Dry Cord Care Research Articles

Umbilical Cord Management and Stump Care in Normal Childbirth in Slovenian and Croatian Maternity Hospitals.

The aim was to investigate first-care procedures for the newborn's umbilical cord at maternity hospitals in Slovenia and Croatia. The study was based on an empirical survey research approach and quantitative research paradigms and included all Slovenian (n=14) and all Croatian (n=35) maternity hospitals. Leaders of midwifery team of 14 Slovenian and 35 Croatian labor wards were invited to participate. The study was conducted in 2013, with 67% of Slovenian and 66% of Croatian maternity hospitals having responded. A causal and non-experimental method of empirical research was used. The research instrument was a questionnaire. Descriptive statistics was used on data analysis. The independence hypothesis was tested with the χ2-test or Kullback 2Î-test. A vast ma-jority of study wards employed delayed umbilical cord clamping, i.e. clamping the cord after pulsa-tion had ceased. Only 10% of Slovenian in comparison with 36.4% of Croatian maternity hospitals practiced dry cord care. Others applied disinfectant on the cord, in Slovenia most frequently 6% po-tassium permanganate, and in Croatia a combination of octenidine and phenoxyethanol. Most Croa-tian -maternity wards (95.7%) still covered the stump, while it was not regular practice in Slovenia. The authors estimate that the prevailing Slovenian and Croatian practices in regard to cord clamping are in accordance with the evidence, while improvements could be made regarding stump care, since dry cord care is the recommended method.

Use of antiseptic for cord care and its association with neonatal mortality in a population-based assessment in Bihar State, India

ObjectivesDry cord care is recommended for all births by the Health Ministry in India. We report prevalence of antiseptic cord care in the context of neonatal mortality in the Indian...

Newborn Care Practices among Adolescent Mothers in Hoima District, Western Uganda.

IntroductionAdolescent childbearing remains a major challenge to improving neonatal mortality especially in Sub Saharan countries which are still struggling with high neonatal mortality rates. We explored essential newborn care practices and associated factors among adolescent mothers in Western Uganda.MethodsData were collected among 410 adolescent mothers with children aged one to six months in Hoima district. Three composite variables (appropriate neonatal breastfeeding, cord care and thermal protection) were derived by combining related practices from a list of recommended newborn care practices. Logistic regression analysis was conducted to identify factors independently associated with practice of essential newborn care.ResultsAppropriate newborn feeding, optimal thermal protection and dry cord care were practiced by 60.5%, 67.2% and 31% of adolescent mothers respectively. Independent predictors’ of cord care were: knowledge of cord care (AOR 5.34, 95% CI (1.51–18.84) and having delivered twins (AOR 0.04, 95% CI (0.01–0.22). The only predictor of thermal care was knowledge (AOR 25.15, 95% CI (7.01–90.20). Staying in a hospital for more than one day postpartum (AOR 2.45, 95%CI (1.23–4.86), knowledge of the correct time of breastfeeding initiation (AOR 14.71, 95% CI (5.20–41.58), predicted appropriate neonatal feeding, whereas; adolescent mothers who had had a caesarean delivery (AOR 0.19, 95% CI (I 0.04–0.96) and a male caretaker in the postnatal period (AOR 0.18, 95% CI (0.07–0.49) were less likely to practice the recommended newborn feeding.ConclusionSub optimal essential newborn care practice was noted especially suboptimal cord care. Adolescent mothers should be a focus of strategies to improve maternal and neonatal health.

Efficacy of chlorhexidine application to umbilical cord on neonatal mortality in Pemba, Tanzania: a community-based randomised controlled trial.

