Effect of delayed vs early umbilical cord clamping on iron status and neurodevelopment at age 12 months: a randomized clinical trial

Umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

BACKGROUND

Placental management strategies such as umbilical cord milking and delayed cord clamping may provide a range of benefits for the newborn. The aim of this review was to assess the effectiveness of umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia.

METHODS

Three databases and five clinical trial registries were systematically reviewed to identify randomised controlled trials comparing umbilical cord milking or delayed cord clamping with control in term and preterm infants. The primary outcome was neonatal hypoglycaemia (study defined). Two independent reviewers conducted screening, data extraction and quality assessment. Quality of the included studies was assessed using the Cochrane Risk of Bias tool (RoB-2). Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis using a random effect model was done using Review Manager 5.4. The review was registered prospectively on PROSPERO (CRD42022356553).

RESULTS

Data from 71 studies and 14 268 infants were included in this review; 22 (2 537 infants) compared umbilical cord milking with control, and 50 studies (11 731 infants) compared delayed with early cord clamping. For umbilical cord milking there were no data on neonatal hypoglycaemia, and no differences between groups for any of the secondary outcomes. We found no evidence that delayed cord clamping reduced the incidence of hypoglycaemia (6 studies, 444 infants, RR = 0.87, CI: 0.58 to 1.30, p = 0.49, I2 = 0%). Delayed cord clamping was associated with a 27% reduction in neonatal mortality (15 studies, 3 041 infants, RR = 0.73, CI: 0.55 to 0.98, p = 0.03, I2 = 0%). We found no evidence for the effect of delayed cord clamping for any of the other outcomes. The certainty of evidence was low for all outcomes.

CONCLUSION

We found no data for the effectiveness of umbilical cord milking on neonatal hypoglycaemia, and no evidence that delayed cord clamping reduced the incidence of hypoglycaemia, but the certainty of the evidence was low.

Anemia, Iron Supplementation, and the Brain

The developing brain is particularly vulnerable to extrinsic environmental events such as anemia and iron deficiency during periods of rapid development. Studies of infants with postnatal iron deficiency and iron deficiency anemia clearly demonstrated negative effects on short-term and long-term brain development and function. Randomized interventional trials studied erythropoiesis-stimulating agents and hemoglobin-based red blood cell transfusion thresholds to determine how they affect preterm infant neurodevelopment. Studies of red blood cell transfusion components are limited in preterm neonates. A biomarker strategy measuring brain iron status and health in the preanemic period is desirable to evaluate treatment options and brain response.

Iron Deficiency Prior to Discharge in Very Low Birth Weight Infants: Screening with Reticulocyte Hemoglobin Content

OBJECTIVE

 This study aimed to assess the iron status prior to discharge in very low birth weight (VLBW) infants utilizing reticulocyte hemoglobin content (CHr) and evaluate the impact of delayed cord clamping (DCC) on iron status.

STUDY DESIGN

 This is a retrospective analysis of VLBW infants from two tertiary level of care Neonatal Intensive Care Units. The primary outcome was the proportion of VLBW infants with low CHr (<29 pg) prior to discharge. Hematologic parameters were also compared between infants who received or did not receive DCC. Infants with a positive newborn screen for hemoglobin Bart's were excluded.

RESULTS

 Among the 315 infants included, 99 infants (31.4%) had low CHr prior to discharge. The median (interquartile range) CHr prior to discharge was 30.8 pg (28.4-39 pg). DCC was performed in 46.7% of infants. Hemoglobin at birth, discharge, and CHr prior to discharge were higher and the need for blood transfusion and the number of infants with low CHr prior to discharge were lower in the DCC group.

CONCLUSION

 Approximately 31.4% of VLBW infants had low CHr near the time of discharge suggesting they were iron deficient. DCC improved hematological parameters prior to discharge in VLBW infants. CHr content can be used to guide iron supplementation in VLBW infants to potentially improve their iron status and long-term neurocognitive outcomes.

KEY POINTS

· DCC was associated with an improved hemoglobin and iron status at discharge in VLBW infants.. · CHr is an early and reliable marker for iron deficiency.. · Approximately one in three VLBW infants can be iron deficient at the time of discharge..

Umbilical cord management - the first opportunity to improve healthcare disparities

This review focuses on iron deficiency and iron deficiency anemia in women and children in the United States. These are common, fixable problems that disproportionally affect minority populations. There are many opportunities for successful screening and management. The knowledge and awareness for identification and treatment of our populations' commonest deficiency is crucial.

Cord clamping - 'hold on a minute' is not enough, and sample your blood gases while waiting

There is confusion regarding the dynamics of the umbilical cord circulation and the concomitant placental transfusion. How long does it continue, and at what rate? These questions remain an enigma for many. In this article we will address some common misconceptions about the management of cord circulation, try to explain why there is a lack of clarity, and call in to question the conclusions from an influential meta-analysis and a recently published guideline on cord clamping. We will do that partly by reviewing the rather extensive literature published on the subject over the past 50 to 70 years, which is easily forgotten, but worth considering. In this review, we will also address the important subject of why and how to sample cord blood correctly and to interpret umbilical gases with a sustained cord circulation, which is a crucial part of our ongoing multicenter study 'Sustained cord circulation And Ventilation', the SAVE-study.

Effects of Placental Transfusion on Late Preterm Infants Admitted to a Mother-Baby Unit

OBJECTIVE

Well-appearing late preterm infants admitted to a mother baby unit may benefit from either delayed cord clamping (DCC) or umbilical cord milking (UCM). However, there are concerns of adverse effects of increased blood volume such as polycythemia and hyperbilirubinemia. The purpose of this study is to examine the short-term effects of placental transfusion on late preterm infants born between 35^0/7 and 36^6/7 weeks of gestation.

STUDY DESIGN

In this pre- and postimplementation retrospective cohort study, we compared late preterm infants who received placental transfusion (161 infants, DCC/UCM group) during a 2-year period after guideline implementation (postimplementation period: August 1, 2017, to July 31, 2019) to infants who had immediate cord clamping (118 infants, ICC group) born during a 2-year period before implementation (preimplementation period: August 1, 2015, to July 31, 2017).

RESULTS

The mean hematocrit after birth was significantly higher in the DCC/UCM group. Fewer infants had a hematocrit <40% after birth in the DCC/UCM group compared with the ICC group. The incidence of hyperbilirubinemia needing phototherapy, neonatal intensive care unit (NICU) admissions, or readmissions to the hospital for phototherapy was similar between the groups. Fewer infants in the DCC/UCM group were admitted to the NICU primarily for respiratory distress. Symptomatic polycythemia did not occur in either group. Median hospital length of stay was 3 days for both groups.

CONCLUSION

Placental transfusion (DCC or UCM) in late preterm infants admitted to a mother baby unit was not associated with increased incidence of hyperbilirubinemia needing phototherapy, symptomatic polycythemia, NICU admissions, or readmissions to the hospital for phototherapy.

KEY POINTS

· Placental transfusion was feasible in late preterm infants.. · Placental transfusion resulted in higher mean hematocrit after birth.. · Placental transfusion did not increase the need for phototherapy.. · Fewer admissions to the NICU for respiratory distress were noted in the placental transfusion group..

Sex Differences in the Association of Pretransfusion Hemoglobin Levels with Brain Structure and Function in the Preterm Infant

OBJECTIVE

To assess sex-specific differences in early brain structure and function of preterm infants after red blood cell (RBC) transfusions.

