In many hospital delivery rooms, it is routine to clamp and cut the umbilical cord immediately after birth. However, there is now convincing evidence that delaying cord clamping by just a few minutes has many benefits and few risks in both full-term and premature babies. Much of the research on delayed cord clamping has only just emerged in the last decade, so many OB/GYNs, midwives, and pediatricians may not be familiar with the benefits and safety of delayed cord clamping. You may have to start the discussion and advocate for yourself. This article gives you information and resources to make an informed decision abbout timing of cord clamping.

What exactly do we mean by delayed cord clamping?

Delayed cord clamping means waiting 2 to 3 minutes after delivery before clamping and cutting the umbilical cord. During this time, blood continues to pulse from the placenta to the baby until the pulses naturally stop around 3 minutes. The transfer of blood from placenta to baby is most effective if the baby is placed on the mother’s abdomen or lower.

What are the benefits of delayed cord clamping?

Research has found that delayed cord clamping allows 20 to 40 mL more blood to pulse from the placenta to the newborn, carrying with it an additional 30 to 35 mg of iron [2].  As a result, babies have higher newborn hemoglobin, lower risk of anemia at birth and through 2-3 months, and higher iron status and storage through 6 months of age [2, 3].

Delayed cord clamping gives your baby more iron. Why is this important? The extra iron is stored and becomes your baby’s main source of iron until she starts eating solid foods, particularly if you breastfeed. Your baby will use that iron to form red blood cells and transport oxygen, to build muscle, and to develop her brain cells. Severe iron deficiency can cause anemia, but iron deficiency during infancy also increases the risk of cognitive, motor, and behavioral deficits that can last into adolescence [4-6]. Breastfed babies are at higher risk for iron deficiency than those fed formula, because formula is fortified with iron. The American Academy of Pediatrics estimates that U.S. infants that are exclusively breast-fed have a 20% risk of iron deficiency by 9-12 months of age [7]. Delayed cord clamping can give babies an extra 1-3 months of iron storage to help bridge their transition from exclusive breastfeeding to solid foods [8].  Certainly other mammals do not rush to clamp the cord immediately after birth and therefore also get that extra dose of iron to baby before cutting her off from mom’s supply. However, immediate cord clamping does not mean your baby is destined to be iron deficient – it just increases the likelihood that she will need a boost from iron supplements and/or iron-fortified foods.

An added benefit of delayed cord clamping is that it may protect your baby from lead exposure. One study found that in breastfed infants at risk for lead exposure, delayed cord clamping was associated with lower blood lead levels than immediate clamping [9]. This effect is also likely related to the improvement in baby’s iron stores.

Delayed cord clamping is even more important for preterm infants, and in fact, is beginning to be adopted by hospitals as general protocol. Preemies are at higher risk for iron deficiency, so the extra iron in cord blood is especially helpful to them. In addition, delayed cord clamping has been shown to decrease the incidence of intraventricular hemorrhage and late-onset sepsis in preemies [10, 11]. Delayed cord clamping improves hematocrit and reduces anemia and the need for blood transfusions in these babies [10]. In one trial, it also improved motor skills in 7-month-old baby boys who were born prematurely [12]. In another, it increased oxygenation of brain tissue in newborn preemies [13]. Many of these studies on preemies used only a 30-45 second delay in cord clamping, but these benefits were observed even with this short delay.

Are there risks to delayed cord clamping?

To date, there is no evidence for significant risks to the mother or the baby associated with delaying cord clamping by 2-3 minutes. However, if your birth staff still has concerns, these recent findings should reassure them:

1. Delayed cord clamping does not increase blood loss in the mother [14].
2. Delayed cord clamping does not increase an infant’s risk of jaundice, elevated bilirubin, or the need for light therapy [2, 3].
3. A few studies have found that delayed cord clamping does slightly increase the risk of polycythemia in newborns, but others have not. Polycythemia occurs when infants have too many red blood cells in circulation – it is the opposite of anemia. However, infants with delayed cord clamping that were diagnosed with polycythemia had no symptoms and did not require treatment. Polycythemia may be a normal outcome of delayed cord clamping in some babies, and as far as we know, it is not dangerous [2].

One other common objection to delayed cord clamping is that it is unnecessary in a developed country, because iron deficiency and anemia are only problems in developing countries. Quite simply, this is not the case. Approximately 10% of toddlers in the U.S. are thought to be iron-deficient [15]. A study in Sweden, a country with a very low prevalence of anemia, still found benefits of delayed cord clamping [3].

When is delayed cord clamping not appropriate?

If a baby is born in distress and in need of resuscitation to help her breath, delaying cord clamping takes a back seat. Babies in distress need immediate attention, and it may not be practical to care for them while the cord is still attached. To get an idea of how quickly pediatricians need to assess newborn health and take appropriate action, check out their guidelines for newborn resuscitation. As more is learned about the benefits of delayed cord clamping, pediatricians may adjust their protocols to do some procedures at the bedside, allowing the cord to remain attached. In the meantime, it is my opinion that we should let them do their jobs and not ask them to practice outside of their comfort zone when it comes to caring for newborn babies. If the cord is clamped immediately, you can make up for the lost iron by giving your baby an iron supplement or feeding her iron-rich foods when she is ready for solids.

Disclaimer: I am not a medical professional, and this article is not to be considered medical advice. Rather, it contains my summary and interpretation of the research on delayed cord clamping and provides resources that you may use in discussion with medical professionals and in making your own decisions.

Other resources:

The Academic OB/GYN blog, written by Dr. Nicholas Fogelson, has several articles on delayed cord clamping, as well as links to a 50-minute Grand Rounds video. Squintmom also has a nice, well-cited article on the topic. Links to abstracts and, when available, full-text journal articles are included below.

References:

1.  Chaparro, C.M., L.M. Neufeld, G. Tena Alavez, R. Eguia-Liz Cedillo, and K.G. Dewey. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet. 367(9527): p. 1997-2004. 2006. (Abstract)
2.  Hutton, E.K. and E.S. Hassan. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 297(11): p. 1241-52. 2007. (Full text available)
3.  Andersson, O., L. Hellstrom-Westas, D. Andersson, and M. Domellof. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. 343: p. d7157. 2011. (Full text available) plus this summary of the study from Medscape Today.
4.  Hurtado, E.K., A.H. Claussen, and K.G. Scott. Early childhood anemia and mild or moderate mental retardation. Am J Clin Nutr. 69(1): p. 115-9. 1999. (Full text available)
5.  Lozoff, B., E. Jimenez, J. Hagen, E. Mollen, and A.W. Wolf. Poorer behavioral and developmental outcome more than 10 years after treatment for iron deficiency in infancy. Pediatrics. 105(4): p. E51. 2000. (Full text available)
6.  Sherriff, A., A. Emond, J.C. Bell, and J. Golding. Should infants be screened for anaemia? A prospective study investigating the relation between haemoglobin at 8, 12, and 18 months and development at 18 months. Arch Dis Child. 84(6): p. 480-5. 2001. (Full text available)
7.  AAP. Pediatric Nutrition Handbook. 6th ed, ed. R.E. Kleinman. Elk Grove Village, IL: American Academy of Pediatrics. 2009.
8.  Chaparro, C.M. Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutr Rev. 69 Suppl 1: p. S30-6. 2011. (Full text available)
9.  Chaparro, C.M., R. Fornes, L.M. Neufeld, G. Tena Alavez, R. Eguia-Liz Cedillo, and K.G. Dewey. Early umbilical cord clamping contributes to elevated blood lead levels among infants with higher lead exposure. J Pediatr. 151(5): p. 506-12. 2007. (Abstract)
10.  Rabe, H., G. Reynolds, and J. Diaz-Rossello. A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology. 93(2): p. 138-44. 2008. (Abstract)
11.  Mercer, J.S., B.R. Vohr, M.M. McGrath, J.F. Padbury, M. Wallach, and W. Oh. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics. 117(4): p. 1235-42. 2006. (Full text available)
12.  Mercer, J.S., B.R. Vohr, D.A. Erickson-Owens, J.F. Padbury, and W. Oh. Seven-month developmental outcomes of very low birth weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping. J Perinatol. 30(1): p. 11-6. 2010. (Full text available)
13.  Baenziger, O., F. Stolkin, M. Keel, K. von Siebenthal, J.C. Fauchere, S. Das Kundu, V. Dietz, H.U. Bucher, and M. Wolf. The influence of the timing of cord clamping on postnatal cerebral oxygenation in preterm neonates: a randomized, controlled trial. Pediatrics. 119(3): p. 455-9. 2007. (Full text available)
14.  McDonald, S.J. and P. Middleton. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. (2): p. CD004074. 2008. (Abstract)
15.  Baker, R.D. and F.R. Greer. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 126(5): p. 1040-50. 2010. (Full text available)