Cord Care: to Treat or Not

A Comparison Review
By Katy Raymond, RN Antoinette Wyman, MSN Ed, RNC

Omphalitis: Umbilical Cord Infection Definition

Infection of the umbilicus and/or surrounding tissues. Predominately a disease of neonates

Symptoms associated with infection:

Characterized by purulent discharge from umbilical stump Including surrounding induration, erythema, tenderness Umbilical stump bleeding may occur as a result of delayed obliteration of umbilical vessels

Pediatrics: To dye or not to dye: a randomized clinical trial of a triple dye/alcohol regime versus dry cord care.
Triple dye is: Comprised of substances known as brilliant green, proflavine, hemisulphate, and crystal violet in an aqueous solution. It is considered a bactericidal treatment. Has been reported to have toxic effects in animal studies May be carcinogenic

The study objective was to compare the outcomes of antibacterial agents versus dry cord care in the newborn
Random assignment of 766 newborns to two groups. Grp #1. Two applications of triple dye to cord stump on day of birth, alcohol swab twice daily until cord fell off Grp#2. Dry care consisted of spot cleaning soiled skin in peri-umbilical area with soap and water, wiping dry with cotton swab or cloth, allowing air dry. Umbilicus on all subjects were swabbed and cultured. Results: One infant in dry care group was diagnosed with omphalitis - Reported normal CBC and blood culture - Colonized with a-hemolytic streptococcus, coagulasenegative staphylococcus

JOGNN: Alcohol versus natural drying for newborn cord care

Study comprised of two groups looked at umbilical cord care 1) separation time and 2) infection rates.

When concern over nursery infection was high, in the 1950s, the practice of swabbing umbilical cord stump with alcohol was adopted. It was believed that the stump would fall off faster with the use of alcohol No evidence has supported this belief

Colonization:

Various cord care practices have been evaluated for their ability to decrease colonization. Colonization rates with the assumed risk of infection were used to support cord care interventions. Researchers challenged this association between colonization and infection Review colonization with Staph aureus and infection in newborns a) 4% of newborns with colonization versus b) 7% without colonization developed omphalitis. No clinical manifestations of infection at any site were noted in 90% of newborns with colonization. No clinical manifestations of infections at any sites were noted in 85% of newborns without manifestations.

Cord Separation Time:

Colonization is not an indication of infection

Statistically significant difference in cord separation time in natural drying group versus the group using topical cord care treatments Natural drying time group shorter by 1.7 days Mean separation time was 8.16 days

Infection:

No newborn in either group was identified with a cord infection Normal healing in a small number of newborns does create a mucky appearance The mucky appearance was not associated with infection Awareness that nursery colonization does not lead to clinical illness has taken the focus of prevention of colonization to prevention of infection While some physicians and parent were concerned if the cord appeared mucky or smelly this appearance did not equate to infection

Up to date: Care of the umbilicus and management of umbilical disorders

Meta-analysis of 10 studies compared dry cord care to a number of different topical agents. Triple dye, alcohol, silver sulfadiazine, and chlorhexidine were compared to dry cord care regimes No difference of death or omphalitis between dry cord care and any agents Bacterial colonization by staph aureus was reduced with the use of triple dye, silver sulfadiazine and chlorhexidine. Mild exudates and odor from the umbilical stump in the absence of inflammatory signs should be considered normal Umbilical cord care is dependant on the quality of care at delivery and post natally.

AWHONN: Neonatal Skin Care Evidence-Based Clinical Practice Guideline

Immediate Care of Umbilical Stump:

Cleanse the cord and surrounding skin Use tap water to remove debris Dry thoroughly with clean gauze Leave umbilical area and clamped cord stump clean, dry and uncovered Implement universal precautions while caring for umbilical stump before initial bath

Clinical Guidelines con't

Ongoing Care Use natural drying for cord care Keep the cord area clean, dry without use of topical agents Maintain aseptic technique to minimize contamination Wash hands before cord care Keep stump exposed to air and loosely covered Keep diaper folded down If stump becomes soiled with urine or stool, cleanse area with water After cleansing dry thoroughly with clean absorbent gauze to remove excess moisture. - One study reported that infants receiving dry cord care may have more exudate and odor as compared with infants treated with topical agents and higher colonization rates but no increase in infections. (Janssen et al., 2003: I)

Discourage the use of topical agents

The use of antimicrobial agents is not supported by current literature.

Isopropyl Alcohol - prolongs cord separation time and does not decrease bacterial colonization or infection rates. Providone-iodine - when absorbed through the skin can cause alteration in thyroid function in premature and term newborns Topical antibacterial agents - is increased due to the developmental immaturity if neonatal skin and can be associated with allergic contact dermatitis.

Clinical Practice Guideline continued

Triple Dye:
Can cause skin necrosis if inadvertently applied to skin surrounding umbilical stump Triple dye cords had the longest separation time when compare with dry cord care and alcohol treated cords. Infants receiving initial cord care with triple dye followed by alcohol had a longer time to cord separation than infants who received only alcohol applied to the cord.

Clinical Guidelines con't

Differentiate Normal Cord Healing

Normal healing may produce a "mucky appearance" This appearance has not been associated with infection Bacteria stimulating effect and wound healing has long been recognized All wound are colonized, but not all wounds are infected Bacteria are believed to initiate the inflammatory (first stage) of wound healing Small amounts of cloudy mucoid material collected at necrotic stump and surrounding skin should not be misinterpreted as pus.

Conditions that place the newborn at risk: - nonvaccinated mother - non sterile delivery conditions - unusual cord care practices

Southeast Michigan Health Institution Cord Care Policies

Institution Providence Beaumont St. John St. Joseph (AnnArbor) Henry Ford McLaren Genesys Hurley Medical Hutzel Sinai-Grace Oakwood System Crittenton Sparrow Botsford Foote Health System U of M Ann Arbor + + + + + + Alcohol once daily Keep stump dry and clean Natural drying greater than five years Evidence base practice guidelines/AWHONN/NANN + + + + + + + In process of changing to AWHONN guidelines Progressed from triple dye to natural dry Alcohol use with cord contamination Hoping to change soon + + Triple Dye Alcohol Natural Drying Comment Antibiotic ointment at birth and discharge

References:
Dore, S., Buchan, D., Coulas, S., Hanber, L., Stewart, M., Cowan, D., et. al. (1998). Alcohol versus natural drying for newborn cord care. JOGNN, 27, 621-627. Janssen, Patricia A. MPH. PhD, Selwood, Barbara L., BSN. MSc., Dobson, Simon R., MD FRCPC, Peacock, Donlim, MD. ChB. FRCPC, Thiessen, Paul N., MD FRCPC. Dye or not to dye: A randomized, clinical trial of a triple dye/alcohol regine versus dry cord care, Pediatrics, Vol:111 No. 1 January 2003. pp.15-20

Palazzi, D. MD., Brandt, M.MD. (2008) Care of the umbilicus in management of umbilical disorders. Up to date, Wayne State University. Retrieved on 2/24/08 from www.uptodate.com