EBNEO Commentary: Two-Year Outcome of Umbilical Cord Milking in Nonvigorous Infants (MINVI)

Dyanne Ifeoma Imo-Ivoke, Joanna Preece review the paper "Katheria AC, El Ghormli L, Clark E, Yoder B, Schmölzer GM, Law BHY, et al. Two-Year Outcomes of Umbilical Cord Milking in Nonvigorous Infants: A Secondary Analysis of the MINVI Randomized Clinical Trial. JAMA Netw Open. 2024 Jul 1;7(7):e2416870. doi: 10.1001/jamanetworkopen.2024.16870. PMID: 38949814; PMCID: PMC11217871." for EBNEO.

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ACTA COMMENTARY:

Acta Paediatrica - 2025 - Imo%E2%80%90Ivoke - EBNEO Commentary Two%E2%80%90Year Outcome of Umbilical Cord Milking in Nonvigorous Infants .pdf

"Close to term, about a third of the fetal blood volume is within the placenta at any time.(1) At birth, blood flow in the umbilical vessels continues for some minutes, allowing the transfusion of blood within the placenta bed to the baby. This can transfer 20 – 30% of additional blood volume to the baby at birth and can be achieved by delayed (deferred) cord clamping, DCC or umbilical cord milking. DCC, which is cutting the cord after 60 seconds, is the preferred cord management method in all newborns. UCM offers similar benefits and is recommended for babies over 28 weeks GA (2) (not recommended in <28 weeks due to concerns of intraventricular haemorrhage). DCC and UCM offer benefits such as increased haemoglobin levels, less delivery room cardiovascular support and lower incidence of moderate-severe hypoxic-ischaemic encephalopathy compared to early (immediate) cord clamping.

Most late preterm (GA between 34+0 and 36+6) and term babies are born in good condition and may only require an assisted transition. In some cases, babies may be born in poor condition, or the mother may require prompt lifesaving actions. In these cases, waiting for 60 seconds may not be possible, and the Resuscitation Council of UK supports milking the umbilical cord in babies >28 weeks GA.(3) The initial actions of drying and stimulating the baby, are parts of the newborn life support (NLS) and can be done while the baby is still attached to the cord. There is no clear evidence of the superiority of cord milking from an intact cord compared to the cut cord, but concerns exist about the effects of clamping the cord before the onset of respiration.(4)

While the short-term benefits of DCC and UCM are widely known, there is not enough data on the long-term sequelae. This study is the largest RCT showing the long-term safety of UCM in babies born at > 35 weeks GA and improves our knowledge of the long-term safety of UCM. Also, it has a high follow-up rate, is a multicentre cross-over trial, thereby limiting bias5, and includes babies born in North America and Europe, making it a desirable study.

This study has some limitations. Parental education plays a role in health outcomes and is variable in the population. However, most babies in this secondary analysis were born to parents with good school education, which can be a limitation when applying this to the general population. Waiver of consent for the primary trial but asking informed consent for the secondary analysis could have introduced some bias as most of the babies included in the secondary analysis had parents with higher educational level. Additionally, UCM is a low-cost intervention, and this study would be most beneficial to low-resource countries where more babies may be nonvigorous at birth due to poor antenatal care. With the study conducted in high-income academic centres where most mothers have sufficient prenatal care, applying this study to low-resource countries may be challenging as there may be different haemodynamic adaptations due to undetected chronic hypoxia."