On crying infants and clamping of cords

All babies cry, and in the first months of life they cry a lot—one to two hours a day on average, according to research quoted by Pamela Douglas and Peter Hill in their clinical review (doi:10.1136/bmj.d7772). But some cry excessively and continue with persistent crying beyond three months, and Douglas and Hill say it’s these babies and their parents who must be taken seriously. Although most will have no long term adverse effects, the strain on the family is associated with higher rates of physical abuse and postnatal depression, as well as behavioural problems in childhood (though cause and effect are hard to establish).

What can you do? History and examination should uncover treatable causes, although gastro-oesophageal reflux disease is no longer thought to be one of them. Feeding problems, functional lactose overload in breastfed babies, cows’ milk allergy in those that are bottle fed, or urinary tract infection should all be sought and managed as promptly as possible. Feeding experts play a crucial part, as do mental health experts for women who may have postnatal depression. Once these factors have been excluded, Douglas and Hill recommend an individually tailored approach centred on the mother and family.

Of course there’s one cry that no parent would want to prevent—the baby’s first, traditionally provoked by a slap on the bottom. Modern childbirth practices tend towards a gentler approach, except for one quite recent and now entrenched intervention: early clamping of the umbilical cord. The BMJ has published before on the growing evidence against this practice (BMJ 2007;335;312) (BMJ 2010;340:c1720) (BMJ 2010;341:c5447). So I was surprised to read in Patrick van Rheenan’s editorial this week that more than 95% of UK obstetricians and midwives still clamp the cord within two minutes of birth (doi:10.1136/bmj.d7127).

Van Rheenan explains how this practice became accepted as the norm. First recommended in the 1970s, it became part of the bundle of interventions that made up the “active management of labour,” along with use of oxytocics and controlled cord traction, all of which were focused on reducing the risk of postpartum haemorrhage. A systematic review of active management in 2000 found that it did indeed reduce maternal blood loss. But a subsequent systematic review in 2007 looked specifically at the timing of cord clamping and found that delayed clamping posed no risk to the mother.

Any concerns about risks to the baby of polycythaemia or other adverse effects from placental transfusion should have been allayed by another 2007 systematic review, which found that delayed cord clamping is beneficial at birth and into infancy. But since some of the evidence came from developing countries with a high prevalence of infant anaemia, questions remained about how this applied in developed countries. This week we publish a randomised controlled trial from Sweden that addresses this concern. Ola Andersson and colleagues found that delaying clamping for three minutes after delivery improved all measures of iron status at 4 months of age with no neonatal adverse effects (doi:10.1136/bmj.d7157). NICE’s current guidance recommends early clamping but is now under review (http://guidance.nice.org.uk/CG/WaveR/109). It’s time for a change of practice.