Article

Journal of Child Health Care

2015, Vol. 19(1) 118–129
Two methods of cord care ª The Author(s) 2013
Reprints and permission:
in high-risk newborns: Their sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1367493513503580

effects on hydration, chc.sagepub.com

temperature, pH, and floras

of the cord area

Youngmee Ahn, Min Sohn, Yonghoon Jun,

Eunyoung Lee and Sangmi Lee
Inha University, Korea

Abstract
This randomized clinical study explored the effects of two cord care methods on hydration,
temperature, pH, and floras at the cord area in high-risk newborns. One group used the water
method; and the other group used the alcohol method. Seventy-two newborns, including prema-
ture newborns, in the neonatal intensive care unit (NICU) of a university-affiliated hospital in South
Korea were enrolled from August 2011 to May 2012. Hydration, temperature, pH, and floras were
measured daily until the cords fell off. The results showed no difference between the groups in
hydration, temperature, pH, and the colonization of floras, but cord detachment in the alcohol
group took 2 days longer (12.8 [5.7] days) than in the water group (10.9 [4.1] days). Our findings
suggest that the clean-and-dry method of cord care, which uses water, could be sufficient, possibly
even better than alcohol in maintaining the physiologic surface milieu of the cord area with less
chance of infection and manipulation in NICUs with optimal infection control.

Keywords
Cord care, floras, high-risk newborn, pH, skin

Introduction
A newborn’s umbilical cord is a unique part of the body that experiences dramatic change. This
fetal lifeline, once part of the abdominal surface during gestation, is discarded within one to two

Corresponding author:
Youngmee Ahn, Department of Nursing, College of Medicine, Inha University, 253 Yonghyun-dong, Nam-ku, 402-751,
Incheon, Korea.
Email: aym@inha.ac.kr
Ahn et al. 119

weeks following birth. The process of ‘cord off’ involves drying and degeneration deprived of
metabolic resources such as hydration or nutrition. Although the cord could be a source of local
and systemic infection if any risk exists, the body activates a defensive mechanism of skin at the
cord area and systemic adaptation of extrauterine life in newborns. Thus, healthy newborns with
minimal risk of infection and medical supervision only require the routine cord care of the clean-
and-dry method, which uses plain water (Zupan et al., 2004). However, if cord infection is a risk,
cord care must be performed in a proscribed manner with professional supervision based on the
nature of the risk and the defensive ability of newborns. Such situations justify the traditional use
of antiseptics, such as alcohol or antibiotic ointments, in the cord care of high-risk newborns in
developing countries where contagious diseases are prevalent and access to medical treatment
to prevent umbilical infection is limited (Pezzati et al., 2002).
However, when high-risk newborns are born in hospital and receive advanced medical care in a
neonatal intensive care unit (NICU), their risk of acquiring an infection, such as cord infection,
differs quite markedly from the risk of those in developing countries, who are highly liable to
develop a communicable disease. The challenge confronting clinicians in providing cord care in
an NICU can be substantial. Is it appropriate to use the clean-and-dry method of cord care for
high-risk infants, as dictated for full-term healthy newborns, if the former are receiving
high-quality care in an NICU with no evidence of infection, or should cord care be aggressively
performed with antimicrobials, such as alcohol, because high-risk newborns are highly susceptible
to infection?
Of course, cord care in an NICU should be performed based on infection control protocol like
other medical procedures. The arbitrary application of antimicrobials, such as alcohol, may alter
the physiologic milieu of the cord area (hydration, temperature, pH, and flora colonization) during
the physiologic process of dryness and detachment of the cord stump from the abdominal surface.
Special attention must be given to the application of antimicrobial agents to the vulnerable skin of
high-risk newborns, as evidenced by alcohol burns in extremely premature infants (Lashkari et al.,
2012). Thus, the general application of antimicrobials is called into question for the cord care of
high-risk newborns in an NICU, considering their increased need for developing a resistant skin
barrier and the NICU’s superior infection control. The benefit of antimicrobials to combat
infection is unquestioned. However, a priori justification for cord care is to prevent possible infec-
tion, not to treat an infection after the fact. Thus, cord care for high-risk newborns must be designed
for the anticipatory purpose of infection prevention while establishing healthy skin conditions for
the cord-off process. Cord care for high-risk newborns demands a scholarly exploration of the
physiologic adaptation of the cord area as it evolves with the cord-off process following birth.
Newborn skin undergoes a dramatic change immediately after birth, transitioning from the
aqueous, sterile environment of the uterus to a gaseous environment with different temperatures
and microbial exposure. Developing healthy skin is of tremendous significance in the process of
extrauterine adaptation for newborns. Healthy skin, including the cord area, involves maintaining
proper hydration, temperature, and pH and colonization of normal floras at the surface. A study of
high-risk infants reported that the hydration and temperature of the skin surface are critical indi-
cators in assessing the quality of fluid balance, systemic circulation, and central and peripheral
thermoregulation (Ahn et al., 2013). Additionally, the keratinization process of the stratum
corneum (SC) is related to the pH change and floras colonizing the external surface of the epider-
mis as part of extrauterine adaptation (Hoeger and Enzmann, 2002; Mancini, 2004). Formation of
adequate pH and flora colonization is highly valuable in the physiologic defensive function of skin
against infection (Chiou and Blume-Peytavi, 2004; Schmid-Wendtner and Korting, 2006).

