Umbilical Cord Care: Do’s and Don’ts

Abstract

Purpose: This article aims to provide comprehensive, evidence-based guidance on umbilical cord care for newborns, specifically outlining essential “Do’s and Don’ts” to prevent infection and promote healthy healing. It seeks to emphasize the critical importance of proper cord care in reducing neonatal morbidity and mortality, particularly in resource-constrained settings, while acknowledging and addressing common traditional practices.

Findings: The umbilical cord stump, a remnant of the vital connection between mother and fetus, requires meticulous care to prevent bacterial colonization and subsequent infection, which can lead to severe conditions like omphalitis, sepsis, and neonatal tetanus. Current global guidelines advocate for “dry cord care” – keeping the stump clean and dry – as the preferred method in low-mortality settings. In high-mortality settings, the application of chlorhexidine is recommended. Conversely, the application of traditional substances (e.g., ash, animal dung, herbs, oils) is strongly discouraged due to their association with increased infection risk. Open communication and culturally sensitive health education are crucial for promoting safe practices.

Research Limitations/Implications: While extensive research supports dry cord care and chlorhexidine application, there remains a need for more localized, context-specific studies within diverse African communities to better understand the prevalence and impact of various traditional practices on neonatal outcomes. The implications highlight that effective public health interventions must integrate scientific evidence with cultural understanding to facilitate the adoption of safe cord care practices, thereby significantly contributing to improved newborn survival rates.

Practical Implications: Healthcare professionals, including midwives, nurses, community health workers, and traditional birth attendants, play a pivotal role in educating new parents and caregivers on appropriate umbilical cord care. Standardized training programs and accessible educational materials, tailored to local languages and cultural contexts, are essential. Promoting hand hygiene, proper diapering techniques, and recognizing warning signs of infection are key practical messages.

Social Implications: Implementing effective umbilical cord care strategies has profound social benefits, directly contributing to the reduction of neonatal infections, a leading cause of infant mortality globally and particularly in Africa. This, in turn, strengthens families, empowers mothers with vital health knowledge, and supports national efforts towards achieving Sustainable Development Goals related to child health and well-being. By fostering healthier newborns, communities can thrive.

Originality/Value: This article synthesizes global evidence on umbilical cord care, translating complex medical guidelines into actionable “Do’s and Don’ts” that are particularly relevant for a broad audience, including those in African contexts. By addressing the interplay between scientific best practices and traditional customs, it offers a practical resource for healthcare providers and families aiming to ensure the safest start for every newborn.

Keywords: Newborn care, umbilical cord, cord care, neonatal infection, omphalitis, sepsis, neonatal tetanus, dry cord care, chlorhexidine, traditional practices, maternal and child health, public health, infant mortality, health education, African context, community health, hygiene, neonatal morbidity.

1. Introduction: Nurturing the New Beginning – The Significance of Umbilical Cord Care

The arrival of a newborn is a moment of immense joy, boundless hope, and profound responsibility for parents and caregivers alike. As families embrace this new, precious life, they are often confronted with a myriad of questions and concerns, particularly regarding the delicate and sometimes intimidating task of newborn care. Among the most crucial aspects of early infant health and survival is the proper management of the umbilical cord stump. This small, seemingly insignificant remnant of the umbilical cord – the remarkable lifeline that connected mother and baby, providing sustenance and oxygen throughout pregnancy – serves as a potential gateway for serious infection if not cared for meticulously and appropriately. While this natural process of drying and detachment typically occurs spontaneously within one to three weeks after birth, the period before its complete separation is a critical window during which improper care can lead to severe, even life-threatening, complications for the vulnerable newborn.

