Early Versus Delayed Cord Clamping in Term and Preterm Births: A Review

Comparison of the Effects of Early Versus Delayed Cord Clamping on Haemoglobin Levels in Neonates Delivered at Term

BACKGROUND

The foetus is connected to the placenta via the umbilical cord, which enters through the abdomen at the umbilicus. A venous catheter for infusion and medication may be inserted via the umbilical vein, as it is directly related to the central circulation. Since delayed cord clamping increases iron storage after birth, it may help prevent anaemia in later infancy.

METHODS

This randomized controlled trial was conducted in the Department of Obstetrics and Gynaecology at Aziz Bhatti Shaheed Teaching Hospital, Pakistan, over a period of six months, from August 2021 to January 2022. A total of 70 females were enrolled. The neonates were randomly divided into two groups using the lottery method. In group 1, neonates underwent early cord clamping, while in group 2, neonates underwent delayed cord clamping after delivery. Haemoglobin levels were noted and analysed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York).

RESULTS

The mean age of patients in the early cord clamping group was 26.80±7.59 years, and in the delayed cord clamping group, it was 28.14±6.12 years. The mean haemoglobin level in the early cord clamping group was 13.84±1.74, while in the delayed cord clamping group, it was 16.34±1.90 (p-value=0.001).

CONCLUSION

In neonates born at term, the mean haemoglobin level in the delayed cord clamping group was significantly higher than that in the early cord clamping group.

A Survey on Current Practices of Umbilical Cord Clamping in Malaysia

Background

Delayed cord clamping (DCC) has been demonstrated to have significant benefits in reducing the incidence of intraventricular hemorrhage, blood transfusion and neonatal mortality in preterm neonates and improving hemodynamic and long-term neurodevelopment among term infants. There is no clear guideline on umbilical cord clamping (UCC) practices in Malaysia.

Objective

The aim of this survey was to assess the knowledge and practice of DCC among obstetric doctors and midwives in Malaysia, and pediatric colleagues who witness the delivery.

Method

This is a cross-sectional survey conducted in childbirth facilities in Malaysia from October 2020 to January 2021. A convenient snowball sampling was adopted. A validated questionnaire was disseminated to practicing obstetric and pediatric doctors and midwives electronically via email and WhatsApp using Google Form. The data were analyzed using descriptive and analytical statistics.

Results

A total of 327 respondents completed the questionnaires, comprising 206 obstetric doctors, 72 pediatric doctors and 49 midwives. The majority of respondents were specialists or higher in rank (53.2%). Only 29% reported the existence of guidelines on UCC in their place of work. Midwives (P = 0.003) and staff of lower ranks and level of education (P < 0.001) appeared to be more aware of the existence of a UCC guideline. Most respondents had positive knowledge of DCC for both term and preterm neonates. A large proportion (82%) of respondents agreed that DCC helped increase neonatal iron stores, and was good for both preterm (70.7%) and term (76.2%) neonates not requiring positive pressure ventilation. Doctors, specialists, those who are 40 years old and above, and those who have been in service for at least 10 years were found to have better knowledge regarding DCC (P < 0.05).

Conclusion

The awareness and practice of obstetric, pediatric and midwifery staff of guidelines on UCC were less than satisfactory. Even though most respondents have good knowledge and positive perception regarding benefits of DCC, these were not translated into their routine practice. Hence, a national guideline emphasizing the benefits of DCC should be made available in all childbirth facilities.

Umbilical Cord Milking in Extremely Preterm Infants: A Randomized Controlled Trial Comparing Cord Milking with Immediate Cord Clamping

OBJECTIVE

This study aimed to assess potential benefits of umbilical cord milking (UCM) when compared with immediate cord clamping (ICC) in extremely preterm infants.

STUDY DESIGN

This is a single-center, randomized controlled trial of infants 24^0/7 to 27^6/7 weeks' gestation who received UCM versus ICC. In the experimental group, 18 cm of the umbilical cord was milked three times. The primary aim was to assess the initial hemoglobin and to assess the number of blood transfusions received in the first 28 days after birth. Secondary outcomes were also assessed, including intraventricular hemorrhage (IVH). A priori, neurodevelopmental follow-up was planned at 15 to 18 months corrected gestational age (CGA).

