Keeping a close watch essential

What is the best available evidence regarding the effectiveness of examining the umbilicus of an infant?

Clinical bottom line
The umbilicus represents a significant portal of infection into the body of an infant, especially within the healing period of the wound after umbilicus separation.

After birth, careful surveillance of the umbilical cord is essential to ensure early identification and treatment of abnormalities. When infection is suspected, prompt treatment is essential.1

Separation
• A normal umbilicus is bluish/white in colour on day one; it then begins to dry and shrink and fall off after 7 -10 days. The wound commonly heals within 15 days.1
• The infant's gestational age, chronological age, ethnicity, geography, mode of birth and cord care practices may impact on the time until complete cord separation.2
• The literature acknowledged that umbilical cords of premature infants and infant boys born by caesarean section have separated later. Cords that have not separated by two weeks are delayed and when separation occurs greater than three weeks after birth, further investigation is warranted.2
• Umbilical erythema and drainage can contribute to delays in cord separation and can result from a variety of infectious conditions (omphalitis, neonatal tetanus, periumbilical necrotising fasciitis and infected umbilical artery).2
• Noninfectious causes of delayed cord separation include umbilical granuloma, vitelline duct anomalies and urachal anomalies.2

Assessment
• Assessing the umbilical cord is a routine part of every infant examination. The site should be inspected for normal drying; the skin around the base of the cord should be checked for erythema and palpated for warmth.2
• The umbilicus may be infected if it is red, swollen, draining pus or foul smelling. The skin surrounding the umbilicus may be red and hardened.1
• Umbilical hernias are usually noted at birth and need no treatment as they resolve as abdominal muscles strengthen.3
• If a skin infection or omphalitis is suspected, suspicion for systemic infection should be investigated and the infant should be assessed for other systemic signs of infection (tachycardia, apnoea, temperature instability).2
• Palpate the periumbilical area for focal masses or induration noting the size, consistency and location of atypical findings. Observe for changes in the texture of the skin (skin dimpling, skin discolouration). Vesicales, bullae or rashes may also indicate a local or systemic infection. Note any signs of focal or more diffuse tenderness (facial grimace, other pain signals).2

Cord care
• The literature acknowledged that current cord care varies across practice and culture.4
• The current standards of cord care are based on the principles of asepsis: the aim is to decrease the likelihood of cord infections. Families should be taught to keep the umbilical cord clean and dry and the importance of seeking medical attention for any erythema and drainage should be emphasised. 2
• Families should be asked about the practices regarding cleaning the umbilical area.3
• Results from a systematic review show there was no difference in infection between cords managed with antiseptics, those with dry cord care and placebo. The use of antiseptics significantly delayed the time to cord separation.4

Best practice recommendations
• Infection prevention practices should be utilised when assessing or examining the umbilicus; all items in direct contact with the umbilicus and/or draining pus should be disposed of appropriately.
• Wash hands before and after handling the umbilical cord.
• Parents/families should be shown how to keep the umbilical cord clean and dry and that the use of antiseptics should not be used routinely.
• Keep the diaper folded below the umbilicus.
• Cleanse the cord with water if soiled with urine or stool.
• Keep stump exposed to air or loosely covered with clean clothes.
• Avoid applying unclean substances, touching the cord and covering it with bandages.
• There is limited evidence to suggest that there is no advantage in using antibiotics or antiseptics compared with keeping the cord clean.
• Sepsis should be treated with cloxacillin IV according to baby's age and weight instead of ampicillin. If baby is already receiving antibiotics for sepsis, substitute cloxacillin IV for ampicillin in addition to gentamicin.
• Skin infection should be treated for if pustules/blisters are present.
• The baby should be observed for 24 hours are discontinuation of antibiotics and discharge if infection has cleared, the baby is feeding well and there are no other problems requiring hospitalisation.

References
1. World Health Organization. Managing newborn problems: a guide for doctors, nurses, and midwives. Integrated Management of Pregnancy and Childbirth. 2003.
2. Donlon CR, Furdon SA. Assessment of the umbilical cord outside the delivery room. Part 2. Adv Neonatal Care. 2002;2(4):187-197.
3. Kaplan B. Assessing a new baby at home. Nursing. 1999;29(2):56hh1-56hh4. (Level IV)
4. Zupan J, Garner P, Omari AAA. Topical umbilical cord care at birth. Cochrane Database Syst Rev. 2004;3.

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