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Specifically, the acidity of the SC, known as the acid mantle barrier, plays an extensive role in
maintaining homeostasis and in pathogenesis, the prevention and treatment of skin diseases
(Rippke et al., 2002).
Flora colonization is one of the most important elements in developing a protective barrier on
the skin surface of newborns. The colonization of some bacterial species creates a functional
environment that prevents the overgrowth and invasion of prohibitive pathogens within the first
few days after birth (Capone et al., 2011). A recent study found more than 25 taxonomic classes of
bacteria on various sites of human skin (Capone et al., 2011). Skin infection may occur when the
balance in types and quantity of floras is interrupted and exposure to a noxious pathogen occurs.
Thus, in assessing the effect of cord care on infection control, investigating flora colonization at the
cord area may be of pivotal importance in high-risk newborns. Thus far, no widely accepted
clinical guidelines have been promulgated that recommend a protocol for cord care practices in
high-risk newborns in an NICU.
Little research has been conducted in a systematic manner on the effects of cord care methods in
high-risk newborns in NICUs. The paucity of knowledge on the changes in skin properties in new-
borns and the lack of studies offering levels I–III evidence have thwarted any attempt to develop a
standard protocol of cord care in NICU. For these reasons, this study was proposed to explore the
effects of the two most commonly used cord care methods in NICUs (the clean-and-dry method
using only water and the antimicrobial method using alcohol) on hydration, temperature, pH, and
floras at the cord area of high-risk newborns.

Method
A randomized clinical trial was conducted to compare hydration, temperature, pH, and floras on
the surface of the cord area in Korean high-risk newborns from birth to cord off. Power analysis
was performed using the pH difference between the methicillin-resistant Staphylococcus aureus
(MRSA)-negative group and the MRSA-positive group (6.12 + .50 vs. 5.44 + .10; the standar-
dized effect size ¼ .69) with .05 of a and .2 of b from a previous study (Ahn, 2012), showing the 36
subjects needed possibly to compare the effect of two types of cord care method.

Sample
All newborns, including those born prematurely, who were admitted to a level III NICU in
a university-affiliated hospital in South Korea, were recruited for this study from August 2011
to May 2012. Newborns transferred from other hospitals or with skin diseases or umbilical
lines were excluded from the study if they lacked complete medical records or if they presented
with abnormal cord conditions. The random allocation process was generated by computer
before subject recruitment. During the study period, data collection was completed for 72 new-
borns: 37 in the water group and 35 in the alcohol group. Only parents of one subject did not
want their newborn to participate in the study. One subject expired due to meconium aspiration
on the fifth day of life before cord detachment occurred and excluded from the study. Before
the commencement of data collection, the NICU nursing staff were informed of the study’s
purpose and content. The type of the group was posted on the medical record and the bedside
table of each subject to ensure that the newborns consistently received their assigned method of
cord care.

