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Rapid Responses: Rapid Responses published:
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Is this not stretching the law of possibilities
- Deepak Parasuraman, Deepak Parasuraman (15 October 2006)
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Need for wider adoption of Public Cord Blood Banking
- Robert James Carpenter Jr MD JD, N/A (15 October 2006)
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Immediate cord clamping is not safe
- David JR David (16 October 2006)
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Umbilical Cord Blood banking in India
- Nirmala Rai, Prathima Reddy, Consultant Obstetrician & Gynaecologist, Mallya Hospital, Bangalore, India (16 October 2006)
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Clamping the umbilical cord can cause a lapse in respiration at birth
- Eileen Nicole Simon (18 October 2006)
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Timing cord clamping at donor deliveries
- Jose Luis Diaz-Rossello (25 October 2006)
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The End of Cord Blood Banking
- George M. Morley (28 October 2006)
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Deepak Parasuraman, Senior SHO Paediatrics Tameside General Hospital , Ol69RW, Deepak Parasuraman
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Dear Sir Mr Edozien has wonderfully laid out the if's and but's of storing cord blood for use in the future. It is obvious that the procedure raises a number of ethical and moral questions. Firstly does the cord blood have a shelf life even with the processing that enables the storage in the first place? If it does do we know how significant this is or would be to the significance of the outcome of any planned or possible future treatment. Should biological insurance be offered and if so is this ethical as even though it promises a cure for many diseases these are still just a remote possibility? Is this so called insurance, not similar to those offered by the storage of human bodies for enormous sums of money so as to revive them at a later stage if this would become a possibility? Would the advertisement of these commercial companies in the NHS set up not amount to emotional black mail causing parents to worry and act about rarely possible illnesses in their otherwise unborn child. Is pregnancy now a period of worrying and planning about illnesses for the baby not anymore a period of looking forward to the joys of an unborn child? Parents do have a right to information about various things that might affect their unborn child but is this not stretching the limits? Competing interests: None declared |
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Robert James Carpenter Jr MD JD, MD - Maternal-Fetal Medicine Houston TX USA 77030-2339, N/A
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Given the availability of NHS public donor access for cord blood (CB) banking, the UK should not follow the American lead in allowing the establishment of private CB banking. Economics and the low rate of ultimate use for any single family clearly argue for public banking to allow for access to compatible stem cells by the person best matching the cells and the one needing it the most. In the U.S. the absence of widespread public banks or the small number of banks willing to process from a specific hospital make public banking less likely. Recently in Houston, the University of Texas M.D. Anderson Hospital has begun a local public banking program now involving two hospitals and soon to be expanded to two others. Some units have already been matched and distributed to non-local transplantation facilities. The other major issue to be faced by ALL parties is the paucity of "minority" donors who frequently have a mix of ethnic origins which complicate the matching process. In such circumstances, personal banking might make more economic sense if it were not for the low utilization rate. Public banking should be encouraged! In the United States it should be substantially funded by the federal government if they choose to put their money where their "beliefs" are expressed. Somehow, I do not expect the Bush administration to put money where its mouth is! Robert J. Carpenter, Jr. MD, JD 6624 Fannin, #2720 Houston, TX 77030 (O) 713-795-4600 (F) 713-795-4422 "Life is difficult" The Road Less Travelled by Scott Peck Competing interests: None declared |
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David JR David, Consultant Obstetrician and Gynaecologist Memorial Hospital, darlington. DL3 8QZ
