Re: Clamping cord time.
From: Betsy Hyde (elishyde@connix.com)
Fri Aug 21 20:38:19 1998
At 1:32 PM 8/21/98, Braun, R. Daniel wrote:
>Is anybody else aware of anything? Besides multiple OLD observational
>studies.
>Dan
here are some old posts/references on delayed cord clamping. Because of
concerns re sending attachments, I am including these in the body of my
post. Hope that is agreeable to list members. It's long, but avoids the
problems of not being able to receive attachments, etc.
--
Betsy Hyde CNM
Branford, CT
> American Journal of Obstetrics and Gynecology
>
> Copyright 1993 by Mosby-Year Book, Inc.
>------------------------------------------------------------------------
>Volume 169(1) Jul 1993 pp 189-193
>------------------------------------------------------------------------
>------------------------------------------------------------------------
>------------------------------------------------------------------------
>
> The Effect of Leboyer Delivery on Blood Viscosity and Other
> Hemorheologic Parameters in Term Neonates
>
> [Clinical Articles]
>
> Nelle, Mathias; Zilow, Eugen P.; Kraus, Martina; Bastert, Gunther;
> Linderkamp, Otwin
>
> From the Division of Neonatology, Departments of Pediatrics and
>Obstetrics and Gynecology, University of Heidelberg.
>
> Supported in part by the German Research Foundation (DFG research
>grant Li 291/4).
>
> Received for publication May 18, 1992; revised November 11, 1992;
>accepted December 16, 1992.
>
> Reprint requests: Otwin Linderkamp, MD, Department of Pediatrics,
>University of Heidelberg, Im Neuenheimer Feld 150, D-6900 Heidelberg,
>Germany.
>
> OBJECTIVE: This study was done to compare postnatal alterations in
>blood viscosity, hematocrit value, plasma viscosity, red blood cell
>aggregation, and red blood cell deformability in term neonates
>undergoing both early umbilical cord clamping and delivery according
>to the Leboyer method.
>
> STUDY DESIGN: The umbilical cords of 15 healthy, term infants were
>clamped within 10 seconds of birth (early cord clamping), and 15
>infants delivered according to the Leboyer method were placed on the
>mother's abdomen, and the umbilical cords were clamped 3 minutes after
>birth. Hemorheologic parameters were studied in umbilical cord blood
>at 2 hours, 24 hours, and 5 days from the time of delivery.
>
> RESULTS: The residual fetal placental blood volume decreased from 45
>+- 8 ml/kg (x +- SD) after early cord clamping to 25 +- 5 ml/kg after
>delivery by the Leboyer method. After Leboyer-method delivery, the
>hematocrit value rose from 48% +- 5% at birth to 58% +- 6% 2 hours
>after delivery, 56% +- 7% at 24 hours, and 54% +- 8% after 5 days.
>Blood viscosity in the Leboyer-method group increased by 32% within
>the first 2 hours but did not change significantly during the
>following 5 days. Plasma viscosity, red blood cell aggregation, and
>red blood cell deformability were not affected by the mode of cord
>clamping.
>
> CONCLUSIONS: Delivery by the Leboyer method leads to a significant
>increase in blood viscosity as a result of increasing hematocrit
>value, whereas other hemorheologic parameters are similar to those of
>infants with early cord clamping. (AM J OBSTET GYECOL 1993;169:189-93.)
REFERENCES
>
>1. Oh W, Blankenship W, Lind J. Further study of neonatal blood volume
> in relation to placental transfusion. Ann Paediatr 1966;207:147-59.
> [Context Link]
>
>2. Saigal S, O'Neill A, Surainder Y, Chua LB, Usher R. Placental
> transfusion and hyperbilirubinemia in the premature. Pediatrics
> 1972;49:406-19. [Medline Link] [Context Link]
>
>3. Ingomar CJ, Klebe JG, Baekgaard P. The transcapillary escape rate of
> T-1824 in healthy newborn infants: the influence of the placental
> transfusion. Acta Paediatr Scand 1973;62:617-20. [Medline Link]
> [Context Link]
>
>4. Linderkamp O. Placental transfusion: determinants and effects. Clin
> Perinatol 1982;9:559-92. [Medline Link] [Context Link]
>
>5. Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet
> 1969:505-8. [Context Link]
>
>6. Linderkamp O, Nelle M, Kraus M, Filow EP. The effect of early and
> late cord-clamping on blood viscosity and other hemorheological
> parameters in full-term neonates. Acta Paediatr 1992;81:745-50.