Globally, neonatal infections continue to be a leading cause of infant morbidity and mortality, with infections originating from the umbilical cord contributing significantly to this tragic burden. This challenge is particularly acute in low-resource settings, where access to sterile birth environments, formal healthcare education, and essential medical supplies may be limited. In many parts of Africa, for instance, traditional practices surrounding cord care are deeply prevalent and culturally significant. While often well-intentioned, some of these customs can unfortunately introduce harmful pathogens to the delicate umbilical stump, dramatically increasing the risk of severe infections such as omphalitis (a localized infection of the cord stump), neonatal sepsis (a life-threatening systemic infection spreading throughout the body), and the devastating, often fatal, neonatal tetanus. This article aims to demystify the complexities of umbilical cord care by providing clear, concise, and evidence-based “Do’s and Don’ts.” Our goal is to empower new parents, dedicated caregivers, and frontline healthcare providers with the essential knowledge and practical skills needed to ensure a safe, healthy, and infection-free start for every newborn. By understanding and diligently implementing these simple yet profoundly vital practices, we can collectively safeguard the health and future of our youngest and most vulnerable population, contributing significantly to global child survival efforts.

2. The Umbilical Cord: A Brief Overview and Its Post-Birth Transition

To truly appreciate the importance of proper umbilical cord care, it helps to understand its structure and function. During the entirety of pregnancy, the umbilical cord serves as the baby’s vital lifeline, a remarkable biological conduit connecting the developing fetus to the placenta within the mother’s womb. This sophisticated cord typically contains three distinct vessels: two umbilical arteries, which carry deoxygenated blood and waste products away from the baby, and one umbilical vein, which delivers oxygenated, nutrient-rich blood from the mother to the baby. All three vessels are encased within a protective, gelatinous substance known as Wharton’s jelly, which provides structural support and prevents compression of the vessels.

At the moment of birth, once the baby has taken its first independent breaths and the lungs are functioning, the umbilical cord’s physiological role ceases. It is then carefully clamped in two places and cut, typically leaving a small stump, usually measuring between 2 to 3 centimeters in length, attached to the baby’s navel. This remaining stump is essentially a piece of living tissue that no longer receives blood flow or serves a functional purpose. Consequently, it begins a natural process of drying out, shriveling, changing color from a moist, bluish-white to a dry, dark brown or black, and eventually detaching completely from the baby’s belly button. This natural process, medically termed mummification and auto-amputation, usually takes approximately 7 to 21 days, though variations within this timeframe are normal. The key to ensuring healthy detachment and subsequent healing lies in preventing bacterial growth and actively promoting a dry environment around the stump, as moisture creates an ideal breeding ground for most harmful pathogens. It is crucial to remember that the navel area, immediately after the cord is cut, is essentially an open wound. This makes it particularly susceptible to bacterial colonization and infection, underscoring why diligent and proper care during this transitional period is paramount for the newborn’s well-being.

3. Why Proper Cord Care Matters: A Gateway to Health or Harm

The umbilical cord stump, despite its small size, represents a direct and vulnerable entry point into the newborn’s circulatory system. Any breach in its delicate integrity or the introduction of harmful bacteria can rapidly escalate into severe, systemic infections that pose a grave threat to the fragile life of a newborn. The consequences of improper or unhygienic cord care can be devastating and, in many cases, fatal:

• Omphalitis: This is a localized infection specifically targeting the umbilical stump and the immediately surrounding tissues. It is characterized by visible signs such as redness, swelling, and warmth around the base of the cord. Other alarming symptoms include the presence of pus-like discharge (which can be yellow, green, or white), a foul odor emanating from the area, and tenderness or pain when the navel area is gently touched. While omphalitis may initially appear as a localized issue, if left untreated or inadequately managed, the infection can quickly spread beyond the stump, leading to more severe complications.
• Neonatal Sepsis: This is a far more severe and life-threatening condition where a localized infection, such as omphalitis, spreads into the newborn’s bloodstream, triggering a systemic inflammatory response that can rapidly affect multiple vital organs. Neonatal sepsis is a leading cause of death in newborns globally, particularly in resource-constrained settings where access to rapid diagnosis and advanced medical care is limited. Symptoms of sepsis in newborns can be non-specific and subtle, making early detection challenging. These may include persistent fever (or sometimes hypothermia), pronounced lethargy or extreme drowsiness, poor feeding or refusal to feed, increased irritability, difficulty breathing (e.g., rapid breathing, grunting), and changes in skin color (e.g., pallor or mottling). Rapid progression of sepsis can lead to organ failure and death if not aggressively treated.
• Neonatal Tetanus: This is a severe, acute, and often fatal disease caused by the neurotoxin produced by the bacterium Clostridium tetani. This bacterium is ubiquitous in the environment, commonly found in soil, dust, and animal feces. When unsterile instruments are used to cut the umbilical cord at birth, or, more commonly, when contaminated substances (such as ash, animal dung, or unsterilized mud) are applied to the umbilical stump as part of traditional practices, tetanus spores can enter the open wound. Once inside the body, these spores germinate and produce toxins that attack the nervous system. Symptoms typically appear within 3 to 14 days after birth and include muscle spasms, particularly “lockjaw” (difficulty opening the mouth), generalized muscle rigidity, difficulty feeding, and severe, painful seizures. Despite advancements in medical care, neonatal tetanus carries an extremely high mortality rate. While largely preventable through maternal immunization with tetanus toxoid vaccine and the strict adherence to hygienic birth practices (including clean cord cutting and care), it remains a significant public health concern in regions where these preventative measures are not universally implemented.

