Hi Ladies, As mentioned earlier, I contact some of the leaders in the delayed clamping movement to find out what their thoughts were about cord blood donation, both in terms of effectiveness of these programs, and in the amount of timing necessary for effective banking, plus the impact of this timing.  Below are their responses, including some pasted journal entries.  I suspect more responses are coming from one or two others that have done extensive research on this topic.  Please read below.  Hopefully some of these references, opinions, and thoughts will help you to educate you families on this topic so we can all do the best thing for babies.  I'm happy to bring back additional questions if anyone desires. Thanks,Kelley  Hi Kelley, I am so glad I got your message - I am sending this cc to others who have been involved in the cord clamping issue also. Dr. David Hucheon, Dr. Morley, and I recently responded to a BMJ article on cord blood banking, pasted below and posted at : http://www.bmj.com/cgi/eletters/333/7572/801 I keep trying to make my position known, but don't know if I really know how to get a message across. My son had to be resuscitated at birth; he seemed to be developing well at first, but then had developmental language problems. I discovered the article by Wm Windle on asphyxia at birth in the October issue of the Scientific American, with its pictures of damage to the auditory system in the midbrain - I still believe this explains why my son could not hear syllable and word boundaries, and never mastered normal speech. A link to my website in his memory is below (conradsimon.org). Dr. Morley found me via this website, nearly five years ago! Earlier this year, because cordclamping went off-line, I started another website, http://www.placentalrespiration.net/concerns.html where I have posted many of my opinions. From this link, you will see a paper I sent to members of the childbirth study group of the National Children's study (NCS). Dr. Morley has setup another website at http://www.cordclamp.com/ . Where are you in Massachusetts? I am in Lexington. I hope we will hear back from you. Eileen Simon--Conrad Simon Memorial Research InitiativeTo seek understanding of brain system impairments in autism.

http://conradsimon.org/ "Sarah J Buckley" sarahjbuckley@uqconnect.net"Mermer, Cory" <CMermer@panynj.gov>, "Frye Anne \(E-mail\)" <afrye@teleport.com>, "George Morley \(E-mail\)" <obgmmorley@aol.com>, "Judy" <judy.mercer@hotmail.com>, "David Hutchon \(E-mail\)" <DJRHutchon@Postmaster.co.uk>, "Peter Dunn \(E-mail\)" <P.M.Dunn@bristol.ac.uk>, "Strange Karen \(E-mail\)" <karenmidwife@yahoo.com>  Thanks Eileen, I have lots about the down side of cord blood banking in my book and have made a commitment to write about it for Mothering next year. Here is an extract re Kelley's questions, below. I would be suprised if the stem cells were transferred last, I would guess that they are evenly distributed in placental blood. Any comments? As far as I know, no studies on denying cord blood to babies, just one increasingly uncontrolled and expensive experiment! BlessingsSarah Cord blood harvesting, which involves collecting the baby’s placental transfusion, requires early clamping – ideally within 30 second of birth – so that an adequate number of stem cells is obtained. Delayed cord clamping, which allows this blood to be transferred to the baby, as above, is likely to lead to an inadequate volume of blood harvested. For example, in one study, the volume of cord blood obtained was reduced from 75 mL, collected when the cord was clamped at 30 seconds after birth, to 39 mL collected when clamping occurred 30 to 180 seconds. A low-volume collection indicates insufficient stem cells to be usable for transfusion.58 Public cord blood banks discard collections below 40 mLs,59 with overall one-third to one-half of collections discarded, mostly because of low volume.60 Private banks, which are paid by parents to collect and store their baby’s blood, do not generally discard the collections, and some may have a policy to accept lower volumes.

58. Donaldson C, et al. Impact of obstetric factors on cord blood donation for transplantation. Br J Haematol 1999;106(1):128-32.59. Smith FO, Thomson BG. Umbilical cord blood collection, banking, and transplantation: current status and issues relevant to perinatal caregivers. Birth 2000;27(2):127-35.60. Lasky LC, et al. In utero or ex utero cord blood collection: which is better? Transfusion 2002;42(10):1261-7.

