Midirs draft Review of Chlohexidine Study in South Africa article
The full reference for this draft article is: Trotter S (2010). MIDIRS reviewer's comments. MIDIRS Midwifery Digest20(2):263-5.
Neonatal skincare is a subject I have followed with interest since 1996. My published work on this and related issues has changed policy within the UK and beyond with my goal of standardised evidence-based guidelines gradually becoming a reality. So when I was sent this article to review I was keen to find out if it contained anything new that would either support or discount the advice I currently provide to parents and professionals on babycare practices, based on the healthy term infant.
While the research study concentrates on both mother (intervention involves the use of chlorhexidine vaginal swabs both internally and externally with a control of sterile water wipes on the external genitalia) and baby (chlorhexidine swabs were used to wipe the infants from head to toe as soon as possible after birth with a control group having only their feet wiped) I was most interested in the comparison between using an antiseptic compared to water only.
Reducing childhood mortality rate for the under five’s is the fourth of eight Millennium Development Goals (MDGs) agreed by world leaders in 2000 . The aim is to reduce this by two thirds by the year 2015 but with neonatal sepsis as a major killer it is vital to understand what steps can be taken to help achieve this goal, especially cost-effective measures that can be applied to population groups in the developing world where the vast majority of these deaths occur.
Cutland et al  studied more than 8000 subjects in their bid to ascertain whether simple washing of both mother and baby with chlorhexidine solution 0.5% had the potential to reduce vertical transmission and/or delay early onset of neonatal sepsis in the first three days of life.
It was no surprise to me that the authors of this study conclude that; ‘the use of chlorhexidine is unlikely to reduce vertically-acquired neonatal infections in any setting or population’, although some would say this is a blanket statement when compared with similar studies with different outcomes. Nonetheless, I wonder whether there are not simpler methods to achieve the same results. I would agree with Mullany & Biggar  who publish a commentary in the same issue that more studies are required but on this particular paper I would question the following:
- There is a lack of emphasis on the importance of good hand-washing techniques
- I believe the use of vaginal swabs during intrapartum period to be unnecessarily invasive
- The inclusion of a range of cultural differences and different definitions for neonatal sepsis creates too many variables for meaningful comparison
- There is no assessment of vertical transmission in the Malawi and Egyptian trials so it is difficult to compare the results
What I would like to have seen mentioned is:
- Stressing the importance of clean instruments for cutting the cord at delivery
- Acknowledging the importance of leaving the vernix rather than removing it soon after birth as it acts as a natural antibacterial and antifungal medium) 
- Recognising the importance of breastfeeding to boost immunity and reduce health risks to neonate
- Discussion around the possibility of 24hr rooming-in as this not only avoids cross infection by healthcare workers, but also encourages early colonization of non-pathogenic organisms, which in turn promotes faster healing of the cord  and normal development of the skin’s protective barrier of the neonate. I would however agree that in certain high risk settings where cord infection is actually a problem, chlorhexidine cleansing of the cord would delay cord separation – but clearly, such separation delay is of negligible concern if the same intervention is reducing mortality rates. 
- Discussion around the potential for delipidization to affect the neonate’s skin barrier due to the removal of natural antibacterials as a result of washing with chlorhexidine, alongside the lipid and water-soluble substances. This could lead to increased bacterial growth that jeopardizes the original skin cleansing technique.
- The introduction of antenatal education programmes for parents on basic babycare issues, especially cord care with its associated risks in developing countries
- The recommendation that post implementation studies would be beneficial to evaluate uptake and corresponding neonatal sepsis following the introduction evidence-based guidelines.
The conclusion of Cutland et al trial, while broadly in line with what I would expect, leaves the reader with more questions than answers. The authors do accept the study has its limitations but overall I believe this is a positive step forward in our understanding of how simple changes in practice can have far-reaching public health effects.
This paper has done nothing to change my view that a simple water-only regime of bathing for mother and neonate continues to be the safest advice. The introduction of antibacterial applications, which may seem innocuous on their own, have the potential to disrupt normal colonisation notwithstanding their potential to irritate sensitive skin. With this in mind, it is sensible to keep exposure to an absolute minimum.
In a bid to gain a wider perspective of the issues, I decided to contact Luke Mullany (author of the comment article in the Lancet). Luke has spent the past few years researching infant and neonatal survival in low-resource settings. His work involves the development of effective, low-cost interventions that may be implemented at the community level which includes; investigations into the use of topical umbilical cord cleansing with chlorhexidine (Nepal, Bangladesh), bacterial colonization of the cord and association with omphalitis (Bangladesh), prevalence, timing, and risk factors for newborn hypothermia (Nepal), development of sign-based algorithms for newborn skin and umbilical cord infections (Bangladesh, Nepal, Tanzania), and examination of the role of minimally-trained community-based health workers in improving maternal and neonatal outcomes (Burma, Nepal). With our shared interests in neonatal skincare and cordcare I was curious to see if Luke would agree with my observations on the Cutland et al study and concur with my minimalist approach to baby skincare advice for parents , , .
I am delighted to report that we were broadly in agreement on many of the points raised above. The main area of difference, though not disagreement, is that Luke’s work is mainly carried out in low resource settings in the developing world whereas my guidelines are aimed at the healthy term infant in the developed world where local resources are high. Nonetheless Luke did agree that in many cases my minimalist approach and recommendations might be applicable, although there may be a need for slight changes, to help make it more applicable in low resource settings.
Similarly I concede that more work needs to be done to understand the optimal practices for newborn care in high-risk, high-mortality settings where the majority of babies are born in home or facility setting where optimal hygienic standards are rarely achieved. In these situations other methods to reduce exposure of the infant to invasive pathogens may need to be implemented in certain circumstances.
The future of baby skincare continues to evolve. If we are to avoid widespread saturation of the market with unsuitable formulations of skincare products, with their associated risks to the integrity of the neonatal skin barrier, we need to provide parents with the best advice, backed up by credible evidence. Routine use of any antibacterial cleansing agent could be the ‘thin end of the wedge’ and we should proceed with caution.
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2. Cutland CL, Madhi S A, Zell E R et al (2009). Chlorhexidine maternal-vaginal and neonate body wipes in sepsis and vertical transmission of pathogenic bacteria in South Africa: a randomised, controlled trial. The Lancet, Volume 374, Issue 9705, Pages 1909 – 1916.
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