Impact of umbilical cord cleansing with 4.0% chlorhexidine on time to cord separation among newborns in southern Nepal: a cluster-randomized, community-based trial

Ethnobotanical survey of medicinal plants used by indigenous knowledge holders to manage healthcare needs in children

Childhood diseases remain an increasing health problem in many developing countries and also associated with an enormous financial burden. In South Africa, many people still rely on traditional medicine for their primary healthcare. However, inadequate documentation of medicinal plants used to manage childhood diseases remain a prominent gap. Hence, the current study explored the importance of medicinal plants to treat and manage childhood diseases in the North West Province, South Africa. An ethnobotanical survey was conducted with 101 participants using semi-structured interviews (face-to-face). Ethnobotanical indices such as Frequency of citation (FC), Use-value (UV) and Informed Consensus Factor (ICF) were used for data analysis. A total of 61 plants from 34 families were recorded as medicine used for managing seven (7) categories of diseases resulting from 29 sub-categories. Skin-related and gastro-intestinal diseases were the most prevalent childhood health conditions encountered by the study participants. Based on their FC values that ranged from approximately 0.9-75%, the most popular medicinal plants used by the participants were Aptosinum elongatum (75.2%), Commelina diffusa (45.5%), Euphorbia prostrata (31.6%) and Bulbine frutescens (31.7%). In terms of the UV, A. elongatum (0.75), C. diffusa (0.45), E. prostrata (0.31), H. hemerocallidea (0.19) and E. elephantina (0.19) were the dominant plants used for treating and managing childhood diseases. Based on ICF, skin-related diseases dominated with the highest ICF value of 0.99. This category had 381 use-reports, comprising 34 plants (55.7% of total plants) used for childhood-related diseases. Particularly, B. frutescens and E. elephantina were the most-cited plants for the aforementioned category. Leaves (23%) and roots (23%) were the most frequently used plant parts. Decoctions and maceration were the main preparation methods, and the plant remedies were mainly administered orally (60%) and topically (39%). The current study revealed the continuous dependence on the plant for primary health care relating to childhood diseases in the study area. We generated a valuable inventory of medicinal plants and associated indigenous knowledge for child healthcare needs. However, investigating the biological efficacies, phytochemical profiles and the safety of these identified plants in relevant test systems remain essential in future research.

Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study

BACKGROUND

Umbilical cord hygiene prevents sepsis, a leading cause of neonatal mortality. The World Health Organization recommends 7.1% chlorhexidine digluconate (CHX) application to the umbilicus after home birth in high mortality contexts. In Bangladesh and Nepal, national policies recommend CHX use for all facility births. Population-based household surveys include optional questions on CHX use, but indicator validation studies are lacking. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study assessing measurement validity for maternal and newborn indicators. This paper reports results regarding CHX.

METHODS

The EN-BIRTH study (July 2017-July 2018) included three public hospitals in Bangladesh and Nepal where CHX cord application is routine. Clinical-observers collected tablet-based, time-stamped data regarding cord care during admission to labour and delivery wards as the gold standard to assess accuracy of women's report at exit survey, and of routine-register data. We calculated validity ratios and individual-level validation metrics; analysed coverage, quality and measurement gaps. We conducted qualitative interviews to assess barriers and enablers to routine register-recording.

RESULTS

Umbilical cord care was observed for 12,379 live births. Observer-assessed CHX coverage was very high at 89.3-99.4% in all 3 hospitals, although slightly lower after caesarean births in Azimpur (86.8%), Bangladesh. Exit survey-reported coverage (0.4-45.9%) underestimated the observed coverage with substantial "don't know" responses (55.5-79.4%). Survey-reported validity ratios were all poor (0.01 to 0.38). Register-recorded coverage in the specific column in Bangladesh was underestimated by 0.2% in Kushtia but overestimated by 9.0% in Azimpur. Register-recorded validity ratios were good (0.9 to 1.1) in Bangladesh, and poor (0.8) in Nepal. The non-specific register column in Pokhara, Nepal substantially underestimated coverage (20.7%).

CONCLUSIONS

Exit survey-report highly underestimated observed CHX coverage in all three hospitals. Routine register-recorded coverage was closer to observer-assessed coverage than survey reports in all hospitals, including for caesarean births, and was more accurately captured in hospitals with a specific register column. Inclusion of CHX cord care into registers, and tallied into health management information system platforms, is justified in countries with national policies for facility-based use, but requires implementation research to assess register design and data flow within health information systems.

