EINC Don’ts & Do’s | Unnecessary Suctioning and Bathing & Properly Timed Cord Clamping

DON’Ts Unnecessary Suctioning and Bathing

Routine suctioning


Routine suctioning has been the norm in newborn resuscitation because it was believed to be necessary to clear the baby’s airway and to stimulate him to breath. However in the presence of clear amniotic fluid especially in a baby who is crying and breathing at birth, routine suctioning has been associated with bradycardia, apnea, and delays in achieving normal oxygen saturations. It also causes mucosal trauma with an increased risk for infection. In a pilot implementation study of the Essential Newborn Care Protocol at a large government hospital in the National Capital Region, unnecessary suctioning of vigorous newborns increased the risk for sepsis (OR 4.49 95% CI 2.26-8.89), mortality (OR 8.75 95%CI 2.60 – 29.4) and severe disease (OR 4.44 95% CI 2.72 – 7.25). Routine suctioning of the newborn is a harmful practice that should be discontinued.

Sources:
Velaphi S, Vidyasagar D. The pros and cons of suctioning at the perineum (intrapartum) and post-delivery with and without meconium. Semin Fetal Neonatal Med 2008 Dec: 13 (6): 375-82. Sobel HL, Silvestre MA, Vitangcol B, Mantaring JB 3rd, Nyunt-U S. The association between immediate newborn care practices and risk of neonatal mortality,sepsis and severe disease in a Philippine hospital. Unpublished

Early Bathing and Washing 

Bathing the newborn immediately after birth predisposes him to developing huypothermia. When hypothermia sets in, there is an increased risk of infection, coagulation defects, acidosis, delayed fetal-to-newborn circulatory adjustment, hyaline membrane disease, and intracranial hemorrhage. It also washes away the vernix caseosa, which has been shown in several studies to have antimicrobial properties similar to that of amniotic fluid and breastmilk. Antimicrobial proteins (lysozyme, lactoferrin, human neutrophil peptides 1-3 and secretory leukocyte protease inhibitor) are present in organized granules embedded in the vernix, and these immune substances were found to be effective in inhibiting the growth of common perinatal pathogens, including group B Streptococcus, K. pneumoniae, L. monocytogenes, C. albicans, and E. coli. Also, washing leads to the baby becoming disorganized, effectively hindering the crawling reflex which is present during the first hour of life. The WHO recommends that bathing be delayed for at least 6 hours after birth to minimize the risk of cold stress during the period of maximum physiologic transition of the newborn. 

Sources: 

Darmstadt GL, Walker N, Lawn JE, Bhutta Z, Haws RA, Cousens S. Saving newborn lives in Asia and Africa:cost and impact of phased scale-up of interventions within the continuum of care. Health Policy and Planning. 2008. 23 (2):101.  Akinbi HT et al. Host defense proteins in vernix caseosa and amniotic fluid, Am J Obstet Gynecol. 191(6), 2090-2096. 2004.  World Health Organization. Thermal Protection of the Newborn: A Practical Guide. Geneva, Switzerland: World Health Organization; 1997.

DO’s Properly Timed Cord Clamping 

Immediate cord clamping has been traditionally been the standard in the country. In the observational study by Sobel et al of 481 births in 51 large government hospitals to evaluate the performance and timing of newborn care interventions, cords were clamped at a median of only 12 seconds with 476 (99.0%) within 60 seconds. Three (0.6%) with nuchal cords were cut prior to delivery. Research that has been done on delayed cord clamping has shown benefits to both full-term and preterm babies. Furthermore traditional practices such as “milking” the cord and using binders have only been proven to increase the risks for infection. Milking the cord towards the baby, for instance, can actually result in a bolus of blood being introduced suddenly into the baby’s system and may conceivably cause complications especially in preterms with fragile blood vessels in the brain. Binders on the other hand, when soiled and unchanged, may harbor germs that will cause infection. The binder can also rub against the skin and cause irritation. In lieu of avoiding the risk for infection, EINC recommends the use of plastic clamp to lessen subsequent cord handling (hence the risk of infection) and eliminate the need to replace the metal clamp with a plastic one later on with the first clamp applied 2 cm from the base of the umbilicus and second one at 5 cm from the base of the umbilicus. 