> [Medline Link] [Context Link]
>
>7. Leboyer F. Birth without violence. New York: Alfred A Knopf, 1975.
> [Context Link]
>
>8. Nelson NM, Enkin MW, Saigal S, et al. A randomized clinical trial of
> the Leboyer approach to childbirth. N Engl J Med 1980;302:655-60.
> [Medline Link] [Context Link]
>
>9. Linderkamp O, Versmold HT, Riegel KP, Betke K. Contributions of red
> cells and plasma to blood viscosity in preterm and full-term infants
> and adults. Pediatrics 1984;74:45-51. [Medline Link] [Context
> Link]
>
>10. Zilow EP, Linderkamp O. Viscosity reduction of red blood cells from
> preterm and full-term neonates and adults in narrow tubes
> (Fahraeus-Lindqist effect). Pediatr Res 1989;25:595-7. [Medline
> Link] [Context Link]
>
>11. Bratteby LE. Studies on erythro-kinetics in infancy. VIII. Mixing,
> disappearance rates and distribution volume of labelled erythrocytes
> and plasma proteins in early infancy. Acta Soc Med Upsala
> 1967;72:249-71. [Context Link]
>
>12. Oh W, Arcilla RA, Lind J, Gessner IH. Arterial blood gas and acid
> base balance in the newborn infant: effect of cord clamping at
> birth. Acta Paediatr Scand 1966;55:593-9. [Medline Link] [Context
> Link]
>
>13. Kunzel W, Chelius HH. Fruhabnabelung --Spatabnabelung: Auswirkung
> auf den Saure-Basen-Status und den aktuellen Kohlensaurepartialdruck
> wahrend der ersten Lebensstunden. Z Geburtsh Gynakol
> 1969;171:309-22. [Context Link]
>
>14. Buchan PC. Impaired erythrocyte deformability and raised blood
> viscosity and perinatal hypoxic brain damage--an in vitro and in
> vivo study. In: Heilmann L, Buchan PC, eds. Hemorrheological
> disorders in obstetrics and neonatology. Stuttgart: Schattauer,
> 1984:98-103. [Context Link]
>
>15. Riegel K, Linderkamp O. Das Neugeborene. In: Betke K, Kunzer W,
> Schaub J, eds. Keller/Wiskott Lehrbuch der Kinderheilkunde.
> Stuttgart: Thieme, 1991:159-70. [Context Link]
>
>16. Oh W. Neonatal polycythemia and hyperviscosity. Pediatr Clin North
> Am 1986;33:523-32. [Medline Link] [Context Link]
>
>17. Shohat M, Merlob P, Reisner SH. Neonatal polycythemia. I. Early
> diagnosis and incidence relating to time of sampling. Pediatrics
> 1984;73:7-10. [Medline Link] [Context Link]
>
>18. Betke K, Marti H, Schlicht I. Estimation of small percentages of
> foetal haemoglobin. Nature 1959;184:1877-8. [Context Link]
>
>19. Stadler AA, Zilow EP, Linderkamp O. Blood viscosity and optimal
> hematocrit in narrow tubes. Biorheology 1990;27:779-88. [Medline
> Link] [Context Link]
>
>20. Schmid-Schonbein H, Volger E, Teitel P, Kiesewetter H, Dauer V,
> Heilmann L. New hemorheological techniques for the routine
> laboratory. Clin Hemorheol 1982;2:93-105. [Context Link]
>
>21. Linderkamp O, Guntner M, Hiltl W, Vargas VM. Erythrocyte
> deformability in the fetus, preterm and term neonate. Pediatr Res
> 1986;20:93-6. [Medline Link] [Context Link]
>
>22. Newton M, Moody AR. Fetal and maternal blood in the human placenta.