Umbilical cord medication in healthy full-term newborns: a before-after uncontrolled quality improvement study

Umbilical cord care can be a stressful practice for parents. Complications of cord care can increase neonatal morbidity and mortality. The extracts of Arnica montana (AM) have been reported to possess antibacterial, anti-inflammatory, antifungal, and immunomodulatory activities. We aim to demonstrate the efficacy of AM on cord detachment and parents' stress level induced by cord medication in healthy full-term newborns. We enrolled full-term infants with a birth weight ≥ 2500 g in healthy conditions. Cord stumps of infants in the PRE-group were cleaned and dried, while cord stumps of infants in the POST-group were cleaned, dried, and medicated with a natural topic dermo-protective powder containing AM. After discharge, we interviewed parents on the stump status during follow-up visits in a pediatric office at 7 and 14 days of life, or by phone calls after follow-up visits. Long-rank test showed that time of cord separation of newborns in the PRE-group was significantly higher compared to that in the POST-group (p < 0.001). Parents of newborns in the PRE-group were significantly more stressed during cord medication compared to parents in the POST-group (2.0 (1.2 to 2.1) vs 1.0 (0.8 to 1.3), p = 0.011). Multivariate analysis showed a significantly linear relation with group assignment for cord separation (p < 0.001) and parents' stress during the medication (p = 0.033).Conclusion: The use of a natural topic dermo-protective powder containing AM reduces the time of cord separation, improves parents' stress level, and reduces the risk of complications. What is Known: • Cord stump care can be a stressful practice for parents. • Antiseptic treatment recommended for cord care could be associated with side effects such as burning and sensitization. What is New: • The medication of cord stump with a natural topic dermo-protective powder containing Arnica montana reduces time of cord detachment and of complication such as redness', bleeding, or secretions. • The use of Arnica montana for cord medication may have a positive impact on the family, reducing parents' stress, and the use of other medications.

Application of 4% chlorhexidine to the umbilical cord stump of newborn infants in lower income countries: a systematic review and meta-analysis

Abstract

There are conflicting results from large randomized controlled trials in different populations regarding the effectiveness of topical application of 4% chlorhexidine to the umbilical stump of newborn infants at reducing neonatal mortality. Meta-analysis and systematic review of trials performed in South Asia and Europe support 4% chlorhexidine application to reduce neonatal mortality, whereas trials performed in Sub-Saharan Africa do not. The aim of this review is to determine the effectiveness of 4% chlorhexidine application to the umbilical stump of newborn infants born in lower income countries in order to reduce neonatal mortality when compared with usual cord care.

Our search strategy included randomized trials published between January1^st 2000 and September 4th, 2018, that compared 4% chlorhexidine with usual cord care (“dry cord care”). The outcome variable of interest was neonatal mortality. Pooled relative risks (RR) with 95% confidence intervals (CIs) using a random-effects model were calculated. Nine trials were included, from six countries: Zambia, Tanzania, Bangladesh, Nepal, India and Pakistan, with a total of 257,153 participants. Five studies (N = 119,833) reported neonatal mortality. There was a 21% reduction in neonatal mortality among with 4% chlorhexidine application: pooled RR (95% CI) 0.79 (0.69–0.90), P = 0.0005. The incidence of omphalitis was decreased by 35% with 4% chlorhexidine (6 studies, N = 108,263): pooled RR (95% CI) 0.65 (0.56–0.75), P = 0.00001. Chlorhexidine application delayed the umbilical cord separation time (4 studies, N = 28,917): mean difference (95% CI) 2.71 (2.63–2.78) days.

In conclusion, this systematic review found that topical application of 4% chlorhexidine to the umbilical cord stump of newborn infants in lower income countries significantly reduces the incidence of neonatal mortality. Chlorhexidine also reduces the incidence of omphalitis, but prolongs umbilical cord separation time.

Trial registration

Systematic Review Registration: CRD42018109280.

Trends, determinants, and newborn mortality related to thermal care and umbilical cord care practices in South Asia

BACKGROUND

Although child mortality has decreased over the last several decades, neonatal mortality has declined less substantially. In South Asia, neonatal deaths account for the majority of all under-five deaths, calling for further study on newborn care practices. We assessed five key practices: immediate drying and wrapping, delayed bathing, immediate skin-to-skin contact after birth, cutting the umbilical cord with a clean instrument, and substances placed on the cord.

METHODS

Using data from Demographic and Health Surveys conducted in Bangladesh, India, and Nepal between 2005 and 2016, we examined trends in coverage of key practices and used multivariable logistic regression to analyze predictors of thermal care and hygienic cord care practices and their associations with neonatal mortality among home births. The analysis excluded deaths on the first day of life to ensure that the exposure to newborn care practices would have preceded the outcome. Given limited neonatal mortality events in Bangladesh and Nepal, we pooled data from these countries.

RESULTS

We found that antenatal care and skilled birth attendance was associated with an increase in the odds of infants' receipt of the recommended practices among home births. Hygienic cord care was significantly associated with newborn survival. After controlling for other known predictors of newborn mortality in Bangladesh and Nepal, antiseptic cord care was associated with an 80% reduction in the odds of dying compared with dry cord care. As expected, skilled care during pregnancy and birth was also associated with newborn survival. Missing responses regarding care practices were common for newborns that died, suggesting that recall or report of details surrounding the traumatic event of a loss of a child may be incomplete.

CONCLUSIONS

This study highlights the importance of maternal and newborn care and services for newborn survival in South Asia, particularly antenatal care, skilled birth attendance, and antiseptic cord care.

Dry care versus chlorhexidine cord care for prevention of omphalitis. Systematic review with meta-analysis

Objective:

to compare the effect of dry care and the application of chlorhexidine to the umbilical cord of newborns at risk of developing omphalitis.

