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Indian Pediatr 2015;52: 749 |
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Delayed Cord Clamping and Umbilical Cord
Milking at Birth
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Siddarth Ramji
From the Department of Neonatology, Maulana Azad
Medical College, New Delhi, India.
Email: [email protected]
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E arly cord clamping could deprive the neonate of
about a quarter of its blood volume and iron (upto 50 mg/kg). World
Health Oganization recommends delaying cord clamping (defined variably
as till pulsations cease or upto 120-180 s) as the standard of care in
the delivery room for newborns not needing resuscitation. The benefits
of delayed cord clamping include improved iron status and hemoglobin,
reduced need for blood transfusion, and improved hemodynamic stability
after birth. Yet, there appears to be concerns about practicing delayed
cord clamping, especially in neonates needing resuscitation. In such
situations, an alternative that could provide the newborn with the
desired additional blood is Umbilical Cord Milking (UCM). In this issue
of Indian Pediatrics, Kumar, et al. [1] report the
hematological effects of UCM compared to early cord clamping in preterm
(32-36 wk) neonates. While they reported higher ferritin and hemoglobin
in the UCM group at 6 weeks postnatal age, they also noted with concern
the higher rates of jaundice needing photo-therapy with UCM. Upadhyay,
et al. [2] from the same center have previously reported similar
results in neonates >35 weeks, but did not note increased jaundice or
the need for phototherapy in UCM group.
A systematic review of UCM in preterm neonates (<33
weeks) reported significantly higher hematocrit, and reduced risk of
oxygen need at 36 weeks and intra-ventricular hemorrhage (IVH) [3].
Another systematic review of delayed cord clamping in neonates between
24-36 weeks (738 infants) reported similar hematological benefits of
higher hematocrit and decreased blood transfusion, better hemodynamic
stability, decreased risk of IVH and necrotizing enterocolitis (NEC)
[4]. However, this analysis also noted higher peak bilirubin
concentrations in those with delayed cord clamping (which did not
apparently translate to increased phototherapy need). It appears that
provision of additional placental blood at birth in preterm neonates is
associated with higher bilirubin levels, but may not be a matter of
concern as it does not translate to increased interventions for
hyperbilirubinemia. Patel, et al. [5] demonstrated the benefits
of UCM even in neonates <30 weeks. In their study amongst preterm
neonates (<32 weeks) delivered by cesarean section, UCM resulted in
better systemic blood flow than those with delayed cord clamping.
There is considerable body of evidence to support the
practice of providing additional blood volume to term and preterm
neonates not needing resuscitation at birth by delaying cord clamping.
Similar results have been observed even amongst neonates where umbilical
cord milking was done. In neonates delivered by cesarean section or
amongst those needing resuscitation, umbilical cord milking may be a
more practical option for providing the additional blood volume to the
neonate resulting in better hematologic parameters and hemodynamic
stability. In under-resourced countries where maternal anemia is highly
prevalent, delayed cord clamping or UCM could decrease anemia in early
infancy, and also possibly improve survival in preterm infants by
decreasing morbidities such as IVH and NEC. There should be a concerted
effort at implementing such low cost but potentially useful strategy in
the delivery room settings globally, but more so in regions where there
is high neonatal mortality.
Funding: None; Competing interest: None
stated.
References
1. Kumar B, Upadhyay A, Gothwal S, Jaiwal V, Joshi P,
Dubey K. Umbilical cord milking and hematological parameters in moderate
to late preterm neonates: A randomized control trial. Indian Pediatr.
2015;52:753-7.
2. Upadhyay A, Gothwa S, Parihar R, Garg A, Gupta A,
Chawla D, et al. Effect of umbilical cord milking in term and
near term infants: Randomized control trial. Am J Obstet Gynecol.
2013;208:120.e1-6.
3. Al-Wassia H, Shah PS. Efficacy and safety of
umbilical cord milking at birth: A systematic review and meta-analysis.
JAMA Pediatr. 2015;169:18-25.
4. Rabe H, Diaz Rossello JL, Duley L, Dowswell T.
Effect of timing of umbilical cord clamping and other strategies to
influence placental transfusion at preterm birth on maternal and infant
outcomes. Cochrane Database Syst Rev. 2012;8:CD003248.
5. Patel S, Clark EAS, Rodriguez CE, Metz TD,
Abbaszadeh M, Yoder BA. Effect of umbilical cord milking on morbidity
and survival in extremely low gestational age neonates. Am J Obstet
Gynecol. 2014,211:519.e1-7.
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