Antiseptic Reduces Umbilical Cord Infection and Neonatal Mortality

Tinker Ready

February 08, 2012

February 7, 2012 — The use of a topical antiseptic to clean the umbilical cords of newborns and infants significantly reduces neonatal mortality, according to findings from 2 large studies conducted in Pakistan and Bangladesh and published online February 8 in the Lancet.

The results confirm earlier research into the efficacy of an approach to care that promises to get at a major cause of neonatal death, although David Osrin, MBBCh, PhD, and Zelee Elizabeth Hill, PhD, from the University College London Institute for Global Health in the United Kingdom, said in an accompanying comment that the approach needs to be duplicated in the context of government health services.

However, they add that the new studies offer evidence to act on and ask, "[I]f the need is clear, the possibilities attractive, and the risk low, how much evidence is necessary before we act on plausible findings?"

More than 3 million infants die worldwide each year, with infections causing about one third of all neonatal deaths, according to the researchers. Although cord stumps can be a source of infection, most research on cord care has been done in high-income countries.

In the first of the Lancet articles, Sajid Soofi, FCPS, from the Division of Women and Child Health, Aga Khan University, Karachi, Pakistan, compared the use of antiseptics, hand washing, and dry cord care (in which the cord stump is allowed to dry without any treatment).

Working in a rural area of the Sindh province in Pakistan, the researchers randomly assigned clusters of traditional birth attendants, or TBAs, to 1 of 4 groups. One group used a "birth kit" containing the antiseptic chlorhexidine (CHX), which was applied to the umbilical cord by a TBA at delivery, and family caregivers were advised to apply the antiseptic daily for 2 weeks. The families also received soap and education about hand washing. In the second treatment group, CHX was used, but no hand-washing education was provided, and in the third group, the families were educated about hand washing, but CHX was not used. The control group used World Health Organization–recommended dry cord care. The outcomes were neonatal omphalitis and neonatal mortality.

A total of 9741 newborn babies were delivered by participating TBAs, with a reduction in risk for infection with CHX application (risk ratio, 0.58; 95% confidence interval [CI], 0.41 - 0.82; P = .002), but no reduction was seen with hand washing (risk ratio, 0.83; 95% CI, 0.61 - 1.13; P = .24). Neonatal mortality also declined for those who received CHX cleansing (risk ratio, 0.62; 95 % CI, 0.45 - 0.85; P = .003), but again, hand-washing promotion had no effect on neonatal mortality. (risk ratio, 1.08; 95% CI, 0.79 - 1.48; P = .62).

The researchers concluded that "these findings have substantial implications for public health in south Asia, where many areas share similar cultural, social, and economic characteristics."

The second study, conducted in Sylhet, Bangladesh, by Shams El Arifeen, DrPH, from the International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh, and colleagues compared education on dry cord care with 2 different approaches: a 1-time use of CHX immediately after birth and a postbirth application followed by daily application for 1 week.

Surprisingly, that study found that risk for neonatal death was lower in the single-application group than it was in the dry cord care group (relative risk, 0.80; 95% CI, 0.65 - 0.98), but not in the multiple-application group (relative risk, 0.94; 95% CI, 0.78 - 1.14).

Questions remain about whether using CHX would be as effective in communities in which family members perform most deliveries, according to the accompanying comment. The approach has also not been tested in areas "where governments are reluctant to engage with traditional birth attendants," according to the comment authors. Still, the commentators agree that the studies produced "encouraging reductions in neonatal mortality” and "improve the knowledge base."

The Bangladesh study was funded by the United States Agency for International Development through cooperative agreements with the Johns Hopkins Bloomberg School of Public Health, and by the Saving Newborn Lives program of Save the Children (USA) through a grant from the Bill & Melinda Gates Foundation. The Pakistani study was supported by the Pakistan Initiative for Mothers and Newborns and John Snow Inc, via a grant from by the US Agency for International Development. The authors and commentators have disclosed no relevant financial relationships.

Lancet. Published online February 8, 2012. Article abstract, Comment summary

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