Nigerian Journal of Paediatrics 2011;38 (4):175 -181
ORIGINAL
Mukhtar-Yola M
Survey of Umbilical Cord care and
Iliyasu Z
Wudil B J
Separation time in Healthy Newborns in
Kano
Received:5th February 2011
A b s t r a c t
B a c k g ro u n d : The
hundred and forty nine (60.9.
Accepted:13th October 2011
interval between delivery and
p e r c e n t )
m o t h e r s
a p p l i e d
umbilical cord separation varies
methylated spirit, 145 (25.3
Mukhtar-Yola M ( )
worldwide. Some maternal, foetal
percent) used hot compress, while
Wudil B J
and perinatal factors including
50 (8.7 percent) applied toothpaste
Department of Paediatrics Aminu cord care practices are known to
on the cord. Twenty (3.5 percent)
Kano Teaching Hospital.
affect this interval.
others applied herbs, while nine
Email : mariyamukhtar@yahoo.com
Objectives: To establish the mean
(1.6 percent) applied dusting
umbilical cord separation time and
powder to the umbilical stump.
the effect of maternal and infant
Cord
separation
time
was
Iliyasu Z
characteristics, perinatal factors
significantly shorter among babies
Department of Community
and cord care practices on this time
whose mothers were of high parity,
Medicine
.
among healthy babies in northern
unbooked, and of low educational
Murtala Mohammed Specialist
Nigeria.
status. In addition, the use of razor
Hospital, Kano Nigeria
M e t h o d s :
A n
i n t e r v i e w e r
blade, thread, hot compress or
questionnaire was administered on
application of herbal preparations
mothers of healthy babies at Child
or
toothpaste
significantly
Welfare Clinics of a tertiary and
shortened the separation time
secondary level hospital in Kano.
(P<0.05).
In each case, information was
Conclusions: Cord separation time
obtained about mother's parity,
and cord care practices varied.
place of antenatal care and
Nigerian mothers often use
delivery, gestational age, birth
unorthodox interventions to shorten
weight, time of umbilical cord
cord separation time; however, the
separation after birth and cord
risk of omphalitis that may result
treatment practices.
from this is real. We recommend
Results: Five hundred and seventy
that each centre should adopt and
seven (96.2 percent) of 600
teach mothers a standard hygienic
mothers interviewed, took part in
c o r d
c a r e
p r a c t i c e
w h i l e
the study, four of these mothers had
discouraging the use of herbs and
twin gestation. Responses showed
untested materials.
that cord separation time ranged
from 2 -14 days (4.20 1.70)Three
Keywords:
Umbilical
cord,
Separation time, Cord care, Kano
Introduction
stiff (dry gangrene). The devitalized tissue of the cord
stump can be an excellent medium for bacterial
EACH year, approximately one million newborns
growth, especially if the stump is kept moist and
unclean substances areapplied to it.
2,3
worldwide die of infection caused by bacteria that
Adequate care
enter the body via the umbilical cord. When the cord
1
of the umbilical cord stump of the newborn infant
is cut, the stump is suddenly deprived of its blood
may prevent infections. At present, various topical
supply. The stump soon dries and turns black and
methods are used for cord care, including washing
176
with soap and water, cleaning of the stump with
newborns in Kano, northern Nigeria. The aim is to
alcohol, application of dry heat, use of dusting
establish the mean separation time and the effect of
powder or antimicrobial creams. Powders currently
maternal and infant characteristics, perinatal factors
used contain varying amounts of zinc oxide, talc,
and cord care practices on the cord separation time.
starch or alum, and other ingredients. Some powders
We also sought to find out the mothers' sources of
also contain hexachlorophane or chlorhexidine.
4
information about cord care and their perceived best
Common antimicrobial agents applied, include triple
cord care practices.
dye, tincture of iodine, iodophors, antibiotic
ointments, silver sulfadiazine, povidone-iodine and
chlorhexidine.
4
Materials and Methods
Setting
The normal process of cord separation is by
inflammation of its junction with the abdominal
skin, resulting in collection of small amounts of
The study was conducted at the Infant Welfare Clinics
cloudy mucoid material at the junction. This is often
ofAminu Kano Teaching Hospital, Kano and Murtala
misinterpreted as pus.
