Cutting the Cord at the Right Time: It's Not Delayed, It's Optimal

I will always feel gratitude for the fact that when our baby was born, my boyfriend's one request was that we not cut her umbilical cord too soon.  At the time, it was a topic I was unfamiliar with.  However, researchers, childbirth advocates, and doulas have been discussing the benefits of optimal cord cutting--sometimes referred to as "delayed" cord cutting--for decades, a technique that can be used with vaginal or cesarean birth.  (I believe one of the benefits for my daughter was that at age 12 months, her blood iron levels were normal even though she never had iron supplementation, on a diet that still consisted almost entirely of breastmilk.)  Over the past year, I have been excited to see this topic emerge more prominently in the mainstream news.  One of its spokespersons is pediatrician and author Dr. Alan Greene, who founded the TICC TOCC campaign to promote optimal cord cutting globally.  Other excellent resources include doula leader Penny Simkin's video that beautifully illustrates the concept, as well as a longer, well-referenced lecture by obstetrician Nicholas Fogelson.  I had the pleasure of meeting Dr. Greene and am happy to share a link to his compelling TEDx Talk about the TICC TOCC campaign, which he also explains below:

TICC TOCC
Improving the health of billions by strategically spreading a simple idea.

The Problem
Anemia hinders a quarter of the global population, and is disproportionately concentrated in low-income groups. Iron deficiency is the leading cause of anemia – but with iron deficiency, anemia is just the tip of the iceberg. Even when iron deficiency is not severe enough to cause anemia, it has been linked to lasting damage to the developing brain. Infancy is thus both one of the most important as well as most common life cycle windows for iron deficiency. The World Health Organization estimates that solving iron deficiency in a developing nation would increase productivity by 20 percent.

The Question
Given that human milk is the ideal food for human infants, why is breast milk relatively low in iron, and why are exclusively breastfed infants at risk for iron deficiency? Perhaps, infants are designed to also receive iron from their mothers in another way.

The Physiology
At the moment of birth, about 2/3 of the baby’s blood (the fetal circulation) is in the baby. The remaining third is still in the umbilical cord and placenta. During the third stage of labor, which lasts from the delivery of the baby to the delivery of the placenta, the cord actively pumps iron-rich, oxygen-rich, stem-cell-rich blood into the baby.

The History
Immediately clamping the umbilical cord was popularized in 1913 as one of three pillars of active management of the third stage of labor. While this intervention began in the West, we exported this technique to developing nations around the world. Today, in some low-income countries as many as 95 percent of delivery clinicians surveyed practice immediate cord clamping. Immediate cord clamping results in up to 10 times the risk of developing iron deficiency anemia.

The Solution
Wait until the cord stops actively pumping fetal blood into the baby, unless there is a strong reason otherwise. This has been studied in countries such as Argentina, Australia, Bangladesh, Canada, India, Libya, Mexico, Pakistan, United Kingdom, USA, and Zambia. Optimal cord clamping (a more accurate term than the more frequent ‘delayed’ cord clamping) has been shown to be both safe and effective at significantly reducing the risk of iron deficiency. Other benefits may include reducing birth asphyxia (inadequate oxygen to the brain) and cerebral palsy. The health benefits from receiving the cord’s pluripotent stem cells may be the most significant impact, but has yet to be understood.

Immediate cord clamping is an active medical intervention with unproven benefit. The WHO no longer recommend immediate cord clamping.

TICC TOCC (Transitioning Immediate Cord Clamping to Optimal Cord Clamping)
Modeled on the success of the WhiteOut Now campaign to end the introduction of processed white flour rice cereal to babies, TICC TOCC will leverage existing networks to spread the word to mothers and those who assist them in giving birth.

Spreading an idea that makes intuitive sense is cost effective and a simple first step to addressing a major global health problem. Moreover, it can be expected to amplify the benefits of existing nutrition and supplement programs.

Not only have people around the world traditionally waited for the cord to stop pulsing until the 20th century innovation, every other mammal studied instinctively waits for the cord to stop pulsing as well.
More than a quarter million babies will be born today. The clock is ticking.

