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Pettinger KJ, Nunn S, Oddie SJ. Deferred cord clamping and polythene bags at delivery: measuring and improving quality. Arch Dis Child Fetal Neonatal Ed 2024; 109:344-345. [PMID: 38641419 DOI: 10.1136/archdischild-2023-326702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 04/10/2024] [Indexed: 04/21/2024]
Affiliation(s)
| | - Sam Nunn
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Sam J Oddie
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Zheng L, Gu X, Zhao P, Yang T, Zhang Q, Jiang S, Cao Y, Lee SK, Zhou W, Wang J. Characteristics of red blood cell transfusion among very preterm infants in China. Vox Sang 2024; 119:572-580. [PMID: 38622920 DOI: 10.1111/vox.13622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 03/03/2024] [Accepted: 03/10/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND AND OBJECTIVES National-level data on the incidence of red blood cell (RBC) transfusions and outcomes among very preterm infants (VPIs) are lacking in China. This study aims to describe the use and variation of RBC transfusion among VPIs in China. MATERIALS AND METHODS This cohort study was conducted among 70 tertiary hospitals participating in the Chinese Neonatal Network (CHNN) from 2019 to 2020 across China. All VPIs admitted to the CHNN neonatal intensive care units (NICUs) were included. RESULTS A total of 13,447 VPIs were enrolled, of whom 7026 (52.2%) received ≥1 RBC transfusions. The mean number of transfusions per infant was 2 (interquartile range [IQR] 1-4 times) and the median age at first transfusion was 15 days (IQR 3-27 days). The transfusion rate was higher in critically ill infants compared with non-critically ill infants (70.5% vs. 39.3%). The transfusion rate varied widely (13.5%-95.0%) between different NICUs. The prevalence of death, severe intra-ventricular haemorrhage, necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP), sepsis, bronchopulmonary dysplasia (BPD), severe retinopathy of prematurity (ROP) and cystic periventricular leukomalacia (cPVL) was significantly higher in the transfused group. Among non-critically ill infants, RBC transfusion was independently associated with BPD, severe ROP and cPVL. CONCLUSION Our study, providing the first baseline data on RBC transfusions among VPIs in China, shows an alarmingly high RBC transfusion rate with significant site variations. There is an urgent need for national guidelines on RBC transfusions for VPIs in China.
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Affiliation(s)
- Lu Zheng
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Xinyue Gu
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Pu Zhao
- Department of Neonatology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Tongling Yang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Qin Zhang
- Department of Neonatology, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Siyuan Jiang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Yun Cao
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Shoo K Lee
- Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Wenhao Zhou
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Neonatal Diseases, Fudan University, Children's Hospital of Fudan University, Shanghai, China
| | - Jin Wang
- Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
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García C, Prieto MT, Escudero F, Bosh-Giménez V, Quesada L, Lewanczyk M, Pertegal M, Delgado JL, Blanco-Carnero JE, De Paco Matallana C. The impact of early versus delayed cord clamping on hematological and cardiovascular changes in preterm newborns between 24 and 34 weeks' gestation: a randomized clinical trial. Arch Gynecol Obstet 2024; 309:2483-2490. [PMID: 37436461 DOI: 10.1007/s00404-023-07119-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/20/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE This study aimed to investigate hematological and cardiac changes after early (ECC) versus delayed cord clamping (DCC) in preterm infants at 24-34 weeks of gestation. METHODS Ninety-six healthy pregnant women were assigned randomly to the ECC (< 10 s postpartum, n = 49) or DCC (45-60 s postpartum, n = 47). Primary endpoint was evaluation of neonatal hemoglobin, hematocrit and bilirrubin levels within the first 7 days after birth. A postpartum blood test was performed in the mother and a neonatal echocardiography in the first week of life. RESULTS We found differences in hematological parameters during the first week of life. On admission, the DCC group had higher hemoglobin levels than the ECC group (18.7 ± 3.0 vs. 16.8 ± 2.4, p < 0.0014) and higher hematocrit values (53.9 ± 8.0 vs. 48.8 ± 6.4, p < 0.0011). Around day 7 of life, hemoglobin levels were also higher in the DCC group compared with the ECC group (16.4 ± 3.8 vs 13.9 ± 2.5, p < 0.005), as was the hematocrit (49.3 ± 12.7 vs 41.2 ± 8.4, p < 0.0087). The need of transfusion was lower in the DCC compared to the ECC (8.5% vs 24.5%; OR: 0.29, 95% CI: 0.09-0.97, p < 0.036). The need for phototherapy was also higher in the DCC (80.9% vs 63.3%; OR: 0.23, 95% CI: 0.06-0.84, p < 0.026). No differences in cardiac parameters or maternal blood tests. CONCLUSION DCC improved neonatal hematological parameters. No changes in cardiac function were found and maternal blood loss did not increase to require transfusion.
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Affiliation(s)
- Carolina García
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Virgen de La Arrixaca University Hospital, 2nd Floor, Carretera Madrid-Cartagena S/N, El Palmar, 30120, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, 30120, Murcia, Spain
| | - María Teresa Prieto
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Virgen de La Arrixaca University Hospital, 2nd Floor, Carretera Madrid-Cartagena S/N, El Palmar, 30120, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, 30120, Murcia, Spain
| | - Fuensanta Escudero
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, 30120, Murcia, Spain
- Departament of Pediatric Cardiologist, Virgen de La Arrixaca University Clinical Hospital, Murcia, Spain
| | - Vicente Bosh-Giménez
- Department of Surgery, Pediatrics, Obstetrics and Gynecology, University of Murcia, Murcia, Spain
| | - Lorenzo Quesada
- Intensive Care Neonatal Unit, Department of Pediatrics, Virgen de La Arrixaca University Clinical Hospital, Murcia, Spain
| | - Monika Lewanczyk
- Department of Surgery, Pediatrics, Obstetrics and Gynecology, University of Murcia, Murcia, Spain
| | - Miriam Pertegal
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Virgen de La Arrixaca University Hospital, 2nd Floor, Carretera Madrid-Cartagena S/N, El Palmar, 30120, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, 30120, Murcia, Spain
| | - Juan Luis Delgado
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Virgen de La Arrixaca University Hospital, 2nd Floor, Carretera Madrid-Cartagena S/N, El Palmar, 30120, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, 30120, Murcia, Spain
| | - Jose Eliseo Blanco-Carnero
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Virgen de La Arrixaca University Hospital, 2nd Floor, Carretera Madrid-Cartagena S/N, El Palmar, 30120, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, 30120, Murcia, Spain
| | - Catalina De Paco Matallana
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Virgen de La Arrixaca University Hospital, 2nd Floor, Carretera Madrid-Cartagena S/N, El Palmar, 30120, Murcia, Spain.
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, 30120, Murcia, Spain.
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Alves N, Rocha G, Flor-de-Lima F, Rosário M, Pissarra S, Mateus M, Azevedo I, Soares H. Neonatal Resuscitation Practices in Portuguese Delivery Rooms: A Cross-Sectional Study. ACTA MEDICA PORT 2024; 37:342-354. [PMID: 38744237 DOI: 10.20344/amp.20009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 09/11/2023] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Data from previous studies have demonstrated inconsistency between current evidence and delivery room resuscitation practices in developed countries. The primary aim of this study was to assess the quality of newborn healthcare and resuscitation practices in Portuguese delivery rooms, comparing current practices with the 2021 European Resuscitation Council guidelines. The secondary aim was to compare the consistency of practices between tertiary and non-tertiary centers across Portugal. METHODS An 87-question survey concerning neonatal care was sent to all physicians registered with the Portuguese Neonatal Society via email. In order to compare practices between centers, participants were divided into two groups: Group A (level III and level IIb centers) and Group B (level IIa and I centers). A descriptive analysis of variables was performed in order to compare the two groups. RESULTS In total, 130 physicians responded to the survey. Group A included 91 (70%) and Group B 39 (30%) respondents. More than 80% of participants reported the presence of a healthcare professional with basic newborn resuscitation training in all deliveries, essential equipment in the delivery room, such as a resuscitator with a light and heat source, a pulse oximeter, and an O2 blender, and performing delayed cord clamping for all neonates born without complications. Less than 60% reported performing team briefing before deliveries, the presence of electrocardiogram sensors, end-tidal CO2 detector, and continuous positive airway pressure in the delivery room, and monitoring the neonate's temperature. Major differences between groups were found regarding staff attending deliveries, education, equipment, thermal control, umbilical cord management, vital signs monitoring, prophylactic surfactant administration, and the neonate's transportation out of the delivery room. CONCLUSION Overall, adherence to neonatal resuscitation international guidelines was high among Portuguese physicians. However, differences between guidelines and current practices, as well as between centers with different levels of care, were identified. Areas for improvement include team briefing, ethics, education, available equipment in delivery rooms, temperature control, and airway management. The authors emphasize the importance of continuous education to ensure compliance with the most recent guidelines and ultimately improve neonatal health outcomes.
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Affiliation(s)
- Natacha Alves
- Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Gustavo Rocha
- Serviço de Neonatologia. Centro Hospitalar e Universitário de São João. Porto. Portugal
| | - Filipa Flor-de-Lima
- Serviço de Neonatologia. Centro Hospitalar e Universitário de São João. Porto; Departamento de Ginecologia-Obstetrícia e Pediatria. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Marta Rosário
- Serviço de Neonatologia. Centro Hospitalar e Universitário de São João. Porto; Departamento de Ginecologia-Obstetrícia e Pediatria. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
| | - Susana Pissarra
- Serviço de Neonatologia. Centro Hospitalar e Universitário de São João. Porto. Portugal
| | - Mário Mateus
- Serviço de Neonatologia. Centro Hospitalar e Universitário de São João. Porto. Portugal
| | - Inês Azevedo
- Departamento de Ginecologia-Obstetrícia e Pediatria. Faculdade de Medicina. Universidade do Porto. Porto; Serviço de Pediatria. Centro Hospitalar e Universitário de São João. Porto. Portugal
| | - Henrique Soares
- Serviço de Neonatologia. Centro Hospitalar e Universitário de São João. Porto; Departamento de Ginecologia-Obstetrícia e Pediatria. Faculdade de Medicina. Universidade do Porto. Porto. Portugal
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Amendolia B, Kilic N, Afridi F, Qari O, Bhat V, Nakhla D, Sadre S, Eckardt R, Nakhla T, Bhandari V, Aghai ZH. Delayed Cord Clamping for 45 Seconds in Very Low Birth Weight Infants: Impact on Hemoglobin at Birth and Close to Discharge. Am J Perinatol 2024; 41:e126-e132. [PMID: 35523407 DOI: 10.1055/a-1845-1816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVES To assess the impact of delayed cord clamping (DCC) for 45 seconds on hemoglobin at birth and close to discharge in very low birth weight (VLBW) infants and to compare modes of delivery in infants who received DCC. STUDY DESIGN In a retrospective study, 888 VLBW infants (≤1,500 g) who survived to discharge and received immediate cord clamping (ICC) were compared with infants who received DCC. Infants who received DCC and born via Cesarean section (C-section) were compared with those born via vaginal birth. RESULTS A total of 555 infants received ICC and 333 DCC. Only 188 out of 333 VLBW infants (56.5%) born during the DCC period received DCC. DCC was associated with higher hemoglobin at birth (15.9 vs. 14.9 g/dL, p = 0.001) and close to discharge (10.7 vs. 10.1 g/dL, p < 0.001) and reduced need for blood transfusion (39.4 vs. 54.9%, p < 0.001). In the DCC group, hemoglobin at birth and close to discharge was similar in infants born via C-section and vaginal birth. CONCLUSION DCC for 45 seconds increased hemoglobin at birth and close to discharge and reduced need for blood transfusion in VLBW infants. DCC for 45 seconds was equally effective for infants born by C-section and vaginal delivery. Approximately 44% of VLBW infants did not receive DCC even after implementing DCC guidelines. KEY POINTS · Studies to date have shown that DCC improves mortality and short- and long-term outcomes in VLBW infants.. · No consistent guidelines for the duration of DCC in preterm and term neonates.. · DCC for 45 seconds increased hemoglobin at birth and close to discharge in VLBW infants..
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Affiliation(s)
- Barbara Amendolia
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Nicole Kilic
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Faraz Afridi
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Omar Qari
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Vishwanath Bhat
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Daniel Nakhla
- Rutgers University, The State University of NJ, New Brunswick, New Jersey
| | - Sara Sadre
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Rebecca Eckardt
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Tarek Nakhla
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Vineet Bhandari
- Division of Neonatology, Department of Pediatrics, The Children's Regional Hospital at Cooper, Camden, New Jersey
| | - Zubair H Aghai
- Division of Neonatology, Department of Pediatrics, Thomas Jefferson University/Nemours, Philadelphia, Pennsylvania
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Hoeller N, Wolfsberger CH, Prethaler E, Schwaberger B, Pichler G, Urlesberger B. Physiological-based cord clamping stabilised cardiorespiratory parameters in very low birth weight infants. Acta Paediatr 2024; 113:931-938. [PMID: 38293717 DOI: 10.1111/apa.17135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 02/01/2024]
Abstract
AIM We investigated the influence of physiological-based cord clamping (PBCC) on cardiorespiratory stability in very low birth weight (VLBW) infants during the first 72 h of life. METHODS This retrospective study comprised VLBW infants born at <32 + 0 weeks of gestation and admitted to the neonatal intensive care unit of the Medical University of Graz, Austria, from December 2014 to April 2021. VLBW infants delivered with PBCC were matched by gestational age and birth weight to delayed cord clamping controls. The PBCC group was stabilised after birth with an intact cord. Routine monitoring parameters were compared between the groups. RESULTS We included 54 VLBW infants. The mean gestational ages of the PBCC group and controls were 27.4 ± 1.9 versus 27.4 ± 1.8 weeks (p = 0.87), and the mean birth weights were 912 ± 288 versus 915 ± 285 g (p = 0.96), respectively. The mean cord clamping time was 191 ± 78 s in the PBCC group. Heart rate was lower in the PBCC group during the first 3 days after birth, reaching significance by 10 h. Other monitoring parameters did not reveal any differences between the two groups. CONCLUSION PBCC stabilised cardiorespiratory parameters in VLBW infants. The lower heart rate in the PBCC group suggested higher blood volume following intact cord resuscitation.