Method:

systematic review with meta-analysis. Clinical trials comparing dry care with the application of clorexidine to evaluate omphalitis were selected. Methodological quality was evaluated using the Consolidated Standards of Reporting Trials.

Results:

the joint analysis of the studies shows a significant decrease in the risk of omphalitis in the chlorhexidine group compared to the dry care group (RR=0.58, CI: 0.53-0.64). However, in the analysis by subgroups, chlorhexidine umbilical cord care did not reduce the risk of omphalitis in hospital births (RR=0.82, CI: 0.64-1.05), in countries with a low infant mortality rate (RR=0.8, CI: 0.5-1.28), or at chlorhexidine concentrations below 4% (RR=0.55, CI: 0.31-1). Chlorhexidine acted as a protective factor at a concentration of 4% (RR=0.58, CI: 0.53-0.64), when applied in cases of home births (RR=0.57, CI: 0.51-0.62), in countries with a high infant mortality rate (RR=0.57, CI: 0.52-0.63).

Conclusion:

dry cord care is effective in countries with low infant mortality rate and in hospital births. However, 4% chlorhexidine for umbilical cord care protects against omphalitis in home births, in countries with a high infant mortality rate.

Effectiveness of a campaign to implement chlorhexidine use for newborns in rural Haiti

Background

Chlorhexidine topical cord application is recommended to prevent umbilical cord infections in newborns delivered at home in low-resource settings. A community campaign introducing chlorhexidine for the first time in Haiti was developed. Traditional birth attendants (TBAs) were identified as implementers since they typically cut newborns’ cords. TBAs were trained to apply chlorhexidine to the cord and demonstrate this procedure to the mother. Concurrently TBAs explained reasons for using chlorhexidine exclusively instead of traditional cord care practices. The campaign’s effectiveness was evaluated 7–10 days post-delivery using a survey administered by community health workers (CHWs) to 198 mothers.

Results

Nearly all mothers heard about chlorhexidine use and applied it as instructed. Most mothers did not initially report using traditional cord care practices. With further probing, the majority reported covering the cord but few applied an unhygienic substance. No serious cord infections were reported.

Conclusion

The campaign was highly successful in reaching mothers and achieving chlorhexidine use. In this study, the concomitant use of traditional cloth coverings or bindings of the cord did not appear harmful; however more research is needed in this area. This campaign provides a model for implementing chlorhexidine use, especially where trained TBAs and CHWs are present.

Impact of Chlorhexidine Cord Cleansing on Mortality, Omphalitis and Cord Separation Time Among Facility-Born Babies in Nepal and Bangladesh

Guidance is needed regarding potential extension of the World Health Organization recommendation for cord cleansing with chlorhexidine to babies born in facilities. Among 3223 facility-born babies from Nepal and Bangladesh, mortality was approximately halved among those allocated to the intervention clusters [10.5/1000 vs. 19.4/1000; relative risk (RR): 0.54; 95% confidence interval: 0.30-0.97]. In high-mortality settings, a single policy for home and facility births is warranted.

Umbilical Cord Care and Infection Rates in Turkey

OBJECTIVE

To compare the efficacy of umbilical cord sponging with 70% alcohol, sponging with 10% povidone-iodine, and dry care on the time to umbilical cord separation and bacterial colonization.

DESIGN

Prospective, interventional experimental study design.

SETTING

Three different family health centers in Istanbul, Turkey.

PARTICIPANTS

In total, 194 newborns were enrolled in one of three study groups: Group 1, 70% alcohol (n = 67); Group 2, 10% povidone-iodine (n = 62); and Group 3, dry care (n = 65).

METHODS

Data were collected between January 2015 and July 2015. Umbilical separation time and umbilical cord bacterial colonization were considered as the study outcomes.

RESULTS

The most commonly isolated bacteria were Staphylococcus aureus, Escherichia coli, and enterococci. There was no significant difference among the groups for umbilical cord separation times (p > .05).

CONCLUSION

Dry care may be perceived as an attractive option because of cost benefits and ease of application.

Essential newborn care after home delivery in Nepal

AIMS

Postnatal care of the newborn is essential in order to reduce neonatal mortality. Nepal has made great efforts to improve maternal and child health by focusing on accessibility and outreach over the past decades. This study aims to examine trends, over the past decade, in levels and equity of facility delivery rates and the provision of newborn care after home delivery in Nepal.

METHODS

Household-level data from the Demographic Health Surveys (DHS) 2006 and 2011 and the Multiple Indicator Cluster Survey (MICS5) from 2014 performed in Nepal was sourced for the study. Coverage rates of facility delivery and newborn care after home delivery were calculated and logistic regression models were used to ascertain inequity.

RESULTS

Home delivery rate dropped from 79.2% in 2006 to 46.5% in 2014, a development showing an inequitable distribution, with a larger share of better-off families shifting to facility delivery. For those who still delivered at home there was an increased rate of early initiation of breastfeeding and adequate temperature control, but only 2.2% of women delivering at home received a home visit by a health professional in the first week of delivery. No inequity in receiving newborn care after home delivery could be detected.