Given the profound and potentially fatal risks associated with improper umbilical cord care, understanding and diligently implementing correct, evidence-based practices is not merely a recommendation; it is a fundamental pillar of newborn survival, a critical component of public health, and a moral imperative for all those involved in the care of a newborn.

4. The “Do’s” of Umbilical Cord Care: Simple Steps for Safety

Adhering to a few straightforward and evidence-based practices can significantly reduce the risk of infection and ensure the umbilical stump heals safely and efficiently. These “Do’s” are largely universal principles that form the foundation of modern, recommended cord care guidelines across the globe:

• Do Keep It Clean and Dry: This is unequivocally the golden rule of umbilical cord care and the most critical step. The primary objective is to maintain an environment around the stump that is inhospitable to bacterial growth, and moisture is a key factor that pathogens thrive on. After bathing (sponge baths are highly recommended until the cord stump has completely fallen off and the navel area is fully healed) or if the cord stump becomes soiled with urine or stool, gently clean it with plain, clean water and a mild, unscented soap. Use a soft, clean cloth or cotton swab for this. Following cleaning, it is absolutely essential to thoroughly pat the stump and the surrounding skin dry with another clean, soft cloth. The drier the stump, the faster it will shrivel and detach, and the less likely it is to become infected. It is important to note that in low-risk settings, the routine application of alcohol or other antiseptics is generally no longer recommended, as they can sometimes delay the natural drying process and irritate the delicate skin. However, in high-mortality settings, specific antiseptic applications like chlorhexidine are recommended by the WHO (see Section 6).
• Do Allow Ample Air Exposure: Air circulation is a natural drying agent that significantly aids the mummification process of the cord stump and helps to inhibit the growth of anaerobic bacteria. To facilitate this, always dress your baby in loose-fitting clothing, such as a loose-fitting vest or onesie, and ensure that diapers are positioned to allow maximum air exposure to the cord. Avoid tight bodysuits, elastic waistbands, or any clothing that might cover the cord stump tightly or trap moisture against it.
• Do Fold Diaper Below the Cord: This simple yet effective technique is crucial for two main reasons. Firstly, it prevents the top edge of the diaper from rubbing directly against the delicate stump, which can cause irritation, friction, and potentially introduce bacteria. Secondly, and equally important, it ensures that urine does not contaminate the cord stump, keeping it dry. Many newborn-sized diapers are designed with a convenient cut-out notch specifically for this purpose. If your diaper does not have this feature, simply fold the top edge down and away from the cord stump before fastening the diaper.
• Do Observe for Any Signs of Infection Daily: Vigilant and consistent visual inspection of the cord stump and the surrounding skin is absolutely crucial during every diaper change or dressing. Parents and caregivers should know what to look for. Key warning signs that warrant immediate medical attention include:
  • Redness or swelling: Any noticeable redness or puffiness around the base of the cord stump, extending onto the surrounding skin.
  • Pus-like discharge: The presence of yellow, green, or white discharge that is thick or foul-smelling. A few drops of clear or slightly blood-tinged fluid are normal as the cord dries, but persistent or purulent discharge is not.
  • Foul odor: A distinctly unpleasant or putrid smell emanating from the cord area.
  • Tenderness or pain: If your baby cries, fusses, or shows signs of discomfort when the area around the cord is gently touched.
  • Excessive or persistent bleeding: While a few drops of blood are normal as the cord separates, persistent or heavy bleeding is a concern.
  • Systemic signs of infection: These are signs that the infection may be spreading throughout the baby’s body, including fever (rectal temperature above 38°C or 100.4°F), lethargy (unusual sleepiness, difficulty waking), poor feeding or refusal to feed, increased irritability, or changes in breathing patterns.
• Do Seek Medical Advice for Any Concerns Promptly: If you observe any of the aforementioned signs of infection, or if you have any other concerns about the cord stump’s appearance, its healing progress, or your baby’s overall well-being, contact your pediatrician, a local clinic, or a healthcare professional immediately. Newborns are highly vulnerable, and infections can progress very rapidly. Early detection and prompt medical intervention are absolutely critical to preventing serious and potentially life-threatening complications. Do not hesitate or delay.
• Do Practice Rigorous Hand Hygiene: This is a cornerstone of infection prevention in all aspects of newborn care, and especially for umbilical cord care. Always wash your hands thoroughly with soap and clean, running water for at least 20 seconds before and after touching the umbilical cord stump. If soap and water are not readily available, use an alcohol-based hand sanitizer with at least 60% alcohol. This simple act prevents the transfer of bacteria from your hands to the delicate, healing area of the cord stump, safeguarding your baby from potential pathogens.

