Delayed Versus Immediate Cord Clamping in Preterm Infants

Abstract

BACKGROUNDThe preferred timing of umbilical-cord clamping in preterm infants is unclear. METHODSWe randomly assigned fetuses from women who were expected to deliver before 30 weeks of gestation to either immediate clamping of the umbilical cord (≤10 seconds after delivery) or delayed clamping (≥60 seconds after delivery). The primary composite outcome was death or major morbidity (defined as severe brain injury on postnatal ultrasonography, severe retinopathy of prematurity, necrotizing enterocolitis, or late-onset sepsis) by 36 weeks of postmenstrual age. Analyses were performed on an intention-to-treat basis, accounting for multiple births. RESULTSOf 1634 fetuses that underwent randomization, 1566 were born alive before 30 weeks of gestation; of these, 782 were assigned to immediate cord clamping and 784 to delayed cord clamping. The median time between delivery and cord clamping was 5 seconds and 60 seconds in the respective groups. Complete data on the primary outcome were available for 1497 infants (95.6%). There was no significant difference in the incidence of the primary outcome between infants assigned to delayed clamping (37.0%) and those assigned to immediate clamping (37.2%) (relative risk, 1.00; 95% confidence interval, 0.88 to 1.13; P = 0.96). The mortality was 6.4% in the delayed-clamping group and 9.0% in the immediate-clamping group (P = 0.03 in unadjusted analyses; P = 0.39 after post hoc adjustment for multiple secondary outcomes). There were no significant differences between the two groups in the incidences of chronic lung disease or other major morbidities. CONCLUSIONSAmong preterm infants, delayed cord clamping did not result in a lower incidence of the combined outcome of death or major morbidity at 36 weeks of gestation than immediate cord clamping.

Patient blood management, what does this actually mean for neonates and infants?

“…The onset of breathing is a critical determinant of cardiovascular adaptation in newborns, and may be a key determinant of the size and effect of delayed cord clamping on patient outcomes (NBA, 2016). The Australian Placental Transfusion Study, a recently published RCT, randomised 1566 infants less than 30-week gestation to immediate cord clamping (within 10 s of delivery) compared with delayed cord clamping (60 s or more) (Tarnow-Mordi et al, 2017). The study found no significant difference in the study's primary composite outcome of death or major morbidity.…”

Umbilical cord blood as a source for red‐blood‐cell transfusion in neonatology: a systematic review

“…The subsequent meta‐analysis of 27 clinical trials included 2834 preterm infants: the practice to postpone the cord clamping at ≥30 s after the birth was associated with decrease of in‐hospital mortality and need for transfusions, whereas the incidence of major neonatal morbidities was not affected . Finally, a recent randomized trial has compared early (≤10 s) and delayed (≥60 s) clamping in 1566 preterm neonates: although no differences in the primary outcome of death or major morbidities were reported, less infant in the delayed‐clamping group received subsequent RBC transfusion by 36 weeks of postmenstrual age .…”

“…In conclusion, autologous UCB can cover the perioperative transfusion supplies in full‐term neonates undergoing surgery . In contrast, in preterm neonates, the most appropriate strategy to reduce the need for allogeneic transfusion seems to be the delayed umbilical cord clamping [ ] .…”

Cord clamping in term and pre‐term infants: how should clinicians proceed?

“…A recent systematic review and meta‐analysis 2 has provided the first high quality evidence that delayed cord clamping (DCC) reduces hospital mortality in pre‐term infants compared with immediate cord clamping (ICC). These findings were largely driven by the recently completed Australian Placental Transfusion Study (APTS), 3 which showed lower mortality in the DCC group than in the ICC group (6.4% v 9.0%), a difference that was not significant in post hoc adjustment for secondary outcomes ( P = 0.39). Further, there was an overall reduction in red cell transfusions in the DCC group compared with the ICC group (52.1% v 60.5%; P = 0.001), 3 which was also shown in the systematic review 2 .…”

“…These findings were largely driven by the recently completed Australian Placental Transfusion Study (APTS), 3 which showed lower mortality in the DCC group than in the ICC group (6.4% v 9.0%), a difference that was not significant in post hoc adjustment for secondary outcomes ( P = 0.39). Further, there was an overall reduction in red cell transfusions in the DCC group compared with the ICC group (52.1% v 60.5%; P = 0.001), 3 which was also shown in the systematic review 2 . The only potential harm identified was an increased incidence of polycythemia, with an increased risk difference of 3%, although this was not associated with morbidity.…”