Effect of routine controlled cord traction as part of the active management of the third stage of labour on postpartum haemorrhage: multicentre randomised controlled trial (TRACOR)

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1541 (Published 28 March 2013)
Cite this as: BMJ 2013;346:f1541

Recent rapid responses

Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.

Displaying 1-2 out of 2 published

Dear Editors,

Iron deficiency in infancy, with or without anaemia, is associated with impaired mental and psychomotor development [4][5][8][10][11][12][13][15][18][19][20][21][22][23][24][25][26][28][30], which persist despite long-term iron therapy [12][17][19][20][21][22][24][25][26][30][31], even up to 19 years of age [15][21][25].

Ferritin and circulating RBC volume measure hematologic effects in infants better than blood Hct. [1][6]

Low ferritin in infancy is associated with altered auditory recognition memory [3], diminished performance in mental and psychomotor tests at 5 years of age [2], alterations in visual attention and concept acquisition [7].

Iron deficiency in infancy has been associated to asthma [9], long term sleep alterations [14][19][26], slower eye-blinking rates [16], impaired upper-extremity motor functions [17], schizophrenia in adulthood [21], impaired social-emotional behaviour [23], long term altered prolactin responses [27], impaired auditory and visual responses [31].

Iron deficiency is very common, even in children from developed Countries. [4][5][8].

Delayed umbilical cord-clamping can reduce iron deficiency anaemia in term infants, even in industrialized Countries, and prevent all these long-term irreversible consequences [29].

The evidence for the usefulness of delayed umbilical cord-clamping is compelling.

NICE should impose delayed umbilical cord-clamping on mainstream obstetric practice.

Ethics Committees must no longer allow clinical studies where immediate umbilical cord-clamping is practiced.

Early cord-clamping can eliminate all benefits from prenatal iron use.

Control children who received early cord-clamping, in this excellent multicentre randomised controlled trial, should be followed up to at least the age of 10, in order to assess auditory and visual functions, prolactin responses, social-emotional behaviour, motor functions, sleep patterns, schizophrenia and asthma incidence, intelligence quotients.

References

[1] Transfusion. 2003 Aug;43(8):1168-72.
Circulating RBC volume, measured with biotinylated RBCs, is superior to the Hct to document the hematologic effects of delayed versus immediate umbilical cord clamping in preterm neonates.
Strauss RG, Mock DM, Johnson K, Mock NI, Cress G, Knosp L, Lobas L, Schmidt RL.
Department of Pathology, University of Iowa Roy J. and Lucille A. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.

http://www.ncbi.nlm.nih.gov/pubmed/12869126

[2] J Pediatr. 2002 Feb;140(2):165-70.
Cord serum ferritin concentrations and mental and psychomotor development of children at five years of age.
Tamura T, Goldenberg RL, Hou J, Johnston KE, Cliver SP, Ramey SL, Nelson KG.
Department of Nutrition Sciences, Civitan International Research Center, University of Alabama at Birmingham 35294-3360, USA.

http://www.ncbi.nlm.nih.gov/pubmed/11865266

[3] Pediatr Res. 2004 Jun;55(6):1034-41.
Iron deficiency alters auditory recognition memory in newborn infants of diabetic mothers.
Siddappa AM, Georgieff MK, Wewerka S, Worwa C, Nelson CA, Deregnier RA.
Division of Neonatology, Department of Pediatrics, University of Minnesota, MN 55455, USA.

http://www.ncbi.nlm.nih.gov/pubmed/15155871

[4] J Paediatr Child Health. 1998 Jun;34(3):250-3.
Iron status and dietary iron intake of 6-24-month-old children in Adelaide.
Oti-Boateng P, Seshadri R, Petrick S, Gibson RA, Simmer K.
Department of Paediatrics and Child Health, Flinders Medical Centre, South Australia, Australia.

http://www.ncbi.nlm.nih.gov/pubmed/9633972

[5] Arch Pediatr Adolesc Med. 1997 Oct;151(10):986-8.
Iron deficiency in 1- to 3-year-old children. A pediatric failure?
Eden AN, Mir MA.
Department of Pediatrics, Wyckoff Heights Medical Center, Brooklyn, NY, USA.

