|Year : 2018 | Volume
| Issue : 1 | Page : 25-30
Effect of topical application of human breast milk versus 4% chlorhexidine versus dry cord care on bacterial colonization and clinical outcomes of umbilical cord in preterm newborns
Daiahunlin Lyngdoh1, Sukhjit Kaur1, Praveen Kumar2, Vikas Gautam3, Sandhya Ghai1
1 National Institute of Nursing Education, Chandigarh, India
2 Department of Pediatrics, Neonatal Unit, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||6-Feb-2018|
C/O L. Wanniang, Lummawsing, Mawtawar, Shillong - 793 022, Meghalaya
Source of Support: None, Conflict of Interest: None
Introduction: The umbilical cord is one of the routes of entry of microorganisms that can cause infection. Hence, affordable, effective, and safe cord care regimens are needed to prevent from such infections. Methods: The study was conducted in Nehru Hospital, PGIMER, Chandigarh, with the objective to assess the effect of two cord care regimens – human breast milk and 4% chlorhexidine on bacterial colonization and other clinical outcomes. A total of 105 newborns were enrolled and randomized into three groups (35 participants in each group) – human breast milk, 4% chlorhexidine, and dry cord care group (control group). The umbilical cord swab baseline sample was taken and cultured from each of the participants. The first application (either breast milk or 4% chlorhexidine) was done immediately after the baseline cord swab sample was taken. In the dry cord care group (control group), nothing was applied on the cord. Cord swab was again taken at 72 ± 12 h and at 120 ± 12 h after birth. Umbilical cord separation time was noted. Results: There was no statistically significant difference in cord colonization at baseline (P = 0.13). At 72 ± 12 h, 34.3%, 5.7%, and 51.4% had colonization in the breast milk, chlorhexidine, and dry cord care, respectively (P < 0.001). At 120 ± 12 h, 22.9% had bacterial colonization in the breast milk group, 71.4% in the dry cord care group whereas only 2.9% in the chlorhexidine group (P < 0.001). The timing of cord separation was 9.09 ± 2.4 days, 12.65 ± 2.9 days, and 10.54 ± 3.1 days in the breast milk, chlorhexidine, and dry cord care, respectively, with maximum separation time with chlorhexidine application and least time taken in the breast milk group (P < 0.001). The main microorganisms detected were Klebsiella pneumoniae, Escherichia coli, Enterococcus faecalis, Acinetobacter baumannii, Enterococcus faecium, Staphylococcus haemolyticus, and Streptococcus. Conclusion: It is concluded that 4% chlorhexidine is very effective in reducing pathogenic bacteria colonization of the cord. Further, human breast milk, to some extent, can reduce bacterial colonization in low-resource settings and is a better alternative to dry cord care.
Keywords: Cord colonization, cord separation time, umbilical cord care
|How to cite this article:|
Lyngdoh D, Kaur S, Kumar P, Gautam V, Ghai S. Effect of topical application of human breast milk versus 4% chlorhexidine versus dry cord care on bacterial colonization and clinical outcomes of umbilical cord in preterm newborns. J Clin Neonatol 2018;7:25-30
|How to cite this URL:|
Lyngdoh D, Kaur S, Kumar P, Gautam V, Ghai S. Effect of topical application of human breast milk versus 4% chlorhexidine versus dry cord care on bacterial colonization and clinical outcomes of umbilical cord in preterm newborns. J Clin Neonatol [serial online] 2018 [cited 2018 May 26];7:25-30. Available from: http://www.jcnonweb.com/text.asp?2018/7/1/25/224817
| Introduction|| |
The umbilical cord is an excellent medium for bacterial colonization during the intrapartum period while passage through the birth canal and immediate postpartum from the environment. The environmental source includes the hands of the caregivers. The umbilical cord vessel is the direct entry route for invasion of microorganisms into the newborn's circulation. Delay in cord detachment may increase the risk of bacterial infection. The tissue of the cord stump can serve as a medium for bacterial growth. This is particularly true in cases where the stump is left moist and certain unclean substances are applied to it. The umbilical stump is a common means of entry for systemic infection in the newborn infant. Umbilical cord infection can either be localized to the cord (omphalitis) or can spread through the blood stream and become systemic causing neonatal sepsis. In hospital settings, Staphylococcus aureus is the most common organism being cultured. The other common organisms that have the potential to cause cord infections in hospitals include Group B streptococci and Escherichia More Details coli. Mir et al. reported that 80% of all pathogens that cause community-acquired omphalitis are S. aureus and beta hemolytic streptococci. Cord infection is most prevalent among newborns born in developing countries and it contributes to the potential risk of developing life-threatening neonatal sepsis. Preterm babies have immature immune system as compared to term babies; therefore, the chance of infection is increased in preterm babies.
