Cordon umbilical

J Perinat Neonat Nurs rVolume 26 Number 3, 269–274 rCopyright C 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
DOI: 10.1097/JPN.0b013e318261ca33
Comparative Effects of Using Alcohol,
Natural Drying, and Salicylic Sugar
Powder on Umbilical Stump Detachment
of Neonates
Mei-Fang Liu, RN; Tzu-Ying Lee, RN; Ying-Ling Kuo, RN; Man-Chen Lien, BS
ABSTRACT
This study compares the effectiveness of alcohol, natu-
ral drying, and salicylic sugar powder on umbilical separa-
tion time of the neonate in our high-humidity region. From
September 2007 to May 2008, a total of 143 neonates in a
community hospital were divided into 3 groups according
to their birth month in sequence. Each umbilical care regi-
men was randomly assigned to a 3-month period. Data on
occurrence of omphalitis and cord separation time were
collected by telephone follow-up until stump separation.
The salicylic sugar powder group had the lowest rates of
colonization and shortest cord separation time compared
with the natural drying and alcohol groups. No omphalitis
developed in any of the 3 groups. Natural drying and sali-
cylic sugar powder are safe and effective ways to care for
the umbilical cord stump in high-humidity regions. Nursing
professionals should consider choosing a more effective
umbilical care regimen and provide mothers with thorough
instruction.
Key Words: alcohol, natural drying, neonate, salicylic sugar
powder, umbilical cord care
Author Affiliations: Department of Nursing, Taipei Medical
University Shuang Ho Hospital (Ms Liu); Department of Nursing (Ms
Kuo), Cardinal Tein Hospital Young-Ho Branch (Ms Lien), New Taipei
City; and School of Nursing, National Taipei University of Nursing and
Health Sciences, Taipei (Ms Liu and Dr Lee), Taiwan, ROC.
The authors thank all mothers who contributed to this research.
Disclosure: The authors have disclosed that they have no significant
relationships with, or financial interest in, any commercial companies
pertaining to this article.
Corresponding Author: Tzu-Ying Lee, PhD, RN, School of Nursing,
National Taipei University of Nursing and Health Sciences, 365, Ming
Te Rd, Peitou 112, Taipei, Taiwan, ROC (tzuying@ntunhs.edu.tw).
Submitted for publication: January 29, 2012; accepted for publication:
May 28, 2012.
T
he umbilical cord is a connective tissue that links
the fetus and the placenta. After the umbilical
cord is cut, the neonate becomes independent.
In full-term neonates, the cord stump gradually withers
and usually detaches 2 weeks after birth.1
Umbilical
cord care is a routine practice performed on every
neonate until the cord stump detaches. Before dis-
charge, the mother learns how to perform umbilical
cord care. However, umbilical cord care in every coun-
try varies according to culture.2
In Taiwan, alcohol is
commonly used for umbilical care. Mothers are often
concerned with the undetached cord stump after dis-
charge from the hospital. Effective umbilical cord care
not only prevents neonatal mortality and morbidity from
bacterial infection but also reduces the mother’s stress.3
Research in different countries found that other regi-
mens such as natural drying and salicylic sugar powder
(SSP) yielded short cord separation times and could pre-
vent omphalitis,4,5
but the effectiveness of the methods
on cord separation time was inconsistent. This study
compares bacterial colonization rates and cord separa-
tion time after using natural drying, SSP, and alcohol to
clarify effective methods for umbilical cord care.
Although microorganisms colonize the neonate’s
skin, bacterial colonization on the cord stump does
not equate to infection.4,6
Omphalitis is referred to as
loss of elasticity in the skin surrounding the stump and
an area of redness and swelling larger than 2 cm or
accompanied with secretion.7
Odor occurs following
anaerobic bacterial infection. Researchers reviewed
medical records of 64 Taiwanese neonates with om-
phalitis between 1994 and 2005 and found that Staphy-
lococcus aureus, coagulase-negative staphylococci, and
Escherichia coli were leading pathogens during the 12-
year period. Staphylococcus aureus caused a significant
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 269

increase in the occurrence of omphalitis during 2000-
2005, and the mean onset of omphalitis was 14.34 ±
10.53 days.8
Umbilical cord care is routinely practiced to prevent
infection. In the 1950s, alcohol was the most common
antiseptic used for reducing neonatal tetanus9
and the
regimen has continued until today. However, several
studies4,5,10−12
found that alcohol prolongs cord sepa-
ration time compared with other umbilical cord care
regimens, mean time ranging from 6.4 to 16.9 days.