Effects on Full-term Infants  There are two meta-analyses evaluating the effects of delayed cord clamping on full term infants. The meta-analysis by Hutton and Hassan included all controlled trials whether randomized or not, while McDonald and Middleton excluded quasi-randomized trials and included also maternal outcomes in their meta-analysis.  Hutton and Hassan in their meta-analysis of 15 controlled trials (n=1912 newborns) found that delaying cord clamping of the umbilical cord in full term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Benefits over ages 2-6 months associated with late clamping include improved hematocrit (WMD 3.7% 95% CI 2.0, 5.4%), ferritin concentration (WMD 17.89 95% CI 16.58-19.21), stored iron (WMD 19.0 95% CI 7.67- 32.13) and a significant reduction in the risk of anemia (RR 0.53 95% CI 0,40-0.70). There was a trend towards an increased risk for polycythemia though asymptomatic in the 2 high quality studies (n=281 infants) RR 3.91 95%CI 1.00-15.36.  McDonald and Middleton’s review of 11 trials (2989 mother-baby dyads) revealed significant increases in newborn hemoglobin levels in the late vs the early cord clamping (WMD 2.17 g/dl 95% CI 0.28, 4.06; 3 trials of 671 infants) although the effect did not persist beyond 6 months. Infant ferritin levels remained higher in the late vs the early clamping group at 6 months. There was a significant increase in infants requiring phototherapy for jaundice (RR 0.59 95% CI 0.38, 0.92; five trials of 1762 infants) in the late vs early clamping group. There were no significant differences seen for maternal postpartum hemorrhage in any of the 5 trials (n=2236 women) which measured this outcome (RR for postpartum hemorrhage of > 500 ml 1.22 95% CI 0.96, 1.55).  Effects on Preterm Infants  Data from a meta-analysis by Rabe et al from 7 randomized controlled trials (n=297 infants) with a maximum delay of 2 minutes (120 secs) revealed that delayed clamping was associated with fewer transfusions for anemia (3 trials, n=111 infants; RR 2.01, 95% CI 1.24 to 3.27, low blood pressure (2 trials, n=58 infants; RR 2.58 95% CI 1.17, 5.67) and less intraventricular hemorrhage (IVH) (5 trials, n=225 infants; RR 1.74, 95% CI 1.08, 2.81). In another study by Van Rheenen on a population of low birth weight/small for gestational age (SGA) infants, the search for both randomized and quasi randomized trials yielded no trials specifically reporting the effects of delayed clamping in SGA infants. Three trials were included, with 190 term and 40 preterm infants, a proportion of whom were SGA. Data showed higher hemoglobin levels in the term infants at follow-up [2 trials, n=127 infants, weighted mean difference WMD 9.17 g/L, 95% CI 5.94-12.40]. In preterm infants, the proportion who required a blood transfusion in the 1st 6 weeks after birth was lower after DCC (one trial, 38 infants, RR 0.56, 95% CI 0.34-0.94).  In a randomized controlled trial, Mercer and co-workers demonstrated that delayed cord clamping in very preterm neonates reduced the incidence of intraventricular hemorrhage and late-onset sepsis. Delayed cord clamping did not protect against the primary outcomes of interest, bronchopulmonary dysplasia and necrotizing enterocolitis. All these studies point to the facts that placental transfusion at birth brought about by properly timed cord clamping increases the infant’s blood volume and iron reserves, and reduces the incidence of iron-deficiency anemia in infancy. In preterm infants, it reduces the need for blood transfusions and decreases the incidence of life-threatening intracranial hemorrhages.

Sources:
Sobel HL, Silvestre MA, Mantaring JB III, Oliveros YE, Nyunt-U S. 2009. Immediate newborn care practices delay thermoregulation and breastfeeding initiation. Acta Paediatrica 2011. DOI:10.1111/j.1651-2227.2011.02215.x. [Epub ahead of print]deprive newborns of natural protections: A minute-by-minute assessment of care in the first hour of life in fifty-one large Philippine hospitals. Unpublished. Available at http://onlinelibrary.wiley.com/doi/10.1111/j.1651-2227.2011.02215.x/pdf Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252. McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2. Rabe H, Reynolds G and Diaz-Rossello. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. van Rheenen PF, Gruschke S, Brabin BJ. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67.

Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics. 2006 Apr;117(4):1235-42.