RESULTS

Baseline characteristics for 56 enrolled infants were similar in both groups with a mean gestational age of 26.1 ± 1.2 weeks and a mean birth weight of 815 ± 204 g. There were no differences in the mean initial hemoglobin in the UCM group when compared with the ICC group, 13.7 ± 2.0 and 13.8 ± 2.6 g/dL, respectively (p = 0.95), with no differences in median number of blood transfusions after birth between the ICC group and the UCM group, 2 (interquartile range [IQR]: 1-4) versus 2.5 (IQR: 1-5) (p = 0.40). There was also no difference in the rate of severe IVH. At 15 to 18 months CGA, there were no differences in death or disability in the ICC group compared with the UCM group (26 vs. 22%; p = 1.0) and no differences in neurodevelopmental outcomes.

CONCLUSION

In a randomized trial of ICC versus UCM in extremely preterm infants, no differences were seen in initial hemoglobin or number of blood transfusions.

KEY POINTS

· Umbilical cord milking may be an alternative to delayed cord clamping, but its safety and efficacy are not established in extremely premature infants.. · There are minimal available published data on the longer term neurodevelopmental outcomes in extremely premature infants who receive umbilical cord milking compared with immediate clamping.. · We did not find a significant difference in the primary outcomes of initial hemoglobin and blood transfusions between the groups, nor did we find a difference in severe IVH with umbilical cord milking..

Intracranial Hemorrhage and 2-Year Neurodevelopmental Outcomes in Infants Born Extremely Preterm

OBJECTIVES

To determine the incidence, timing, progression, and risk factors for intracranial hemorrhage (ICH) in infants 24^0/7 to 27^6/7 weeks of gestational age and to characterize the association between ICH and death or neurodevelopmental impairment (NDI) at 2 years of corrected age.

STUDY DESIGN

Infants enrolled in the Preterm Erythropoietin Neuroprotection Trial had serial cranial ultrasound scans performed on day 1, day 7-9, and 36 weeks of postmenstrual age to evaluate ICH. Potential risk factors for development of ICH were examined. Outcomes included death or severe NDI as well as Bayley Scales of Infant and Toddler Development, 3rd Edition, at 2 years of corrected age.

RESULTS

ICH was identified in 38% (n = 339) of 883 enrolled infants. Multiple gestation and cesarean delivery reduced the risk of any ICH on day 1. Risk factors for development of bilateral Grade 2, Grade 3, or Grade 4 ICH at day 7-9 included any ICH at day 1; 2 or more doses of prenatal steroids decreased risk. Bilateral Grade 2, Grade 3, or Grade 4 ICH at 36 weeks were associated with previous ICH at day 7-9. Bilateral Grade 2, any Grade 3, and any Grade 4 ICH at 7-9 days or 36 weeks of postmenstrual age were associated with increased risk of death or severe NDI and lower Bayley Scales of Infant and Toddler Development, 3rd Edition, scores.

CONCLUSIONS

Risk factors for ICH varied by timing of bleed. Bilateral and increasing grade of ICH were associated with death or NDI in infants born extremely preterm.

Delayed Cord Clamping in Infants of Diabetic Mothers: Laboratory and Clinical Outcomes

The aim of this study was to compare the effects of delayed cord clamping (DCC) and early cord clamping (ECC) on venous hematocrit (htc) and clinical outcomes in infants of diabetic mothers (IDMs). This prospective randomized study included 157 term IDMs. The umbilical cords of these infants were clamped at least 60 seconds in group I (DCC group, n = 79) and as soon as possible after birth in group II (ECC group, n = 78). The two groups were compared regarding neonatal venous htc levels, hypoglycemia rates, jaundice requiring phototherapy, respiratory distress, and admission to the neonatal intensive care unit (NICU). Hematocrit levels were significantly higher in the DCC group, both at 6 and 24 hours postnatally (p = 0.039 and 0.01), respectively. Polycythemia frequency was higher in DCC than the ECC group, but no patient in either group needed partial exchange transfusion (PET). Rates of jaundice were significantly higher in the DCC group (p = 0.028), but there was no significant difference between the two groups regarding jaundice requiring phototherapy (p = 0.681). There were no differences between the groups regarding hypoglycemia rates, need for glucose infusion, or respiratory distress. The incidence of admission to NICU was lower in the DCC group (p = 0.005). Early clamping was a significant predictor for increased risk of NICU admission. DCC increased polycythemia and jaundice rates but did not increase the need for PET or phototherapy. Also, DCC reduced the severity of respiratory distress and the subsequent need for NICU admission.

