Evaluation of risk factors of omphalitis in newborn beef calves with indoor housing

BACKGROUND

Omphalitis is the third most common cause for diseases and infections in newborn calves. Its risk factors are well described in dairy production, but data in beef production is limited.

OBJECTIVE

To identify and quantify the risk factors of omphalitis in cow-calf operations with seasonal indoor calving period.

ANIMALS

Nine hundred sixty-four calves included from 22 cow-calf operations in central France were included.

METHODS

A prospective cohort study involved data collection during two visits for each calf. Simple and multivariable logistic regression analyses evaluated the association between omphalitis and the variables.

RESULTS

Among 964 included calves, 311 (32.3%) calves had an omphalitis. Accounting for farms' random effect, risk factors for omphalitis highlighted by the univariable analysis were: absence of navel disinfection (odds ratio (OR) = 2.3, [1.45-3.04]), wetness of bedding calving area (OR = 1.8-2.1, [0.78-2.83]-[0.63-3.57]), cleanliness of calves' pen (OR =1.6-2.8, [1.22-2.27]-[2.02-3.84]), wetness of calves' pen bedding (OR = 1.7-3.2, [1.12-2.06]-[3.08-3.84]), calf weight at birth >50 kg (OR = 2.0-5.0, [1.02-2.38]-[1.51-11.1]), umbilical cord length <3 cm (OR = 2.2-2.3, [1.53-3.11]-[1.24-4.38]), and sex (male vs female) (OR = 2.6, [2.08-3.69]). The multivariable analysis, accounting for farms' random effect, showed that the absence of navel disinfection (OR= 2.2, [1.44-3.09]), wetness of bedding calving area (OR = 1.9-2.4, [0.55-2.83]-[0.59-3.28]), calf weight at birth >50 kg (OR = 1.9-2.6, [1.03-2.56]-[1.43-12.5]) and sex (male vs female) (OR =2.4, [2.09-3.49]) were risk factors for omphalitis.

CONCLUSIONS AND CLINICAL IMPORTANCE

These observations may help identify animals at early risk (>50 kg, male, short umbilical cord) and pay particular attention to the wetness of bedding and cleanliness of housing. This study highlights the importance of calving-pen bedding, calf characteristics and navel disinfection.

Failure of Passive Immunity Transfer Is Not a Risk Factor for Omphalitis in Beef Calves

Omphalitis is the third most frequent disease in newborn calves after neonatal diarrhea and bovine respiratory disease (BRD), but limited data on the prevalence and risk factors are available in the literature. Failure of passive immunity transfer (FPIT) is recognized as a major risk factor for diseases and mortality in calves. However, the association between omphalitis and FPIT remains poorly described. To assess this association, 964 suckler beef calves from 22 farms were included in a longitudinal cohort study for 5 months. Each calf was examined twice (mean ages: 4.4 and 11.1 days old) to diagnose omphalitis through clinical examination and ultrasonographic evaluation (USE) if necessary. Measurements of the total solids percentage (TS-%Brix) and total protein (TP) were performed on the serum during the first visit to evaluate the calves' passive immunity status. FPIT (fair and poor) was defined as serum %Brix < 8.1 or TP < 5.1 g/dL; among calves with omphalitis, 14% had FPIT and among calves without omphalitis 12% had FPIT. The omphalitis prevalence was 32.3% in calves without any other disease (overall prevalence of 30.9%). No statistical association between the prevalence of omphalitis and FPIT was observed. Further research is needed to identify the risk factors and promote the prevention measures for omphalitis in cow-calf systems, such as calving difficulty, hygiene of housing, and navel disinfection.

Quantitative assessment of umbilical cord care practices amongst mothers in Jos, Plateau State, Nigeria

Introduction

A newly cut neonatal umbilical stump is a potential portal of pathogen entry leading to omphalitis. Neonatal sepsis can complicate omphalitis, but good cord care practices can reduce this risk.

Objective

The objective of this study was to assess umbilical cord care practices in tertiary-, secondary- and primary-level healthcare facilities in Jos, Nigeria.