In low-income countries, including the east African region, a third of neonatal deaths are due to infections. A substantial proportion of these have been attributed to sepsis, which can result from umbilical cord infections. Evidence from Asia suggests that chlorhexidine application to the neonatal umbilical cord reduces mortality, but no data from Africa are available. We aimed to assess the effect of umbilical cord cleansing with 4% chlorhexidine solution on neonatal mortality and omphalitis in rural settings of sub-Saharan Africa. We did a community-based randomised controlled trial on Pemba Island, Zanzibar, Tanzania. All eligible babies (aged 1 h to 48 h, without congenital malformations) from hospital-based and community-based deliveries on Pemba Island were enrolled. Participants were randomly assigned to either 4% free chlorhexidine for cord care or to dry cord care using a computer-generated random sequence. For babies allocated to the chlorhexidine group, mothers or caretakers were advised to apply the solution to the cord every day until 3 days after the cord had dropped off. Cord stumps were examined for redness, pus, swelling, and foul odour on day 0, 1, 4, 10, and 28. The primary outcome for this study was mortality until day 28 on an intention-to-treat basis. The trial is registered with ClinicalTrials.gov, number NCT01528852. Between May 19, 2011, and Aug 31, 2014, 36 911 newborn babies were enrolled into the chlorhexidine (n=18 015) and dry cord care study (n=18 896) groups. 17 468 (96·9%) of 18 015 neonates in the chlorhexidine group were available for complete follow-up (28 days) compared with 18 384 (97·3%) of 18 896 neonates in the dry cord care group. Mortality rate in the chlorhexidine group (10·5 deaths per 1000 livebirths) was not significantly lower than that in the dry cord care group (11·7 per 1000 livebirths; relative risk 0·90, 0·74-1·09; p=0·27). Our findings do not support the use of chlorhexidine for reduction of neonatal mortality in this east African setting, which might not justify a change in the WHO policy. To inform global policy, a detailed meta-analysis and pooled analysis needs to be undertaken using data from both African and Asian settings. Bill & Melinda Gates Foundation.

Umbilical Cord Care in the Newborn Infant.

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

Effect of 4% chlorhexidine on cord colonization among hospital and community births in India: a randomized controlled study.

BackgroundInfections are the single most important cause of neonatal mortality in developing countries. Results from trials in Asia evaluating the effect of chlorhexidine on neonatal mortality have been encouraging but limited data are available on the impact of cord cleansing on bacterial colonization. Further, no data from facility deliveries and impact with time is available. This pilot study was aimed to evaluate the impact of 4 % commercially prepared chlorhexidine on cord colonization and density of colonization among newborns in India.MethodsThree hundred twenty-six newborns (hospital-247; community-79) were enrolled within 24 h of birth and randomly assigned to one of three groups: chlorhexidine, placebo or dry cord care. Umbilical swabs were collected at baseline, 2- and 48- hours after intervention application.ResultsAt baseline, growth positivity (any bacterial growth) was 20 % (50 of 247 swabs) and 81 % (64 of 79 swabs) among hospital and community born neonates, respectively. In both settings, chlorhexidine compared to placebo and dry cord care, reduced colonization following 2- and 48-hour post application. Chlorhexidine significantly reduced 48-hour post application colony counts in comparison to placebo [Hospital: mean difference = −1.01; 95 % CI: −1.72, −0.30 Community: mean difference = −1.76; 95 % CI: −2.60, −0.93] and dry cord care [Hospital: mean difference = −1.16; 95 % CI: −1.93, −0.39 Community: mean difference = −2.23; 95 % CI: −3.18, −1.29]. Differences were similar for gram-positive and gram-negative bacteria.ConclusionsCord cleansing with 4 % chlorhexidine soon after birth reduced colonization as well as density of colonization significantly; however this pilot study does not address the impact of chlorhexidine on mortality. The control preparation neither increased or decreased colonization.Trial registrationClinical Trial Registration: clinicaltrials.gov: NCT01528852, Registered February 7, 2012. Electronic supplementary materialThe online version of this article (doi:10.1186/s12887-016-0625-7) contains supplementary material, which is available to authorized users.