2,3
Variable times for cord
Mohammed Specialist Hospital, Kano. These are the
separation have been reported, with the commonly
two largest hospitals in metropolitan Kano. The study
reported periods being between five and fifteen days
was conducted over a period of three months
after birth.
4,5
Factors that may alter this process of
(October-December) in 2006. Mothers of all healthy
cord separation include delivery by caesarean
newborns delivered during this period were eligible.
section, antibiotic use, application of antiseptics to
Mothers whose babies had omphalocoele or other
the cord, defective neutrophil mobility, and infection
related congenital abnormalities and those who
in the neonate.
3,6
required hospital admission for illnesses at birth,
were excluded from the study. Informed consent was
Antiseptics have also been associated with delayed
obtained from mothers before recruitment to the
cord separation, besides making neonatal care more
7
study. Permission was obtained from both hospital
expensive. A study by Mugford et al
8
indicated that
authorities and the institutional ethical committee of
in countries where mothers are visited by midwives
Aminu Kano Teaching Hospital. A standardized
during the postnatal period, problems with the cord
interviewer administered questionnaire was pretested
often determine the number of visits.
and modified for clarity before being used to
interview 600 mothers. Only mothers who had their
Data on the pattern of umbilical cord stump care,
babies
within
the
preceding
six
weeks
separation time and the effect of different cord care
wereinterviewed to enhance recall. A pair of trained
regimens are useful for many reasons. They will
research assistants that were fluent in the local
guide health care providers in differentiating
(Hausa) language administered the questionnaires at
between normal and abnormal cord separation time
the two hospitals.
in order to avoid unnecessary interventions, which
may lead to neonatal morbidity and mortality
Information was obtained on the age and sex of the
especially in developing countries where the level of
infant, antenatal care, gestational age at delivery,
hygiene is low. It is also important in designing
4
place of delivery, mother's parity, mode of delivery,
neonatal care programmes for mothers and other
birth weight, cord care practices and cord separation
caregivers.
time.
Mothers in Africa often worry and sometimes get
Data analysis
quite anxious about the time it takes for the cord to
fall off. As a result of this, different interventions are
The data was 'cleaned', validated and analysed using
SPSS version 12.
10
often practised to shorten the cord separation time.
Quantitative variables were
Although umbilical cord separation time and the
summarised using range, mean and standard
effect of cord care practices and perinatal factors
deviation. Categorical variables were tabulated using
have been reported from Ibadan
9
in southwest
frequencies and percentages. The student t test and
Nigeria, no such studies have been published from
Analysis of variance (ANOVA) were used for
northern Nigeria, where the culture and climatic
comparing means depending on the number of
conditions are different.
groups. Bonferonni's correction was applied for
multiple comparisons. The level of significance for
It is against this background that we report the
all tests was set at P< 0.05.
umbilical cord care and separation time in healthy
177
Result
Table 2: Maternal and Infant Characteristics and Time of Cord
Out of the 600 mothers requested to participate in the
Separation (n=577)
study, 577 (96.2%) accepted. The rest either declined
Cord Separation Time (days)
Characteristics
No. (%)
Mean±
SD t or F value df P value
consent or had exclusion criteria mainly due to
admissions in the neonatal period. The babies of the
Antenatal care
respondents consisted of 277 (48.0%) males and 300
Booked
561 (97.2) 4.22±
1.71 2.52
575 0.023
(52.0%) females. The time interval between birth
Unbooked
16 (2.8)
3.38±
1.31
and separation of the umbilical cord ranged from 2 to
Gestational age (wks)
14 days with a mean of 4.20 ± 1.70 days. The
umbilical cord separated within the early neonatal
(range 28 - 44 wks)
period (1 week of life) in 95.8 percent of all infants,
st
<32
3 (0.5)
3.67±
0.58
4.4
3
0.002
and the rest of the cords separated by the end of two
32-36
17 (2.9)
4.53± 1.33
weeks of life. Table 1.