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Affiliation(s)
- Nina Hoeller
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Christina Helene Wolfsberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Ernst Prethaler
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Schwaberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gerhard Pichler
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Berndt Urlesberger
- Division of Neonatology, Department of Paediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Zemouri C, Mestdagh E, Stiers M, Torfs K, Kuipers Y. Deferred cord clamping to improve neonatal blood values: A systematic review and meta-analysis. Int J Nurs Stud 2024; 153:104718. [PMID: 38417349 DOI: 10.1016/j.ijnurstu.2024.104718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/01/2024] [Accepted: 02/05/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND Practices related to umbilical cord clamping at birth should be evidence-based. Deferred cord clamping, compared to immediate cord clamping, shows benefits for preterm neonates but this may also apply to healthy term neonates. Different blood sampling techniques are used to measure effect of deferred and immediate cord clamping. OBJECTIVE To assess the statistical and effect size differences between blood biomarkers from umbilical cord and capillary blood samples of healthy term neonates following either immediate or deferred cord clamping. DESIGN Systematic review and meta-analysis. METHODS The databases PubMed, Medline, CENTRAL, CINAHL and EMBASE were systematically searched. We included studies with a randomised clinical trial design comparing deferred and immediate cord clamping among healthy term neonates born by a spontaneous vaginal birth, reporting on blood biomarkers. Studies including caesarean births and premature births/neonates were excluded. Study attributes, sampling technique, blood biomarkers, mean differences, and standard deviations were extracted. The standardised mean differences (SMD) and sampling errors were calculated for effect size estimation. Meta-analyses were performed if ≥2 studies reported the same outcome using RevMan 5. Subgroup analyses distinguished effects from umbilical cord and capillary blood samples. Moderator tests and publication bias analyses were performed using JASP. RESULTS Fifteen studies were included for analysis. The biomarkers haematocrit, haemoglobin, and bilirubin were reported in ≥2 studies and thus eligible for pooling. No differences were found in haemoglobin (SMD -0.04, 95%CI -0.57 to 0.49) or bilirubin values (SMD 0.13, 95%CI -0.03 to 0.28) between umbilical cord blood samples collected after deferred or immediate cord clamping. Deferred cord clamping led to lower haematocrit values (SMD -0.3, 95%CI -0.53 to -0.07). Higher haematocrit (SMD 0.67, 95%CI 0.37 to 0.97) and haemoglobin values (SMD 0.76, 95%CI 0.56 to 0.97) from capillary blood samples, collected 2 to 72 h postpartum, showed when cord clamping was deferred. No effect was found on bilirubin values (SMD 0.13, 95%CI -0.03 to 0.28) irrespective of the sampling technique. CONCLUSIONS Blood collected after deferred umbilical cord clamping showed increased haemoglobin and haematocrit values up to 72 h after birth, opposed to bilirubin values. Clinical evaluation of blood biomarkers from the umbilical cord shows different values compared to capillary blood. Sampling time and technique therefore seem essential in estimating the effects of deferred cord clamping. TWEETABLE ABSTRACT This meta-analysis shows that sampling time and technique are essential in estimating the effects of deferred cord clamping on neonatal blood values.
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Affiliation(s)
- Charifa Zemouri
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Zemouri et al, Amsterdam, the Netherlands
| | - Eveline Mestdagh
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Centre for Research and Innovation in Care, University Antwerp, Antwerp, Belgium
| | - Mieke Stiers
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium
| | - Kimberly Torfs
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium
| | - Yvonne Kuipers
- School of Health and Life Science, Artesis Plantijn University of Applied Sciences, Antwerp, Belgium; Centre for Research and Innovation in Care, University Antwerp, Antwerp, Belgium; School of Health and Social Care, Edinburgh Napier University, Edinburgh, Scotland, UK.
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Dunne EA, O'Donnell CPF, Nakstad B, McCarthy LK. Thermoregulation for very preterm infants in the delivery room: a narrative review. Pediatr Res 2024; 95:1448-1454. [PMID: 38253875 PMCID: PMC11126394 DOI: 10.1038/s41390-023-02902-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 10/28/2023] [Accepted: 11/02/2023] [Indexed: 01/24/2024]
Abstract
Abnormal temperature in preterm infants is associated with increased morbidity and mortality. Infants born prematurely are at risk of abnormal temperature immediately after birth in the delivery room (DR). The World Health Organization (WHO) recommends that the temperature of newly born infants is maintained between 36.5-37.5oC after birth. When caring for very preterm infants, the International Liaison Committee on Resuscitation (ILCOR) recommends using a combination of interventions to prevent heat loss. While hypothermia remains prevalent, efforts to prevent it have increased the incidence of hyperthermia, which may also be harmful. Delayed cord clamping (DCC) for preterm infants has been recommended by ILCOR since 2015. Little is known about the effect of timing of DCC on temperature, nor have there been specific recommendations for thermal care before DCC. This review article focuses on the current evidence and recommendations for thermal care in the DR, and considers thermoregulation in the context of emerging interventions and future research directions. IMPACT: Abnormal temperature is common amongst very preterm infants after birth, and is an independent risk factor for mortality. The current guidelines recommend a combination of interventions to prevent heat loss after birth. Despite this, abnormal temperature is still a problem, across all climates and economies. New and emerging delivery room practice (i.e., delayed cord clamping, mobile resuscitation trolleys, early skin to skin care) may have an effect on infant temperature. This article reviews the current evidence and recommendations, and considers future research directions.
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Affiliation(s)
- Emma A Dunne
- Department of Neonatology, The National Maternity Hospital, Holles Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Colm P F O'Donnell
- Department of Neonatology, The National Maternity Hospital, Holles Street, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Britt Nakstad
- Division of Pediatric and Adolescent Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Lisa K McCarthy
- Department of Neonatology, The National Maternity Hospital, Holles Street, Dublin, Ireland.
- School of Medicine, University College Dublin, Dublin, Ireland.
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Orton M, Theilen L, Clark E, Baserga M, Lauer S, Ou Z, Presson AP, Dupont T, Katheria A, Singh Y, Chan B. Thermoregulation-Focused Implementation of Delayed Cord Clamping among <34 Weeks' Gestational Age Neonates. Am J Perinatol 2024; 41:e3099-e3106. [PMID: 37989208 DOI: 10.1055/s-0043-1776916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE Delayed cord clamping (DCC) is recommended for all neonates; however, adapting such practice can be slow or unsustainable, especially among preterm neonates. During DCC neonates are exposed to a cool environment, raising concerns for neonatal hypothermia. Moderate hypothermia may induce morbidities that counteract the potential benefits of DCC. A quality improvement project on a thermoregulation-focused DCC protocol was implemented for neonates less than 34 weeks' gestational age (GA). The aim was to increase the compliance rate of DCC while maintaining normothermia. STUDY DESIGN The DCC protocol was implemented on October 1, 2020 in a large Level III neonatal intensive care unit. The thermoregulation measures included increasing delivery room temperature and using heat conservation supplies (sterile polyethylene suit, warm towels, and thermal pads). Baseline characteristics, the compliance rate of DCC, and admission temperatures were compared 4 months' preimplementation and 26 months' postimplementation RESULTS: The rate of DCC increased from 20% (11/54) in preimplementation to 57% (240/425) in postimplementation (p < 0.001). The balancing measure of admission normothermia remained unchanged. In a postimplementation subgroup analysis, the DCC cohort had less tendency to experience admission moderate hypothermia (<36°C; 9.2 vs. 14.1%, p = 0.11). The DCC cohort had more favorable secondary outcomes including higher admission hematocrit, less blood transfusions, less intraventricular hemorrhage, and lower mortality. Improving the process measure of accurate documentation could help to identify implementation barriers. CONCLUSION Performing DCC in preterm neonates was feasible and beneficial without increasing admission hypothermia. KEY POINTS · Thermoregulation-focused DCC protocol was implemented to increase DCC while maintaining normothermia.. · DCC rate increased from 20 to 57% while admission normothermia rate remained the same.. · DCC practice on preterm neonates is safe and feasible while maintaining normothermia..
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Affiliation(s)
- Melissa Orton
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Lauren Theilen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Erin Clark
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Mariana Baserga
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Sarah Lauer
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Tara Dupont
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Anup Katheria
- San Diego Neonatology, Department of Pediatrics, Sharp Mary Birch Hospital for Women and Newborn, San Diego, California
- Division of Neonatology, Department of Pediatrics, University of California at San Diego, San Diego, California
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California
| | - Belinda Chan
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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10
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Wang ZM, Zhou JY, Tang W, Jiang YY, Wang R, Wang LS. Effect of Placental Transfusion on Long-Term Neurodevelopmental Outcomes in Premature Infants: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pediatr Neurol 2024; 154:20-25. [PMID: 38452434 DOI: 10.1016/j.pediatrneurol.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 01/10/2024] [Accepted: 01/22/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The pathophysiology and the potential risks of placental transfusion (PT) differ substantially in preterm infants, necessitating specific studies in this population. This study aimed to evaluate the safety and efficacy of PT in preterm infants from the perspective of long-term neurodevelopmental outcomes. METHODS We conducted a systematic literature search using placental transfusion, preterm infant, and its synonyms as search terms. Cochrane Central Register of Controlled Trials, Medline, and Embase were searched until March 07, 2023. Two reviewers independently identified, extracted relevant randomized controlled trials, and appraised the risk of bias. The extracted studies were included in the meta-analysis of long-term neurodevelopmental clinical outcomes using fixed-effects models. RESULTS A total of 5612 articles were identified, and seven randomized controlled trials involving 2551 infants were included in our meta-analysis. Compared with immediate cord clamping (ICC), PT may not impact adverse neurodevelopment events. No clear evidence was found of a difference in the risk of neurodevelopmental impairment (risk ratio [RR]: 0.89, 95% confidence interval [CI]: 0.76 to 1.03, P = 0.13, I2 = 0). PT was not associated with the incidence of cerebral palsy (RR: 1.23, 95% CI: 0.59 to 2.57, P = 0.79, I2 = 0). Analyses showed no differences between the two interventions in cognitive, language, and motor domains of neurodevelopment. CONCLUSIONS From the perspective of long-term neurodevelopment, PT at preterm birth may be as safe as ICC. Future studies should focus on standardized, high-quality clinical trials and individual participant data to optimize cord management strategies for preterm infants after birth.
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Affiliation(s)
- Zi-Ming Wang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Jia-Yu Zhou
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Wan Tang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Ying-Ying Jiang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China
| | - Rui Wang
- Fudan University GRADE Center, Children's Hospital of Fudan University, Shanghai, China
| | - Lai-Shuan Wang
- National Health Commission Key Laboratory of Neonatal Diseases, Department of Neonatology, Children's Hospital of Fudan University, Shanghai, China.
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11
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Heeger LE, Koster MIJ, Caram-Deelder C, Bekker V, van der Bom JG, Lopriore E. Umbilical Cord Blood as an Alternative to Neonatal Blood for Complete Blood Count: A Comparison Study. J Pediatr 2024; 271:114059. [PMID: 38636783 DOI: 10.1016/j.jpeds.2024.114059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 04/08/2024] [Accepted: 04/14/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To assess concordance between umbilical cord blood (UCB) and neonatal blood (NB) laboratory test results at birth. STUDY DESIGN This retrospective study considered very preterm neonates (<32 weeks' gestational age) admitted to a tertiary neonatal intensive care unit from 2012 to 2023. Inclusion criteria required neonates with a complete blood count measured in both UCB and NB drawn within 2 hours after birth. Median hemoglobin (Hb) and hematocrit (Hct) concentrations were compared between UCB (venous samples) and NB (venous, arterial, or capillary samples). RESULTS A total of 432 neonates with paired UCB and NB values were included in the study. Hb concentration in UCB was 14.7 g/dL (IQR 13.5-16.1 g/dL) compared with 14.8 g/dL (IQR 12.6-19.3 g/dL) in venous NB samples, 13.9 g/dL (IQR 12.9-15.3 g/dL) in arterial NB and 18.7 g/dL (IQR 16.6-20.8 g/dL) in capillary NB. The regression equation showed a correction factor of 1.08 for converting Hb values from UCB to venous NB. Median Hct concentration in UCB was 0.45 L/L (IQR: 0.41-0.49 L/L) compared with 0.48 L/L (IQR 0.43-0.54 L/L) in venous NB, 0.42 L/L (IQR 0.38-0.45 L/L) in arterial NB and 0.57 L/L, (IQR 0.51-0.63 L/L) in capillary NB. CONCLUSIONS Hb and Hct concentrations measured in UCB are similar to those measured in venous blood in very preterm infants and are valid alternatives for NB tests at birth. Hb and Hct concentrations in arterial and capillary NB are respectively lower and higher compared with UCB measurements.