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Sir, Leroy C Edozien has provided a very balanced analysis of the issue of commercial cord banking. It is important to understand that the analysis is about commercial banking. There is a need for further emphasis on the importance of delayed cord clamping. In addition to the Cochrane metanalysis (1), further trials have shown substantial benefits in very low birth weight infants (2) and also term infants. Cord blood collection must not be allowed to restrict this practice. The value of delayed cord clamping has been demonstrated whilst the value of commercial cord blood banking is still largely hypothetical at present. Commercial cord blood banking is an insurance, not with a monetary return in the event of a claim but with the prospect of a successful medical treatment. Like all commercial insurance there is a premium to pay and risk of collapse unless the venture it is underwritten by the government or the insurance industry as a whole. David Hutchon, Obstetrician References 1. Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database Syst Rev 2004;(4): CD003248. 2. Mercer JS, Vohr, BR, McGrath MM, Padbury JF, Wallach M, and Oh W Delayed Cord Clamping in Very Preterm Infants Reduces the Incidence of Intraventricular Hemorrhage and Late-Onset Sepsis: A Randomized, Controlled Trial PEDIATRICS Vol. 117 No. 4 April 2006, pp. 1235-1242 Competing interests: None declared |
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Nirmala Rai, Clinical Research Fellow Cardiff and Vale NHS Trust, University Hospital of Wales, Cardiff CF14 4XN, Prathima Reddy, Consultant Obstetrician & Gynaecologist, Mallya Hospital, Bangalore, India
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Cord blood banking is a relatively new phenomenon in India. All except one (run by Reliance Life Sciences, Bombay) are commercial banks. Despite this, for increasing numbers of young rich Indian’s a one off payment of Rs 59,900 ($1,321 USD) 1 is a small price to pay to “insure” the health of their unborn child. With a population of over 1 billion and an annual birth rate of 25 million, India has enough material and ethnic diversity to offer exciting possibilities for the future of cord blood research and therapy. However this benefit would be far reaching only if public cord blood banks are set up and altruistic donation is encouraged. At present India does not have a National Cord Blood Bank, although plans are underway to start one in collaboration with a private company. A public – private partnership is inevitable due to the high costs involved.2 With the possibility of more Indian parents opting for cord blood banking (commercial or public) in the future, we strongly agree with Leroy C E that time spent on collecting cord blood raises several risk management issues, amongst others. India already faces an acute shortage of trained midwifery and nursing staff and this would only add to the existing problems and compromise care. One solution would be to adopt the practice of the NHS Cord Blood Bank, where a separate team collects cord blood.3, 4 The hospital that the second author (PR) works at is one of the centers for commercial cord blood collection. She does not encourage commercial cord blood banking in low risk families. However, for those mothers that wish to bank their baby’s cord blood, (despite being given adequate information about the statements of various medical bodies5, 6,) she insists that trained staff from the cord blood bank be present for the collection. The mother is then counseled that in the event of an emergency, the medical situation would take precedence over the collection. All mothers (and fathers) till date have agreed that the health of their baby and themselves is of paramount importance. 1 Life Cell – India 2 Public-private partnership must for stem cell research – The Hindu, Sept 22, 2005 3 Armitage S, Warwick R, Fehily D, Navarrete C, Contreras M. Cord blood banking in London: the first 1000 collections. Bone Marrow Transplant 1999; 24:139-45 4 Lasky LC, Lane TA, Miller JP, Lindgren B, Patterson HA, Haley NR, et al. In utero or ex utero cord blood collection: which is better? Transfusion 2002; 42:1261-7 5 Royal College of Obstetricians and Gynaecologists. Umbilical cord blood banking. SAC opinion paper 2. London RCOG, 2006. 6 American Academy of Pediatrics Work Group on Cord Blood Banking. Cord blood banking for potential future transplantation: subject review. Pediatrics 1999; 104:116-8 Competing interests: Dr P Reddy works at Mallya Hospital which is a center for commercial cord blood collection |
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Eileen Nicole Simon, Nurse Bridgewater State Hospital, Bridgewater MA 02324, USA
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Blood in the umbilical cord is in transit from the placenta to capillaries surrounding the alveoli [1]. Transition from fetal to neonatal respiration depends upon transfer of placental blood to the lungs, a large part of which occurs with the first breath [2]. The great majority of infants breathe before the cord is clamped, but those who do not may need resuscitation. The research of Jaykka in 1957 provided evidence that ventilation with air does not produce uniform expansion of the alveoli throughout the lungs [1]. The alveoli open only with filling of the capillaries around them, initiating exchange of carbon dioxide for oxygen. Until expansion of the lungs is complete, the infant's heart continues to pump blood through the fetal circulatory route back to the placenta. Shunts in the fetal