Methods

A multi-centre, cross-sectional study of 284 mothers of infants aged 3-6 weeks old attending immunisation clinics in the three-level healthcare facilities using multistage sampling technique between April and September 2019. Data were analysed using SPSS version 23.0. Pearson's Chi-squared test was used to compare categorical variables. Adjusted odds ratios (AORs) and 95% confidence interval (CI) were used as point and interval estimates, respectively. P < 0.05 was adjudged to be statistically significant.

Results

The mean age of the mothers and infants was 25 ± 6 years and 5 ± 1 week, respectively. Only 2.2% of mothers used chlorhexidine (CHX) gel for cord care. Mothers showed good knowledge but poor practice of cord care. A significant positive relationship was observed between quality of cord care practices and level of healthcare facility (χ2 = 15.213; df = 2; P < 0.001). Good cord care practices were predicted by mothers' age 30-46 (AOR = 3.6; CI: 1.4-9.1) and good knowledge of cord care (AOR = 4.7; 95% CI: 2.2-9.9).

Conclusions

The study has highlighted the good knowledge but poor practices of cord care by mothers and the need to scale up the uptake of CHX gel in Jos. Mother's age and good knowledge of cord care are predictors of good cord care practices.

Umbilical Cord Stump Infections in Central Uganda: Incidence, Bacteriological Profile, and Risk Factors

Umbilical cord stump infection (omphalitis) is a risk factor for neonatal sepsis and death. We assessed the incidence of omphalitis, described the bacteriological and antibiotic-resistance profile of potentially pathogenic bacteria isolated from the umbilical cord stump of omphalitis cases, and evaluated whether bacteria present in the birth canal during birth predicted omphalitis. We enrolled 769 neonates at birth at three primary healthcare facilities and followed them for 28 days with scheduled visits on days 3, 7, 14, and 28. Cox regression models were used to estimate the rates of omphalitis associated with potential risk factors. Sixty-five (8.5%) neonates developed omphalitis, with an estimated incidence of 0.095 cases per 28 child-days (95% CI 0.073, 0.12). Potentially pathogenic bacteria were isolated from the cord stump area of 41 (63.1%) of the 65 neonates with omphalitis, and the most commonly isolated species were Escherichia coli (n = 18), Klebsiella pneumoniae (n = 10), Citrobacter freundii (n = 5), and Enterobacter spp. (n = 4). The Enterobacteriaceace isolates were resistant to gentamicin (10.5%, 4/38), ampicillin (86.8%, 33/38), and ceftriaxone (13.2%, 5/38). Delayed initiation of breastfeeding was associated with an increased risk of omphalitis (aHR 3.1; 95% CI 1.3, 7.3); however, vaginal colonization with potentially pathogenic bacteria did not predict omphalitis.

Evaluating the effectiveness of a single application of 7% iodine tincture umbilical dip as a prevention of infection of the external umbilical structures in dairy calves

The objective of this randomized clinical trial was to evaluate the effectiveness of a single application of 7% iodine tincture-based umbilical dip for preventing infection of the external umbilical structures in dairy calves. Five dairy farms in southern Ontario were visited twice weekly from September 2020 through June 2021. Female (n = 244) and male (n = 40) Holstein calves were randomly assigned at birth to receive either a 7% iodine tincture-based umbilical dip (n = 140) or no treatment (n = 144). Calves in the 7% iodine tincture umbilical dip group had the product administered once by the producer shortly after birth. For each newborn calf, the experimental group, calving difficulty, volume and timing of colostrum administration, time of birth, calving pen cleanliness, and the dam ID were recorded. Calf body weight was recorded during the first visit after birth, and a blood sample was collected for measurement of serum IgG concentration. Calves were health scored twice weekly from enrollment until approximately 30 d of age for assessment of external umbilical infection, joint inflammation, respiratory disease, and diarrhea. The primary outcome of the study was external umbilical infection, which was defined as an enlarged umbilicus with pain, heat, or a malodorous discharge. Calves were also weighed at 30 and 60 d to determine average daily gain. Serum IgG concentration and birth weight did not differ significantly between groups. Twenty-nine calves (20%) in the umbilical dip group developed an external umbilical infections, compared with 31 calves (22%) in the control group. A mixed logistic regression model, accounting for farm as a random effect, showed no effect of treatment on the incidence of an external umbilical infection. However, for every additional hour that calves received colostrum after birth, the odds of developing an external umbilical infection increased during the first month of life (odds ratio = 1.15; 95% confidence interval: 1.04-1.26). Additionally, treatment had no effect on respiratory disease, joint inflammation, diarrhea, average daily gain, or mortality, compared with the untreated control. These findings suggest that administering a single application of 7% iodine tincture dip to the umbilicus around the time of birth may not be effective for preventing external umbilical infections. Farm-level management factors, including colostrum management, appear to have more influence on risk of this disease.