CONCLUSIONS

There have been significant improvements in facility delivery rates over the last 10 years in Nepal and postnatal care at home has improved. There is, however, an alarmingly low level of home visits during an infant's first week.

Effectiveness of 4% chlorhexidine umbilical cord care on neonatal mortality in Southern Province, Zambia (ZamCAT): a cluster-randomised controlled trial

BACKGROUND

Chlorhexidine umbilical cord washes reduce neonatal mortality in south Asian populations with high neonatal mortality rates and predominantly home-based deliveries. No data exist for sub-Saharan African populations with lower neonatal mortality rates or mostly facility-based deliveries. We compared the effect of chlorhexidine with dry cord care on neonatal mortality rates in Zambia.

METHODS

We undertook a cluster-randomised controlled trial in Southern Province, Zambia, with 90 health facility-based clusters. We enrolled women who were in their second or third trimester of pregnancy, aged at least 15 years, and who would remain in the catchment area for follow-up of 28 days post-partum. Newborn babies received clean dry cord care (control) or topical application of 10 mL of a 4% chlorhexidine solution once per day until 3 days after cord drop (intervention), according to cluster assignment. We used stratified, restricted randomisation to divide clusters into urban or two rural groups (located <40 km or ≥40 km to referral facility), and randomly assigned clusters (1:1) to use intervention (n=45) or control treatment (n=45). Sites, participants, and field monitors were aware of their study assignment. The primary outcomes were all-cause neonatal mortality within 28 days post-partum and all-cause neonatal mortality within 28 days post-partum among babies who survived the first 24 h of life. Analysis was by intention to treat. Neonatal mortality rate was compared with generalised estimating equations. This study is registered at ClinicalTrials.gov (NCT01241318).

FINDINGS

From Feb 15, 2011, to Jan 30, 2013, we screened 42 356 pregnant women and enrolled 39 679 women (mean 436·2 per cluster [SD 65·3]), who had 37 856 livebirths and 723 stillbirths; 63·8% of deliveries were facility-based. Of livebirths, 18 450 (99·7%) newborn babies in the chlorhexidine group and 19 308 (99·8%) newborn babies in the dry cord care group were followed up to day 28 or death. 16 660 (90·0%) infants in the chlorhexidine group had chlorhexidine applied within 24 h of birth. We found no significant difference in neonatal mortality rate between the chlorhexidine group (15·2 deaths per 1000 livebirths) and the dry cord care group (13·6 deaths per 1000 livebirths; risk ratio [RR] 1·12, 95% CI 0·88-1·44). Eliminating day 0 deaths yielded similar findings (RR 1·12, 95% CI 0·86-1·47).

INTERPRETATION

Despite substantial reductions previously reported in south Asia, chlorhexidine cord applications did not significantly reduce neonatal mortality rates in Zambia. Chlorhexidine cord applications do not seem to provide clear benefits for newborn babies in settings with predominantly facility-based deliveries and lower (<30 deaths per 1000 livebirths) neonatal mortality rates.

FUNDING

Bill & Melinda Gates Foundation.

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

BACKGROUND

Infections 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.

METHODS

Three 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.

RESULTS

At 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.

CONCLUSIONS

Cord 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 REGISTRATION

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov: NCT01528852, Registered February 7, 2012.

Neonatal mortality and topical application of chlorhexidine on umbilical cord stump: a meta-analysis of randomized control trials

OBJECTIVE

To examine the efficacy of topical chlorhexidine as an intervention on neonatal umbilical cord stumps and its association with neonatal mortality and omphalitis.

STUDY DESIGN

Meta-analysis of randomized controlled trials (RCTs).

METHOD

PubMed, EMBASE, CINAHL, IMSEAR, Google Scholar, Cochrane Central Register of Controlled Trials, Cochrane Pregnancy and Childbirth Group's Trials Register and Clinicaltrials.gov were screened until September 1, 2015 to identify RCTs that met the inclusion criteria. Pooled relative risks (RR) with 95% confidence intervals (CI) were calculated.

RESULTS

Five RCTs, conducted in Italy, Bangladesh, Nepal, Pakistan and India with a total of 55,008 participants were identified. Analysis revealed a significant reduction in the incidence of neonatal mortality among the intervention group as compared to the control group (pooled RR = 0.8; 95% CI: 0.6-1.0; P = 0.04; random effects model, I² = 58%; χ² = 9.5; P = 0.05). Additionally, decreased incidence in omphalitis was seen in the intervention group as compared to the control group (pooled RR = 0.4; 95% CI: 0.3-0.7; P < 0.001; random effects model, I² = 50%; χ² = 8.0; P = 0.09).

CONCLUSIONS

Application of chlorhexidine to newborn umbilical cord stumps, significantly reduce the incidences of both neonatal mortality and omphalitis. However, high-quality trials from different regions and obstetric settings may help form more conclusive judgement on universal application of topical chlorhexidine.