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Affiliation(s)
- Lisanne E Heeger
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands; Sanquin Blood Supply Foundation, Clinical Center for Transfusion Research, Amsterdam, The Netherlands
| | - Myrthe I J Koster
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Camila Caram-Deelder
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Vincent Bekker
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Johanna G van der Bom
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Division of Neonatology, Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
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12
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Burgess-Shannon J, Clarke R, Rowell V, Aladangady N. Achieving optimal cord management: a multidisciplinary quality improvement initiative. BMJ Open Qual 2024; 13:e002662. [PMID: 38626936 PMCID: PMC11029183 DOI: 10.1136/bmjoq-2023-002662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/09/2024] [Indexed: 04/19/2024] Open
Abstract
Optimal cord management (OCM), defined as waiting at least 60 seconds (s) before clamping the umbilical cord after birth, is an evidence-based intervention that improves outcomes for both term and preterm babies. All major resuscitation councils recommend OCM for well newborns.National Neonatal Audit Programme (NNAP) benchmarking data identified our tertiary neonatal unit as a negative outlier with regard to OCM practice with only 12.1% of infants receiving the recommended minimum of 60 s. This inspired a quality improvement project (QIP) to increase OCM rates of ≥ 60 s for infants <34 weeks. A multidisciplinary QIP team (Neonatal medical and nursing staff, Obstetricians, Midwives and Anaesthetic colleagues) was formed, and robust evidence-based quality improvement methodologies employed. Our aim was to increase OCM of ≥ 60 s for infants born at <34 weeks to at least 40%.The percentage of infants <34 weeks receiving OCM increased from 32.4% at baseline (June-September 2022) to 73.6% in the 9 months following QIP commencement (October 2022-June 2023). The intervention period spanned two cohorts of rotational doctors, demonstrating its sustainability. Rates of admission normothermia were maintained following the routine adoption of OCM (89.2% vs 88.5%), which is a complication described by other neonatal units.This project demonstrates the power of a multidisciplinary team approach to embedding an intervention that relies on collaboration between multiple departments. It also highlights the importance of national benchmarking data in allowing departments to focus QIP efforts to achieve long-lasting transformational service improvements.
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Affiliation(s)
| | - Rebecca Clarke
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Victoria Rowell
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Narendra Aladangady
- Neonatal Unit, Homerton University Hospital NHS Foundation Trust, London, UK
- Queen Mary University of London, London, UK
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13
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Watson ED, Roberts LF, Harding JE, Crowther CA, Lin L. Umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:248. [PMID: 38589786 PMCID: PMC11000397 DOI: 10.1186/s12884-024-06427-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/14/2024] [Indexed: 04/10/2024] Open
Abstract
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.
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Affiliation(s)
- Estelle D Watson
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Lily F Roberts
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Jane E Harding
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Caroline A Crowther
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand
| | - Luling Lin
- Liggins Institute, The University of Auckland, 85 Park Road, Grafton, Auckland, 1023, New Zealand.
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14
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Satar M, Erol AH, Özdemir M, Özbarlas N, Atmış A, Özlü F, Büyükkurt S. Influence of umbilical cord clamping time on cerebral oxygenation and early cardiac function in term infants. J Neonatal Perinatal Med 2024:NPM230223. [PMID: 38607769 DOI: 10.3233/npm-230223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
BACKGROUND Delayed cord clamping is the standard of care for both term and preterm infants worldwide. The aim of this study was to evaluate the effect of 60-second or 180-second delayed cord clamping during labor on cerebral oxygenation and cardiac function. METHODS Healthy newborns were divided into two groups: a 60-second delay in cord clamping (60-s DCC) and a 180-second delay in cord clamping (180-s DCC) at birth. Pulse oximetry and cerebral near-infrared spectroscopy (cNIRS) probes were placed during postnatal care. A total of 84 healthy newborns were included in this study. Preductal oxygen saturation (SpO2), heart rate, and cNIRS values were recorded at 5 and 10 minutes after delivery. The cardiac function of the infants was assessed by echocardiography at 3-7 days postnatally. RESULTS There was no significant difference between the groups in SpO2 and cNIRS values at 5 and 10 min. While there was no significant difference in the number of neonates with targeted SpO2 at the 5th and 10th min and targeted cNIRS values at the 10th min, there was a significant difference in the number of neonates with target cNIRS values at the 5th min between groups (p < 0.001). Echocardiographic findings showed that pulmonary flow velocity was increased in the 180-s DCC group; the difference was statistically significant (p = 0.04). CONCLUSION Our results showed that the number of infants with normal cNIRS values regarding cerebral oxygenation was higher in the 180-s DCC group. The pulmonary flow velocity was significantly increased in the 180-s DCC group in terms of echocardiographic findings.
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Affiliation(s)
- M Satar
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - A H Erol
- Department of Pediatrics, Faculty of Medicine Çukurova University, Adana, Turkey
| | - M Özdemir
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - N Özbarlas
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - A Atmış
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - F Özlü
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Çukurova University, Adana, Turkey
| | - S Büyükkurt
- Department of Obstetrics and Gynecology, Faculty of Medicine, Çukurova University, Adana, Turkey
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15
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Wu R, Zhang Y, Chen J, Zhang T, Yang X, Xu X, Li M, Li D, Liu X, Lu M. Relationship between the natural cessation time of umbilical cord pulsation in full-term newborns delivered vaginally and maternal-neonatal outcomes: a prospective cohort study. BMC Pregnancy Childbirth 2024; 24:236. [PMID: 38575874 PMCID: PMC10993427 DOI: 10.1186/s12884-024-06444-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 03/25/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND To analyze the impact of the time of natural cessation of the umbilical cord on maternal and infant outcomes in order to explore the time of clamping that would be beneficial to maternal and infant outcomes. METHODS The study was a cohort study and pregnant women who met the inclusion and exclusion criteria at the Obstetrics and Gynecology Department of Qilu Hospital of Shandong University from September 2020 to September 2021. Analysis using Kruskal-Wallis rank sum test, Pearson's Chi-squared test, generalized linear mixed model (GLMM) and repeated measures ANOVA. If the difference between groups was statistically significant, the Bonferroni test was then performed. A two-sided test of P < 0.05 was considered statistically significant. RESULTS A total of 345 pregnants were included in this study. The subjects were divided into the ≤60 seconds group (n = 134), the 61-89 seconds group (n = 106) and the ≥90 seconds group (n = 105) according to the time of natural arrest of the umbilical cord. There was no statistically significant difference in the amount of postpartum hemorrhage and the need for iron, medication, or supplements in the postpartum period between the different cord spontaneous arrest time groups for mothers (P > 0.05). The weight of the newborns in the three groups was (3316.27 ± 356.70) g, (3387.26 ± 379.20) g, and (3455.52 ± 363.78) g, respectively, and the number of days of cord detachment was 12.00 (8.00, 15.75) days, 10.00 (7.00, 15.00) days and 9.00 (7.00, 13.00) days, respectively, as the time of natural cessation of the cord increased. The neonatal lymphocyte ratio, erythrocyte pressure, and hemoglobin reached a maximum in the 61-89 s group at (7.41 ± 2.16) %, (61.77 ± 8.17) % and (194.52 ± 25.84) g/L, respectively. Lower incidence of neonatal hyperbilirubinemia in the 61-89 s group compared to the ≥90s group 0 vs 4.8 (P < 0.05). CONCLUSIONS In full-term singleton vaginal births, maternal and infant outcomes are better when waiting for 61-89 s after birth for the cord to stop pulsating naturally, suggesting that we can wait up to 90s for the cord to stop pulsating naturally, and if the cord does not stop pulsating after 90s, artificial weaning may be more beneficial to maternal and infant outcomes.
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Affiliation(s)
- Ruijie Wu
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Yuan Zhang
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China
- Clinical Research Center, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Jiaqi Chen
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Tongchao Zhang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China
- Clinical Research Center, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Xiaorong Yang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China
- Clinical Research Center, Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Xiangyu Xu
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Mi Li
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Dong Li
- Department of Paediatrics, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China
| | - Xiaoyan Liu
- Department of Gynecology and Obstetrics, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China.
| | - Ming Lu
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, 250012, People's Republic of China.
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, Shandong, 250012, People's Republic of China.
- Clinical Research Center, Shandong University, Jinan, Shandong, 250012, People's Republic of China.
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16
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Stichtenoth G, Gonser M, Hentschel R, Janke E, Maul H, Schmitt A, Steppat S, Werner J, Herting E. Betreuung von Neugeborenen in der Geburtsklinik (Entwicklungsstufe
S2k, AWMF-Leitlinien-Register-Nr. 024–005, März 2021). Z Geburtshilfe Neonatol 2024; 228:137-150. [PMID: 38608666 DOI: 10.1055/a-2195-3995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Affiliation(s)
- Guido Stichtenoth
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck
| | - Markus Gonser
- Universitätsspital Zürich, Klinik für Geburtshilfe, Zürich, Schweiz
| | - Roland Hentschel
- Neonatologie/Intensivmedizin, Zentrum für Kinder- und Jugendmedizin, Universitätsklinikum Freiburg
| | - Evelin Janke
- Katholische Bildungsstätte für Berufe im Sozial- und Gesundheitswesen GmbH, Akademie St. Franziskus, Lingen (Ems)
| | - Holger Maul
- Geburtshilfe und Pränatalmedizin, Asklepios Klinik Barmbek, Hamburg
| | - Anne Schmitt
- Hochschule für Technik und Wirtschaft des Saarlandes, Saarbrücken
| | | | - Janne Werner
- Florence-Nightingale-Krankenhaus, Kaiserswerther Diakonie, Düsseldorf
| | - Egbert Herting
- Klinik für Kinder- und Jugendmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck
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17
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Smolich JJ, Kenna KR, Mynard JP. Extended period of ventilation before delayed cord clamping augments left-to-right shunting and decreases systemic perfusion at birth in preterm lambs. J Physiol 2024; 602:1791-1813. [PMID: 38532618 DOI: 10.1113/jp285799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/26/2024] [Indexed: 03/28/2024] Open
Abstract
Previous studies have suggested that an extended period of ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. However, it is unknown whether this greater rise in PA flow is accompanied by increases in left ventricular (LV) output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale (FO), with decreased systemic arterial perfusion. Using an established preterm lamb birth transition model, this study compared the effect of a short (∼40 s, n = 11), moderate (∼2 min, n = 11) or extended (∼5 min, n = 12) period of initial mechanical lung ventilation before DCC on flow probe-derived perinatal changes in PA flow, LV output, total systemic arterial blood flow, ductal shunting and FO shunting. The LV output was relatively stable during initial ventilation but increased after DCC, with similar responses in all groups. Systemic arterial flow patterns displayed only minor differences during brief and moderate periods of initial ventilation and were similar after DCC. However, an increase in PA flow was augmented with an extended initial ventilation (P < 0.001), owing to an earlier onset of left-to-right ductal and FO shunting (P < 0.001), and was accompanied by a pronounced reduction in total systemic arterial flow (P = 0.005) that persisted for 4 min after DCC (P ≤ 0.039). These findings suggest that, owing to increased left-to-right shunting and a greater reduction in systemic arterial perfusion, an extended period of ventilation before DCC does not result in greater perinatal circulatory benefits than shorter periods of initial ventilation in the birth transition. KEY POINTS: Previous studies suggest that an extended period of initial ventilation before delayed cord clamping (DCC) augments birth-related rises in pulmonary arterial (PA) blood flow. It is unknown whether this greater rise in PA flow is accompanied by an increased left ventricular output and systemic arterial perfusion or whether it reflects enhanced left-to-right shunting across the ductus arteriosus and/or foramen ovale, with decreased systemic arterial perfusion. Anaesthetized preterm fetal lambs instrumented with central arterial flow probes underwent a brief (∼40 s), moderate (∼2 min) or extended (∼5 min) period of ventilation before DCC. Perinatal changes in left ventricular output were similar in all groups, but extended initial ventilation augmented both perinatal increases in PA flow, owing to earlier onset and greater left-to-right ductal and foramen ovale shunting, and perinatal reductions in total systemic arterial perfusion. Extended ventilation before DCC does not confer a greater perinatal circulatory benefit than shorter periods of initial ventilation.