STUDY DESIGN

A single-center subset of infants with a birth weight <1000 g and gestational age 22-29 weeks were enrolled from the National Institute of Child Health and Human Development's Neonatal Research Network Transfusion of Prematures Trial. Hemoglobin (Hb) concentration obtained directly before each transfusion (pretransfusion Hb [ptHb]) was obtained longitudinally throughout each infant's neonatal intensive care unit stay and used as a marker of degree of anemia (n = 97). Measures of regional brain volumes using magnetic resonance imaging were obtained at ∼40 weeks postmenstrual age or at hospital discharge, if earlier (n = 29). Measures of brain function were obtained at 12 months corrected age using the Bayley Scales of Infant & Toddler Development, 3rd Edition (n = 34).

RESULTS

PtHb was positively correlated with neonatal cerebral white matter volume in males (B = +0.283; P = .006), but not females (B = -0.099; P = .713), resulting in a significant sex interaction (P = .010). Bayley-III gross motor scores and a pooled mean score were significantly lower in association with higher ptHb in females (gross motor score: B = -3.758; P = .013; pooled mean score: B = -1.225; P = .030), but not males (gross motor score: B = +1.758; P = .167; pooled mean score: B = +0.621; P = .359). Higher ptHb was associated with descriptively lower performance on multiple Bayley-III subscales in females, but not in males.

CONCLUSIONS

This study demonstrates sex-specific associations between an early marker of anemia and RBC transfusion status (ie, ptHb) with both neonatal white matter volume and early cognitive function at age 12 months in preterm infants.

Haemoglobin and red blood cell reference intervals during infancy

OBJECTIVES

There is a need for updated haematological reference data in infancy. This study aimed to define intervals for haemoglobin and red blood cell biomarkers based on data from a large cohort of longitudinally followed Swedish infants.

DESIGN

Longitudinal cohort study.

SETTING

Two Swedish study centres.

PARTICIPANTS

Three community-based populations including 442 presumably healthy infants born at term and with umbilical cord clamping delayed to 30 s or more after birth.

METHODS

Blood samples were collected from umbilical cord blood (a), at 48-118 hours (b), at 4 months (c) and at 12 months (d). Reference intervals as the 2.5th and 97.5th percentiles were calculated in coherence with Clinical and Laboratory Standards Institute guidelines.

RESULTS

Reference intervals for haemoglobin (g/L) were: (a) 116-189, (b) 147-218, (c) 99-130, (d) 104-134, and for mean cell volume (fL): (a) 97-118, (b) 91-107, (c) 71-85, (d) 70-83. Reference intervals for erythrocyte counts, reticulocyte counts, reticulocyte haemoglobin, mean cell haemoglobin and mean cell haemoglobin concentration were also estimated. According to the WHO definition of anaemia, a haemoglobin value less than 110 g/L, 16% of this presumably healthy cohort could be classified as anaemic at 12 months.

CONCLUSION

We found mainly narrower reference intervals compared with previously published studies. The reference intervals for each parameter varied according to the infants' age, demonstrating the necessity of age definitions when presenting infant reference intervals. The discrepancy with the WHO classification for anaemia at 12 months, despite favourable conditions in infancy, needs future investigation.

The Effects of Delayed Cord Clamping on 12-Month Brain Myelin Content and Neurodevelopment: A Randomized Controlled Trial

OBJECTIVE

This study aimed to determine if delayed cord clamping (DCC) affected brain myelin water volume fraction (VFm) and neurodevelopment in term infants.

STUDY DESIGN

This was a single-blinded randomized controlled trial of healthy pregnant women with term singleton fetuses randomized at birth to either immediate cord clamping (ICC) (≤ 20 seconds) or DCC (≥ 5 minutes). Follow-up at 12 months of age consisted of blood work for serum iron indices and lead levels, a nonsedated magnetic resonance imaging (MRI), followed within the week by neurodevelopmental testing.

RESULTS

At birth, 73 women were randomized into one of two groups: ICC (the usual practice) or DCC (the intervention). At 12 months, among 58 active participants, 41 (80%) had usable MRIs. There were no differences between the two groups on maternal or infant demographic variables. At 12 months, infants who had DCC had increased white matter brain growth in regions localized within the right and left internal capsules, the right parietal, occipital, and prefrontal cortex. Gender exerted no difference on any variables. Developmental testing (Mullen Scales of Early Learning, nonverbal, and verbal composite scores) was not significantly different between the two groups.

CONCLUSION

At 12 months of age, infants who received DCC had greater myelin content in important brain regions involved in motor function, visual/spatial, and sensory processing. A placental transfusion at birth appeared to increase myelin content in the early developing brain.

KEY POINTS

· DCC resulted in higher hematocrits in newborn period.. · DCC appears to increase myelin at 12 months.. · Gender did not influence study outcomes..

Immediate vs delayed cord clamping in preterm infants: A systematic review and meta-analysis

To compare and evaluate the efficacy and safety of immediate cord clamping (ICC) and delayed cord clamping (DCC) in preterm infants. We performed a comprehensive and systematic meta-analysis of randomised controlled trials (RCTs) assessing ICC and DCC in preterm infants by searching PUBMED, EMBASE, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Database (from inception to 30 September 2020). Summary odds ratios or mean differences with 95% confidence intervals were calculated using a fixed- or random-effect model. A total of 20 RCTs with 1807 preterm infants were included in the study. DCC provided more benefits in increasing the haematocrit and haemoglobin levels at 24 hours of life (%), thus reducing the incidence of anaemia, necrotising enterocolitis, length of hospital stay and mortality than when ICC was performed. No significant differences were found between ICC and DCC in terms of peak bilirubin level; need for blood transfusion, mechanical ventilation (MV) and phototherapy; duration of MV and phototherapy; and incidences of intraventricular haemorrhage, retinopathy of prematurity, patent ductus arteriosus, respiratory distress syndrome, sepsis, jaundice, polycythaemia, periventricular leukomalacia and bronchopulmonary dysplasia. DCC is a safe, beneficial and feasible intervention for preterm infants. However, rigorously designed and large-scale RCTs are necessary to identify the role and ideal timing of DCC.

COVID-19 in Pregnancy and Early Childhood (COPE): study protocol for a prospective, multicentre biobank, survey and database cohort study

INTRODUCTION

There is limited knowledge on how the SARS-CoV-2 affects pregnancy outcomes. Studies investigating the impact of COVID-19 in early pregnancy are scarce and information on long-term follow-up is lacking.The purpose of this project is to study the impact of COVID-19 on pregnancy outcomes and long-term maternal and child health by: (1) establishing a database and biobank from pregnant women with COVID-19 and presumably non-infected women and their infants and (2) examining how women and their partners experience pregnancy, childbirth and early parenthood in the COVID-19 pandemic.

METHODS AND ANALYSIS

This is a national, multicentre, prospective cohort study involving 27 Swedish maternity units accounting for over 86 000 deliveries/year. Pregnant women are included when they: (1) test positive for SARS-CoV-2 (COVID-19 group) or (2) are non-infected and seek healthcare at one of their routine antenatal visits (screening group). Blood, as well as other biological samples, are collected at different time points during and after pregnancy. Child health up to 4 years of age and parent experience of pregnancy, delivery, early parenthood, healthcare and society in general will be examined using web-based questionnaires based on validated instruments. Short- and long-term health outcomes will be collected from Swedish health registers and the parents' experiences will be studied by performing qualitative interviews.

ETHICS AND DISSEMINATION

Confidentiality aspects such as data encryption and storage comply with the General Data Protection Regulation and with ethical committee requirements. This study has been granted national ethical approval by the Swedish Ethical Review Authority (dnr 2020-02189 and amendments 2020-02848, 2020-05016, 2020-06696 and 2021-00870) and national biobank approval by the Biobank Väst (dnr B2000526:970). Results from the project will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04433364.

