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Meta-Analysis
. 2013 May 31;2013(5):CD008635.
doi: 10.1002/14651858.CD008635.pub2.

Umbilical cord antiseptics for preventing sepsis and death among newborns

Aamer Imdad  1 , Resti Ma M Bautista, Kathlynne Anne A Senen, Ma Esterlita V Uy, Jacinto Blas Mantaring 3rd, Zulfiqar A Bhutta
Affiliations
Meta-Analysis

Umbilical cord antiseptics for preventing sepsis and death among newborns

Aamer Imdad et al. Cochrane Database Syst Rev. .

Abstract

Background: The umbilical cord is a structure made of blood vessels and connective tissue that connects the baby and placenta in utero. The umbilical cord is cut after birth, which separates the mother and her baby both physically and symbolically. Omphalitis is defined as infection of the umbilical cord stump. Tracking of bacteria along the umbilical vessels may lead to septicaemia that can result in neonatal morbidity and mortality, especially in developing countries.

Objectives: To determine the effect of application of antimicrobials on newborn's umbilical cord versus routine care for prevention of morbidity and mortality in hospital and community settings.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 October 2012). In addition, we also searched LILACS (1982 to 11 October 2012) and HERDIN NeON (October 2012)

Selection criteria: We included randomized, cluster-randomized and quasi-randomized controlled trials of topical cord care compared with no topical care, and comparisons between different forms of care.

Data collection and analysis: Two review authors independently assessed trials for inclusion, trial quality and subsequently extracted data. Data were checked for accuracy.

Main results: The search identified 77 trials. We included 34 trials in the review involving 69,338 babies, five studies are awaiting classification and there are two ongoing community trials. Included studies were conducted in both developed and developing countries. Among the 34 included trials, three were large, cluster-randomized trials conducted in community settings in developing countries and 31 studies were conducted in hospital settings mostly in developed countries. Data for community and hospital studies were analyzed separately. The three trials conducted in community settings contributed 78% of the total number of children included in this review. Of the trials conducted in hospital settings, the majority had small sample sizes. There were 22 different interventions studied across the included trials and the most commonly studied antiseptics were 70% alcohol, triple dye and chlorhexidine.Only one antiseptic, chlorhexidine was studied in community settings for umbilical cord care. Three community trials reported data on all-cause mortality that comprised 1325 deaths in 54,624 participants and combined results showed a reduction of 23% (average risk ratio (RR) 0.77, 95% confidence interval (CI) 0.63 to 0.94, random-effects, T² = 0.02, I² = 50%) in the chlorhexidine group compared with control. The reduction in omphalitis ranged from 27% to 56% depending on the severity of infection. Cord separation time was increased by 1.7 days in the chlorhexidine group compared with dry cord care (mean difference (MD) 1.75 days, 95% CI 0.44 to 3.05, random-effects, T² = 0.88, I² = 100%). Washing of umbilical cord with soap and water was not advantageous compared with dry cord care in community settings.Among studies conducted in hospital settings, no study reported data for mortality or tetanus. No antiseptic was advantageous to reduce the incidence of omphalitis compared with dry cord care in hospital settings. Topical triple dye application reduced bacterial colonization with Staphylococcus aureus compared with dry cord care (average RR 0.15, 95% CI 0.10 to 0.22, four studies, n = 1319, random-effects, T² = 0.04, I² = 24%) or alcohol application (average RR 0.45, 95% CI 0.25 to 0.80, two studies, n = 487, random-effects, T² = 0.00, I² = 0%). There was no advantage of application of alcohol and triple dye for reduction of colonization with streptococcus. Topical alcohol application was advantageous in reduction of colonization with Enterococcus coli compared with dry cord care (average RR 0.73, 95% CI 0.58 to 0.92, two studies, n = 432, random-effects, T² = 0.00, I² = 0%) and in a separate analysis, triple dye increased the risk of colonization compared with alcohol (RR 3.44, 95% CI 2.10 to 5.64, one study, n = 373). Cord separation time was significantly increased with topical application of alcohol (MD 1.76 days, 95% CI 0.03 to 3.48, nine studies, n = 2921, random-effects, T² = 6.54, I² = 97%) and triple dye (MD 4.10 days, 95% CI 3.07 to 5.13, one study, n = 372) compared with dry cord care in hospital settings. The number of studies was insufficient to make any inference about the efficacy of other antiseptics.

