Benefits and Risks of Cleansing Agents
Topical cleansing agents have been used for neonatal baths and umbilical cord care. Table 1 provides a comparison of cleansing agents and usage recommendations. It is imperative to remember that topical use does not guarantee safety, as demonstrated by the widespread use and associated toxicity of hexachlorophane baths in the 1950s and 1960s. Other than systemic absorption and toxicity, risks of topical antimicrobials range from local irritation, chemical burns, sensitization and allergic contact dermatitis, and accidental ingestion and poisoning.
The dangers of percutaneous absorption in children are well documented. There have been numerous reports describing toxic side effects from systemic absorption of topically applied agents in infants.[23,30] Although the structure of the epidermal barrier in full-term infants is mature, its thickness is 40 to 60% less than that found in an adult, some risk for percutaneous toxicity still remains. Several unique pediatric features help to explain this, such as the increased ratio of skin surface area to body weight; immature hepatic and renal function, which impairs drug metabolism and excretion; and decreased plasma protein binding that allows toxicity at lower drug doses.[4,2830]
Immature epidermal barriers as seen in preterm infants place them at even greater risk for percutaneous toxicity. The skin barrier function of infants of 25 weeks' gestation and less may take 4 to 8 weeks to mature. This delay in skin maturation also increases the risk for secondary problems such as opportunistic infection, mechanical fragility, and absorption of topical agents.[4,23,28] A conservative approach is mandated due to the increased permeability of neonatal skin. The use of topical preparations should be limited to only essential compounds and washing them off should further minimize exposure as soon as their purpose has been accomplished. Observation of the umbilical area may be more appropriate than cleaning.
Isopropyl alcohol (alcohol) is widely used for cord care. It usually evaporates before it is absorbed by normal skin. Cases of acute alcohol toxicity in infants up to 21 days old have been reported after generous applications of alcohol to the umbilical stump and one case where the parents placed a dressing of alcohol under an occlusive barrier (occlusion) over the umbilical stump. Toxicities from alcohol absorption include hemorrhagic skin necrosis, dysfunction of the central nervous system, metabolic acidosis, and hypoglycemia. Physicians and nurse practitioners should limit or avoid the use of alcohol for cord care if possible despite its comfortable familiarity.[29,30]
In one study of an alcohol cord care regimen, umbilical cord cultures showed a dramatic increase in bacterial colonization almost immediately after a perinatal unit initiated the new alcohol cord care regimen. Approximately 6 months after implementation of the new alcohol cord care regimen, physicians in the community, who were unaware of the change in hospital practices, reported an increase in the number of infant skin infections. All cases cultured positive for Staphylococcus aureus .
Povidone-iodine (Betadine) is another common topical antimicrobial used for umbilical cord care. When absorbed in significant amounts, this agent has increased serum iodine levels enough to stimulate neonatal hypothyroidism. Disturbance of thyroid function can be associated with intraventricular hemorrhage, cognitive abnormalities, growth and motor retardation, and death. Studies indicate that preterm and low-birth-weight infants are at greatest risk for significant iodine absorption. Some dispute the significant risks of these events in the United States, because this phenomenon occurs primarily in countries with relative iodine deficiency. If iodinated compounds are used, application should be brief, followed by a thorough rinsing, and never under occlusion.
Topical antibacterial agents such as Bacitracin (Pharmaraia & Upjohn Company, Kalamazoo, MI), neomycin, gentamicin, and silver sulfadiazine (Silvadene) are also used to treat the umbilical stump. Safety depends on avoidance of systemic absorption, local irritation and tissue destruction, and hypersensitivity. Toxicities from topical antimicrobials include allergic contact dermatitis, anaphylaxis (rare), and neural deafness (rare). Emergence of bacterial resistance has also been seen with topical use of antibiotics that are used systemically. Therefore it is recommended to avoid their use if possible. It has also been documented that antimicrobial ointment exposure can sensitize the skin to allergic reactions later in life.
Hexachlorophane (pHisohex®, GlaxoSmithKlein, Research Triangle Park, NC) and chlorhexidine (Hibiscrub® or Hibiclens®, 3 Com, Marlborough, MA) are broad-spectrum antimicrobials against gram-positive and -negative bacteria, and some yeast. Due to past problems with hexachlorophane, chlorhexidine was introduced as an effective and safe alternative. Now it is accepted that hexachlorophane is safe when properly used and has been reintroduced. Both agents are generally safe when used appropriately as topical preparations without occlusion on term infants. Some local reactions and systemic absorption has been noted in preterm infants. If alcohol is used as a vehicle for either of these agents, its toxicities should be considered as well.
Triple dye, an agent bactericidal to both gram-positive and -negative bacteria, contains three ingredients: brilliant green, crystal violet, and proflavine hemisulfate. It was widely used in the 1950s until the popularity of hexachlorophane baths. In 1971, when hexachlorophene baths were not recommended, triple dye was reappraised. Since the early 1970s, triple dye has been used commonly for umbilical cord care. Toxicity of triple dye is rare. It can cause skin necrosis if it is inadvertently applied to the skin surrounding the umbilical stump. Prolonged use of gentian violet in adults may also cause nausea, vomiting, diarrhea, and mucosal ulceration. It is reasonable to surmise that prolonged use of triple dye could cause the same adverse effects in neonates. When applying to the cord, inadvertent applications or leakage onto the abdominal wall should be avoided if possible and washed off if necessary.
Many studies have compared topical antimicrobial treatments of the umbilical stump. Table 2 provides an overview of recent studies regarding umbilical cord care and Table 3 provides an overview of the substantiated evidence and the fittedness and feasibility of these recent studies. In several studies, triple dye was found to be significantly better than castile soap, hexachlorophane (pHisoHex®, GlaxoSmithKlein, Triangle Park, NC), alcohol, povidone iodine, silver sulfanazine (Silvadene), and Bacitracin® (Pharmaraia & Upjohn Company, Kalamazoo, MI) in reducing cord colonization.[17,18,21,24] These studies were different from the 1957 study of triple dye because they limited triple dye application to one-time application instead of daily application. It should be noted that some studies dispute the efficacy of triple dye on gram-negative bacteria.
Although it is unclear which antimicrobial is the most beneficial for cord care treatment, many researchers recommend their use as a result of their studies. Others argue that the role of decreasing bacterial colonization has an uncertain relationship with the development of infection. If topical antimicrobials are going to be used in the prophylactic treatment of infection in newborns, it is important to realize the potential for adverse local and systemic reactions.
NAINR. 2004;4(4):211-222. © 2004 W.B. Saunders
Cite this: Trends in Umbilical Cord Care: Scientific Evidence for Practice - Medscape - Dec 01, 2004.