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400 | Healio.com /Pediatrics ‘Stumped’ by the Newborn Umbilical Cord Stan L. Block, MD, FAAP T he postnatal management for the newborn umbilical cord is surprisingly controversial. Nu - merous investigators have explored the optimal approach to cord care, whether it is performed during the rst 24 hours of life, or in the rst weeks of life until the body. The average length of cord retention varies from 3 to 45 days, with a mean separation time of 13.9 days. 1 During past comparative evaluations of several treatment options of the cord, a few op - tions have been shown to prolong the separation of the cord. However, when compared with dry cord care, most treatments have been associated with a decreased risk for secondary infections. Initial options also vary widely from - ply triple dye, chlorhexidine, or po - vidone iodine, whereas others use no treatment. Recommendations for the post- hospital management of the cord also range from daily applications of al - cohol, to soap and water washings, to nontreatment. TREATMENT RATIONALES In the past, most pediatricians were concerned about bacterial colonization of the cord and subsequent increased risk for secondary invasive bacterial infection. With its slowly necrotizing tissue, the umbilical stump is a prime source for colonization by gram-nega - tive bacteria such as Escherichia coli , Klebsiella , and pseudomonas, along with gram-positive bacteria such as Staphylococcus aureus and streptococ - cal species. Secondary infections of the cord/ stump include a commonly encountered mild purulent discharge some have 2 (see Figure 1), occasional impetigo or cellulitis, and very rare infections such as severe fu - nisitis, frank omphalitis, and necrotiz - ing fasciitis. Funisitis is an infection of the con - nective tissue of the cord itself, usu - ally associated with mild malodorous discharge from streptococcal species, but also may be associated with a more severe infection of chorioamnionitis, which is usually seen in stillborns and preterm infants. 2,3 Omphalitis is a severe infection of the entire umbilical stump and surround - ing skin, most often associated with S. aureus . 3 Stan L. Block, MD, FAAP, is Professor of Clinical Kentucky, Lexington, KY; President, Kentucky Pedi - atric and Adult Research Inc.; and general pediatri - cian, Bardstown, KY. Address correspondence to Stan L. Block, MD, FAAP, via email: slblock@pol.net. Disclosure: Dr. Block has disclosed no relevant nancial relationships. doi: 10.3928/00904481-20120924-05 Figure 1. The bottom (A) and top (B) of the um - bilical cord base in a 10-day old female whose PEDIATRIC ANNALS 41:10 | OCTOBER 2012 Healthy Baby Practical advice for treating newborns and toddlers. the cord away from the base of the stump re - vealed the origin of a foul smell — the green and sanguinous discharge had accumulated since birth. The child was managed with three times daily cotton-tip applications with rubbing alco - hol on both sid

es of the umbilical base. The cord discharge resolved rapidly. A B Healio.com /Pediatrics | 401 Healthy Baby BACTERIAL COLONIZATION OF THE UMBILICAL CORD Three studies of neonates conducted in the UK during the 1990s evaluated the correlation between S. aureus colo - nization and infection when the umbili - cal cord was left untreated. Untreated cords in 102 neonates were 1.75 times more likely to be colonized with S. au - reus than treated cords. 4 An untreated cord was associated with a heavy colonization by S. aureus in 49% (171 neonates) of patients. More importantly, 12% (44 neonates) of the entire sample size developed a staphy - lococcal infection. 5 When dry cord care was compared with hexachlorophane (which should probably not be used due to reports of neurotoxicity when used inappropriately) or chlorhexidine, the rate of S. aureus colonization was unac - ceptably high. Dry cord care has also been asso - ciated with intermittent outbreaks of neonatal bullous impetigo. 6 Another randomized trial of 766 newborns in British Columbia compared dry cord care with a treatment regimen of two applications of triple dye on the day of birth along with twice daily alcohol swabbing until cord separation. 