The Impact of Nutrition-Specific and Nutrition-Sensitive Interventions on Hemoglobin Concentrations and Anemia: A Meta-review of Systematic Reviews

Anemia is a multifactorial condition arising from inadequate nutrition, infection, chronic disease, and genetic-related etiologies. Our aim was to assess the impact of nutrition-sensitive and nutrition-specific interventions on hemoglobin (Hb) concentrations and anemia to inform the prioritization and scale-up of interventions to address the multiple causes of anemia. We performed a meta-review synthesis of information by searching multiple databases for reviews published between 1990 and 2017 and used standard methods for conducting a meta-review of reviews, including double independent screening, extraction, and quality assessment. Quantitative pooling and narrative syntheses were used to summarize information. Hb concentration and anemia outcomes were pooled in specific population groups (children aged <5 y, school-age children, and pregnant women). Methodological quality of the systematic reviews was assessed using Assessing the Methodological Quality of Systematic Reviews (AMSTAR) criteria. Of the 15,444 records screened, we identified 118 systematic reviews that met inclusion criteria. Reviews focused on nutrition-specific interventions (96%). Daily and intermittent iron supplementation, micronutrient powders, malaria treatment, use of insecticide-treated nets (ITNs), and delayed cord clamping were associated with increased Hb concentration in children aged <5 y. Among children older than 5 y, daily and intermittent iron supplementation and deworming, and in pregnant women, daily iron-folic acid supplementation, use of ITNs, and delayed cord clamping, were associated with increased Hb concentration. Similar results were obtained for the reduced risk of anemia outcome. This meta-review suggests the importance of nutrition-specific interventions for anemia and highlights the lack of evidence to understand the influence of nutrition-sensitive and multifaceted interventions on the condition.

Iron Deficiency Anemia in Children Residing in High and Low-Income Countries: Risk Factors, Prevention, Diagnosis and Therapy

Iron deficiency and iron-deficiency anemia (IDA) affects approximately two billion people worldwide, and most of them reside in low- and middle-income countries. In these nations, additional causes of anemia include parasitic infections like malaria, other nutritional deficiencies, chronic diseases, hemoglobinopathies, and lead poisoning. Maternal anemia in resource-poor nations is associated with low birth weight, increased perinatal mortality, and decreased work productivity. Maintaining a normal iron balance in these settings is challenging, as iron-rich foods with good bioavailability are of animal origin and either expensive and/or available in short supply. Apart from infrequent consumption of meat, inadequate vitamin C intake, and diets rich in inhibitors of iron absorption are additional important risk factors for IDA in low-income countries. In-home iron fortification of complementary foods with micronutrient powders has been shown to effectively reduce the risk of iron deficiency and IDA in infants and young children in developing countries but is associated with unfavorable changes in gut flora and induction of intestinal inflammation that may lead to diarrhea and hospitalization. In developed countries, iron deficiency is the only frequent micronutrient deficiency. In the industrialized world, IDA is more common in infants beyond the sixth month of life, in adolescent females with heavy menstrual bleeding, in women of childbearing age and older people. Other special at-risk populations for IDA in developed countries are regular blood donors, endurance athletes, and vegetarians. Several medicinal ferrous or ferric oral iron products exist, and their use is not associated with harmful effects on the overall incidence of infectious illnesses in sideropenic and/or anemic subjects. However, further research is needed to clarify the risks and benefits of supplemental iron for children exposed to parasitic infections in low-income countries, and for children genetically predisposed to iron overload.

Effect of Delayed Cord Clamping at 30 Seconds and 1 Minute on Neonatal Hematocrit in Term Cesarean Delivery: A Randomized Trial

Objective

To compare the effect of delayed cord clamping at 30 seconds and 1 minute on the incidence of neonatal hematocrit, anemia, maternal and neonatal complications in term cesarean delivered neonates.