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Affiliation(s)
- Joseph J Smolich
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Kelly R Kenna
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Jonathan P Mynard
- Heart Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
- Department of Biomedical Engineering, University of Melbourne, Parkville, Victoria, Australia
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18
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Jegatheesan P, Lee HC, Jelks A, Song D. Quality improvement efforts directed at optimal umbilical cord management in delivery room. Semin Perinatol 2024; 48:151905. [PMID: 38679508 DOI: 10.1016/j.semperi.2024.151905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Delayed or deferred cord clamping (DCC) and umbilical cord milking (UCM) benefit all infants by optimizing fetal-neonatal transition and placental transfusion. Even though DCC is recommended by almost all maternal and neonatal organizations, it has not been universally implemented. There is considerable variation in umbilical cord management practices across institutions. In this article, we provide examples of successful quality improvement (QI) initiatives to implement optimal cord management in the delivery room. We discuss a number of key elements that should be considering among those undertaking QI efforts to implement DCC and UCM including, multidisciplinary team collaboration, development of theory for change, mapping of the current and ideal process and workflow for cord management, and creation of a unit-specific evidence-based protocol for cord management. We also examine important strategies for implementation and provide suggestions for developing a system for measurement and benchmarking.
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Affiliation(s)
- Priya Jegatheesan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
| | - Henry C Lee
- Department of Pediatrics, Division of Neonatology, University of California San Diego, San Diego, CA, USA
| | - Andrea Jelks
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
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19
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Balasubramanian H, Bhanushali M, Tripathi V, Srinivasan L, Sakharkar S, Pillai A, Kabra NS. Effect of minimization of early blood sampling losses among extremely premature neonates- A randomized clinical trial. J Pediatr 2024:114002. [PMID: 38447757 DOI: 10.1016/j.jpeds.2024.114002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/08/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
OBJECTIVE To evaluate the effect of blood sampling stewardship on transfusion requirements among infants born extremely preterm. STUDY DESIGN In this single-center, randomized controlled trial, infants born at <28 weeks of gestation and birth weight of <1000 g were randomized at 24 hours of age to two different blood sampling approaches: restricted sampling versus conventional sampling. The stewardship intervention in the restricted sampling group included targeted reduction in blood sampling volume and frequency and point of care testing methods in the first six weeks after birth. Both groups received early recombinant erythropoietin from day three of age. Primary outcome was the rate of early red blood cell (RBC) transfusions in the first six postnatal weeks. RESULTS A total of 102 infants (mean gestational age: 26 weeks; birth weight: 756 g) were enrolled. Fidelity to the sampling protocol was achieved in 95% of the infants. Sampling losses in the first six weeks were significantly lower in the restricted sampling group (16.8 ml/kg vs 23.6 ml/kg, P<0.001). The restricted sampling group had a significantly lower rate of early postnatal RBC transfusion (41% versus 73%, RR: 0.56 [0.39-0.81], P=0.001). The hazard of needing a transfusion during NICU stay was reduced by 55% by restricted sampling. Mortality and neonatal morbidities were similar between the two groups. CONCLUSION Minimization of blood sampling losses by approximately one third in the first six weeks after birth leads to substantial reduction in the early RBC transfusion rate in infants born extremely preterm who weighed <1000 g at birth. TRIAL REGISTRATION http://www.ctri.nic.in (CTRI/2020/01/022964).
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Affiliation(s)
| | | | | | | | | | - Anish Pillai
- Surya Children's Hospital, Mumbai, Maharashtra, India
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20
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Hersh AR, Carroli G, Hofmeyr GJ, Garg B, Gülmezoglu M, Lumbiganon P, De Mucio B, Saleem S, Festin MPR, Mittal S, Rubio-Romero JA, Chipato T, Valencia C, Tolosa JE. Third stage of labor: evidence-based practice for prevention of adverse maternal and neonatal outcomes. Am J Obstet Gynecol 2024; 230:S1046-S1060.e1. [PMID: 38462248 DOI: 10.1016/j.ajog.2022.11.1298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 03/12/2024]
Abstract
The third stage of labor is defined as the time period between delivery of the fetus through delivery of the placenta. During a normal third stage, uterine contractions lead to separation and expulsion of the placenta from the uterus. Postpartum hemorrhage is a relatively common complication of the third stage of labor. Strategies have been studied to mitigate the risk of postpartum hemorrhage, leading to the widespread implementation of active management of the third stage of labor. Initially, active management of the third stage of labor consisted of a bundle of interventions including administration of a uterotonic agent, early cord clamping, controlled cord traction, and external uterine massage. However, the effectiveness of these interventions as a bundle has been questioned, leading to abandonment of some components in recent years. Despite this, upon review of selected international guidelines, we found that the term "active management of the third stage of labor" was still used, but recommendations for and against individual interventions were variable and not necessarily supported by current evidence. In this review, we: (1) examine the physiology of the third stage of labor, (2) present evidence related to interventions that prevent postpartum hemorrhage and promote maternal and neonatal health, (3) review current global guidelines and recommendations for practice, and (4) propose future areas of investigation. The interventions in this review include pharmacologic agents to prevent postpartum hemorrhage, cord clamping, cord milking, cord traction, cord drainage, early skin-to-skin contact, and nipple stimulation. Treatment of complications of the third stage of labor is outside of the scope of this review. We conclude that current evidence supports the use of effective pharmacologic postpartum hemorrhage prophylaxis, delayed cord clamping, early skin-to-skin contact, and controlled cord traction at delivery when feasible. The most effective uterotonic regimens for preventing postpartum hemorrhage after vaginal delivery include oxytocin plus ergometrine; oxytocin plus misoprostol; or carbetocin. After cesarean delivery, carbetocin or oxytocin as a bolus are the most effective regimens. There is inconsistent evidence regarding the use of tranexamic acid in addition to a uterotonic compared with a uterotonic alone for postpartum hemorrhage prevention after all deliveries. Because of differences in patient comorbidities, costs, and availability of resources and staff, decisions to use specific prevention strategies are dependent on patient- and system-level factors. We recommend that the term "active management of the third stage of labor" as a combined intervention no longer be used. Instead, we recommend that "third stage care" be adopted, which promotes the implementation of evidence-based interventions that incorporate practices that are safe and beneficial for both the woman and neonate.
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Affiliation(s)
- Alyssa R Hersh
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia.
| | | | - G Justus Hofmeyr
- University of Botswana, Gaborone, Botswana; University of the Witwatersrand, Johannesburg, Johannesburg, South Africa; Walter Sisulu University, Mthatha, South Africa
| | - Bharti Garg
- Oregon Health & Science University, Portland, OR
| | | | - Pisake Lumbiganon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Bremen De Mucio
- Latin American Center for Perinatology, Women and Reproductive Health, Montevideo, Uruguay
| | - Sarah Saleem
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Mario Philip R Festin
- Department of Obstetrics and Gynecology, College of Medicine, University of the Philippines, Manila, Philippines
| | | | | | - Tsungai Chipato
- Faculty of Health Sciences, Department of Obstetrics and Gynaecology, University of Zimbabwe, Harare, Zimbabwe
| | - Catalina Valencia
- FUNDARED-MATERNA, Bogotá, Colombia; Medicina Fetal SAS, Medellin, Colombia
| | - Jorge E Tolosa
- Oregon Health & Science University, Portland, OR; FUNDARED-MATERNA, Bogotá, Colombia; St. Luke's University Health Network, Bethlehem, PA
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21
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Cucerea M, Simon M, Anciuc-Crauciuc M, Marian R, Rusneac M, Ognean ML. Updated Clinical Practice Guidelines in Resuscitation and the Management of Respiratory Distress Syndrome in Extremely Preterm Infants during Two Epochs in Romania: Impact on Outcomes. J Clin Med 2024; 13:1103. [PMID: 38398420 PMCID: PMC10889373 DOI: 10.3390/jcm13041103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 02/06/2024] [Accepted: 02/11/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Adequate perinatal management is essential in caring for extremely preterm (EP) infants. We aimed to evaluate and compare the impact of different protocols on short-term outcomes. METHODS A retrospective study was conducted on EP infants in a Romanian perinatal tertiary center during 2008-2012 and 2018-2022. RESULTS Data on 270 EP infants (121 in period I, 149 in period II) were analyzed collectively and stratified into two subgroups by gestational age. Initial FiO2 administration (100% vs. 40%% p < 0.001), lung recruitment at birth (19.0% vs. 55.7% p < 0.001), early rescue surfactant administration (34.7% vs. 65.8%; p < 0.001), and the mechanical ventilation rate (98.3% vs. 58.4%; p < 0.001) were significantly improved during period II. Survival rates of EP infants significantly improved from 41.3% to 72.5%, particularly in the 26-28 weeks subgroup (63.8% to 83%). Compared to period I, the overall frequency of severe IVH decreased in period II from 30.6% to 14.1%; also, BPD rates were lower (36.6% vs. 23.4%; p = 0.045) in the 26-28 weeks subgroup. Despite improvements, there were no significant differences in the frequencies of NEC, sepsis, PVL, ROP, or PDA. CONCLUSIONS Implementing evidence-based clinical guidelines can improve short-term outcomes.
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Affiliation(s)
- Manuela Cucerea
- Department of Neonatology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology, 540142 Targu Mures, Romania; (M.C.); (M.A.-C.)
| | - Marta Simon
- Department of Neonatology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology, 540142 Targu Mures, Romania; (M.C.); (M.A.-C.)
| | - Mădălina Anciuc-Crauciuc
- Department of Neonatology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology, 540142 Targu Mures, Romania; (M.C.); (M.A.-C.)
| | - Raluca Marian
- Department M1, Cellular and Molecular Biology, 540142 Targu Mures, Romania;
| | - Monika Rusneac
- Clinical Department, Targu Mures Clinical and Emergency County Hospital, 540142 Targu Mures, Romania;
| | - Maria Livia Ognean
- Clinical Department, Faculty of Medicine, Lucian Blaga University Sibiu, 550169 Sibiu, Romania;
- Neonatology Department, Sibiu Clinical and Emergency County Hospital, Lucian Blaga University Sibiu, 550245 Sibiu, Romania
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22
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Wu Y, Ou J, Chen G, Zhu Y, Zhong X. Comparing two different placental transfusion strategies for very preterm infants at birth: a matched-pairs study. Ann Med 2024; 55:2301589. [PMID: 38242076 PMCID: PMC10802796 DOI: 10.1080/07853890.2023.2301589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/29/2023] [Indexed: 01/21/2024] Open
Abstract
OBJECTIVE To evaluate the clinical outcomes of using the extra-uterine placental transfusion (EPT) approach in very preterm infants (VPIs, gestational age <32 weeks) and compare this to delayed cord clamping (DCC) after birth. METHODS In this matched pairs study, we compared the clinical outcomes of the EPT group to those of the DCC group. EPT were performed in fifty-three VPIs, of whom 27 were singletons and 25 were twins. The singleton VPIs were matched for gestational age (±5 days) and delivery mode, and the twin VPIs were matched between each other with the first twin subjected to DCC and the second twin to EPT. Data on the infants were collected and analysed as an overall group. A twin subgroup consisting of DCC and EPT groups was also analysed separately. The primary study outcome was either death or major morbidities. RESULTS In total, 100 infants were included (n = 50 EPT group, n = 50 DCC group). The gestational ages of the DCC and EPT groups were (29.16 ± 1.76) and (29.12 ± 1.84) weeks, respectively. There were no differences in either deaths or major morbidities and other clinical outcomes, including the resuscitation variables, haemoglobin levels and red blood cell transfusion, between the two groups. In twin subgroups (gestational age 29.05 ± 1.89 weeks), EPT was associated with a higher rate of necrotizing enterocolitis (NEC) when compared with DCC (odds ratio = 7 (95% CI, 1.06 to 56.89), p = 0.031). CONCLUSIONS In twin subgroups, the incidence of NEC was higher in the EPT group when compared to the DCC group and therefore based on an abundance of caution the use of EPT in very preterm twins is not recommended.
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Affiliation(s)
- Yan Wu
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jiangfeng Ou
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Gongxue Chen
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yefang Zhu
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoyun Zhong
- Department of Pediatrics, Chongqing Health Center for Women and Children, Women and Children’s Hospital of Chongqing Medical University, Chongqing, China
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23
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Seidler AL, Aberoumand M, Hunter KE, Barba A, Libesman S, Williams JG, Shrestha N, Aagerup J, Sotiropoulos JX, Montgomery AA, Gyte GML, Duley L, Askie LM. Deferred cord clamping, cord milking, and immediate cord clamping at preterm birth: a systematic review and individual participant data meta-analysis. Lancet 2023; 402:2209-2222. [PMID: 37977169 DOI: 10.1016/s0140-6736(23)02468-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Umbilical cord clamping strategies at preterm birth have the potential to affect important health outcomes. The aim of this study was to compare the effectiveness of deferred cord clamping, umbilical cord milking, and immediate cord clamping in reducing neonatal mortality and morbidity at preterm birth. METHODS We conducted a systematic review and individual participant data meta-analysis. We searched medical databases and trial registries (from database inception until Feb 24, 2022; updated June 6, 2023) for randomised controlled trials comparing deferred (also known as delayed) cord clamping, cord milking, and immediate cord clamping for preterm births (<37 weeks' gestation). Quasi-randomised or cluster-randomised trials were excluded. Authors of eligible studies were invited to join the iCOMP collaboration and share individual participant data. All data were checked, harmonised, re-coded, and assessed for risk of bias following prespecified criteria. The primary outcome was death before hospital discharge. We performed intention-to-treat one-stage individual participant data meta-analyses accounting for heterogeneity to examine treatment effects overall and in prespecified subgroup analyses. Certainty of evidence was assessed with Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO, CRD42019136640. FINDINGS We identified 2369 records, of which 48 randomised trials provided individual participant data and were eligible for our primary analysis. We included individual participant data on 6367 infants (3303 [55%] male, 2667 [45%] female, two intersex, and 395 missing data). Deferred cord clamping, compared with immediate cord clamping, reduced death before discharge (odds ratio [OR] 0·68 [95% CI 0·51-0·91], high-certainty evidence, 20 studies, n=3260, 232 deaths). For umbilical cord milking compared with immediate cord clamping, no clear evidence was found of a difference in death before discharge (OR 0·73 [0·44-1·20], low certainty, 18 studies, n=1561, 74 deaths). Similarly, for umbilical cord milking compared with deferred cord clamping, no clear evidence was found of a difference in death before discharge (0·95 [0·59-1·53], low certainty, 12 studies, n=1303, 93 deaths). We found no evidence of subgroup differences for the primary outcome, including by gestational age, type of delivery, multiple birth, study year, and perinatal mortality. INTERPRETATION This study provides high-certainty evidence that deferred cord clamping, compared with immediate cord clamping, reduces death before discharge in preterm infants. This effect appears to be consistent across several participant-level and trial-level subgroups. These results will inform international treatment recommendations. FUNDING Australian National Health and Medical Research Council.