Chlorhexidine Cleansing of the Umbilical Cord and Cord Separation Time: A Hospital Based Study in Bangladesh

Background: Cord separation time has evolved as an important justification for recommending against the topical use of chlorhexidine on the cord. Objective: This present study was undertaken to determine the impact of cord cleansing with chlorhexidine on cord separation time and maternal acceptance of chlorhexidine in umbilical cord care. Methods: Between April 2013 to July 2014, 340 newborns were randomly assigned within a tertiary level hospital in Bangladesh to receive 1 of 2 cord care regimens: clean and dry cord care (control) and single cord cleansing with 4% chlorhexidine. Results: The mean cord separation time in newborns of chlorhexidine group was significantly longer than dry cord care group (p < 0.001). Mother of newborns in chlorhexidine group more frequently reported “longer than usual” cord separation time. Overall satisfaction of mother with cord separation time was high (95.9%). Conclusion: Topical chlorhexidine significantly increased cord separation time.Journal of Science Foundation, 2015;13(2):27-30DOI: http://dx.doi.org/10.3329/jsf.v13i2.27929

Comparative Study of Dry Cord Care Versus Application of 4% Chlorhexidine on Umbilical Cord in Newborns

Introduction: Infections are the most important cause of infant mortality, of which, umbilical cord infections are an important precursor. In developing countries, umbilical cord infections constitute a major source of neonatal morbidity and pose significant risk for mortality. Methods: Prospective analytical study was conducted at KVG Medical College and Hospital, Sullia with an objective to study the aerobic bacteriological profile of umbilical cord in new born and their characterization and to compare two umbilical cord care regimens, that is, dry cord care, and 5% povidone iodine for their impact on colonization and infection. 50 cases, each in category of dry cord care and 5% povidone iodine application on umbilical cord were studied. Results: The study showed that 5% povidone iodine application to the umbilical cord though appeared to reduce colonization with S. aureus, fail to inhibit it completely. Conclusion: Antimicrobial application may enhance colonization with more dangerous multidrug resistant staphylococci (MRSA and MR-CONS). 5% povidone-iodine appeared to be inferior to dry cord care in preventing clinical manifestation in infants. Keywords: 5% povidone iodine, Dry cord care, Newborns, Infant mortality

Comparative Study of Dry Cord Care versus Application of 5% Povidone-Iodine on Umbilical Cord in Newborns

Comparative Study of Dry Cord Care versus Application of 5% Povidone-Iodine on Umbilical Cord in Newborns

What impact do essential newborn care practices have on neonatal mortality in low and lower-middle income countries? Evidence from Bangladesh.

To assess the impact of essential newborn care (ENC) practices on the mortality of neonates delivered at home in Bangladesh. This study used cross-sectional data from the 2011 Bangladesh Demographic and Health Survey. Adjusted logistic regression model was used to examine the effect of ENC practices on neonatal mortality based on 3190 live-born infants. Delayed bathing (72 h after delivery) significantly contributed to reducing neonatal mortality. A significant but counterintuitive relation was observed between the dry cord care and neonatal deaths. Neonatal mortality may be reduced through emphasizing delayed bathing. Specific guidelines on the cleanliness of the fabric used to dry and wrap newborns, as well as emphasizing the use of clean delivery kits and initiation of immediate and exclusive breastfeeding, may improve neonatal outcomes. Further, the ENC guidelines in Bangladesh should include the application of topical antiseptics to the cord stump.

Effect of the Uganda Newborn Study on care-seeking and care practices: a cluster-randomised controlled trial