Translation and Cultural Adaptation of the Ages and Stages Questionnaires (ASQ) Worldwide: A Scoping Review

OBJECTIVE

This scoping review aims to provide a data mapping and narrative synthesis of the available peer-reviewed scientific literature on the translation and cultural adaptation processes relative to the Ages and Stages Questionnaires (ASQ) as reported by the authors. It also seeks to paint an overall portrait of the implementation of the translated and culturally adapted ASQ worldwide.

METHODS

Articles published between 1995 and May 11, 2018, were identified via systematic searches of peer-reviewed literature carried out using CINAHL, Scopus, MEDLINE, Education Source, PsycINFO, and ERIC. The articles included in the qualitative synthesis were coded based on an extraction form developed for the study.

RESULTS

In the 46 articles surveyed, 37 different cultural adaptations were identified in 29 languages and 27 countries. Translations were included in 33 cultural adaptations, and language modifications were reported in 18 adaptations. The forward-backward translation method was reported in 25 cases. The authors declared having made cultural content, language, visual, and/or conceptual modifications in 26 adaptations. Cultural content modifications were reported in 24 adaptations. At least one method (pilot study, individual interview, survey or focus group with respondents) was reported in 24 adaptations.

CONCLUSION

Cultural modifications were relatively minor and were, in general, made to establish equivalence with the source version. As well, the processes used to translate and culturally adapt the ASQ varied widely based on the types of methods. Additional work should be conducted to document the process of this crucial phase.

Cord Management of the Term Newborn

Keeping the umbilical cord intact after delivery facilitates transition from fetal to neonatal circulation and allows a placental transfusion of a considerable amount of blood. A delay of at least 3 minutes improves neurodevelopmental outcomes in term infants. Although regarded as common sense and practiced by many midwives, implementation of delayed cord clamping into practice has been unduly slow, partly because of beliefs regarding theoretic risks of jaundice and lack of understanding regarding the long-term benefits. This article provides arguments for delaying cord clamping for a minimum of 3 minutes.

Effects of Umbilical Cord Milking on Term Infants Delivered by Cesarean Section

OBJECTIVE

Umbilical cord milking (UCM) is an efficient way to achieve optimal placental transfusion in term infants born by cesarean section (CS). However, it is not frequently performed due to concern for short-term adverse effects of increased blood volume, such as polycythemia and hyperbilirubinemia. The aim of this study is to evaluate the short-term effects of UCM on term infants delivered by CS.

STUDY DESIGN

We conducted a pre- and postimplementation cohort study comparing term infants delivered by CS who received UCM five times (141 infants, UCM group) during a 6-month period (August 1, 2017 to January 31, 2018) to those who received immediate cord clamping (ICC) during the same time period (105 infants, postimplementation ICC) and during a 3-month period (October1, 2016 to December 31, 2016) prior to the implementation of UCM (141 infants, preimplementation ICC).

RESULTS

Mothers were older in UCM group compared with both ICC groups. There were no significant differences in other maternal or neonatal characteristics. Although this study was not powered to detect differences in outcomes, the occurrence of hyperbilirubinemia needing phototherapy, symptomatic polycythemia, NICU admissions, or readmissions for phototherapy was similar between the groups.

CONCLUSION

UCM intervention was not associated with increased incidence of phototherapy or symptomatic polycythemia in term infants delivered by CS.

Soluble Transferrin Receptor during infancy and reference intervals for the Roche Cobas platform

INTRODUCTION

Infant iron status assessments may be difficult to interpret due to infections. The soluble transferrin receptor (sTfR) has been suggested as a biomarker mainly unaffected by the acute phase response. Reference intervals reflecting dynamics of infant growth first year in life are not well established.

METHODS

The sTfR and CRP concentrations were measured in samples from 451 term infants with the Roche Cobas platform in umbilical cord, at 48-96 hours, 4 and 12 months. Reference values were constructed as the 2.5th and 97.5th percentiles. The relationship between CRP concentrations >1 mg/L and sTfR was tested by Kendall correlation.

RESULTS

Reference intervals for girls and boys were 2.4-9.5 mg/L at birth, 2.9-8.4 mg/L at 48-96 hours, 2.6-5.7 mg/L at 4 months and 3.0-6.3 mg/L at 12 months. No differences between sexes were observed except for at 4 months. sTfR did not covariate with CRP concentrations >1 mg/L except in 48-96 hours samples.

CONCLUSION

This study reports reference intervals for sTfR from birth to 12 months of age in a large group of infants in a low-risk area for iron deficiency. sTfR might add value to infant iron status diagnostics since no covariation with CRP was found at birth, at 4 months or at 12 months.

Hepcidin is a relevant iron status indicator in infancy: results from a randomized trial of early vs. delayed cord clamping

BACKGROUND

We aimed to evaluate whether serum hepcidin is a useful indicator of iron status in infants.

METHODS

Term infants (n = 400) were randomized to delayed (≥180 s) or early (≤10 s) cord clamping (CC). Iron status was assessed at 4 and 12 months. In all cases with iron depletion or iron deficiency (ID) (as defined in "Methods") (n = 30) and 97 randomly selected iron-replete infants, we analyzed hepcidin and explored its correlation to the intervention, iron status, and perinatal factors.

RESULTS

Serum hepcidin concentrations were significantly lower in the early CC group at both time points and in ID infants at 4 months. Median (2.5th-97.5th percentile) hepcidin in non-ID infants in the delayed CC group (suggested reference) was 64.5 (10.9-142.1), 39.5 (3.5-157.7), and 32.9 (11.2-124.2) ng/mL in the cord blood and at 4 and 12 months, respectively. The value of 16 ng/mL was a threshold detecting all cases of iron depletion/ID at 4 months. No similar threshold for ID was observed at 12 months. The strongest predictor of hepcidin at both ages was ferritin.

CONCLUSIONS

Hepcidin is relevant as iron status indicator in early infancy and may be useful to detect ID. Levels <16 ng/mL at 4 months of age indicates ID.

IMPACT

Serum hepcidin is a relevant indicator of iron status in early infancy. Normal reference in healthy infants is suggested in this study. Serum hepcidin may be useful in clinical practice to detect iron deficiency.

Delayed Umbilical Cord Clamping After Birth: ACOG Committee Opinion, Number 814

Delayed umbilical cord clamping appears to be beneficial for term and preterm infants. In term infants, delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes. There is a small increase in the incidence of jaundice that requires phototherapy in term infants undergoing delayed umbilical cord clamping. Consequently, obstetrician-gynecologists and other obstetric care providers adopting delayed umbilical cord clamping in term infants should ensure that mechanisms are in place to monitor and treat neonatal jaundice. In preterm infants, delayed umbilical cord clamping is associated with significant neonatal benefits, including improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage. Delayed umbilical cord clamping was not associated with an increased risk of postpartum hemorrhage or increased blood loss at delivery, nor was it associated with a difference in postpartum hemoglobin levels or the need for blood transfusion. Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30-60 seconds after birth. The ability to provide delayed umbilical cord clamping may vary among institutions and settings; decisions in those circumstances are best made by the team caring for the mother-infant dyad.

Neonatal blood pressure before and after delayed umbilical cord clamping

OBJECTIVE

To describe values of blood pressure (BP) before and after delayed cord clamping (DCC) in healthy term neonates born to low risk pregnancies, examine differences in the temporal patterns of BP during this transition, and assess potential correlation of these parameters with maternal and perinatal clinical and demographic variables.

