Chlorhexidine reduces umbilical cord infections in newborns

A new Cochrane review finds that chlorhexidine likely cuts umbilical cord infection rates by about 29% in low- and middle-income countries, and may reduce newborn deaths.

Umbilical cord care is a key part of newborn hygiene that helps prevent infection and promotes healthy healing. According to the World Health Organization (WHO), approximately 2.3 million newborn babies died in 2023, with the highest burden in low- and middle-income countries (LMICs).

Cord care practice varies widely around the world, shaped by local culture, healthcare infrastructure and available resources.

In settings with adequate obstetric care and low neonatal mortality, current WHO guidelines recommend dry cord care, involving keeping the stump clean and dry without antiseptics. In settings with higher neonatal mortality, the guidelines recommend daily application of 4% chlorhexidine for a week.

Antiseptic cord care offers protection

The researchers systematically reviewed 18 randomized controlled trials involving 143,150 newborns to evaluate whether applying antiseptics to the umbilical cord stump reduces infection, death, or delays cord separation compared to no treatment. The review covered antiseptics including 4.0% chlorhexidine (CHX), 70% alcohol, silver sulfadiazine, and povidone iodine.

The findings show that applying chlorhexidine to newborns' umbilical cords likely reduces the number of infections from around 87 to 62 per 1,000 newborns and the numbers of deaths may fall from around 18 to 15 per 1,000 newborns in LMICs. Chlorhexidine likely also delays the time it takes for the cord stump to fall off by one to two days.

Only one study from a high-income country evaluated chlorhexidine. Evidence for preventing the bacterial infection omphalitis and its effect on cord separation was very uncertain, meaning conclusions cannot be drawn for these settings at this time.

In many parts of the world, newborns are still born into environments where hygiene conditions are poor. Simple and accessible cord-care interventions can significantly reduce infections in these settings, which is critical given the large share of neonatal deaths linked to infection."

Dr Aamer Imdad, lead author, University of Iowa

Evidence for alcohol use in LMICs was very uncertain for both infection prevention and cord separation time. In high-income countries, moderate-certainty evidence suggests alcohol delays cord separation by approximately 1.6 days, but no studies reported on mortality or omphalitis in these settings.

Umbilical cord care should be contextualized to local settings

Dry cord care remains the recommended approach in countries with adequate obstetric care and low neonatal mortality.

The authors explain that in many places, clean and dry cord care may be sufficient, while in others antiseptic approaches can reduce infection risk. The key is choosing interventions that match the realities families and health systems face.

"Our findings broadly support current World Health Organization guidance, but they also underline an important point: these interventions are not necessarily universal solutions. The benefits depend strongly on the context in which babies are born," says Professor Zulfiqar Ahmed Bhutta, senior author from the Centre for Global Child Health in Canada and Aga Khan University in Pakistan. "What works best depends on local circumstances."

Many studies did not share individual patient data, which the authors say would have helped answer some remaining questions more clearly. Greater and timely data sharing could greatly strengthen transparency and in-depth scientific analysis for policy.