Cost and consequences of using 7.1 % chlorhexidine gel for newborn umbilical cord care in Kenya

Background

Omphalitis is an important contributor to neonatal mortality in Kenya. Chlorhexidine digluconate 7.1 % w/w (CHX; equivalent to 4 % w/w chlorhexidine) was identified as a life-saving commodity for newborn cord care by the United Nations and is included on World Health Organization and Kenyan Essential Medicines Lists. This pilot study assessed the potential resource savings and breakeven price of implementing CHX for neonatal umbilical cord care versus dry cord care (DCC) in Kenya.

Methods

We employed a cost-consequence model in a Kenyan birth cohort. Firstly, the number of omphalitis cases and cases avoided by healthcare sector were estimated. Incidence rates and treatment effect inputs were calculated from a Cochrane meta-analysis of randomised clinical trials (RCTs) (base case) and 2 other RCTs. Economic outcomes associated with omphalitis cases avoided were determined, including direct, indirect and total cost of care associated with omphalitis, resource use (outpatient visits and bed days) and societal impact (caregiver workdays lost). Costs and other inputs were sourced from literature and supplemented by expert clinical opinion/informed inputs, making necessary assumptions.

Results

The model estimated that, over 1 year, ~ 23,000 omphalitis cases per 500,000 births could be avoided through CHX application versus DCC, circumventing ~ 13,000 outpatient visits, ~ 43,000 bed days and preserving ~ 114,000 workdays. CHX was associated with annual direct cost savings of ~ 590,000 US dollars (USD) versus DCC (not including drug-acquisition cost), increasing to ~ 2.5 million USD after including indirect costs (productivity, notional salary loss). The most-influential model parameter was relative risk of omphalitis with CHX versus DCC. Breakeven analysis identified a budget-neutral price for CHX use of 1.18 USD/course when accounting for direct cost savings only, and 5.43 USD/course when including indirect cost savings. The estimated breakeven price was robust to parameter input changes. DCC does not necessarily represent standard of care in Kenya; other, potentially harmful, approaches may be used, meaning cost savings may be understated.

Conclusions

Estimated healthcare cost savings and potential health benefits provide compelling evidence to implement CHX for umbilical cord care in Kenya. We encourage comprehensive data collection to make future models and estimates of impacts of upscaling CHX use more robust.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06971-7.

Methylated spirit versus chlorhexidine gel: A randomized non-inferiority trial for prevention of neonatal umbilical cord infection in Jos, North-Central Nigeria

Background

Omphalitis is an important cause of neonatal sepsis (NNS) and mortality. Quantitative estimates of risk of omphalitis-related neonatal death is about 10%-19%. Topical applications of antiseptics have been shown to reduce this risk burden but has not been well investigated.

Aim

To demonstrate non-inferiority of methylated spirit to chlorhexidine (CHX) gel for prevention of omphalitis, NNS and mortality at day 28.

Methods

This was a randomized, non-inferiority trial of methylated spirit versus CHX gel with 161 and 162 mother-baby pairs, respectively, conducted between July 2017 and May 2018. SPSS version 23.0 was used for data analysis to examine for incidence of omphalitis, time-to-cord separation, NNS and mortality. Relative risk and 95% confidence interval were used as point and interval estimates, respectively, with a non-inferiority margin of 10% set for CHX gel while a P values <0.05 was statistically significant.