The 6.4 days might relate to the dry and hot climate in
Egypt.12
Natural drying is another umbilical cord care regi-
men that uses soap and water to cleanse the skin sur-
rounding the stump and then cotton swab or gauze to
dry and let the site air-dry.13
Natural drying is the most
economical approach to umbilical cord care. Overall,
cord separation time in the natural drying group ranged
from 4.4 to 7.7 days11,12,14
and was shorter than that in
the alcohol group. The study conducted by Chamnan-
vanakij et al9
was unique because the findings showed
no difference in cord separation time between the nat-
ural drying and alcohol groups. Although the use of no
antiseptic increases the percentage of bacterial culture
(E coli, coagulase-negative staphylococci, S aureus, and
Streptococcus group B), the rate of omphalitis is not dif-
ferent from that of other regimens.1,5,11−14
Because the
use of antiseptics may prolong cord separation time,
increase cost, and create extra workload, the American
Academy of Pediatrics1
supports natural drying care for
full-term neonates.
Salicylic sugar powder, as suggested by Pezzati
et al,5,6
could detach the umbilical cord early and has
a high rate of negative umbilical swabs compared with
other regimens. Janssen et al13
infer that salicylic sugar
in powder form has rapid water-absorbent characteris-
tics that dries up the cord stump soon and thus yields
a shorter cord separation time than alcohol.
The literature review shows that several effective
cord care regimens exist. However, alcohol concen-
tration used in many studies was either not specified
or 70% (different from the 75% commonly used in Tai-
wan). In addition, Taiwan has both tropical and sub-
tropical weather patterns, with high humidity all year
round. The effect of the natural drying and SSP regi-
mens on cord separation time, colonization, and rates
of omphalitis under this climate is unknown. This study
demonstrates an effective umbilical cord regimen ap-
propriate to the Taiwanese environment.
METHODS
This study had 2 experimental groups (natural drying
and SSP) and 1 control group (alcohol). Research was
conducted in a community hospital. To be included
in this study, neonates had to be at least 37 weeks’
gestational age, be medically stable, and stay at the
baby room after birth. Neonates were excluded from
the study if they had an infection, had received systemic
antibiotics, had a congenital or neuromuscular disease,
or had undergone surgery. Statistical power analysis
was used to calculate the required sample size. With an
α value of .05, an effect size of 0.3, and a power of 0.8
to detect a difference between groups, sample size had
to be at least 35 patients per group.
A historical comparison study was designed to not
confuse the staff in the unit. Each umbilical cord
regimen was applied on the neonates for 3 birth
months (September-November, December-February,
and March-May) in sequence. The 3 umbilical cord care
regimens, alcohol, natural drying, and SSP, were ran-
domly allocated to the 3 study periods. Before the study
started, the researchers trained nurses in the unit to per-
form the 3 types of umbilical cord care until they were
fluent in every procedure.
Data collection
Data were collected from September 2007 to May 2008.
The study was approved by the university and hospi-
tal ethics committees. Parents of the neonates who met
the sample criteria were informed about the purposes
of the study and potential benefits and risks, and they
were assured of the confidentiality of all data. Following
written parental consent, the neonate would receive the
umbilical cord care assigned at that time. Each neonate
received only one type of umbilical cord regimen. Par-
ents were informed that if they chose not to participate,
their neonate would receive the traditional umbilical
cord care (alcohol) and should not be included in the
study.
The first umbilical cord care started after the neonate
had its first bath in the baby room. For neonates in the
alcohol group, the cord stump was dried and 75% alco-
hol was applied using a cotton swab. For the neonates
in the natural drying group, the cord stump was dried
by cotton swab and then air-vented. In the SSP group,
a small bottle of SSP containing 97% powdered sugar
and 3% salicylic acid6
was made and sterilized by the
hospital pharmacy. Every week, the powder was ana-
lyzed to ensure no contamination. When administering
umbilical cord care, the cord stump was dried with cot-
ton swabs before SSP was sprinkled on its entire sur-
face. Excess powder was cleaned off.
Regardless of care regimen, both umbilical stump
and clamp were covered by sterile gauze after every
instance of umbilical cord care. The cord clamp was
removed on the third day after birth according to the
unit’s routine. To know whether the colonization would
270 www.jpnnjournal.com July/September 2012

relate to later occurrence of omphalitis, an umbilical
swab culture was performed on every neonate by the
same nurse and sent to the laboratory. The results of
bacterial colonization were reported with the neonates’
identification numbers instead of their names. The tech-
nician who reviewed the culture results was unaware of
which group the neonate belonged to. The researcher
recorded daily unit temperature and humidity during
the neonate’s hospitalization.