Antiseptic use in the neonatal intensive care unit - a dilemma in clinical practice: An evidence based review

Infants in the neonatal intensive care unit are highly susceptible to healthcare associated infections (HAI), with a substantial impact on mortality, morbidity and healthcare costs. Effective skin disinfection with topical antiseptic agents is an important intervention in the prevention or reduction of HAI. A wide array of antiseptic preparations in varying concentrations and combinations has been used in neonatal units worldwide. In this article we have reviewed the current evidence of a preferred antiseptic of choice over other agents for topical skin disinfection in neonates. Chlorhexidine (CHG) appears to be a promising antiseptic agent; however there exists a significant concern regarding the safety of all agents used including CHG especially in preterm and very low birth weight infants. There is substantial evidence to support the use of CHG for umbilical cord cleansing and some evidence to support the use of topical emollients in reducing the mortality in infants born in developing countries. Well-designed large multicentre randomized clinical trials are urgently needed to guide us on the most appropriate and safe antiseptic to use in neonates undergoing intensive care, especially preterm infants.

Umbilical cord cleansing with chlorhexidine in neonates: a systematic review

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the efficacy of chlorhexidine application to the umbilical cord in neonates. We searched MEDLINE and other electronic databases, and included all RCTs that evaluated the effect of single or multiple chlorhexidine cord applications on the neonatal mortality rate (NMR) and/or the incidence of systemic sepsis and omphalitis. A total of six RCTs-four community-based cluster RCTs and two hospital-based trials-were included in the review. Of the four cluster RCTs, three were conducted in South Asia in settings with high rates of home births (>92%) while the fourth, available only as an abstract, was conducted in Africa. Pooled analysis by the 'intention-to-treat' principle showed a significant reduction in NMR after chlorhexidine application (four studies; relative risk (RR) 0.85; 95% confidence interval (CI) 0.76 to 0.95; fixed effects (FE) model). On subgroup analysis, only multiple applications showed a significant effect (four studies; RR 0.88; 95% CI 0.78 to 0.99) whereas a single application did not (one study; RR 0.86; 0.73 to 1.02). Similarly, only the community-based trials showed a significant reduction in NMR (three studies; RR 0.86; 95% CI 0.77 to 0.95), while the hospital-based study did not find any effect (RR 0.11; 0.01 to 2.03). Since all the studies were conducted in high-NMR settings (⩾30 per 1000 live births), we could not determine the effect in settings with low NMRs. Only one study-a hospital-based trial from India-reported the incidence of neonatal sepsis; it did not find a significant reduction in any sepsis (RR 0.67; 95% CI 0.35 to 1.28). Pooled analysis of community-based studies revealed significant reduction in the risk of omphalitis in infants who received the intervention (four studies; RR 0.71; 95% CI 0.62 to 0.81). The hospital-based trial had no instances of omphalitis in either of the two groups. Chlorhexidine application delayed the time to cord separation (four studies; mean difference 2.11 days; 95% CI 2.07 to 2.15; FE model). Chlorhexidine application to the cord reduces the risk of neonatal mortality and omphalitis in infants born at home in high-NMR settings. Routine chlorhexidine application, preferably daily for 7 to 10 days after birth, should therefore be recommended in these infants. Given the paucity of evidence, there is presently no justification for recommending this intervention in infants born in health facilities and/or low-NMR settings.

70% Alcohol Versus Dry Cord Care in the Umbilical Cord Care: A Case-Control Study in Italy

Recently the use of antibacterial agents to clean and dry the stump of the newborns' umbilical cord (UC) after birth has been abandoned by many neonatal units in favor of dry cord care. Aim of this study was to compare the occurrence of adverse events (AEs) and time to cord separation among newborns treated with dry cord care versus 70% alcohol in an Italian Academic Hospital (AH).From December 2014 to March 2015, 239 infants were born at the AH. The number of eligible infants was 200 and they were equally assigned to either case group (dry cord care) or control group (70% alcohol, standard procedure). Standard cord care consisted in 1 application of 70% alcohol at birth followed by other 2 times a day, while experimental dry cord care procedure was executed by the only application of a sterile gauze around the base of the UC at the 1st day of life and after the cord has been exposed to air off the diaper edge. The time to UC separation and any AEs such as local and systemic infections, hemorrhage, and granuloma formation were reported by mothers.We found a significant difference in the mean cord separation time between the 2 groups (dry cord care: 10.1 days [standard deviation, SD = 4.0] vs 70% alcohol: 12.0 days [SD = 4.2]; P < 0.001), while no significant AEs resulted. Incidence rate of granuloma was 0.67 × 1000 days of life in dry cord care group.Dry cord care is an easy, straight-forward, and safe method of handling the UC in healthy newborn infants born in a high-income hospital setting.

Comparing the Impact of Topical Application of Human Milk and Chlorhexidine on Cord Separation Time in Newborns

OBJECTIVES

The best umbilical cord care after birth is a controversial issue. Aim of this research was to compare the effect of topical application of human milk and chlorhexidin on cord separation time in newborns.