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Ahn et al. 121

Cord care and data collection

The hospital’s institutional review board approved this study. After full explanation on the
assurance on autonomously voluntary participation, free to withdraw without any threat, and the
confidentiality and anonymity, informed consent to participate in the study was obtained from
the parents of the newborns. Cord care was done at about 6:00 a.m. on the day after birth, which is
when newborns are generally given their bath. At this time, the water group received the clean-and-
dry method of cord care, which involved cord care during bathing using plain water and towel dry
like other body surface. The alcohol group received the alternative method of cord care, involving
the application of 70% isopropyl alcohol with a sterile cotton ball to the skin surface of cord area
including the residual cord part itself in circular motions for about 10 seconds. After care, new-
borns were placed in a supine position with the cord area disclosed without diaper or by folding
the diaper under the cord site to promote the natural ventilation for cord detachment. No adverse
consequences at cord areas, such as infections, were observed during the study period that would
have disrupted study protocol and required the application of antimicrobials.
Data on hydration, temperature, pH, and floras were collected at about 10:00 a.m. for five days:
day 1 (right before the first cord care), day 2, day 3, day 5 of life, and cord-off day (after cord off).
A structured manual was determined among research to make sure the standards and tangibility of
concrete data collection before initiating actual data collection. All measurements were performed
by two persons who have been working as NICU nurses actively (5 years for LEY and 12 years for
LSM among authors) to ensure the reliable measurements with daily cross-check between two
collectors and among researchers in following manners.
Microbial specimens of floras at the cord area were first obtained with a sterile swab kit (Amies
Agar Gel Swaps—no charcoal; 134C Copan Diagnostics Inc., Murrieta, California, USA), a
standard method of routine culture study in NICU, to eliminate the effect of wipeout by any contact
in subsequent measurements. After the cotton swab was applied to a one-inch diameter of cord area
in a circular motion, it was soaked with liquid medium for transport to the microbial laboratory.
Floras were identified by the degree of the colonization. Flora growth covering within one-third
of the surface on the culture plate is classified as ‘a few’, covering one-third but less than half
of the plate as ‘moderate’, and covering more than half of the plate as ‘many’. Laboratory person-
nel were blinded to the assignment of cord care methods.
To measure hydration of the SC in the cord area, a skin hydrometer (National DM-R2, Japan),
which has a rounded probe like a digital thermometer (0–99% in one decimal point), was lightly
applied to the cord area. A skin pH meter (HI 99181, HANNA Instruments, Romania) measured
temperature (5 to 105 C in one decimal point) and the pH (2 to 16 in two decimal points) of the
cord area by placing the probe on the cord area. Only a few seconds were required to obtain stable
measurements with these devices; measurements were displayed on a digital screen, which indi-
cated significance by an audible beep. Environmental humidity and temperature were measured
with a hydrometer (model 608-H2; TESTO Inc., Sparta, New Jersey, USA) in the NICU. Table 1
provides the subjects’ demographic data that were obtained from their medical records.

Analysis
Three hundred sixty sets of data were obtained. Data were analyzed using predictive analytics
software 19.0, with a ¼ .05, in a two-tailed test in which the subjects in both groups were blinded.
Hydration, temperature, and pH of the cord area were analyzed for daily variations and group

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Table 1. Homogeneity of subject characteristics at baseline (n ¼ 72).

Water (n ¼ 37) Alcohol (n ¼ 35)

Characteristics Frequency (%) or Mean (SD) 2 (p) or F (p)

Sex Female (n ¼ 32) 16 (43.2) 16 (45.7) 0.04 (1.000)

Male (n ¼ 40) 21 (56.8) 19 (54.3)
Delivery type Vaginal (n ¼ 19) 11 (29.7) 8 (22.9) 0.44 (.597)
Operation (n ¼ 53) 26 (70.3) 27 (77.1)
Preterm birth* No (n ¼ 8) 6 (16.2) 2 (5.7) 2.01 (.262)
Yes (n ¼ 74) 31 (83.8) 33 (94.3)
Use of antibiotics No (n ¼ 36) 19 (51.4) 17 (48.6) 0.06 (1.000)
Yes (n ¼ 36) 18 (48.6) 18 (51.4)
Bed type Radiant warmer (n ¼ 49) 24 (64.9) 25 (71.4) 0.36 (.618)
Incubator (n ¼ 23) 13 (35.1) 10 (28.6)
Environmental humidity (%) 35.9 (21.4) 34.7 (21.5) 0.06 (.812)
Environmental temperature ( C) 30.6 (2.4) 30.5 (2.6) 0.06 (.807)
Gestational age (week) 34.1 (2.5) 33.4 (2.2) 1.20 (.277)
Birth weight (g) 2009.5 (569.5) 1980.1 (535.8) 0.05 (.822)
Apgar score at five minutes 7.5 (2.0) 7.7 (1.5) 0.33 (.570)
*Fisher’s exact test.

comparisons using a generalized linear model (GLM). Because it was impossible to count the num-
ber of floras in each colony, the number of different floras (expressed as the number of the floras
later) was analyzed using GLM to compare the longitudinal variation in flora colonization between
groups. In addition, univariate analysis of variance and 2 were used to compare the number of
floras and the degree of the floras between groups at cord-off day. The attending physician was
notified if any unusual colonization, such as MRSA, was identified.

