This article is part of the supplement: The Lives Saved Tool in 2013: new capabilities and applications

Open Access Review

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

Aamer Imdad1, Luke C Mullany2, Abdullah H Baqui23, Shams El Arifeen3, James M Tielsch2, Subarna K Khatry24, Rasheduzzaman Shah2, Simon Cousens5, Robert E Black2 and Zulfiqar A Bhutta1*

Author Affiliations

1 Division of Women and Child Health, Aga Khan University, Karachi, Pakistan

2 Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA

3 International Centre for Diarrheal Diseases Research, Bangladesh

4 Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal

5 London School of Tropical Medicine & Hygiene, London, UK

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BMC Public Health 2013, 13(Suppl 3):S15  doi:10.1186/1471-2458-13-S3-S15

Published: 17 September 2013

Abstract

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.