METHODS

Prospective observational study of term infants eligible for DCC born vaginally from uncomplicated pregnancies. Neonatal BP was estimated noninvasively before DCC, at 30 min and 24 h of life. Median, minimum, maximum, mean and standard deviation, as well as percentiles for BP values were calculated. Pearson correlation assessed the correlation between demographic and clinical variables and BP measurements. Spearman correlation studied the association between BP parameters prior to DCC and Apgar scores. Repeated measures ANOVA and Tukey post hoc analyses were used to compare BP measurements over time. A p-value of <.05 was considered significant.

RESULTS

A total of 54 patients were included. Mean neonatal birthweight was 3185 g and gestational age 39/3 weeks. The mean values for the systolic, diastolic, and mean BP prior to DCC were 97 ± 24.9 mmHg, 58 ± 21.9 mmHg and 67 ± 27.7 mmHg respectively. A statistically significant difference was detected when comparing BP values obtained before DCC with those measured afterwards (Figure 1). A positive correlation was found between SBP and MAP prior to DCC and Apgar scores at 1 min. [Figure: see text].

CONCLUSION

We describe novel values of BP before DCC in healthy term infants following vaginal delivery. Data suggest that neonates whose cord is clamped in a delayed fashion experience an increase blood pressures immediately after birth, followed by a significant drop within 30 min to levels that remain unchanged at 24 h of life. BP values obtained after DCC in our study are similar to those found by previous authors. Further studies are needed to determine the clinical significance of these findings and assess the potential of BP prior to DCC to evaluate immediate postnatal adaptation.

LIMITATIONS

Results generalizability may have been limited by varying degrees of neonatal resuscitation, inability to perform more than one measurement before cord clamping ensued, as well as an unequal distribution of self-reported race in our cohort. Also, noninvasive BP estimates have proven less accurate that invasive methods. Finally, our cohort was comprised by a relatively small sample and larger studies will be required to corroborate our findings.

Effect of Delayed Cord Clamping on Neurodevelopment at 3 Years: A Randomized Controlled Trial

INTRODUCTION

Iron deficiency (ID) is associated with poor neurodevelopment. We have previously shown that delayed umbilical cord clamping (CC) improves iron stores at 8 months and neurodevelopment at 1 year in term, healthy infants in Nepal.

OBJECTIVE

The aim of this study was to assess the effects of delayed CC (≥180 s) compared to early CC (≤60 s) on neurodevelopment using the Ages and Stages Questionnaire (ASQ) at age 3 years.

METHODS

In 2014, 540 healthy Nepalese infants born at term were randomized in a 1:1 ratio to delayed or early CC. At 3 years of age, ASQ assessment was performed by phone interviews with parents. A score >1 standard deviation below the mean was defined as "at risk" for developmental impairment.

RESULTS

At 3 years of age, 350 children were followed up, 170 (63.0%) in the early CC group and 180 (66.7%) in the delayed CC group. No significant differences in ASQ scores in any domains between groups were found. However, more girls were "at risk" for affected gross motor development in the early CC group: 14 (18.9%) versus 6 (6.3%), p = 0.02.

CONCLUSION

There were no significant differences in ASQ scores in any domains between groups. In the subgroup analysis, fewer girls who underwent delayed CC were "at risk" for delayed gross motor development. Due to the pronounced difference in iron stores at 8 months postpartum in this cohort, follow-up studies at an older age are motivated since neurodevelopmental impairment after early ID may be more detectable with increasing age.

Does Delayed Cord Clamping Improve Long-Term (≥4 Months) Neurodevelopment in Term Babies? A Systematic Review and a Meta-Analysis of Randomized Clinical Trials

Background: Recently, the literature suggested that placental transfusion facilitated by delayed cord clamping (DCC), besides having benefits on hematological parameters, might improve the infants' brain development. Objective: The present review primarily evaluates the Ages and Stages Questionnaire (ASQ) total score mean difference (MD) at long-term follow-up (≥4 months) comparing DCC (>90 or >180 s) to early cord clamping (ECC). Secondary aims consisted of evaluating the ASQ domains' MD and the results obtained from other methods adopted to evaluate the infants' neurodevelopment. Methods: MEDLINE, Scopus, Cochrane, and ClinicalTrials.gov databases were searched (up to 2nd November 2020) for systematic review and meta-analysis. All randomized controlled trials (RCTs) of term singleton gestations received DCC or ECC. Multiple pregnancies, pre-term delivery, non-randomized studies, and articles in languages other than English were excluded. The included studies were assessed for bias and quality. ASQ data were pooled stratified by time to follow up. Results: This meta-analysis of 4 articles from 3 RCTs includes 765 infants with four-month follow-up and 672 with 12 months follow-up. Primary aim (ASQ total score) pooled analysis was possible only for 12 months follow-up, and no differences were found between DCC and ECC (MD 1.1; CI 95: -5.1; 7.3). DCC approach significantly improves infants' communication domains (MD 0.6; CI 95: 0.1; 1.1) and personal-social assessed (MD 1.0; CI 95: 0.3; 1.6) through ASQ at 12 months follow-up. Surprisingly, the four-month ASQ personal social domain (MD -1.6; CI 95: -2.8; -0.4) seems to be significantly lower in the DCC group than in the ECC group. Conclusions: DCC, a simple, non-interventional, and cost-effective approach, might improve the long-term infants' neurological outcome. Single-blinding and limited studies number were the main limitations. Further research should be performed to confirm these observations, ideally with RCTs adopting standard methods to assess infants' neurodevelopment. Trial registration: NCT01245296, NCT01581489, NCT02222805, NCT01620008, IRCT201702066807N19, and NCT02727517.

Transfusion in Neonatal Patients: Review of Evidence-Based Guidelines

Transfusion of red blood cells, platelets, and fresh frozen plasma in neonatal patients has not been well characterized in the literature, with guidelines varying greatly between institutions. However, anemia and thrombocytopenia are highly prevalent, especially in preterm neonates. When transfusing a neonatal patient, clinicians must take into consideration physiologic differences, gestational and postnatal age, congenital disorders, and maternal factors while weighing the risks and benefits of transfusion. This review of existing literature summarizes current evidence-based neonatal transfusion guidelines and highlights areas of current ongoing research and those in need of future studies.

Timing of umbilical cord clamping among infants with congenital heart disease

The optimal timing of clamping and cutting the umbilical cord at birth among infants with congenital heart disease (CHD) remains a subject of controversy and debate. The benefits of delayed umbilical cord clamping (DCC) among term infants without CHD are well described, but the evidence base for DCC among infants with CHD has not been characterized adequately. The goals of the present review are to: 1) compare outcomes of DCC versus early cord clamping (ECC) in term (≥37 weeks of gestation) infants; 2) discuss potential risk/benefit profiles in applying DCC among term infants with CHD; 3) use rigorous systematic review methodology to assess the quality and quantity of published reports on cord clamping practices among term infants with CHD; 4) identify needs and opportunities for future research and interdisciplinary collaboration. Our systematic review shows that previous trials have largely excluded infants with CHD. Therefore, the supposition that DCC is advantageous because it is associated with improved neurologic and hematologic outcome is untested in the CHD population. Given that CHD is markedly heterogeneous, to minimize unnecessary and potentially harmful cord clamping practices, identification of subgroups (single-ventricle, cyanotic lesions) most likely to benefit from optimal cord clamping practices is necessary to optimize risk/benefit profiles. The available evidence base suggests that contemporary, pragmatic, randomized controlled trials comparing DCC with ECC among infants with CHD are needed.

Prelabour caesarean section and neurodevelopmental outcome at 4 and 12 months of age: an observational study

Background

With prelabour caesarean section rates growing globally, there is direct and indirect evidence of negative cognitive outcomes in childhood. The objective of this study was to assess the short-term neurodevelopmental outcomes after prelabour caesarean section as compared to vaginally born infants.