> Obstet Gynecol 1961;18:305-8. [Context Link]
>
>23. Kleinberg F, Dong L, Phibbs RH. Cesarean section prevents
> placenta-to-infant transfusion despite delayed cord clamping. AM J
> OBSTET GYNECOL 1975;121:66-70. [Medline Link] [Context Link]
>
>24. Buonocore G, Berni S, Gioia D, Garosi G, Bracci R. Whole blood
> filterability in the neonate. Clin Hemorrheol 1991;11:41-8.
> [Context Link]
>
>25. Ramamurthy RS, Brans YW. Neonatal polycythemia. I. Criteria for
> diagnosis and treatment. Pediatrics 1981;68:168-72. [Medline Link]
> [Context Link]
>
*****************************************************************************
> The British Medical Journal
>
> Copyright 1993 by the British Medical Journal.
>------------------------------------------------------------------------
>Volume 306(6871) Jan 16, 1993 pp 172-175
>------------------------------------------------------------------------
>------------------------------------------------------------------------
>------------------------------------------------------------------------
>
> Umbilical Cord Clamping and Preterm Infants: A Randomised Trial.
>
> [Papers]
>
> Kinmond, S; Aitchison, T C; Holland, B M; Jones, J G; Turner, T L;
> Wardrop, C A J.
>
> Queen Mother's Hospital, Department of Child Health, University of
>Glasgow; Department of Statistics, University of Glasgow; Department
>of Biochemistry, University of Wales, Cardiff; Department of
>Haematology, University of Wales College of Medicine, Cardiff.
>
> Correspondence to: Dr S Kinmond, Special Care Baby Unit, Ayrshire
>Central Hospital, Irvine KA12 8SS.
>
>ABSTRACT
>
> Objective - To investigate the clinical effects of regulating
>umbilical cord clamping in preterm infants.
>
> Design - A prospective randomised study.
>
> Setting - The Queen Mother's Hospital, Glasgow.
>
> Subjects - 36 vaginally delivered infants over 27 and under 33
>weeks' gestation.
>
> Intervention - Holding the infant 20 cm below the introitus for 30
>seconds before clamping the umbilical cord ("regulated" group, 17
>patients), or conventional management ("random" group, 19 patients).
>
> Main outcome measures - Initial packed cell volume, peak serum
>bilirubin concentrations, red cell transfusion requirements, and
>respiratory impairment (assessed by ventilatory requirements,
>arterial-alveolar oxygen tension ratio over the first day in
>ventilated infants, and duration of dependence on supplemental oxygen).
>
> Results - There were statistically significant differences between
>the two groups in mean initial packed cell volume (regulated group
>0.564, random group 0.509) and median red cell transfusion
>requirements (regulated group zero, random group 23 ml/kg). 13 infants
>from each group underwent mechanical ventilation and showed
>significant differences in mean minimum arterial-alveolar oxygen
>tension ratio on the first day (regulated group 0.42, random group
>0.22) and in median duration of dependence on supplemental oxygen
>(regulated group three days, random group 10 days). Differences in
>final outcome measures such as duration of supplemental oxygen
>dependence and red cell transfusion requirements were mediated
>primarily through arterial-alveolar oxygen tension ratio and also
>packed cell volume.
>
> Conclusions - This intervention at preterm deliveries produces
>clinical and economic benefits.
>------------------------------------------------------------------------
******************************************************************************
>------------------------------------------------------------------------
>------------------------------------------------------------------------
> The British Medical Journal
>
> Copyright 1993 by the British Medical Journal.
>Volume 306(6877) Feb 27, 1993 pp 578-579
>------------------------------------------------------------------------
>
>------------------------------------------------------------------------
> Umbilical Cord Clamping in Preterm Infants.
>------------------------------------------------------------------------
>
> [Letters]
>
> Editor, - The paper by S Kinmond and colleagues suggests that
>modification of a common practice - clamping of the umbilical cord -
>may have important implications for the wellbeing of immature babies
>(Ref. 1). Most of the previous research into the timing of cord
>clamping has concentrated on babies born near term (Ref. 2). Rigorous
>steps to avoid selection biases seem to have been taken in only two of
>the four studies of immature babies - namely, those of Hofmeyr et al
>(Ref. 3,4).