Results

The median age of newborns was 18 h; (IQR: 8-24) h with the risk of omphalitis being 2% higher with CHX gel compared to methylated spirit (RR = 1.020; 95% CI; 0.988-1.053; P = 0.053). The median times-to-cord separation were 7.0 days (IQR: 2-17) and 7.0 days (IQR: 2-18) for methylated spirit and CHX gel, respectively (mean difference: ‒0.2145; 95% CI = ‒0.9085-0.4759; P = 0.544). There was no difference in the risks of NNS and mortality among those treated with methylated spirit compared to those exposed to CHX gel (RR: 1.0; 95% CI = 0.984-1.017; P = 1.000) and (RR: 1.0; 95% CI = 0.994-1.018; P = 0.986) respectively.

Conclusions

There is no evidence that 96% methylated spirit is inferior to 4% CHX gel in preventing neonatal omphalitis; hence, it may be considered a safe and effective alternative where CHX gel is unavailable.

Prevalence of disorders in preweaned dairy calves from 731 dairies in Germany: A cross-sectional study

The objective of this cross-sectional study was to determine the prevalence of disorders in preweaned calves in 3 regions in Germany, exemplary for structural diversity in dairy farming. A farm visit was performed on a single occasion on 731 dairy farms in the northern, eastern, and southern regions of Germany between December 2016 and July 2019. Farms differed in herd size, geographical location, and management. In the northern region, the farms had a median of 90 milking cows and were often run as full-time family businesses, partly with external workers. The eastern region tended to have larger farms (a median of 251 milking cows), which were often large-scale agricultural enterprises with employees. In the southern region, the farms had a median of 39 milking cows and were often traditional family businesses, some of these being part-time businesses. Clinical examinations were performed on 14,164 preweaned dairy calves (median 12 calves per farm) by trained veterinarians. A complete data set was available for 13,656 calves. Almost half (42.0%) of the evaluated calves were classified as being affected by at least 1 of the common calf disorders. Omphalitis (O, 20.9%; n = 2,876) and diarrhea (D, 18.5%; n = 2,670) were the most frequently recorded diagnoses, whereas respiratory diseases (RD) were observed to a lesser extent (8.7%; n = 1,100). A striking feature was the fact that 7.1% (n = 987) of the calves were affected by more than 1 disorder at the same time (multimorbidity, M). The following combinations of disorders were frequently observed: O and D (n = 596), O and RD (n = 164), and D and RD (n = 140). Disorders such as O and D, as well as M, were predominantly observed in calves aged 2 wk. A gradual increase in the frequency of RD was observed with age. For all disorders except RD, male calves were more often affected than females. Omphalitis was predominantly diagnosed in the summer months, whereas RD, D, and M were more common in the fall. We detected several statistically significant differences in the prevalence of clinical signs and disorders in preweaned dairy calves between the 3 exemplary regions. The prevalence of RD was higher in the south (10.8%) than in the north (8.2%) and east (7.4%). In the north (33.2%), O was observed more frequently than in the other regions (east: 18.9%; south: 10.5%), whereas D was found less frequently in the north (13.8%) than in the east (21.6%) and south (20.0%).

Investigation of haptoglobin, serum amyloid A, and some biochemical parameters in calves with omphalitis

Aim:

In this study, it was aimed to determine the concentration of some important acute phase proteins (APPs) and some biochemical parameters pre-operative and post-operative in calves with omphalitis.

Materials and Methods:

A total of 20 calves were used in the study and they consist of 10 clinically healthy calves that were used as a control and 10 calves with omphalitis were used as the treatment group. Blood samples were collected from Vena jugularis of animals to tubes with anticoagulant (sodium citrate) and without anticoagulants, pre-operative (day 0), and post-operative (day 7). Samples were used to determine the concentration of haptoglobin (Hp), serum amyloid A (SAA), ceruloplasmin (Cp), fibrinogen, glucose, total protein, albumin, urea, total bilirubin, creatinine, calcium, phosphorus, aspartate aminotransferase (AST), alkaline phosphatase (ALP), and gamma-glutamyl transferase (GGT) concentrations.