heart close as the lungs expand. Circulation to the lungs takes over, and circulation to the placenta is no longer needed. Pulsations of the umbilical cord cease, and little if any blood will remain in the cord. Clamping of the umbilical cord immediately at birth leaves the infant vulnerable to a lapse in respiration. The idea that an infant can tolerate a few minutes of oxygen deprivation derives from the ability of the infant heart to recover [3]. An infant's brain is as susceptible to ischemic damage as that of an adult who suffers circulatory arrest [3, 4]. The idea that umbilical cord blood could be banked began in the 1930s [5]. By the 1950s Apgar developed her scoring system for the newborn, when immediate clamping of the cord came into vogue to remove the infant from "the sterile field" for suturing the episiotomy or Cesarean incision [6]. Apgar et al. in 1958 noted that many obstetricians still practiced "slow delivery," waiting for pulsations of the umbilical cord to cease [7]. Until about 20 years ago, most textbooks advised waiting at least a minute or two before clamping the cord. As noted by Dr. Hutchon in his reply to this article, many research papers are now advocating "delayed clamping" of the cord - as though immediate clamping had always been the rule. Ischemic impairment of the brain, cardiac murmurs, and injury to other organs should be investigated as possible consequences of umbilical cord clamping. Clamping the cord for umbilical cord blood banking should be stopped. How many parents are truly "informed" about cord blood banking? How many have any awareness of the current obstetric protocol for immediate clamping of the cord [8, 9]? More at http://www.inferiorcolliculus.org/fnpsabstract1.html. Eileen Nicole Simon,
References: 1. Jäykkä, S (1958) Capillary erection and the structural appearance of fetal and neonatal lungs. Acta Pædiatrica 47:484-500. 2. Redmond A, Isana S, Ingall D (1965) Relation of onset of respiration to placental transfusion. Lancet 1 (6 Feb):283-285. 3. Miller JR, Myers RE (1972) Neuropathology of systemic circulatory arrest in adult monkeys. Neurology 22:888-904. 4. Windle, W. F. (1969). Brain damage by asphyxia at birth. Scientific American, 221 (#4), 76-84. 5. Barton FE, Hearne TM (1939) The use of placental blood for transfusion. JAMA 113:1475-1478. 6. Apgar V (1953) A proposal for a new method of evaluation of the newborn infant. Current Researches in Anesthesia and Analgesia 32:260-267. 7. Apgar V, Holaday DA, James LS, Weisbrot IM (1958) Evaluation of the newborn infant – second report. JAMA 168(15):1985-1989, p 1987. 8. Turrentine JE (2003) Clinical Protocols in Obstetrics and Gynecology, Second Edition. The Parthenon Publishing Group, New York. 9. Cunningham FG, Hauth JC, Leveno KJ, Gilstrap L III, Bloom SL, Wenstrom KD, eds, Williams Obstetrics - Twenty-second edition, New York: McGraw-Hill Medical Publishing Division, 2005. Competing interests: None declared |
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Jose Luis Diaz-Rossello, Perinatal Pediatrics Latin American Centre for Perinatology PAHO/WHO Casilla Correo 627 Montevideo Uruguay
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Edozien’s article (1)opens a necessary debate on the ethical issues of the practice of harvesting neonatal umbilical cord blood (UCB) for stem cell banking. Changes in the timing of cord clamping, not mentioned in his article, should be of concern to parents and health professionals. The Royal College of Obstetricians and Gynaecologists recently stated that there is ”pressure to ensure that a sufficiently large volume is collected, since the likelihood of successful transplantation of cord blood is related to the volume and cell dose collected”. (2; 3) There is strong evidence that earlier cord clamping interrupts the placental transfusion of blood to the baby, with adverse effects and no evidence of benefit. If the procedures of cord blood collection shorten the time to cord clamping, they may reduce the physiological transfer of iron reserves from the mother to the infant. A recent randomized controlled trial in healthy Mexican mothers showed that full term healthy infants have impaired iron reserves at 6 months as a consequence of early clamping (average clamping time 16 seconds vs. 94 seconds).(4) The issue of potential harm to neonates is not a mere abstract ethical issue. Enforcement of the RCOGs recommendation not to change third stage practices should be implemented. Registering the timing of cord clamping in seconds at every UCB donor birth should ensure that the physiological adaptation of donor neonates is not altered by the pressure to increase the volume collected. Parents should also be informed of the importance of iron for their infant’s development and the adverse consequence of an iatrogenic decrease in their baby’s iron reserves at birth.(5) Reference List (1) Edozien LC. NHS maternity units should not encourage commercial banking of umbilical cord blood. BMJ 2006 October 14;333(7572):801-4. (2) Scientific Advisory Committee of the Royal College of Obstetricians and Gynaecologists. Opinion Paper on UMBILICAL CORD BLOOD BANKING . London; 2006 Jun. Report No.: 2. (3) Shlebak AA, Roberts IA, Stevens TA, Syzdlo RM, Goldman JM, Gordon MY. The impact of antenatal and perinatal variables on cord blood haemopoietic stem/progenitor cell yield available for transplantation. Br J Haematol 1998 December;103(4):1167-71. (4) Chaparro CM, Neufeld LM, Tena AG, Eguia-Liz CR, Dewey KG. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet 2006 June 17;367(9527):1997-2004. (5) Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev 2006 May;64(5 Pt 2):S34-S43. Jose Luis Díaz-Rossello MD