METHODS

One hundred seventy four neonates attending from hospitals affiliated to Kashan University of Medical Sciences were included. Newborns from birth were randomized to two groups. In group mother's milk, mother will rub her own milk to cord stump two times a day. chlorhexidin (group 2) were applied to the umbilical stump every 12 hours. The time to umbilical cord separation and any discomfort such as infection, hemorrhage, and discharge and odor were documented. Data was analyzed by SPSS software. Independent Samples t-Test, χ(2), Fisher were used in this study.

RESULTS

Results showed a significant statistical difference between cord separation time in two groups and the mean cord separation time in the human milk group (7.15±2.15days) was shorter than the chlorhexidin group (13.28±6.79 days). In addition, a significant correlation was found between Signs of infection (discharge, redness, swelling and odor) in both groups.

CONCLUSIONS

Topical application of breast milk on umbilical cord care leads to quick cord separation time and can be used as easy, cheep, non injury methods for umbilical cord care.

Umbilical and periumbilical dermatoses

The umbilicus may be the site of congenital and acquired malformations and may harbor clinical clues to the diagnosis of potentially fatal inherited disorders, primary skin conditions, and a variety of infectious diseases. Both benign and malignant tumors may involve the umbilicus, and some are unique to this site. Finally, cutaneous signs localized to this anatomic location may be found in diverse systemic diseases.

Newborn cord care practices in Haiti

Newborn cord infections commonly lead to neonatal sepsis and death, particularly in low-resource countries where newborns may receive unhygienic cord care. Topical application of chlorhexidine to the newborn's cord has been shown to prevent infection. Such benefits may be particularly important in Haiti. We explored current cord care practices by conducting a qualitative study using five focus groups among key community stakeholders (mothers of newborns/children under age two years, pregnant women, traditional birth attendants, community health workers, traditional healers) in Petit-Goâve, Haiti. Data collection was guided by the Health Belief Model. Results suggest community stakeholders recognise that infants are susceptible to cord infection and that cord infection is a serious threat to newborns. Long-held traditional cord care practices are potential barriers to adopting a new cord care intervention. However, all groups acknowledged that traditional practices could be harmful to the newborn while expressing a willingness to adopt practices that would protect the newborn. Results demonstrate potential acceptability for altering traditional cord care practices among neonatal caretakers in Haiti. An informational campaign designed to educate local health workers and new mothers to eliminate unhygienic cord applications while promoting chlorhexidine application may be a strong approach for preventing neonatal cord infections.

Two methods of cord care in high-risk newborns: their effects on hydration, temperature, pH, and floras of the cord area

This randomized clinical study explored the effects of two cord care methods on hydration, temperature, pH, and floras at the cord area in high-risk newborns. One group used the water method; and the other group used the alcohol method. Seventy-two newborns, including premature newborns, in the neonatal intensive care unit (NICU) of a university-affiliated hospital in South Korea were enrolled from August 2011 to May 2012. Hydration, temperature, pH, and floras were measured daily until the cords fell off. The results showed no difference between the groups in hydration, temperature, pH, and the colonization of floras, but cord detachment in the alcohol group took 2 days longer (12.8 [5.7] days) than in the water group (10.9 [4.1] days). Our findings suggest that the clean-and-dry method of cord care, which uses water, could be sufficient, possibly even better than alcohol in maintaining the physiologic surface milieu of the cord area with less chance of infection and manipulation in NICUs with optimal infection control.

Umbilical cord care in Ethiopia and implications for behavioral change: a qualitative study

Background

Infections account for up to a half of neonatal deaths in low income countries. The umbilicus is a common source of infection in such settings. This qualitative study investigates practices and perspectives related to umbilical cord care in Ethiopia.

Methods

In-depth interviews (IDI) were conducted in a district in each of the four most populous regions in the country: Oromia, Amhara, Tigray and Southern Nations, Nationalities and Peoples Region (SNNPR). In each district, one community was purposively selected; and in each study community, IDIs were conducted with 6 mothers, 4 grandmothers, 2 Traditional Birth Attendants and 2 Health Extension Workers (HEWs). The two main questions in the interview guide related to cord care were: How was the umbilical cord cut and tied? Was anything applied to the cord stump immediately after cutting/in the first 7 days? Why was it applied/not applied?

Results

The study elucidates local cord care practices and the rational for these practices. Concepts underlying cord tying practices were how to stem blood flow and facilitate delivery of the placenta. Substances were applied on the cord to moisturize it, facilitate its separation and promote healing. Locally recognized cord problems were delayed healing, bleeding or swelling. Few respondents reported familiarity with redness of the cord - a sign of infection. Grandmothers, TBAs and HEWs were influential regarding cord care.

Conclusions

This study highlights local rationale for cord practices, concerns about cord related problems and recognition of signs of infection. Behavioral change messages aimed at improving cord care including cleansing with CHX should address these local perspectives. It is suggested that HEWs and health facility staff target mothers, grandmothers, TBAs and other community women with messages and counseling.

Local perceptions, cultural beliefs and practices that shape umbilical cord care: a qualitative study in Southern Province, Zambia

Background

Global 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 Findings

This 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.

Conclusion

Umbilical 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.

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

Background

There 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).

Methods

Systematic 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.

Results

There 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.

