Umbilical Cord Infection in Newborns: Signs, Treatment & Prevention

What Is Umbilical Cord Infection (Omphalitis)?

Umbilical cord infection, medically known as omphalitis, is a bacterial infection of the umbilical stump and surrounding tissues in newborns. It occurs when bacteria colonize the healing umbilical cord stump during the first few weeks of life, causing local inflammation that can potentially spread to the bloodstream.

When a baby is born, the umbilical cord that connected them to their mother is clamped and cut, leaving behind a small stump attached to the baby's navel. This stump is essentially an open wound that takes time to heal and separate from the body. Under normal circumstances, the stump dries out, turns dark, and falls off naturally within one to three weeks after birth. However, because the stump contains blood vessels that once connected directly to the baby's bloodstream, it presents a potential entry point for harmful bacteria.

Omphalitis develops when bacteria, most commonly Staphylococcus aureus, Streptococcus pyogenes, or Escherichia coli, invade the umbilical stump before it has fully healed and separated. These bacteria can cause local inflammation characterized by redness, swelling, and discharge. In more severe cases, the infection can spread into the surrounding abdominal tissues or enter the bloodstream, potentially leading to life-threatening complications such as neonatal sepsis.

The term "omphalitis" comes from the Greek word "omphalos," meaning navel, and "-itis," indicating inflammation. While the condition has become relatively rare in developed countries due to improved hygiene practices and healthcare access, it remains a significant concern in regions with limited medical resources. According to the World Health Organization, omphalitis continues to be one of the leading causes of neonatal mortality in developing countries, emphasizing the importance of proper umbilical cord care education worldwide.

Normal Cord Separation vs. Infection

Understanding what constitutes normal umbilical cord healing is essential for distinguishing between the natural separation process and an actual infection. During normal healing, the cord stump progressively dries out, changing from a yellow-green color to brown or black as it mummifies. It's common to see a small amount of clear or slightly blood-tinged fluid at the base of the stump, and there may be a mild odor as the tissue naturally breaks down. These are not signs of infection.

The key difference lies in the appearance of the surrounding skin and the nature of any discharge. In normal cord separation, the skin around the navel remains its normal color and texture, and any fluid present is clear or only slightly yellowish. In contrast, an infected cord stump causes the surrounding skin to become red, warm, and swollen, often with the redness spreading outward from the navel. Any discharge from an infected cord is typically thick, purulent (pus-like), and has a distinctly foul, unpleasant smell.

What Are the Symptoms of an Infected Umbilical Cord?

The primary symptoms of umbilical cord infection include redness and swelling spreading from the navel onto the surrounding skin, foul-smelling yellowish or greenish discharge (pus), warmth around the umbilical area, and the baby showing discomfort when the area is touched. Severe infections may cause fever, lethargy, poor feeding, and gray or pale skin.

Recognizing the symptoms of umbilical cord infection early is crucial because prompt treatment can prevent serious complications. The signs typically appear during the first two weeks of life, with most cases developing between three and seven days after birth. Symptoms can range from mild, localized inflammation to severe systemic illness, depending on how far the infection has progressed.

The earliest and most visible sign of omphalitis is periumbilical erythema - redness of the skin surrounding the umbilical stump. In a healthy, uninfected cord, the skin at the junction between the stump and the belly remains its normal color. When infection sets in, this area becomes pink or red, and the discoloration spreads outward, sometimes extending several centimeters onto the abdominal wall. The affected skin often feels warm to the touch and may appear swollen or indurated (hardened).

Another hallmark symptom is abnormal discharge from the umbilical area. While some clear fluid is normal during cord separation, infected stumps produce purulent discharge - thick, yellowish or greenish pus that has a distinctly foul, often putrid smell. This odor is markedly different from the mild smell that may accompany normal cord drying and is usually the symptom that first alerts parents that something is wrong.

