Purpose
Cord management enhancing placental transfusion may improve neonatal transitional circulation and stabilization. Current neonatal resuscitation guidelines generally recommend delayed cord clamping (DCC) for vigorous term and preterm babies who do not require resuscitation. However, for non-vigorous term and preterm (≥gestational age 28 weeks) infants, umbilical cord milking (UCM) might be an effective intervention. The implementation of these practices varies due to resource availability and institutional policies. This study aims to investigate current cord management practice in Asia by analyzing data from the Asian Neonatal Network Collaboration (AsianNeo) survey.
Materials & Methods
We conducted an institutional survey in 2022 across 336 hospitals in 8 Asian countries (Japan, Korea, Taiwan, Thailand, Malaysia, Indonesia, Philippines, and Singapore). The survey assessed NICU resources and clinical practices for preterm infants. Institutions reported the proportion of preterm infants receiving DCC (>30 seconds) and UCM on a four-level scale (0-9%, 10-49%, 50-89%, 90-100%). Hospitals answering these items (n=290) were included. We described the frequency distribution by country and classified frequent practice as application to at least 50% of infants, cross-classifying DCC and UCM into four practice patterns. We also assessed associations with neuroprotective policies using Kendall's tau analysis, and with institutional characteristics using multivariable ordinal logistic regression.
Results
Among the participating hospitals, cord management practices showed a distinct dichotomy. Geographically, hospitals in Japan showed a strong preference for UCM, whereas DCC was more common elsewhere (Fig. 1). However, cross-classification revealed that 135 hospitals (46.6%) practiced neither frequently (Fig. 2), including 57 (19.7%) that reported both as rarely or never performed. A significant negative correlation was observed between the frequency of DCC and UCM (Kendall's tau = -0.16, p=0.002; Fig. 3). In multivariable ordinal regression, higher delivery volume (OR 0.66, 95% CI 0.57-0.75) and adherence to AAP NRP guidelines (OR 0.39, 0.23-0.66) were associated with less frequent UCM, while higher delivery volume was associated with more frequent DCC (OR 1.13, 1.01-1.27; Fig. 4). Prenatal magnesium sulfate use was positively correlated with DCC but negatively with UCM. Neutral head position showed no correlation with DCC but was negatively correlated with UCM (Fig. 3).
Figure 1
Tap a country to see the numbers.
Figure 2
Tap a bar or a country to see the numbers.
A. Overall (n = 290)
B. By country
Figure 3
Tap a cell to see tau, p and n.
Column labels: DCC, UCM, ACS = Antenatal Corticosteroids, MgSO4, Head = Head Position.
Figure 4
Tap a row to see OR, 95% CI and p.
Conclusions
This AsianNeo survey highlights significant variation in cord management across Asia. Larger institutions adopt DCC more often, and those following AAP NRP guidelines are less likely to practice UCM. Notably, the preference for DCC aligns with the use of prenatal magnesium sulfate, suggesting that institutional protocols and neuroprotective strategies are associated with cord management practices. However, nearly half of hospitals frequently performed neither practice, indicating a considerable gap between guideline recommendations and current practice in the region.
About the Presenter
Shau-Ru Ho, MD
Pediatrician & Neonatologist
Attending Physician at National Taiwan University Hsinchu Branch. Specializing in general pediatrics, neonatal and prematurity care.
shauruho@gmail.comCertifications
Education
- 2025-National Taiwan UniversityInternational College, Smart Medicine and Health Informatics Master's Program (in progress)
- 2010-2017Taipei Medical UniversitySchool of Medicine, Doctor of Medicine
Experience
- 2023-Pediatric and Neonatology Attending PhysicianNational Taiwan University Hospital Hsinchu branch
- 2021-2023Neonatology Fellowship TrainingNational Taiwan University Hospital; Observation visit to National Center for Child Health and Development, Japan
- 2018-2021Pediatric Resident TrainingNational Taiwan University Hospital; National Taiwan University Hospital Hsinchu branch
- 2017-2018Postgraduated Resident TrainingChang Gung Memorial Hospital, Taiwan
- 2016Clerkship & Observational visitKeio University Hospital, Japan
- 2015-2017Clerkship & InternshipTaipei Medical University Hospital, Taiwan; Taipei Municipal Wanfang Hospital, Taiwan; Shuang-Ho Hospital, Taiwan
Publications
- The Impact of Phototherapy on the Accuracy of Transcutaneous Bilirubin Measurements in Neonates: Optimal Measurement Site and Timing. Diagnostics (Basel). 2021 Sep; 11(9): 1729
- Silver nitrate burns following umbilical granuloma treatment. Pediatr Neonatol. 2023 Aug 25:S1875-9572(23)00137-7