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Affiliation(s)
- Anna Lene Seidler
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia.
| | - Mason Aberoumand
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Kylie E Hunter
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Angie Barba
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Sol Libesman
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Nipun Shrestha
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | - Jannik Aagerup
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
| | | | - Alan A Montgomery
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lelia Duley
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Lisa M Askie
- University of Sydney, NHMRC Clinical Trials Centre, Sydney, NSW, Australia
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24
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Chapman M, Keir A. Patient Blood Management in Neonates. Clin Perinatol 2023; 50:869-879. [PMID: 37866853 DOI: 10.1016/j.clp.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Patient blood management (PBM) is an evidence-based care package to improve patient outcomes by optimizing a patient's blood, minimizing blood loss, and the effective management and, when appropriate, the tolerance of anemia. It is relatively well-developed in adult medicine and remains in its infancy in neonatology. This review explores why evidence-based guidelines are insufficient, discusses the variations in neonatal transfusion practice and why this matters, and provides the key updates in neonatal transfusion practice. The authors give examples of a successful neonatal PBM program and single-center projects.
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Affiliation(s)
- Michelle Chapman
- Department of Perinatal Medicine, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia 5006, Australia
| | - Amy Keir
- Department of Perinatal Medicine, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia 5006, Australia; Women's and Children's Hospital, North Adelaide and Clinical Associate Professor, Adelaide Medical School, University of Adelaide, South Australia, Australia.
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25
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Glaser K, Härtel C, Dammann O, Herting E, Andres O, Speer CP, Göpel W, Stahl A. Erythrocyte transfusions are associated with retinopathy of prematurity in extremely low gestational age newborns. Acta Paediatr 2023; 112:2507-2515. [PMID: 37667535 DOI: 10.1111/apa.16965] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/20/2023] [Accepted: 08/24/2023] [Indexed: 09/06/2023]
Abstract
AIM Retinopathy of prematurity (ROP) is a major morbidity in preterm infants causing visual impairment including blindness. Prevention and timely treatment are critical. We investigated the potential role of red blood cell (RBC) transfusions as risk factor for ROP development. METHODS Retrospective cohort study of data from 68 tertiary level neonatal intensive care units in Germany. Preterm infants born at 22 + 0 to 28 + 6 weeks of gestation between January 2009 and December 2021 were enrolled. RESULTS We included n = 12 565 infants. Prevalence of any ROP was 49.2% with most infants being diagnosed with stage 1 (21.5%) and 2 disease (17.2%). ROP stage 3 was present in 10.2%, stage 4 in 0.3%, and ROP requiring treatment in 6.6%. Infants with ROP had significantly more frequently a history of RBC transfusions. Adjusting for confounders, RBC transfusions were associated with increased odds of ROP (OR 1.4, p < 0.001), ROP progression (OR 2.1, p < 0.01) and ROP requiring treatment (OR 3.6, p < 0.001). Restrictive transfusion approaches correlated with decreased (OR 0.7, p < 0.001), liberal regimes with increased odds (OR 1.2, p = 0.001). CONCLUSION The present study confirmed an association of RBC transfusions and ROP. Our findings emphasise the need for anaemia prevention and critical re-evaluation of transfusion practices in preterm infants.
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Affiliation(s)
- Kirsten Glaser
- Division of Neonatology, Department of Women's and Children's Health, University of Leipzig Medical Center, Leipzig, Germany
| | - Christoph Härtel
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Olaf Dammann
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Egbert Herting
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Oliver Andres
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Christian P Speer
- Department of Pediatrics, University Hospital of Würzburg, Würzburg, Germany
| | - Wolfgang Göpel
- Department of Pediatrics, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Andreas Stahl
- Department of Ophthalmology, University Medicine Greifswald, Greifswald, Germany
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26
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Wang L, Ou J, Wu Y, Xiao G, Gong H, Chen W, Zhou L, Zhong X. Delayed versus immediate cord clamping in dichorionic twins <32 weeks: a retrospective study. J Matern Fetal Neonatal Med 2023; 36:2203300. [PMID: 37120713 DOI: 10.1080/14767058.2023.2203300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
OBJECTIVES Strong evidence imply that delayed cord clamping (DCC) provides significant benefits for singleton neonates. However, there is little information about the safety or efficacy of DCC in twins to recommend for or against DCC in twins in guidelines. We aimed to determine the effect of DCC on dichorionic twins born at <32 weeks of gestation. STUDY DESIGN This is a retrospective cohort study comparing the neonatal and maternal outcomes of immediate cord clamping (ICC) [<15 second (s)] versus DCC (at 60 s). Generalized estimating equations models were performed accounting for twin correlation. RESULTS A total of 82 pairs of twins (DCC: 41; ICC: 41) were included in analysis. The primary outcome of death before discharge occurred in 3.66% of twins in the DCC group and 7.32% in the ICC group, without a significant difference between the groups. Compared to ICC group, DCC was associated with increased hemoglobin levels [β1 coefficient 6.51; 95% confidence interval (CI) 0.69-12.32. β2 coefficient 5.80; 95% CI 0.07-11.54] at 12-24 h of life. There were no significant differences between the groups in neonatal death, neonatal major morbidities and maternal bleeding complications, although DCC was associated with higher estimated maternal blood loss in the cesarean section group (p = .005). CONCLUSIONS DCC for 60 s in dichorionic twins born at <32 weeks of gestation was associated with increased neonatal hemoglobin levels, when compared with ICC. The finding of a higher estimated maternal blood loss by cesarean section in the DCC group calls for further trials to assess maternal safety of this procedure in this patient population.
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Affiliation(s)
- Li Wang
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Jiangfeng Ou
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Yan Wu
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Guiyuan Xiao
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Hua Gong
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Wen Chen
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ligang Zhou
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Xiaoyun Zhong
- Department of Pediatrics, Women and Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
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27
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Kumar P, Polavarapu M. A simple scoring system for prediction of IVH in very-low-birth-weight infants. Pediatr Res 2023; 94:2033-2039. [PMID: 37479747 DOI: 10.1038/s41390-023-02744-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND To develop a simple scoring system to predict either any or severe IVH in VLBW infants. METHODS In this retrospective cohort study, 923 VLBW infants were randomly divided into derivation (n = 431) and validation (n = 492) cohorts. After stepwise multivariable logistic regression analyses, a risk score was assigned to independent predictors. RESULTS The overall rates of any and severe IVH were 22.9% and 9.9%. Gestational age, maternal race, location of birth and sex were independent predictors of any IVH (AUC 0.75 in derivation cohort and 0.69 for validation cohort). Birth weight, Apgar score at 1 minute, location of birth and sex were independent predictors of severe IVH (AUC 0.84 in derivation cohort and 0.77 for validation cohort). For any IVH, infants in the high-risk category (total score 4 or 5) had > 50% likelihood of any IVH with a negative predictive value of 82.6%. For severe IVH, the total risk score ranged from 0-8, and infants in high-risk category (total score 6-8) had 30% likelihood of severe IVH with a negative predictive value of 94.9%. CONCLUSION We report an easy to calculate, validated scoring system with a high NPV to identify VLBW infants at highest risk of IVH. IMPACT We report a simple validated scoring system with a high NPV for prediction of IVH in VLBW infants. The variables in the proposed model are available at birth and unlikely to be influenced by provider bias. This scoring system can identify infants at risk of any and severe IVH, while most previous models predict only severe IVH. This scoring system does not require access to web-based resources. This scoring system can help in employing prevention strategies only for infants at highest risk of IVH and thus eliminate the risks of interventions in a large majority of VLBW infants.
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Affiliation(s)
- Praveen Kumar
- Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, IL, USA.
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28
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Loechl CU, Datta-Mitra A, Fenlason L, Green R, Hackl L, Itzkowitz L, Koso-Thomas M, Moorthy D, Owino VO, Pachón H, Stoffel N, Zimmerman MB, Raiten DJ. Approaches to Address the Anemia Challenge. J Nutr 2023; 153 Suppl 1:S42-S59. [PMID: 37714779 PMCID: PMC10797550 DOI: 10.1016/j.tjnut.2023.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 09/17/2023] Open
Abstract
Anemia is a multifactorial condition; approaches to address it must recognize that the causal factors represent an ecology consisting of internal (biology, genetics, and health) and external (social/behavioral/demographic and physical) environments. In this paper, we present an approach for selecting interventions, followed by a description of key issues related to the multiple available interventions for prevention and reduction of anemia. We address interventions for anemia using the following 2 main categories: 1) those that address nutrients alone, and, 2) those that address nonnutritional causes of anemia. The emphasis will be on interventions of public health relevance, but we also consider the clinical context. We also focus on interventions at different stages of the life course, with a particular focus on women of reproductive age and preschool-age children, and present evidence on various factors to consider when selecting an intervention-inflammation, genetic mutations, nutrient delivery, bioavailability, and safety. Each section on an intervention domain concludes with a brief discussion of key research areas.
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Affiliation(s)
- Cornelia U Loechl
- Division of Human Health, International Atomic Energy Agency, Vienna, Austria
| | - Ananya Datta-Mitra
- Department of Pathology and Laboratory Medicine, University of California, Davis, Davis, CA, United States
| | - Lindy Fenlason
- Bureau for Global Health, USAID, Washington, DC, United States
| | - Ralph Green
- Department of Pathology and Laboratory Medicine, University of California, Davis, Davis, CA, United States
| | - Laura Hackl
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, United States
| | - Laura Itzkowitz
- Bureau for Global Health, USAID, Washington, DC, United States
| | - Marion Koso-Thomas
- Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, Unites States
| | - Denish Moorthy
- USAID Advancing Nutrition, John Snow Inc., Arlington, VA, United States.
| | | | - Helena Pachón
- Food Fortification Initiative, Emory University, Atlanta, GA, United States
| | - Nicole Stoffel
- Laboratory of Human Nutrition, Department of Health Sciences and Technology, ETH Zurich, Zu¨rich, Switzerland; MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Michael B Zimmerman
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Daniel J Raiten
- Eunice Kennedy Shriver National Institute of Child Health and Development, National Institutes of Health, Bethesda, MD, Unites States
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29
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Taha S, Simpson RB, Sharkey D. The critical role of technologies in neonatal care. Early Hum Dev 2023; 187:105898. [PMID: 37944264 DOI: 10.1016/j.earlhumdev.2023.105898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
Neonatal care has made significant advances in the last few decades. As a result, mortality and morbidity in high-risk infants, such as extremely preterm infants or those infants with birth-related brain injury, has reduced significantly. Many of these advances have been facilitated or delivered through development of medical technologies allowing clinical teams to be better supported with the care they deliver or provide new therapies and diagnostics to improve management. The delivery of neonatal intensive care requires the provision of medical technologies that are easy to use, reliable, accurate and ideally developed for the unique needs of the newborn population. Many technologies have been developed and commercialised following adult trials without ever being studied in neonatal patients despite the unique characteristics of this population. Increasingly, funders and industry are recognising this major challenge which has resulted in initiatives to develop new ideas from concept through to clinical care. This review explores some of the key medical technologies used in neonatal care and the evidence to support their adoption to improve outcomes. A number of devices have yet to realise their full potential and will require further development to optimise and find their ideal target population and clinical benefit. Examples of emerging technologies, which may soon become more widely used, are also discussed. As neonatal care relies more on medical technologies, we need to be aware of the impact on care pathways, especially from a human factors approach, the associated costs and subsequent benefits to patients alongside the supporting evidence.
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Affiliation(s)
- Syed Taha
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Rosalind B Simpson
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Don Sharkey
- Centre for Perinatal Research, School of Medicine, University of Nottingham, Nottingham NG7 2UH, United Kingdom.