Local Symptoms of Mild to Moderate Infection

In the early stages of umbilical cord infection, symptoms are typically localized to the navel and immediate surrounding area. Parents may notice that the base of the cord stump, where it attaches to the baby's skin, appears red and irritated. The baby may cry or show signs of discomfort when the area is cleaned or when the diaper rubs against the navel. Additional local symptoms include:

• Redness spreading from the navel: The pink or red discoloration extends beyond the cord stump onto the surrounding abdominal skin
• Swelling: The area around the umbilicus may appear puffy or raised compared to the rest of the abdomen
• Warmth: The infected area feels warmer than the surrounding skin when touched
• Discharge: Yellow, green, or blood-tinged pus oozing from the cord stump or its base
• Foul odor: A strong, unpleasant smell emanating from the umbilical area
• Delayed cord separation: The stump may take longer than usual to dry out and fall off

Systemic Symptoms Indicating Severe Infection

When omphalitis progresses beyond a localized infection, bacteria can enter the bloodstream and cause neonatal sepsis, a life-threatening condition requiring emergency treatment. Because newborns have immature immune systems, sepsis can develop rapidly and may initially present with subtle symptoms that escalate quickly. Parents should seek immediate medical attention if their baby displays any of the following warning signs:

• Fever or hypothermia: A rectal temperature above 38°C (100.4°F) or below 36°C (96.8°F)
• Lethargy: The baby is unusually sleepy, difficult to wake, or less responsive than normal
• Poor feeding: Refusal to breastfeed or bottle-feed, or inability to complete feeds
• Irritability: Inconsolable crying or unusual fussiness
• Skin color changes: Gray, pale, or mottled skin, especially if generalized
• Rapid or difficult breathing: Fast breathing, grunting, or visible effort to breathe
• Abdominal distension: A swollen, tense, or hard belly

When Should You Seek Medical Care?

Seek immediate medical attention if you notice redness spreading from the navel onto surrounding skin, foul-smelling or purulent discharge, or if your baby develops fever, becomes lethargic, or refuses to feed. Call emergency services if your baby has difficulty breathing, appears gray or pale, or is difficult to wake.

As a new parent, it can be challenging to determine when changes in your baby's umbilical cord warrant medical attention versus when they represent normal healing. Understanding the distinction is important because early intervention can prevent a minor infection from becoming a serious health threat, while unnecessary worry over normal cord changes can add stress during an already demanding time.

The general rule is that any sign of infection in a newborn should be evaluated by a healthcare professional promptly. Newborns have immature immune systems that may not respond to infection the same way older children or adults do, meaning infections can progress more rapidly and with less obvious warning signs. When in doubt, it is always better to have your baby examined and receive reassurance than to wait and risk a worsening condition.

Contact Your Healthcare Provider If:

You should contact your pediatrician, family doctor, or the clinic where your baby was born if you observe any of the following changes in your baby's umbilical cord or surrounding area. These symptoms suggest a possible infection that needs professional evaluation, though they may not represent an emergency:

• The skin around the umbilical stump becomes red, pink, or swollen
• There is discharge that appears yellow, green, or pus-like
• The umbilical area has a foul, unpleasant smell
• Your baby seems uncomfortable when the area is touched or during diaper changes
• The cord stump has not fallen off after three weeks
• Bleeding from the cord stump that doesn't stop with gentle pressure
• The cord stump appears wet or oozing for more than a few days after separation

Seek Emergency Care If:

Certain symptoms indicate that an umbilical cord infection may have spread to the bloodstream or surrounding tissues, creating a medical emergency. If you observe any of the following, do not wait - seek emergency medical care immediately by calling your local emergency number or going directly to the nearest emergency department:

• Fever: A rectal temperature above 38°C (100.4°F) in a newborn
• Hypothermia: A temperature below 36°C (96.8°F)
• Lethargy: Your baby is unusually sleepy, limp, or difficult to wake
• Poor feeding: Your baby refuses to eat or cannot complete feeds
• Skin changes: Your baby's skin appears gray, pale, mottled, or bluish
• Breathing problems: Fast or labored breathing, grunting, or flaring nostrils
• Abdominal changes: The belly appears swollen, hard, or tender
• Spreading redness: The redness extends more than 2 cm from the navel or is spreading rapidly

What Causes Umbilical Cord Infection?

Umbilical cord infection is caused by bacteria, most commonly Staphylococcus aureus, group A Streptococcus, and Escherichia coli, that colonize the healing umbilical stump. Risk factors include unsterile cord cutting, application of traditional substances to the stump, premature birth, low birth weight, prolonged labor, and chorioamnionitis (infection of the fetal membranes).

