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Respiratory Support prior to Cord Clamping in Very Preterm Infants: A Narrative Review with Pooled Results from
Michael P Meyer1,2, Satyan Lakshminrusimha3, Anup C Katheria4
1Department of Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand.
Insights
Providing respiratory support before umbilical cord clamping in very preterm infants did not improve major neonatal outcomes like death or severe brain bleeds. While hypothermia was slightly more common in the intervention group, overall results showed no significant benefit for this practice.
Area of Science:
- Neonatal Medicine
- Perinatal Research
- Pediatric Critical Care
Background:
- The benefit of respiratory support before umbilical cord clamping in very preterm infants remains unclear.
- Recent randomized controlled trials have shed light on this critical knowledge gap.
- Previous studies included infants less than 32 weeks gestational age undergoing deferred cord clamping (DCC).
Purpose of the Study:
- To evaluate the impact of respiratory support provided prior to umbilical cord clamping on neonatal outcomes in very preterm infants.
- To synthesize evidence from multiple randomized controlled trials on this intervention.
Main Methods:
- Systematic review and meta-analysis of 6 randomized controlled trials involving preterm infants (<32 weeks gestational age).
- Intervention group received respiratory support (CPAP or positive pressure ventilation) during deferred cord clamping (50-120s).
- Control group received time-based cord clamping (30-60s) without respiratory support or cord milking.
Main Results:
- No significant difference in major neonatal outcomes (death, severe intraventricular hemorrhage, bronchopulmonary dysplasia) between intervention and control groups (moderate certainty of evidence).
- The intervention group experienced a significantly lower mean admission temperature, indicating a mild hypothermia risk.
- Other outcomes like transfusion rates were also comparable between groups.
Conclusions:
- Provision of respiratory support during deferred cord clamping does not improve key neonatal outcomes in very preterm infants.
- Current evidence does not support routine use of this procedure, but further research is warranted.
- Maintaining normothermia was challenging, with a slight increase in mild hypothermia observed in the intervention group.
Background:
Whether very preterm infants benefit from provision of respiratory support prior to cord clamping has been an important knowledge gap. Four randomised controlled trials have recently been published on this topic and have provided new insights. These 4 studies and 2 previous ones included preterm infants less than 32 weeks of gestational age receiving deferred cord clamping (DCC). The intervention consisted of providing respiratory support in the form of continuous positive airways pressure or positive pressure ventilation via T piece. The intervention group had cord clamping performed when preset stability criteria were met in one study or after an elapsed time of up to 120 s was achieved in the other 5 studies (50-120 s range). The control group had time-based cord clamping after 30-60 s without respiratory support (5 studies) or cord milking (1 study).
Summary:
Outcome measures based on important neonatal outcomes such as death, severe intraventricular haemorrhage (sIVH), and bronchopulmonary dysplasia (BPD) were reported as were other outcomes such as admission temperature and transfusions. Overall outcomes (death, sIVH, and BPD) were similar in intervention and control groups in these studies with moderate certainty of evidence to conclude there was no benefit for these outcomes. Maintaining normothermia was difficult, and the mean difference in admission temperature was significantly lower in the intervention group, although hypothermia was generally mild.
Key Message:
Overall, the provision of respiratory support during DCC did not improve important neonatal outcomes (moderate certainty of evidence). Although we do not currently recommend the procedure as routine practice, we acknowledge there is room for further studies.
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