Each neonate received umbilical cord care twice (in
the morning and after the evening bath) per day. The
nurse performed the procedure once, and the mother
(under the nurse’s guidance) performed it once. Spe-
cific umbilical cord care guidance was provided to the
mothers of all 3 groups. Nurses taught the mothers how
to administer the assigned umbilical cord care and ob-
serve for signs and symptoms of infection at home.
Before the neonates were discharged from the unit, the
mothers were asked to demonstrate the assigned um-
bilical cord care and to continue the practice at home.
Upon discharge from the hospital, the neonate was ex-
amined by a neonatologist and a nurse.
Three infant characteristics (sex, birth weight, and
gestational age) and 4 maternal characteristics (age,
method of delivery, experience in umbilical cord care,
and level of distress related to umbilical cord care) were
recorded to examine group differences. Level of dis-
tress was measured by asking the mothers how they
felt regarding umbilical cord care: “1” (distress) or “0”
(no distress). After discharge from the hospital, data on
occurrence of redness around the umbilical cord or om-
phalitis were collected by telephone follow-up twice a
week until stump separation. Mothers were instructed
to call the hospital if they had problems, questions, or
found signs of infection.
Data analysis
Data were analyzed by SPSS 17.0 version for Windows
(SPSS Inc, Chicago, Illinois) and summarized as the
mean and standard deviation for continuous variables
and as proportions for categorical variables. Pearson
correlations and t tests were used to analyze the re-
lationships between maternal and infant characteristics
and separation time. Multiple regression analysis was
used to adjust the inequality of the confounding covari-
ance in 3 groups to investigate the unique contribution
of umbilical cord care.
RESULTS
Over a 9-month period, 150 neonates met the en-
rollment criteria and their mothers agreed to partic-
ipate. Seven were excluded because of maternal re-
quests to use different regimens (3 from alcohol to
SSP, 2 from SSP to alcohol, and 2 from natural dry-
ing to alcohol.) These requests were influenced by
other mothers or family members. In total, 143 neonates
with 51, 40, and 52 members of the alcohol, natural
drying, and SSP groups, respectively, were included.
Means and standard deviations of the neonate, mater-
nal, and unit variables in the 3 groups are summarized
in Table 1. The age of the mothers ranged from 21
to 45 years, and 77 (53.8%) of them were first-time
mothers who had no experience in administering um-
bilical cord care. Thirty-seven mothers (25.9%) gave
birth by cesarean delivery, and 42 mothers (29.3%) felt
distressed regarding the umbilical cord care. No sig-
nificant differences were found in neonate sex, birth
weight, gestational age, type of delivery, maternal age,
experience in umbilical cord care, and maternal dis-
tress among the 3 groups. The unit temperature dur-
ing the entire study period ranged from 21.6◦
C to
26.9◦
C (70.88◦
F to 80.42◦
F). The mean unit temperatures
in 3-month periods (September-November, December-
February, and March-May) were not significantly dif-
ferent among groups (F = 1.604, P = .203). However,
daytime unit humidity during the entire study period
ranged from 26% to 78%. The mean unit humidity in
each 3-month period was significantly different (F =
44.3, P ≤ .001), with the lowest for the natural drying
group and the highest for the alcohol group.
Table 2 shows numbers of the culture with different
bacteria colonization. For the rates of colonization, ev-
ery culture (N = 40) in the natural drying group had
positive colonization, whereas 94.1% of cultures (N =
48) in the alcohol group and 55.8% of cultures (N =
29) in the SSP group were positive. No omphalitis de-
veloped during the study periods.