37-42
452 (78.3)
4.32±
1.79
Table 1 Time of Cord Separation and Baby's Gender (n=577)
>42
105 (18.2)
4.04±
1.86
Birth weight (kg)
Cord separation
Males
Females
Total
(range 1.2- 5.9kg)
time
No(%)
No(%)
<1.5
1 (0.2)
4.00±
0.0
0.41
3
0.75
(Days)
1.5-2.499
16 (3.5)
3.81±
1.05
2-4
195(50.9)
188(49.1)
383(66.4)
2.5-4.0
383 (84.2) 4.28±
1.82
5-7
69(40.6)
101(59.4)
170(29.5)
>4.0
55 (12.1)
4.18±
11.61
8-10
12(57.1)
9(42.9)
21(3.6
>10
1(33.3)
2(66.7)
3(0.5)
Though 577 mothers knew their approximate
Total
277(48.0)
300(52.0)
577(100.0)
gestational ages by date, only 455 knew the birth
2
weight of their babies, as 105 babies were delivered at
=0.38 df=1 P=0.54 Range=2-14 days MeanSD
home and 17 mothers could not recall the birth
[All=4.201.70; Males=4.10± 1.69; Females=4.28± 1.71]
[t=-1.29 df=575 P=0.20]
weights of their babies delivered in hospital. It is not
uncommon in this environment to attend antenatal
There was no significant difference in cord
care which is free but to deliver at home because of
separation time by gender. Three hundred and forty
cost implications. . There was no significant
nine (60.9%) mothers applied methylated spirit, 145
relationship between the cord separation time and
(25.3%) hot compress, and 50 (8.7%) used
birth weight. Babies of primiparous mothers had
toothpaste ( Macleans ). Other applications included
significantly longer cord separation time compared to
herbal preparation in 20 (3.5%) and dusting powder
those of higher parity (F=3.53 df=4 P=0.007).
in nine (1.6%) others.
Similarly, among educated mothers, the higher the
level of education the longer the cord separation time
Five hundred and sixty one (97.2%) mothers booked
(F=8.41 df=4 P=0.0001). Furthermore, babies of
for antenatal care. Babies whose mothers had
lower birth order had longer cord separation time
antenatal care had significantly longer cord
compared to those of higher birth order (F=3.36 df=4
separation time (t=2.52 df=575 P=0.023). Four
P=0.01).
hundred and fifty two (78.3%) of the babies were
term, 20 (3.5%) were preterm and 105 (18.2%) post
Babies delivered by caesarean section had
term. Babies delivered before 32 weeks of
significantly longer cord separation time compared to
gestational age had significantly shorter cord
those delivered spontaneously through the vagina. In
separation time compared to more mature babies
contrast, assisted vaginal delivery (forceps or
(F=4.4 df=3 P=0.002). Three hundred and eighty
ventouse) was associated with shorter cord separation
three (84.2%) of the babies had normal birth weight,
time compared to others methods of delivery. (F=5.55
16 (3.5%) had low birth weight while 55 (12.1%)
df=2 P=0.004). Babies delivered at home had shorter
babies were macrosomic while one baby was of
cord separation time compared with those delivered
extreme low birth weight. Table 2
in the hospital (F=11.07 df=2 P=0.0001).
178
The effects of certain perinatal factors on the mean
cutting the umbilical cord at birth remained
cord separation time are shown in Table 3. There
Independent predictors of cord separation time as
were 573 responses as 4 mothers had twins. It can be
shown in table 4.
seen that the use of razor blade instead of hospital
scissors to cut the cord, shortened separation time
Regarding sources of knowledge about cord care, 363
(F=14.02 df=2 P=0.0001). Similarly, the use of
(62.9 % ) of the mothers reported that health workers
thread instead of plastic cord clamp to ligate the
told them how to care for the cord during antenatal
umbilical
cord
(F=9.69
df=2
P=0.0001)
visits or before discharge from hospital following
significantly shortened the cord separation time.
delivery. Others sources included their own mothers
Regarding cord treatment, babies whose cords were
in 146 (25.3 % ) instances, their grandmothers in 40
treated by the application of methylated spirit
(6.9 % ) and friends in 28 (4.9 % ) others. Respondents
(alcohol) had the longest mean separation time. In
opined that even though they might not have used the
contrast, those babies whose cords were treated with
option at birth, they thought the best cord care
Macleans
(toothpaste) had the shortest cord
methods included methylated spirit (277; 48.0 % ), hot
separation time. The separation time for those who
water compress (164; 28.4 % ), methylated spirit plus
used hot compress or herbal preparations were in
hot compress (67; 11.6 % ), Macleans toothpaste (29;
between the other two. After controlling for the
5.0 % ), herbal preparation (19; 3.3 % ), Macleans plus
confounding effects of other variables, only
hot compress (16; 2.8 % ) and five (0.9 % ) mentioned
maternal education and the instrument used for
dusting powder.