Methods

An opened labelled, randomized controlled trial was undertaken. The 160 healthy term cesarean-born neonates were randomly allocated to either 30 seconds or 1-minute groups of delayed cord clamping (DCC) (groups 1 and 2). Neonatal venous hematocrit (Hct) and microbilirubin (Mb) were measured at 48–72 hours after birth.

Results

One hundred and fifty-nine neonates completed this study. Mean neonatal hematocrit ± standard deviation at 48–72 hours was 49.9 ± 6.0% in group 1 and 51.2 ± 5.9% in group 2 without a statistical difference. Neonatal anemia (Hct less than 45%) occurred in 14/79 neonates (17.7%) in group 1 and in 8/80 cases (10.0%) in group 2 without a significant difference between groups. The incidence of neonatal jaundice and polycythemia (hematocrit more than 65%) was similar between groups. There were no significant differences; in the estimated blood loss during the operation, the incidence of postpartum hemorrhage and other maternal and neonatal complications.

Conclusion

Neonatal hematocrit was not significantly different following DCC at 30 seconds and at 1 minute, but the incidence of neonatal anemia decreased with the longer timing of DCC. The estimated blood loss and other complications were not different between the two groups. Therefore, one minute-DCC should be considered for neonatal anemic prevention when compared with 30 seconds-DCC.

The "DUC" trial: a pilot randomized controlled trial of immediate versus delayed cord clamping in preterm infants born between 24 and 32 weeks gestation

Purpose: To determine the feasibility of a randomized controlled trial of delayed umbilical cord clamping in preterm infants.Methods: Following informed consent, women between 24 to 32 weeks gestation experiencing imminent preterm birth were randomly assigned to either an immediate cord clamping (ICC) or delayed cord clamping (DCC) group. Umbilical cord clamping directions were 0-15 s for the ICC group and 30-45 s for the DCC group. Information regarding recruitment rate and trial compliance was collected. Neonatal outcomes of intraventricular hemorrhage (IVH), sepsis, anemia, and hyperbilirubinemia were also compared between the two groups. This trial was registered at https://clinicaltrials.gov/. (ClinicalTrials.gov Identifier: NCT00562536).Results: Thirty-eight women were recruited in total, 19 each to the ICC and DCC groups respectively. The study recruitment rate was 33% and study compliance rate was 97%. The average time for cord clamping was 5.4 s in the ICC group and 39.7 s in the DCC group (p < .05). The incidence of IVH and sepsis was the same in both groups (16 and 11% respectively). Thirty-seven percent of the ICC group and 21% of the DCC group required a blood transfusion. Hyperbilirubinemia requiring phototherapy occurred in 37% of the ICC group and 26% of the DCC group.Conclusion: This study demonstrates that a trial of a short delay in umbilical cord clamping (30-45 s) is feasible for women and physicians. Larger scale studies of long term outcomes are warranted.

Neuroprotection Strategies in Preterm Encephalopathy

Advances in neonatology have led to unprecedented improvements in neonatal survival such that those born as early as 22 weeks of gestation now have some chance of survival, and over 70% of those born at 24 weeks of gestation survive. Up to 50% of infants born extremely preterm develop poor outcomes involving long-term neurodevelopmental impairments affecting cognition and learning, or motor problems such as cerebral palsy. Poor outcomes arise because the preterm brain is vulnerable both to direct injury (by events such as intracerebral hemorrhage, infection, and/or hypoxia), or indirect injury due to disruption of normal development. This neonatal brain injury and/or dysmaturation is called "encephalopathy of prematurity". Current and future strategies to improve outcomes in this population include prevention of preterm birth, and pre-, peri-, and postnatal approaches to protect the developing brain. This review will describe mechanisms of preterm brain injury, and current and upcoming therapies in the antepartum and postnatal period to improve preterm encephalopathy.

Delayed cord clamping in term large-for-gestational age infants: A prospective randomised study

AIM

To compare the post-natal effects of delayed cord clamping (DCC) and early cord clamping (ECC) in term large-for-gestational age (LGA) infants.

METHODS

This prospective randomised study included 51 term LGA infants. The umbilical cords of these infants were clamped at 15 s in group 1 (ECC group (n = 26)) and at 60 s in group 2 (DCC group (n = 25)). Data for Apgar scores, cord blood, pH and lactate values, second haematocrit, 24th bilirubin levels, duration of hospital stay and admission to the neonatal intensive care unit (NICU) were recorded.