>
> The first of these two studies is referred to in Kinmond and
>colleagues' paper as showing a reduction in the incidence of
>periventricular and intraventricular haemorrhage with delayed cord
>clamping (Ref. 3). In addition, however, this policy was associated
>with more neonatal deaths. As the authors explain, the small sample
>size (38 babies) led to imbalances in the baseline variables, which
>could explain the differences in outcome. Because of this the
>investigators subsequently carried out a larger trial (in 86 babies),
>which did not confirm either the reduction in haemorrhage or the
>increase in mortality (Ref. 4). There also seem to have been
>considerable baseline imbalances in the trial reported by Kinmond and
>colleagues, judged on the few characteristics described in table I,
>and so the same concerns must apply.
>
> The inclusion of birth weight as one of the enrolment
>characteristics is probably inappropriate. Increased placental
>transfusion in the regulated group should surely have resulted in an
>increased birth weight, as found in other studies in which cord
>clamping was delayed (Ref. 5). Birth weight is therefore more
>reasonably considered to be an outcome variable.
>
> The principal outcome, and the measure on which the trial sample
>size was based, is the number of transfusions. In appraising the
>trial's results it would therefore be helpful to know the indications
>for transfusion that applied at the Queen Mother's Hospital during the
>trial and whether the decision to transfuse was made without knowledge
>of the policy on cord clamping.
>
> Immature babies are even more likely than others to have their
>umbilical cords clamped and cut immediately after birth to allow
>resuscitation and transfer to neonatal intensive care. Kinmond and
>colleagues' study suggests that a short delay may improve outcome
>without any obvious deleterious effects. But, on the basis of
>currently available evidence, uncertainty remains. Before widespread
>changes in practice are made this finding needs confirmation in a
>larger trial with mortality and major respiratory and cerebral
>morbidity as the primary outcomes.
>
>Diana Elbourne
>
>Perinatal Trials Service, National Perinatal Epidemiology Unit,
>Radcliffe Infirmary, Oxford OX2 6HE
>
> REFERENCES
>
>1. Kinmond S, Aitchison TC, Holland BM, Jones JG, Turner TL, Wardrop
> CAJ. Umbilical cord clamping in preterm infants: a randomised trial.
> BMJ 1993; 306:172-5. (16 January.) [Medline Link] [Fulltext Link]
> [Context Link]
>
>2. Prendiville W, Elbourne D. Care during the third stage of labour.
> In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in
> pregnancy and childbirth. Oxford: Oxford University Press,
> 1989:1145-69. [Context Link]
>
>3. Hofmeyr GJ, Bolton KD, Bowen DC, Govan JJ.
> Periventricular/intraventricular haemorrhage and umbilical cord
> clamping: findings and hypothesis. S Afr Med J 1988; 73:104-6.
> [Medline Link] [Context Link]
>
>4. Hofmeyr GJ, Gobetz L, Bex PJM, Van Der Griendt M, Nikodem VC,
> Skapinker R, et al. Periventricular/intraventricular haemorrhage
> following early and delayed umbilical cord clamping. In: Chalmers I,
> ed. Oxford database of perinatal trials, version 1.2, disk issue 6,
> autumn. Oxford: Oxford University Press, 1991. [Context Link]
>
>5. Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol
> third stage trial: active versus physiological management of third
> stage of labour. BMJ 1988; 297:1295-300. [Medline Link] [Context
> Link]
>
>------------------------------------------------------------------------
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>------------------------------------------------------------------------
>------------------------------------------------------------------------
>Full Text of: Pisacane: BMJ, Volume 312(7024).January 20, 1996.pp 136-137.
>***************************
>British Medical Journal
>
>The British Medical Journal is a copyright of the British Medical
>Association, 1996. All Rights Reserved.
>
>Volume 312(7024).January 20, 1996.pp 136-137.
>
>Neonatal prevention of iron deficiency: Placental transfusion is a cheap
>and physiological solution
>
>[Editorials]
>
>Pisacane, Alfredo
>
>Dipartimento di Pediatria, Universita di Napoli Federico II, 80131 Naples,
>Italy.