Alan Greene, MD, FAAP

Bibliography
Andersson, O., Hellstrom-Westas, L., Andersson, D., & Domellof, M. (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. Bmj, 343 (nov15 1), d7157-d7157. doi:10.1136/bmj.d7157
Arroyo, P., Pardío, J., & Loria, A. (2011). Special issue: Iron deficiency and iron deficiency anemia in early infancy; etiology, consequences, prevalence, and prevention. Foreword. Nutrition reviews, 69 Suppl 1(Id), S1-2. doi:10.1111/j.1753-4887.2011.00427.x
Balarajan, Y., Ramakrishnan, U., Ozaltin, E., Shankar, A. H., & Subramanian, S. V. (2011). Anaemia in low-income and middle-income countries. Lancet, 378(9809), 2123-35. Elsevier Ltd. doi:10.1016/S0140-6736(10)62304-5
Beard, J. L. (2008). Why Iron Deficiency Is Important in Infant Development. Experimental Biology, (2), 2534-2536.
Benton, D. (2010). The influence of dietary status on the cognitive performance of children. Molecular nutrition & food research, 54(4), 457-70. doi:10.1002/mnfr.200900158
Berger, J., Wieringa, F. T., Lacroux, A., & Dijkhuizen, M. a. (2011). Strategies to prevent iron deficiency and improve reproductive health. Nutrition reviews, 69 Suppl 1, S78-86. doi:10.1111/j.1753-4887.2011.00436.x
Bimbashi, A., Ndoni, E., Dokle, A., & Duley, L. (2010). Care during the third stage of labour: obstetricians views and practice in an Albanian maternity hospital. BMC pregnancy and childbirth, 10, 4. doi:10.1186/1471-2393-10-4
Cameron, B. M., & Neufeld, L. M. (2011). Estimating the prevalence of iron deficiency in the first two years of life: technical and measurement issues. Nutrition reviews, 69 Suppl 1, S49-56. doi:10.1111/j.1753-4887.2011.00433.x
Ceriani Cernadas, J. M., Carroli, G., Pellegrini, L., Otaño, L., Ferreira, M., Ricci, C., Casas, O., et al. (2006). The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics, 117(4), e779-86. doi:10.1542/peds.2005-1156
Cernadas, C., Carroli, G., Pellegrini, L., Ferreira, M., Ricci, C., Casas, O., Lardizabal, J., et al. (2010). Efecto del clampeo demorado del cordón umbilical en la ferritina sérica a los seis meses de vida . Estudio clínico controlado aleatorizado. Group, 108 (3), 201-208.
Chaparro, C. M. (2011). Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutrition reviews, 69 Suppl 1, S30-6. doi:10.1111/j.1753-4887.2011.00430.x
Chaparro, C. M., Neufeld, L. M., Tena Alavez, G., Eguia-Líz Cedillo, R., & Dewey, K. G. (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet, 367 (9527), 1997-2004. doi:10.1016/S0140-6736(06)68889-2
Cm, B., Gml, G., Devane, D., Mcguire, W., & Weeks, A. (2011). Active versus expectant management for women in the third stage of labour ( Review ). Assessment, (11).
Davis, P. G., & Dawson, J. A. (2012). New concepts in neonatal resuscitation. Current opinion in pediatrics, 24(2), 147-53. doi:10.1097/MOP.0b013e3283504e11
Georgieff, M. K. (2011). Long-term brain and behavioral consequences of early iron deficiency. Nutrition reviews, 69 Suppl 1, S43-8. doi:10.1111/j.1753-4887.2011.00432.x
Gülmezoglu, a M., Lumbiganon, P., Landoulsi, S., Widmer, M., Abdel-Aleem, H., Festin, M., Carroli, G., et al. (2012). Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. The Lancet, 6736 (12), 1-7. doi:10.1016/S0140-6736(12)60206-2
Hutton, E. K., & Hassan, E. S. (2007). CLINICIAN ’ S CORNER Late vs Early Clamping of the Umbilical Cord in Full-term Neonates Systematic Review and Meta-analysis of Controlled Trials. Main, 297 (11), 1241-1252.
Jaleel, R., Deeba, F., & Khan, A. (n.d.). Original Article Timing of umbilical cord clamping and neonatal haematological status. American Journal of Obstetrics and Gynecology, 468-470.
Matar, H. E., Almerie, M. Q., Alsabbagh, M., Jawoosh, M., Almerie, Y., Abdulsalam, A., & Duley, L. (2010). Policies for care during the third stage of labour: a survey of maternity units in Syria. BMC pregnancy and childbirth, 10, 32. doi:10.1186/1471-2393-10-32
Mercer, J. S. (2001). Current best evidence: a review of the literature on umbilical cord clamping. Journal of midwifery & women’s health, 46 (6), 402-14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11783688
Mercer, J. S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics, 117 (4), 1235-42. doi:10.1542/peds.2005-1706
Mercer, J., & Erickson-Owens, D. (2006). Delayed cord clamping increases infants’ iron stores. Lancet, 367 (9527), 1956-8. doi:10.1016/S0140-6736(06)68858-2
Miller, E. M. (2010). Maternal hemoglobin depletion in a settled northern Kenyan pastoral population. American journal of human biology : the official journal of the Human Biology Council, 22 (6), 768-74. doi:10.1002/ajhb.21078
Oh, W. (2007). Timing of umbilical cord clamping at birth in full-term infants. JAMA : the journal of the American Medical Association, 297 (11), 1257-8. doi:10.1001/jama.297.11.1257
Rabe, H., Reynolds, G., & Diaz-Rossello, J. (2008). A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology, 93 (2), 138-44. doi:10.1159/000108764
Sommers, R., Stonestreet, B. S., Oh, W., Laptook, A., Yanowitz, T. D., Raker, C., & Mercer, J. (2012). Hemodynamic effects of delayed cord clamping in premature infants. Pediatrics, 129 (3), e667-72. doi:10.1542/peds.2011-2550
Ultee, C. a, van der Deure, J., Swart, J., Lasham, C., & van Baar, a L. (2008). Delayed cord clamping in preterm infants delivered at 34 36 weeks’ gestation: a randomised controlled trial. Archives of disease in childhood. Fetal and neonatal edition, 93 (1), F20-3. doi:10.1136/adc.2006.100354
van Rheenen, P. (2011). Delayed cord clamping and improved infant outcomes. Bmj, 343 (nov15 1), d7127-d7127. doi:10.1136/bmj.d7127