Table 3: Perinatal factors and cord care by age of cord separation
Cord Separation Time (days)
Characteristics
No. (%)
Mean±
SD
t or F value
df
P Value
Instrument used to cut cord
Hospital scissors
338 (58.6)
4.50±
1.81
New blade
238 (41.2)
3.76±
1.42
14.02
2
0.0001
Old blade
1 (0.2)
3.00±
0.00
Cord ‘clamp’ used
Thread
332 (57.5)
3.94±
1.57
Plastic cord clamp
239 (41.4)
4.56±
1.79
9.69
2
0.0001
Others
6 (1.0)
3.83±
2.23
Cord treatment
Methylated spirit
349 (60.9)
4.54±
1.84
Hot compress
145 (25.3)
3.82±
1.23
Macleans tooth paste
50 (8.7)
3.12±
1.22
11.77
4
0.0001
Herbal preparation
20 (3.5)
3.95±
1.70
Dusting powder
9 (1.6)
3.44±
0.88
NB Four mothers has twins.
179
Table 4: Predictors of Cord separation Time among Healthy Newborns in Kano
Non-standardized
Standardized
Coefficients
Coefficients
B
Std. Error
Beta
T
P Value
(Constant)
4.500
0.444
10.138
0.001
Parity
-0.090
0.405
-0.128
-0.223
0.824
Mode of delivery
0.033
0.088
0.016
0.377
0.706
Maternal education
0.180
0.061
0.132
2.941
0.003
Cord cutting instrument
-0.454
0.168
-0.133
-2.702
0.007
Cord Clamp
-0.175
0.164
-0.053
-1.064
0.007
Separation time compared to those who had
Discussion
spontaneous vaginal or assisted delivery. This was
also reported by earlier workers
3,5,15
who suggested
The interval between birth and umbilical cord
that it could be a reflection of decreased bacterial
separation among newborns in Kano ranged from
contamination of the umbilical cord in those delivered
two to 14 days with a mean of 4.201.70 days. This is
by caesarean section with consequent decreased
leukocyte migration to the cord. This tends to be
2
shorter than the mean separation time found in
Ibadan, Nigeria (8.73.7 days),
9
Ankara, Turkey
supported by reports indicating that umbilical cord
(8.23.2 days) and other developing countries.
1
4,11
In
separation is mediated through leukocyte infiltration
addition, the mean separation time was much shorter
and digestion.
3,11,12
Therefore, interventions that limit
than the figures reported from Europe and United
4
cord contamination may cause significant delays in
States of America (13.9 days). The different cord
3
cord separation time.
care regimens had various effects on cord separation
time as observed by earlier workers.
6,8
In contrast to previous studies,
4,5
For instance,
we found significant
we found significantly shorter separation time among
effects of maternal booking status, gestational age,
babies whose cords were treated with hot compress,
parity and types of instruments and ligatures used on
herbal preparation, Macleans (toothpaste) and
cord separation time. Babies of booked mothers had
dusting powder compared to those whose cords were
longer cord separation time. This could be related to
treated with methylated spirit (alcohol). The
the increased likelihood of booked mothers to be
differences in cord separation time could be
informed about hygienic cord care practices. In
attributed to the effect of unorthodox cord care
addition, booked mothers are also more likely to
practices coupled with the generally low level of
deliver in hospital and have the umbilical cord cut
hygiene, which probably resulted in higher rates of
with sterile hospital scissors, and to use methylated
bacterial colonization, and early falling off of the
spirit (alcohol) as a means of cord care. Babies
umbilical cord.
11
Hayward et al reported that
delivered preterm had shorter cord separation time
umbilical cord separation is mediated through
that could be related to differences in immune
leukocyte infiltration and digestion. Another reason
12
response.
may be because of the very hot weather and low
humidity in northern Nigeria.