Dr Sarah J BuckleyGP/family physicianwww.sarahjbuckley.comAuthor of Gentle Birth, Gentle Mothering; The wisdom and science of gentle choices in pregnancy, birth, and parenting 245 Sugars RdAnstead, Qld 4070

AustraliaPh 61 7 3202 9052Fax Aust 07 3202 5851 

BMJ Responses (pasted below)Immediate cord clamping is not safe16 October 2006David JR David, Consultant Obstetrician and Gynaecologist Memorial Hospital, darlington. DL3 8QZ

Leroy C Edozien has provided a very balanced analysis of the issue of commercial cord banking. It is important to understand that the analysis is about commercial banking.

There is a need for further emphasis on the importance of delayed cord clamping. In addition to the Cochrane metanalysis (1), further trials have shown substantial benefits in very low birth weight infants (2) and also term infants. Cord blood collection must not be allowed to restrict this practice. The value of delayed cord clamping has been demonstrated whilst the value of commercial cord blood banking is still largely hypothetical at present.

Commercial cord blood banking is an insurance, not with a monetary return in the event of a claim but with the prospect of a successful medical treatment. Like all commercial insurance there is a premium to pay and risk of collapse unless the venture it is underwritten by the government or the insurance industry as a whole.

David Hutchon, Obstetrician

References

1. Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database Syst Rev 2004;(4): CD003248.

2. Mercer JS, Vohr, BR, McGrath MM, Padbury JF, Wallach M, and Oh W Delayed Cord Clamping in Very Preterm Infants Reduces the Incidence of Intraventricular Hemorrhage and Late-Onset Sepsis: A Randomized, Controlled Trial PEDIATRICS Vol. 117 No. 4 April 2006, pp. 1235-1242

 Clamping the umbilical cord can cause a lapse in respiration at birth18 October 2006Eileen Nicole Simon, Nurse Bridgewater State Hospital, Bridgewater MA 02324, USA 

Blood in the umbilical cord is in transit from the placenta to capillaries surrounding the alveoli [1]. Transition from fetal to neonatal respiration depends upon transfer of placental blood to the lungs, a large part of which occurs with

the first breath [2]. The great majority of infants breathe before the cord is clamped, but those who do not may need resuscitation.

The research of Jaykka in 1957 provided evidence that ventilation with air does not produce uniform expansion of the alveoli throughout the lungs [1]. The alveoli open only with filling of the capillaries around them, initiating exchange of carbon dioxide for oxygen. Until expansion of the lungs is complete, the infant's heart continues to pump blood through the fetal circulatory route back to the placenta. Shunts in the fetal heart close as the lungs expand. Circulation to the lungs takes over, and circulation to the placenta is no longer needed. Pulsations of the umbilical cord cease, and little if any blood will remain in the cord.

Clamping of the umbilical cord immediately at birth leaves the infant vulnerable to a lapse in respiration. The idea that an infant can tolerate a few minutes of oxygen deprivation derives from the ability of the infant heart to recover [3]. An infant's brain is as susceptible to ischemic damage as that of an adult who suffers circulatory arrest [3, 4].

The idea that umbilical cord blood could be banked began in the 1930s [5]. By the 1950s Apgar developed her scoring system for the newborn, when immediate clamping of the cord came into vogue to remove the infant from "the sterile field" for suturing the episiotomy or Cesarean incision [6].

Apgar et al. in 1958 noted that many obstetricians still practiced "slow delivery," waiting for pulsations of the umbilical cord to cease [7]. Until about 20 years ago, most textbooks advised waiting at least a minute or two before clamping the cord. As noted by Dr. Hutchon in his reply to this article, many research papers are now advocating "delayed clamping" of the cord - as though immediate clamping had always been the rule.

