Our understanding of the best approach to umbilical cord management has evolved, with current recommendations for delayed cord clamping (DCC) for full-term infants and preterm infants to improve transitional circulation, hematologic status, and improve longer-term health outcomes. DCC is challenging for preterm infants that require ventilatory assistance or full resuscitation. An alternative to DCC in this circumstance is umbilical cord milking (UCM), which can be done in 20 seconds compared with 30–180 seconds for DCC. However, prior studies suggest that UCM is associated with increased risk of intraventricular hemorrhage. Other studies have not found this risk. Katheria et al. (10.1542/peds.2023-063113) report a study early released in Pediatrics to assess if UCM is at least as good (“non-inferior”) to DCC.
The authors share an analysis of data from a non-inferiority randomized controlled trial comparing UCM to DCC in more than a thousand preterm infants from 28-32 weeks’ gestation from 19 birthing centers in 4 countries. The primary outcome was a grade 3-4 IVH or death. While there is a lot of interesting data to review in this article, the bottom line is that the rates of IVH in both arms was the same (1.4%), leading to the conclusion that UCM is a safe alternative to DCC in this population. Should we start doing UCM rather than DCC for all preterm infants born needing resuscitation?
Not so fast—at least according to an accompanying commentary (10.1542/peds.2023-063505) by neonatologist Dr. Roger Soll from the University of Vermont Larner College of Medicine. Dr. Soll compliments the authors on their methods and findings but also speaks to some important limitations of this study. Dr. Soll raises concerns about the size of the study and the ability to find a difference based on the population that was enrolled. Dr. Soll suggests we also consider a more physiologic transition at birth without aggressive ventilatory intervention that would also enable DCC to continue to be used without difficulty and calls for trials to support his hypothesis.
Read both the study and commentary and see if you too are in accord with realizing either method will likely improve a baby’s physiologic transitions to breathing satisfactorily after birth.