Understanding the causes and risk factors for omphalitis helps explain why proper umbilical cord care is so important and which babies may be at higher risk. The umbilical cord stump is essentially a healing wound that remains exposed to the environment during a vulnerable period when the newborn's immune system is still developing. Multiple factors can increase the likelihood of bacterial colonization and subsequent infection.

The umbilical stump provides an ideal environment for bacterial growth because it contains devitalized (dead) tissue rich in proteins and other nutrients. Under normal circumstances, the stump dries out quickly, which inhibits bacterial growth and allows the natural healing process to proceed. However, if the stump remains moist or is exposed to harmful bacteria, infection can develop. The stump's proximity to the diaper area also means it may come into contact with fecal bacteria, increasing infection risk if proper hygiene is not maintained.

Bacteria That Cause Omphalitis

Several types of bacteria have been identified as causative agents in umbilical cord infection. The specific organisms involved can influence how quickly the infection progresses and which antibiotics are most effective for treatment. The most common bacteria include:

• Staphylococcus aureus: The most frequent cause of omphalitis in developed countries, this bacteria lives on skin and can cause localized skin infections or more serious invasive disease
• Group A Streptococcus (Streptococcus pyogenes): Can cause rapidly progressive infections and is associated with more severe cases of omphalitis
• Escherichia coli and other gram-negative bacteria: Often involved in infections acquired during or shortly after birth, particularly in premature or hospitalized infants
• Anaerobic bacteria: These organisms thrive in oxygen-poor environments and can contribute to particularly foul-smelling infections
• Mixed flora: Many cases of omphalitis involve multiple bacterial species working together

Risk Factors for Umbilical Cord Infection

While any newborn can potentially develop omphalitis, certain factors increase the risk. Awareness of these risk factors can help healthcare providers identify high-risk infants and ensure appropriate monitoring and preventive care. Major risk factors include:

• Unsterile cord cutting: When the umbilical cord is cut with non-sterile instruments, bacteria can be introduced directly to the wound
• Application of harmful substances: Traditional practices involving the application of substances like ash, cow dung, butter, or other materials to the cord stump significantly increase infection risk
• Home births without trained attendants: Births occurring without proper sterile technique and trained supervision carry higher risk
• Premature birth: Premature infants have less developed immune systems and skin barrier function
• Low birth weight: Babies weighing less than 2,500 grams have increased susceptibility to infections
• Prolonged rupture of membranes: When the amniotic sac breaks more than 18-24 hours before delivery, bacteria have more opportunity to reach the baby
• Chorioamnionitis: Maternal infection of the fetal membranes during pregnancy increases neonatal infection risk
• Multiple gestations: Twins, triplets, and other multiples may have increased risk
• Umbilical catheterization: Medical procedures involving insertion of catheters into umbilical vessels can introduce bacteria

How Can You Prevent Umbilical Cord Infection?

Prevent umbilical cord infection by keeping the stump clean and dry, washing hands before touching the baby's navel, folding diapers below the stump to allow air circulation, and avoiding application of any substances unless directed by a healthcare provider. Allow the cord to fall off naturally - never pull it off.

The good news is that most cases of umbilical cord infection are preventable through simple hygiene practices and proper cord care. The World Health Organization and leading pediatric organizations have established evidence-based guidelines for umbilical cord care that, when followed, dramatically reduce the risk of omphalitis. These recommendations have evolved over time as research has provided better understanding of what truly protects against infection.

The cornerstone of umbilical cord care is keeping the stump clean and dry. A dry environment inhibits bacterial growth and promotes the natural mummification process that leads to cord separation. While past recommendations often included routine application of alcohol or antiseptics to the cord stump, current evidence in developed countries with good hygiene conditions suggests that "dry cord care" - keeping the cord clean with water and allowing it to air dry - is equally effective and may lead to faster cord separation.