RESULTS

The demographic characteristics of the infants in the study group were not significantly different. No statistically significant difference was observed in the post-natal haematocrit and bilirubin levels between the groups. Six infants (group 1, n = 3; group 2, n = 3) were diagnosed with polycythaemia (P = 0.79); however, these infants remained asymptomatic, and no treatment was required. One infant in each group developed hyperbilirubinemia, which required phototherapy (P = 1.00). The infant with hyperbilirubinemia in the DCC group presented with asymptomatic polycythaemia. Three neonates in the DCC group required admission to the NICU for transient tachypnoea.

CONCLUSIONS

No significant increase in the rate of post-natal complications of DCC in term LGA infants was observed in the study. However, before recommending DCC on a routine basis, studies with a larger sample size and long-term follow-up are required to elucidate the risks and benefits of DCC in this group of infants.

ABM Clinical Protocol #7: Model Maternity Policy Supportive of Breastfeeding

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Implementation of Delayed Cord Clamping in Vigorous Preterm Neonates

OBJECTIVE

To adopt evidence-based recommendations to delay cord clamping in vigorous preterm neonates.

DESIGN

Evidence-based practice change project with quantitative data.

SETTING/LOCAL PROBLEM

Delayed cord clamping (DCC) was not a usual practice at the hospital where this project took place, despite research findings that show benefits of DCC for preterm neonates.

PARTICIPANTS

Vigorous neonates born before 37 weeks completed gestation.

INTERVENTION/MEASUREMENT

An interprofessional obstetric team of obstetricians and registered nurses implemented DCC for up to 1 minute for vigorous preterm neonates.

RESULTS

We found that Apgar scores at 1 minute (mean [M] = 8.35, standard deviation [SD] = .551, n = 31) were statistically significantly higher with DCC than at 1 minute with immediate cord clamping (M = 7.16, SD = 1.834, n = 19) at t (20.008) = 1.197, p = .012. The Apgar scores at 5 minutes (M = 9.00, SD = 0.258, n = 31) were statistically significantly higher with DCC than at 5 minutes with immediate cord clamping (M = 8.58, SD = .838, n = 19) at t (20.116) = 2.130, p = 0.046.

CONCLUSION

Delayed cord clamping was adopted as a usual clinical practice, and implementation of this practice in vigorous preterm neonates increased their Apgar scores. The obstetric team's awareness, experience, and professional perspectives about DCC improved.

Improving Neonatal Care: A Global Perspective

Each year, approximately 2.7 million babies die during the neonatal period; more than 90% of these deaths occur in developing countries, largely from preventable causes. The known, evidence-based, simple, low-cost interventions that may improve neonatal survival often have low or unknown baseline coverage rates. Gaps in coverage of essential interventions and in quality of care may be amenable to improvement strategies. However, often these gaps are not easily identified. A variety of international organizations have recommended key indicators of quality and established roadmaps for improving neonatal outcomes. Quality improvement at the facility level is an area for future investment.

Neonatal Resuscitation in Low-Resource Settings

Almost one quarter of newborn deaths are attributed to birth asphyxia. Systematic implementation of newborn resuscitation programs has the potential to avert many of these deaths as basic resuscitative measures alone can reduce neonatal mortality. Simplified resuscitation training provided through Helping Babies Breathe decreases early neonatal mortality and stillbirth. However, challenges remain in providing every newborn the needed care at birth. Barriers include ineffective educational systems and programming; inadequate equipment, personnel and data monitoring; and limited political and social support to improve care. Further progress calls for renewed commitments to closing gaps in the quality of newborn resuscitative care.

Umbilical Cord Blood: Counselling, Collection, and Banking

OBJECTIVE

To review current evidence regarding umbilical cord blood counselling, collection, and banking and to provide guidelines for Canadian health care professionals regarding patient education, informed consent, procedural aspects, and options for cord blood banking in Canada.

OPTIONS

Selective or routine collection and banking of umbilical cord blood for future stem cell transplantation for autologous (self) or allogeneic (related or unrelated) treatment of malignant and non-malignant disorders in children and adults. Cord blood can be collected using in utero or ex utero techniques.

