Cord Milking: Current Guideline and Controversies

Introduction

Umbilical cord milking (UCM) involves stripping blood from the umbilical cord toward the newborn. It is a rapid method to achieve placental transfusion (within seconds) compared to Delayed Cord Clamping (DCC), which requires $\ge 60$ seconds.

Current Guidelines (NRP 9th Edition & ILCOR)

Guidelines are stratified by gestational age and vigor:

1. Term and Late Preterm ($\ge 35$ weeks):

   • Vigorous: DCC is preferred.
   • Non-Vigorous: Intact UCM is a reasonable alternative to early cord clamping. It allows placental transfusion without delaying resuscitation efforts.

2. Preterm ($28$ to $34$ weeks):

   • There is currently insufficient evidence to recommend routine UCM.

3. Extreme Preterm ($<28$ weeks):

   • Contraindicated. UCM should not be performed.
   • Rationale: Associated with an increased risk of severe Intraventricular Hemorrhage (IVH).

Controversies and Pathophysiology regarding UCM

• Hemodynamic Instability (The "Bolus" Effect): Rapid stripping creates a sudden bolus of volume and pressure. In extremely fragile cerebral vasculature ($<28$ weeks), this fluctuation in cerebral blood flow is linked to high-grade IVH.
• Comparison with DCC: While UCM provides volume expansion similar to DCC, it does not provide the sustained oxygenation that occurs during the physiological transition of DCC (where the infant breathes while attached to the placenta).
• Standardization: The technique varies (number of strips, speed, length of cord milked), leading to variable transfusion volumes in studies.

Cord Care in Neonates

Principles

The primary goals of umbilical cord care are the prevention of infection (omphalitis, neonatal tetanus) and the promotion of timely separation. The devitalized cord stump is an excellent medium for bacterial growth ($S.aureus$, $E.coli$, $C.tetani$).

Recommendations by Setting (AAP/WHO)

1. Hospital/High-Resource Settings (Low Neonatal Mortality)

• Standard of Care: Dry Cord Care.
• Method: Keep the cord clean and exposed to air. If soiled, clean with soap and sterile water and dry thoroughly.
• Topical Agents: Application of antiseptics (alcohol, triple dye, povidone-iodine) is not recommended.
  • Rationale: They do not reduce infection rates in clean settings and significantly delay cord separation by killing commensal leukocytes/bacteria required for the drying/separation process.

2. Home Births/Low-Resource Settings (High Neonatal Mortality)

• Standard of Care: Chlorhexidine Application.
• Method: Topical application of 4% Chlorhexidine (solution or gel) to the cord stump.
• Timing: Apply within the first 24 hours of life.
• Evidence: proven to reduce neonatal mortality (by ~12%) and omphalitis risk (by ~50%) in community settings in South Asia/sub-Saharan Africa.

General Hygiene Practices

• Cutting: Use sterile instruments (prevention of Tetanus Neonatorum).
• Diapering: Fold diapers below the umbilicus to prevent urine contamination and allow aeration.
• Cultural Practices: Strictly avoid harmful traditional applications (cow dung, ash, mud, oil), which are potent sources of tetanus spores.

Cord Separation

• Normal timeframe: 5 to 15 days.
• Delayed separation ($>3$ weeks) warrants evaluation for urachal anomalies or Leukocyte Adhesion Deficiency (LAD).