Elsevier

The Journal of Pediatrics

Volume 232, May 2021, Pages 87-94.e4
The Journal of Pediatrics

Original Article
Umbilical Cord Milking vs Delayed Cord Clamping and Associations with In-Hospital Outcomes among Extremely Premature Infants

Portions of this study were presented at the Pediatric Academic Societies webinar series, June 19, 2020 (virtual).
https://doi.org/10.1016/j.jpeds.2020.12.072Get rights and content

Objective

To compare in-hospital outcomes after umbilical cord milking vs delayed cord clamping among infants <29 weeks of gestation.

Study design

Multicenter retrospective study of infants born <29 weeks of gestation from 2016 to 2018 without congenital anomalies who received active treatment at delivery and were exposed to umbilical cord milking or delayed cord clamping. The primary outcome was mortality or severe (grade III or IV) intraventricular hemorrhage (IVH) by 36 weeks of postmenstrual age (PMA). Secondary outcomes assessed at 36 weeks of PMA were mortality, severe IVH, any IVH or mortality, and a composite of mortality or major morbidity. Outcomes were assessed using multivariable regression, incorporating mortality risk factors identified a priori, confounders, and center. A prespecified, exploratory analysis evaluated severe IVH in 2 gestational age strata, 22-246/7 and 25-286/7 weeks.

Results

Among 1834 infants, 23.6% were exposed to umbilical cord milking and 76.4% to delayed cord clamping. The primary outcome, mortality or severe IVH, occurred in 21.1% of infants: 28.3% exposed to umbilical cord milking and 19.1% exposed to delayed cord clamping, with an aOR that was similar between groups (aOR 1.45, 95% CI 0.93, 2.26). Infants exposed to umbilical cord milking had higher odds of severe IVH (19.8% umbilical cord milking vs 11.8% delayed cord clamping, aOR 1.70 95% CI 1.20, 2.43), as did the 25-286/7 week stratum (14.8% umbilical cord milking vs 7.4% delayed cord clamping, aOR 1.89 95% CI 1.22, 2.95). Other secondary outcomes were similar between groups.

Conclusions

This analysis of extremely preterm infants suggests that delayed cord clamping is the preferred practice for placental transfusion, as umbilical cord milking exposure was associated with an increase in the adverse outcome of severe IVH.

Trial registration

ClinicalTrials.gov: NCT00063063.

Section snippets

Methods

This was a retrospective analysis of prospectively collected data from the NRN Generic Database (GDB). The cohort includes infants born between 220/7and 286/7 weeks of gestation in NRN centers from January 1, 2016 to December 31, 2018. Each participating center obtained institutional review board approval for the NRN GDB registry. Based on the study objective to compare the 2 modes of placental transfusion, infants exposed to immediate cord clamping were not included in the analysis. The

Results

Between January 1, 2016 and December 31, 2018, 5332 infants 220/7-286/7 weeks of gestation were born in participating NRN centers and 2514 infants were exposed to placental transfusion. After applying the exclusion criteria, 1834 were included in the final analysis, of which 23.6% (n = 432) were exposed to umbilical cord milking and 76.4% (n = 1402) were exposed to delayed cord clamping (Figure 1). Between 2016 and 2018, delayed cord clamping was the primary mode of placental transfusion in the

Discussion

In this large, contemporary, observational study, umbilical cord milking was not associated with the primary outcome of mortality or severe IVH by 36 weeks of PMA but was associated with higher odds of the secondary outcome of severe IVH. These results are similar to the large randomized trial comparing delayed cord clamping and umbilical cord milking, which favored delayed cord clamping.16 Over the past 3 years in the NRN, delayed cord clamping was the more frequently used mode of placental

Data Statement

Data sharing statement available at www.jpeds.com.

References (39)

  • Timing of umbilical cord clamping after birth

    Pediatrics

    (2013)
  • J.M. Perlman et al.

    Part 7: neonatal resuscitation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations (Reprint)

    Pediatrics

    (2015)
  • C.C. Roehr et al.

    The 2010 Guidelines on Neonatal Resuscitation (AHA, ERC, ILCOR): similarities and differences—what progress has been made since 2005?