5. The “Don’ts” of Umbilical Cord Care: Practices to Avoid

Just as important as knowing and diligently following the recommended practices is understanding and consciously avoiding certain actions and substances that can be detrimental to the newborn’s health. These “Don’ts” are crucial for preventing infection and promoting safe healing:

• Don’t Apply Traditional Remedies or Harmful Substances: This is arguably the most critical “don’t” and is particularly relevant in many African and other global contexts where various traditional practices are deeply ingrained. It is absolutely essential to avoid applying any unproven or potentially contaminated substances to the umbilical cord stump. These include, but are not limited to:
  • Ash (e.g., from wood or charcoal): While sometimes used for its perceived drying or antiseptic properties, ash is often non-sterile and can introduce tetanus spores (Clostridium tetani) and a host of other harmful bacteria directly into the open wound of the umbilical stump.
  • Animal Dung (e.g., cow dung): This is highly contaminated with a vast array of bacteria, including Clostridium tetani, making it an extremely high-risk substance for causing severe neonatal infections, most notably neonatal tetanus, which is almost always fatal.
  • Herbs, Oils, Lotions, or Petroleum Jelly: These substances can create a moist environment around the stump, which is highly conducive to bacterial growth. They can also introduce irritants, allergens, or unsterile particles, potentially delaying healing or causing localized infections.
  • Saliva: The practice of “mouth-licking” the cord stump, sometimes done with the intention of cleaning or healing, is extremely dangerous as human saliva contains numerous bacteria that can cause serious infections.
  • Powders (e.g., talcum powder, cornstarch): These can clump around the cord, trapping moisture and providing a favorable medium for bacterial proliferation. They can also be inhaled by the baby, posing respiratory risks.
  • Breast Milk: While breast milk is incredibly beneficial for a baby’s nutrition and immunity when ingested, applying it topically to the cord stump can keep the area moist and potentially introduce bacteria, hindering the drying process. The World Health Organization (WHO) unequivocally and strongly advises against the application of any traditional, non-recommended, or potentially contaminated substances to the umbilical cord stump due to their well-documented association with a significantly increased risk of severe neonatal infections (WHO, 2013).
• Don’t Cover It Tightly with Bandages or Tight Clothing: The umbilical cord stump needs air to dry effectively. Avoid placing bandages, gauze, tight clothing, or anything that restricts air circulation around the cord stump. A tight covering traps moisture, creates a warm, humid environment, and can prevent the stump from drying properly, all of which significantly increase the risk of bacterial growth and infection. Allow the stump to be exposed to air as much as possible.
• Don’t Pull, Pick, or Force It Off: The umbilical cord stump is designed to detach naturally when it is ready. Never, under any circumstances, attempt to pull, pick, or force the stump off, even if it appears to be hanging by a thin thread or seems ready to fall. Doing so can cause unnecessary pain to the baby, lead to significant bleeding, and create an open wound that is highly susceptible to infection. Patience is key; it will fall off on its own.
• Don’t Bathe in a Tub Until It Falls Off and Heals: Until the umbilical cord stump has completely fallen off and the navel area is fully dry and healed, it is crucial to stick to sponge baths. Submerging the stump in bathwater can delay the natural drying process, increase the risk of contamination from bathwater (even if clean), and potentially introduce bacteria, thereby increasing the risk of infection. Once the stump has detached and the underlying skin is completely dry and free of discharge, regular tub baths can be safely resumed.
• Don’t Ignore Any Warning Signs or Delay Seeking Medical Attention: As emphasized in the “Do’s” section, it is paramount to never dismiss, underestimate, or delay seeking professional medical attention if you observe any of the warning signs of infection (such as persistent redness, swelling, pus, foul odor, or excessive bleeding) or if your baby develops systemic signs of illness (like fever, lethargy, poor feeding, or unusual irritability). Newborn infections can progress with alarming speed, and early detection coupled with prompt medical treatment is absolutely vital for a positive outcome. Your vigilance can save your baby’s life.