Covariates, including birth weight and experience
(P < .1) associated with separation time, coloniza-
tion, and types of umbilical cord care, were entered
into a regression. Colonization was coded by “0” (no
colonization) and “1” (existing colonization). Colo-
nization had no significant effect on cord separa-
tion time (B = 1.29, P = .13). After adjusting for
the birth weight, experience, and colonization, signifi-
cant differences emerged for each group. The natural
drying group (B = − 3.36; 95% confidence interval [CI],
− 4.741 to − 1.978; P < .001) and the SSP group (B =
− 7.54; 95% CI, − 8.967 to − 6.113; P < .001) had sig-
nificant shorter cord separation time than the alcohol
group. Moreover, comparing stump separation time ef-
fects between the 2 intervention groups, the SSP group
had significantly shorter cord separation time than the
natural drying group (B = − 4.18, P < .001). The use
of SSP in umbilical cord care yielded the shortest mean
cord separation time (6.8 days; range, 2-17 days), nat-
ural drying was the second shortest (11.7 days; range,

Table 1. Means and standard deviations of neonate, maternal, and unit variables in the 3 groups
Alcohol (N = 51) Natural drying (N = 40) SSP (N = 52)
Mean (SD) n (%) Mean (SD) n (%) Mean (SD) n (%) F χ2
P
Boy 30 (58.8) 20 (50.0) 26 (50.0) 1.03 .599
Birth weight, g 3062 (434) 3211 (439) 3115 (402) 1.39 .251
Gestational age, wk 38.55 (1.1) 38.87 (1.0) 39.77 (1.1) 1.16 .317
Maternal age 32.0 (4.3) 31.0 (4.7) 31.4 (4.6) .64 .528
Cesarean delivery 10 (19.6) 12 (30.0) 15 (28.8) 1.64 .441
Mother has no past
experience in
umbilical cord care
25 (49.0) 24 (60.0) 28 (53.8) 1.09 .581
Maternal distress
toward the
umbilical cord
Care
11 (21.5) 17 (42.5) 14 (27.0) 4.97 .083
Unit temperature,a
◦
C
24.82 (0.93) 24.55 (1.5) 24.70 (1.06) 1.60 .203
Unit humidity,b
% 59.31 (6.22) 49.14 (8.54) 54.04 (6.90) 44.3 <.001
*Abbreviation: SSP, salicylic sugar powder.
a
Unit temperature represents the mean temperature for the unit during each group’s study period.
b
Unit humidity represents the mean humidity for the unit during each group’s study period.
6-18 days), and alcohol yielded the longest time (14.8
days; range, 6-28 days).
DISCUSSION
The purpose of administering umbilical cord care is to
reduce the risk of infection. This study compares 3 dif-
ferent umbilical cord care regimens. No omphalitis was
found. Furthermore, the use of SSP yields the shortest
cord separation time and lowest percentages of bacte-
rial colonization. The results of using natural drying are
also better than using 75% alcohol.
The observed longer cord separation time with the
alcohol regimen compared with the natural drying or
SSP care regimens is in line with data from other
studies.5,9
Unlike several studies with 16.9 days,5
9.35
days,11
14 days,4
and 11.7 days,15
mean cord separation
time in the alcohol group was 14.8 days. For the nat-
ural drying groups, the cord separation time in several
studies was 12 days,4
7.5 days,5
7.64 days,11
7.7 days,14
or 10.6 days,15
with 11.7 days in this study. Perhaps a
different percentage of alcohol was used in other stud-
ies; several studies did not specify. In addition, local
temperature, humidity, and practice procedures might
all contribute to the time length difference, but those
studies did not report these details.
For using SSP, mean cord separation time was short-
est in this study (6.8 days) and close to the study ﬁnd-
ings of 5.6 days5
and 6 days.6
The shortest period was
2 days in this study’s SSP group. This supports the con-
clusion that the use of powder form is more effective in
Table 2. Outcomes of bacteria colonization on umbilical cord and stump separation time in 3
groups
Alcohol (N = 51) Natural drying (N = 40) SSP (N = 52)
n (%) Mean (SD) n (%) Mean (SD) n (%) Mean (SD)
Coagulase-negative staphylococci 22 (43.1) 16 (40.0) 15 (28.8)
Escherichia coli 6 (11.8) 4 (10.0) 4 (7.7)
Klebsiella pneumoniae 4 (7.8) 5 (12.5) 2 (3.8)
Enterobacter 3 (5.9) 3 (7.5) 2 (3.8)
Staphylococcus aureus 4 (7.8) 8 (20.0) 3 (5.8)
Streptococcus 6 (11.8) 1 (2.5) 2 (3.8)
Others 3 (5.9) 3 (7.5) 1 (1.9)
Colonization 48 (94.1) 40 (100) 29 (55.8)
Stump separation time, d 14.8 (4.1) 11.7 (2.5) 6.8 (3.3)
Abbreviation: SSP, salicylic sugar powder.

