Skip Ribbon Commands
Skip to main content
SharePoint

PublicComment

 Feedback

If you have any comments or questions on this page, please email us at:
 

Delayed Cord Clamping in Preterm Infants Requiring Resuscitation

Question Type:
Intervention
Full Question:
In preterm infants, including those who received resuscitation
 (P), does delayed cord clamping (> 30 seconds)
 (I), compared with immediate cord clamping
 (C), change survival (death), long-term developmental outcome, intraventricular hemorrhage, cardiovascular stability, necrotizing enterocolitis, temperature on admission to a newborn area, Hyperbilrubinemia (O)?
Consensus on Science:
For the critical outcome of infant death, we identified very-low-quality (downgraded for imprecision and very high risk of bias) evidence from 11 randomized clinical trials enrolling 591 patients showing no benefit to delayed cord clamping (odds ratio [OR], 0.6; 95% confidence interval [CI], 0.26–1.36). (Hofmeyr 1988, 104; Hofmeyr 1993; Kinmond 1993, 172; McDonnell 1997, 308; Rabe 2000, 775; Mercer 2003, 466; Mercer 2006, 1235; Baenziger 2007, 455; Kugelman 2007, 307; Strauss 2008, 658; Oh 2011, S68)For the critical outcome of severe IVH, we identified very-low-quality evidence (downgraded for imprecision and very high risk of bias) from 5 randomized clinical trials enrolling 265 patients showing no benefit to delayed cord clamping (OR, 0.85; 95% CI, 0.20–3.69). (Hofmeyr 1988, 104; Hofmeyr 1993; Mercer 2003, 466; Mercer 2006, 1235)For the critical outcome of periventricular hemorrhage (PVH)/IVH, we identified very-low-quality evidence (downgraded for imprecision and very high risk of bias) from 9 randomized clinical trials enrolling 499 patients showing benefit of delayed cord clamping (OR, 0.49; 95% CI, 0.29–0.82).(Hofmeyr 1988, 104; Hofmeyr 1993; McDonnell 1997, 308; Rabe 2000, 775; Mercer 2003, 466; Mercer 2006, 1235; Kugelman 2007, 307; Strauss 2008, 658; Oh 2011, S68)For the critical outcome of neurodevelopment, we did not identify any evidence.For the critical outcome of cardiovascular stability as assessed by mean blood pressure at birth, we identified very-low-quality evidence (downgraded for imprecision and very high risk of bias) from 2 randomized clinical trials enrolling 97 patients showing higher blood pressure associated with delayed cord clamping (mean difference [MD], 3.52; 95% CI, 0.6–6.45).(Mercer 2003, 466; Kugelman 2007, 307)For the critical outcome of cardiovascular stability as assessed by mean blood pressure at 4 hours after birth, we identified very-low-quality evidence (downgraded for imprecision and very high risk of bias) from 3 randomized clinical trials enrolling 143 patients showing increased mean blood pressure at 4 hours of age after delayed cord clamping (MD, 2.49; 95% CI, 0.74–4.24).(Mercer 2003, 466; Mercer 2006, 1235; Baenziger 2007, 455)For the critical outcome of cardiovascular stability as assessed by blood volume, we identified very-low-quality evidence (downgraded for imprecision and very high risk of bias) from 2 randomized clinical trials enrolling 81 patients showing benefit of delayed cord clamping (MD, 8.25; 95% CI, 4.39–12.11). (Aladangady 2006, 93; Strauss 2008, 658)For the critical outcome of temperature, on admission we identified very-low-quality evidence (downgraded for imprecision and very high risk of bias) from 4 randomized clinical trials enrolling 208 patients showing no statistically significant benefit from delayed cord clamping (MD, 0.1; 95% CI, −0.04 to 0.24). (Rabe 2000, 775; Mercer 2003, 466; Mercer 2006, 1235; Kugelman 2007, 307)For the important outcome of need for transfusion, we identified very-low-quality evidence from 7 randomized clinical trials enrolling 398 patients showing less need for transfusion after delayed cord clamping (OR, 0.44; 95% CI, 0.26–0.75). (Kinmond 1993, 172; McDonnell 1997, 308; Rabe 2000, 775; Aladangady 2006, 93; Mercer 2006, 1235; Kugelman 2007, 307; Strauss 2008, 658)For the important outcome of necrotizing enterocolitis, we identified very-low-quality evidence (downgraded for imprecision and very high risk of bias) from 5 randomized clinical trials enrolling 241 patients showing lower incidence of necrotizing enterocolitis (OR, 0.3; 95% CI, 0.19–0.8). (Rabe 2000, 775; Mercer 2003, 466; Mercer 2006, 1235; Kugelman 