Available online 17 March 2023, 151745

Author links open overlay panel, , , , , , ABSTRACT

Umbilical cord clamping practices impact nearly 140 million births each year. Current evidence has led professional organizations to recommend delayed cord clamping (DCC), as opposed to early cord clamping (ECC), as the standard of care in uncomplicated term and preterm deliveries. However, variability remains in cord management practices for maternal-infant dyads at higher risk of complications. This review examines the current state of evidence on the outcomes of at-risk infant populations receiving differing umbilical cord management strategies. Review of contemporary literature demonstrates members of high-risk neonatal groups, including those affected by small for gestational age (SGA) classification, intrauterine growth restriction (IUGR), maternal diabetes, and Rh-isoimmunization, are frequently excluded from participation in clinical trials of cord clamping strategies. Furthermore, when these populations are included, outcomes are often underreported. Consequently, evidence regarding optimal umbilical cord management in at-risk groups is limited, and further research is needed to guide best clinical practice.

Section snippetsINTRODUCTION

Umbilical cord clamping impacts 3.6 million deliveries in the United States1 and nearly 140 million newborns worldwide each year2. Growing evidence supports the assertion that the practice of delayed cord clamping (DCC) results in better short and long-term outcomes in both preterm and term infants than does early cord clamping (ECC)3, 4, 5, 6. Based on the strength of current evidence, multiple professional societies, including the American Academy of Pediatrics (AAP), American College of

Sources

A MEDLINE (PubMed) search was performed in October of 2022 using the search terms ‘delayed cord clamping’ OR ‘cord milking’ OR ‘placental transfusion’ AND ‘clinical trial’ OR ‘randomized clinical trial’. Search results were restricted to all randomized clinical trials (RCTs) published within the last 10 years (2012 – 2022) available as English language manuscripts. Researchers also examined the bibliographies of the most recently published umbilical cord clamping meta-analyses3, 4, 5 and

RESULTS

A total of 117 manuscripts describing 112 clinical trials involving ECC, DCC, and/or UCM were included in the final review (Figure 1), covering 20,653 allocated study participants. Of these, 47 (42.0%) trials included only term infants, 47 (42.0%) included only preterm infants, and 18 (16.1%) included both preterm and term infants. The data comprised 90 trial reports (80.4%) that included ECC groups, 89 trial reports (79.5%) that included DCC groups, 44 trial reports (39.3%) that included UCM

DISCUSSION

Identifying the ideal method of umbilical cord management in neonates has been a topic of clinical interest for decades. Meta-analyses have demonstrated associations between DCC and increased hematologic parameters in the first week of life as well as improved iron stores, resulting in lower risks of iron deficiency in the first 6 months of life than with ECC3,6. For preterm infants, DCC has also been shown to confer increased hemodynamic stability, decreased need for inotropic support,

CONCLUSION

Despite recent advancement in the knowledge of umbilical cord management practices over the last several decades, significant gaps remain in the evidence regarding best practices for infants at increased risk of complications. The present study highlights the underrepresentation of high-risk maternal-infant dyads in the current literature, and the variability across clinical trials that complicates the interpretation of outcomes. This reinforces the need for additional evidence to guide

ACKNOWLEDGEMENTS

The authors would like to thank Nationwide Children's Hospital reference librarian Elizabeth Lyman, MLIS, AHIP for assistance with the literature search.

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