Step-by-Step Umbilical Cord Care

Proper umbilical cord care is straightforward but requires consistency. Here is a detailed guide to caring for your newborn's umbilical stump:

1. Wash your hands: Always wash your hands thoroughly with soap and water before touching your baby's umbilical cord area. This single step is perhaps the most important for preventing infection.
2. Keep the area clean: If the cord stump becomes soiled with urine or stool, clean it gently with a cotton ball or swab dipped in plain, clean water. Clean around the base where the stump meets the skin.
3. Dry thoroughly: After cleaning, use a clean, dry cotton ball or soft cloth to gently pat the area dry. Moisture promotes bacterial growth, so thorough drying is essential.
4. Allow air exposure: The cord stump heals best when exposed to air. Fold your baby's diaper below the umbilicus so the stump is not covered. Avoid tight clothing over the area.
5. Sponge baths until separation: Until the cord falls off, give your baby sponge baths rather than submerging them in water. This helps keep the stump dry.
6. Do not pull: Allow the cord stump to fall off naturally, even if it appears to be hanging by a thread. Pulling can cause bleeding and introduce bacteria.
7. Avoid harmful substances: Do not apply alcohol, antiseptics, powder, lotions, or any traditional substances to the cord unless specifically directed by your healthcare provider.
8. Monitor daily: Check the cord stump and surrounding skin daily for any signs of infection - redness, swelling, discharge, or foul odor.

What to Avoid

Certain practices can increase the risk of umbilical cord infection or delay healing. Parents should be aware of these common mistakes:

• Applying traditional substances: Materials like ash, cow dung, butter, oil, or herbal preparations can introduce harmful bacteria
• Covering the stump tightly: Bandages, belly bands, or tight clothing that trap moisture against the stump
• Submersion in water: Full baths before the cord has separated can keep the stump wet and promote bacterial growth
• Touching without handwashing: Handling the cord area with unwashed hands is a primary route for bacterial introduction
• Pulling or twisting the stump: Attempting to speed up separation can cause bleeding and create entry points for bacteria
• Ignoring signs of infection: Delaying medical evaluation when symptoms appear allows infection to progress

How Is Umbilical Cord Infection Treated?

Treatment for umbilical cord infection depends on severity. Mild cases may be treated with topical antiseptics like chlorhexidine and careful cleaning. Moderate infections require oral antibiotics. Severe omphalitis necessitates hospitalization with intravenous antibiotics, and in rare cases, surgical drainage may be needed.

The treatment approach for umbilical cord infection varies based on the severity of the infection and whether it remains localized to the cord stump or has spread to surrounding tissues or the bloodstream. Early detection and appropriate treatment are crucial for achieving good outcomes and preventing complications. Healthcare providers will assess the extent of infection through physical examination and, when necessary, laboratory tests to guide treatment decisions.

The mainstay of omphalitis treatment is antibiotic therapy to eliminate the causative bacteria. The specific antibiotics chosen depend on the suspected organisms, the severity of infection, and local antibiotic resistance patterns. Treatment may begin with broad-spectrum antibiotics that cover the most likely pathogens and then be adjusted based on culture results that identify the specific bacteria involved.

Treatment for Mild Infections

When the infection is limited to mild redness or minimal discharge without systemic symptoms, treatment may begin with outpatient management under close medical supervision. Mild infections are typically treated with:

• Topical antiseptics: Application of chlorhexidine or other antiseptic solutions to the infected area several times daily
• Enhanced cleaning: More frequent cleaning of the cord stump with antiseptic solution followed by thorough drying
• Close monitoring: Daily assessment by parents with clear instructions on when to return for re-evaluation
• Possible oral antibiotics: Depending on the healthcare provider's assessment, oral antibiotics may be prescribed even for mild cases to prevent progression

Parents of babies with mild umbilical cord infections should watch carefully for any progression of symptoms and return immediately if redness spreads, discharge increases, or the baby develops any systemic symptoms like fever or poor feeding.

Treatment for Moderate to Severe Infections

When omphalitis involves significant spreading redness, substantial purulent discharge, or any systemic symptoms, more aggressive treatment is required. Moderate to severe infections typically necessitate:

• Hospitalization: Most babies with moderate to severe omphalitis are admitted to the hospital for close monitoring and intravenous antibiotic administration
• Intravenous antibiotics: Antibiotics given directly into the bloodstream achieve higher concentrations and work faster than oral medications. Common regimens include combinations of antibiotics that cover both gram-positive and gram-negative bacteria
• Blood cultures: Before starting antibiotics, blood samples are taken to check for bacteria in the bloodstream (sepsis) and to identify the specific organism causing infection
• Wound cultures: Swabs of the umbilical discharge help identify the causative bacteria and guide antibiotic selection
• Supportive care: Intravenous fluids, temperature regulation, and nutritional support as needed
• Monitoring for complications: Regular assessment for signs of sepsis, peritonitis, or other serious complications

Duration of Treatment

The length of antibiotic treatment depends on the severity of infection and the baby's response to therapy. Mild infections treated with oral antibiotics typically require 7 to 10 days of treatment. More severe infections requiring intravenous antibiotics may need 10 to 14 days or longer, with initial IV treatment often followed by a course of oral antibiotics after the baby has improved.

