How is omphalitis prevented?

Updated: May 20, 2019
  • Author: Patrick G Gallagher, MD; Chief Editor: Santina A Zanelli, MD  more...
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Answer

The World Health Organization (WHO) recommends dry cord care after institutional delivery or after home delivery in locales where neonatal mortality rates are low primarily because there have not been strong studies supporting routine application of topical antiseptic agents. [8, 50] These recommendations for dry cord care in developed countries are supported by large, systematic reviews. [51, 52, 53, 54]

A Cochrane review of 12 trials showed that information regarding the effects of chlorhexidine applied to the umbilical cords of newborns in hospital settings on neonatal mortality is not clear. [53] Two trials had moderate-quality evidence that chlorhexidine cord cleansing reduced the risk of omphalitis/infections compared with dry cord care. Another two trials had low-quality evidence that no difference exists for omphalitis/infections between groups receiving chlorhexidine skin cleansing and dry cord care. However, there was high-quality evidence that chlorhexidine skin or cord care in the community setting led to a 50% reduction in the incidence of omphalitis and a 12% reduction in neonatal mortality. [53] No difference was noted for neonatal mortality or the risk of infections in hospital settings for maternal vaginal chlorhexidine use compared to usual care.

Dry cord care may not be appropriate in certain populations. Because there is increased risk of omphalitis and other serious neonatal infections when delivery occurs in a nonhygienic environment and neonatal mortality is high, application of a topic antiseptic agent to the cord may be indicated. The WHO recommends topical application of chlorhexidine to the umbilical cord stump during the first week of life for neonates born at home where hygienic conditions are poor or neonatal mortality is high (>30 deaths per live births). [8]

Several trials comparing dry cord care to chlorhexidine application have been completed in a variety of settings. [55, 56, 57] In addition, there have been several meta-analyses and/or Cochrane reviews analyzing studies of topical cord care. [51, 52, 53, 55, 58, 59, 60, 61] The interpretations of the results of these trials in aggregate have been controversial, with conclusions on a spectrum from chlorhexidine should be applied universally to no changes to the WHO guidelines are indicated. [62, 63, 64] These various interpretations may be due to a number of factors, including comparisons of different study groups in locales with varying rates of neonatal sepsis, varying end points for the studies, and variation in control groups. However, overall, the recommendations for topical antisepsis cord care in locales where hygienic conditions are poor or neonatal mortality is high are supported by these systematic reviews, [58, 59] noting this intervention significantly reduced the incidence of omphalitis as well as overall neonatal mortality. [56, 60, 61] Optimal dosing strategies for chlorhexidine application are unknown. [58]

In 2016, the American Academy of Pediatrics Committee on Fetus and Newborn guidelines updated their guidelines for umbilical cord care in the newborn. [9] The conclusions of this report were essentially the same as those of the WHO. Application of antimicrobial agents to the cord is appropriate in resource poor settings where the risk of omphalitis and its complications are high, whereas the benefit in high-resource settings is unclear. These guidelines also emphasize the importance of parental education regarding signs and symptoms of omphalitis.

Dry cord care leads to earlier separation of the cord after birth. It also leads to reports of wetter, odoriferous cords (described by some parents as "nasty," "smelly," or "yucky") and higher colonization rates with S aureus and other bacteria (sometimes dramatically so). Whether this increased colonization rate is, or will be, associated with higher rates of omphalitis or other neonatal infection is controversial. Some studies have suggested that higher colonization rates are associated with increased infection, whereas others have not.


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