6. Cultural Considerations and Public Health in Africa: Bridging Tradition and Science

Umbilical cord care practices are often deeply embedded in cultural beliefs, traditional customs, and ancestral wisdom across numerous African communities. Historically, various substances and rituals have been applied to the cord stump, often with specific intentions such as promoting rapid healing, protecting the newborn from perceived evil spirits or illnesses, or fulfilling important cultural and spiritual rituals associated with birth and new life. These practices can include the application of ash (from specific trees or charcoal), animal dung (e.g., cow dung), various local herbs, traditional oils, specific types of clays, or even human saliva. While these traditions are often carried out with profound love and the best intentions for the newborn’s well-being, scientific evidence unequivocally demonstrates that many of these substances are unhygienic, non-sterile, and significantly increase the risk of severe neonatal infections, including omphalitis, sepsis, and, most critically, neonatal tetanus (Sreeramareddy et al., 2016; WHO, 2013).

Addressing these deeply rooted and culturally significant practices requires an approach characterized by profound cultural sensitivity, respect, and a commitment to collaborative engagement, rather than outright condemnation or dismissal. Public health initiatives and healthcare providers operating within diverse African contexts must adopt strategies that effectively bridge the gap between traditional wisdom and modern medical science:

• Understand and Respect Local Practices: Before attempting to introduce or enforce new guidelines, it is absolutely crucial for healthcare providers to invest time in understanding the prevailing traditional cord care practices within a specific community. This includes learning about the beliefs, values, and reasons that underpin these customs. This foundational understanding fosters trust, builds rapport, and allows for more effective, tailored, and respectful communication, avoiding a confrontational stance.
• Engage and Empower Community Leaders: Involving respected traditional birth attendants (TBAs), influential community elders, religious leaders, and local women’s groups in health education campaigns can significantly enhance the acceptance, adoption, and sustainability of evidence-based practices. These trusted figures often hold immense influence within their communities and can act as powerful advocates for positive change, translating medical advice into culturally resonant messages.
• Emphasize “Clean and Dry” and Rigorous Hand Hygiene as Universal Principles: Promoting simple, universal, and easily actionable principles like keeping the cord stump meticulously clean and dry, and emphasizing rigorous hand hygiene for anyone who touches the newborn, can be highly effective. These practices are often easier to integrate into existing routines and are less likely to conflict with deeply held beliefs than the outright prohibition of all traditional applications. The focus should be on the outcome (preventing infection) rather than simply condemning the method.
• Strategic Introduction of Chlorhexidine in High-Mortality Settings: In settings identified by the World Health Organization as having high neonatal mortality rates, particularly those where hygienic birth practices are challenging to maintain, the topical application of 7.1% chlorhexidine digluconate (which delivers 4% chlorhexidine) to the umbilical cord stump is strongly recommended by WHO. This antiseptic has been rigorously proven to significantly reduce the incidence of omphalitis and, crucially, neonatal mortality (WHO, 2013; Imdad et al., 2013). This highly effective intervention has demonstrated remarkable success in countries like Nepal and Bangladesh and is actively being scaled up and integrated into newborn care protocols in various African nations as a life-saving measure.
