A Cochrane review finds that chlorhexidine may slash umbilical cord infection rates by about 29% in low- and middle- income countries and reduce newborn deaths, but the authors advise that interventions need to match the realities of the specific families and healthcare systems involved,
Umbilical cord care is a key part of newborn hygiene that helps prevent infection and promotes healthy healing. According to the World Health Organisation (WHO), about 2.3m newborn babies died in 2023, with the highest burden in low- and middle-income countries (LMICs).
Cord care practice varies widely worldwide, 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 protects
The researchers systematically reviewed 18 randomised controlled trials involving 143 150 newborns to evaluate whether applying antiseptics to the umbilical cord stump reduces infection, death, or delays cord separation, compared with no treatment. The review covered antiseptics including 4.0% chlorhexidine (CHX), 70% alcohol, silver sulfadiazine, and povidone iodine. T
The findings show that applying chlorhexidine to newborns’ umbilical cords is likely to reduce 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 may also delay, by one to two days, the time it takes for the cord stump to fall off.
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,” said Dr Aamer Imdad, Department of Paediatrics, Division of Gastroenterology, Hepatology, Pancreatology and Nutrition, 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 1.6 days, but no studies reported on mortality or omphalitis in these settings.
Contextualised to local settings
Dry cord care remains the recommended approach in countries with adequate obstetric care and low neonatal mortality. The authors said 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 faced by families and health systems.
“Our findings broadly support current WHO 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. What works best depends on local circumstances,” noted Professor Zulfiqar Ahmed Bhutta, Centre for Global Child Health in Canada and Aga Khan University in Pakistan.
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.
Study details
Umbilical cord antiseptics for preventing sepsis and death among newborns
Aamer Imdad, Melissa Medina, Chris Cooper, Zulfiqar A Bhutta, supported by the Cochrane Neonatal Review Group
Published in Cochrane on 26 March 2026
Abstract
Rationale
The umbilical cord, composed of blood vessels and connective tissue, connects the foetus to the placenta during pregnancy. After birth, the remaining cord stump may serve as an entry point for harmful bacteria, potentially leading to serious infection (neonatal sepsis) and death, particularly in low‐ and middle‐income countries (LMICs). Applying antiseptics — substances that prevent the growth of microorganisms on living tissues — may help reduce the risk of infection through the umbilical stump.
Objectives
To evaluate the benefits and harms of the application of antiseptics on a newborn’s umbilical cord versus no antiseptics for the prevention of morbidity and mortality in infants in low‐ or middle‐income countries (LMICs), and high‐income countries (HIC).
Search methods
We searched CENTRAL, MEDLINE, Embase, LILACS and trial registries in December 2025. We checked reference lists of included studies and/or studies/systematic reviews where subject matter related to the intervention or population examined in this review.
Eligibility criteria
We included individual and cluster‐randomised controlled trials comparing any antiseptic with no antiseptic applied to the umbilical cord of newborns (0 to 28 days of life), regardless of gestational age, birthweight, delivery setting, or maternal infection risk. We excluded studies involving newborns with congenital malformations, quasi‐randomised or observational designs, trials comparing different formulations or concentrations of the same antiseptic, and studies involving only topical antibiotics or antiseptic‐antibiotic combinations.
Outcomes
Our outcomes were all‐cause neonatal mortality, omphalitis, and cord separation time. All the outcomes were measured during the neonatal period (i.e. from birth to 28 days of life).
Risk of bias
The risk of bias was assessed by using the Cochrane risk of bias tool (RoB 1).
Synthesis methods
Two review authors independently assessed studies for inclusion and evaluated the risk of bias. One review author extracted the data, and a second author verified the extraction for accuracy. We analysed studies conducted in low‐ and middle‐income countries (LMICs) separately from those in high‐income countries (HICs), given the differing baseline risks. Where appropriate, we synthesised results using random‐effects meta‐analysis. We assessed the certainty of the evidence for each outcome using the GRADE approach.
Included studies
We included 18 trials in the review (143,150 participants), two studies are awaiting classification and four studies are ongoing trials. The included studies evaluated antiseptics such as 70% alcohol, 4.0% chlorhexidine (CHX), silver sulfadiazine, and povidone iodine in LMICs. In HIC, the studies evaluated CHX and alcohol.
Synthesis of results
Five population‐based trials looking at CHX in LMICs reported data on all‐cause mortality that comprised 2280 deaths in 129,381 participants. Combined results showed that topical application of CHX may lead to a small reduction in all‐cause neonatal mortality from 18/1000 to 15/1000 participants (average risk ratio (RR) 0.86; 95% confidence interval (CI) 0.73 to 1.01; 129,381 participants, 5 studies; low‐certainty evidence). Among the CHX studies that took place in an LMIC, the topical application of CHX likely reduces the risk of omphalitis from 87/1000 participants in the control group to 62/1000 participants in the CHX group (RR 0.71; 95% CI 0.60 to 0.85; 128,486 participants, 5 studies; moderate‐certainty evidence). The topical application of CHX likely increases cord separation time by 1.85 days in the CHX group compared with control (mean difference (MD) 1.85 days; 95% CI 0.81 to 2.90; 47,533 participants, 6 studies; moderate‐certainty evidence) in studies conducted in LMICs.
One study evaluated CHX in a HIC and did not report all‐cause neonatal mortality data. The evidence was very uncertain about the use of topical application of CHX for the prevention of omphalitis (RR 0.28; 95 % CI 0.06 to 1.35; 669 participants, 1 study; very low‐certainty evidence), indicating that the findings should be interpreted with caution. Similarly, the effect on cord separation time (MD: ‐0.80; 95 % CI ‐1.21 to ‐0.39; 669 participants, 1 study; very low‐certainty evidence) was very uncertain.
Four studies in LMICs evaluated the topical application of alcohol but none reported data on all‐cause mortality. The evidence for the prevention of omphalitis from topical application of alcohol is very uncertain based on two studies (RR 1.22; 95% CI 0.34 to 4.44; 270 participants, 2 studies; very low‐certainty evidence). The effect of alcohol on cord separation time is very uncertain based on data from four trials (MD −0.00 days; 95% CI −1.75 to 1.75; 598 participants, 4 studies; very low‐certainty evidence).
Four studies conducted in a HIC evaluated the topical application of alcohol. The pooled results showed that cord separation time was likely increased by 1.63 days in the alcohol group compared to the control group (MD 1.63 days; 95 % CI 1.11 to 2.15; 2117 participants, 4 studies; moderate‐certainty evidence). None of the four studies in HIC that evaluated the topical application of alcohol reported data on the prevention of all‐cause mortality or omphalitis.
Overall, the included studies had a moderate risk of selection and attrition bias, a high risk of detection and performance bias, and unclear risk of reporting bias.
Conclusions
Topical application of 4.0% chlorhexidine to the umbilical cord likely reduces the risk of cord infection and may reduce neonatal mortality in low‐ and middle‐income countries, though it probably delays cord separation by about two days. In high‐income countries, evidence for chlorhexidine is very uncertain.
For 70% alcohol, evidence from low‐ and middle‐income countries is very uncertain for prevention of infection, and its use may result in little or no difference in cord separation time. In high‐income countries, moderate‐certainty evidence suggests that alcohol likely delays cord separation slightly.
Cochrane News article – Simple antiseptic can reduce newborn infections (Open access)
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