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Umbilical cord milking may benefit nonvigorous newborns
Clinical Question
Does umbilical cord milking reduce neonatal intensive care unit admissions among nonvigorous neonates?
Bottom line
UCM for nonvigorous infants born at 35 to 42 weeks' gestation was not associated with a statistically significant reduction in NICU admissions. However, it was associated with reduced need for delivery room cardiorespiratory support, lower incidence of moderate-to-severe hypoxic-ischemic encephalopathy, and less use of therapeutic hypothermia. The UCM intervention took an average of 9 seconds to perform and was not associated with evidence of harm. 1b-
Reference
Study design: Cross-over trial (randomized)
Funding: Government
Setting: Inpatient (ward only)
Synopsis
Delayed cord clamping (> 60 seconds) to allow placental transfusion has become routine practice for vigorous infants. These researchers wanted to assess whether umbilical cord milking (UCM) versus a control of early cord clamping (ECC) would reduce neonatal intensive care unit (NICU) admissions among nonvigorous neonates born at 35 to 42 weeks' gestation. Since it is not feasible to obtain consent from individual patients at the time of presentation of a nonvigorous newborn, the investigators conducted a cluster-randomized crossover trial at 10 hospitals in the United States (n = 7), Canada (n = 2), and Poland (n = 1). The institutional review boards agreed to provide a waiver to allow UCM without individual consent for this study. The hospitals were randomized to UCM in either a first period or second period and then crossed over to ECC in the alternate period. Masking of patients and clinicians was not feasible, but outcome assessment was masked. The authors used a standardized assessment to determine the nonvigorous newborn status based on tone, pallor, and respiration. They also used standardized criteria for NICU admission related to the nonvigorous status. On reaching enrollment of 600 consented infants, and after a 1- to 2-month washout and retraining period, each hospital crossed over to the other intervention until they reached the predetermined total sample size of 1200 consented infants (1207 actual). UCM was standardized as milking 20 cm of the cord for 2 seconds 4 times. The vast majority of infants were treated per protocol (96% and 94%). Mean time to cord clamping was 29 seconds in the UCM group versus 19 seconds in the ECC group. The principal outcome of NICU admission within 24 hours after birth for a long list of indications considered relevant was not statistically different between groups after adjustment for clinical site (adjusted odds ratio [aOR] 0.69; 95% CI 0.41 - 1.14). However, UCM was associated with lower odds of several secondary outcomes: 1-minute Apgar score of 3 or less (30% vs 34%; OR 0.72; 0.56 - 0.92); Apgar 4 to 6 (33% vs 36%; OR 0.74; 0.58 - 0.95), receipt of delivery room cardiorespiratory support (61% vs 71%; OR 0.57; 0.33 - 0.99), and therapeutic hypothermia (3% vs 4%; OR 0.57; 0.33 - 0.99). Moderate to severe hypoxic-ischemic encephalopathy was also less common in the UCM group (1% vs 3%; OR 0.48; 0.24 - 0.96). Several other outcomes did not differ between groups, including phototherapy for hyperbilirubinemia (88/606 [14.5%] vs 77/613 [12.6%]; OR 1.18; 0.85 - 1.64).
Reviewer
Linda Speer, MD
Professor and Chair, Department of Family Medicine
University of Toledo
Toledo, OH
Comments
cord milking benefit
no ob for me; done that
Impact assessment
Very good
Umbilical Cord Milking
UCM has been standard practice since medical school - in my case, 1962-68. The physiological base should be obvious.
UCM of value
Good to know
Umbilical cord milking in nonvigorous newborns.
Interesting that there was no difference in the general principle outcome (ICU admission) but several clinically important secondary outcomes showed a difference. It makes one naturally wonder if the difference in ICU admission was driven by less clinically important outcomes such as observed wrt phototherapy. The ease of the procedure and the lack of evidence for harm is encouraging. It may be a procedure that could be considered for paramedics to perform when indicated.