Results
The homogeneity analysis (Table 1) showed no differences between the water group and the
alcohol group before intervention in demographic characteristics (i.e. sex, delivery type, preterm
birth, and environmental humidity and temperature) and clinical conditions (i.e. antibiotic use, bed
type, gestation, weight at birth, and five-minute Apgar score).

Hydration, temperature, pH, and flora colonization at cord area in groups

The changes in hydration, temperature, and pH of cord area in both groups were presented across
days until the cord-off day (Table 2 and Figure 1). Hydration levels were similar in both groups at
day 1: 34.6% in the water group and 35.3% in the alcohol group (t ¼ .29, p ¼ .591). The level
decreased slightly at the cord-off day (F ¼ 2.43, p ¼ .050) in the water group, but no changes
occurred in the alcohol group (F ¼ 1.55, p ¼ .191), resulting in a significant difference between
the groups by cord-off day (t ¼ 4.61, p ¼ .035). For temperature, both groups started with similar
levels of 29.1 and 29.3 at day1 (t ¼ .19, p ¼ .666). No changes in either group were observed dur-
ing study days, and no difference between groups was detected at cord-off day. The groups’ pH
levels showed similar values of 6.95 and 6.88 at day 1 (t ¼ .77, p ¼ .382), then significantly

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 Table 2. Changes in hydration, temperature, pH, and floras of cord area between groups (n ¼ 72).

Cord-off
Day 1 Day 2 Day 3 Day 5 day

Methods Mean (SD) F (p)

Hydration (%) Water 34.6 (4.7) 33.5 (4.5) 33.1 (3.8) 33.4 (3.3)31.8 (2.6) 2.43 (.050)
Alcohol 35.3 (5.3) 33.6 (4.9) 34.0 (4.5) 33.1 (3.0)33.8 (4.2) 1.55 (.191)
t (p) 0.29 (.591) 4.61 (.035)
Temperature ( C) Water 29.1 (1.9) 28.5 (1.4) 28.5 (1.5) 28.4 (1.1) 28.2 (1.7) 1.55 (.191)
Alcohol 29.3 (1.6) 28.4 (1.4) 28.3 (1.8) 28.3 (1.4) 28.4 (2.0) 2.40 (.052)
t (p) 0.19 (.666) 0.06 (.809)
pH Water 6.95 (0.36) 6.55 (0.36) 6.24 (0.28) 6.04 (0.22) 5.83 (0.28) 75.85 (<.001)
Alcohol 6.88 (0.29) 6.49 (0.27) 6.18 (0.24) 5.95 (0.21) 5.76 (0.24) 108.20 (<.001)
t (p) 0.77 (.382) 1.27 (.265)
Number of floras* in all newborns (section A) Water 0.5 (0.7) 1.1 (0.8) 1.3 (0.7) 1.3 (0.6) 1.4 (0.7) 9.33 (<.001)
Alcohol 0.6 (0.8) 0.7 (0.8) 1.0 (0.7) 1.2 (0.6) 1.3 (0.7) 6.75 (<.001)
t (p) .13 (.725) .15 (.699)
Number of floras* in cases with any flora (section B) Water 1.2 (0.4) 1.4 (0.6) 1.4 (0.6) 1.4 (0.5) 1.5 (0.6) .96 (.433)
Alcohol 1.4 (0.5) 1.3 (0.6) 1.3 (.5) 1.3 (0.5) 1.5 (0.5) .60 (.665)
t (p) 1.97 (.171) .01 (.909)
Number of floras* in cases with moderate or  floras Water 1.3 (.5) 1.4 (.6) 1.5 (0.6) 1.4 (.5) 1.6 (.6) .75 (.557)
(section C) Alcohol 1.5 (.5) 1.5 (.7) 1.4 (.6) 1.3 (.6) 1.5 (.5) .52 (.724)
t (p) 1.20 (.285) .21 (.648)
*The number of flora kinds.

