Recent discussions
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Ola Andersson
As an active researcher on umbilical cord clamping for 15 years, I find myself asking several questions regarding some choices made in the review. The most important one is perhaps the definition of later (delayed) cord clamping as ‘cord clamping after a delay of at least 30 seconds’ This definition is rather rare and is difficult to understand from a physiological point of view and also in the perspective of how most of the studies in the review have defined later cord clamping, which is rather after 2-3 minutes. The umbilical cord circulation continues far beyond 30 seconds, which have importance for the immediate transition and the placental transfusion. From the outside, one might suspect that the 30-second definition is borrowed from preterm cord clamping research where this definition is commonly used. Another question is choice of primary outcomes. 1. Survival without moderate to severe neurodevelopmental impairment in early childhood. As an overwhelming part of the studies in the review have included vigorous term and late preterm infants this outcome is comparatively rare and would need a very high number of infants studied to show significance, due to the very low prevalence of moderate to severe neurodevelopment. 2. Anemia by four to six months after birth (lowest hematocrit or hemoglobin or as reported by the study authors). Repeated studies on cord clamping have shown that at the age of 4-6 months, the effect is evident on iron stores, not on anemia. Even with low iron stores, hemoglobin levels are prioritized in the body. The effect on anemia is more pronounced the first months after birth (due to the direct transfusion) and later in infancy (8-12 months) Most studies in this review are downgraded due to risk of bias, most likely depending on lack of blinding. By the nature of the intervention this is unavoidable, and the reviewers might reflect on this. An outcome, often discussed in combination with cord clamping, is the subjects of hyperbilirubinemia, jaundice, and phototherapy. It would have been interesting if the reviewers included levels of bilirubin as an outcome. Surprisingly, I find studies that do not report level of bilirubin among the ones included in the presented outcome ‘hyperbilirubinemia treated with phototherapy´. By tradition as well as in current guidelines, delayed cord clamping is defined as > 60 seconds, and the chosen definition in this review is hard to understand. Contrary, studies that have shown effects on iron deficiency, anemia and/or improved neurodevelopment have defined delayed cord clamping mostly as after 180 seconds which also corresponds rather well with the median closure time of the umbilical artery and a levelling of the placental transfusion. -
Виктория Антонова
For resource-rich countries, the financial and social-emotional costs of hospital admission for phototherapy due to hyperbilirubinemia in term babies (born at 37 completed weeks or later) that is (weakly) associated with DCC in this group does not seem justified. However, surprisingly that even 30 sec of DCC (if I'm interpreting the subgroup analysis correctly) is associated with the need for phototherapy. -
Виктория Антонова
Somehow this seems terribly unhelpful -
Виктория Антонова
Is there any literature about rhythm analysis during transport? Is there a statement about whether or not to shock patients during transportation? -
Виктория Антонова
What about a recommendation about delayed cord clamping between 30-60 seconds rather than >= 60 seconds. That seems much more likely to happen. Any evidence about that? -
Виктория Антонова
Recommending a T-piece resuscitator over a BVM is not unexpected. T-piece resuscitators limit peak inspiratory pressures and provides consistent CPAP as long a seal is kept on the face. . The majority of the weak evidence appears to support this thought as well. It is very easy to over ventilate and induce lung injury with a BVM. Thanks for sharing. -
Виктория Антонова
Although the evidence of late clamping of the umbilical cord of vigorous newborns over 34 weeks is still weak, this attitude seems more sensible and more consistent with the nature of the act of birth. We have some evidence of decreased anemia and for less developed countries it can have a long-term impact. -
Виктория Антонова
Although there are still many gaps in relation to the best equipment, recent evidence has demonstrated the importance of the role of the T-piece resuscitator, especially in terms of reducing lung injury. In this sense, it seems to me important that the neonatal resuscitation program encourages universal training -
Виктория Антонова
T-piece is theoretically superior. In practice, when you have less support(which happens more often than we expected in non-academic settings) in the delivery room, using a T-piece can be cumbersome to use. To get a good chest rise, you may need to change the T-piece dial a few times, requiring assistance from a well-versed person. People lose time struggling to change the pressures on a T-piece. At least, in the first few breaths, when we determine the PIP required to see a good chest rise, a self-inflating bag may be superior as we can change the PIP with each breath until the team achieves desired PIP. -
Виктория Антонова
PEEP expiratory valves are dependent on tidal volume being delivered and exhaled when used with self-inflating bags. Since no flow occurs through the inspiratory valve without the bag being compressed PEEP exhalation valves are likely unreliable in providing PEEP with very low tidal volumes. With flow-inflating bags, the valve controls flow and PEEP together given that the exhalation valve is a fixed orifice. This ties the rate of bag insufflation with PEEP being administered. With higher rates of PPV (remember the rate is 40-60 in NRP) this can lead to inadequate insufflation of the bag. Furthermore, depending on how the flow is set up and adjusted during PPV, PEEP is often only established towards the beginning of the next breath rather than end inspiration; i.e there is a dip in circuit pressure close to 0 cm H2O which could potentially hamper recruitment of FRC efforts.