http://www.ncbi.nlm.nih.gov/pubmed/9343007

[6] J Fam Pract. 1996 Mar;42(3):237-40.
Failure of hematocrit to detect iron deficiency in infants.
Kazal LA Jr.
Navajo Nation Health Foundation, Sage Memorial Hospital, Ganado, Arizona 86505, USA.

http://www.ncbi.nlm.nih.gov/pubmed/8636674

[7] Kobe J Med Sci. 1995 Apr;41(1-2):1-17.
The effect of iron deficiency and mental stimulation on Indonesian children's cognitive performance and development.
Soewondo S.
Faculty of Psychology, University of Indonesia, Jakarta, Indonesia.

http://www.ncbi.nlm.nih.gov/pubmed/7490909

[8] Arch Fr Pediatr. 1989 Aug-Sep;46(7):487-90.
Iron deficiency and psychomotor development tests. Longitudinal study between 10 months and 4 years of age.
Dommergues JP, Archambeaud MP, Ducot B, Gerval Y, Hiard C, Rossignol C, Tchernia G.
Departement de Pediatrie, Hopital de Bicetre, Le Kremlin-Bicetre.

http://www.ncbi.nlm.nih.gov/pubmed/2596947

[9] Lung India. 2010 Apr;27(2):51-3.
Anemia as a risk factor for childhood asthma.
Ramakrishnan K, Borade A.
Department of Pediatrics, Amrita School of Medicine, Kochi, India.

http://www.ncbi.nlm.nih.gov/pubmed/20616934

[10] J Child Neurol. 2011 Aug 29. [Epub ahead of print]
Effect of Chronic Iron Deficiency on Neuropsychological Domains in Infants.
Beltrán-Navarro B, Matute E, Vásquez-Garibay E, Zarabozo D.
Instituto de Neurociencias, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico.

http://www.ncbi.nlm.nih.gov/pubmed/21876067

[11] J Nutr. 2011 Apr 1;141(4):740S-746S. Epub 2011 Feb 23.
Early iron deficiency has brain and behavior effects consistent with dopaminergic dysfunction.
Lozoff B.
Center for Human Growth and Development and Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI 48109, USA.

http://www.ncbi.nlm.nih.gov/pubmed/21346104

[12] Indian J Pediatr. 2011 Jan;78(1):58-64. Epub 2010 Oct 15.
Developmental and neurophysiologic deficits in iron deficiency in children.
Madan N, Rusia U, Sikka M, Sharma S, Shankar N.
Department of Pathology, University College of Medical Sciences & Guru Tegh Bahadur Hospital, New Delhi, 110092, India.

http://www.ncbi.nlm.nih.gov/pubmed/20953851

[13] Pediatrics. 2010 Aug;126(2):e427-34. Epub 2010 Jul 26.
Iron deficiency anemia and cognitive function in infancy.
Carter RC, Jacobson JL, Burden MJ, Armony-Sivan R, Dodge NC, Angelilli ML, Lozoff B, Jacobson SW.
Division of Emergency Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA.

http://www.ncbi.nlm.nih.gov/pubmed/20660551

[14] Sleep Med. 2010 Aug;11(7):637-42.
Sleep alterations and iron deficiency anemia in infancy.
Peirano PD, Algarín CR, Chamorro RA, Reyes SC, Durán SA, Garrido MI, Lozoff B.
Sleep and Functional Neurobiology Laboratory, Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago, Chile.

http://www.ncbi.nlm.nih.gov/pubmed/20620103

[15] Nutr Neurosci. 2010 Apr;13(2):54-70.
Iron deficiency in infancy and neurocognitive functioning at 19 years: evidence of long-term deficits in executive function and recognition memory.
Lukowski AF, Koss M, Burden MJ, Jonides J, Nelson CA, Kaciroti N, Jimenez E, Lozoff B.
Department of Psychology and Social Behavior, University of California, Irvine, California 92697, USA.