shortening cord separation time than the use of liquid
form.6
It is inferred that powder can absorb the mois-
ture of the cord surface13
and reduce bacterial growth.
Meanwhile, salicylic acid, commonly contained in nu-
merous skincare products, can cause the cells of the
epidermis to shed more readily.16
Staphylococcus aureus, Streptococcus, and E coli are
common pathogens of omphalitis.1
Pezzati et al5
found
no significant difference in the percentages of S au-
reus, Streptococcus, E coli and total colonization in the
alcohol, natural drying, and SSP groups. Although no
neonate developed omphalitis, and the rate of om-
phalitis was not necessarily related to the colonization
rate,4,6,9
in this study, colonization percentages were
high in the alcohol and natural drying groups. It is pos-
sible that the swab sites in the SSP group had already
shown less moisture and fast withering in comparison
with the other groups on the third day after birth. Re-
gardless of the different types of umbilical cord care,
colonization did not have a significant demonstrated
effect on cord separation time in this study. Mothers in
the 3 groups did not show different distress levels. It is
possible that because researchers investigated on ma-
ternal distress before the stump completely separated,
some mothers might have felt uncomfortable, regard-
less of umbilical cord care method. Future study should
include maternal satisfaction with umbilical cord care
after the stump has completely separated.
One limitation of the study was that the neonates
could not be randomly assigned to 3 different groups
within the same time span. Although researchers
recorded the daily unit temperature and unit humidity,
and the hospital’s humidity varied significantly among
the 3 groups in the daytime, home humidity could
not be measured. Therefore, whether humidity vari-
ations affect cord separation time remains unknown.
However, according to the Central Weather Bureau,
the usual mean temperatures in northern Taiwan from
September to December range from 27.4◦
C to 17.9◦
C
(81.32◦
F-64.22◦
F) and humidity from 75.8% to 75.4%.
Mean temperatures from January to May were from
16.1◦
C to 25.2◦
C (60.98◦
F-77.36◦
F) and humidity was
from 78.5% to 76.6%.17
This study demonstrates that the
use of natural drying is better than using 75% alcohol
even in a city with high humidity. This finding is con-
sistent with previous studies in other countries.
Instead of a home visit by a nurse, the mothers in this
study were asked to report if the symptoms of infection
had occurred on their infant’s umbilical cord and the
mothers were taught how to observe for infection and
received guidance about this before discharge home.
Each mother was called twice a week at home until the
stump detached to ensure the accuracy of the report.
Also, every neonate routinely returned to the well-baby
clinic for a checkup 1 week after discharge. No mothers
reported omphalitis.
Implications for practice
To date, few studies5,6
report that SSP is effective and
safe for earlier cord detachment. This study also sup-
ports the conclusion that neonates in the SSP group had
the shortest cord detachment time and lowest bacterial
colonization than 2 other groups. Early cord detachment
might reduce maternal distress. Therefore, if parents are
concerned with the natural drying or alcohol methods,
SSP might be provided by the hospital pharmacy and
the care procedure taught.
Although SSP has the shortest cord separation time,
the use of natural drying can decrease cost and ex-
tra workload. The American Academy of Pediatrics has
supported the use of natural drying in neonatal umbili-
cal cord care.1
Many studies, including this one, support
the conclusion that omphalitis rates with the natural dry-
ing regimen were not higher than other regimens.5,11−14
If enough information and training were provided, nat-
ural drying care would be easy to apply in clinical
practice9,14
and many parents would continue to use
natural drying care at home.18
In Taiwan, because the
use of alcohol for umbilical cord care has existed for
years, if the umbilical cord care were changed from al-
cohol (an antiseptic liquid) to natural drying (no treat-
ment), the nurse would need to assess the primary care-
giver’s tolerance for the effects of natural drying care
such as possible unpleasant odor and cord drainage.
Sufficient teaching can inform parents of what to ex-
pect and how to keep the area clean and dry.18
CONCLUSION
Even with the low incidence of omphalitis, the open
wound of the umbilical stump remains an entry point
for pathogenic bacteria and the undetached cord stump
often worries mothers. Rapid healing of the cord is an
important aspect of infection prevention. This study
compares both natural drying and SSP regimens with
the alcohol regimen and their respective effectiveness.
We can conclude that natural drying and SSP are safe
and effective ways to care for the umbilical cord stump
in high-humidity regions. Depending on maternal con-
cerns and background, the nurse can choose an effec-
tive umbilical cord care regimen and provide mothers
with thorough instruction.
References
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