Ischemic impairment of the brain, cardiac murmurs, and injury to other organs should be investigated as possible consequences of umbilical cord clamping. Clamping the cord for umbilical cord blood banking should be stopped. How many parents are truly "informed" about cord blood banking? How many have any awareness of the current obstetric protocol for immediate clamping of the cord [8, 9]?

More at http://www.inferiorcolliculus.org/fnpsabstract1.html.

Eileen Nicole Simon, eileen4brainresearch@yahoo.com

References:

1. Jäykkä, S (1958) Capillary erection and the structural appearance of fetal and neonatal lungs. Acta Pædiatrica 47:484-500.

2. Redmond A, Isana S, Ingall D (1965) Relation of onset of respiration to placental transfusion. Lancet 1 (6 Feb):283-285.

3. Miller JR, Myers RE (1972) Neuropathology of systemic circulatory arrest in adult monkeys. Neurology 22:888-904.

4. Windle, W. F. (1969). Brain damage by asphyxia at birth. Scientific American, 221 (#4), 76-84.

5. Barton FE, Hearne TM (1939) The use of placental blood for transfusion. JAMA 113:1475-1478.

6. Apgar V (1953) A proposal for a new method of evaluation of the newborn infant. Current Researches in Anesthesia and Analgesia 32:260-267.

7. Apgar V, Holaday DA, James LS, Weisbrot IM (1958) Evaluation of the newborn infant – second report. JAMA 168(15):1985-1989, p 1987.

8. Turrentine JE (2003) Clinical Protocols in Obstetrics and Gynecology, Second Edition. The Parthenon Publishing Group, New York.

9. Cunningham FG, Hauth JC, Leveno KJ, Gilstrap L III, Bloom SL, Wenstrom KD, eds, Williams Obstetrics - Twenty-second edition, New York: McGraw-Hill Medical Publishing Division, 2005.

 Timing cord clamping at donor deliveries25 October 2006Jose Luis Diaz-Rossello, Perinatal Pediatrics Latin American Centre for Perinatology PAHO/WHO Casilla Correo 627 Montevideo Uruguay 

Edozien’s article (1)opens a necessary debate on the ethical issues of the practice of harvesting neonatal umbilical cord blood (UCB) for stem cell banking. Changes in the timing of cord clamping, not mentioned in his article, should be of concern to parents and health professionals.

The Royal College of Obstetricians and Gynaecologists recently stated that there is ”pressure to ensure that a sufficiently large volume is collected, since the likelihood of successful transplantation of cord blood is related to the volume and cell dose collected”. (2; 3)

There is strong evidence that earlier cord clamping interrupts the placental transfusion of blood to the baby, with adverse effects and no evidence of benefit.

If the procedures of cord blood collection shorten the time to cord clamping, they may reduce the physiological transfer of iron reserves from the mother to the infant. A recent randomized controlled trial in healthy Mexican mothers showed that full term healthy infants have impaired iron reserves at 6 months as a consequence of early clamping (average clamping time 16 seconds vs. 94 seconds).(4)

The issue of potential harm to neonates is not a mere abstract ethical issue. Enforcement of the RCOGs recommendation not to change third stage practices should be implemented. Registering the timing of cord clamping in seconds at every UCB donor birth should ensure that the physiological adaptation of donor neonates is not altered by the pressure to increase the volume collected.

Parents should also be informed of the importance of iron for their infant’s development and the adverse consequence of an iatrogenic decrease in their baby’s iron reserves at birth.(5)

Reference List

(1) Edozien LC. NHS maternity units should not encourage commercial banking of umbilical cord blood. BMJ 2006 October 14;333(7572):801-4.

(2) Scientific Advisory Committee of the Royal College of Obstetricians and Gynaecologists. Opinion Paper on UMBILICAL CORD BLOOD BANKING . London; 2006 Jun. Report No.: 2.