Umbilical cord care after birth until its separation is an important component in newborn care. Usually, the umbilical cord can become colonized with potential pathogenic bacteria during the intrapartum or postpartum period. These pathogenic bacteria are likely to invade the umbilical stump, which can lead to omphalitis. Colonization of the cord stump by pathogenic organisms leading to infection can cause morbidity and mortality of newborns, especially in the developing countries.
The cord care interventions that are followed in both developed and developing countries to help reduce exposure of the cord to pathogens include use of clean cord cutting device, proper hand washing before and after handling the baby, bathing the infant with antimicrobial agents, and to apply these agents on the cord. The WHO recommends application of chlorhexidine daily on the umbilical cord of newborns during the 1st week of life. This is particular with the newborn born in hospital setting or in other settings where the neonatal mortality rate is high.
Current routine cord care in India includes keeping the cord dry. However, findings from the study conducted by Kaur demonstrated 100% positive finding for pathogenic bacteria with dry cord care. Although the practices of cord care such as applying of harmful substances are reduced, Bhatt et al. reported in their study that oil or ghee including cream and turmeric powder was applied on the umbilical cord.
Current protocols for aseptic cord care are based on research studies being done in developed countries. These evidence generated do not provide a clear understanding of the best cord care practices. In developing countries, there is a significant difference in the availability of resources, social customs and values, and environmental cleanliness which serve as a barrier for implementation of research evidence from developed countries.
Triple dye, ethyl alcohol, betadine, or chlorhexidine was applied at the tip and around the base of the umbilical stump daily to prevent colonization. Antiseptic solutions such as chlorhexidine can decrease the risk of infections as well as bacterial colonization in health-care settings.,,,,, A randomized controlled trial found that skin cleansing using chlorhexidine is safe and can reduce skin flora in newborns.
Human breast milk was applied on the cord which reduced bacterial colonization and cord separation time., Human milk contains large amounts of IgA antibodies  which can improve the immunity of babies. It promotes growth and repair of musculoskeletal system. The presence of polymorph nuclear leukocytes and other immunologic compounds in the breast milk can decrease the process of cord separation. Colostrum contains a large amount of natural antimicrobial agents and can provide specific and nonspecific passive immunity to the babies.
The objective of the study was to compare the effect of topical application of human breast milk versus 4% chlorhexidine versus dry cord care on bacterial colonization, and to find the clinical outcomes of umbilical cord in preterm newborns. The clinical outcomes of umbilical cord include cord separation time and presence of umbilical cord infection.
| Methods|| |
An experimental research design was used in the study. A total of 105 preterm newborn ≤34 weeks of gestation born in Nehru Hospital, PGIMER, Chandigarh, were enrolled in the study. Both healthy and sick preterm neonates were recruited between 3 and 12 h after birth. Newborn with cord abnormalities such as omphalocele and mothers of newborn who refuse to participate in the study were excluded. The mothers of the newborn were then informed about the aim of the study and written consent was obtained. A structured interview schedule was used to gather information about the baseline data of neonates.
After collection of baseline data, baseline umbilical cord swab sample was taken from each of the neonate. Thereafter, each neonate enrolled was randomized to either of the three groups – human breast milk, 4% chlorhexidine, and dry cord care group. The first application (either breast milk or 4% chlorhexidine) was done immediately after the baseline cord swab sample was taken. In the dry cord care group (control group), the umbilical cord was kept dry and exposed to air and napkin was folded below stump. Topical application of human breast milk or 4% chlorhexidine was done once a day daily till the cord falls off. Cord swab was again taken on the 3rd and 5th days after birth. Umbilical cord separation time and also the presence of any cord infection were noted.