Results:

While the Hp, SAA, Cp, fibrinogen, urea, creatinine, total bilirubin, ALP, and GGT concentrations were statistically and significantly increasing rather than the control group during the pre-operative period for calves with omphalitis, they decreased to the post-operative period. Moreover, an insignificant increase in the glucose, total protein, and AST concentrations and an insignificant decrease in the albumin, calcium, and phosphorus concentrations were statistically determined.

Conclusion:

We have the opinion that the assessment of biochemical parameters and especially APP levels in calves with the omphalitis together with the clinical findings may be important in terms of the treatment and prognosis.

Can community health workers identify omphalitis? A validation study from Southern Province, Zambia

OBJECTIVE

Omphalitis, or umbilical cord infection, is an important cause of newborn morbidity and mortality in low-resource settings. We tested an algorithm that task-shifts omphalitis diagnosis to community-level workers in sub-Saharan Africa.

METHODS

Community-based field monitors and Zambian paediatricians independently evaluated newborns presenting to health facilities in Southern Zambia using a signs and symptoms checklist. Responses were compared against the paediatrician's gold standard clinical diagnosis.

RESULTS

Of 1009 newborns enrolled, 6.2% presented with omphalitis per the gold standard clinical diagnosis. Paediatricians' signs and symptoms with the highest sensitivity were presence of pus (79.4%), redness at the base (50.8%) and newborn flinching when cord was palpated (33.3%). The field monitor's signs and symptoms answers had low correlation with paediatrician's answers; all signs and symptoms assessed had sensitivity <16%.

CONCLUSION

Despite extensive training, field monitors could not consistently identify signs and symptoms associated with omphalitis in the sub-Saharan African setting.

Umbilicus and its extensive clinical repertoire

The umbilicus is involved in a wide range of abnormalities in infants and children. The most severe are evident at birth and include exomphalos (omphalocele) and gastroschisis, both of which can be life-threatening but are easy to diagnose. Exomphalos is often associated with other congenital abnormalities, whereas the associated problems in gastroschisis are largely confined to the gut. Infection of the umbilicus in the neonate presents as omphalitis. The causes of a moist umbilicus following separation of the umbilical stump are multiple, from the relatively minor umbilical granuloma or ectopic bowel mucosa to the more significant patent urachus that leaks urine. Patency of the entire vitello-intestinal (omphalomesenteric) tract allows air and faecal fluid to drain through the umbilicus. The clinical manifestations of persistence of the vitello-intestinal tract vary markedly according to which part remains: clinical presentations include melaena and anaemia, closed-loop bowel obstruction and Meckel diverticulitis. An umbilical hernia occurs when the umbilical cicatrix fails to close. On the other hand, the umbilicus has its uses, which range from being a route for intravenous access in the neonate to being a convenient point of access in laparoscopic surgery.

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.

Advances in pharmacotherapeutic management of common skin diseases in neonates and infants

INTRODUCTION

neonatal and infantile skin diseases are frequently encountered in the clinical practice and represent worldwide a socioeconomic issue. They encompass a wide range of acquired or congenital conditions, including infections, vascular lesions and inflammatory diseases and can present with different degrees of severity, leading in some cases to dramatic complications. Areas covered: In this paper we report the most recent evidences on the management of some common skin diseases in neonates and infants. Hemangiomas, viral, fungal and bacterial infections, omphalitis, atopic and seborrhoeic dermatitis, napkin disease will be treated and discussed. Expert opinion: The majority of the dermatologic alterations in neonates are physiological, transient and do not require any treatment, thus the parents can be reassured about the good prognosis. However, in some cases, serious conditions must be excluded. In particular neonatal and infantile infections should be promptly recognized and properly managed, to avoid severe complications. The therapeutic options include traditional and, although few, innovative medical treatments, which will be carefully taken into consideration by the expert Dermatologists and Paediatricians.