(3) Shlebak AA, Roberts IA, Stevens TA, Syzdlo RM, Goldman JM, Gordon MY. The impact of antenatal and perinatal variables on cord blood haemopoietic stem/progenitor cell yield available for transplantation. Br J Haematol 1998 December;103(4):1167-71.

(4) Chaparro CM, Neufeld LM, Tena AG, Eguia-Liz CR, Dewey KG. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet 2006 June 17;367(9527):1997-2004.

(5) Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev 2006 May;64(5 Pt 2):S34-S43.

Jose Luis Díaz-Rossello MD Perinatal Pediatrics Latin American Centre for Perinatology, Women Maternal and Reproductive Health Unit (CLAP/WMR), Pan American Health Organization, World Health Organization, Casilla de Correo 627, Montevideo, Uruguay

  The End of Cord Blood Banking28 October 2006George M. Morley, Retired obstetrician/gynecologist Northport, Michigan 49670 

Edozien’s article, Diaz-Rossella’s response and RCOG’s positions on cord clamping illustrate how uninformed the perinatal professions are about placental transfusion (PT).

Physiological PT (PPT) occurs during the physiological third stage of labour; physiological closure of cord vessels ends PPT. Gravity and / or uterine contractions effect PPT; 100 to 150 ccs (gms) of blood are transfused, finalizing the blood volume at 300 to 350 ccs (gms). PPT is adjusted, regulated and terminated reflexively by the newborn. PPT results in an optimal, maximum blood volume; it is usually finished in 3 to 5 minutes, but can extend past 20 minutes. [1]

Disruption of this physiological event with a cord clamp injures the child; the severity of the injury is proportional to the amount of blood volume amputated. PPT (no cord clamp used) supplies the newborn with enough iron to prevent anemia for one year – when the child should be ingesting iron.

The injurious effect of immediate cord clamping (ICC) is illustrated in every article published in the last ten years on encephalopathy and cerebral palsy. Every child in these studies has had ICC to obtain an arterial cord blood pH – a procedure promoted by RCOG and ACOG. ICC at birth ensures maximum depletion of blood volume – HYPOVOLEMIA; the neonatal term is “sick neonates.”

“Sick neonates are one of the most heavily transfused groups of patients in modern medicine.” [2] “Sick” babies display all the signs and symptoms of hypovolemic shock – “multi-organ dysfunction”. [3] The radiologist diagnoses ISCHEMIC Encephalopathy – deficient blood flow. The basal ganglia are “infarcted” and the germinal matrix of the preemie has hemorrhagic infarction. The degree of blood loss is accurately assessed by the degree of anemia that eventually develops in these “heavily transfused” babies.

Diaz-Rossello’s “adverse consequences” of iatrogenic (cord clamp) anemia are the consequences of brain ischemia / hypovolemia. Red cell transfusion corrects the anemia; it does not reverse ischemic brain damage. The long lasting mental deficiency [4] is the result of mal- perfusion of the child’s brain during a period of active brain growth and development immediately after birth. The degree of mental retardation (IQ in grade school) is proportional to the degree of infant anemia (Hbg gms – birth blood loss.) [5]

Diaz-Rossello’s example of clamping at 16 seconds compared to 94 seconds illustrates that the 16’s were more injured than the 94’s. However, if the cord is pulsating 94 seconds after delivery, a cord clamp will remove a major volume of blood with resulting hypovolemia / ischemia / brain damage – and eventual anemia / mental retardation. The integrity of a neonate’s brain is guaranteed by the child’s physiology, not by the misconception that physiology obeys a clock.

I agree with Dr. Diaz-Rossello that parents should be informed of the iatrogenic brain injuries caused by the cord clamp. In North America, thousands of informed parents choose home birth with midwives who routinely cut cords AFTER the placenta has delivered. This practice should eventually end the autism epidemic and the birth litigation industry. Blood banking will also end as after PPT, the cord vessels are often empty, and a few ccs of blood may be drawn from placental vessels.