http://www.ncbi.nlm.nih.gov/pubmed/20406573

[16] J Nutr. 2010 May;140(5):1057-61. Epub 2010 Mar 24.
Eye-blinking rates are slower in infants with iron-deficiency anemia than in nonanemic iron-deficient or iron-sufficientinfants.
Lozoff B, Armony-Sivan R, Kaciroti N, Jing Y, Golub M, Jacobson SW.
Center for Human Growth and Development and; 4Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI 48109, USA.

http://www.ncbi.nlm.nih.gov/pubmed/20335633

[17] Infant Behav Dev. 2009 Dec;32(4):366-75. Epub 2009 Jul 9.
Iron deficiency anemia in infancy and reach and grasp development.
Shafir T, Angulo-Barroso R, Su J, Jacobson SW, Lozoff B.
The Molecular & Behavioral Neuroscience Institute (MBNI), University of Michigan, 205 Zina Pitcher Pl, Rm 1066, Ann Arbor, MI 48109-0720, USA.

http://www.ncbi.nlm.nih.gov/pubmed/19592115

[18] Brain Dev. 2010 Mar;32(3):213-6. Epub 2009 Mar 26.
Effect of iron deficiency anemia on visual evoked potential of growing children.
Monga M, Walia V, Gandhi A, Chandra J, Sharma S.
Department of Physiology, All India Institute of Medical Sciences, New Delhi, India.

http://www.ncbi.nlm.nih.gov/pubmed/19327925

[19] J Pediatr Gastroenterol Nutr. 2009 Mar;48 Suppl 1:S8-15.
Sleep and neurofunctions throughout child development: lasting effects of early iron deficiency.
Peirano PD, Algarín CR, Chamorro R, Reyes S, Garrido MI, Duran S, Lozoff B.
Sleep and Functional Neurobiology Laboratory, Institute of Nutrition and Food Technology (INTA), University of Chile, Santiago, Chile.

http://www.ncbi.nlm.nih.gov/pubmed/19214058

[20] Biochem Soc Trans. 2008 Dec;36(Pt 6):1267-71.
The role of iron in neurodevelopment: fetal iron deficiency and the developing hippocampus.
Georgieff MK.
Department of Pediatrics, Division of Neonatology, University of Minnesota School of Medicine, Minneapolis, MN 55455, USA.

http://www.ncbi.nlm.nih.gov/pubmed/19021538

[21] Arch Gen Psychiatry. 2008 Oct;65(10):1136-44.
Maternal iron deficiency and the risk of schizophrenia in offspring.
Insel BJ, Schaefer CA, McKeague IW, Susser ES, Brown AS.
New York State Psychiatric Institute, 1051 Riverside Dr, Unit 23, New York, NY 10032, USA.

http://www.ncbi.nlm.nih.gov/pubmed/18838630

[22] Neurotox Res. 2008 Aug;14(1):45-56.
Brain iron deficiency and excess; cognitive impairment and neurodegeneration with involvement of striatum and hippocampus.
Youdim MB.
Eve Topf and USA National Parkinson Foundation, Centers of Excellence for Neurodegenerative Diseases Research and Department of Pharmacology, Rappaport Family Research Institute, Technion-Faculty of Medicine, Haifa, Israel.

http://www.ncbi.nlm.nih.gov/pubmed/18790724

[23] J Pediatr. 2008 May;152(5):696-702, 702.31-3. Epub 2007 Nov 19.
Dose-response relationships between iron deficiency with or without anemia and infant social-emotional behavior.
Lozoff B, Clark KM, Jing Y, Armony-Sivan R, Angelilli ML, Jacobson SW.
Center for Human Growth and Development, University of Michigan, Ann Arbor, MI 48109-5406, USA.

http://www.ncbi.nlm.nih.gov/pubmed/18410777

[24] Food Nutr Bull. 2007 Dec;28(4 Suppl):S560-71.
Iron deficiency and child development.
Lozoff B.
Center for Human Growth and Development, Department of Pediatrics and Communicable Diseases, University of Michigan, 300 N. Ingalls, Ann Arbor, MI 48109-5406, USA.