BackgroundCare for women and babies before, during, and after the time of birth is a sensitive measure of the functionality of any health system. Engaging communities in preventing newborn deaths is a promising strategy to achieve further progress in child survival in sub-Saharan Africa.ObjectiveTo assess the effect of a home visit strategy combined with health facility strengthening on uptake of newborn care-seeking, practices and services, and to link the results to national policy and scale-up in Uganda.DesignThe Uganda Newborn Study (UNEST) was a two-arm cluster-randomised controlled trial in rural eastern Uganda. In intervention villages volunteer community health workers (CHWs) were trained to identify pregnant women and make five home visits (two during pregnancy and three in the first week after birth) to offer preventive and promotive care and counselling, with extra visits for sick and small newborns to assess and refer. Health facility strengthening was done in all facilities to improve quality of care. Primary outcomes were coverage of key essential newborn care behaviours (breastfeeding, thermal care, and cord care). Analyses were by intention to treat. This study is registered as a clinical trial, number ISRCTN50321130.ResultsThe intervention significantly improved essential newborn care practices, although many interventions saw major increases in both arms over the study period. Immediate breastfeeding after birth and exclusive breastfeeding were significantly higher in the intervention arm compared to the control arm (72.6% vs. 66.0%; p=0.016 and 81.8% vs. 75.9%, p=0.042, respectively). Skin-to-skin care immediately after birth and cord cutting with a clean instrument were marginally higher in the intervention arm versus the control arm (80.7% vs. 72.2%; p=0.071 and 88.1% vs. 84.4%; p=0.023, respectively). Half (49.6%) of the mothers in the intervention arm waited more than 24 hours to bathe the baby, compared to 35.5% in the control arm (p<0.001). Dry umbilical cord care was also significantly higher in intervention areas (63.9% vs. 53.1%, p<0.001). There was no difference in care-seeking for newborn illness, which was high (around 95%) in both arms. Skilled attendance at delivery increased in both the intervention (by 21%) and control arms (by 19%) between baseline and endline, but there was no significant difference in coverage across arms at endline (79.6% vs. 78.9%; p=0.717). Home visits were pro-poor, with more women in the poorest quintile visited by a CHW compared to families in the least poor quintile, and more women who delivered at home visited by a CHW after birth (73.6%) compared to those who delivered in a hospital or health facility (59.7%) (p<0.001). CHWs visited 62.8% of women and newborns in the first week after birth, with 40.2% receiving a visit on the critical first day of life.ConclusionConsistent with results from other community newborn care studies, volunteer CHWs can be effective in changing long-standing practices around newborn care. The home visit strategy may provide greater benefit to poorer families. However, CHW strategies require strong linkages with and concurrent improvement of quality through health system strengthening, especially in settings with high and increasing demand for facility-based services.