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Figure1. Variations in hydration, temperature, and pH of skin surface at cord area between groups.

Table 3. Analysis of variations in hydration, temperature, pH, and floras of cord area across days between
groups (n ¼ 72).

Number of
floras in
cases with
Number of Number of moderate
floras in all floras in cases or many
newborns with any floras floras
F (p) Hydration Temperature pH (section A) (section B) (section C)

Methods 1.52 (.219) .02 (.899) 5.56 (.019) 5.86 (.016) .07(.799) 1.62 (.168)
Days 3.45 (.009) 3.78 (.005) 177.19 (<.001) 14.32 (<.001) .93(.449) .61 (.653)
Methods  days .46 (.762) .19 (.946) .06 (.993) 1.62 (.168) .73(.573) .56 (.691)

declined to 5.83 in the water group (F ¼ 75.85, p < .001) and 5.76 in the alcohol group
(F ¼ 108.20, p < .001) throughout the study, resulting in no difference in pH at cord-off day
(t ¼ 1.27, p ¼ .265).
For flora colonization in all newborns (Table 2, section A), the groups showed similar mean
numbers (.5 and .6 at day 1 (t ¼ .13, p ¼ .725)), which then increased to 1.4 in the water group
(F ¼ 9.33, p < .001) and 1.3 in the alcohol group (F ¼ 6.75, p < .001) during the following days,
resulting in no difference in the number of floras at cord-off day (t ¼ .15, p ¼ .699). In analyzing
newborns with any positive growth of flora (Table 2, section B), the mean number of floras was 1.2
in the water group and 1.4 in the alcohol group at day 1 (t ¼ 1.97, p ¼ .171). Similar results were
observed for newborns with floras in more than moderate number (Table 2, section C); no differ-
ence was observed between day 1 and cord-off day, and no changes occurred in the groups
throughout the intervening days.
Table 3 shows the comparison of the variations in hydration, temperature, pH, and floras at the
cord area between groups during the study period. Significant changes were observed in hydration,
temperature, pH, and the number of floras in all newborns (section A) across days
(3.45 < F < 177.19, p < .010). However, in analyzing the newborns with positive growth (excluding
the ones who did not show any flora growth at the day), no daily changes in the number of floras

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Table 4. The most frequent floras between groups and duration for cord detachment (n ¼ 360).*

Water group Alcohol group

Frequency (%) or mean (SD) 2 (p) or t (p)

MRSA Absence (n ¼ 224) 107 (57.8) 117 (66.9) 3.11 (.083)

Presence (n ¼ 136) 78 (42.2) 58 (33.1)
CNS Absence (n ¼ 290) 147 (79.5) 143 (81.7) .29 (.597)
Presence (n ¼ 70) 38 (20.5) 32 (18.4)
Enterococcus Absence (n ¼ 307) 156 (84.3) 151 (86.3) .28 (.656)
Presence (n ¼ 53) 29 (15.7) 24 (13.7)
Klebsiella Absence (n ¼ 327) 167 (90.3) 160 (91.4) .15 (.719)
Presence (n ¼ 33) 18 (9.7) 15 (8.6)
Duration for cord detachment (days) 10.9 (4.1) 12.8 (5.7) 12.87 (<.001)

MRSA: methicillin-resistant Staphylococcus aureus; CNS: coagulase-negative Staphylococcus.

*n denotes the number of observations.

were observed for both newborns with any floras (section B; F ¼ .93, p ¼ .449) and with floras in
more than moderate number (section C; F ¼ .61, p ¼ .653). Significant differences between the
two groups were observed in pH (F ¼ 5.56, p ¼ .019) and the number of floras (section A;
F ¼ 5.86, p ¼ .016), but no group differences were observed in hydration and temperature or in the
number of the floras in cases with positive growth of the floras in any degree (sections B and C).
However, GLM did not reveal any variation in measurements between the cord care methods and
study days.

