- parents are unaware of how to properly of birth along with twice daily alcohol kocyte adhesion deficiency (LAD-1), apply alcohol onto the base of the cord. 7 swabbing until cord separation. Com- which has a mutation in the beta2 inte- Although it has been proven to prolong pared with the treatment group, the ma- grin subunit, CD18, localized to chro- cord separation, it does dry up the dis- jor findings in the dry cord care group mosome 21. Yet, since the disorder was charge and foul odor associated with were the following: a 10-fold higher identified more than 30 years ago, ac- nontreatment of the stump. With heavy rate of S. aureus colonization (31.3% cording to the latest edition (6th) of Text- exposure or an occlusive dressing, it vs. 2.8%); higher rates of cord exudates book of Pediatric Infectious Diseases,2 could cause alcohol intoxication and (7.4% vs. 0.3%) and foul odor (2.9% it has been identified in only about 150 subsequent acidosis and hypoglycemia. vs. 0.7%); and a single case of ompha- individuals worldwide. It also has a • Povidone iodine. This has been litis. broad ethnic diversity. demonstrated to be less effective than The authors in each of these studies The issue of delayed cord separation triple dye for both prevention of coloni- concluded that prevention of early S. has evolved into a major justification for zation and infection. Iodine toxicity and aureus colonization was the most criti- dry cord care. Some argue that the lon- transient hypothyroidism is possible, cal factor in routine cord care. The study ger the cord stays on, the higher the risk particularly for low birth weight infants, by Verber and colleagues6 surmised that of becoming infected. The commonly as plasma iodide levels may increase up perhaps, hospital physicians do not be- used treatments (triple dye, alcohol, and to 400% for nearly 3 days.11 come aware of some of the cord prob- chlorhexidine) delay cord separation • Topical antibiotics (eg, neomycin, lems and the rare actual infections that for merely 1 to 5 days. However, even bacitracin). These may promote bacteri- may occur until the cord separates. when over 15,000 neonates with treated al antibiotic resistance and later hyper-

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Figure 5. Application of a silver nitrate stick to the umbilical base of the child in Figure 4. Any areas touched by the stick will turn black or a grayish color for a week or so. Although the cord may ooze some serous discharge in the initial few hours, it will quickly dry up. Clinicians should attempt to only touch the cord area, and avoid the skin, when applying the silver nitrate stick. The application appears to be Figure 2. The umbilical cord of a 14-day-old male mildly uncomfortable for the infant, and his legs should be briefly restrained by the parent. Only a single infant whose cord was treated with an initial application is usually needed. single application of triple dye. No further treat- ment was used. Once the cord remnant was lifted from the base of the umbilicus, a purulent wet discharge was noted. The cord was treated with sensitivity to antibiotics. Triple dye has ommend the application of alcohol three times daily applications of rubbing alcohol, and the discharge dried up within a few days. been shown to be superior for preven- to the base of the cord with a cotton- tion of both colonization and infection. tipped applicator 2 to 3 times daily until • Chlorhexidine. Although an ef- the cord is separated. Even though it is fective broad spectrum antimicrobial, a poor antibacterial and still of unprov- particularly for cord colonization with en efficacy,14 alcohol applications usu- S. aureus, some recent studies suggest it ally seem to prevent the putrid, green may promote bacterial resistance when discharge and the foul odor associated used frequently.12 with either dry cord care or with soap In underdeveloped countries, and water care of the cord. chlorhexidine has been shown to signif- During the first office visit at day 4 icantly reduce mortality from omphali- or 5 of life, when the infant’s upper cord tis.13 Occlusion must be avoided; local has mostly dried up, I demonstrate to skin reactions may occur. A single daily the parents the technique of separating application is necessary for at least the the cord inferiorly and superiorly from first week of life. the umbilical skin (See Figure 1, page 400). At this visit, many babies will

Figure 3. The base of an umbilical cord in a ADVICE FOR CORD CARE already have developed a wet, green 2-week-old male infant . The purulent discharge Several days of delayed separation purulent discharge at the unseparated was still exuding from the stump, and treatment of the cord, regardless of which treat- junction of skin and cord (See Figure 2 by cauterization with silver nitrate was selected (see Figure 5). ment, is probably not an important con- and Figure 3). sideration relative to possible increased I also recommend that parents only risk for colonization and infection of sponge bathe the baby until the cord the cord. I think at least a single appli- separates, and not to get the cord wet at cation of triple dye in the nursery may all. In my experience, the worst smell- be optimal because this method appears ing and the worst umbilical discharge to have the lowest rates of colonization is associated with water-wetted cords, and infection. We have been success- probably due to pseudomonas over- Figure 4. A tube of 100 applicators of silver ni- fully using this technique in our nursery growth. trate. A single applicator is often used to cauterize the base of weeping purulent stumps — with or for over 30 years. When the cord finally separates, without the cord attached. After hospital discharge, I also rec- some mild bleeding at the base is nor-