7 Com - pared with the treatment group, the ma - jor ndings in the dry cord care group were the following: a 10-fold higher rate of S. aureus colonization (31.3% vs. 2.8%); higher rates of cord exudates (7.4% vs. 0.3%) and foul odor (2.9% vs. 0.7%); and a single case of ompha - litis. The authors in each of these studies concluded that prevention of early S. aureus colonization was the most criti - cal factor in routine cord care. The study by Verber and colleagues 6 surmised that perhaps, hospital physicians do not be - come aware of some of the cord prob - lems and the rare actual infections that may occur until the cord separates. For example, when a community hos - pital in Tampa, FL with 3,000 annual births instituted a dry cord care policy, three cases of S. aureus bullous impetigo of the umbilicus were reported within 3 months of the new policy compared with no cases in the previous years. 8 THE DRY CORD ARGUMENT Many pediatricians become quite concerned when spontaneous separation of the cord is delayed beyond the age of 3 to 4 weeks. We have been taught about the association between delayed cord separation and genetic defect of diminished neutrophil mobility/severe recurrent bacterial infections. 9 This phenomenon is usually caused by a severe autoimmune, autosomal recessive disorder known as type 1 leu - kocyte adhesion deciency (LAD-1), which has a mutation in the beta 2 inte - grin subunit, CD18, localized to chro - mosome 21. Yet, since the disorder was identied more than 30 years ago, ac - cording to the latest edition (6 th ) of Text - book of Pediatric Infectious Diseases , 2 it has been identied in only about 150 individuals worldwide. It also has a broad ethnic diversity. The issue of delayed cord separati

on has evolved into a major justication for dry cord care. Some argue that the lon - ger the cord stays on, the higher the risk of becoming infected. The commonly used treatments (triple dye, alcohol, and chlorhexidine) delay cord separation for merely 1 to 5 days. However, even when over 15,000 neonates with treated cords were prospectively evaluated, de - layed cord separation was not associ - ated with an increased risk of infection when compared with dry cord care. 1,10 Furthermore, topical applications of an antiseptic which may prolong cord separation cannot create an exceedingly rare genetic defect. UMBILICAL CORD CARE OPTIONS The current treatment options for umbilical cord care usually include: 7 Triple dye (brilliant green, proa - vine hemisulfate, and crystal violet). This is considered one of the most effec - tive agents for bacteriocidal prophylax - is, particularly for S. aureus , but argu - ably it also may promote gram-negative bacteria colonization. Parents complain about the purple cord, the inadvertent purple staining of the surrounding ab - dominal skin, and the brittle nature of the cord at home. One or two applica - tions have not been shown to be toxic. Isopropyl alcohol . By itself, this may have the least antibacterial activity of all agents. It also dries out and may irritate the periumbilical skin. Many parents are unaware of how to properly apply alcohol onto the base of the cord. Although it has been proven to prolong cord separation, it does dry up the dis - charge and foul odor associated with nontreatment of the stump. With heavy exposure or an occlusive dressing, it could cause alcohol intoxication and subsequent acidosis and hypoglycemia. Povidone iodine. This has been demonstrated to be less effective than triple dye for both prevention of coloni - zation and infection. Iodine toxicity and transient hypothyroidism is possible, particularly for low birth weight infants, as plasma iodide levels may increase up to 400% for nearly 3 days. 11 Topical antibiotics (eg, neomycin, bacitracin). These may promote bacteri - al antibiotic resistance and later hyper - The issue of delayed cord separation has evolved into a major justication for dry cord care. 402 | Healio.com /Pediatrics Healthy Baby sensitivity to antibiotics. Triple dye has been shown to be superior for preven - tion of both colonization and infection. Chlorhexidine . Although an ef - fective broad spectrum antimicrobial, particularly for cord colonization with S. aureus , some recent studies suggest it may promote bacterial resistance when used frequently. 12 In underdeveloped countries, chlorhexidine has been shown to signif - icantly reduce mortality from omphali - tis. 13 Occlusion must be avoided; local skin reactions may occur. A single daily application is necessary for at least the rst week of life. ADVICE FOR CORD CARE Several days of delayed separation of the cord, regardless of which treat - ment, is probably not an important con - sideratio

