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Giving premature and full-term babies a better start in life

A baby’s birth can be an anxious time for any parent, but premature (or pre-term) babies are particularly vulnerable when they are born. They’re more likely to suffer complications than full-term babies, some of which can affect later development. Now, thanks to research and training developed at Brighton and Sussex Medical School (BSMS), the outlook for premature babies around the world is much brighter.

Challenges for pre-term babies

In the uterus, blood flows through the umbilical cord from the placenta to the baby, ensuring a steady supply of oxygen and nutrients like iron, which is crucial for healthy brain development. At birth, all babies then have to adjust to controlling their circulation and blood pressure independently of their mothers. 

But the organs of babies born before they reach full-term aren’t fully mature and don’t yet function properly. This means that babies may struggle to stabilise their blood pressure and to adapt to life outside the womb. They may suffer with anaemia and its complications. 

Fluctuations in blood pressure can cause haemorrhaging (bleeding) into the brain, leading to problems with neurological development later in life, and many more blood transfusions are needed in pre-term babies. 

But research into the benefits of delayed umbilical cord clamping (DCC) led by is improving the outcomes for premature babies both in hospitals across Sussex and in healthcare settings around the world.

A global effort

Heike’s team brings together researchers from , clinicians and healthcare professionals across the hospitals of , and collaborators from across the globe. Academics and clinicians from Uppsala 5XÉçÇøÊÓƵ in Sweden, Brown 5XÉçÇøÊÓƵ, Rhode Island and San Diego in the US, to Mexico, Australia and Nepal, are all working to bring the benefits of DCC to babies and their parents. It’s a truly global network.

So, what are the benefits of delaying clamping?

At birth, around one-third of a baby’s blood is in the placenta. If the umbilical cord is clamped immediately (early cord clamping), the blood remains in the placenta and simply goes to waste. Heike is researching and promoting the benefits of delaying the clamping (this can be anywhere from 60 seconds to three minutes), so the blood can flow into the baby as an extra blood transfusion.

The extra blood volume helps to stabilise blood pressure and delivers extra iron-rich haemoglobin to the baby (iron is particularly important for healthy development). It also reduces the need for later invasive transfusions, which can themselves carry complications, and are often viewed with understandable concern by parents.

• An extra blood transfusion (text version) 

  The amount of blood that can be transferred by delaying baby cord clamping is the same as giving an adult a two-litre blood transfusion. 

  Rabe H, Diaz-Rosello JL, Duley L, Dowswell T, (2012)  Cochrane Database of Systematic Reviews 2012, Issue 8. 

Studies in Mexico also suggest that babies who undergo DCC also have fewer infections – particularly of the gut – in the first six months of life. And a recent study in Australia shows if you give extra blood to the pre-term baby the in-hospital mortality rate is reduced by 30%. 

The scale of the impact is sobering – a reduction in deaths, a reduction in transfusions, and a reduction in infections which, in turn, means a reduced need to use antibiotics in the very young, in a world where antibiotic resistance is a growing concern. 

‘And, of course,’ says Heike ‘the great thing about the blood from the cord is it’s free. You don’t get that very often in healthcare ­­­– a treatment that comes at no cost! It’s important in the context of squeezed NHS resources, but its significance is just as great in developing countries, where mothers may not be able to pay for healthcare and their nutritional status may be poor. The extra iron that DCC provides can help set babies up for the first few months of life.

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The great thing about the blood from the cord is it's free. You don't get that very often in healthcare - a treatment that comes at no cost.”Dr Heike RABE 
Brighton and Sussex Medical School (BSMS)

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Cord milking

But DCC means asking healthcare staff to wait before handing over a premature baby to the paediatricians. Staff and parents worry that a baby may get cold or otherwise suffer because of delayed specialist care. So Heike and her team have been researching gently ‘milking’ the cord four times over a 30-second period to squeeze the blood in to the baby. The baby gets all the benefits of the extra blood, in a shorter time and with no negative effects. 

Heike has also been working to ensure that staff are fully trained in the technique so they feel confident about the delay. She is overcoming concerns through developing care pathways that allow for the baby to be wrapped up warmly and to breast feed without milking getting in the way. It’s all part of an overall care package that helps both mother and baby. 

In fact, obstetricians in local NHS trusts are now actively requesting cord milking be done as standard for premature babies because it’s an active and guaranteed way of transferring the blood.

The benefits are also acknowledged in Caesarean births where the baby hasn’t been subjected to the contractions of the uterus and the transfer of blood from DCC alone can be quite variable.

Full-term babies benefit too

And it’s not just pre-term babies who are benefitting. Studies in full-term babies show better neurodevelopment in babies who have had DCC compared with those who haven’t. All babies can benefit from the extra iron – crucial for brain development – received in cord blood. 

The effects are particularly marked in boys, who show better motor skills when followed up at the age of four years. Girls don’t show the same effects because they experience the protective effect of oestrogen in the womb, but boys are more vulnerable, so they benefit more. ‘This is quite remarkable, explains Heike, ‘because you see this effect in highly developed countries where there’s no malnutrition so, genuinely, all babies can benefit.’

Changing World Health Organization guidelines

In the light of growing evidence from around the world that DCC benefits pre-term babies, and the results of her own research, Heike was asked to write a prestigious of the evidence in 2004.  

Following publication of the updated Review in 2012, Heike’s team were contacted by experts who were reporting to the World Health Organization in Geneva, and her data were shown there. So convincing was the evidence, that the World Health Organization incorporated the use of DCC for pre-term infants in their global guidelines. 

‘That,’ she recalls, ‘was a unique moment in my life. Learning that they had adopted DCC in their guidelines was wonderful. Even better is the knowledge that as a direct result, at this moment, somewhere in the world, a baby is getting DCC and will do better because of it.’ 

Heike’s team is now developing teaching programmes that can be used anywhere in the world and she’s rolled out a and web-based materials that are constantly evolving. ‘Staff using DCC in Nepal are in the feedback loop, telling us how we can improve the training materials. It’s so important to take the healthcare professionals on the journey with us. It’s a two-way process – we learn from each other.’

Involving parents is crucial

Heike’s team has also been careful to involve parents every step of the way. ‘Part of the challenge with the research is that parents need to enrol their baby before it’s born. It’s a stressful situation in which to give consent when you’re expecting a pre-term baby. But because we’ve involved parents early and clearly explained the benefits they’ve been very positive.’ 

Mothers especially have reported that they feel that they are contributing something to their baby´s care. It’s important to them that they can give their baby the placental blood. 

Parents also said they trusted the healthcare professionals to do the right thing. ‘We’ve built a huge amount of trust,’ reflects Heike. ‘It’s really helped our understanding of the process of informed consent before birth and we can apply what we’ve learned in all sorts of situations where informed consent is needed. It’s an iterative process.’

Cord blood for all babies

Asked if she feels there are any areas in the world where it would be particularly useful to roll out DCC, and cord milking in particular, Heike is clear. ‘Everywhere. My dream is that by the time I retire every baby, premature or not, will get their own cord blood at birth.’ 

‘I’m a clinician, a neonatologist. For me it’s all about improving patient care, but it must be based on evidence, clear evidence of benefit. It’s great to know that babies who might otherwise not have done so well, can go on to have good lives long after I’m dead and gone.’

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Author: Rachael Miller, 5XÉçÇøÊÓƵ
Date published: 3 October 2018

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Brighton and Sussex Medical School is a partnership between the Universities of Sussex and Brighton and NHS trusts across the Sussex and Surrey regions.

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