Conclusions

Application 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.

Sex differences in neonatal mortality in Sarlahi, Nepal: the role of biology and environment

BACKGROUND

Studies in South Asia have documented increased risk of neonatal mortality among girls, despite evidence of a biological survival advantage. Associations between gender preference and mortality are cited as reasons for excess mortality among girls. This has not, however, been tested in statistical models.

METHODS

A secondary analysis of data from a population-based randomised controlled trial of newborn infection prevention conducted in rural southern Nepal was used to estimate sex differences in early and late neonatal mortality, with girls as the reference group. The analysis investigated which underlying biological factors (immutable factors specific to the newborn or his/her mother) and environmental factors (mutable external factors) might explain observed sex differences in mortality.

RESULTS

Neonatal mortality was comparable by sex (Ref=girls; OR 1.06, 95% CI 0.92 to 1.22). When stratified by neonatal period, boys were at 20% (OR 1.20, 95% CI 1.02% to 1.42%) greater risk of early and girls at 43% (OR 0.70, 95% CI 0.51% to 0.94%) greater risk of late neonatal mortality. Biological factors, primarily respiratory depression and unconsciousness at birth, explained excess early neonatal mortality among boys. Increased late neonatal mortality among girls was explained by a three-way environmental interaction between ethnicity, sex and prior sibling composition (categorised as primiparous newborns, infants born to families with prior living boys or boys and girls, and infants born to families with only prior living girls).

CONCLUSIONS

Risk of neonatal mortality inverted between the early and late neonatal periods. Excess risk of early neonatal death among boys was consistent with biological expectations. Excess risk for late neonatal death among girls was not explained by overarching gender preference or preferential care-seeking for boys as hypothesised, but was driven by increased risk among Madeshi girls born to families with only prior girls.

Umbilical cord antiseptics for preventing sepsis and death among newborns

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.

Chlorhexidine cleansing of the umbilical cord and separation time: a cluster-randomized trial

OBJECTIVE

Cord cleansing with chlorhexidine reduces neonatal mortality. We aimed to quantify the impact of this intervention on cord separation time and the implications of such an increase on maternal and other caretaker's acceptance of chlorhexidine in future scaled up programs.

METHODS

Between June 2007 and September 2009, 29,760 newborns were randomly assigned within communities in Bangladesh to receive 1 of 3 cord regimens: dry and clean cord care (comparison), single-cleansing, or multiple-cleansing with 4.0% chlorhexidine. Workers recorded separation status during home visits. Mothers of 380 infants in randomly selected clusters reported age at separation and satisfaction with cord regimen.

RESULTS

Compared with dry and clean care (mean 4.78 days), separation time was longer in the single (mean 6.90 days, difference = 2.10; 95% confidence interval: 1.85-2.35) and multiple (mean 7.49 days, difference = 2.69; 95% confidence interval: 2.44-2.95) cleansing groups. Increased separation time was not associated with omphalitis. Mothers in these groups more frequently reported "longer than usual" separation times and dissatisfaction with the separation time (11.1% and 17.6%, respectively) versus the comparison group (2.5%). Overall satisfaction with the received cord care regimen was high (96.2%).

CONCLUSIONS

Topical chlorhexidine increased cord separation time by ∼50%. Caretakers are likely to detect this increase and might express dissatisfaction but still accept the intervention overall. When scaling up chlorhexidine cord cleansing, inclusion of appropriate messaging on expectation and nonrisks of increased cord separation time, in addition to the benefits of reduced infection and improved survival, might improve compliance.

Topical umbilical cord care for prevention of infection and neonatal mortality

Umbilical cord care varies often reflecting community or health-worker beliefs. We undertook a review of current evidence on topical umbilical cord care. Study quality was assessed using the Grading of Recommendations, Assessment, Development and Evaluation system, and a meta-analysis was conducted for comparable trials. Available moderate-quality to high-quality evidence indicate that cord cleansing with 4% chlorhexidine may reduce the risk of neonatal mortality and sepsis (omphalitis) in low-resource settings.

Improving hygiene in home deliveries in rural Ghana: how to build on current attitudes and practices

INTRODUCTION

Clean delivery of newborns is a key intervention for reducing infection-related neonatal mortality. Understanding local practices and beliefs is important for designing appropriate interventions. There are few data from Africa. This study explored delivery practices in Ghana to identify behaviors for intervention and to determine behavioral influencers.

METHODS

Data on the prevalence of clean delivery behaviors, collected through a demographic surveillance system, were analyzed for 2631 women who delivered at home within a 1-year period. Qualitative data on delivery practices were collected through birth narratives, in-depth interviews, and focus groups with recently delivered/pregnant women, traditional birth attendants, grandmothers, and husbands.

RESULTS

Most women delivered on a covered surface (79%), had birth attendants who washed their hands (79%), cut the cord with a new blade (98%), and tied it with a new thread (90%). Eight percent of families practiced dry cord care. Families understood the importance of a clean delivery surface and many birth attendants knew the importance of hand-washing. Delivering on an uncovered surface was linked to impromptu deliveries and a belief that a swept floor is clean. Not washing hands was linked to rushing to help the woman, not being provided with soap, forgetfulness, and a belief among some that the babies are born dirty. The frequent application of products to the cord was nearly universal and respondents believed that applying nothing to the cord would have serious negative consequences.

