UMBILICAL CORD MILKING IN ELBW INFANTS

Hosono S, Mugishima H, Fujita H, et al. Umbilical cord milking in infants born at less than 29 weeks’ gestation. Arch Dis Child Fetal Neonatal Ed 2008;93:F14-F19 [Full Text] [Full Text (PDF)]

Objective. To investigate the effects of umbilical cord milking on the need for red blood cell (RBC) transfusion and morbidity in very preterm infants.

Methods. 40 singleton infants born between 24 and 28 weeks’ gestation were randomly assigned to receive umbilical cord clamped either immediately (control group, n=20) or after umbilical cord milking (milked group, n=20). Primary outcome measures were the probability of not needing transfusion, determined by Kaplan–Meier analysis, and the total number of RBC transfusions. Secondary outcome variables were haemoglobin value and blood pressure at admission.

Results. There were no significant differences in gestational age and birth weight between the two groups. The milked group was more likely not to have needed red cell transfusion (p=0.02) and had a decreased number (mean (SD)) of RBC transfusions (milked group 1.7 (3.0) vs controls 4.0 (4.2); p=0.02). The initial mean (SD) haemoglobin value was higher in the milked group (165 (14) g/l) than in the controls (141 (16) g/l); p=0.01). Mean (SD) blood pressure at admission was significantly higher in the milked group (34 (9) mm Hg) than in the controls 28 (8) mm Hg; p=0.03). There was no significant difference in mortality between the groups. The milked group had a shorter duration of ventilation or supplemental oxygen than the control group.

Conclusions. Milking the umbilical cord is a safe procedure, reducing the need for RBC transfusions, and the need for circulatory and respiratory support in very preterm infants.

Comments. This is yet another study that documents short term benefits of peripartum autotransfusion (see for example J Perinatol 2007;23:466-472 , Pediatrics 2006;117:1235-1242). This time, active milking of the umbilical cord in ELBW infants lead to higher admission hemoglobin levels, higher admission arterial blood pressures, and fewer blood transfusions. Since such a procedure takes less than 10 seconds, concerns about delaying resuscitation (an argument that has been used against delayed cord clamping) are minimized. But, as the authors state, larger trials are needed to confirm their results and add necessary safety data. TMB

Editor’s Comment: The purported benefits of delayed cord clamping in premature deliveries have frequently been touted in NeoNotes (see 1-024, 3-019, 4-038, 7-013, 8-009). In the past, I have cautioned against “cord stripping” in these babies for fear of causing IVH with rapid circulatory pressure and volume changes. This was NOT seen in the present study. In fact, the rates of severe IVH and PVL in this study were twice as high in the control group vs the group with cord stripping. This difference was not statistically significant. Delayed cord clamping (and possibly “cord stripping”) are low-cost, high yield improvement measures to implement for preterm deliveries. ABK.

21May 2008
18:27:08

Though the results do seem encouraging, there are methodical concerns with this article rendering its conclusions less applicable. Notably, they obtained their sample size data from an article published after their trial was started (as per their references) making one question their study. Also, the excessive amount of analyses done in a study of less than 40 patients makes one concerned for data dredging. Clearly a new study on this subject must be done prior to considering it as a routine intervention.

UserName: Gregory Moore
Institution: University of Ottawa, Canada
telephone: (613) 737-8561
email: gmoore@cheo.on.ca

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