MANAGEMENT OF A PATENT URACHUS AND YOLK COELOMITIS IN A PREHENSILE-TAILED SKINK (CORUCIA ZEBRATA)

An 11-day-old, captive-born, male prehensile-tailed skink (Corucia zebrata) was evaluated for a chronically swollen umbilicus. On presentation, the skink appeared dehydrated and weak. The umbilical stump was sensitive, edematous, and erythematous. Yellow fluid was readily expressed during palpation of the surrounding area, suggestive of urine. Following several days of supportive care, a positive contrast cloacagram supported the diagnosis of a patent urachus. An exploratory celiotomy was performed, confirming yolk coelomitis and a patent urachus. Both were corrected surgically, and the skink improved steadily thereafter. This report confirms the presence of a urinary bladder in C. zebrata and is the first report of a patent urachus in a reptile. Surgical intervention and medical management of concurrent infectious coelomitis were curative in this case.

Unusual neonatal presentation of type I leukocyte adhesion deficiency

Leukocyte adhesion deficiency type I is an extremely serious and rare form of congenital immunodeficiency with recurrent episodes of infection since neonatal period. It is usually diagnosed in childhood, but if diagnosed early in neonatal period then definitive treatment can be instituted early with promising results. High index of suspicion is necessary to diagnose this condition in neonates. Neonate may present with serious bacterial infections with a leukemoid reaction.

Imaging diagnosis-aortic aneurysm and ureteral obstruction secondary to umbilical artery abscessation in a 5-week-old foal

A 5-week-old foal was evaluated for fever and hematuria of 3 days duration. Cystoscopy localized the blood to be originating from the left ureter. Abdominal ultrasonography revealed left hydronephrosis, hydroureter, and omphaloarteritis of the left umbilical artery with abscess formation that communicated with an arterial structure. Computed tomography (CT) revealed a large aortic aneurysm within the center of the abscess. An exploratory celiotomy was performed and the infection was nonresectable. The prognosis for life was grave; therefore the colt was euthanized. Necropsy findings confirmed the antemortem diagnosis. Ultrasound and CT imaging in this case provided an accurate antemortem diagnosis.

Risk of mortality subsequent to umbilical cord infection among newborns of southern Nepal: cord infection and mortality

BACKGROUND

Neonatal sepsis may stem from local umbilical cord infections. Signs of cord infection are common in low-resource settings, yet the risk of mortality subsequent to these signs has not been quantified in either developed or developing countries. We compared the risk of mortality between infants with and without signs of umbilical cord infection during a community-based trial of chlorhexidine interventions in southern Nepal.

METHODS

Newborns were evaluated for signs of umbilical cord infection (pus, redness, swelling). A nested case-control approach was used to estimate the odds of mortality between infants with and without umbilical cord infection as defined by various levels of severity. For each death in the parent trial, 10 controls were selected, matched on sex, treatment group, and number of cord assessments. The main outcome measures were all-cause and sepsis-specific mortality.

RESULTS

Among 23,246 assessed infants, there were 392 deaths. Odds of all-cause mortality were 46% (8-98%) higher among infants with redness extending onto the abdominal skin. A nonsignificant increased odds of mortality [odds ratio (OR): 2.31; 95% confidence interval (CI): 0.66-8.10] was observed among infants with severe redness and pus. Infections occurring after the third day of life were associated with subsequent risk of all-cause (OR: 3.11; 95% CI: 1.68-5.74) and sepsis-specific (OR: 4.63; 95% CI: 2.15-9.96) mortality.

CONCLUSIONS

This study provides evidence that common local signs of cord infection are associated with increased risk of mortality. Where exposure of the umbilical cord to potentially invasive pathogens is high, interventions to increase hygienic care of the cord should be promoted and including hand washing, avoiding harmful topical applications, and topical cord antisepsis.

Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries

Affordable, efficacious, and safe interventions to prevent infections and improve neonatal survival in low-resource settings are needed. Chlorhexidine is a broad-spectrum antiseptic that has been used extensively for many decades in hospital and other clinical settings. It has also been given as maternal vaginal lavage, full-body newborn skin cleansing, and/or umbilical cord cleansing to prevent infection in neonates. Recent evidence suggests that these chlorhexidine interventions may have significant public health impact on the burden of neonatal infection and mortality in developing countries. This review examines the available data from randomized and nonrandomized studies of chlorhexidine cleansing, with a primary focus on potential uses in low-resource settings. Safety issues related to chlorhexidine use in newborns are reviewed, and future research priorities for chlorhexidine interventions for neonatal health in developing countries are discussed. We conclude that maternal vaginal cleansing combined with newborn skin cleansing could reduce neonatal infections and mortality in hospitals of sub-Saharan Africa, but the individual impact of these interventions must be determined, particularly in community settings. There is evidence for a protective benefit of newborn skin and umbilical cord cleansing with chlorhexidine in the community in south Asia. Effectiveness trials in that region are required to address the feasibility of community-based delivery methods such as incorporating these interventions into clean birth kits or training programs for minimally skilled delivery assistants or family members. Efficacy trials for all chlorhexidine interventions are needed in low-resource settings in Africa, and the benefit of maternal vaginal cleansing beyond that provided by newborn skin cleansing needs to be determined.

Development of clinical sign based algorithms for community based assessment of omphalitis

BACKGROUND

In developing countries, newborn omphalitis contributes significantly to morbidity and mortality. Community based identification and management of omphalitis will require standardised clinical sign based definitions.

OBJECTIVE

To identify optimal sign based algorithms to define omphalitis in the community and to evaluate the reliability and validity of cord assessments by non-specialist health workers for clinical signs of omphalitis.

DESIGN

Within a trial of the impact of topical antiseptics on umbilical cord infection in rural Nepal, digital images of the umbilical cord were collected. Workers responsible for in-home examinations of the umbilical cord evaluated the images for signs of infection (pus, redness, swelling). Intraworker and interworker agreement was evaluated, and sensitivity and specificity compared with a physician generated gold standard ranking were estimated.

RESULTS

Sensitivity and specificity of worker evaluations were high for pus (90% and 96% respectively) and moderate for redness (57% and 95% respectively). Swelling was the least reliably identified sign. Measures of observer agreement were similar to that previously recorded between experts evaluating subjective skin conditions. A composite definition for omphalitis that combined pus and redness without regard to swelling was the most sensitive and specific.

CONCLUSIONS

Two sign based algorithms for defining omphalitis are recommended for use in the community. Focusing on redness extending to the skin around the base of the stump will identify cases of moderate and high severity. Requiring both the presence of pus and redness will result in a definition with very high specificity and moderate to high sensitivity.

Role of antimicrobial applications to the umbilical cord in neonates to prevent bacterial colonization and infection: a review of the evidence

In developing countries umbilical cord infections constitute a major cause of neonatal morbidity and pose significant risk for mortality, whereas outbreaks of cord infections continue to occur in developed country nurseries. Cord infections in developing countries can be prevented through increasing access to tetanus toxoid immunization during pregnancy, promoting clean cord care and reducing harmful cord applications and behaviors. Interventions introduced in both developed and developing countries to reduce exposure of the cord to infectious pathogens include clean cord cutting, hand-washing before and after handling the baby, bathing of the infant with antimicrobial agents and application of antimicrobials to the cord. Despite the importance of umbilical cord care, both traditionally and medically, there have been few randomized trials investigating the impact of different cord care regimens on rates of local or systemic infections, particularly in developing countries. This review examines available data on umbilical cord care, with a particular focus on those comparing rates of bacterial colonization and/or rates of cord infection among neonates receiving different umbilical cord care regimens. Although most investigators agree that topical antimicrobials reduce bacterial colonization of the cord, a firm relationship between colonization and infection has not been established. Further research in developed countries, including follow-up beyond hospital discharge, is required before advising on "best cord care practices." The paucity of published reports from developing countries indicates the need to investigate the impact of antimicrobial applications on cord and systemic infections in a community-based, prospective manner.