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

Affordable, feasible and efficacious interventions to reduce neonatal infections and improve neonatal survival are needed. Chlorhexidine, a broad spectrum topical antiseptic agent, is active against aerobic and anaerobic organisms and reduces neonatal bacterial colonisation and may reduce infection. To evaluate the efficacy of neonatal skin or cord care with chlorhexidine versus routine care or no treatment for prevention of infections in late preterm or term newborn infants in hospital and community settings. We searched CENTRAL, latest issue of The Cochrane Library, MEDLINE (1966 to November 2013), EMBASE (1980 to November 2013), and CINAHL (1982 to November 2013). Ongoing trials were detected by searching the following databases: www.clinicaltrials.gov and www.controlled-trials.com. Cluster and individual patient randomised controlled trials of chlorhexidine use (for skin care, or cord care, or both) in term or late preterm neonates in hospital and community settings were eligible for inclusion. Three authors independently screened and selected studies for inclusion. Two review authors independently extracted data, and assessed study risk of bias. The quality of evidence for each outcome was assessed using GRADE. We calculated pooled risk ratios (RRs) and risk differences (RDs) with 95% confidence intervals (CIs), and presented results using GRADE 'Summary of findings' tables. We included 12 trials in this review. There were seven hospital-based and five community-based studies. In four studies maternal vaginal wash with chlorhexidine was done in addition to neonatal skin and cord care. Newborn skin or cord cleansing with chlorhexidine compared to usual care in hospitalsLow-quality evidence from one trial showed that chlorhexidine cord cleansing compared to dry cord care may lead to no difference in neonatal mortality (RR 0.11, 95% CI 0.01 to 2.04). Moderate-quality evidence from two trials showed that chlorhexidine cord cleansing compared to dry cord care probably reduces the risk of omphalitis/infections (RR 0.48, 95% CI 0.28 to 0.84).Low-quality evidence from two trials showed that chlorhexidine skin cleansing compared to dry cord care may lead to no difference in omphalitis/infections (RR 0.88, 95% CI 0.56 to 1.39). None of the studies in this comparison reported effects of the treatments on neonatal mortality. Newborn skin or cord cleansing with chlorhexidine compared to usual care in the communityHigh-quality evidence from three trials showed that chlorhexidine cord cleansing compared to dry cord care reduces neonatal mortality (RR 0.81, 95% CI 0.71 to 0.92) and omphalitis/infections (RR 0.48, 95% CI 0.40 to 0.57).High-quality evidence from one trial showed no difference between chlorhexidine skin cleansing and usual skin care on neonatal mortality (RR 1.03, 95% CI 0.87 to 1.23). None of the studies in this comparison reported effects of the treatments on omphalitis/infections. Maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention (sterile saline solution) in hospitalsModerate-quality evidence from one trial showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on neonatal mortality (RR 0.98, 95% CI 0.67 to 1.42). High-quality evidence from two trials showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on the risk of infections (RR 0.93, 95% CI 0.82 to 1.16).Findings from one trial showed that maternal vaginal cleansing in addition to total body cleansing results in increased risk of hypothermia (RR 1.33, 95% CI 1.19 to 1.49). Maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention (sterile saline solution) in the communityLow-quality evidence from one trial showed no difference between maternal vaginal chlorhexidine in addition to total body cleansing and no intervention on neonatal mortality (RR 0.20, 95% CI 0.01 to 4.03). Moderate-quality evidence from one trial showed that maternal vaginal chlorhexidine in addition to total body cleansing compared to no intervention probably reduces the risk of neonatal infections (RR 0.69, 95% CI 0.49 to 0.95). These studies did not report effect on omphalitis. There is some uncertainty as to the effect of chlorhexidine applied to the umbilical cords of newborns in hospital settings on neonatal mortality. The quality of evidence for the effects on infection are moderate for cord application and low for application to skin. There is high-quality evidence that chlorhexidine skin or cord care in the community setting results in a 50% reduction in the incidence of omphalitis and a 12% reduction in neonatal mortality. Maternal vaginal chlorhexidine compared to usual care probably leads to no difference in neonatal mortality in hospital settings. Maternal vaginal chlorhexidine compared to usual care results in no difference in the risk of infections in hospital settings. The uncertainty over the effect of maternal vaginal chlorhexidine on mortality outcomes reflects small sample sizes and low event rates in the community settings.

Engagement of the community, traditional leaders, and public health system in the design and implementation of a large community-based, cluster-randomized trial of umbilical cord care in Zambia.

Conducting research in areas with diverse cultures requires attention to community sensitization and involvement. The process of community engagement is described for a large community-based, cluster-randomized, controlled trial comparing daily 4% chlorhexidine umbilical cord wash to dry cord care for neonatal mortality prevention in Southern Province, Zambia. Study preparations required baseline formative ethnographic research, substantial community sensitization, and engagement with three levels of stakeholders, each necessitating different strategies. Cluster-specific birth notification systems developed with traditional leadership and community members using community-selected data collectors resulted in a post-natal home visit within 48 hours of birth in 96% of births. Of 39,679 pregnant women enrolled (93% of the target of 42,570), only 3.7% were lost to follow-up or withdrew antenatally; 0.2% live-born neonates were lost by day 28 of follow-up. Conducting this trial in close collaboration with traditional, administrative, political, and community stakeholders facilitated excellent study participation, despite structural and sociocultural challenges.

