Posted On: July 19, 2013

Waiting Longer to Cut the Umbilical Cord Helps the Newborn

During a medical procedure, the difference between 30 and 60 seconds often is critical only for emergency situations. But a new study supports the idea that cutting the umbilical cord slightly later is better for the newborn baby and poses no harm to the mother.

Most doctors, as described by the New York Times, generally clamp and sever the umbilical cord within one minute of birth. This the-quicker-the-better approach has been thought to reduce the risk of the mother hemorrhaging. But the new study, published in The Cochrane Database of Systematic Reviews found that waiting at least a minute after birth to clamp the cord allows more blood flow from the placenta, improving the baby’s iron and hemoglobin. There was no additional risk of severe postpartum hemorrhage, blood loss or reduced hemoglobin levels to the mother.

The Cochrane review analyzed data from 15 randomized trials involving 3,911 women and infant pairs.

The Times’ story indicates that the timing of clamping—which occurs in two places along the umbilical cord, the cut to be made between the clamps—has been controversial for a long time.

The Cochrane paper showed higher hemoglobin levels 24 to 48 hour after birth in newborns whose cords were clamped later. These babies also were less likely to be iron-deficient three to six months after birth, compared with term babies who had earlier cord clamping. Birth weight also was significantly higher in the late clamping group, partly because babies received more blood from their mothers.

The World Health Organization (WHO) recommends clamping of the cord from one to three minutes after birth, according to The Times, because it “improves the iron status of the infant.” Sometimes, delayed clamping can cause jaundice in infants because of liver trouble or an excessive loss of red blood cells. The WHO says that where later clamping is practiced, jaundice treatment should be available.

As noted in our backgrounder, jaundice is an uncommon type of birth-related brain injury; the yellow skin signaling jaundice means the baby has too much bilirubin, the yellowish color in bile, in his or her blood.

A committee of the American College of Obstetricians and Gynecologists last year reviewed much of the same evidence as the Cochrane study, but came to a different conclusion from the WHO. It found the material “insufficient to confirm or refute the potential for benefits from delayed umbilical cord clamping in term infants, especially in settings with rich resources.”

The committee said that the risks of jaundice and the relative infrequency of iron deficiency in the U.S. meant that the long-standing practice of immediate clamping should not be changed.

There are circumstances in which early clamping is required—if an infant requires resuscitation or aspirates its own stool. The new analysis found a 2% increase in jaundice among babies who got delayed cord clamping. Those babies should tested three to five days after birth.

Dr. Eileen Hutton, a midwife who teaches obstetrics at McMaster University in Ontario and published a systematic review on cord clamping, said the Cochrane report was “comprehensive and well done,” but she would have preferred a conclusion that was even stronger in favor of delayed cord clamping.

“The implications are huge,” Hutton told The Times. “We are talking about depriving babies of 30 to 40 percent of their blood at birth—and just because we’ve learned a practice that’s bad.”

Dr. Tonse Raju, a neonatologist at the National Institute of Child Health and Human Development agreed: “It’s a good chunk of blood the baby is going to get, if you wait a minute and a half or two minutes,” he told The Times. “They need that extra amount of blood to fill the lungs.”

Healthy babies manage to compensate if they do not get the blood from the cord, Raju said, but researchers do not know how.

Because the Cochrane review had few subjects who had undergone Caesarean delivery, “We don’t have enough information on the effects of delayed cord clamping for someone undergoing a Caesarean delivery in terms of postpartum hemorrhage,” Dr. Cynthia Gyamfi-Bannerman, medical director of the perinatal clinic at Columbia University, told The Times. “Waiting 30 or 60 seconds in a vaginal delivery in a low-risk patient is probably something we could do and wouldn’t have maternal consequences, but in a Caesarean delivery, you’re cutting into a pregnant uterus that has a huge amount of blood.” In some scenarios, “there’s an increased risk of postpartum hemorrhage.”

Also, there was no data on long-term neurological outcomes. But, according to The Times, improved iron stores might help reduce the risk of learning deficiencies and cognitive delay in children. Those problems have been linked to iron-deficiency anemia in school-age children.

If you are expecting, discuss the timing of cord clamping and cutting well before your due date. Your doctor or midwife should give you as complete a picture as possible of the nature of your pregnancy, and whether you and your new family member are candidates for waiting just a bit longer to cut that cord.

For more information, see our backgrounder on prenatal care.

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Posted On: July 12, 2013

More Muscle to Protect Children’s Online Information

The Children’s Online Privacy Protection Act (COPPA) regulates how companies collect, use and disclose personal information a child provides to a website, app or online program. COPPA’s intent is to have a parent or other legal guardian monitor kids’ online information and to run interference between them and commercial or other interests that might exploit them. The Federal Trade Commission (FTC) enforces COPPA.

This month, COPPA was amended “to clarify the scope of the Rule and strengthen its protections for children’s personal information, in light of changes in online technology since the Rule went into effect in April 2000.”

