Grand Rounds

Preterm Umbilical Cord Milking vs Delayed Cord Clamping: Is There a Difference in Severe Intraventricular Hemorrhage?

BACKGROUND AND PURPOSE:

Katheria et al. (JAMA, 2019) investigated whether umbilical cord milking vs delayed umbilical cord clamping had an impact on death or severe IVH among preterm infants

Multicentered noninferiority randomized clinical trial (RCT)
Setting (2017-2018)
- 9 university and private medical centers | 4 countries
Participants were randomized in to 2 gestational age strata
- 23w0d through 27w6d | 28w0d through 31w6d
Interventions
- Umbilical cord milking: 20 cm of the cord was milked during approximately 2 seconds allowing refill and repeated 3 more times
- Delayed umbilical cord clamping: ≥60 seconds
Study termination
- Planned enrollment was 750 per group
- Enrollment was halted early due to an observed imbalance in the number of severe IVH events by study group
Primary outcome
- Composite of death or severe IVH

474 infants were included | 236 milking group | 238 delayed clamping group
- Mean gestational age: 28 weeks
There was no significant difference in the composite primary outcome between the groups (P = 0.16)
- Milking group: 12%
- Delayed clamping group: 8%
- Risk difference: 4% (95% CI, −2% to 9%)
Severe IVH was significantly higher in the umbilical cord milking group (P = 0.02)
- Milking group: 8%
- Delayed clamping group: 3%
- Risk difference: 5% (95% CI, 1% to 9%)
When comparisons were assessed based on gestational age, severe IVH risk was found among the infants in the 23 to 27 week strata among the umbilical cord milking group (P = 0.002)
- milking group: 22%
- Delayed clamping group: 6%
- Risk difference: 16% (95% CI, 6% to 26%)

There was a significantly higher rate of severe IVH with umbilical cord milking
The authors note that
- Because the study was terminated early, the results were based on a post hoc analyses rather than the original planned study plan
- Therefore, conclusions of this study are not definitive

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