We read with interest the article on delayed cord clamping in preterm infants (1)

The authors looked at the outcomes of early versus delayed cord clamping in babies born between 34 and 36 weeks of gestation on haemoglobin and blood glucose levels during early neonatal period and haemoglobin and ferritin levels at 10 weeks of age. They found that the haemoglobin levels were consistently higher at both early neonatal and at 10 weeks of age in the delayed cord clamping group. They have concluded that the immediate clamping of the cord should be discouraged based on these results.

We presented this article at one of the journal club meetings in our department and this generated an interactive discussion. Though there may be a place for the delay in clamping umbilical cord in this group of patients the study number and overall benefit has not been fully displayed by the conduct and neither the long term benefit. There was also no regard or suggestion about practice in the delivery suites in relation to the positioning of the babies (below, same level or above the delivery couch).

Also with 34 babies accounting for the results published (comprising of only 18 in the delayed cord clamping group),This seems a small number for the authors to come to the conclusion that early cord clamping be discouraged. It will be of interest to know if delayed clamping leads to problems of polycaethaemia and its known complications. And to show any relationship between delayed cord clamping and pathological jaundice and polycythaemia, the study would need a larger study population.

To incorporate delayed cord clamping into practice, this study should be conducted on a larger scale (Multi centre) looking at the effect of delayed clamping in relation to morbidity.

Ref: 1. Ultee CA, van der Deure J, Swart J, Lasham C, van Baar AL. Delayed cord clamping in preterm infants delivered at 34-36 weeks’ gestation: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2008; 93: F20-F23

Dear Editor,

This article links immediate cord clamping (ICC) to childhood mental retardation (MR).

“NO CONSENSUS EXSISTS ABOUT THE OPTIMAL TIME TO CLAMP THE UMBILICAL CORD.”

The study shows that ICC generates more anemia than delayed cord clamping (DCC) – by removing more blood volume than DCC removes. The amount of placental transfusion (PT) determines a neonate’s blood volume. ICC causes “hypotension, hypovolemia and infant anemia” [1] resulting in “cognitive deficits.” At what time will DCC prevent these injuries?

Physiological Placental transfusion (PPT) is generated by gravity and / or by uterine contraction, is regulated by the child’s reflexes, and is terminated by reflexive closure of the umbilical vessels when the child has attained a maximal, optimal blood volume. [2] PPT provides enough iron to prevent infant anemia during the first year of life. [3]

This study (and all others on cord clamping) fails to define the physiological norm – a cohort of babies 34 – 36 weeks with physiological cord closure (PCC) – that would have established normal values for hemoglobin and ferritin at one hour and at ten weeks. PPT (no cord clamp used) results in a healthy neonate with a normal blood volume. This ensures optimal function of all vital organs and optimal growth and development of the brain; ischemic encephalopathy, infant anemia, and MR are prevented. Physiology is not harmful.

PCC often occurs within 3 to 5 minutes of birth, but some cords will pulsate for more than 15 minutes. [2] A portion of the DCC group in this study could have optimal blood volumes. The study is very valuable in emphasizing the dangers of immediate cord clamping (ICC) – infant anemia and childhood mental retardation in the western world.

In relation to the above, a large study (Dade Co. Florida, 2000+ children in the WIC program, 1999) correlated IQ in grade school with infant anemia – Hgb in gms/l. [4]

• For each decrement in hemoglobin, the risk of mental retardation increased by 1.28

• Children with low birth weights were 2.5 times more likely to be retarded than children with normal birth weights

• Boys were 2.17 times more likely to be retarded than girls

Iron is given to women, infants and children in the WIC program. ICC is the only plausible explanation for the above anemia. Anemic preterm babies are “high risk” for MR. Most autistic children are mentally retarded; there are many more autistic boys than autistic girls. ICC is widely practiced. The autism epidemic parallels the ICC and infant anemia epidemics.

It is high time for the perinatal professions TO CLAMP ALL CORDS AT THE OPTIMAL TIME – AFTER THE PLACENTA IS DELIVERED. Normal placental transfusion prevents infant anemia and prevents “cognitive deficits.”

obgmmorley@aol.com

www.autism-end-it-now.org

References:

[1] Linderkamp O. Placental Transfusion: Determinants and Effects. Clinics in Perinatology, 1982, 9: 559-592

[2] Gunther M. The transfer of blood between the baby and the placenta in the minutes after birth. Lancet 1957;I:1277-1280.

[3] Wilson, Windle, Howard. Deprivation of Palcental Blood as a Cause of Iron Deficiency in Infants. American Journal of Childhood Diseases 1941

[4] Elyse Krieger Hurtado, Angelika Hartl Claussen, and Keith G, Scott. Early Childhood Anemia and mild or moderate mental retardation. Am. J. Clin. Nutr. 1999: 69:115-9.