OUTCOMES

Umbilical cord blood counselling, collection, and banking, education of health care professionals, indications for cord blood collection, short- and long-term risk and benefits, maternal and perinatal morbidity, parental satisfaction, and health care costs.

EVIDENCE

Published literature was retrieved through searches of Medline and PubMed beginning in September 2013 using appropriate controlled MeSH vocabulary (fetal blood, pregnancy, transplantation, ethics) and key words (umbilical cord blood, banking, collection, pregnancy, transplantation, ethics, public, private). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. Searches were updated on a regular basis and incorporated in the guideline to September 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, and national and international medical specialty societies.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).

BENEFITS, HARMS, AND COSTS

Umbilical cord blood is a readily available source of hematopoetic stem cells used with increasing frequency as an alternative to bone marrow or peripheral stem cell transplantation to treat malignant and non-malignant conditions in children and adults. There is minimal harm to the mother or newborn provided that priority is given to maternal/newborn safety during childbirth management. Recipients of umbilical cord stem cells may experience graft-versus-host disease, transfer of infection or genetic abnormalities, or therapeutic failure. The financial burden on the health system for public cord blood banking and on families for private cord blood banking is considerable. Recommendations 1. Health care professionals should be well-informed about cord blood collection and storage and about factors that influence the volume, quality, and ability to collect a cord blood unit. (III-A) 2. Health care professionals caring for women and families who choose private umbilical cord blood banking must disclose any financial interests or potential conflicts of interest. (III-A) 3. Pregnant women should be provided with unbiased information about umbilical cord blood banking options, including the benefits and limitations of public and private banks. (III-A) 4. Health care professionals should obtain consent from mothers for the collection of umbilical cord blood prior to the onset of active labour, ideally during the third trimester, with ample time to address any questions. (III-A) 5. Health care professionals must be trained in standardized procedures (ex utero and in utero techniques) for cord blood collection to ensure the sterility and quality of the collected unit. (II-2A) 6. Umbilical cord blood should be collected with the goal of maximizing the content of hematopoietic progenitors through the volume collected. The decision to bank the unit will depend upon specific measures of graft potency. (II-2A) 7. Umbilical cord blood collection must not adversely affect the health of the mother or newborn. Cord blood collection should not interfere with delayed cord clamping. (III-E) 8. Health care professionals should inform pregnant women and their partners of the benefits of delayed cord clamping and of its impact on cord blood collection and banking. (II-2A) 9. Cord blood units collected for public or private banking can be used for biomedical research, provided consent is obtained, when units cannot be banked or when consent for banking is withdrawn. (II-3B) 10. Mothers may be approached to donate cells for biomedical research. Informed consent for research using cord blood should ideally be obtained prior to the onset of active labour or elective Caesarean section following established research ethics guidelines. (II-2A).

Skin, thermal and umbilical cord care practices for neonates in southern, rural Zambia: a qualitative study

BACKGROUND

In Choma District, southern Zambia, the neonatal mortality rate is approximately 40 per 1000 live births and, although the rate is decreasing, many deliveries take place outside of formal facilities. Understanding local practices during the postnatal period is essential for optimizing newborn care programs.

METHODS

We conducted 36 in-depth interviews, five focus groups and eight observational sessions with recently-delivered women, traditional birth attendants, and clinic and hospital staff from three sites, focusing on skin, thermal and cord care practices for newborns in the home.

RESULTS

Newborns were generally kept warm by application of hats and layers of clothing. While thermal protection is provided for preterm and small newborns, the practice of nighttime bathing with cold water was common. The vernix was considered important for the preterm newborn but dangerous for HIV-exposed infants. Mothers applied various substances to the skin and umbilical cord, with special practices for preterm infants. Applied substances included petroleum jelly, commercial baby lotion, cooking oil and breastmilk. The most common substances applied to the umbilical cord were powders made of roots, burnt gourds or ash. To ward off malevolent spirits, similar powders were reportedly placed directly into dermal incisions, especially in ill children.

CONCLUSIONS

Thermal care for newborns is commonly practiced but co-exists with harmful practices. Locally appropriate behavior change interventions should aim to promote chlorhexidine in place of commonly-reported application of harmful substances to the skin and umbilical cord, reduce bathing of newborns at night, and address the immediate bathing of HIV-infected newborns.