Safety of Arnica/Echinacea Powder in the Care of the Umbilical Stump

The main concerns about neonates’ umbilical stump are delay in its falling, umbilical cord infections and bleeding. Optimal umbilical cord care is therefore an important issue for both nurseries’ staff and neonates’ caregivers. Many investigators have explored the optimal cord care treatment. Among current umbilical cord care options, topical application of chlorhexidine decreases omphalitis and neonatal mortality, both in primary and community care settings in developing countries; whereas dry cord care has proved to be adequate in hospital settings, in developed countries. We here report our experience on arnica/echinacea powder, a safe method of treating the umbilical cord in developed countries. Clinical Practice Article Scurati-Manzoni et al.; JSRR, 5(6): 435-440, 2015; Article no.JSRR.2015.110 436

Comparison of the effect of topical application of human milk and dry cord care on the bacterial colonization of umbilical cord in newborn infants

Background: Breast milk contains significant amounts of compounds that act as natural antimicrobial agents. This study was conducted to compare the effect of topical application of human milk and dry cord care on bacterial colonization in the umbilical cord of newborn infants. Methods: This clinical trial study was carried out on 174 infants in Kashan. The newborns were randomized to mother's milk group and dry cord care group from the birth. In group 1, the mother rubbed her own milk on the cord stump every 12 hours from 3 hours after birth to 2 days after the umbilical cord separation. In group 2, the mother was recommended not to use any material on the cord. Then, the cord samples were taken four times; 3hours after birth, at days 3 and 7, and 2 days after the umbilical cord separation. Results: The findings of the culture two days after umbilical cord separation indicated that low percentage of neonates in the breast milk (23.1%) and dry cord care (28.8%) groups had bacterial colonization. Moreover, no significant difference was found between the two groups in terms of growth of pathogenic organisms and normal flora of the skin (P>0.05). Conclusion: Given the low prevalence of pathogenic microorganisms in the two groups, it seems using breast milk and dry cord care are equally effective methods of taking care of umbilical cord.

Newborn care practices at home and in health facilities in 4 regions of Ethiopia

BackgroundEthiopia is one of the ten countries with the highest number of neonatal deaths globally, and only 1 in 10 women deliver with a skilled attendant. Promotion of essential newborn care practices is one strategy for improving newborn health outcomes that can be delivered in communities as well as facilities. This article describes newborn care practices reported by recently-delivered women (RDWs) in four regions of Ethiopia.MethodsWe conducted a household survey with two-stage cluster sampling to assess newborn care practices among women who delivered a live baby in the period 1 to 7 months prior to data collection.ResultsThe majority of women made one antenatal care (ANC) visit to a health facility, although less than half made four or more visits and women were most likely to deliver their babies at home. About one-fifth of RDWs in this survey had contact with Health Extension Workers (HEWS) during ANC, but nurse/midwives were the most common providers, and few women had postnatal contact with any health provider. Common beneficial newborn care practices included exclusive breastfeeding (87.6%), wrapping the baby before delivery of the placenta (82.3%), and dry cord care (65.2%). Practices contrary to WHO recommendations that were reported in this population of recent mothers include bathing during the first 24 hours of life (74.7%), application of butter and other substances to the cord (19.9%), and discarding of colostrum milk (44.5%). The results suggest that there are not large differences for most essential newborn care indicators between facility and home deliveries, with the exception of delayed bathing and skin-to-skin care.ConclusionsImproving newborn care and newborn health outcomes in Ethiopia will likely require a multifaceted approach. Given low facility delivery rates, community-based promotion of preventive newborn care practices, which has been effective in other settings, is an important strategy. For this strategy to be successful, the coverage of counseling delivered by HEWs and other community volunteers should be increased.

