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ELECTRONIC ARTICLE:
Laurent Egreteau, Jean-Yves Pauchard, Denis S. Semama, Jacqueline Matis, Anne Liska, Bernard Romeo, Fabrice Cneude, Isabelle Hamon, and Patrick Truffert
Chronic Oxygen Dependency in Infants Born at Less Than 32 Weeks' Gestation: Incidence and Risk Factors
Pediatrics 2001; 108: e26 [Abstract] [Full text] [PDF]
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P3Rs published:

[Read P3R] How About Studying Infants Not Subjected to Iatrogenic Injury?
George Malcolm Morley   (4 September 2001)
[Read P3R] Response to Dr Morley' s letter
Egreteau   (9 September 2001)

How About Studying Infants Not Subjected to Iatrogenic Injury? 4 September 2001
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George Malcolm Morley,
OB/GYN (retired)

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Re: How About Studying Infants Not Subjected to Iatrogenic Injury?

rush1{at}aol.com George Malcolm Morley

The study by Egreteau et al is typical of all that are currently published on premature birth - an investigation of a set of premature infants who have all been subjected to the same birth injury and are exhibiting a variety of related symptoms, signs and complications. I am referring of course to the injury of iatrogenically induced fractured blood volume, produced by a cord clamp in an archaic practice with no credible evidence base.

What is missing in a study like this is a control group of uninjured preemies to demonstrate which abnormalities are due to the premature cord clamping and which are due to prematurity.

The control group should be allowed to experience physiological cord closure, which entails not interfering with the cord until after the placenta is delivered. The umbilical vein may remain somewhat patent after arterial pulsation ceases, and the placental transfusion (effected by gravity and / or uterine contraction) is reflexively regulated and terminated by the child. The result is a physiological blood volume optimal for survival and proper development.

Closure of the umbilical vein is inside the child's abdomen. When the cord is cut after the placenta is delivered, blood still oozes from the placental end of the vein, but not a drop comes out of the umbilical stump. At the very least, clamping should be delayed until cord pulsation ceases.

Even just allowing a small delay in clamping (partial placental transfusion for 30 seconds at 20cms of gravity drainage) has been shown to reduce average oxygen dependency from 10 days to just 3 days (1). With such obvious results, just imagine what a complete placental transfusion could do. Although it wasn't reported how many went on to "chronic" dependency (COD), but it would seem that fast clamping and COD would have a "cause and effect" relationship.

In premature infants, with lungs that cannot adequately oxygenate the child, preservation of the placental circulation in a warm bath of oxygenated, nutrient fluid would seem to offer the best chances to survive and thrive as much as possible.

REFERENCE:

1. Kinmond S, Aitchison TC, Holland BM, Jones JG, Turner TL, Wardrop CA. Umbilical cord clamping and preterm infants: a randomised trial. BMJ 1993 Jan 16;306(6871):172-5.

Response to Dr Morley' s letter 9 September 2001
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Egreteau,
Neonatalogist
PhD

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Re: Response to Dr Morley' s letter

legreteau{at}chu-reims.fr Egreteau

We thank Dr Morley for taking an interest to our study.

His letter is focused on the duration of cord clamping and its effect on chronic oxygen dependency (COD) to increse the infant blood volume from placental circulation and so to enhance oxygenation of the infant. His assumption is that increasing blood volume from placental circulation will enhance infant's oxygenation and thus decrease oxygen needs. Oxygen toxicity would be reduced and COD incidence woulb be decreased.

First, he objects to our study the absence of a control group compared to our population "subjected to the same injury birth". We do not agree with this affirmation, as demonstrated by gestational ages from 24 to 31 weeks and by very various scores on Critical Risk Index for Babies (CRIB) in our population. Moreover, we did not try to analyse the influence of a single factor (cord clamp i.e.) in our population compared to a control group, on COD development. We enrolled infants in a prospective cohort to assess the incidenceof COD and risk factors for COD occurence by stepwise logistic regression analysis. Duration of cord clamping was not a studied variable.

Identified significant risk factors were a low gestational age, a high CRIB score, intrauterine growth restriction, need for surfactant treatment. Thus, oxygen toxicity was not the only risk factor for COD occurence.

We think that cord clamping could not have any positive influence on any of these factors. Moreover, an excessive blood volume which leads to an increased insterstitial lung water may have a deleterious effect on severity of respiratory distress syndrome in those very preterm infants."