Methods

We conducted a prospective, observational study of infants delivered by prelabour caesarean section at the Hospital of Halland, Halmstad, Sweden and compared their development with an historical group of infants born by non-instrumental vaginal delivery.

Results

Infants born by prelabour caesarean section were compared with a group of vaginally born infants. Follow-up assessments were performed at 4 and 12 months. Prelabour caesarean infants (n = 66) had significantly lower Ages and Stages Questionnaire, second edition (ASQ-II) scores in all domains (communication, gross motor, fine motor, problem solving and personal-social) at 4 months of age with an adjusted mean difference (95% CI) of − 20.7 (− 28.7 to − 12.6) in ASQ-II total score as compared to vaginally born infants (n = 352). These differences remained for gross-motor skills at the 12 month assessment, adjusted mean difference (95% CI) -4.7 (− 8.8 to − 0.7), n = 62 and 336.

Conclusions

Adverse neurodevelopmental outcomes in infants born by prelabour caesarean section may be apparent already a few months after birth. Additional studies are warranted to explore this relationship further.

Is Anemia in Low Income Pregnant Women Related to Their Infants' Having Anemia? A Cohort Study of Pregnant Women-Infant Pairs in the United States

OBJECTIVE

Given evidence that anemia in the first year of life is associated with long-term cognitive, motor, and behavioral deficits, reducing infant anemia is important. The primary objective of this research is to examine whether anemia in low income pregnant women in the United States is associated with anemia in the women's infants.

METHODS

This cohort study linked Centers for Disease Control and Prevention surveillance data on pregnant women with incomes below 185% of the federal poverty level from 2010 and 2011 with data on 6-11 month olds from 2011, resulting in a sample of 21,246 uniquely matched mother-infant pairs. We examined bivariate and multivariate relationship between anemia severity in pregnant women and in their infants.

RESULTS

Seventeen percent of women had anemia (13.1% mild and 3.9% moderate to severe) and 20.1% infants had anemia (16.4% mild and 3.7% moderate to severe). For both women and infants, blacks had substantially higher anemia rates than whites. In bivariate analysis and multivariate analyses maternal anemia showed a dose-response relationship to infant anemia. In predicted probabilities from the multivariate models, 27.2% of infants born to pregnant women with moderate to severe anemia had anemia, compared to 23.3% for infants whose mothers had mild anemia, and 18.3% for infants whose mothers did not have anemia.

CONCLUSION

This study provides strong evidence of a relationship between maternal and infant anemia in the United States among people with low incomes. Efforts to reduce anemia during pregnancy may be an important strategy for minimizing childhood anemia.

Umbilical Cord Practices of Members of the American College of Nurse-Midwives

INTRODUCTION

Mercer et al surveyed members of the American College of Nurse-Midwives (ACNM) about their umbilical cord clamping practices in 2000. Over the last 20 years, a significant body of research supporting delayed cord clamping (DCC) has been published. The purpose of this study was to learn how midwives today manage the umbilical cord at birth.

METHODS

To better understand the current practices of midwives, in 2017, a national online survey of ACNM members was conducted. A total of 24 questions were asked about DCC, cord milking, specific clinical circumstances, and the presence of policies or guidelines.

RESULTS

A total of 5306 surveys were sent with 1106 responses. After applying inclusion criteria, 1050 were available for analysis. Respondents practiced in all settings: home, birth centers, and hospitals. Compared with 2000, a 46% increase in the practice of DCC was identified. In this study, 98% of the participants reported facilitating DCC for full-term vaginal births as compared with 67% in 2000. In addition, 25% practiced DCC for near-term and 65% for preterm neonates. Cord milking was practiced by 37% of participants. When asked about barriers to practicing DCC, 54% of participants identified time pressures to hand off the newborn as the greatest detriment. It was challenging to practice DCC in situations wherein the newborn needed resuscitation or in breech births. Far fewer midwives practice cord milking compared with DCC.

DISCUSSION

The survey results suggest there has been an increase in the practice of DCC over the last 20 years. Cord milking is not as widely practiced as DCC, and respondents were less likely to be convinced by the evidence for cord milking. This speaks to the opportunity for more education for midwives. There is also a need for clinical guidelines that address umbilical cord management when challenging circumstances arise such as breech birth, shoulder dystocia, and the need for resuscitation.

Association of a Delayed Cord-Clamping Protocol With Hyperbilirubinemia in Term Neonates

OBJECTIVE

To evaluate the implementation of a delayed cord-clamping protocol at an academic medical center, and its short-term associations on term neonates.

METHODS

This was a retrospective cohort study of women aged 18 years or older delivering a term neonate at an academic medical center before and 5-7 months after implementation of a universal delayed cord-clamping protocol (October-December 2015 and October-December 2016, respectively). The primary outcome measure was the mean peak neonatal transcutaneous bilirubin level, with secondary outcome measures including mean initial transcutaneous bilirubin levels, mean serum bilirubin levels, number of serum bilirubin levels drawn, incidence of clinical jaundice, and phototherapy.

RESULTS

Protocol adherence was 87.8%. Data are presented on 424 neonates. The mean peak neonatal transcutaneous bilirubin levels were significantly higher among neonates in the postprotocol group (10.0±3.4 mg/dL vs 8.4±2.7 mg/dL, P<.01). More neonates in the postprotocol group were diagnosed with jaundice (27.2% vs 16.6%; odds ratio [OR] 1.88; 95% CI 1.17-3.01) and required serum blood draws (43.7% vs 29.4%; OR 1.86; 95% CI 1.25-2.78). However, there were no differences in mean peak serum bilirubin levels between groups (9.7±3.0 mg/dL vs 9.1±3.1 mg/dL, P=.17) or need for phototherapy (5.2% vs 6.6%, OR 1.28; 95% CI 0.57-2.89).

CONCLUSION

Implementation of a delayed cord-clamping protocol for term neonates was associated with significantly higher mean transcutaneous bilirubin levels, an increased number of serum blood draws, and more clinical diagnoses of jaundice, although there was no increase in the incidence of phototherapy.

Effects of clamping umbilical cord on the neonatal viability of puppies delivered by cesarean section

In human neonates, when the umbilical cord is kept intact postpartum, blood continues to flow to the neonate, but this procedure might be difficult in dogs owing to a shorter umbilical cord and several neonates in a litter. However, it might be possible to detach the placenta and keep the umbilical cord intact, allowing residual blood to flow to the puppies. This study compared the effects of clamping versus no clamping of the umbilical cord in dogs born by cesarean section on neonatal vitality. The puppies were assessed by Apgar and reflex scores. Fifty puppies delivered from 16 bitches were randomly allocated to receive immediate umbilical cord clamping (n=25) or no clamping for at least 3 min after the onset of breathing (n=25). The puppies were assessed during the first 5 min of life and 10 min after the first assessment. The no clamping group showed significantly higher Apgar scores (second assessment, P<0.01) and reflex scores (first and second assessments, P<0.05) than the clamping group, implying higher vitality in the no clamping group. The differences observed between the moments (first versus second assessment) of each group was significant (P<0.01), revealing higher vitality in the second assessment. The results suggest that keeping the umbilical cord intact for at least 3 min after the onset of breathing may contribute to increased vitality in puppies delivered by cesarean section without any negative consequences.

Strategies for implementing placental transfusion at birth: A systematic review

BACKGROUND

Enhanced placental transfusion reduces adverse neonatal outcomes, including death. Despite being endorsed by the World Health Organization in 2012, the method has not been adopted widely in practice.

METHODS

We performed a systematic literature search and included quality improvement projects on placental transfusion at birth and studies on barriers to implementation. We extracted information on population, methods of implementation, obstacles to implementation, and strategies to overcome them.