Throughout treatment, healthcare providers monitor for improvement in local symptoms (decreasing redness, less discharge) and normalization of any abnormal vital signs or laboratory values. The baby is typically considered recovered when the umbilical area has healed, cultures are negative, and the baby is feeding and behaving normally.

What Are the Potential Complications?

Untreated or severe umbilical cord infection can lead to serious complications including neonatal sepsis (bloodstream infection), peritonitis (abdominal cavity infection), necrotizing fasciitis (rapidly spreading tissue infection), portal vein thrombosis, and in severe cases, death. Early treatment dramatically reduces these risks.

While most cases of umbilical cord infection resolve completely with appropriate treatment, understanding potential complications emphasizes the importance of prompt medical attention. The umbilical vessels remain open to the baby's circulatory system for a period after birth, creating a direct pathway for bacteria to enter the bloodstream. Additionally, the proximity of the umbilicus to the abdominal cavity means infections can potentially spread to involve internal organs.

The risk of serious complications is directly related to how quickly the infection is recognized and treated. In developed countries with good healthcare access, severe complications are relatively rare because most cases are caught early. However, in settings where medical care is delayed or unavailable, the mortality rate from omphalitis can reach 7-15%, underscoring the condition's potential severity.

Neonatal Sepsis

The most significant complication of omphalitis is neonatal sepsis - a systemic bacterial infection of the bloodstream. When bacteria from the infected umbilical stump enter the circulation, they can spread throughout the body, causing widespread inflammation and organ dysfunction. Signs of sepsis include high or low temperature, lethargy, poor feeding, rapid breathing, and skin color changes. Neonatal sepsis is a medical emergency requiring immediate intensive care and intravenous antibiotics.

Other Serious Complications

Beyond sepsis, umbilical cord infection can lead to several other serious conditions:

• Peritonitis: Spread of infection into the abdominal cavity, causing severe abdominal pain, distension, and systemic illness
• Necrotizing fasciitis: A rapidly progressive infection of the soft tissues surrounding the umbilicus that destroys skin, fat, and muscle. This condition requires emergency surgical intervention.
• Umbilical abscess: Formation of a localized collection of pus that may require surgical drainage
• Portal vein thrombosis: Blood clots in the portal vein (which carries blood from intestines to liver) can develop as a complication of umbilical infection
• Hepatic abscess: Infection can spread along the umbilical vein to form abscesses in the liver
• Osteomyelitis: In rare cases, infection can spread to involve the bones, particularly those of the spine

What Is the Outlook for Babies with Umbilical Cord Infection?

With prompt diagnosis and appropriate antibiotic treatment, the prognosis for umbilical cord infection is excellent. The vast majority of babies recover completely without any long-term effects. Mortality is less than 1% in developed countries when treatment is timely. Complete healing of the umbilical area typically occurs within days to weeks of starting treatment.

Parents whose babies develop umbilical cord infection can feel reassured that with modern medical care, outcomes are overwhelmingly positive. The key factors in achieving a good outcome are recognizing symptoms early, seeking medical attention promptly, and completing the full course of prescribed treatment. When these steps are followed, complications are rare and babies recover fully.

During treatment, parents will typically see improvement within the first 24 to 48 hours of starting antibiotics. The redness begins to recede, discharge decreases, and the baby's behavior returns to normal. The umbilical area continues to heal over the following days to weeks, and once fully healed, there are no lasting effects from the infection. The baby's navel will look and function completely normally.

Long-term follow-up is generally not required for uncomplicated omphalitis. However, babies who experienced severe infection or complications may need periodic monitoring to ensure complete recovery. Your pediatrician will advise if any follow-up testing or appointments are necessary based on your baby's specific situation.