Very often, in my Lamaze classes and in my antenatal checkups I am asked by parents-to-be questions about the pros and cons of Cord Blood Banking. There will always be two sides to this issue and we respect parents’ informed choices in this regard, which are based on correct information and evidence based practice. Therefore, I thought I would write some more on what are the current lines of thought regarding not only cord blood banking, but also about delayed cord clamping which is inextricably linked to this topic.

Both the American Academy of Pediatrics (AAP) and the Royal College of Obstetricians and Gynecologists (RCOG) feel that the families may be vulnerable to emotional marketing at the time of birth of their child. According to RCOG, advertising leaflets regarding cord blood banking are distributed to antenatal clinics, obstetric practices, in women’s magazines and on the World Wide Web. Wordings such as “stem cells can be collected only at the time of birth”; “unimaginable possibilities”; “like freezing a spare immune system”; “saving the key components for future medical use”; and “saving something that may conceivably save his or her life someday”, may not be completely above board from the perspective of “truth in advertising”.

So, lets’ demystify this cord blood debate a bit. What exactly is cord blood? Cord blood contains haemopoietic stem cells (HSC). These cells have greater proliferative and colony forming capacity than those obtained from bone marrow, and are more responsive to some growth factors. Also, because they are “naïve”, they seem to produce fewer complications than those associated with some aspects of other HSC transplantation. Currently, they are most frequently used in the treatment of leukemia. In the future, cord blood might be a useful source of stem cells, rather than hemopoietic precursors. Reports suggest that not only mesenchymal and neural precursor cells present, but that some cord blood cells, in extremely low frequency may have the capacity to develop into many different lineages including cartilage, fat cells, hepatic and cardiac cells. RCOG in its 2nd Edition of its Scientific Advisory Committee Opinion Report on Cord Blood Banking, says unequivocally that research is still at an early stage, and “despite the amount of interest in the field, the therapeutic role for such cells remains speculative”.

While neurologists, endocrinologists, and others are actively evaluating autologous cord blood to treat conditions such as brain injury, cerebral palsy, type 1 diabetes, and many other diseases, it is still a nascent field. The AAP, in its subject review and policy statement “Cord Blood Banking and its Potential for Future Transplants” says that no accurate estimates exist of the likelihood of children who will need their own stored cells. The range of estimates varies from 1:20,000 to 1:200,000. They say that based on the weight of the current evidence, it is difficult to recommend that parents store their child’s blood for future use. While both the AAP and the RCOG recommend more research and banking with strictly regulated public cord blood banks, they are both critical of private storage of cord blood as “biological insurance”. In India, the cord blood banking market is neither as strictly regulated, nor are there avenues for mass public banking at this time.

What then are the known pros of cord blood banking? Private cord blood banking can be a good idea for families that have a child suffering from leukemia, lymphoma, other cancers, sickle cell disease and thallasemia. In this case, they can donate and store their baby’s cord blood for use in the sibling suffering from the disease. Such programs are available for free in the US such as the Children’s’ Hospital Oakland Research Institute Sibling Donor Cord Blood Program. Author and researcher Dr. Steven Joffe, who is a transplant physician at Boston’s Dana Farber Cancer Institute says that “in the absence of a family member known to be a candidate for stem cell transplant, the chances that privately stored cord blood will be used are quite small.” Similar opinions come through clearly in Dr. Sarah Buckley’s well-researched book “Gentle Birth, Gentle Mothering”. She states:

• The likelihood of low-risk children needing their own stored cells has been estimated at 1:20,000
• Cord blood donations are likely to be ineffective for the treatment of adults, because the numbers of stored stem cells are too small.
• Cord blood may contain pre-leukemic changes and may risk relapse if used in the affected individual.
• All other uses are speculative at this point.

So, now to the other side of the debate – What are the benefits of delayed cord clamping, and why is this inextricably linked to this debate of cord blood banking? Cord blood banking companies require 60-120 ml of cord blood, which can only be made available only if the cord is clamped and cut within the first minute or two. In practice, we see that the cord continues to pulse for much longer – sometimes 5, sometimes 10 minutes, and the longest I have seen the cord pulse is an hour after the baby’s birth. Did this particular baby need the extra transfer of blood and nutrients? We will never know.

Here is what is known about the benefits of delayed cord clamping:

1) Studies done at UC Davis, UC Granada and others, show that delayed cord clamping results in:
• Increased levels of iron ( 2 minute delay in cord clamping = 27-47 mg iron store transfer to the baby, which is equivalent to 1-2 months of an infant’s iron requirements)
• Low risk of anemia
• Less transfusions
• Less incidence of intraventricular hemorrhage
• Better protection from late onset sepsis
• Baby can receive the complete retinue of clotting factors
• Significant benefits demonstrated in premature babies, low birth weight babies and babies born to mothers with iron deficiency.

