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To the Editor.—
We read with interest the article by Janssen et al.1 After reviewing the literature regarding umbilical cord care,2,3 our hospital began instituting the natural drying technique in December 2000. Within several months, three healthy newborns, of 
3000 deliveries per year, were noted to have bullous impetigo around the umbilical area, all culture-positive for Staphylococcus aureus.
After these infections, we surveyed local general pediatricians to determine their experiences with dry cord care and parents’ acceptance of this change. Thirty-seven pediatricians responded to our survey. Eighty percent of the respondents noted that some or most of their parents continued with the natural drying process after discharge. Seventy-three percent of the parents had no complaints about the drying method, but of those who did, most complaints were about cord drainage. Redness and odor were also noted. No additional cases of impetigo or omphalitis were reported.
One pediatrician who works with a primarily Spanish-speaking population noted problems with language barriers. Parents did not understand how to care for the umbilicus and the need to keep it clean while allowing natural drying to occur.
Sixty-nine percent of the pediatricians in our area do not recommend natural drying of the cord, citing odor and drainage as the reason. Another stated, "I prefer natural drying, but I need to counsel families more in regards to odor and how to clean the area well enough to keep the odor away." Additionally, 69% did not note earlier separation of the umbilical cord from the skin, either, although this is one of the arguments sometimes made for the natural method.
Based on these preliminary results, we believe that the natural drying method may work well in clinical populations for which sufficient teaching can be accomplished to inform the parents what to expect and how to keep the area clean and dry. However, in populations for which there are significant language and cultural barriers to care, this may not be feasible. We hope that additional studies will help clarify the issue of the best umbilical cord care in varied populations of patients.
REFERENCES
In Reply.—
The rate of 1 case of bullous impetigo per 1000 newborns reported by Weathers et al falls within the 95% confidence intervals of 0 to 8.57 cases per 1000 for the incidence of serious infection reported in our study. Weathers et al raise a critical point with respect to teaching parents about how to care for the cord stump. Practicing pediatricians in our setting are reporting that "dry" cord care is sometimes being interpreted as "no" cord care by the parents who are reluctant to touch the cord. Teaching approaches to overcome language and cultural barriers need to be implemented in settings in which dry cord care is practiced. It is not our intention to dictate a change in individual practices but rather to emphasize the need to exercise vigilant attention to signs of infection when dry cord care is implemented. We note in the Weathers et al letter that, although 69% of pediatricians do not recommend natural drying of the cord, 80% noted that some or most of their parents continued with the natural drying method. These findings suggest that parents prefer the natural drying method, thus underscoring the need for careful teaching. Larger clinical trials and/or mandatory reporting of omphalitis in varied populations are indeed indicated.
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