RESULTS

We screened 99 studies out of which 18 were included in the review. The preferred methods of implementation were protocol development (86% of studies) reinforced by targeted education (64% of studies) and multidisciplinary team involvement (43% of studies). Barriers to implementation were mentioned in 12 studies and divided into four categories: general factors such as lack of staff awareness (5 studies) and professional resistance to change (5 studies); obstetrician-specific concerns, including the impact during cesarean (3 studies) and the risk of postpartum hemorrhage (3 studies); pediatrician-specific concerns, including the need for resuscitation (5 studies), risk of jaundice (3 studies), and polycythemia (2 studies); and logistical difficulties. The main strategies to facilitate placental transfusion at birth included effective multidisciplinary team collaboration, protocol development, targeted education, and constructive feedback sessions.

CONCLUSIONS

Placental transfusion implementation requires a multidisciplinary approach, with obstetricians, midwives, nurses, and pediatricians central to adoption of the practice. Understanding the obstacles to implementation informs strategies to increase placental transfusion adoption of practice worldwide. We suggest a stepwise approach to implementation and enhancement of placental transfusion into practice.

Early versus delayed umbilical cord clamping on maternal and neonatal outcomes

Purpose

Policies for timing of cord clamping varied from early cord clamping (ECC) in the first 30 s after birth, to delayed cord clamping (DCC) in more than 30 s after birth or when cord pulsation has ceased. DCC, an inexpensive method allowed physiological placental transfusion. The aim of this article is to review the benefits and the potential harms of early versus delayed cord clamping.

Methods

Narrative overview, synthesizing the findings of the literature retrieved from searches of computerized databases.

Results

Delayed cord clamping in term and preterm infants had shown higher hemoglobin levels and iron storage, the improved infants’ and children’s neurodevelopment, the lesser anemia, the higher blood pressure and the fewer transfusions, as well as the lower rates of intraventricular hemorrhage (IVH), chronic lung disease, necrotizing enterocolitis, and late-onset sepsis. DCC was seldom associated with lower Apgar scores, neonatal hypothermia of admission, respiratory distress, and severe jaundice. In addition, DCC was not associated with increased risk of postpartum hemorrhage and maternal blood transfusion whether in cesarean section or vaginal delivery. DCC appeared to have no effect on cord blood gas analysis. However, DCC for more than 60 s reduced drastically the chances of obtaining clinically useful cord blood units (CBUs).

Conclusion

Delayed cord clamping in term and preterm infants was a simple, safe, and effective delivery procedure, which should be recommended, but the optimal cord clamping time remained controversial.

Iron Metabolism and Brain Development in Premature Infants

Iron is important for a remarkable array of essential functions during brain development, and it needs to be provided in adequate amounts, especially to preterm infants. In this review article, we provide an overview of iron metabolism and homeostasis at the cellular level, as well as its regulation at the mRNA translation level, and we emphasize the importance of iron for brain development in fetal and early life in preterm infants. We also review the risk factors for disrupted iron metabolism that lead to high risk of developing iron deficiency and subsequent adverse effects on neurodevelopment in preterm infants. At the other extreme, iron overload, which is usually caused by excess iron supplementation in iron-replete preterm infants, might negatively impact brain development or even induce brain injury. Maintaining the balance of iron during the fetal and neonatal periods is important, and thus iron status should be monitored routinely and evaluated thoroughly during the neonatal period or before discharge of preterm infants so that iron supplementation can be individualized.

Comparative use of the Ages and Stages Questionnaires in the USA and Scandinavia: a systematic review

AIM

The aim of this systematic review was to investigate screening practices with the Ages and Stages Questionnaires (ASQ) and the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) in the USA and Scandinavia and to identify practical lessons and research opportunities.

METHOD

The review was performed for ASQ- and ASQ:SE-related studies in children from birth to 5 years. From nine databases and 1689 references (published from 1988-2018), 127 articles were included and categorized using Covidence online software. The Critical Appraisal Skills Programme Checklists were used before data synthesis.

RESULTS

US studies primarily use the ASQ/ASQ:SE to detect delays in general and at-risk populations in medical settings, which increases early detection, clinician-referral, and intervention rates. Scandinavian studies commonly use the ASQ/ASQ:SE to monitor developmental-behavioural differences in intervention/exposure-based cohorts. Pre-visit screening yields completion/return rates of 83% to more than 90% and fosters same-day interpretation. When referrals are indicated, systemwide care coordination or colocation with a developmental-behavioural specialist is beneficial.

INTERPRETATION

Practical implementation lessons are reviewed. Research opportunities include investigating and measuring the ASQ/ASQ:SE's 'overall' sections. Danish, Norwegian, and Swedish translations are available but up-to-date norming and validation studies are needed throughout Scandinavia. Randomized controlled trials are needed to investigate outcomes in screened versus unscreened cohorts.

WHAT THIS PAPER ADDS

General and at-risk populations broadly benefited from periodic Ages and Stages Questionnaires (ASQ) and/or Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) screening. Pre-visit ASQ and/or ASQ:SE screenining implementation systems work best. The ASQ and ASQ:SE 'overall' sections are not quantifiable and under-researched.

Association between hemoglobin concentrations at discharge from the neonatal intensive care unit with markers of neurodevelopmental outcomes in premature neonates

BACKGROUND

Premature neonates are often subjected to multiple transfusions with red blood cells during their hospitalization in the neonatal intensive care unit (NICU). The hemoglobin threshold for transfusion prior to discharge from the NICU varies significantly among different centers. The aim of the present study is to investigate the association between hemoglobin concentration at discharge with neurodevelopmental outcomes in premature neonates.

METHODS

Retrospective observation study with regression analysis was performed with follow up assessment in the neuro-developmental outpatient clinic at 30 months of adjusted age.

RESULTS

Data from 357 neonates born at less than 37 weeks' gestation were analyzed. Sensory and motor neurodevelopment at 30 months of adjusted age, were not associated with the hemoglobin concentration at discharge (p=0.5891 and p=0.4575, respectively). There was no association between the hemoglobin concentration at discharge with fine or gross motor development (p=0.1582 and p=0.3805, respectively). Hemoglobin concentration at discharge was not associated with poor neurodevelopmental outcomes up until 30 months of adjusted age.

CONCLUSIONS

The data of the present study indicate that the hemoglobin concentration of premature neonates at the time of discharge is not associated with poorer markers of neurodevelopmental outcomes at 30 months of adjusted age. Comorbidities such as BPD and IVH that are present to premature neonates were identified as potential risk factors for certain aspects of the neurodevelopment.

Effects of delayed cord clamping on infants after neonatal period: A systematic review and meta-analysis

BACKGROUND

The majority of current evidences simply showed the short-term benefits of delayed cord clamping, mainly focusing on the first week after birth. Without follow-up data, we can hardly come to the conclusion that delayed cord clamping may do more harm than good.

OBJECTIVE

To evaluate the long-term effects of delayed cord clamping compared with early cord clamping on infants after neonatal period.

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

DATA SOURCES

PubMed, EMBASE, and the Cochrane Library were systematically searched from inception date to June 22, 2018 for randomized clinical trials comparing early cord clamping with delayed cord clamping in infants beyond 1 month of age.

REVIEW METHODS

Two reviewers independently assessed trial eligibility and quality and extracted all infants' follow-up data after one month of age, which were divided into two groups for analysis, with follow-up periods of less than 6 months (<6 months) and beyond 6 months (≥6 months) respectively.