Courtesy of FDA Law Blog, here’s a primer about COPPA and how the FTC is on alert for food, drug and device manufacturers that go astray of its rules. In general, according to Law Blog, food companies that market online or appeal mostly to children are at the greatest risk of FTC scrutiny.

Food companies have encountered COPPA enforcement regarding child-directed web programs promoting snack foods. The FTC’s new round of enforcement, says Law Blog, probably will include food companies whose websites, apps or other online programs collect, use or disclose personal information from children.

Drug and device companies, the blog says, probably are less likely to be hammered because they are less likely to use online programs that appeal to children. “There have been no enforcement actions to our knowledge against a drug or device company,” it says. Still, in developing online programs or services for children’s drugs or devices, such as a kid-oriented app to help parents teach how to use an inhaler, COPPA could apply.

The FTC’s definition of personal information (PI) includes a first and last name, telephone numbers, electronic files containing a child’s image or voice and “persistent identifiers” that can recognize a user over time and across different online programs. According to the FTC, COPPA applies to three types of entities that might encounter this type of PI:

  • operators of commercial websites or online programs (including mobile apps) directed to children younger than 13 and that collect, use or disclose PI provided by children under 13;

  • operators of commercial websites or online programs that are directed to a general audience if the operator has “actual knowledge” that it is collecting, using or disclosing PI provided by children under 13; and

  • companies that have actual knowledge that they are collecting PI via another company’s website or online service directed to children.

If a company is covered by COPPA, the FTC expects it to:

  • post a clear and comprehensive privacy policy describing its practices for PI collected from children;

  • provide a parent or legal guardian with prior “direct notice” of the collection of PI from children;

  • obtain a parent or legal guardian’s prior “verifiable consent” for any collection (subject to some limited exceptions);

  • provide the parent or legal guardian access to their child’s PI to review and/or delete;

  • maintain the confidentiality, security and integrity of PI collected from children;
  • retain PI collected from children for only as long as is necessary to fulfill the purpose for which it was collected; and

  • delete PI collected from children using reasonable measures to protect against unauthorized access or use.

For additional information about the vulnerability of children on the Internet, see our blog “The Perils of Underage Use of Social Media.”

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Posted On: July 5, 2013

Is Disrupted Sleep Worse for Kids or Parents?

Kids’ sleep issues are common complaints among parents, but a new study presented at the annual meeting of the Associated Professional Sleep Societies was unable to determine just who is harmed most by troubled sleep.

The study is preliminary, because it hasn’t been published in a peer-reviewed journal.

The most common reports of troubled sleep reported in the survey were waking up at night and snoring. Among 300 respondents at two Cleveland health clinics, irregular sleep was a common complaint of 1 in 5, and snoring by nearly 14 in 100. About 5 in 100 said that both problems affected the child's health or family life, according to the presenter, Dr. Jyoti Krishna of the Sleep Disorders Center at the Cleveland Clinic.

But Krishna told MedPage Today that "We were unable to tease out whether the child's sleep problem was more of a problem for the parent than for the child."

The American Academy of Pediatrics recommends that clinicians screen for pediatric sleep disorders. Pediatrician Mark Patterson said he tries to perform sleep screenings on a regular basis and cautions that sleep problems should be evaluated and diagnosed by a clinician because some parents would call any sleep disturbance a disorder, especially if it interrupts their own sleep.

"Some of these children's room monitors are so sensitive,” he said at the meeting, “they pick up any grunt or turn the child makes in his or her sleep.”

Pediatric sleep issues commonly are diagnosed by the BEARS questionnaire, a user-friendly screening tool whose name is an acronym of the questions it asks:

B - Bedtime

  • Does my child have trouble going to bed? Or
    trouble falling asleep?

E - Excessive Daytime Sleepiness

  • Is my child difficult to awaken in the

  • Does my child seem sleepy or groggy during
    the day?

  • Does my child often seem tired during the
    day? (In children, tired may mean moody,
    hyperactive, “out-of-it,” as well as sleepy.)

A - Awakening During the Night

  • Does my child awaken during the night and have trouble going back to sleep?

  • Is anything else interrupting my child’s sleep?

R - Regularity and Duration of Sleep

  • How many hours of sleep does my child need at this age?

  • What time does my child go to bed and get up on weekdays? On weekends?

  • Does this allow my child to get enough sleep every day?

S - Snoring

  • Does my child snore? Loudly? Every Night?

  • Does my child stop breathing, gasp, or choke during sleep?

Although disorders identified by this measure are common, you have to ask yourself: If there are no or minimal effects on your child’s happiness or daily functioning, if the problem is solely disrupted sleep, is that a medical issue or an inconvenience?

For additional information and to help you determine if your kid’s sleep issue bears medical attention, see “Sleep Tips for Children and Infants” on the website of the American Academy of Pediatrics.

Also, see our blogs, “Getting Your Baby to Sleep,” and “Early Sleep Problems Signal Later Emotional Troubles.”

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