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Wang H, Huang JL, Peng H. Effect of delayed cord clamping on cerebral hemodynamics in preterm infants. Heliyon 2023; 9:e22525. [PMID: 38034701 PMCID: PMC10687287 DOI: 10.1016/j.heliyon.2023.e22525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 11/01/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023] Open
Abstract
Background Unstable cerebral hemodynamics is an important cause of intracranial hemorrhage in premature infants. The increased blood flow of delayed cord clamping (DCC) compared to immediate cord clamping (ICC) is equivalent to 1/3-1/4 of newborn blood volume. Our objective was to assess whether the increased blood flow causes fluctuations in cerebral blood flow and how. Methods This experiment was a prospective, observational study. Neonatologists selected preterm infants eligible for inclusion and exclusion, and divided them into DCC group and ICC group according to the way of umbilical cord ligation performed by obstetrics department, and matched them 1:1 according to gestational age. The peak systolic velocity (PSV) ,end diastolic velocity (EDV),and resistance index (RI) of middle cerebral artery was measured by Mindray M9 color ultrasonic diagnostic instrument within 1 h, 24±1 h, 48±1 h, 72±1 h, respectively. Results There was no significant difference in PSV, EDV and RI in middle cerebral artery between DCC group and ICC group (P > 0.05). There were no significant differences between groups and time (P > 0.05). The hemoglobin and hematocrit in DCC group were higher than those in ICC group within 2 h after birth (P < 0.05). (P > 0.05). Conclusion DCC can increase hemoglobin and hematocrit in preterm infants, but does not cause cerebral blood flow fluctuation within a certain range. DCC is a safe method of placental transfusion.
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Affiliation(s)
- Hui Wang
- Departerment of Pediatrics, Suining Central Hospital, Suining City, 629000, Sichuan province, China
| | - Jiu-lang Huang
- Departerment of Pediatrics, Suining Central Hospital, Suining City, 629000, Sichuan province, China
| | - Hao Peng
- Departerment of Pediatrics, Suining Central Hospital, Suining City, 629000, Sichuan province, China
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Roberts CT, O'Shea JE. Alternatives to neonatal intubation. Semin Fetal Neonatal Med 2023; 28:101488. [PMID: 38000926 DOI: 10.1016/j.siny.2023.101488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.
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Affiliation(s)
- Calum T Roberts
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, VIC, Australia.
| | - Joyce E O'Shea
- Department of Paediatrics, Royal Hospital for Sick Children, Glasgow, Scotland, United Kingdom
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Edwards H, Dorner RA, Katheria AC. Optimizing transition: Providing oxygen during intact cord resuscitation. Semin Perinatol 2023; 47:151787. [PMID: 37380527 PMCID: PMC10529853 DOI: 10.1016/j.semperi.2023.151787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Delayed clamping and cutting of the umbilical cord at birth is standard practice for management for all newborns. Preterm infants may additionally benefit from a combination of ventilation and oxygen provision during intact cord resuscitation. This review highlights both the potential benefits of such a combined approach and the need for further rigorous studies, including randomized controlled trials, of delivery room management in this population.
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Affiliation(s)
- Hannah Edwards
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Rebecca A Dorner
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States
| | - Anup C Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, United States.
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B SA, Mendu SB, Pandala P, Kotha R, Yerraguntla VN. Outcomes of Neonatal Resuscitation With and Without an Intact Umbilical Cord: A Meta-Analysis. Cureus 2023; 15:e44449. [PMID: 37791162 PMCID: PMC10544125 DOI: 10.7759/cureus.44449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/05/2023] Open
Abstract
Around the world, very few babies require a more intensive resuscitative effort for stabilization. The optimal timing of an intact umbilical cord to help with resuscitation is controversial. Our objective in the review is to compare the outcomes of neonatal resuscitation with and without an intact umbilical cord. A search of six electronic database libraries was explored for data released between 2014 and 2023. A manual search of secondary references in relevant studies was also performed. Studies focused only on randomized controlled trials comparing the outcomes of neonatal resuscitation with and without an intact umbilical cord at any gestational age. Two reviewers retrieved data for relevant outcomes and independently evaluated trial quality and eligibility. Mortality rate and APGAR (appearance, pulse, grimace, activity, and respiration) scores were noted as common in the two studies. Four randomized control trials were assessed for the impact of delayed cord clamping on neonates. One study focused on neurodevelopmental outcomes and noted significant improvement. Other studies noted delayed clamping as beneficial for improving oxygen saturation, APGAR score, and mortality rate. The meta-analysis included three controlled trials with a total of 528 babies and tested the effects of clamping the umbilical cord either late (n = 264) or early (n = 264). The heterogeneity of mortality and APGAR score at 5 minutes were not significant, which may be because only two studies of each case were available to compare. We concluded that very few studies are available to identify a significant impact of delayed cord clamping in neonates. However, delayed clamping for up to 5 minutes is noted as beneficial to the newborn.
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Affiliation(s)
- Santosh Avinash B
- Department of Pediatrics Intensive Care, Osmania Medical College, Hyderabad, IND
| | - Suresh Babu Mendu
- Department of Pediatrics, Government Medical College, Siddipet, Siddipet, IND
| | - Paramesh Pandala
- Department of Pediatrics, Government Medical College, Jangaon, Hyderabad, IND
| | - Rakesh Kotha
- Department of Neonatology, Osmania Medical College, Hyderabad, IND
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34
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McDonald SD. Deferred cord clamping and cord milking: Certainty and quality of the evidence in meta-analyses, and systematic reviews of randomized control trials, guidelines, and implementation studies. Semin Perinatol 2023:151790. [PMID: 37349189 DOI: 10.1016/j.semperi.2023.151790] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Deferred1 cord clamping (DCC) saves lives, so why is it not implemented more routinely? Despite neonatal benefits, DCC is under-utilized, particularly in preterm births. Umbilical cord milking (UCM) also improves some outcomes for preterm infants such as decreasing the need for transfusions. At term, DCC and UCM improve hematological indices. OBJECTIVE The objective of this chapter is to examine the quality of evidence for both preterm and term DCC (and UCM), clinical practice guidelines and implementation issues. METHODS Key evidence, primarily from network meta-analyses, meta-analyses and systematic reviews on both preterm and term DCC (and UCM) from randomized clinical trials, clinical practice guidelines and implementation studies, are summarized through a lens of the certainty and quality of the evidence. Regarding the certainty of evidence, for network meta-analysis the Confidence in Network Meta-analysis tool was used, and for meta-analyses the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used. Guideline quality was appraised with two tools: Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) and AGREE-Recommendation EXcellence (AGREE-REX). Implementation study quality was evaluated using The Mixed Method Appraisal tool. RESULTS In a network meta-analysis of 56 RCTs of cord management strategies, DCC reduced the odds of mortality in preterm infants by 30% compared to immediate cord clamping (ICC), including in the subgroup of infants born before 33 weeks', both with a moderate confidence assessment using the Confidence in Network Meta-analysis tool. DCC reduced the odds of any intraventricular hemorrhage (IVH) by 30%, and the odds of red blood cell transfusion by more than 50%, both with high ratings on the Confidence in Network Meta-analysis. Umbilical Cord Milking (UCM) did not reduce mortality compared to ICC. In contrast to the benefits shown in preterm birth with DCC, a systematic review showed that at term, there were no mortality benefits and few benefits at all except for improved hematological indices. A systematic review of clinical practice guidelines demonstrated that all of them endorsed DCC for uncompromised preterm infants, and 11 more cautiously noted that cord milking might be considered when DCC was not feasible. However, only half (49%) of the recommendations in the guidelines on the optimal duration of DCC were supported by high-quality evidence per AGREE-II and AGREE-REX. Fewer than one in 10 statements (8%) cited a mortality benefit with DCC for preterm infants. Regarding the uptake of DCC, a systematic review of 18 studies on facilitators and barriers to implementation found that almost all (12 of the 14 studies) focused on strategies such as protocols, policy, or toolkits; additionally, 8 of 14 studies used didactic teaching sessions. Only 8 of 18 studies scored high on all four domains of the Mixed Method Appraisal tool. CONCLUSIONS Compared to ICC, DCC in preterm infants conferred significant benefits for mortality, IVH and red blood cell transfusion, with confidence ratings of moderate (mortality) or high. Although guidelines worldwide encouraged preterm (and term) DCC, the quality of the clinical practice guidelines had room for improvement; only half of the recommendations on the optimal duration of preterm DCC were supported by high-quality evidence. Most guidelines did not mention a mortality benefit with preterm DCC and lacked details on practical aspects of implementation. Among implementation studies, which have focused mainly on protocols, policies, toolkits or didactic teaching, quality also demonstrated an opportunity for improvement.
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Affiliation(s)
- Sarah D McDonald
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, ON, Canada; Department of Radiology, McMaster University, ON, Canada.
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Rabe H, Mercer J. Knowledge gaps in optimal umbilical cord management at birth. Semin Perinatol 2023:151791. [PMID: 37357042 DOI: 10.1016/j.semperi.2023.151791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
In 2014 the World Health Organisation recommended providing placental blood to all newborn infants by waiting for at least one minute before clamping the umbilical cord. Mounting evidence supports providing a placental transfusion at the time of birth for all infants. The optimal time before clamping and cutting the umbilical cord is still not yet known, and debate exists around other cord management issues. The newborn's transition phase from intra- to extra-uterine life and the effects of blood volume on the many necessary adaptations are understudied. How best to support these adaptations guides our suggested research questions. Parents' perceptions of enrolling their unborn infant into a study play important parts in the conduct of such trials. This article aims to address these topics and suggest research questions for further studies.
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Affiliation(s)
- Heike Rabe
- Academic Department of Paediatrics, Brighton and Sussex Medical School, University of Sussex, UK.
| | - Judith Mercer
- Neonatal Research Institute at Sharp Mary Birch Hospital for Women and Newborns, San Diego CA, USA; College of Nursing, University of Rhode Island, Kingston RI, USA
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Tarnow-Mordi WO, Robledo K, Marschner I, Seidler L, Simes J. To guide future practice, perinatal trials should be much larger, simpler and less fragile with close to 100% ascertainment of mortality and other key outcomes. Semin Perinatol 2023:151789. [PMID: 37422415 DOI: 10.1016/j.semperi.2023.151789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
The Australian Placental Transfusion Study (APTS) randomised 1,634 fetuses to delayed (≥60 s) versus immediate (≤10 s) clamping of the umbilical cord. Systematic reviews with meta-analyses, including this and similar trials, show that delaying clamping in preterm infants reduces mortality and need for blood transfusions. Amongst 1,531 infants in APTS followed up at two years, aiming to delay clamping for 60 s or more reduced the relative risk of the primary composite outcome of death or disability by 17% (p = 0.01). However, this result is fragile because nominal statistical significance (p < 0.05) would be abolished by only 2 patients switching from a non-event to an event, and the primary composite outcome was missing in 112 patients (7%). To achieve more robust evidence, any future trials should emulate the large, simple trials co-ordinated from Oxford which reliably identified moderate, incremental improvements in mortality in tens of thousands of participants, with <1% missing data. Those who fund, regulate, and conduct trials that aim to change practice should repay the trust of those who consent to participate by doing everything possible to minimise missing data for key outcomes.
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Affiliation(s)
- William Odita Tarnow-Mordi
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia; Neonatal and Perinatal Trials, NHMRC Clinical Trials Centre, Medical Foundation Building, Medical Levels 4-6, 92-94 Parramatta Rd, Camperdown NSW 2050, Australia.
| | - Kristy Robledo
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - Ian Marschner
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - Lene Seidler
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
| | - John Simes
- From the National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Australia
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37
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Holzapfel LF, Rysavy MA, Bell EF. Red Blood Cell Transfusion Thresholds for Anemia of Prematurity. Neoreviews 2023; 24:e370-e376. [PMID: 37258497 PMCID: PMC10865726 DOI: 10.1542/neo.24-6-e370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Anemia of prematurity affects the majority of preterm infants, particularly extremely low birthweight infants. Anemia of prematurity arises from both innate and iatrogenic causes and results in more than 80% of extremely preterm infants receiving red blood cell transfusions during the first month after birth. Multiple randomized controlled trials were conducted to evaluate the effect of using lower versus higher transfusion thresholds based on hemoglobin levels. These trials showed no difference in the primary outcome of neurodevelopmental impairment at 2 years of age between lower and higher thresholds. However, some uncertainties about transfusion thresholds remain. This review elaborates the following: 1) the etiology, prevention, and treatment of anemia of prematurity with a focus on red blood cell transfusions, 2) the history of randomized controlled trials on the treatment of anemia of prematurity, and 3) limitations of the evidence and remaining questions about thresholds for red blood cell transfusions in preterm infants.