    Klin Padiatr

    (2011)
  • A.C. Katheria

    Umbilical cord milking: a review

    Front Pediatr

    (2018)
  • S.Y. Song et al.

    Safety of umbilical cord milking in very preterm neonates: a randomized controlled study

    Obstet Gynecol Sci

    (2017)
  • V. Lago Leal et al.

    Effect of milking maneuver in preterm infants: a randomized controlled trial

    Fetal Diagn Ther

    (2019)
  • S. Hosono et al.

    Umbilical cord milking reduces the need for red cell transfusions and improves neonatal adaptation in infants born at less than 29 weeks’ gestation: a randomised controlled trial

    Arch Dis Child Fetal Neonatal

    (2008)
  • H. Rabe et al.

    Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: a randomized controlled trial

    Obstet Gynecol

    (2011)
  • A.C. Katheria et al.

    Umbilical cord milking versus delayed cord clamping in preterm infants

    Pediatrics

    (2015)
  • Cited by (20)

    • Placental Transfusion in the Newborn

      2023, Principles of Neonatology
    • Perinatal management: Lessons learned from the neonatal research network

      2022, Seminars in Perinatology
      Citation Excerpt :

      However, placental transfusion was independently associated with a reduction in the adjusted odds of mortality before 36 weeks’ post-menstrual age (aOR 0.71, 95% CI 0.55 to 0.92). Subsequently, Kumbhat et al directly compared outcomes following two common placental transfusion practices (delayed cord clamping vs. umbilical cord milking) among 1834 infants born before <29 weeks’ gestation.17 There was no difference between groups in the adjusted odds of the primary outcome, a composite of in-hospital mortality by 36 weeks post-menstrual age or severe IVH.

    • Pathogenesis and prevention of intraventricular hemorrhage

      2022, Seminars in Perinatology
      Citation Excerpt :

      Studies have suggested that umbilical cord milking (UCM) is associated with increased risk of IVH in preterm infants. A retrospective study of 1834 infants <29 weeks gestation found that infants receiving UCM had a higher odds ratio of severe IVH compared with those who received DCC (aOR 1.7, 95% CI 1.2 – 2.43).65 Indeed, the PREMOD-2 trial which compared DCC to UCM was prematurely halted due to a signal of harm in the cord milking group.66

    • Practical procedures for the delivery room resuscitation of micropreemies

      2022, Seminars in Fetal and Neonatal Medicine
      Citation Excerpt :

      Placental transfusion for preterm infants has improved short-term outcomes, including death and morbidities, as well as long-term outcomes, including neurodevelopment [7,8]. Delayed cord clamping is more widely-practiced than cord milking [9] but there are insufficient numbers of micropreemies in clinical trials or practice to warrant a definitive recommendation for either. On the other hand, while the rapid establishment of respiratory and circulatory stability is crucial for improving outcomes among micropreemies, maneuvers for placental transfusion should not interfere with the resuscitation process and due to the lack of evidence, no specific practice for cord transfusion is recommended here.

    • How can obstetricians improve outcomes for infants born extremely preterm?

      2021, Seminars in Perinatology
      Citation Excerpt :

      Retrospective data from infants born at less than 29 weeks in 2016 to 2017 indicate that delayed cord clamping or umbilical cord milking (an alternative means of achieving placental transfusion) is associated with decreased mortality by 36 weeks’ postmenstrual age (aOR 0.71, 95% CI 0.55 – 0.92) and a decreased need to treat hypotension in the first 24 postnatal hours (aOR 0.66, 95% CI 0.53 – 0.82).89 The observed increased rate of severe intraventricular hemorrhage among extremely preterm infants exposed to umbilical cord milking (aOR 1.70, 95% CI 1.20 – 2.43) renders delayed cord clamping the preferred approach.90 The precise timing of cord clamping to optimize neonatal outcome is not yet known, with a delay of 30 to 60 seconds being the most common recommendation.91

    View all citing articles on Scopus

    Funding and disclosure information is available at www.jpeds.com.

    List of additional members of the Generic Database Subcommittee of the National Institute of Child Health and Human Development (NICHD) Neonatal Research Network is available at www.jpeds.com (Appendix).

    View full text