n relative to possible increased risk for colonization and infection of the cord. I think at least a single appli - cation of triple dye in the nursery may be optimal because this method appears to have the lowest rates of colonization and infection. We have been success - fully using this technique in our nursery for over 30 years. After hospital discharge, I also rec - ommend the application of alcohol to the base of the cord with a cotton- tipped applicator 2 to 3 times daily until the cord is separated. Even though it is a poor antibacterial and still of unprov - en efcacy, 14 alcohol applications usu - ally seem to prevent the putrid, green discharge and the foul odor associated with either dry cord care or with soap and water care of the cord. During the rst ofce visit at day 4 or 5 of life, when the infant’s upper cord has mostly dried up, I demonstrate to the parents the technique of separating the cord inferiorly and superiorly from the umbilical skin (See Figure 1, page 400). At this visit, many babies will already have developed a wet, green purulent discharge at the unseparated junction of skin and cord (See Figure 2 and Figure 3). I also recommend that parents only sponge bathe the baby until the cord separates, and not to get the cord wet at all. In my experience, the worst smell - ing and the worst umbilical discharge is associated with water-wetted cords, probably due to pseudomonas over - growth. When the cord nally separates, some mild bleeding at the base is nor - Figure 2. The umbilical cord of a 14-day-old male infant whose cord was treated with an initial single application of triple dye. No further treat - ment was used. Once the cord remnant was lifted from the base of the umbilicus, a purulent wet discharge was noted. The cord was treated with three times daily applications of rubbing alcohol, and the discharge dried up within a few days. Figure 3. The base of an umbilical cord in a 2-week-old male infant . The purulent discharge was still exuding from the stump, and treatment by cauterization with silver nitrate was selected (see Figure 5). Figure 4. A tube of 100 applicators of silver ni - trate. A single applicator is often used to cauterize the base of weeping purulent stumps — with or without the cord attached. Figure 5. Application of a silver nitrate stick to the umbilical base of the child in Figure 4. Any areas touched by the stick will turn black or a grayish color for a week or so. Although the cord may ooze some serous discharge in the initial few hours, it will quickly dry up. Clinicians should attempt to only touch the cord area, and avoid the skin, when applying the silver nitrate stick. The application appears to be mildly uncomfortable for the infant, and his legs should be briey restrained by the parent. Only a single application is usually needed. PEDIATRIC ANNALS 41:10 | OCTOBER 2012 Healio.com /Pediatrics | 403 mal. If bleeding, malodor, or green discharge of the umbilicus persists be -

yond the rst week, I advocate an ap - plication of a 75% silver nitrate stick to the interior of the umbilicus if the cord has separated already, or to the in - terior base of the cord-skin junction if the cord is still attached (See Figure 4 and Figure 5, page 402). UMBILICAL GRANULOMA Occasionally, a small 3- to 5-mm fungating mass, which has a mild green or sanguinous discharge, may develop within the umbilical stump. This lesion is best eradicated with an application or two of 75% silver nitrate stick to the entire mass. Very rarely, when the le - sion does not respond to this therapy, or when the lesion is larger than 10 mm, you are likely dealing with an umbili - cal polyp. Polyps often contain intesti - nal or urachal remnants; they are best managed by surgical removal. EVALUATION FOR THE SINGLE UMBILICAL ARTERY I wish to clarify an important issue regarding umbilical cord management. It is commonly believed that neonates with a single umbilical artery (SUA), reported in 0.2% to 0.6% of live born infants, have a signicantly increased risk for congenital renal anomalies. 14 This notion prompts many practitio - ners to obtain a renal ultrasound in all infants who have SUA, at considerable expense and notable parental anxiety. But what are the real odds of nding any signicant congenital renal abnor - malities? Two different studies, which evalu - ated about 45,000 infants in the 1960s and 1970s, reported no increased risk of renal abnormalities in infants with SUA. The only malformation reported as signicantly higher in children with SUA than in a control population was the rate of inguinal hernia. Forego the renal ultrasound. 