Ethical approval for the study was obtained from the Institute's Ethics Committee. Mothers were informed about the procedure and written consent was taken. Protocol for topical application of human breast milk and 4% chlorhexidine was developed. The study was registered under the Clinical Trial Registry India-ctri.nic.in, CtriNo: CTRI/2017/07/009146.
The statistical analysis of the data collected was done using Statistical Package for the Social Sciences (SPSS version 20.0 ibm spss statistics 20, India). Both descriptive and inferential statistics were used for data analysis and interpretation for the 105 participants. Dichotomous outcomes and categorical data were compared by Chi-square test. Analysis of Variance was used to compare the mean between groups and Kruskal–Wallis test was used for comparison of median.
| Results|| |
[Table 1] describes the distribution of subjects according to baseline data. The mean gestational age and weight was 31 weeks and 1400 grams respectively.
[Table 2] shows the distribution of newborn according to time period from birth to the first intervention. In majority of the subjects the time gap of first intervention ranges between 6-12 hours.
|Table 2: Distribution of newborn according to time period from birth to the first intervention (n=105)|
Click here to view
[Table 3] shows the comparison of newborn colonised with pathogenic bacteria between the three groups. The groups showed statistical significant difference in bacterial colonisation at 72±12 hrs (p<0.001) and at 120±12 hrs (p<0.001) with the highest colonisation in the dry cord care group and the least in the chlorhexidine group.
|Table 3: Comparison of newborns colonized with pathogenic bacteria in different groups (n=105)|
Click here to view
[Table 4] shows the comparison of umbilical cord separation time between the three groups. The maximum cord separation time was in the chlorhexidine group and minimum time in the breast milk group. Cord separation time was statistically significant between the three groups (p<0.001).
|Table 4: Comparison of timing of umbilical cord separation in different groups (days) (n=105)|
Click here to view
[Figure 1] depicts the newborn colonised by pathogenic organisms at baseline. The main microorganisms detected were Klebsiella pneumonia, E.coli , Enterococcus fecalis, Acinatobacter baumanii, Staphylococcus homonis, Enterococcus faecium, Staphyloccocus hemolyticus, Streptoccoccus.
[Figure 2] shows the percentage of newborn colonised by pathogenic organisms at 72±12 hours. The most common microorganisms found were Klebsiella pneumonia, E.coli, Enterococcus fecalis, Acinatobacter baumanii, Staphylococcus aureus, Staphylococcus homonis, Enterococcus faecium, Staphyloccocus hemolyticus, Streptoccoccus, Enterococcus gallinarum.
[Figure 3] depicts the colonization of newborn with pathogenic bacteria at 120 ±12 hours. The pathogenic microorganisms that were cultured includes Klebsiella pneumonia, E.coli, Enterococcus fecalis, Acinatobacter baumanii, Staphylococcus homonis, Enterococcus faecium, Staphyloccocus hemolyticus, Streptoccoccus. Majority of colonisation was seen in the dry cord care group as compared to the breast milk and chlorhexidine group.
| Discussion|| |
In the present study, preterm newborns ≤34 weeks' gestation were recruited with majority of the newborns' birth weight <2500 g. This is similar to the study of Pezzati et al., whereby preterm newborns <34 weeks and birth weight of <2500 g were included to compare the effect of salicylic sugar versus chlorhexidine.
In the present study, baseline culture was taken just before the interventions. Similar protocol was followed in the study by Mahrous et al. where baseline umbilical cord swab was taken after birth and before interventions. The umbilical cord swab sample for bacterial colonization was taken using sterile cotton swab stick and single stroke was made at the umbilical cord base. This protocol is matched with that of the study by Hamid et al and AllamNAet al. where the first cord swab was taken from the umbilical cord stump after delivery., Three cord swab sampling were taken at baseline cord swab, the 2nd culture at 72 ± 12 h, and the 3rd sample at 120 ± 12 h, which is in contrast with that of Hamid et al. whereby two cord swab samples were taken immediately at birth and after 3 days. About 40% of the neonates' baseline culture was taken within 6 h of birth in the breast milk group while 37% and 54% in the chlorhexidine and dry cord care group, respectively. Hamid et al. in their study comparing different cord care regimens took the first swab 3 h after birth.
