A new Cochrane review finds that chlorhexidine likely cuts umbilical cord infection rates by about 29% in low- and middle-income countries, and may reduce newborn deaths.
Umbilical cord care is a key part of newborn hygiene that helps prevent infection and promotes healthy healing. According to the World Health Organization (WHO), approximately 2.3 million newborn babies died in 2023, with the highest burden in low- and middle-income countries (LMICs).
Cord care practice varies widely around the world, shaped by local culture, healthcare infrastructure and available resources.
In settings with adequate obstetric care and low neonatal mortality, current WHO guidelines recommend dry cord care, involving keeping the stump clean and dry without antiseptics. In settings with higher neonatal mortality, the guidelines recommend daily application of 4% chlorhexidine for a week.
Antiseptic cord care offers protection
The researchers systematically reviewed 18 randomized controlled trials involving 143,150 newborns to evaluate whether applying antiseptics to the umbilical cord stump reduces infection, death, or delays cord separation compared to no treatment. The review covered antiseptics including 4.0% chlorhexidine (CHX), 70% alcohol, silver sulfadiazine, and povidone iodine.
The findings show that applying chlorhexidine to newborns' umbilical cords likely reduces the number of infections from around 87 to 62 per 1,000 newborns and the numbers of deaths may fall from around 18 to 15 per 1,000 newborns in LMICs. Chlorhexidine likely also delays the time it takes for the cord stump to fall off by one to two days.
Only one study from a high-income country evaluated chlorhexidine. Evidence for preventing the bacterial infection omphalitis and its effect on cord separation was very uncertain, meaning conclusions cannot be drawn for these settings at this time.
“In many parts of the world, newborns are still born into environments where hygiene conditions are poor,” says lead author Dr Aamer Imdad from the University of Iowa. “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.”
Evidence for alcohol use in LMICs was very uncertain for both infection prevention and cord separation time. In high-income countries, moderate-certainty evidence suggests alcohol delays cord separation by approximately 1.6 days, but no studies reported on mortality or omphalitis in these settings.
Umbilical cord care should be contextualized to local settings
Dry cord care remains the recommended approach in countries with adequate obstetric care and low neonatal mortality.
The authors explain that in many places, clean and dry cord care may be sufficient, while in others antiseptic approaches can reduce infection risk. The key is choosing interventions that match the realities families and health systems face.
“Our findings broadly support current World Health Organization guidance, but they also underline an important point: these interventions are not necessarily universal solutions. The benefits depend strongly on the context in which babies are born,” says Professor Zulfiqar Ahmed Bhutta, senior author from the Centre for Global Child Health in Canada and Aga Khan University in Pakistan. “What works best depends on local circumstances.”
Many studies did not share individual patient data, which the authors say would have helped answer some remaining questions more clearly. Greater and timely data sharing could greatly strengthen transparency and in-depth scientific analysis for policy.
Cochrane Database of Systematic Reviews
10.1002/14651858.CD008635.pub3
Systematic review
People
Umbilical cord antiseptics for preventing sepsis and death among newborns
25-Mar-2026
AI: Dr. Imdad was a co-author on one of the trials on CHX conducted in population settings (Soofi 2012). The data from this paper was included in the previous version of this review. The study eligibility decisions, data extraction, and risk of bias assessment were conducted by other members of the team. AI was involved in GRADE assessment of outcomes where the study they authored contributed evidence, alongside MM who was not involved. These judgments reflected the overall body of evidence across all included studies. No commercial or non-commercial conflicts of interest relevant to this review were declared by Dr Imdad. ZAB: Professor Bhutta was a co-author on one of the trials on CHX conducted in population settings (Soofi 2012). The data from this paper were included in the previous version of this review. The study eligibility decisions, data extraction, risk of bias assessment, and GRADE assessment were conducted by other members of the team. No commercial or non-commercial conflicts of interest relevant to this review were declared by Professor Bhutta. MM: No commercial or non-commercial conflicts of interest relevant to this review. CC: Is an Information Specialist for Cochrane Neonatal; however, he did not participate in the acceptance or editorial processes for this review.