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Affiliation(s)
- Lindsay F Holzapfel
- McGovern Medical School at University of Texas Health Science Center, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew A Rysavy
- McGovern Medical School at University of Texas Health Science Center, Houston, TX
- Children's Memorial Hermann Hospital, Houston, TX
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38
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Handley SC, Kumbhat N, Eggleston B, Foglia EE, Davis AS, Van Meurs K, Lakshminrusimha S, Walsh M, Watterberg KL, Wyckoff MH, Das A, DeMauro SB. Exposure to umbilical cord management approaches and death or neurodevelopmental impairment at 22-26 months' corrected age after extremely preterm birth. Arch Dis Child Fetal Neonatal Ed 2023; 108:224-231. [PMID: 36253076 PMCID: PMC10108713 DOI: 10.1136/archdischild-2022-324565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/25/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare death or severe neurodevelopmental impairment (NDI) at 22-26 months' corrected age (CA) among extremely preterm infants following exposure to different forms of umbilical cord management. DESIGN Retrospective study. SETTING Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry. PATIENTS Infants born <27 weeks' gestation in 2016-2018 without severe congenital anomalies who received active treatment after birth and underwent neurodevelopmental assessments between 22 and 26 months' CA. EXPOSURES Immediate cord clamping (ICC), delayed cord clamping (DCC) or umbilical cord milking (UCM). MAIN OUTCOMES AND MEASURE Primary composite outcome of death or severe NDI at 22-26 months' CA, defined as severe cerebral palsy, Bayley-III cognitive/motor composite score <70, bilateral deafness or blindness; individual components were examined as secondary outcomes. Multivariable regression examined associations, adjusting for risk factors identified a priori and potential confounders. Mediation analysis explored the effect of severe intraventricular haemorrhage (IVH) on the exposure-outcome relationship. RESULTS Among 1900 infants, 64.1% were exposed to ICC, 27.8% to DCC and 8.1% to UCM. Compared with ICC-exposed infants, DCC-exposed infants had lower odds of death or severe NDI (adjusted OR 0.64, 95% CI 0.50 to 0.83). No statistically significant differences were observed when comparing UCM with either ICC or DCC, or between secondary outcomes across groups. Association between cord management and the primary outcome was not mediated by severe IVH. CONCLUSION Compared with ICC, DCC exposure was associated with lower death or severe NDI at 22-26 months' CA among extremely preterm infants, which was not mediated by severe IVH.
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Affiliation(s)
- Sara C Handley
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neha Kumbhat
- Pediatrics/Neonatology, Stanford University, Stanford, California, USA
| | - Barry Eggleston
- Biostatistics and Epidemiology, RTI International, Research Triangle Park, North Carolina, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alexis S Davis
- Pediatrics/Neonatology, Stanford University, Stanford, California, USA
| | - Krisa Van Meurs
- Pediatrics/Neonatology, Stanford University, Stanford, California, USA
| | | | - Michele Walsh
- Department of Pediatrics, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
| | - Kristi L Watterberg
- Department of Paediatrics, University of New Mexico, Albuquerque, New Mexico, USA
| | - Myra H Wyckoff
- Pediatrics, UT Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Abhik Das
- Biostatistics, RTI International, Rockville, Maryland, USA
| | - Sara B DeMauro
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Seidler AL, Hunter KE, Barba A, Aberoumand M, Libesman S, Williams JG, Shrestha N, Aagerup J, Gyte G, Montgomery A, Duley L, Askie L. Optimizing cord management for each preterm baby - Challenges of collating individual participant data and recommendations for future collaborative research. Semin Perinatol 2023:151740. [PMID: 37019711 DOI: 10.1016/j.semperi.2023.151740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
The optimal cord management strategy at birth for each preterm baby is still unknown, despite more than 100 randomized controlled trials (RCTs) undertaken on this question. To address this, we brought together all RCTs examining cord management strategies at preterm birth in the iCOMP (individual participant data on COrd Management at Preterm birth) Collaboration, to perform an individual participant data network meta-analysis. In this paper, we describe the trials and tribulations around obtaining individual participant data to resolve controversies around cord clamping, and we derive key recommendations for future collaborative research in perinatology. To reliably answer outstanding questions, future cord management research needs to be collaborative and coordinated, by aligning core protocol elements, ensuring quality and reporting standards are met, and carefully considering and reporting on vulnerable sub-populations. The iCOMP Collaboration is an example of the power of collaboration to address priority research questions, and ultimately improve neonatal outcomes worldwide.
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Affiliation(s)
- Anna Lene Seidler
- Senior Research Fellow, NHMRC Clinical Trials Centre, University of Sydney, Australia.
| | - Kylie E Hunter
- Human Mvt, Senior Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Angie Barba
- Senior Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Mason Aberoumand
- Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Sol Libesman
- Post Doctoral Research Associate, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Jonathan G Williams
- BMedBiotech, Evidence Analyst, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Nipun Shrestha
- Post Doctoral Research Associate, NHMRC Clinical Trials Center, University of Sydney, Australia
| | - Jannik Aagerup
- Research Administration Officer, NHMRC Clinical Trials Centre, University of Sydney, Australia
| | - Gill Gyte
- Consumer Editor, Cochrane Pregnancy and Childbirth, University of Liverpool, UK
| | - Alan Montgomery
- Professor of Medical Statistics and Clinical Trials, Nottingham Clinical Trials Unit, University of Nottingham, UK
| | | | - Lisa Askie
- MPH FAHMS FHEA, University of Sydney, Australia
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40
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Prachukthum S, Tanprasertkul C, Somprasit C. Premature infants receiving delayed cord clamping with and without cord milking: a randomized control trial. BMC Pediatr 2023; 23:123. [PMID: 36932370 PMCID: PMC10024362 DOI: 10.1186/s12887-023-03933-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 02/22/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND Preterm infants often have long hospital stays and frequent blood tests; they often develop anemia requiring multiple blood transfusions. Placental transfusion via delayed cord clamping (DCC) or umbilical cord milking (UCM) helps increase blood volume. We hypothesized umbilical cord milking (UCM), together with DCC, would be superior in reducing blood transfusions. OBJECTIVES To compare the effects of DCC and DCC combined with UCM on hematologic outcomes among preterm infants. METHODS One hundred twenty singleton preterm infants born at 280/7- 336/7 weeks of gestation at Thammasat University Hospital were enrolled in an open-label, randomized, controlled trial. They were placed into three groups (1:1:1) by a block-of-three randomization: DCC for 45 s, DCC with UCM performed before clamping (DCM-B), and DCC with UCM performed after clamping (DCM-A). The primary outcomes were hematocrit levels and number of infants receiving blood transfusions during the first 28 days of life. Intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) were secondary outcomes. Analyses were performed with an intent-to-treat approach. RESULTS One hundred twenty preterm infants were randomized. There was no statistically significant difference in neonatal outcomes; hematocrit on admission 54.0 ± 5.5, 53.3 ± 6.0, and 54.3 ± 5.8 (p = 0.88), receiving blood transfusions 25%, 20%, and 12.5% (p = 0.24), incidence of NEC 7.5, 0 and 10% (p = 0.78) in the DCC, DCM-B and DCM-A groups, respectively. There were no preterm infants with severe IVH, polycythemia, maternal or neonatal death. CONCLUSION The placental transfusion techniques utilized, DCC and DCC combined with UCM, provided the same benefits for preterm infants born at GA 28 and 33 weeks in terms of reducing the need for RBC transfusions, severities of IVH and incidence of NEC without increasing comorbidity. TRIAL REGISTRATION TCTR20190131002 . Registered 31 January 2019-Retrospectively registered.
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Affiliation(s)
- Sariya Prachukthum
- Department of Pediatrics, Faculty of Medicine, Thammasat University, Pathumthani, 12120, Thailand.
| | - Chamnan Tanprasertkul
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
| | - Charintip Somprasit
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Thammasat University, Pathumthani, Thailand
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41
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Song D, Jelks A, Narasimhan SR, Jegatheesan P. Cord management strategies in multifetal gestational births. Semin Perinatol 2023:151743. [PMID: 37005172 DOI: 10.1016/j.semperi.2023.151743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
Multifetal gestations are associated with high risks of neonatal mortality and morbidities primarily due to prematurity. Delayed cord clamping and cord milking facilitate the postnatal transition and improve outcomes. Limited evidence shows that delayed cord clamping for 30-60 s and cord milking are feasible without causing harm and potentially beneficial in uncomplicated multifetal deliveries. However, data on maternal bleeding from the limited studies are inconsistent. Based on current knowledge of the risk vs. benefits, it is reasonable to perform delayed cord clamping or cord milking (>28 weeks of gestation) in uncomplicated monochorionic and dichorionic multiples. Clearly defined criteria for suitable candidates, indications for clamping or milking the cord during delivery, and improved obstetric techniques in Cesarean deliveries are critical to minimize risks and optimize neonatal transition. Research is needed to identify safe and optimal cord-management strategies for improving survival and long-term outcomes in this high-risk population.
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Affiliation(s)
- Dongli Song
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea Jelks
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sudha Rani Narasimhan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Priya Jegatheesan
- Department of Pediatrics, Division of Neonatology, Santa Clara Valley Medical Center, San Jose, CA 95128, USA; Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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Erickson-Owens D, Salera-Vieira J, Mercer J. Midwifery and nursing: Considerations on cord management at birth. Semin Perinatol 2023:151738. [PMID: 37032272 DOI: 10.1016/j.semperi.2023.151738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Mounting evidence overwhelmingly supports the practice of the return of an infant's placental blood volume at the time of birth. Waiting just a few minutes before clamping the umbilical cord can provide health benefits to infants of all gestational ages. Despite the robust evidence, uptake of delayed cord clamping (DCC) into mainstream obstetrical practice is moving slowly. The practice of DCC is influenced by various factors that include the setting in which the birth takes place, the use of evidence-informed guidelines and other influences that facilitate or hinder the practice of DCC. Through communication, collaboration, and unique disciplinary perspectives, midwives and nurses work with other members of their respective care team to develop strategies for best practice to improve an infant's well-being through optimal cord management. Midwifery has been practiced for centuries throughout the world and midwives have supported DCC since the beginning of recorded history. An important tenet of midwifery philosophy is watchful waiting and non-intervention in normal processes. Nurses are vital to care of birthing families in- and out-of-hospitals as well as in prenatal and postpartum ambulatory care. Nurses and midwives are positioned to be involved in the process of adapting to the mounting evidence for DCC. Strategies to increase better utilization of the practice of DCC have been proposed. For all, teamwork and collaboration among disciplines participating in maternity care are essential for adapting to the new evidence. Involving midwives and nurses as partners in an interdisciplinary approach to plan, implement and sustain DCC at birth increases success.
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Affiliation(s)
- Debra Erickson-Owens
- College of Nursing, University of Rhode Island, Kingston RI 02881 USA; 120 Pine Tree Circle, North Kingstown, RI 02852, USA
| | - Jean Salera-Vieira
- Professional Development, Women and Infants Hospital, Providence, RI 02905 USA; 18 Acacia Road, Bristol, RI 02809, USA
| | - Judith Mercer
- College of Nursing, University of Rhode Island, Kingston RI 02881 USA; Alpert School of Medicine, Brown University, Providence, RI 02912 USA; Neonatal Research Institute at Sharp Mary Birch Hospital, San Diego, CA 92123 USA; 670 Front Street, Marion, MA 02738, USA.
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Uribe K, Chiruvolu A, Jelin AC. Maternal implications of placental transfusion. Semin Perinatol 2023:151733. [PMID: 37068968 DOI: 10.1016/j.semperi.2023.151733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
Placental transfusion for 30-60 s after delivery is recommended by numerous professional societies and is now a common practice. Numerous studies document neonatal benefit with minimal maternal risk when routine neonatal stabilization and active management of the third stage of labor are undertaken during the period of delayed cord clamping. Maternal outcomes do not show any increased incidence of postpartum hemorrhage, or need for blood product transfusion in the case of vaginal delivery or cesarean section. Fetomaternal hemorrhage is also likely decreased with delayed cord clamping. In the case of fetal anomalies, cord management should be individualized according to each special circumstance, but is unlikely to lead to increased maternal morbidity. While few studies have investigated maternal outcomes with umbilical cord milking, this practice has not been as widely adopted. With careful monitoring of maternal and fetal well-being, a period of placental transfusion following delivery is advised for benefit of the neonate without significant maternal risk.
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Affiliation(s)
- Katelyn Uribe
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Phipps 228, Baltimore, MD 228, USA.
| | - Arpitha Chiruvolu
- Department of Pediatrics, Division of Neonatology, Baylor University Medical Center, Pediatrix Medical Group, Dallas, TX, USA
| | - Angie C Jelin
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins School of Medicine, 600 N. Wolfe Street, Phipps 228, Baltimore, MD 228, USA
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McAdams RM. A global perspective of delayed cord clamping in infants. Semin Perinatol 2023:151748. [PMID: 37012136 DOI: 10.1016/j.semperi.2023.151748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Delayed umbilical cord clamping, DCC, a practice in which the umbilical cord is not clamped immediately after birth, promotes placental transfusion to preterm and term neonates. DCC may improve outcomes in preterm neonates by reducing mortality and blood transfusion requirements and increasing iron stores. Despite the recommendations from multiple governing bodies, including the World Health Organization, research on DCC in LMICs remains limited. Given that iron deficiency is prevalent, and most neonatal deaths occur in LMICs, DCC has the potential to improve outcomes in these settings. This article aims to provide a global perspective on DCC in LMICs and to identify knowledge gaps that offer future research opportunities.