Single or multiple cleansing with 4% chlorhexidine to the cord sump using cotton swabs was done  which was also done in the present study where application of 4% chlorhexidine was done using sterile cotton swabs once a day till cord separates.
Findings of this research showed no statistically significant difference in colonization rate with baseline culture (P = 0.13). At 72 ± 12 h, 34.3% of the neonates in the breast milk group were colonized with pathogenic bacteria as compared to 5.7% in the chlorhexidine group and 51.4% in the dry cord care group. Statistical analysis of the findings showed a highly significant difference in the bacterial colonization between the three groups at 72 ± 12 h of life (P < 0.001). A high percentage of pathogenic organisms (71.4%) was found in the dry cord care group at 120 ± 12 h whereas it is an interesting finding that only 2.9% of the neonates in the chlorhexidine group had bacterial colonization. Highly significant difference in bacterial colonization was reported at 120 ± 12 h (P < 0.001). This study is comparable to findings by Mahrous et al. where there was a significant difference in bacterial colonization during the follow-up visits.
The mean cord separation time in chlorhexidine group was 12 days as compared to 10 days in dry cord care group and 9 days in breast milk group. The mean cord separation time had significant difference among the three groups (P < 0.001). Study of Abbaszadeh et al. also reported shorter cord separation in human milk group (7.15 ± 2.15 days) than in chlorhexidine group (13.28 ± 6.79 days).
The different pathogenic microorganisms that colonized the umbilical cord were Klebsiella pneumonia, E. coli, Enterococcus faecalis, Acinetobacter baumannii, Staphylococcus hominis, Enterococcus faecium, Staphylococcus haemolyticus, and Streptococcus, and is in accordance with findings reported in various studies where the most common pathogenic microorganisms were E. coli, K. pneumonia, Pseudomonas, and Staphylococcus.,
| Conclusion|| |
The objective of this study is to compare the effect of topical application of human breast milk versus 4% chlorhexidine versus dry cord care on bacterial colonization, and to find the clinical outcomes of umbilical cord in preterm newborns. The findings of the study show that there was statistically significant difference in the bacterial colonization and umbilical cord separation time between the three groups (P < 0.005). It can be concluded that 4% chlorhexidine is very effective in reducing bacterial colonization of the umbilical cord. Further, human breast milk to some extent can reduce bacterial colonization in low-resource settings and is a better alternative to dry cord care.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dutta DC. Textbook of Obstetrics. 7th
ed. Delhi: New Central Book Agency (P) Ltd.; 2011. p. 28, 35, 39-40.
Hamid AA, Fadil NA, Azzam HF. Effect of two different cord care regimens on umbilical cord stump separation time among neonates at Cairo University Hospitals. J Am Sci 2011;7:920-6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795877
. [Last accessed on 2015 Sep 2015].
Farahani L, Mohammadzadeh A, Tafazzoli M, Esmaeli H, Ghazvini K. Effect of topical application of breast milk and dry cord care on bacterial colonization and umbilical cord separation time in neonates. J Chin Clin Med 2008;3:327-32. Available from: https://www. Ncbi. Nlm.nih. Gov/pmc/articles/PMC4795877
. [Last accessed on 2015 Sep 15].
Ahmadpour-Kacho M, Zahedpasha Y, Hajian K, Javadi G, Talebian H. The effect of topical application of human milk, ethyl alcohol 96%, and silver sulfadiazine on umbilical cord separation time in newborn infants. Arch Iran Med 2006;9:33-8.
Mir F, Tikmani SS, Shakoor S, Warraich HJ, Sultana S, Ali SA, et al.
Incidence and etiology of omphalitis in Pakistan: A community-based cohort study. J Infect Dev Ctries 2011;5:828-33.
