Anna Lene Seidler1, Gillian M L Gyte2, Heike Rabe3, José L Díaz-Rossello4, Lelia Duley5, Khalid Aziz6, Daniela Testoni Costa-Nobre7, Peter G Davis8, Georg M Schmölzer9, Colleen Ovelman10, Lisa M Askie11, Roger Soll10. 1. National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia; lene.seidler@ctc.usyd.edu.au. 2. Cochrane Pregnancy and Childbirth Group, University of Liverpool, Liverpool, United Kingdom. 3. Academic Department of Paediatrics, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom. 4. Departamento de Neonatologia del Hospital de Clínicas, Universidad de la Republica, Montevideo, Uruguay. 5. Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, United Kingdom. 6. Department of Pediatrics, University of Alberta, Edmonton, Canada. 7. Department of Paediatrics, Universidade Federal de São Paulo, São Paulo, Brazil. 8. Newborn Research Centre, The Royal Women's Hospital and The University of Melbourne, Melbourne, Victoria, Australia. 9. Division of Neonatology, Department of Pediatrics, Medical University Graz, Graz, Austria. 10. Department of Pediatrics, The Robert Larner College of Medicine, The University of Vermont, Burlington, Vermont; and. 11. National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, Australia.
Abstract
CONTEXT: The International Liaison Committee on Resuscitation prioritized scientific review of umbilical cord management strategies at preterm birth. OBJECTIVE: To determine the effects of umbilical cord management strategies (including timing of cord clamping and cord milking) in preterm infants <34 weeks' gestation. DATA SOURCES: Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, CINAHL, and trial registries were searched through July 2019 for randomized controlled trials assessing timing of cord clamping and/or cord milking. STUDY SELECTION: Two authors independently assessed trial eligibility, extracted data, appraised risk of bias, and assessed evidence certainty (GRADE). DATA EXTRACTION: We identified 42 randomized controlled trials (including 5772 infants) investigating 4 different comparisons of cord management interventions. RESULTS: Compared to early cord clamping, delayed cord clamping (DCC) and intact-cord milking (ICM) may slightly improve survival; however, both are compatible with no effect (DCC: risk ratio: 1.02, 95% confidence interval: 1.00 to 1.04, n = 2988 infants, moderate certainty evidence; ICM: risk ratio: 1.02, 95% confidence interval: 0.98 to 1.06, n = 945 infants, moderate certainty evidence). DCC and ICM both probably improve hematologic measures but may not affect major neonatal morbidities. LIMITATIONS: For many of the included comparisons and outcomes, certainty of evidence was low. Our subgroup analyses were limited by few researchers reporting subgroup data. CONCLUSIONS: DCC appears to be associated with some benefit for infants born <34 weeks. Cord milking needs further evidence to determine potential benefits or harms. The ideal cord management strategy for preterm infants is still unknown, but early clamping may be harmful.
CONTEXT: The International Liaison Committee on Resuscitation prioritized scientific review of umbilical cord management strategies at preterm birth. OBJECTIVE: To determine the effects of umbilical cord management strategies (including timing of cord clamping and cord milking) in preterm infants <34 weeks' gestation. DATA SOURCES: Cochrane Central Register of Controlled Trials, Medline, PubMed, Embase, CINAHL, and trial registries were searched through July 2019 for randomized controlled trials assessing timing of cord clamping and/or cord milking. STUDY SELECTION: Two authors independently assessed trial eligibility, extracted data, appraised risk of bias, and assessed evidence certainty (GRADE). DATA EXTRACTION: We identified 42 randomized controlled trials (including 5772 infants) investigating 4 different comparisons of cord management interventions. RESULTS: Compared to early cord clamping, delayed cord clamping (DCC) and intact-cord milking (ICM) may slightly improve survival; however, both are compatible with no effect (DCC: risk ratio: 1.02, 95% confidence interval: 1.00 to 1.04, n = 2988 infants, moderate certainty evidence; ICM: risk ratio: 1.02, 95% confidence interval: 0.98 to 1.06, n = 945 infants, moderate certainty evidence). DCC and ICM both probably improve hematologic measures but may not affect major neonatal morbidities. LIMITATIONS: For many of the included comparisons and outcomes, certainty of evidence was low. Our subgroup analyses were limited by few researchers reporting subgroup data. CONCLUSIONS: DCC appears to be associated with some benefit for infants born <34 weeks. Cord milking needs further evidence to determine potential benefits or harms. The ideal cord management strategy for preterm infants is still unknown, but early clamping may be harmful.
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