• Focus on Effective Risk Communication and Education: Rather than simply stating that certain traditional practices are “wrong,” it is far more effective to clearly, respectfully, and patiently explain why these practices are harmful. This involves linking them directly to the scientifically proven risks of infection, illness, and even death, using relatable examples and communicating in local languages. Visual aids, demonstrations, and interactive discussions can be powerful tools in conveying these messages effectively. Education should be empowering, not shaming.
• Integrate Health Education into Existing Health Systems and Community Structures: Consistent and reinforced messaging about safe cord care should be a routine and integral part of all antenatal care visits, community health worker home visits, postnatal check-ups, and child welfare clinics. Leveraging existing community structures, such as women’s groups, youth groups, and local gatherings, for health education sessions can ensure wider reach and greater impact. Repetition, consistency, and reinforcement of key messages are paramount for achieving sustainable behavior change.

By bridging the gap between traditional wisdom and modern medical science, and by empowering communities with accurate, actionable, and culturally appropriate health information, healthcare systems can make monumental strides in reducing neonatal infections and dramatically improving newborn survival rates across the African continent and indeed, globally. This collaborative approach ensures that cultural heritage is respected while prioritizing the health and safety of the most vulnerable.

7. Conclusion: A Healthy Start for Every Child

The umbilical cord stump, though a small and temporary part of a newborn’s anatomy, holds immense significance for their early health, well-being, and ultimately, their survival. Proper umbilical cord care – meticulously centered on keeping the stump clean and dry, ensuring ample air exposure, and maintaining vigilant observation for any signs of infection – represents a simple yet profoundly impactful intervention. Equally vital is the conscious and deliberate avoidance of practices that can introduce harmful pathogens, such as the application of traditional remedies or the use of tight coverings that impede the natural drying process.

For healthcare providers, particularly those operating within the rich and diverse cultural landscapes of Africa and other regions where traditional practices are prevalent, the responsibility extends beyond merely disseminating evidence-based guidelines. It necessitates doing so with profound cultural sensitivity, unwavering respect, and a deep understanding of local contexts. By fostering open, non-judgmental communication, providing accessible and culturally tailored education, and, where appropriate, strategically integrating proven interventions like chlorhexidine, we can collectively empower new parents and dedicated caregivers. Ultimately, ensuring safe and hygienic umbilical cord care contributes directly and powerfully to the reduction of preventable neonatal infections, safeguarding precious young lives, and laying a robust foundation for a healthy, thriving future for every child. This concerted effort not only strengthens individual families but also contributes significantly to the overall health, resilience, and prosperity of communities across Africa and around the world.

References

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Imdad, A., Mullany, L. C., Psaki, S. R., & Bhutta, Z. A. (2013). The effect of topical umbilical cord antiseptics on neonatal mortality and omphalitis in low- and middle-income countries: a systematic review and meta-analysis. Journal of Perinatology, 33(S1), S38-S49. https://doi.org/10.1038/jp.2013.4

Sreeramareddy, C. T., Joshi, R., Soneji, S., & Hussain, R. (2016). Practices and beliefs related to umbilical cord care in South Asia: a systematic review. BMC Pediatrics, 16(1), 179. https://doi.org/10.1186/s12887-016-0715-4

World Health Organization. (2013). WHO recommendations on postnatal care of the mother and newborn. WHO Press. https://apps.who.int/iris/bitstream/handle/10665/97603/9789241506649_eng.pdf