Authors' conclusions: There is significant evidence to suggest that topical application of chlorhexidine to umbilical cord reduces neonatal mortality and omphalitis in community and primary care settings in developing countries. It may increase cord separation time however, there is no evidence that it increases risk of subsequent morbidity or infection.There is insufficient evidence to support the application of an antiseptic to umbilical cord in hospital settings compared with dry cord care in developed countries.

PubMed Disclaimer

Conflict of interest statement

Aamer Imdad and Zulfiqar Ahmed Bhutta were authors for study Soofi 2012. Data for Soofi 2012 were not extracted by these two authors.

Figures

1
1
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 1 All‐cause mortality.
1.2
1.2. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 2 Omphalitis: Algorithm 1: Redness extending to skin.
1.3
1.3. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 3 Omphalitis: Algorithm 2: Redness with pus or severe redness.
1.4
1.4. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 4 Omphalitis: Algorithm 3: severe redness with pus.
1.5
1.5. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 5 Bacterial colonization: Staphyococcus aureus.
1.6
1.6. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 6 Bacterial colonization: E.coli.
1.7
1.7. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 7 Bacterial colonization: Streptococcus.
1.8
1.8. Analysis
Comparison 1 Antispetics vs dry cord care/placebo. Studies conducted in community settings, Outcome 8 Cord separation time (days).
2.1
2.1. Analysis
Comparison 2 Antiseptics vs dry cord care/placebo. Studies conducted in hospital settings, Outcome 1 Omphalitis.
2.2
2.2. Analysis
Comparison 2 Antiseptics vs dry cord care/placebo. Studies conducted in hospital settings, Outcome 2 Bacterial colonization: Staphylococcus aureus.
2.3
2.3. Analysis
Comparison 2 Antiseptics vs dry cord care/placebo. Studies conducted in hospital settings, Outcome 3 Bacterial colonization: Streptococcus.
2.4
2.4. Analysis
Comparison 2 Antiseptics vs dry cord care/placebo. Studies conducted in hospital settings, Outcome 4 Bacterial colonization: E. coli.
2.5
2.5. Analysis
Comparison 2 Antiseptics vs dry cord care/placebo. Studies conducted in hospital settings, Outcome 5 Parental satisfaction.
2.6
2.6. Analysis
Comparison 2 Antiseptics vs dry cord care/placebo. Studies conducted in hospital settings, Outcome 6 Time to cord separation (days).
3.1
3.1. Analysis
Comparison 3 Antiseptic vs antibiotic. Studies conducted in hospital settings, Outcome 1 Bacterial colonization: Staphylococcus aureus.
3.2
3.2. Analysis
Comparison 3 Antiseptic vs antibiotic. Studies conducted in hospital settings, Outcome 2 Time to cord separation (days).
4.1
4.1. Analysis
Comparison 4 Antiseptic vs antiseptic. Studies conducted in hospital settings, Outcome 1 Sepsis.
4.2
4.2. Analysis
Comparison 4 Antiseptic vs antiseptic. Studies conducted in hospital settings, Outcome 2 Omphalitis.
4.3
4.3. Analysis
Comparison 4 Antiseptic vs antiseptic. Studies conducted in hospital settings, Outcome 3 Bacterial colonization: Staphylococcus aureus.
4.4
4.4. Analysis
Comparison 4 Antiseptic vs antiseptic. Studies conducted in hospital settings, Outcome 4 Bacterial colonization: Streptococcus.
4.5
4.5. Analysis
Comparison 4 Antiseptic vs antiseptic. Studies conducted in hospital settings, Outcome 5 Bacterial colonization: E. coli.
4.6
4.6. Analysis
Comparison 4 Antiseptic vs antiseptic. Studies conducted in hospital settings, Outcome 6 Time to cord separation (days).
5.1
5.1. Analysis
Comparison 5 Single vs multiple application. Studies conducted in community settings, Outcome 1 All‐cause mortality.
5.2
5.2. Analysis
Comparison 5 Single vs multiple application. Studies conducted in community settings, Outcome 2 Omphalitis: Algorithem 1.
5.3
5.3. Analysis
Comparison 5 Single vs multiple application. Studies conducted in community settings, Outcome 3 Omphalitis: Algorithem 2.
5.4
5.4. Analysis
Comparison 5 Single vs multiple application. Studies conducted in community settings, Outcome 4 Omphalitis: Algorithem 3.
5.5
5.5. Analysis
Comparison 5 Single vs multiple application. Studies conducted in community settings, Outcome 5 Bacterial colonization: Staphylococcus aureus.
5.6
5.6. Analysis
Comparison 5 Single vs multiple application. Studies conducted in community settings, Outcome 6 Bacterial colonization: Streptococcus.
5.7
5.7. Analysis
Comparison 5 Single vs multiple application. Studies conducted in community settings, Outcome 7 Bacterial colonization: E. coli.
6.1
6.1. Analysis
Comparison 6 Single vs multiple application. Studies conducted in hospital settings, Outcome 1 Cord separation time (days).
7.1
7.1. Analysis
Comparison 7 Washing cord vs dry cord care. Studies conducted in community settings, Outcome 1 All‐cause mortality.
7.2
7.2. Analysis
Comparison 7 Washing cord vs dry cord care. Studies conducted in community settings, Outcome 2 Omphalitis: Algorithem 1.
7.3
7.3. Analysis
Comparison 7 Washing cord vs dry cord care. Studies conducted in community settings, Outcome 3 Omphalitis: Algorithem 2.
7.4
7.4. Analysis
Comparison 7 Washing cord vs dry cord care. Studies conducted in community settings, Outcome 4 Omphalitis: Algorithem 3.
7.5
7.5. Analysis
Comparison 7 Washing cord vs dry cord care. Studies conducted in community settings, Outcome 5 Cord separation time (days).
8.1
8.1. Analysis
Comparison 8 Washing cord vs dry cord care. Studies conducted in hospital settings, Outcome 1 Bacterial colonization: Staphylococcus aureus.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD008635

