Toward greater nuance in delayed cord clamping

Abstract

Purpose of reviewFor over a decade, the International Liaison Committee on Resuscitation has recommended delayed cord clamping (DCC), but implementation has been variable due to lack of consensus on details of technique and concerns for risks in certain patient populations. This review summarizes recent literature on the benefits and risks of DCC in term and preterm infants and examines alternative approaches such as physiologic-based cord clamping or intact cord resuscitation (ICR) and umbilical cord milking (UCM).Recent findings DCC improves hemoglobin/hematocrit among term infants and may promote improved neurodevelopment. In preterms, DCC improves survival compared to early cord clamping; however, UCM has been associated with severe intraventricular hemorrhage in extremely preterm infants. Infants of COVID-19 positive mothers, growth-restricted babies, multiples, and some infants with cardiopulmonary anomalies can also benefit from DCC. Large randomized trials of ICR will clarify safety and benefits in nonvigorous neonates. These have the potential to dramatically change the sequence of events during neonatal resuscitation. SummaryUmbilical cord management has moved beyond simple time-based comparisons to nuances of technique and application in vulnerable sub-populations. Ongoing research highlights the importance of an individualized approach that recognizes the physiologic equilibrium when ventilation is established before cord clamping.

Physiologically based cord clamping for infants ≥32+0 weeks gestation: A randomised clinical trial and reference percentiles for heart rate and oxygen saturation for infants ≥35+0 weeks gestation

“…In addition, other advances in resuscitation may be more impactful than PBCC. Consumers and policymakers may also interpret our findings as evidence that the known benefits of DCC (in relation to iron stores and neurodevelopmental outcomes) can be feasibly extended to infants who require resuscitation at birth [35].…”

Ventilatory Assistance Before Umbilical Cord Clamping in Extremely Preterm Infants

“…8 Importantly, however, infants not breathing well were excluded from many of these trials. 9 Several small clinical trials have demonstrated feasibility of providing ventilatory assistance to preterm infants with intact placental circulation without identified safety concerns. [10][11][12][13] The aim of this trial was to test the hypothesis that providing assisted ventilation starting 30 seconds after birth and clamping the cord at 120 seconds, compared with delaying cord clamping for 30 to 60 seconds with breathing assistance given afterward, would reduce any grade of IVH on head ultrasonography 7 to 10 days after birth or the competing outcome of death before day 7 in extremely preterm infants.…”

“…A 2023 individual participant data meta-analysis reported that deferring cord clamping for increasingly longer periods was associated with progressively lower mortality . Importantly, however, infants not breathing well were excluded from many of these trials . Several small clinical trials have demonstrated feasibility of providing ventilatory assistance to preterm infants with intact placental circulation without identified safety concerns …”

“… 8 Importantly, however, infants not breathing well were excluded from many of these trials. 9 Several small clinical trials have demonstrated feasibility of providing ventilatory assistance to preterm infants with intact placental circulation without identified safety concerns. 10 , 11 , 12 , 13 …”

New insights in pediatrics in 2021: choices in allergy and immunology, critical care, endocrinology, gastroenterology, genetics, haematology, infectious diseases, neonatology, neurology, nutrition, palliative care, respiratory tract illnesses and telemedicine

“…Delayed cord clamping (DCC) [ 117 ] is recommended for both preterm [ 118 ] and vigorous term neonates [ 119 ]. In a retrospective study [ 120 ] on 796 women and their term neonates delivered by cesarean section, the authors compare the effects of early versus DCC (< 30, 30–60 and 61–120 s), on short-term neonatal hematological status (hemoglobin and hematocrit) and jaundice (transcutaneous bilirubin levels on 0 to 5 days of life and the rate of phototherapy).…”