RESULTS

A total of twenty RCTs were identified and included in this study. All data of the twenty studies were pooled for final meta-analysis (3733 infants). Among preterm deliveries, delayed cord clamping slightly increased hematocrit (6-10 weeks) and serum ferritin (6-10 weeks). For term infants, delayed cord clamping reduced the incidence of anemia after six months of age (≥6 months), iron deficiency (< 6 months, ≥6 months) and iron deficiency anemia (4-12 months), while increased mean corpuscular volume before six months of age (< 6 months), hemoglobin after six months of age (≥6 months), serum iron (2-4 months), total body iron (4-6 months), serum ferritin (< 6 months, ≥6 months) and transferrin saturation (2-12 months). There were no significant differences between early versus late cord clamping groups for other variables.

CONCLUSION

Delayed cord clamping modestly improved hematological and iron status of both preterm and term infants after neonatal period. This affords cogent evidence on the practice of delayed cord clamping for medical staff, especially for countries and regions suffering from relatively higher prevalence rate of iron deficiency during infancy and childhood.

Effect of Delayed Cord Clamping of Term Babies on Neurodevelopment at 12 Months: A Randomized Controlled Trial

BACKGROUND

Delayed cord clamping (DCC) is associated with an improved iron status at 8 months, a reduction of anemia at 12 months, and an improved development at 4 years. Assessment of the development after DCC has not been performed earlier in a setting with a high prevalence of iron deficiency.

OBJECTIVE

The aim of this paper was to investigate the effects of DCC compared to early cord clamping (ECC) on the development evaluated with the Ages and Stages Questionnaire (ASQ) at 12 months of age.

METHOD

We conducted a randomized controlled trial investigating the effect of DCC (≥180 s) versus ECC (≤60 s) in 540 full-term deliveries. Twelve months after delivery, the parents reported their infant's development by ASQ. Infants having a score < 1 standard deviation (SD) under the mean score were considered "at risk" of affected neurodevelopment.

RESULTS

At 12 months of age, 332 (61.5%) infants were assessed. Fewer children in the DCC group were "at risk" of having affected neurodevelopment measured by the ASQ total score, 21 (7.8%) versus 49 (18.1%) in the ECC group. The relative risk was 0.43 (0.26-0.71). Infants in the DCC group had higher mean total scores (SD), 290.4 (10.4) versus 287.2 (10.1), p = 0.01. Significantly fewer infants in the delayed group were "at risk" and had higher scores in the domains "communication", "gross motor", and "personal-social".

CONCLUSIONS

DCC after 3 min was associated with an improvement of the overall neurodevelopment assessed at 12 months of age as compared to infants in the group with cord clamping within 1 min.

Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether placental transfusion influences brain myelination at 4 months of age.

STUDY DESIGN

A partially blinded, randomized controlled trial was conducted at a level III maternity hospital in the US. Seventy-three healthy term pregnant women and their singleton fetuses were randomized to either delayed umbilical cord clamping (DCC, >5 minutes) or immediate clamping (ICC, <20 seconds). At 4 months of age, blood was drawn for ferritin levels. Neurodevelopmental testing (Mullen Scales of Early Learning) was administered, and brain myelin content was measured with magnetic resonance imaging. Correlations between myelin content and ferritin levels and group-wise DCC vs ICC brain myelin content were completed.

RESULTS

In the DCC and ICC groups, clamping time was 172 ± 188 seconds vs 28 ± 76 seconds (P < .002), respectively; the 48-hour hematocrit was 57.6% vs 53.1% (P < .01). At 4 months, infants with DCC had significantly greater ferritin levels (96.4 vs 65.3 ng/dL, P = .03). There was a positive relationship between ferritin and myelin content. Infants randomized to the DCC group had greater myelin content in the internal capsule and other early maturing brain regions associated with motor, visual, and sensory processing/function. No differences were seen between groups in the Mullen testing.

CONCLUSION

At 4 months, infants born at term receiving DCC had greater ferritin levels and increased brain myelin in areas important for early life functional development. Endowment of iron-rich red blood cells obtained through DCC may offer a longitudinal advantage for early white matter development.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01620008.

Reference intervals for reticulocyte hemoglobin content in healthy infants

OBJECTIVES

Iron deficiency anemia in childhood is a serious public health problem worldwide. Reticulocyte hemoglobin content (Ret-He) is a novel biomarker of iron deficiency adopted for adults but there is a lack of reference intervals for Ret-He in infants. The aim of this study was to provide data from healthy infants.

METHODS

Swedish infants (n = 456), born at term after normal pregnancies were included. Ret-He was measured at birth (umbilical cord sample), 48-72 h, 4 months, and 12 months. Reference intervals were calculated as ±2 standard deviations from the mean of Ret-He.

RESULTS

Reference intervals for newborn Ret-He were 27.4 to 36.0 pg/L (N = 376) in the cord sample, 28.1-37.7 pg/L (N = 253) at 48-72 h, 25.6-33.4 pg/L (N = 341) at four months and 24.9-34.1 pg/L (N = 288) at 12 months. Ret-He was significantly lower among iron-deficient infants, at 4 months mean difference (95% CI) -4.2 pg/L (-6.1 to -2.4) and at 12 months mean difference (95% CI) -3.4 pg/L (-5.0 to -1.8).

CONCLUSIONS

This longitudinal study presents Ret-He reference intervals based on non-anemic and non-iron-deficient infants and constitutes a step towards standardizing Ret-He as a pre-anemia biomarker of iron deficiency in children.

Umbilical cord clamping practices of U.S. obstetricians

BACKGROUND

Delayed umbilical cord clamping is associated with significant benefits to preterm and term newborns and is recommended for all infants by the World Health Organization and the American College of Obstetricians and Gynecologists (ACOG). Little is known about the cord management practices of U.S. obstetricians.

OBJECTIVE

The objective of this study was to describe current cord clamping practices by U.S. obstetricians and investigate factors associated with delayed cord clamping.

STUDY DESIGN

A cross-sectional survey was sent to 500 members of the American College of Obstetricians and Gynecologists. Umbilical cord practices were assessed, and factors related to delaying cord clamping were examined using Chi-square tests and multivariate logistic regression models.

RESULTS

The overall response rate was 37% with 74% of those opening the email responding. Sixty-seven percent of respondents reported DCC by one minute or more after vaginal births at term. After preterm and near-term vaginal births, 73% and 79% said they waited at least 30 seconds before clamping. The factor most consistently and strongly related to delaying cord clamping in both bivariate and multivariate analyses was having the belief that the timing of clamping was important. Additional analysis revealed that believing the timing was important was positively associated with the physician's institution having a written policy on the cord clamping.

CONCLUSIONS

In this study, a majority of respondents reported delaying cord clamping and indicated that employing strategies to implement the full uptake of this practice could be valuable. Findings suggest that institutional policies may influence attitudes on cord clamping.

Early Versus Delayed Umbilical Cord Clamping on Physiologic Anemia of the Term Newborn Infant

AIM

Our study aims to make a comparison between the effects of milking of umbilical cord versus delayed cord clamping on Hemoglobin level at 6 weeks from delivery among term neonates and which method is more beneficial for them.

DESIGN

It was a randomised control study. Participants were randomised into 2 groups; Group 1: 125 women were assigned to delay cord clamping; Group 2: 125 women were assigned to milking of the umbilical cord 5 times before cutting. Student t-test was used to compare between the two groups for quantitative data, for qualitative data chi-square test and the Correlation coefficient was done to test the association between variables.

SETTING

This study was at El-Galaa Teaching Hospital, labour suite. Cairo, Egypt.

PARTICIPANTS

A group of 250 pregnant women starting from ≥ 37 weeks' gestational age.

INTERVENTION

In this study, we searched if the mechanism of milking or delayed cord clamping could give some of the positive benefits for neonates or not.