References

References to studies included in this review

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References to studies awaiting assessment

Covas 2011 {published data only}
    1. Covas MC, Alda ER, Medina MS, Ventura S, Esandi ME, Pezutti O, et al. Alcohol versus bath and natural drying for term newborns' umbilical cord care: a prospective randomized clinical trial. Pediatric Academic Societies Annual Meeting; 2010 May 1‐4; Vancouver, Canada. 2010. - PubMed
    1. Covas Mdel C, Alda E, Medina MS, Ventura S, Pezutti O, Paris de Baeza A, et al. Alcohol versus bath and natural drying for term newborns' umbilical cord care: A prospective randomized clinical trial [Spanish]. Archivos Argentinos de Pediatria 2011;109(4):305‐13. - PubMed
Nasrallah 2003 {published data only}
    1. Nasrallah BK, Rox AK, Mazer B, Richards L, Chuachingco J, Naqvi M. Comparison of two methods of umbilical cord care: application of 70% isopropyl alcohol vs. natural drying. Pediatric Academic Societies Annual Meeting; 2003 May 1‐4; Seattle Washington, USA. 2003.
Sellares Casas 2002 {published data only}
    1. Sellares Casas E, Yanez Juan A, Lopez de Aguileta Ibisate A, Peix Sambola MA, Esteva Nuto N, Domenech Terricabras P. Efficacy of one versus three applications of merbromin in achieving umbilical cord detachment [Spanish] [Efficacia de una aplicacion frente a tres de merbromina en el tiempo de caida del cordon]. Acta Pediatrica Espanola 2002;60(9):521‐5.
Srinivasan 2003 {published data only}
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Taffazoli 2008 {published data only}
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References to ongoing studies

Hamer 2010 {published data only}
    1. Hamer DH. Zambia Chlorhexidine Application Trial (ZamCAT). Clinicaltrials.gov (http://clinicaltrials.gov) (accessed 2010) 2010.
    1. Herlihy JM, Semrau K, Mazimba A, Yeboah‐Antwi K, Grogan C, Banda B, et al. Chlorhexidine 4% umbilical wash lengthens time to cord separation. Pediatric Academic Societies Annual Meeting 2012 April 29‐May 1; Boston, USA. 2012.
Sazawal 2012 {published data only}
    1. Sazawal S. Chlorhexidine cordcare for reduction in neonatal mortality and omphalitis (CHX‐Pemba). ClinicalTrials.gov 2012.

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References to other published versions of this review

Zupan 2004
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