CONCLUSIONS

Delivery surfaces, hand-washing, and cord cutting and tying appear appropriate for the majority of women. Changing cord care practices is likely to be difficult unless replacement products are provided.

Evaluation of cluster-randomized trials on maternal and child health research in developing countries

OBJECTIVE

To summarize and evaluate all publications including cluster-randomized trials used for maternal and child health research in developing countries during the last 10 years.

METHODS

All cluster-randomized trials published between 1998 and 2008 were reviewed, and those that met our criteria for inclusion were evaluated further. The criteria for inclusion were that the trial should have been conducted in maternal and child health care in a developing country and that the conclusions should have been made on an individual level. Methods of accounting for clustering in design and analysis were evaluated in the eligible trials.

RESULTS

Thirty-five eligible trials were identified. The majority of them were conducted in Asia, used community as randomization unit, and had less than 10,000 participants. To minimize confounding, 23 of the 35 trials had stratified, blocked, or paired the clusters before they were randomized, while 17 had adjusted for confounding in the analysis. Ten of the 35 trials did not account for clustering in sample size calculations, and seven did not account for the cluster-randomized design in the analysis. The number of cluster-randomized trials increased over time, and the trials generally improved in quality.

CONCLUSIONS

Shortcomings exist in the sample-size calculations and in the analysis of cluster-randomized trials conducted during maternal and child health research in developing countries. Even though there has been improvement over time, further progress in the way that researchers utilize and analyse cluster-randomized trials in this field is needed.

Newborn umbilical cord and skin care in Sylhet District, Bangladesh: implications for the promotion of umbilical cord cleansing with topical chlorhexidine

Newborn cord care practices may directly contribute to infections, which account for a large proportion of the four million annual global neonatal deaths. This formative research study assessed current umbilical and skin care knowledge and practices for neonates in Sylhet District, Bangladesh, in preparation for a cluster-randomized trial of the impact of topical chlorhexidine cord cleansing on neonatal mortality and omphalitis. Unstructured interviews (n=60), structured observations (n=20), rating and ranking exercises (n=40) and household surveys (n=400) were conducted to elicit specific behaviors regarding newborn cord and skin care practices. These included hand-washing, skin and cord care at the time of birth, persons engaged in cord care, cord cutting practices, topical applications to the cord at the time of birth, wrapping/dressing of the cord stump and use of skin-to-skin care. Overall 90% of deliveries occurred at home. The umbilical cord was almost always (98%) cut after delivery of the placenta, and cut by mothers in more than half the cases (57%). Substances were commonly (52%) applied to the stump after cord cutting; turmeric was the most common application (83%). Umbilical stump care revolved around bathing, skin massage with mustard oil and heat massage on the umbilical stump. Overall 40% of newborns were bathed on the day of birth. Mothers were the principal provider for skin and cord care during the neonatal period and 9% of them reported umbilical infections in their infants. Unhygienic cord care practices are prevalent in the study area. Efforts to promote hand-washing, cord cutting with clean instruments and avoiding unclean home applications to the cord may reduce exposure and improve neonatal outcomes. Such efforts should broadly target a range of caregivers, including mothers and other female household members.

Verbal autopsy methods to ascertain birth asphyxia deaths in a community-based setting in southern Nepal

OBJECTIVES

The goals of this study were to (1) develop an approach to ascertain birth asphyxia deaths by using verbal autopsy data from a community-based setting in Nepal, and (2) explore variations in birth asphyxia mortality fractions by using different birth asphyxia case definitions and hierarchical classifications.

PATIENTS AND METHODS

Data were prospectively collected during a cluster-randomized, community-based trial of health interventions on neonatal mortality in Sarlahi, Nepal from 2002 to 2006. To assign cause of death, 4 computer-assigned, symptom-based asphyxia case definitions; Nepali physician classification; and our independent review of verbal autopsy open narratives were used. Various hierarchical classification approaches to assign cause of death were also explored.

RESULTS

Birth asphyxia specific mortality ranged from 26% to 54%, depending on the computer case definition used. There was poor agreement between computer and physician classification of birth asphyxia. By comparing computer results, physician results, and our independent ascertainment of cause of death, we identified 246 cases of birth asphyxia (32% of neonatal deaths). Allowing for >1 cause of death, 30% and 42% of asphyxia cases also met criteria for prematurity and serious infection, respectively. When a hierarchy was used to assign a single cause of death, the birth asphyxia proportionate mortality was reduced to 12% when identification of deaths because of congenital anomalies, prematurity, and serious infections preceded birth asphyxia.

CONCLUSIONS

The use of various verbal autopsy definitions and hierarchical approaches to assign cause of death may substantially affect estimates of birth asphyxia-specific mortality and analyses of risk factors. Verbal autopsy methods need to be standardized and validated to generate accurate global estimates to direct policy and resource allocation in low-middle-income countries.