July is proving to be an exciting month here in the UK. Andy Murray is the new Wimbledon Champion, we’re enjoying lots of wonderful warm weather and we’re anticipating the arrival of the new royal baby. But before the Duke and Duchess of Cambridge have news for us, we have news for them, for these are exciting times too in the world of Cochrane and yesterday saw the publication of new evidence that delaying clamping the cord after birth benefits babies.
In many high-income countries it is usual to clamp the baby’s cord within a minute of birth, which may reduce the amount of blood that passes from mum to baby, affecting the baby’s iron stores. On the other hand, delaying cord clamping may slightly increase the risk of jaundice. A newly updated Cochrane review has assessed the effect of the timing of cord clamping in fifteen trials with almost 4000 women and their babies. The overall quality of the evidence was moderate to high. Clamping the cord later made no difference to the mums’ iron levels or blood loss but it was good for babies, who had higher haemoglobin levels one to two days after birth and were less likely to be short of iron three to six months later. They also had higher birth weights. More babies for whom cord clamping was delayed had jaundice. The reviewers concluded that delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice needing light therapy is available.
One of the review authors, Philippa Middleton (there’s a coincidence!), commented in a press release that in the light of the available evidence “a more liberal approach to delaying clamping of the umbilical cord in healthy babies appears to be warranted” and that “later cord clamping to increase iron stores may be particularly beneficial in settings where severe anaemia is common”. An earlier review found there may also be health benefits of later cord clamping for preterm babies.
Childbirth’s looking like my favourite topic at the moment, with my recent blog on fetal monitoring and one coming up on support during labour and, before we move away from the subject of babies, I’ll flag up an important update to a review on intravenous immunoglobulin (IVIG) for suspected or proven infection in neonates. In earlier versions of the review, the authors highlighted the need for good trials looking at whether IVIG improves outcomes for these babies and one large, high quality trial has now been done and is included in the review. The INIS trial, with almost 3500 infants, found no reduction in death or major disability at two years in babies treated with IVIG and the reviewers judge these results to be ‘unequivocal’, with no further research needed. The review of IVIG for preventing infection in preterm and low birth weight babies has also been updated but with no new studies to add. IVIG offers a very small reduction in infection but it doesn’t cut the length of time spent in hospital or appear to confer any benefit in terms of other clinically important outcomes, including death.
Many of you not giving birth this summer may be looking ahead to holidays or work trips abroad and will be hoping to avoid ‘travellers diarrhoea’. Enterotoxigenic Escherichia coli bacteria (ETEC) is a major cause of this and can be passed on through drinking unclean water or food. It’s similar to the bacteria that causes cholera and a new review has looked at whether vaccines to prevent ETEC infections or to prevent cholera are effective in preventing diarrhoea caused by ETEC. Twenty-four randomized controlled trials with over 52,000 people were included, but they were rather a mixed bag and at present there isn’t enough evidence to support the use of oral cholera vaccine Dukoral® for protecting travellers against ETEC diarrhoea. The reviewers say that further work needs to be done on developing safe and effective vaccines. Staycation anyone?
You can’t make a silk purse out of a sow’s ear and whilst the valiant team of reviewers at the Stroke Group made various improvements to their review on cognitive rehabilitation for spatial neglect following stroke for its latest update, including adding a number of secondary outcomes which had been identified as being important to people after stroke, the evidence remains too poor to say whether or not cognitive rehabilitation is helpful. The authors say that the emerging evidence does justify further trials, but well designed and properly reported ones please.
I’ll be bringing you another round-up in a fortnight to give you some more gems from the Cochrane Library but before that I’ll be looking at a review or two in more depth. Gems and silk purses may well be amongst the gifts soon to be showered on newborn HRH (rather ironic that we await a major royal delivery just as plans are announced to sell off the Royal Mail) but I think a knitted hat with the Cochrane logo on the top would be just the thing. If you haven’t read the story of our logo, you can do so here. It beautifully illustrates how the evidence from good systematic reviews can save lives.
McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub3
Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub3. Cochrane summary http://summaries.cochrane.org/CD003248/early-cord-clamping-versus-delayed-cord-clamping-or-cord-milking-for-preterm-babies
Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066.pub2.
Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub4.
Fetal monitoring in labour: the challenge of balancing the benefits with harms. Evidently Cochrane, July 3 2012.
Ohlsson A, Lacy JB. Intravenous immunoglobulin for suspected or proven infection in neonates. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD001239. DOI: 10.1002/14651858.CD001239.pub4.
Ohlsson A, Lacy JB. Intravenous immunoglobulin for preventing infection in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD000361. DOI: 10.1002/14651858.CD000361.pub3
Ahmed T, Bhuiyan TR, Zaman K, Sinclair D, Qadri F. Vaccines for preventing enterotoxigenicEscherichia coli (ETEC) diarrhoea. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009029. DOI: 10.1002/14651858.CD009029.pub2.
Bowen A, Hazelton C, Pollock A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003586. DOI: 10.1002/14651858.CD003586.pub3.