The umbilical cord is clamped after birth. This separates the circulations of mother and newborn and prevents bleeding. The cord is subsequently cut with a sterile instrument, leaving an exposed stump. The remaining cord detaches at about 7 days post birth after a period of progressive drying and atrophy. This process is influenced by exposure to ambient air, degradation mediated by phagocytic cells and colonization by exogenous bacteria.3

The withering tissue of the stump provides a suitable environment for bacterial colonization and growth, and colonization by pathogenic bacteria may lead to the development of omphalitis. The aetiological agent most frequently involved in these cases is Staphylococcus aureus, followed by the bacteria present in the birth canal. Omphalitis may become complicated with development of cellulitis, necrotizing fasciitis or systemic infection, which may threaten the life of the newborn.4

The incidence of omphalitis varies significantly depending on the level of hygiene in the environment of the newborn and the care provided. Thus, in low-income countries this adverse event may develop in up to 22% of newborns delivered at home, and the severity of the infections also tends to be greater.5 In countries with greater resources, the incidence is much lower. The figures reported in the literature range between 0.1% and 2%,6,7 a heterogeneity that can be partly attributed to differences in the applied definition of omphalitis. In any case, severe forms are very rare in our region.8

There are other complications related to the healing of the umbilical cord stump whose incidence may vary based on the approach to cord care. These include bleeding, granuloma, delayed cord separation and the development of secretions. The latter can give rise to anxiety in the caregiver, additional health care visits and the need for related treatments.9

Since 1998, the World Health Organization (WHO) has recommended dry cord care.10 The recommendations of the WHO were last updated in 201311 and have been endorsed by other organizations at the international level, such as the National Institute for Health and Care Excellence12 and the American Academy of Pediatrics.4 However, survey-based studies in countries neighboring Spain have highlighted a significant variability in the recommendations given to families as regards umbilical cord care. These studies have also revealed a very frequent use of antiseptics.13,14

Dry cord care consists in the initial cleansing of the stump with tepid water and a neutral soap and then keeping the cord dry.15,16 Additional measures have been proposed for this approach, such as covering the stump with clean gauze, exposing it to air by keeping it outside the diaper or avoiding its immersion in water,17,18 but no studies of quality have yet been conducted that address these particular interventions.

Different antiseptics have been used with the aim of preventing infection of the navel. The two that have been studied most extensively are 70° alcohol and 4% chlorhexidine, administered in different dosage forms (alcoholic or aqueous solution, gel or powder). Other antiseptics used for the purpose are triple dye (a combination of 3 disinfectant solutions frequently used in the United States), povidone–iodine and salicylic acid, among others.18–20 Topical antibiotics such as silver sulfadiazine, tetracyclines or neomycin have also been used.19,21

Finally, the literature describes other methods that are used less frequently, some based on traditional customs, such as mixtures of herbs, ash, breast milk or oils from different sources. Such practices are common in geographical regions like Asia and Africa, and some of them may carry an increased risk of infection by Clostridium tetani.20,22

In 2004, the Cochrane Review published a first systematic review including the studies available to date on the subject of umbilical cord care. It analyzed 21 studies, most conducted in developed countries, that had compared dry cord care with alternative approaches such as alcohol, chlorhexidine, silver sulfadiazine or triple dye. This review concluded that the use of antiseptics or antibiotics did not achieve a reduction in the risk of omphalitis but was associated with an increase in the time it took the cord to detach.21

One of the limitations acknowledged in this first systematic review was the lack of studies conducted in lower-income countries. In 2013, Imdad et al. published an update that added 13 new studies, 10 of which conducted in developing Asian countries.23 This updated review found a significant decrease in mortality and in the incidence of omphalitis with the use of chlorhexidine in low-income countries. However, this effect did not extend to more developed countries. In the same year, 2 other meta-analyses were published, reporting similar findings.20,24

In the past 5 years, another 3 systematic reviews have been published that focused on the potential advantages of the use of chlorhexidine compared to dry cord care.3,25,26 These reviews have included a total of 14 studies with data from 86308 newborns. Of these studies, only 3 (corresponding to 1.7% of total participants) were conducted in high-income countries. The conclusions of all of them are similar: the use of chlorhexidine is associated with a reduction in the incidence of omphalitis in low-income countries. In addition, this effect is greater in home births, and is associated with a decrease in neonatal mortality. When it came to high-income countries, the reviews did not find sufficient evidence to justify this intervention.

These last systematic reviews were followed by the publication of 2 new clinical trials comparing different umbilical cord care strategies in middle- to high-income countries. In Turkey, Ozdemir et al. compared dry cord care with the use of 70% alcohol, 4% chlorhexidine and povidone–iodine. The time elapsed to cord detachment was longer in patients that received an antiseptic, and there were no differences in the incidence of omphalitis.18 In France, Gras-Le Guen et al. conducted a prospective, multicentre cross-over study that evaluated the effects of different antiseptics, including alcohol and chlorhexidine, to dry cord care. Dry cord care was proven noninferior to the use of antiseptics for prevention of omphalitis. The median time elapsed to umbilical cord detachment was 1 day shorter with dry cord care.

When it comes to inpatient umbilical cord care in newborns that require hospitalization, the published evidence is scarce. In 2004, Evens et al. included 109 preterm newborns delivered before 34 weeks’ gestation in a clinical trial in the United States comparing dry cord care with the use of 70% alcohol. They found a significant delay in the detachment of the cord in the alcohol group and no difference between groups in the incidence of infection.27 In 2013, Gathwala et al. published the results of a clinical trial conducted in India that compared the use of 2.5% chlorhexidine with dry cord care. The sample included 140 newborns delivered after 32 weeks’ gestation that were hospitalised for more than 5 days. They found a lower incidence of confirmed sepsis and earlier cord detachment in the group treated with chlorhexidine. However, they found no differences in the results of culture of stump secretions between the two interventions.28