Local Perceptions, Cultural Beliefs and Practices That Shape Umbilical Cord Care: A Qualitative Study in Southern Province, Zambia

BackgroundGlobal policy regarding optimal umbilical cord care to prevent neonatal illness is an active discussion among researchers and policy makers. In preparation for a large cluster-randomized control trial to measure the impact of 4% chlorhexidine as an umbilical wash versus dry cord care on neonatal mortality in Southern Province, Zambia, we performed a qualitative study to determine local perceptions of cord health and illness and the cultural belief system that shapes umbilical cord care knowledge, attitudes, and practices.Methods and FindingsThis study consisted of 36 focus group discussions with breastfeeding mothers, grandmothers, and traditional birth attendants, and 42 in-depth interviews with key community informants. Semi-structured field guides were used to lead discussions and interviews at urban and rural sites. A wide variation in knowledge, beliefs, and practices surrounding cord care was discovered. For home deliveries, cords were cut with non-sterile razor blades or local grass. Cord applications included drying agents (e.g., charcoal, baby powder, dust), lubricating agents (e.g., Vaseline, cooking oil, used motor oil) and agents intended for medicinal/protective purposes (e.g., breast milk, cow dung, chicken feces). Concerns regarding the length of time until cord detachment were universally expressed. Blood clots in the umbilical cord, bulongo-longo, were perceived to foreshadow neonatal illness. Management of bulongo-longo or infected umbilical cords included multiple traditional remedies and treatment at government health centers.ConclusionUmbilical cord care practices and beliefs were diverse. Dry cord care, as recommended by the World Health Organization at the time of the study, is not widely practiced in Southern Province, Zambia. A cultural health systems model that depicts all stakeholders is proposed as an approach for policy makers and program implementers to work synergistically with existing cultural beliefs and practices in order to maximize effectiveness of evidence-based interventions.

Impact of chlorhexidine cleansing of the umbilical cord on cord separation time and neonatal mortality in comparison to dry cord care – a nursery-based randomized controlled trial

Aim: To study the impact of chlorhexidine cleansing of the umbilical cord on cord separation time and neonatal mortality in comparison to dry cord care.Methods: This is the secondary analysis of the data of the study which was conducted in the NICU of a teaching hospital in north India between 2010 and 2011. Newborns (>32 weeks of gestation and weighing >1500 g) were randomized into chlorhexidine application and dry cord care groups. Here, we analyze the data regarding time of cord separation, umbilical sepsis and mortality in both the groups.Results: One hundred and forty (dry care group 70, chlorhexidine group 70) were enrolled and finally analyzed. A significant difference was observed among groups in terms of time to cord separation (8.92 ± 2.77 days versus 10.31 ± 3.23 days; t = 2.20; p = 0.02, significant) and neonatal mortality (χ2 = 4.11; p = 0.042, significant).Conclusion: Use of chlorhexidine for umbilical cord care shortens duration of cord separation and decreases neonatal mortality in NICU. This simple intervention can be used as mode for decreasing neonatal mortality.

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

BackgroundThere is an increased risk of serious neonatal infection arising through exposure of the umbilical cord to invasive pathogen in home and facility births where hygienic practices are difficult to achieve. The World Health Organization currently recommends ‘dry cord care’ because of insufficient data in favor of or against topical application of an antiseptic. The primary objective of this meta-analysis is to evaluate the effects of application of chlorhexidine (CHX) to the umbilical cord to children born in low income countries on cord infection (omphalitis) and neonatal mortality. Standardized guidelines of Child Health Epidemiology Reference Group (CHERG) were followed to generate estimates of effectiveness of topical chlorhexidine application to umbilical cord for prevention of sepsis specific mortality, for inclusion in the Lives Saved Tool (LiST).MethodsSystematic review and meta-analysis. Data sources included Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, CINHAL and WHO international clinical trials registry. Only randomized trials were included. Studies of children in hospital settings were excluded. The comparison group received no application to the umbilical cord (dry cord care), no intervention, or a non-CHX intervention. Primary outcomes were omphalitis and all-cause neonatal mortality.ResultsThere were three cluster-randomised community trials (total participants 54,624) conducted in Nepal, Bangladesh and Pakistan that assessed impact of CHX application to the newborn umbilical cord for prevention of cord infection and mortality. Application of any CHX to the umbilical cord of the newborn led to a 23% reduction in all-cause neonatal mortality in the intervention group compared to control [RR 0.77, 95 % CI 0.63, 0.94; random effects model, I2=50 %]. The reduction in omphalitis ranged from 27 % to 56 % compared to control group depending on severity of infection. Based on CHERG rules, effect size for all-cause mortality was used for inclusion to LiST model as a proxy for sepsis specific mortality.ConclusionsApplication of CHX to newborn umbilical cord can significantly reduce incidence of umbilical cord infection and all-cause mortality among home births in community settings. This inexpensive and simple intervention can save a significant number of newborn lives in developing countries.