15,16 As stated in the 2012 online medical text - book, Uptodate.com : “We do not per - form further imaging for healthy term infants with an isolated SUA, as there is a low likelihood of a renal or uro - logical abnormality.” 14 REFERENCES Novack AH: Umbilical separation in the nor - mal newborn. Am J Dis Child. 1988,142:220- 223. Feigin R, Cherry J, Demmler-Harrison G, Kaplan S. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases , 6th edition. Philadelphia: WB Saunders; 2009. Brien JH. An 18-month-old female pres - ents with fever, erythema, swelling around umbilicus. Infectious Diseases in Children . 2012, (2)18-19. Available at www.healio. com/pediatrics/news/print/infectious-dis - eases-in-children/%7Ba272c863-16e1- 4626-9ad3-5bda62b3b6af%7D/ an-18-month-old-female-presents-with- fever-erythema-swelling-aroundumbilicus. Accessed Sept. 10, 2012. Watkinson M, Dyas A. Staphylococcus au - reus still colonizes the untreated neonatal umbilicus. J Hosp Infect . 1992;21:131-135. Stark V, Harrison SP. Staphylococcus aureus colonization of the newborn in a Darlington hospital. J Hosp Infect . 1992;21:205-211. Verber IG, Pagan S. What cord care — if any? Arch Dis Child . 1993;68:594-596. Janssen PA, Selwood BL, Dobson SR, Pea - cock D, Thiessen PN. To dye or not to dye: a randomized,

clinical trial of a triple dye/ alcohol regime versus dry cord care. Pediat - rics . 2003;111(1):15-20. Weathers L, Takagishi J, Rodriguez L. Um - bilical cord care. Pediatrics . 2004;113(3 Pt 1):625-626; author reply 625-626. Hayward AR, Harvey BA, Leonard J, Green - wood MC, Wood CB, Soothill JF. Delayed separation of the umbilical cord, widespread infections, and defective neutrophil mobility. Lancet . 1979;1(8126):1099-1101. Mullany LC, Darmstadt GL, Khatry SK, LeClerq SC, Katz J, Tielsch JM. Impact of umbilical cord cleansing with 4.0% chlorhexidine on time to cord separation among newborns in southern Nepal: a clus - ter-randomized, community-based trial. Pe - diatrics . 2006;118:1864-1871. Pyati SP, Ramamurthy RS, Krauss MT, Pil - des RS Absorption of iodine in the neonate following topical use of povidone iodine. J Pediatr . 1977;91:825-828. Batra R, Cooper BS, Whiteley C, Patel AK, Wyncoll D, Edgeworth JD. Efcacy and limitation of a chlorhexidine-based decolo - nization strategy in preventing transmission of methicillin-resistant Staphylococcus au - reus in an intensive care unit. Clin Infect Dis . 2010;50(2):210-217 Mullany LC, Saha SK, Shah R, et al. Impact of 4.0% chlorhexidine cord cleansing on the bacteriologic prole of the newborn umbilical stump in rural Sylhet District, Bangladesh: a community-based, cluster-randomized trial. Pediatr Infect Dis J . 2012;31(5):444-450. Froehlich LA, Fujikura T. Follow-up of in - fants with single umbilical artery. Pediatrics. 1973;52:6-13. Van Leeuwen G. Single umbilical artery [let - ter]. Pediatrics . 1973;52:890. Palazzi DL, Brandt ML. Care of the umbilicus and management of umbili - cal disorders. Available at http://www. uptodate.com/contents/care-of-the-um - bilicus-and-management-of-umbilical- disorders?source=search_result&search=Car e+of+the+umbilicus+and+management+of+ umbilical+disorders.&selectedTitle=1~150. Accessed Sept. 14, 2012. Healthy Baby It’s more than a new destination. It’s a more powerful platform. Personalized to place your interests  rst. Subspecialized to  t your daily practice. At Healio.com, you’ll  nd more new ways to stay informed, gain perspective, and earn CME credits – with more exciting updates arriving all the time. Award-winning news reportingDynamic video and multimediaCurbside Consultation: Q&APeer-reviewed journalsactivitiesPowered by SLACK Incorporated® General knowledge has its place.Specialty experience lives here. NOW LIVE!The new online home of PEDIATRICGet to know Healio.com/PediatricsI encourage you to visit Healio.com. The enhanced website will allow you access to books, journals, and educational materials, and comprehensive news coverage of general pediatrics and many other relevant specialties. Healio.com allows you to design your own daily newsfeed according to your personal interests, and receive breaking news alerts for the subjects you care about most. Stanford T. Shulman, MDEditor-in-Chief, EDIATRIC PEDIATRIC ANNALS 41:10 | OCTOBER