Duration for cord detachment and the frequently observed floras between groups
In all, 13 taxonomic kinds of flora were identified from the 360 specimens taken from the surface
of cord areas: MRSA (37.8%), coagulase-negative Staphylococcus (CNS; 19.4%), Enterococcus
(14.7%), Klebsiella (9.2%), Bacillus (5.6%), Escherichia coli (4.2%), Enterobacter (3.3%),
Pseudomonas (3.1%), Acinetobacter (2.8%), Candida albicans (1.9%), Corynebacterium (1.4%),
Strenotrophomonas (1.1%), and Streptococcus (.8%). Because the B and C sections of Tables 2 and
3 indicated neither variations in the two groups nor differences between the groups in the number of
floras once they were observed, differences in the frequency of the most frequently observed floras
(MRSA, CNS, Enterococcus, and Klebsiella), were analyzed using 2 test (Table 4). The results
showed no differences between the groups (.15 < 2 < 3.11, p > .05). In addition, a significant dif-
ference was observed in the time for cord off between the water group and the alcohol group (10.9
days vs. 12.8 days, respectively; t ¼ 12.87, p < .001).

Discussion
In an NICU, cord care for high-risk newborns has a clear aim: facilitating the physiologic process
of building up healthy skin at the cord area and controlling for infection. In this randomized clinical
trial on cord care for 72 Korean high-risk newborns in an NICU, the effects of cord care using
water only and alcohol on hydration, temperature, pH, and floras of cord area were compared. The

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study’s results suggest that cord care using alcohol has no beneficial, and possibly adverse, effects
on high-risk newborns in an NICU based on the following findings.
First, using alcohol for cord care rather than water may not be beneficial on hydration,
temperature, pH, and flora colonization of skin at the cord area based on three study findings: no
meaningful differences between the two groups in hydration, temperature, and the number of
floras, particularly at day 1 and the cord-off day (Tables 2 and 3); no variation in the number of
floras (Table 3); and no difference in the most frequently observed floras (Table 4). Similarly, pre-
vious research found no change in hydration between tap water cleansing and detergent cleansing
in healthy infants (Gfatter et al., 1997). For skin temperature of the cord area, Ahn et al. (2013)
reported no changes before cord detachment in high-risk newborns, regardless of various environ-
mental exposures such as bed types. For pH, the degree of variation across study days between
groups seemed too trivial (.09 maximum at day 5) to infer clinical meaning consistent with other
findings that have shown that cleansing with water seems comparable with cleansing with other
supplements on skin acidification for newborns (Blume-Peytavi et al., 2012; Garcia Bartels
et al., 2010).
Although the overall number of floras were less in the alcohol group than that in the water
group, more emphasis must be given on no difference in major flora colonization once they are
observed as evidenced by neither changes throughout the study period (sections B and C in
Table 2) nor variation between groups in the number of the floras with positive growth (sections B
and C in Tables 3 and 4). In studies with healthy newborns, no difference was reported in types and
quantity of bacteria at the umbilical swab between bathing with water only and with additional
soap (Medves and O’Brien, 2001) or with washing gel (Garcia Bartels et al., 2010). For premature
infants, a study reported no difference in either pluricolonization or the major flora colonization
between salicylate sugar and chlorhexidine for cord care methods (Pezzati et al., 2002). Similarly,
in a study on bathing with water only or with soap and water in premature newborns, skin colo-
nization did not differ between groups (da Cunha and Procianoy, 2005). Although the protocols
and subjects of the above studies differ from ours, all share a similar finding: flora colonization
may be a function of time rather than the type of care regimen applied to the cord area of newborns.
Thus, the study findings on hydration, temperature, pH, and flora colonization at the cord area
found little benefit in the use of alcohol for cord care in newborns in an NICU.
Furthermore, this study found that cord detachment in the alcohol group took 2 days longer than
in the water group (Table 4). Several studies of healthy newborns have reported that the natural
clean-and-dry method of cord care facilitates cord off in a shorter amount of time than cord care
with alcohol use: 4.7 days versus 6.4 days (Shoaeib et al., 2005) and 11.7 days versus 14.8 days
(Liu et al., 2012). It is even superior to chlorhexidine use: 4.24 days versus 5.32 days (Mullany
et al., 2006). Additionally, a randomized trial reported that cord off following cord care with
alcohol took longer (16.9 days) than with 1% basic fuchsin (10.3 days) and triple dye (11.6 days;
Pezzati et al., 2002). In premature infants, a study reported the shorter duration for cord off in the
natural dry group than the alcohol group (13.6 days vs. 17.0 days; Evens et al., 2004). Our study
and all of those above support the effectiveness of natural dry cord care to facilitate cord off in the
shortest amount of time in high-risk and healthy newborns who have access to anticipatory care.
With respect to sloughing and the drying process in cord detachment, a delay in cord detachment
may involve an increased risk of infection with a greater chance of irritation and manipulation
(Pezzati et al., 2002). In this study, cord off took longer to occur when alcohol was used; thus, the
routine application of alcohol at the cord site may raise the risk of infection in high-risk newborns
in an NICU.