Recent evidence
Cord care was not standardized in the centres where
indicates that rubbing alcohol does not promote
this study was conducted.
drying, is less effective against bacteria than other
This is the reason for the varied cord treatment
antimicrobials, and delays cord separation time
4,13,14
methods used. However, the majority of mothers used
thread or plastic cord clamps. A WHO review
4
however, it may reduce the incidence of omphalitis
which remains a clinical issue, especially in
reported that plastic cord clamps effectively close all
developing countries.
vessels in the umbilical cord and are easy to use.
However, they are more expensive and may not be
In keeping with most previous studies, we did not
easily available in the rural areas. Majority of mothers
observe significant differences in the mean cord
in the present study applied methylated spirit
separation time by gender.
3,5
However, this finding
(alcohol) and this was associated with the
contrasts with the report from Ibadan , where a
9
longestmean separation time. This study found that a
shorter cord separation time was found among male
quarter of mothers applied heat treatment by using hot
infants.It was observed that babies delivered by
compress, which resulted in a shorter separation time.
The danger here is not the heat itself, but the use of
180
Rags and heated soil, which may introduce bacterial
doing anything better than keeping the cord clean is
helpful ” . Few interventions for cord care have been
16
spores leading to sepsis and tetanus.
evaluated by randomized controlled trials. However,
Another interesting emerging method of cord care
the following have been recommended: hand
used by more than eight percent of mothers is the
Washing before and after contact with the umbilical
application of toothpaste to the cord stump. Babies of
area, use of sterile instruments to cut the cord,
such mothers had the shortest mean separation time of
keeping the cord clean and dry, water on cotton swabs
3.12 days. The ingredients of commonly used
may be used to clean the base of the cord, exposing
toothpastes in the study area include sorbitol,
the cord to air or covering loosely with lose clean
hydrated silica, fluoride and cellulose gum. The
cloth, folding the diaper below the level of the
effects of these constituents on cord tissue need
umbilicus and encouraging breast feeding and skin-
further evaluation. Similarly, the use of herbal
skin contact with the mother to promote colonization
preparations in cord care by some mothers may
with non pathogenic bacteria from the mother's skin
introduce toxic substances or lead to bacterial
flora.
contamination of the cord. In order to prevent
neonatal morbidity and mortality due to neonatal
This study has limitations. The first is that the study
sepsis and tetanus, it is particularly important to
was hospital based. Therefore, participants are more
inform mothers, especially primigravida on good
likely to be educated, booked and to have delivered in
cord care practices.
hospital. Hence, our findings may not reflect all
varieties of cord care practices in the community,
They should be instructed to keep the cord clean by
particularly in relation to herbal substances applied to
washing with warm water and soap and exposing it to
the umbilical stump. Similarly, although most
room air. They should not to apply any substance to
communities in northwest Nigeria tend to have
the cord, and should seek medical attention if there
similar socio-cultural characteristics, other parts of
are signs of swelling or redness in the peri-umbilical
northern Nigeria are not as homogenous; therefore,
region or if there are systemic symptoms. In our study
cord care practices may be different in those parts.
population, even among booked mothers, up to 38
percent of mothers said they were not informed about
In conclusion, centres should identify safe, cheap and
cord care during antenatal care. A high proportion
easy to follow guidelines for cord care. Since
(42.4%) of those who delivered in hospital said they
controlled trials have shown that cutting the cord with
were not taught how to care for the cord before
clean instruments, washing with clean warm water or
discharge from hospital. These missed opportunities
cleaning the base with moist cotton wool and
call for the development of strategies under the
exposure to room air are effective ways of caring for
maternal-newborn continuum of care to reduce
the cord, healthcare workers should therefore
neonatal mortality in similar centres in developing
encourage mothers to practise these in addition to
Countries.
exclusive breast feeding. The application of
dangerous and untested substances to the umbilical
There seems to be no consensus on the best cord care
stump should be discouraged while further
practice. The Cochrane data base of systematic
investigations should be undertaken to determine the
reviews concluded that “ we are unable to be sure what
effects of these unorthodox substances on umbilical
is the best practice for cord care in institutions in
cord tissue.
developed countries ” but there is no evidence that
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