Topical Umbilical Cord Care

Reply: We thank the authors of the recent letter for their careful reading of the article and useful comments. Four issues were raised and we will respond to these in turn. The design effect that is relevant to cluster-randomized controlled trial was overlooked in calculating pooled 95% confidence interval (CI)1. All the 3 cluster-randomized controlled trials 2–4 reported cluster-adjusted risk ratios (RRs) and 95% CIs. Our reported confidence interval for the risk of neonatal mortality of chlorhexidine versus dry cord care (RR 0.83, 95% CI: 0.74–0.94)5 was narrower than it should have been, and the recalculated cluster-adjusted 95% CI is slightly wider as the correspondents point out (RR 0.83, 95% CI: 0.72–0.96). The Intention to Treat (ITT) analysis reported in the primary studies did have some deficiencies. If we take account of this then the reported 17% reduction in overall neonatal mortality may be an over estimation of effect. When we try to account for this then the estimate of effect is somewhat reduced to 13% RR 0.87 (95% CI: 0.79–0.96) while remaining a significant effect. This fact was referred to by Goldenberg et al6 in their commentary. Again the correspondents point out that further data may be included by assuming no interaction in the trial by Soofi et al4 reporting a factorial design. We have explored this after including these data the direction of effect is not altered and the point estimate for effect is slightly larger (RR 0.82, 95% CI: 0.73–0.92). Finally, the variation in clinical definitions for omphalitis does make pooling results more challenging. Due to differences in the description of omphalitis by the original study authors,2–4 we felt that combining the studies in a meta-analysis was not appropriate and thus we did not give an overall effect on omphalitis as an outcome as a main finding. We hoped that Figure 2 in our original article5 demonstrating significant heterogeneity (I2 of 92%) would illustrate this. Overall, the correspondents have provided useful input to help adjust and explore further the estimates of effect. There remains evidence of effectiveness for 4% chlorhexidine for neonatal cord care, but we would agree that these findings should be used as one part of a broader decision-making process on whether or not to introduce this intervention into routine settings. As further trials in Africa7,8 are under way then additional evidence to inform policy will be welcome. Jamlick Karumbi, B.Pharm Division of Paediatrics Ministry of Medical Services Afya House, Nairobi, Kenya SIRCLE Collaboration KEMRI-Wellcome Trust Research Programme Nairobi, Kenya School of Pharmacy University of Nairobi Nairobi, Kenya Mercy Mulaku, B.Pharm SIRCLE Collaboration KEMRI-Wellcome Trust Research Programme Nairobi, Kenya School of Pharmacy University of Nairobi Nairobi, Kenya Jalemba Aluvaala, MMed Division of Paediatrics Ministry of Medical Services Afya House, Nairobi, Kenya SIRCLE Collaboration KEMRI-Wellcome Trust Research Programme Nairobi, Kenya Department of Paediatrics University of Nairobi Nairobi, Kenya Mike English, PhD SIRCLE Collaboration KEMRI-Wellcome Trust Research Programme Nairobi, Kenya Nuffield Department of Medicine University of Oxford John Radcliffe Hospital Headington, Oxford, United Kingdom Newton Opiyo, MSc SIRCLE Collaboration KEMRI-Wellcome Trust Research Programme Nairobi, Kenya