Perinatal factors in patent ductus arteriosus in very low-birthweight infants

BACKGROUND

The relationship between hemoglobin and patent ductus arteriosus (PDA) has not been discussed before. The aim of this study was to assess the influence of hemoglobin and perinatal factors on PDA in very low-birthweight (VLBW) infants.

METHODS

Using data from the Premature Baby Foundation of Taiwan (PBFA), the characteristics, perinatal factors, and hemoglobin of VLBW infants with and without PDA and treatment were compared.

RESULTS

Between January 2008 and December 2010, 89 VLBW infants were admitted to hospital. The overall survival rate was 87.6%. Twelve infants were excluded. Compared to those without PDA, the 34 infants with PDA received oral indomethacin or surgery, had smaller mean gestational age (GA; 27.93 ± 1.818 weeks, P = 0.000003), lower mean birthweight (BW; 1031 ± 259 g, P = 0.0001), significantly lower Apgar score at 5 min, more severe respiratory distress syndrome (RDS; grade 3 or 4), greater use of surfactants, and lower mean hemoglobin (P = 0.018) after birth than those without PDA. Compared to those with indomethacin, the seven infants with surgery had lower mean GA (26.43 ± 1.718 weeks, P = 0.011), significantly lower Apgar scores at 1 min, but higher platelet count (P = 0.002) after birth, and more red blood cell transfusions (P = 0.039).

CONCLUSIONS

Smaller GA, lower BW, lower Apgar score at 5 min, more severe RDS, greater use of surfactants, and lower hemoglobin after birth place VLBW infants at greater risk of PDA. Proper prenatal care, and prevention of premature labor and delivery may be the most important preventative factors. The appropriate hemoglobin level for PDA closure requires further investigation.

Infant iron status affects iron absorption in Peruvian breastfed infants at 2 and 5 mo of age

BACKGROUND

Effects of prenatal iron supplementation on maternal postpartum iron status and early infant iron homeostasis remain largely unknown.

OBJECTIVE

We examined iron absorption and growth in exclusively breastfed infants in relation to fetal iron exposure and iron status during early infancy.

DESIGN

Longitudinal, paired iron-absorption (⁵⁸Fe) studies were conducted in 59 exclusively breastfed Peruvian infants at 2-3 mo of age (2M) and 5-6 mo of age (5M). Infants were born to women who received ≥ 5100 or ≤ 1320 mg supplemental prenatal Fe. Iron status was assessed in mothers and infants at 2M and 5M.

RESULTS

Infant iron absorption from breast milk averaged 7.1% and 13.9% at 2M and 5M. Maternal iron status (at 2M) predicted infant iron deficiency (ID) at 5M. Although no infants were iron deficient at 2M, 28.6% of infants had depleted iron stores (ferritin concentration <12 μg/L) by 5M. Infant serum ferritin decreased (P < 0.0001), serum transferrin receptor (sTfR) increased (P < 0.0001), and serum iron decreased from 2M to 5M (P < 0.01). Higher infant sTfR (P < 0.01) and breast-milk copper (P < 0.01) predicted increased iron absorption at 5M. Prenatal iron supplementation had no effects on infant iron status or breast-milk nutrient concentrations at 2M or 5M. However, fetal iron exposure predicted increased infant length at 2M (P < 0.01) and 5M (P < 0.05).

CONCLUSIONS

Fetal iron exposure affected early infant growth but did not significantly improve iron status or absorption. Young, exclusively breastfed infants upregulated iron absorption when iron stores were depleted at both 2M and 5M.

Delayed cord clamping: a collaborative practice to improve outcomes

Delayed cord clamping is a collaboration between the obstetric team and the neonatal team. Although the optimal timing for clamping the umbilical cord after birth continues to be subject to study, delaying clamping for at least 30-60 seconds, with the newborn held at or below the level of the uterus/placenta supports normal physiology and has proven benefits. Practical issues such as thermoregulation and equipment can be overcome with team collaboration and prebriefing planning. Neonatal nurses who attend deliveries are perfectly poised to influence this practice and improve short- and long-term outcomes for their patients.