Delayed cord clamping - weighing the evidence

Paul Thiessen

No conflicts to declare

Objectives Determine the optimal timing of

umbilical cord clamping to ensure best neonatal and infant health care outcomes

Background Anemia in infancy has potentially serious

adverse effects on neurodevelopment In developing countries up to 50% of

infants become anemic by 12 months Prevention of iron deficiency and anemia

is therefore a high priority Compared to early clamping, delay of ~2

minutes provides 20-40 ml/kg transfusion

Background If delayed clamping of the umbilical

cord could reduce the incidence of anemia, then this would clearly be a desirable strategy

What is the evidence for the best time to clamp the cord?

Definitions Early cord clamping (ECC) - immediate Late cord clamping (LCC) > 1 ½ minutes

after delivery

Delayed clamping – systematic reviewHutton EK, et al, JAMA vol 297, p1241, March 21, 2007

Meta analysis of 15 controlled trials involving 1912 newborns >37 weeks

Late clamping was delayed for 2 minutes in 1001 infants

Early clamping occurred immediately after birth in 911

Risk of anemia

Ferritin levels

Outcomes – summary of Hutton review

Delaying cord clamping in term infants for minimum of 2 minutes is beneficial to the newborn with evidence for Higher ferritin at 2-3 mos. and at 6 mos. Anemia at 6 months - 6 in ECC vs 1 in the

LCC as defined by low ferritin Overall risk of anemia was reduced 47% in

the LCC vs ECC groups

Outcomes – Hutton review No significant increase in tachypnea or

RDS in LCC Asymptomatic increase in polycythemia No significant increase in jaundice

needing treatment

Cochrane database reviewMcDonald SJ et al, 2009

11 trials with 2989 mothers/infants Significant increase in hemoglobin in

LCC – mean 2.17 g/dL Ferritin levels higher at 6 mos in LCC Increase in infants needing Rx with

phototherapy in the LCC – (Rrisk .59)

Late cord clamping – Mexican studyChaparro CM et al, Lancet, vol 367 June 17, 2006

RCT of 358 mother/infant pairs with ECC vs LCC

Primary outcome was infant hematologic status at 6 months

Outcomes of late cord clamping – Mexican study

At 6 mos, LCC had higher MCV – 81 vs 79.5 (p.001) higher ferritin – 51 vs 34.4 (p.0002)

Effect of delayed clamping greater for infants whose mothers had low ferritin at delivery

Delayed cord clamping by 2 minutes increased 6 month iron stores by 27-47 mg

Argentina study of delayed CCCernandes JM et al, Pediatrics, 117:e779

RCT of 276 newborns with delayed cord clamping

Results similar to that of Chaparro in Mexican study – prevalence of anemia (hct <45) reduced in first months of life

Delayed cord clamping in prematures < 32 weeks

Mercer, JD et al, Pediatrics vol 117. #4 April 2006

72 mother/infant pairs with mean gestational age 28 weeks

Delayed cord clamping resulted in decreased IVH – 2/23 in LCC vs 8/19 immediately clamped group

Sepsis decreased in LCC group – none in LCC vs 6/19 in ICC group

Summary Delay in cord clamping by 2-3 minutes

appears to reduce incidence of anemia and improve iron stores in first 6 months of life, which is a major positive outcome

There may be some increase in jaundice needing phototherapy

Summary In prematures, DCC appears to reduce

the incidence of intraventricular hemorrhage and sepsis

It seems advisable to delay cord clamping for at least 2 minutes whenever practical and take advantage of “Mankind’s first natural stem cell transplant”