Kaur P. A Study to Compare the Efficacy of 4% Chlorhexidine, 70% Isopropyl Alcohol and Dry Cord Care on Colonization of Umbilical Cord with Pathogenic Bacteria and Cord Separation Time in Preterm Babies <35 Weeks of Gestation Born at Labour Room, PGIMER, Unpublished Thesis Chandigarh; 2010-11.
Singh M. Care of the Newborn. 7th
ed. New Delhi: Sagar Publications; 2010. p. 123, 219.
Abbaszadeh F, Hajizadeh Z, Atrian M, Bagheri A, Sarafraz N. Comparison of the effect of topical application of human milk and dry cord care on the bacterial colonization of umbilical cord in newborn infants. J Kermanshah Univ Med Sci 2014;18:1-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795877/
. [Last accessed on 2015 Sept 06].
Mullany LC, Khatry SK, Sherchand JB, LeClerq SC, Darmstadt GL, Katz J, et al.
A randomized controlled trial of the impact of chlorhexidine skin cleansing on bacterial colonization of hospital-born infants in Nepal. Pediatr Infect Dis J 2008;27:505-11.
Golshan M, Hossein N. Impact of ethanol, dry care and human milk on the time for umbilical cord separation. J Pak Med Assoc 2013;63:1117-9.
Mullany LC, Shah R, El Arifeen S, Mannan I, Winch PJ, Hill A, et al.
Chlorhexidine cleansing of the umbilical cord and separation time: A cluster-randomized trial. Pediatrics 2013;131:708-15.
Imdad A, Mullany LC, Baqui AH, El Arifeen S, Tielsch JM, Khatry SK, et al.
The effect of umbilical cord cleansing with chlorhexidine on omphalitis and neonatal mortality in community settings in developing countries: A meta-analysis. BMC Public Health 2013;13 Suppl 3:S15.
Mullany LC, Darmstadt GL, Tielsch JM. Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries. Pediatr Infect Dis J 2006;25:665-75.
Block SL. 'Stumped' by the newborn umbilical cord. Pediatr Ann 2012;41:400-3.
Zupan J, Garner P, Omari AA. Topical umbilical cord care at birth. Cochrane Database Syst Rev 2004;:CD001057.
Imdad A, Bautista RM, Senen KA, Uy ME, Mantaring JB 3rd
, Bhutta ZA, et al.
Umbilical cord antiseptics for preventing sepsis and death among newborns. Cochrane Database Syst Rev 2013;:CD008635.
Chamnanvanakij S, Decharachakul K, Rasamimaree P, Vanprapar N. A randomized study of 3 umbilical cord care regimens at home in Thai neonates: Comparison of time to umbilical cord separation, parental satisfaction and bacterial colonization. J Med Assoc Thai 2005;88:967-72.
Darmstadt GL, Hassan M, Balsara ZP, Winch PJ, Gipson R, Santosham M, et al.
Impact of clean delivery-kit use on newborn umbilical cord and maternal puerperal infections in Egypt. J Health Popul Nutr 2009;27:746-54.
Hiali SJ, Al-Mawla SO, Saeed WW, Yousif AM. Omphalitis in neonates admitted to Al-Ramadi maternity and children hospital. Ann Trop Pediatr 2007;27:155-6. Available from: http://www.iasj.net/iasj?func=fulltext&aId=15664
. [Last accessed on 2015 Oct 09].
Semrau KEA, Herlihy J, Grogan C, Musokotwane K, Yeboah-Antwi K, Mbewe R, et al.
Effectiveness of 4% chlorhexidine umbilical cord care on neonatal mortality in southern province, Zambia (ZamCAT): A cluster-randomised controlled trial. Lancet Glob Health 2016;4:e827-36.
Abbaszadeh F, Hajizadeh Z, Jahangiri M. Comparing the impact of topical application of human milk and chlorhexidine on cord separation time in newborns. Pak J Med Sci 2016;32:239-43.
Pezzati M, Rossi S, Tronchin M, Dani C, Filippi L, Rubaltelli FF, et al.
Umbilical cord care in premature infants: The effect of two different cord-care regimens (salicylic sugar powder vs. chlorhexidine) on cord separation time and other outcomes. Pediatrics 2003;112:e275.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]