Competing interests: None declared |
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George M. Morley, Retired obstetrician/gynecologist Northport, Michigan 49670
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The End of Cord Blood Banking Edozien’s article, Diaz-Rossella’s response and RCOG’s positions on cord clamping illustrate how uninformed the perinatal professions are about placental transfusion (PT). Physiological PT (PPT) occurs during the physiological third stage of labour; physiological closure of cord vessels ends PPT. Gravity and / or uterine contractions effect PPT; 100 to 150 ccs (gms) of blood are transfused, finalizing the blood volume at 300 to 350 ccs (gms). PPT is adjusted, regulated and terminated reflexively by the newborn. PPT results in an optimal, maximum blood volume; it is usually finished in 3 to 5 minutes, but can extend past 20 minutes. [1] Disruption of this physiological event with a cord clamp injures the child; the severity of the injury is proportional to the amount of blood volume amputated. PPT (no cord clamp used) supplies the newborn with enough iron to prevent anemia for one year – when the child should be ingesting iron. The injurious effect of immediate cord clamping (ICC) is illustrated in every article published in the last ten years on encephalopathy and cerebral palsy. Every child in these studies has had ICC to obtain an arterial cord blood pH – a procedure promoted by RCOG and ACOG. ICC at birth ensures maximum depletion of blood volume – HYPOVOLEMIA; the neonatal term is “sick neonates.” “Sick neonates are one of the most heavily transfused groups of patients in modern medicine.” [2] “Sick” babies display all the signs and symptoms of hypovolemic shock – “multi-organ dysfunction”. [3] The radiologist diagnoses ISCHEMIC Encephalopathy – deficient blood flow. The basal ganglia are “infarcted” and the germinal matrix of the preemie has hemorrhagic infarction. The degree of blood loss is accurately assessed by the degree of anemia that eventually develops in these “heavily transfused” babies. Diaz-Rossello’s “adverse consequences” of iatrogenic (cord clamp) anemia are the consequences of brain ischemia / hypovolemia. Red cell transfusion corrects the anemia; it does not reverse ischemic brain damage. The long lasting mental deficiency [4] is the result of mal- perfusion of the child’s brain during a period of active brain growth and development immediately after birth. The degree of mental retardation (IQ in grade school) is proportional to the degree of infant anemia (Hbg gms – birth blood loss.) [5] Diaz-Rossello’s example of clamping at 16 seconds compared to 94 seconds illustrates that the 16’s were more injured than the 94’s. However, if the cord is pulsating 94 seconds after delivery, a cord clamp will remove a major volume of blood with resulting hypovolemia / ischemia / brain damage – and eventual anemia / mental retardation. The integrity of a neonate’s brain is guaranteed by the child’s physiology, not by the misconception that physiology obeys a clock. I agree with Dr. Diaz-Rossello that parents should be informed of the iatrogenic brain injuries caused by the cord clamp. In North America, thousands of informed parents choose home birth with midwives who routinely cut cords AFTER the placenta has delivered. This practice should eventually end the autism epidemic and the birth litigation industry. Blood banking will also end as after PPT, the cord vessels are often empty, and a few ccs of blood may be drawn from placental vessels. G. M. Morley, M.B. Ch.B. FACOG (retired obstetrician / gynecologist) Email obgmmorley@aol.com www.cordclamp.com References: 1. Gunther M. The transfer of blood between the baby and the placenta in the minutes after birth. Lancet 1957;I:1277-1280. 2. N A Murray and I A G Roberts. Neonatal transfusion practice. Arch. Dis. Child. Fetal Neonatal Ed., Mar 2004; 89: F101 – 107 3. Shah, P. Riphogen, J, Beyene, J, Perlaman, M. Multiorgan Dysfunction in Infants with Post-asphyxial Hypoxic Ischaemic Encephalopathy. Arch Dis Child Fetal Neonatal Ed 2004;89;F152-155. doi: 10.1136/adc.2002.023093 http://fn.bmjjournals.com/cgi/eletters/89/2/F152#434 4. Lozoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev 2006 May;64(5 Pt 2):S34-S43. 5. Hurtado E, Claussen AH, Scott KG. Early Childhood Anemia and Mild to Moderate Mental Retardation. Am.J. Clin Nut. 1999:69:115-119 Competing interests: None declared |
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