>
>Iron deficiency anaemia in childhood is common even in socially advantaged
>populations. Low birth weight, early consumption of cows' milk, fast
>growth rate, and poor dietary iron intake are considered the main risk
>factors. (Ref. 1) Iron enriched infant formula and cereals have been shown
>to be effective preventive measures. (Ref. 2,3) In developing countries,
>where iron deficiency anaemia is common and iron enriched formula and
>cereals are often not available, preventing iron deficiency is not easy:
>infants who enjoy prolonged and exclusive breast feeding have been found
>to have good iron status, (Ref. 4) but such breastfeeding is increasingly
>rare; and although medicinal iron is cheap, its use may be culturally
>unacceptable or difficult to implement. Moreover, dietary iron
>supplementation can be dangerous in settings where malaria and diarrhoeal
>infection are endemic (Ref. 2,5) and for children whose iron stores are
>adequate. (Ref. 6)
>
>Iron stores at birth show huge individual variations, which correlate with
>iron stores in the same individuals at 6, 9, and 12 months of age. (Ref.
>7) This may explain why the iron status of some infants remains
>sufficient, even if they do not receive adequate daily iron. Dietary iron
>seems to represent only one of the factors that influence iron status in
>the first year of life, (Ref. 8,9) probably because iron absorption from
>formula and cereals is modest and is inhibited by many components of the
>diet such as polyphenols in fruit and vegetables. If high neonatal iron
>stores are associated with a good iron status in late infancy, (Ref. 7)
>how can we safely increase neonatal stores?
>
>The merits of early or late clamping of the umbilical cord have been
>controversial for many years. (Ref. 10) According to Usher et al, (Ref.
>11) the estimated volume of placental transfusion varies from 20 percent
>to 60 percent of the existing blood volume (54-160 ml) depending on the
>time of clamping and the position in which the infant is held before
>clamping. (Ref. 12) Linderkamp and colleagues estimated that the amount of
>placental transfusion is about 35 ml/kg of birth weight when term infants
>are kept at the level of the vaginal opening and the cord is clamped three
>minutes after birth. (Ref. 13) The same authors have recently investigated
>the effect of placing the neonate on the mother's abdomen and clamping the
>cord only once it stops pulsating (Leboyer delivery). (Ref. 14) They found
>that these babies had blood volumes 32 percent higher than babies whose
>cords were clamped immediately after birth. The packed cell volume in cord
>blood was not affected by placental tr!
>ansfusion, but after 2-4 hours it rose in the group of infants whose cord
>was clamped late, from 0.51 (SD 0.05) to 0.62 (0.06). This difference was
>statistically significant when compared with infants whose cords were
>clamped early.
>
>A moderate placental transfusion as achieved in the Leboyer delivery does
>not significantly increase neonatal jaundice, nor does it incur
>detrimental haemodynamic changes, (Ref. 14) although occasional cases of
>circulatory overload from excessive placental transfusion have been
>reported. (Ref. 10) Moreover, a moderate transfusion of about 20-30 ml/kg
>endows about 30-50 mg of "extra" iron and can help prevent or delay
>depletion of iron stores during late infancy.
>
>Recent research from Denmark favours this hypothesis. (Ref. 7) Studying 9
>month old infants born in a hospital whose policy was to clamp the cord
>late, the researchers found serum ferritin values higher than those
>reported for infants from other European countries, (Ref. 15-17) whose
>cords were assumed to have been clamped immediately after birth. Higher
>neonatal iron stores associated with late cord clamping could be one
>explanation for this observation. The positive effects of delayed cord
>clamping could be even more clinically and economically important among
>infants in developing countries. For those children a moderate placental
>transfusion could represent a physiological and inexpensive means of
>increasing iron stores. At the same time, delayed cord clamping represents
>a change in routine practice that favours early contact between a mother
>and her newborn baby. An overview of randomised controlled trials found a
>statistically significant association between such early!
> contact and subsequent prolonged breast feeding (Ref. 18); this could
>therefore represent another measure to prevent iron deficiency.