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Affiliation(s)
- Ryan M McAdams
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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Hocq C, Van Grambezen A, Carkeek K, Van Grambezen B, Yoxall CW, Debiève F, Piersigilli F, Danhaive O. Implementing intact cord resuscitation in very preterm infants: feasibility and pitfalls. Eur J Pediatr 2023; 182:1105-1113. [PMID: 36575308 DOI: 10.1007/s00431-022-04776-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/29/2022]
Abstract
The purpose of this study is to evaluate the feasibility of intact cord resuscitation (ICR) in very preterm infants using a custom-equipped mobile resuscitation trolley (LifeStart®). We collected maternal and neonatal data of all inborn infants < 32 weeks eligible for ICR per our protocol over 9 months from ICR implementation. We compared rates of ICR between the beginning and the end of the study period. We reviewed maternal and neonatal adverse events related to the procedure and direct outcomes. In order to assess potential quality improvements related to the procedure, we collected the same data in the infants born in the 9-month period preceding ICR implementation. Out of 44 infants born < 32 weeks during the period, 27 were eligible for ICR. Failure to initiate ICR occurred in 9/27, exclusively in the first 5.5 months of the study. In one infant, ICR was interrupted prior to 2 min due to placental abruption. No ICR procedure had to be interrupted due to insufficient cord length. Among the 18 infants who completed ICR, cord clamping timing increased significantly over the study period, from 3.0 [2.5-3.5] to 4.2 min [3.1-8.3] (p = 0.02). No significant maternal blood loss or wound complications were noted. No infant deaths were attributable to failure or direct consequence of ICR, and no infant experienced hypoxic respiratory failure (intubation, FiO2 ≥ 0.4), asphyxia (pH < 7.2), or blood pressure instability (< 2 SD) following stabilization. Hemoglobin level after cord clamping was higher in the ICR cohort than in the pre-implementation group. Seven out of 18 infants exposed to ICR had a temperature < 36.5 °C on admission. Conclusion: ICR is feasible in very preterm infants. Temperature management requires special attention. Multidisciplinary simulation training before implementation and systematic post-implementation quality improvement meetings may significantly increase ICR program success. What is Known: • Because infants born < 32 weeks often require cardiorespiratory resuscitation at birth, they are not offered delayed cord clamping in the majority of neonatal intensive care units. • Recently, fully equipped mobile trolleys have been developed in order to allow bedside resuscitation with an intact cord. What is New: • Variable timing of cord clamping based on the infant's transition and respiratory stability, i.e., "physiology-based cord clamping," is safely achievable in very preterm infants. • Intact cord resuscitation requires specific equipment, operational protocols, and a high level of preparation from both obstetrical and neonatal teams, with a learning curve that can be streamlined by multidisciplinary simulation training.
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Affiliation(s)
- Catheline Hocq
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium.
| | - Aurianne Van Grambezen
- Division of Obstetrics, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Katherine Carkeek
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Bénédicte Van Grambezen
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | | | - Frédéric Debiève
- Division of Obstetrics, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Fiammetta Piersigilli
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Olivier Danhaive
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, 10 Avenue Hippocrate, 1200, Brussels, Belgium
- Division of Neonatology, Benioff Children's Hospital, University of California , San Francisco, CA, USA
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Cardiac Asystole at Birth Re-Visited: Effects of Acute Hypovolemic Shock. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020383. [PMID: 36832512 PMCID: PMC9955546 DOI: 10.3390/children10020383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/31/2023] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
Births involving shoulder dystocia or tight nuchal cords can deteriorate rapidly. The fetus may have had a reassuring tracing just before birth yet may be born without any heartbeat (asystole). Since the publication of our first article on cardiac asystole with two cases, five similar cases have been published. We suggest that these infants shift blood to the placenta due to the tight squeeze of the birth canal during the second stage which compresses the cord. The squeeze transfers blood to the placenta via the firm-walled arteries but prevents blood returning to the infant via the soft-walled umbilical vein. These infants may then be born severely hypovolemic resulting in asystole secondary to the loss of blood. Immediate cord clamping (ICC) prevents the newborn's access to this blood after birth. Even if the infant is resuscitated, loss of this large amount of blood volume may initiate an inflammatory response that can enhance neuropathologic processes including seizures, hypoxic-ischemic encephalopathy (HIE), and death. We present the role of the autonomic nervous system in the development of asystole and suggest an alternative algorithm to address the need to provide these infants intact cord resuscitation. Leaving the cord intact (allowing for return of the umbilical cord circulation) for several minutes after birth may allow most of the sequestered blood to return to the infant. Umbilical cord milking may return enough of the blood volume to restart the heart but there are likely reparative functions that are carried out by the placenta during the continued neonatal-placental circulation allowed by an intact cord.
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Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GH, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome: 2022 Update. Neonatology 2023; 120:3-23. [PMID: 36863329 PMCID: PMC10064400 DOI: 10.1159/000528914] [Citation(s) in RCA: 101] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/12/2022] [Indexed: 02/17/2023]
Abstract
Respiratory distress syndrome (RDS) care pathways evolve slowly as new evidence emerges. We report the sixth version of "European Guidelines for the Management of RDS" by a panel of experienced European neonatologists and an expert perinatal obstetrician based on available literature up to end of 2022. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, appropriate maternal transfer to a perinatal centre, and appropriate and timely use of antenatal steroids. Evidence-based lung-protective management includes initiation of non-invasive respiratory support from birth, judicious use of oxygen, early surfactant administration, caffeine therapy, and avoidance of intubation and mechanical ventilation where possible. Methods of ongoing non-invasive respiratory support have been further refined and may help reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation by targeted use of postnatal corticosteroids remains essential. The general care of infants with RDS is also reviewed, including emphasis on appropriate cardiovascular support and judicious use of antibiotics as being important determinants of best outcome. We would like to dedicate this guideline to the memory of Professor Henry Halliday who died on November 12, 2022.These updated guidelines contain evidence from recent Cochrane reviews and medical literature since 2019. Strength of evidence supporting recommendations has been evaluated using the GRADE system. There are changes to some of the previous recommendations as well as some changes to the strength of evidence supporting recommendations that have not changed. This guideline has been endorsed by the European Society for Paediatric Research (ESPR) and the Union of European Neonatal and Perinatal Societies (UENPS).
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Affiliation(s)
- David G. Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, UK
| | - Virgilio P. Carnielli
- Department of Neonatology, University Polytechnic Della Marche, University Hospital Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Children and Adolescents, Oulu University Hospital and Medical Research Center, University of Oulu, Oulu, Finland
| | - Katrin Klebermass-Schrehof
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Medical University of Vienna, Vienna, Austria
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C. Roehr
- Faculty of Health Sciences, University of Bristol, UK and National Perinatal Epidemiology Unit, Oxford Population Health, Medical Sciences Division, University of Oxford, Oxford, UK
| | - Ola D. Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Christian P. Speer
- Department of Pediatrics, University Children's Hospital, Wuerzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerry H.A. Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L. Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, UK
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Nevill E, Mildenhall LFJ, Meyer MP. Effect of Breathing Support in Very Preterm Infants Not Breathing During Deferred Cord Clamping: A Randomized Controlled Trial (The ABC Study). J Pediatr 2023; 253:94-100.e1. [PMID: 36152686 DOI: 10.1016/j.jpeds.2022.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine if providing respiratory support to very preterm infants who fail to breathe regularly during deferred cord clamping (DCC) decreased red cell transfusion. STUDY DESIGN Infants less than 31 weeks of gestation undergoing DCC who were apneic or not breathing regularly at 15 seconds underwent stratified randomization. Pale, limp, and nonresponsive infants were excluded. The standard group received gentle stimulation in a neutral position for 50 seconds; the intervention group received intermittent positive pressure ventilation via face mask and T piece from 20 to 50 seconds of age with a fractional inspired oxygen of 0.3. The primary outcome was the proportion transfused, with a secondary composite outcome of death, severe intraventricular hemorrhage, or chronic lung disease. RESULTS Of 311 assessed infants, 113 met the inclusion criteria and were studied; 57 received the intervention and 56 standard treatment. Patient characteristics were similar. Overall, 105 infants (93%) received the intended 50 seconds DCC (54 in the intervention group and 51 in the standard group). Rates of transfusion were similar (28% vs 30% in the intervention vs control groups), as were rates of the composite outcome (46% vs 38% in the intervention vs the control arms; P = .45). CONCLUSIONS Providing breathing support during 50 seconds of DCC in this single-center cohort seemed to be safe and feasible, but did not decrease the transfusion rates or improve outcomes. TRIAL REGISTRATION http://www.anzctr.org.au/ACTRN12615001026516.aspx.
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Affiliation(s)
| | - Lindsay F J Mildenhall
- Middlemore Hospital, Auckland, New Zealand; Department of Pediatrics, The University of Auckland, Auckland, New Zealand
| | - Michael P Meyer
- Middlemore Hospital, Auckland, New Zealand; Department of Pediatrics, The University of Auckland, Auckland, New Zealand
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Nielsen ST, Lytsen RM, Strandkjær N, Hansen MK, Sillesen AS, Vøgg ROB, Raja AA, Rasmussen IJ, Kamstrup PR, Benn M, Iversen K, Bundgaard H, Frikke-Schmidt R. Red blood cell parameters in early childhood: a prospective cohort study. Clin Chem Lab Med 2023; 61:275-284. [PMID: 36377310 DOI: 10.1515/cclm-2022-0826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Red blood cell parameters are frequently used biomarkers when assessing clinical status in newborns and in early childhood. Cell counts, amounts, and concentrations of these parameters change through gestation and after birth. Robust age-specific reference intervals are needed to optimize clinical decision making. METHODS The Copenhagen Baby Heart Study (CBHS) and the COMPARE study are prospective cohort studies including red blood cell parameters from 7,938 umbilical cord blood samples and 295 parallel venous blood samples from newborns with follow-up at two and at 14-16 months after birth. RESULTS For venous blood at birth, reference intervals for hemoglobin, erythrocytes, and hematocrit were 145-224 g/L, 4.1-6.4 × 1012/L, and 0.44-0.64, respectively. Hemoglobin, erythrocytes, and hematocrit were lower at birth in children delivered by prelabor cesarean section compared to vaginal delivery. Conversion algorithms based on term newborns were: venous hemoglobin=(umbilical cord hemoglobin-86.4)/0.39; venous erythrocytes=(umbilical cord erythrocytes-2.20)/0.44; and venous hematocrit=(umbilical cord hematocrit-0.24)/0.45. CONCLUSIONS This study presents new reference intervals for red blood cell parameters in early childhood, describes the impact of delivery mode, and provide exact functions for converting umbilical cord to venous blood measurements for term newborns. These findings may improve clinical decision making within neonatology and infancy and enhance our clinical understanding of red blood cell parameters for health and diseases in early life.
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Affiliation(s)
- Sofie Taageby Nielsen
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Rikke Mohr Lytsen
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Nina Strandkjær
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Malene Kongsgaard Hansen
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Anne-Sophie Sillesen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - R Ottilia B Vøgg
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Anna Axelsson Raja
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Ida Juul Rasmussen
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Pia R Kamstrup
- Department of Clinical Biochemistry, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
| | - Marianne Benn
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte Hospital, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ruth Frikke-Schmidt
- Department of Clinical Biochemistry, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Yan J, Ren JD, Zhang J, Li J, Zhang X, Ma Y, Gao L. The Short and Long Term Consequences of Delayed Cord Clamping on Late Pre-Term Infants. Int J Womens Health 2023; 15:361-368. [PMID: 36942048 PMCID: PMC10024498 DOI: 10.2147/ijwh.s385800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Abstract
Objective To explore the effect of delayed cord clamping on preterm infants. Methods A retrospective analysis was conducted using the clinical data of 163 preterm infants with a gestational age of 34-36 weeks + 6 who were admitted to the neonatology department within 2 hours after birth. The blood routine examination indices within 2 hours and at 3-5 days after birth, the biochemical indices and arterial blood gas (ABG) indices within 2 hours after birth, and the hemoglobin level 5-6 months after birth were compared between the early cord clamping (ECC) group and the delayed cord clamping (DCC) group. Results Compared with the ECC group, the DCC group had significantly higher venous blood levels of red blood cells, hemoglobin, and hematocrit within 2 hours and at 3-5 days after birth. The ABG bicarbonate (HCO3) level within 2 hours after birth was obviously higher in the DCC group than in the ECC group, and the ABG absolute base excess(BE) and lactate levels were lower in the DCC group than in the ECC group (P < 0.05). There was no significant difference between the two groups in the incidence of hypothermia, hypoglycemia, respiratory distress, septicemia, feeding intolerance, polycythemia, and hyperbilirubinemia requiring phototherapy during hospitalization (P > 0.05). Compared with the ECC group, the DCC group had a significantly higher venous blood hemoglobin level 5-6 months after birth. The incidence of anemia in the DCC group was significantly lower than in the ECC group (P < 0.05). Conclusion Delayed cord clamping can significantly increase the hemoglobin levels of preterm infants at birth and at 5-6 months after birth and can improve the oxygen circulation supply to the organs of such infants. Therefore, delayed cord clamping can improve the prognosis of preterm infants.
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Affiliation(s)
- Jie Yan
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Jian-Dong Ren
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
- Correspondence: Jian-Dong Ren, Department of Neonatology, Suzhou Ninth People’s Hospital, No. 2666 Ludang Road, Wujiang District, Suzhou, Jiangsu, 215000, People’s Republic of China, Tel +8615050371917, Email
| | - Jie Zhang
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Jun Li
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Xu Zhang
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Yan Ma
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
| | - Li Gao
- Department of Neonatology, Suzhou Ninth People’s Hospital, Suzhou, People’s Republic of China
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