Can chlorhexidine (antiseptic) be used in children?

Use of Chlorhexidine in Children

Chlorhexidine can be used in children over 2 months of age with appropriate precautions, but should be used with extreme caution in infants under 2 months, particularly premature and very low birth weight infants, due to risks of skin injury and systemic absorption. 1, 2

Age-Based Recommendations

Children Over 2 Months of Age

• Chlorhexidine is safe and effective for routine use in children over 2 months for skin antisepsis before procedures, wound cleansing, and general skin preparation 1, 2
• The FDA label specifically states to "use with care in premature infants or infants under 2 months of age" but does not prohibit use in older children 2
• 2% chlorhexidine in 70% isopropyl alcohol is recommended for skin disinfection before central venous catheter insertion in this age group 1

Infants Under 2 Months of Age

• The use of chlorhexidine in infants younger than 2 months cannot be recommended due to potential side effects, according to ESPGHAN/ESPEN guidelines 1
• The FDA has not approved chlorhexidine products for children younger than 2 months of age 1
• Despite this lack of approval, chlorhexidine is commonly used in neonatal intensive care units in the USA, primarily for central venous access preparation 1

Special Considerations for Neonates and Premature Infants

Risk Factors for Complications

• Premature infants and very low birth weight infants face increased risks including contact dermatitis, chemical burns, and systemic absorption 1
• Alcohol-based chlorhexidine preparations have caused burns in infants of 24-26 weeks' gestational age 1
• Infants less than 36 weeks' gestational age may have detectable chlorhexidine blood levels after topical application due to immature skin barrier function 1

Clinical Evidence in Neonates

• Large clinical trials involving tens of thousands of neonates have used chlorhexidine for vaginal lavage, whole body cleansing, and umbilical cord care without significant adverse events 1
• Transient contact dermatitis has been reported with long-term chlorhexidine-impregnated dressings, though this may be due to dressing pressure rather than chlorhexidine itself 1
• No adverse consequences have been reported from chlorhexidine absorption in neonates, though the clinical significance of trace blood levels remains unknown 1

Application Guidelines for Pediatric Use

Proper Technique

• Allow chlorhexidine solution to dry completely before proceeding with any procedure to minimize risk of complications 1
• Use pre-soaked antiseptic applicators when possible to minimize spillage and contamination 3
• A single application is sufficient; repeated applications are unnecessary and may increase complication risk 1

Areas to Avoid

• Never use chlorhexidine in contact with eyes, ears, mouth, or mucous membranes 2
• Do not use in the genital area or in contact with meninges 2
• Avoid use as preoperative skin preparation on the head or face due to proximity to sensitive structures 2
• Do not instill in the middle ear through perforated eardrums as it may cause deafness 2

Formulation Considerations

Concentration and Vehicle

• 2% chlorhexidine in 70% isopropyl alcohol is the preferred formulation for skin antisepsis before invasive procedures in children over 2 months 1
• For infants under 2 months, if chlorhexidine must be used, aqueous solutions may be considered to avoid alcohol-related burns, though efficacy is reduced 1
• 0.5% chlorhexidine in alcohol has been studied for specific applications like neuraxial blockade 1

Adverse Reactions and Monitoring

Allergic Reactions

• Hypersensitivity reactions can occur at any age, including contact dermatitis, urticaria, and rarely anaphylaxis 1
• Contact dermatitis from chlorhexidine has been documented in young children, with some cases occurring in infants as young as 8 months 4
• Benzalkonium chloride (often present in chlorhexidine products) can also cause contact dermatitis in children 4
• Most severe anaphylactic reactions have involved application to mucous membranes or use of chlorhexidine-impregnated devices 1

When to Stop Use

• Discontinue immediately if irritation, sensitization, or allergic reaction occurs and persists for 72 hours 2
• Stop use if wheezing, difficulty breathing, shock, facial swelling, hives, or rash develop 2
• Seek immediate medical attention for any signs of severe allergic reaction 2

Common Pitfalls to Avoid

• Do not assume chlorhexidine is contraindicated in all neonates—while caution is warranted, it has been used safely in large trials and is commonly employed in NICUs 1
• Avoid alcohol-based preparations in extremely premature infants (less than 26 weeks' gestation) due to burn risk 1
• Do not apply to deep wounds or third-degree burns in any pediatric patient 2
• Ensure complete drying before procedures to prevent CSF contamination or other complications 1
• Be aware that systematic antiseptic use for umbilical cord care may cause sensitization in newborns, potentially leading to contact dermatitis 4