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Three Part Question

In [preterm babies] does [delayed cord clamping] prevent [late onset of sepsis]?

Clinical Scenario

A baby is born by spontaneous vaginal delivery at 29 weeks gestation. The infant's mother had a previous child born at 28 weeks gestation, who died due to late onset sepsis. The obstetrician clamps the cord immediately after the baby is delivered. Later the paediatrician, whom was present at delivery, asks why the cord was clamped immediately instead of delaying to 30-45 second. The paediatrician highlights the numerous benefits of delayed cord clamping including the prevention of late onset sepsis. A debate ensues as to the best practise and evidence behind the paediatrician's argument.

Search Strategy

Primary search:Cochrane database
Secondary search: Searched Medline, Embase and CINAHL databases via Dialog Datastar
June 2006 - Keywords: Delayed Cord clamping (DCC), late onset sepsis (LOS), Preterm

Search Outcome

1 relevant article

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
J.S Mercer et al 4 April 2006	72 mother/infant pairs were randomized. Babies less than 32 weeks included Comparing ICC (cord clamped 5-10seconds vs. DCC (cord clamped 30- 45 seconds)	Randomised unmasked trial (level 2b).	Delayed cord clamping seems to protect VLBW infants from IVH and LOS, especially for male infants	Significant differences were found between the ICC and DCC groups. In the DCC group 14% had IVH and 3% had LOS vs. 36% and 22% in the ICC group. CI 1.1-11 and 0.01-0.84 respectively. No male infants were diagnosed with LOS in the DCC group.ICC; Immediate cord clamping, IVH; Intraventricular haemorrhage

Comment(s)

Neonatal sepsis may be classified according to the time of onset of the disease: early onset and late onset. In the literature, however, there is little consensus as to what age limits apply, with early onset ranging from 48 hours to 6 days after. Various strategies have been developed in order to prevent and if needed, manage infected neonates. We needed to clarify the evidence favouring the benefits of delayed cord clamping before changing the practice in our unit. There are a few limitations in the study by Mercer et al. Power analysis was based on the event rate of BPD. Secondary outcomes need to be interpreted with caution. The study was in-adequately powered in regards to the studies conclusion. Multiple gestations were deemed part of the exclusion criteria. Although we can hypothesis to this reason, is not clearly stated in the methodology. Within the results, the authors briefly highlight the use of blood cultures and the discrepancy of positive cultures between the two sample groups. As the findings are largely based upon these results it would be interesting, in addition, to have documented which organisms were isolated and what percentage were thought to be contaminated. This data will obviously affect the interpretation and hence appliance of the study in clinical practise. As a final point, it is evident that a higher proportion of mother/infant pairs in the delayed cord clamping group received magnesium sulphate antenatally. In view of this it would be beneficial to highlight this within the discussion as to the affects, if any, of magnesium sulphate on the incidence of intraventricular haemorrhage and late-onset-sepsis. The benefits of delayed cord clamping have been the focus of numerous studies as identified in the Cochrane review.2 The most noted benefit is the reduced incidence of intraventricular haemorrhage. Due to the benefits highlighted in this study, in combination with the above findings, we feel there is a potential to change clinical practice. In regards to late onset sepsis alone this study provides inadequate evidence to justify encouraging delayed cord clamping. As it is an outcome that is readily and easily applicable to all the units, we conclude that further studies are required with suitable powers regarding late onset sepsis as a primary outcome.

Clinical Bottom Line

Delayed cord clamping reduces the incidence of IVH in preterm infants Further studies are needed to confirm the benefit in the prevention of late onset sepsis

References

1. Judith S. Mercer et al 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.
2. H Rabe, G Reynolds, J Diaz-Rossello. Early versus delayed umbilical cord clamping in preterm infants. The Cochrane Database of Systematic Reviews 2004 Issue 4