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mal. If bleeding, malodor, or green any significant congenital renal abnor- cock D, Thiessen PN. To dye or not to dye: discharge of the umbilicus persists be- malities? a randomized, clinical trial of a triple dye/ alcohol regime versus dry cord care. Pediat- yond the first week, I advocate an ap- Two different studies, which evalu- rics. 2003;111(1):15-20. plication of a 75% silver nitrate stick ated about 45,000 infants in the 1960s 8. Weathers L, Takagishi J, Rodriguez L. Um- to the interior of the umbilicus if the and 1970s, reported no increased risk bilical cord care. Pediatrics. 2004;113(3 Pt 1):625-626; author reply 625-626. cord has separated already, or to the in- of renal abnormalities in infants with 9. Hayward AR, Harvey BA, Leonard J, Green- terior base of the cord-skin junction if SUA. The only malformation reported wood MC, Wood CB, Soothill JF. Delayed the cord is still attached (See Figure 4 as significantly higher in children with separation of the umbilical cord, widespread infections, and defective neutrophil mobility. and Figure 5, page 402). SUA than in a control population was Lancet. 1979;1(8126):1099-1101. the rate of inguinal hernia. 10. Mullany LC, Darmstadt GL, Khatry SK, UMBILICAL GRANULOMA Forego the renal ultrasound.15,16 As LeClerq SC, Katz J, Tielsch JM. Impact Occasionally, a small 3- to 5-mm stated in the 2012 online medical text- of umbilical cord cleansing with 4.0% chlorhexidine on time to cord separation fungating mass, which has a mild green book, Uptodate.com: “We do not per- among newborns in southern Nepal: a clus- or sanguinous discharge, may develop form further imaging for healthy term ter-randomized, community-based trial. Pe- within the umbilical stump. This lesion infants with an isolated SUA, as there diatrics. 2006;118:1864-1871. 11. Pyati SP, Ramamurthy RS, Krauss MT, Pil- is best eradicated with an application is a low likelihood of a renal or uro- des RS Absorption of iodine in the neonate or two of 75% silver nitrate stick to the logical abnormality.”14 following topical use of povidone iodine. J entire mass. Very rarely, when the le- Pediatr. 1977;91:825-828. 12. Batra R, Cooper BS, Whiteley C, Patel AK, sion does not respond to this therapy, or REFERENCES Wyncoll D, Edgeworth JD. Efficacy and 1. Novack AH: Umbilical separation in the nor- when the lesion is larger than 10 mm, limitation of a chlorhexidine-based decolo- mal newborn. Am J Dis Child. 1988,142:220- nization strategy in preventing transmission you are likely dealing with an umbili- 223. of methicillin-resistant Staphylococcus au- cal polyp. Polyps often contain intesti- 2. Feigin R, Cherry J, Demmler-Harrison G, reus in an intensive care unit. Clin Infect Dis. Kaplan S. Feigin and Cherry’s Textbook of nal or urachal remnants; they are best 2010;50(2):210-217 Pediatric Infectious Diseases, 6th edition. managed by surgical removal. 13. Mullany LC, Saha SK, Shah R, et al. Impact Philadelphia: WB Saunders; 2009. of 4.0% chlorhexidine cord cleansing on the 3. Brien JH. An 18-month-old female pres- bacteriologic profile of the newborn umbilical ents with fever, erythema, swelling around EVALUATION FOR THE SINGLE stump in rural Sylhet District, Bangladesh: a umbilicus. Infectious Diseases in Children. UMBILICAL ARTERY community-based, cluster-randomized trial. 2012, (2)18-19. Available at www.healio. Pediatr Infect Dis J. 2012;31(5):444-450. I wish to clarify an important issue com/pediatrics/news/print/infectious-dis- 14. Froehlich LA, Fujikura T. Follow-up of in- eases-in-children/%7Ba272c863-16e1- regarding umbilical cord management. fants with single umbilical artery. Pediatrics. 4626-9ad3-5bda62b3b6af%7D/ It is commonly believed that neonates 1973;52:6-13. an-18-month-old-female-presents-with- 15. Van Leeuwen G. Single umbilical artery [let- with a single umbilical artery (SUA), fever-erythema-swelling-aroundumbilicus. ter]. Pediatrics. 1973;52:890. reported in 0.2% to 0.6% of live born Accessed Sept. 10, 2012. 16. Palazzi DL, Brandt ML. Care of the 4. Watkinson M, Dyas A. Staphylococcus au- infants, have a significantly increased umbilicus and management of umbili- reus still colonizes the untreated neonatal risk for congenital renal anomalies.14 cal disorders. Available at http://www. umbilicus. J Hosp Infect. 1992;21:131-135. uptodate.com/contents/care-of-the-um- This notion prompts many practitio- 5. Stark V, Harrison SP. Staphylococcus aureus bilicus-and-management-of-umbilical- colonization of the newborn in a Darlington ners to obtain a renal ultrasound in all disorders?source=search_result&search=Car hospital. J Hosp Infect. 1992;21:205-211. infants who have SUA, at considerable e+of+the+umbilicus+and+management+of+ 6. Verber IG, Pagan S. What cord care — if umbilical+disorders.&selectedTitle=1~150. expense and notable parental anxiety. any? Arch Dis Child. 1993;68:594-596. Accessed Sept. 14, 2012. But what are the real odds of finding 7. Janssen PA, Selwood BL, Dobson SR, Pea-

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