G. M. Morley, M.B. Ch.B. FACOG (retired obstetrician / gynecologist)

Email obgmmorley@aol.com

www.cordclamp.com

References: 1. Gunther M. The transfer of blood between the baby and the placenta in the minutes after birth. Lancet 1957;I:1277-1280.

2. N A Murray and I A G Roberts. Neonatal transfusion practice. Arch. Dis. Child. Fetal Neonatal Ed., Mar 2004; 89: F101 – 107

3. Shah, P. Riphogen, J, Beyene, J, Perlaman, M. Multiorgan Dysfunction in Infants with Post-asphyxial Hypoxic Ischaemic Encephalopathy. Arch Dis Child Fetal Neonatal Ed 2004;89;F152-155. doi: 10.1136/adc.2002.023093 http://fn.bmjjournals.com/cgi/eletters/89/2/F152#434

4. Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev 2006 May;64(5 Pt 2):S34-S43.

5. Hurtado E, Claussen AH, Scott KG. Early Childhood Anemia and Mild to Moderate Mental Retardation. Am.J. Clin Nut. 1999:69:115-119 

A practical approach to timing cord clamping in resource poor settings (van Rheenen and Brabin (4 November 2006)

http://www.bmj.com/cgi/content/full/333/7575/954

Rapid Responses - http://www.bmj.com/cgi/eletters/333/7575/954

Re: cord clamping in uk

David JR Hutchon,Consultant Obstetrician and GynaecologistMemorial Hospital, Darlington DL3 8QZ

Sir, Immediate cord clamping is clearly not physiological. Immediate clamping probably does even more harm in developing countries than in the developed countries because immediate clamping leads to anaemia. There are however other implications and neonatal anaemia is still important in the developed countries. In Darlington, we have a guideline to delay cord clamping for at least 40 seconds, the details can be seen at: http://www.hutchon.net/NFMMSIG/cordclamp.htm and this guideline has been in place at the Darlington Memorial Hospital for the past two months. It was a pragmatic decision to make 40 seconds the interval and the rather longer time as suggested by Patrick F van Rheenen and Bernard J Brabin is likely to be closer to the physiological interval. We have also developed a method of resuscitation of the neonate at caesarean section with the cord intact. (Annual meeting of the RANZCOG Nelson 2005). Although we have not included this method in the guideline there are plans to do so. Fetal distress is a common reason for instrumental delivery or caesarean section. The fetal compromise is often due to cord compression associated with a nuchal cord. A nuchal cord results in compression of the low pressure venous return of oxygenated blood from the placenta. Blood continues to be pumped out by the fetal heart and the obstructed return from the placenta results in a congested placenta and a depleted fetal blood volume. If the cord is clamped immediately at delivery, although the return from the placenta is now relieved, the excess blood, which is oxygenated blood, never has any opportunity to return to the newborn. In these circumstances it is particularly important to be able to resuscitate the baby with the cord return still intact. Preparation for neonatal resuscitation needs to be made at the same as preparation for the caesarean section. Every maternity unit in the UK needs to adopt these guidelines. -David Hutchon

Lotus birth: an alternative to cord clamping?Martino Dall'Antonia, (email - mdallantonia@nhs.net)Microbiology consultantQueen Elizabeth Hospital Woolwich London SE18 4QH

Dear Sir,The article adds to the body of evidence of the beneficial effects of delayed umbilical cord clamping. Umbilical cord infections contribute to neonatal mortality and morbidity in resource poor settings. We should question if cord clamping is necessary. The experience of mothers and midwifes that practice the so-called lotus birth would suggest the contrary. Unfortunately, there is at present an almost complete lack of scientific evidence to support it.

Click on the graphic below to read a nuchal cord paper written by van Reenan and Brabin.