2) In a recent study published in the Journal Pediatrics in 2010, Dr. Dong-Hyuk Park, Dr. Paul Sandberg, and Dr. Stephen Klasko, argue that delaying clamping of the umbilical cord for a slightly longer period of time allows for more umbilical cord blood volume to transfer to the infant, and with that critical period extended, many good physiological “gifts” are transferred through “nature’s first stem cell transplant” occurring at birth. Dr. Paul Sandberg also concludes that many common disorders of the newborn relating to immaturity of organ systems may receive benefits from delayed cord clamping. These may include respiratory distress, anemia, sepsis, and intraventricular hemorrhage. Midwives have always known this – it is like a backup security system until the infant’s organ system starts functioning fully well! Dr. Stephen Klasko, Sr. Vice President of University of San Fransisco (USF) Health Services, and Dean of the USF College of Medicine concludes the article by saying that there remains no consensus among scientists and clinicians on cord clamping and proper cord blood collection. He says “ The most important thing is to avoid losing transfer of valuable stem cells to the infant during and just after delivery”.

3) The World Health Organization (WHO) in its publication “Care in normal birth: A Practical Guide” states “…. late clamping (or no clamping at all) is the physiological way of treating the cord, and early clamping is an intervention that needs justification”.

4) Early cord clamping is s recent medical trend which has only been in practice since the 1940s, and that too only in a few countries. Julie Cook, mother and author of the book, “Unvaccinated, home schooled and TV-free” cites Erasmus Darwin and says that early cord clamping is not natural, normal or based on any evolutionary need. Umbilical cord blood is a baby’s life blood until birth. It contains magnificent cells such as red blood cells, stem cells and cancer-fighting T-cells. It comes from the placenta, since the umbilical cord is attached to it. The placenta really belongs to the baby; it is one of the baby’s organs while the baby is growing inside the mother. When the baby is born, and the umbilical cord is cut quickly, it is akin to amputating a live organ from a person. It is the same as submitting the newborn to severe hemorrhaging. If the umbilical cord is not cut, the placenta will expire naturally in an hour or so, after the blood has fully drained into the baby.

Birthing methods have changed over the last century. In the early years mothers gave birth in “squatting” or other gravity-assisted positions which probably speeded up the stem cell transfer through cord blood. At Healthy Mother, we follow this as part of our care practice. However, in current hospitals, mothers are invariably made to lie down on their backs to give birth, and early cord clamping is the norm. While sometimes the cord is clamped early to facilitate medical resuscitation, in others, it is done quickly to facilitate cord blood banking. As the RCOG Bulletin points out, “ …. the collection procedures must be undertaken either during the third stage (while the placenta remains in utero) or shortly thereafter, a time when there is risk of postpartum hemorrhage and when mother and baby require maximum one-to-one care. This can prove to be a distraction to the hospital staff…. There is also pressure to ensure that a sufficiently large volume of cord blood is collected, since the likelihood of successful transplantation of cord blood HSC is related to the volume and cell dose collected.” In our practice at Healthy Mother, we see that staff from cord blood companies are not necessarily sufficiently trained to carry out the collection, and that they sometimes do not carry the requisite supplies. This lands up being an additional distraction in the immediate post birth minutes. Having said that, we are also about giving choice and should our customers choose to bank their baby’s blood after going through all the information, we sit down with the cord blood company representative to facilitate the process while preserving gentle birth of the baby.

Dr. Vijaya Krishnan, DPT, MS, LCCE, Apprentice Midwife
Director, Healthy Mother Natural Birthing Center, The Sanctum

References:

1. http://www.rcog.org.uk/files/rcog-corp/uploaded-files/SAC2UmbilicalCordBanking2006.pdf
2. http://aap.org/advocacy/releases/jan07cordbloodfaq.htm
3. http://washingtonpost.com/wp-dyn/content/article/2009/04/13/AR2009041301860.html
4. Gentle Birth, Gentle Mothering, Dr. Sarah Buckley (2005)
5. http://www.news.ucdavis.edu/search/news_detail.lasso?id=7729
6. http://www.indianpediatrics.net/feb2002/feb-130-135.htm
7. http://www.sciencedaily.com/releases/2010/05/100524111728.htm
8. World Health Organization (1996). Care in Normal Birth: A Practical Guide

 

To Clamp or not to Clamp... "When?" is the Question