http://www.ncbi.nlm.nih.gov/pubmed/18297894

[25] Arch Pediatr Adolesc Med. 2006 Nov;160(11):1108-13.
Double burden of iron deficiency in infancy and low socioeconomic status: a longitudinal analysis of cognitive test scores to age 19 years.
Lozoff B, Jimenez E, Smith JB.
Center for Human Growth and Development, and Department of Pediatrics and Communicable Diseases, University of Michigan, 300 N. Ingalls, Ann Arbor, MI 48109, USA.

http://www.ncbi.nlm.nih.gov/pubmed/17088512

[26] Food Nutr Bull. 2003 Dec;24(4 Suppl):S104-10.
Effect of iron-deficiency anemia on cognitive skills and neuromaturation in infancy and childhood.
Walter T.
Institute of Nutrition and Food Technology, University of Chile, Santiago.

http://www.ncbi.nlm.nih.gov/pubmed/17016952

[27] Pediatr Res. 2006 Nov;60(5):513-7. Epub 2006 Sep 11.
Iron deficiency in infancy predicts altered serum prolactin response 10 years later.
Felt B, Jimenez E, Smith J, Calatroni A, Kaciroti N, Wheatcroft G, Lozoff B.
Center for Human Growth and Development, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI 48109-0406, USA.

http://www.ncbi.nlm.nih.gov/pubmed/16966351

[28] Asia Pac J Public Health. 2005;17(1):19-21.
Iron deficiency anaemia and child development.
Hokama T, Gushi Ken M, Nosoko N.
Maternal & Child and Global Health, School of Health Science, Faculty of Medicine, University of the Ryukyus, Japan.

http://www.ncbi.nlm.nih.gov/pubmed/16044827

[29] Ann Trop Paediatr. 2004 Mar;24(1):3-16.
Late umbilical cord-clamping as an intervention for reducing iron deficiency anaemia in term infants in developing and industrialised countries: a systematic review.
van Rheenen P, Brabin BJ.
Emma Kinderziekenhuis, Academic Medical Centre, Amsterdam, The Netherlands.

http://www.ncbi.nlm.nih.gov/pubmed/15005961

[30] J Nutr. 2003 May;133(5 Suppl 1):1468S-72S.
Iron deficiency alters brain development and functioning.
Beard J.
Graduate Program in Nutrition, The Pennsylvania State University, University Park, PA 16802, USA.

http://www.ncbi.nlm.nih.gov/pubmed/12730445

[31] Pediatr Res. 2003 Feb;53(2):217-23.
Iron deficiency anemia in infancy: long-lasting effects on auditory and visual system functioning.
Algarín C, Peirano P, Garrido M, Pizarro F, Lozoff B.
Laboratory of Sleep and Functional Neurobiology, INTA, University of Chile, Chile.

http://www.ncbi.nlm.nih.gov/pubmed/12538778

Competing interests: None declared

Stavros Saripanidis, Consultant in Obstetrics and Gynaecology

Private Surgery, Thessaloniki, Greece

Click to like:

Out of the three strategies of active management of third stage of labour to prevent Post Partum Haemorrhage, the first strategy of oxytocin administration after birth is the most widely tested.

The present research has raised controversies for early cord-clamping and cutting. For instance, according to Levy and Blickstein (1):

Early cord clamping (within the first 30 s after birth) is usually
justified for potential prevention of postpartum hemorrhage and for immediate
treatment of the newborn, but at the same time, may increase Rh-sensitization.
Delayed cord clamping is performed after a period of 30 s during which 'placental
transfusion' of approximately 80 mL of blood occurs. This amount seems to protect
the baby from childhood anemia without increasing hypervolemia-related risks. In
preterm infants, delayed clamping appears to reduce the risk of intraventricular
hemorrhage and the need for neonatal transfusion.

Controlled cord traction may also result into inversion of uterus if not done correctly. Authors themselves say that-In countries such as France, where controlled cord traction is not recommended, pulling the cord in the absence of any sign of placenta separation is considered poor practice because of the potential risk of uterine inversion2.

References:

1.Levy T, Blickstein I.Timing of cord clamping revisited.J Perinat Med. 2006;34(4):293-7.

2. BMJ 2013;346:f1541

Competing interests: None declared

Neeru Gupta, Scientist E

Indian Council of Medical Research, Ansari Nagar, New Delhi110029

Click to like:

THIS WEEK'S POLL