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Ahn et al. 127

In addition to the findings above, this study yielded an unusual finding about flora colonization,
including MRSA, which demands the special attention of infection control personnel in NICUs. In
healthy infants, S. aureus, CNS, and Streptococcus are major microbial colonizers (Capone et al.,
2011; Liu et al., 2012; Medves and O’Briane, 2011). Their numbers could be decreased somewhat
with the development of other microbiomes (Capone et al., 2011). However, in this study, MRSA
was consistently the dominant colonizer, followed by CNS, Enterococcus, and Klebsiella, with
little change throughout the study period.
Recently, the Korea Centers for Disease Control and Prevention reported that 39% of 964
Korean neonates were MRSA positive and 10 of 964 neonates had infection currently. Therefore,
the actual infection rate was about 1% (Korean Ministry of Health and Welfare, 2012). This study
identified a similar MRSA exposure with 37.8% in positive and no actual infection event among 72
high-risk neonates. Therefore, the high rate of MRSA exposure with little infection event seems a
general phenomenon in all neonatal care places of Korea rather than a unique episode in this study.
One explanation on this could be the overuse of the broad-spectrum antibiotics for infection control
in a process of rapid modernization during past 30 years. Antibiotics have been over-the-counter
drug in Korea until 2000. It has brought a special alert on antibiotic resistances to make a current
policy on prescription requirement for antibiotics.
Although colonization itself does not imply infection and no subject in this study developed
signs of local or systemic infection, the dominance of MRSA may be responsible for the imbalance
of diverse flora colonization, which in turn may affect the physiologic milieu of the skin at the cord
area. Considering that only 7 of 72 subjects developed the acid mantle layer (5.5 pH), which acts
as a skin barrier, and the imbalance of flora colonization, the vulnerability and immaturity of skin
in high-risk newborns may allow for the easy spread of MRSA if it is proximate to an NICU. The
detection of MRSA colonization was immediately disclosed to NICU staff, including attending
physicians. The MRSA-positive neonates were placed in the distal corner of the NICU to keep
distance from other infants or isolated in a separate room. And NICU infection control procedures
were thoroughly reviewed and the enhancement with modification implemented regarding staff edu-
cation, staff practices and audits, instruments, policies, and the rearrangement of unit environment.

Conclusion
In the dramatic transition from womb to room, the skin of newborns confronts the immediate need
to develop a healthy physiologic milieu, a barrier to protection. A European round table meeting on
bathing and cleansing newborns reports that the normal acid mantle of the skin surface should not
be altered by bathing, soaps, or antimicrobials (Blume-Peytavi et al., 2012). The essence of cord
care is to maintain the cord area in a healthy condition, keeping the newborn safe from infection as
the stump of cord dries and detaches from the abdominal skin. Research-based evidence on the
effects of different cord care methods for high-risk newborns is scarce, and a standard cord care
protocol for NICUs has yet to be adopted.
Our study compared two cord care methods, one used water and the other used alcohol. We
found no difference between them in hydration, temperature, pH, and flora colonization of the skin
surface at the cord area and verified that high-risk newborns who received cord care that used alco-
hol experienced cord off later than newborns who received cord care with water. We conclude that
the natural clean-and-dry cord care method could be sufficient, possibly even better, in maintaining
the physiologic surface milieu of the cord area with less chance of infection and manipulation in
NICUs if high-quality infection control is the norm. Uncertainty still remains, however, about the

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process of acid mantle formation and flora colonization, which is critical to understanding skin bar-
rier function for infection control in the newborn population. Further longitudinal investigation is
warranted on these processes and how they relate to newborns.

Declaration of Conflicting Interests

The authors declared no conflicts of interest.

Funding
This research was supported by Basic Science Research Program through the National Research
Foundation of Korea funded by the Ministry of Education, Science and Technology (No.
2010-0021971).

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