2007, 307; Oh 2011, S68)For the important outcome of hyperbilirubinemia and peak bilirubin concentrations (mmol/L), we identified moderate-quality evidence from 6 randomized clinical trials enrolling 280 patients showing higher peak bilirubin value in those neonates with delayed cord clamping (MD, 16.15; 95% CI, 6.13–26.17). (McDonnell 1997, 308; Mercer 2003, 466; Mercer 2006, 1235; Kugelman 2007, 307; Strauss 2008, 658; Oh 2011, S68)For the important outcome of treated hyperbilirubinemia (need for phototherapy), we identified low-quality evidence from 1 randomized clinical trial enrolling 143 patients showing no statistically significant difference (relative risk [RR], 1.29; 95% CI, 1.00–1.67).(Strauss 2008, 658)
Treatment Recommendation:
We suggest delayed umbilical cord clamping for preterm infants not requiring immediate resuscitation after birth (weak recommendation, very-low-quality evidence).There is insufficient evidence to recommend an approach to cord clamping for preterm infants who do receive resuscitation immediately after birth, because many babies who were at high risk of requiring resuscitation were excluded from or withdrawn from the studies. Values, Preferences, and Task Force Insights Overall, the quality of evidence for the question was very low. Despite drawing evidence from randomized controlled trials, the small sample size in most trials and the associated imprecision limited the quality of evidence for all outcomes of interest. Although 2 larger observational trials were considered, the quality and size of effect were not sufficient to influence the conclusions. The quality of evidence for necrotizing enterocolitis and hyperbilirubinemia was limited by inconsistent definitions of the outcome, and inconsistent thresholds for treatment with phototherapy across studies. Balance of consequences favors delayed cord clamping, as desirable consequences probably outweigh undesirable consequences in most settings. The results of randomized controlled trials and nonrandomized observational studies with comparison groups were generally consistent. However, small and sick infants who received immediate resuscitation were generally excluded from the available randomized controlled trials, so data are very limited for this group at highest risk for physiologic instability, complications of prematurity, and mortality who may also realize highest benefit or harm from the intervention.Preferences (parents’) favor delayed clamping, which has received strong popular support through social media and Internet sites. The advantages of delayed cord clamping assume heightened importance in resource-limited settings where specialty care for preterm neonates may be limited. Improving initial cardiovascular stability with maintenance of temperature and lower risk of morbidities such as necrotizing enterocolitis and severe intracranial hemorrhage may offer significant survival advantages, even where neonatal intensive care is not available. In areas where maternal anemia is prevalent, iron supplementation is limited, and a safe blood supply is often unavailable, the reduction in need for transfusion and improved blood volume at birth may have increased significance.A major debate surrounded the issue as to whether the quality of the studies was low or very low. Overall, the group thought that downgrading the evidence as suggested by the GRADE tool was not reasonable, given that this was one of the areas with the most randomized trial data. However, eventually based on the GRADE criteria, it was necessary to classify most of the outcomes as very-low-quality evidence. It was noted that the existing studies enrolled very few extremely premature infants and very few who received resuscitation. The group was unanimous in stressing the need for additional research, which parallels a Cochrane review reflecting similar sentiments of a need for more high-quality evidence. Some members questioned how to reconcile with obstetric guidelines, which has an out clause for babies requiring resuscitation (2012, 1522)
CoSTR Attachments:
Consensus on Science and GRADE Grid - Delayed cord clamping_n.docx    
DCC in Preterm 20150101(non-RCT).rm5    
DCC in Preterm 20150101(RCT).rm5    

 Contact Us

 
If you have any comments or questions on this page, please email us at: