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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”