>
>Immediate cord clamping is currently routine practice, but its widespread
>acceptance was not preceded by studies evaluating the effects of depriving
>neonates of a significant volume of blood. A large clinical trial to
>compare the short and long term effects of placental transfusion is
>needed.
>
>ALFREDO PISACANE
>
>Senior lecturer
>
>Dipartimento di Pediatria,
>
>Universita di Napoli Federico II,
>
>80131 Naples, Italy
>
>REFERENCES AND NOTES
>
>1. Oski FA. The causes of iron deficiency in infancy. In: Filer LD Jr, ed.
>Dietary iron: birth to two years. New York: Raven, 1989:63-70.
>
>2. Yip R, Walsh KM, Goldfarb MG, Binkin NJ. Declining prevalence of anemia
>in childhood. A pediatric success story? Pediatrics 1987;80:330-4.
>
>3. Walter T, Dallman PR, Pizarro F, Velozo L, Pena G, Bartholmey SJ, et
>al. Effectiveness of iron-fortified cereal in prevention of iron
>deficiency anemia. Pediatrics 1993;91:976-82.
>
>4. Pisacane A, De Vizia B, Vaccaro F, Valiante F, Russo M, Grillo G, et
>al. Iron status in breast-fed infants. J Pediatrics 1995;127:429-31.
>
>5. Oppenheimer SJ. Iron and infection: the clinical evidence. Acta
>Paediatr Scand 1989;361(suppl): 53-62.
>
>6. Idjradinata P, Watkins WE, Pollitt E. Adverse effect of iron
>supplementation on weight gain of iron replete young children. Lancet
>1994;343:1252-4.
>
>7. Michaelsen KF, Milman N, Samuelson G. A longitudinal study of iron
>status in healthy Danish infants: effects of early iron status, growth
>velocity and dietary factors. Acta Paediatr 1995;84:1035-44.
>
>8. Duggan MB, Steel G, Elwys G, Noble C. Iron status, energy intake, and
>nutritional status of healthy young Asian children. Arch Dis Child
>1991;66:1386-9.
>
>9. Stevens D, Nelson A. The effect of iron in formula milk after 6 months
>of age. Arch Dis Child 1995;73:216-20.
>
>10. Peltonen T. Placental transfusion: advantage and disadvantage. Eur J
>Pediatr 1981;137:141-6.
>
>11. Usher R, Shephard M, Lind J. The blood volume of the newborn infant
>and placental transfusion. Acta Paediatr Scand 1963;52:497-512.
>
>12. Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet
>1969;ii:505-8.
>
>13. Linderkamp O, Nelle M, Kraus M, Zilow EP. The effect of early and late
>cord clamping on blood viscosity and other hemorheological parameters in
>full-term neonates. Acta Paediatr 1992;81: 745-50.
>
>14. Nelle M, Zilow EP, Bastert G, Linderkamp O. Effect of Leboyer
>childbirth on cardiac output, cerebral and gastrointestinal blood flow
>velocities in full-term neonates. Am J Perinatol 1995;12:212-6.
>
>15. Mekki N, Galan P, Rossignol C, Farnier MA, Hercberg S. Le statut en
>fer chez l'enfant de 10 mois, 2 ans et 4 ans presum beta bien-portant.
>Arch Fr Pediatr 1989;46:481-5.
>
>16. Haschke F, Vanura H, Male C, Owen G, Pietschnig B, Schuster E, et al.
>Iron nutrition and growth of breast- and formula-fed infants during the
>first 9 months of life. J Pediatr Gastroenterol Nutr 1993;16:151-6.
>
>17. Fernandez-Ballart J, Domenech-Massons JM, Arija V, Marti-Henneberg C.
>The influence of nutrient intake on the biochemical parameters of iron
>status in a healthy paediatric population. Eur J Clin Nutr 1992;46:143-9.
>
>18. Perez-Escamilla R, Pollitt E, Lonnerdal B, Dewey KG. Infant feeding
>policies in maternity wards and their effect on breast-feeding success: an
>overview. Am J Public Health 1994;84:89-97.