RESULTS

In this study, we found that milking of the umbilical cord five times as in group 1 was associated with higher hemoglobin levels at 6 weeks after birth, at physiological anemia of the fetus and significant but clinically there was no difference between the two groups (10.4 ± 0.5 and 10.6 ± 0.5 respectively, P < 0.001). Also, there was a positive correlation between haemoglobin of the mother and the newborn during the first day and after 6 weeks with r = 0.349 and 0.283 respectively and a P value < 0.001. Furthermore, there was a positive correlation between the haemoglobin of the fetus after the first day and fetus at 6 weeks with r = 0.534 and a P value < 0.001. For most other outcomes (including APGAR score, positive pressure ventilation, poor neonatal outcomes such as respiratory distress syndrome there were no significant differences between the two groups. Our study may recommend the use of umbilical cord milking in term babies when delayed cord clamping is unavailable.

CONCLUSION

Umbilical cord blood milking after its clamping improves some important haematological parameters for newborns, especially in countries with high incidence of anaemia in newborns and children.

Baby-directed umbilical cord clamping: A feasibility study

INTRODUCTION

Over five percent of infants born worldwide will need help breathing after birth. Delayed cord clamping (DCC) has become the standard of care for vigorous infants. DCC in non-vigorous infants is uncommon because of logistical difficulties in providing effective resuscitation during DCC. In Baby-Directed Umbilical Cord Clamping (Baby-DUCC), the umbilical cord remains patent until the infant's lungs are exchanging gases. We conducted a feasibility study of the Baby-DUCC technique.

METHODS

We obtained antenatal consent from pregnant women to enroll infants born at ≥32 weeks. Vigorous infants received ≥2 min of DCC. If the infant received respiratory support, the umbilical cord was clamped ≥60 s after the colorimetric carbon dioxide detector turned yellow. Maternal uterotonic medication was administered after umbilical cord clamping. A paediatrician and researcher entered the sterile field to provide respiratory support during a cesarean birth. Maternal and infant outcomes in the delivery room and prior to hospital discharge were analysed.

RESULTS

Forty-four infants were enrolled, 23 delivered via cesarean section (8 unplanned) and 15 delivered vaginally (6 via instrumentation). Twelve infants were non-vigorous. ECG was the preferred method for recording HR. Two infants had a HR < 100 BPM. All HR values were >100 BPM by 80 s after birth. Median time to umbilical cord clamping was 150 and 138 s in vigorous and non-vigorous infants, respectively. Median maternal blood loss was 300 ml.

CONCLUSIONS

It is feasible to provide resuscitation to term and near-term infants during DCC, after both vaginal and cesarean births, clamping the umbilical cord only when the infant is physiologically ready.

Impact of delayed umbilical cord clamping on public cord blood donations: can we help future patients and benefit infant donors?

BACKGROUND

Cord blood (CB) is a widely accepted stem cell source and its clinical utilization depends, to a great extent, on its cell content. Birth-to-clamping (BTC) time of umbilical cord determines placental transfusion to the newborn, and the remaining blood that can be collected and banked. The 2017 Committee Opinion of the American College of Obstetrics and Gynecologists (ACOG) recommends a delay of "at least 30-60 seconds" before clamping the cord for all newborns to ensure adequate iron stores. The impact of delayed cord clamping (DCC) on public CB banking can be substantial.

STUDY DESIGN AND METHODS

Cord blood units (CBUs) collected from 1210 mothers at one hospital were evaluated for total nucleated cells (TNCs) and weight/volume based on time to clamping. Bank staff recorded BTC time in seconds as reported by obstetricians; collections were performed ex utero. Immediate clamping was defined as BTC of less than 30 seconds, whereas DCC was defined as BTC of 30 seconds or more.

RESULTS

Cord clamping was immediate in 903 (75%) and delayed in 307 (25%) deliveries. Successful recovery (% clinical CBUs) decreased 10-fold with DCC of more than 60 seconds (22% vs. 2.4%, p < 0.001). CBUs collected after DCC of more than 60 seconds had significantly lower TNC counts than those after DCC of less than 60 seconds (p < 0.0001). Furthermore, 38% to 46% of CBUs after DCC of more than 60 seconds had volume of less than 40 mL.

CONCLUSION

Our study indicates that DCC of 30 to 60 seconds has a small negative impact on collection of high-TNC-count CBUs. However, increasing BTC to more than 60 seconds decreases significantly both TNC content and volume, reducing drastically the chances of obtaining clinically useful CBUs.

How to Engage Your Team to Implement Delayed Cord Clamping

This article describes how a health care team changed practice by implementing delayed cord clamping as standard practice. After administration of a survey to assess clinicians' knowledge and to discover barriers to this proposed practice change, members of a multidisciplinary committee used the results to create a guideline for delayed cord clamping and a plan for successful implementation. Integral to embedding and sustaining changes in practice was development of the Delivery Room Brief and Debrief Tool and inclusion of the process into nursing guidelines and the electronic health record. Through the use of these tools and teamwork, delayed cord clamping was implemented as standardized practice across six hospitals within this health care system.

High Neonatal Blood Iron Content Is Associated with the Risk of Childhood Type 1 Diabetes Mellitus

(1) Background: Iron requirement increases during pregnancy and iron supplementation is therefore recommended in many countries. However, excessive iron intake may lead to destruction of pancreatic β-cells. Therefore, we aim to test if higher neonatal iron content in blood is associated with the risk of developing type 1 diabetes mellitus (T1D) in childhood; (2) Methods: A case-control study was conducted, including 199 children diagnosed with T1D before the age of 16 years from 1991 to 2005 and 199 controls matched on date of birth. Information on confounders was available in 181 cases and 154 controls. Iron was measured on a neonatal single dried blood spot sample and was analyzed by laser ablation inductively coupled plasma mass spectrometry. Multivariate logistic regression was used to evaluate if iron content in whole blood was associated with the risk of T1D; (3) Results: A doubling of iron content increased the odds of developing T1D more than two-fold (odds ratio (95% CI), 2.55 (1.04; 6.24)). Iron content increased with maternal age (p = 0.04) and girls had higher content than boys (p = 0.01); (4) Conclusions: Higher neonatal iron content associates to an increased risk of developing T1D before the age of 16 years. Iron supplementation during early childhood needs further investigation, including the causes of high iron in neonates.

Caesarean delivery and anaemia risk in children in 45 low- and middle-income countries

Caesarean delivery (CD) may reduce placental transfusion and cause poor iron-related haematological indices in the neonate. We aimed to explore the association between CD and anaemia in children aged <5 years utilising data from Demographic and Health Surveys conducted between 2005 and 2015 in 45 low- and middle-income countries (N = 132,877). We defined anaemia categories based on haemoglobin levels, analysed each country's data separately using propensity-score weighting, pooled the country-specific odds ratios (ORs) using random effects meta-analysis, and performed meta-regression to determine whether the association between CD and anaemia varies by national CD rate, anaemia prevalence, and gross national income. Individual-level CD was not associated with any anaemia (OR 0.95, 95% confidence interval (CI) [0.86, 1.06]; I²  = 40.2%), mild anaemia (OR 0.91, 95% CI [0.81, 1.02]; I²  = 24.8%), and moderate/severe anaemia (OR 0.97, 95% CI [0.85, 1.11]; I²  = 47.7%). CD tended to be positively associated with moderate/severe anaemia in upper middle-income countries and negatively associated with mild anaemia in lower middle-income countries; however, meta-regression did not detect any variation in the association between anaemia and CD by the level of income, CD rate, and anaemia prevalence. In conclusion, there was no evidence for an association between CD and anaemia in children younger than 5 years in low- and middle-income countries. Our conclusions were consistent when we looked at only countries with CD rate >15% with data stratified by individual-level wealth status and type of health facility of birth.