VLBW infants have complications related to prematurity, particularly ICH, hypotension and anemia/need for transfusion

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1 Problem Is there a problem priority? VLBW infants have complications related to prematurity, particularly ICH, hypotension and anemia/need for transfusion Benefits & harms of the s What is the overall certainty of this evidence? Is there important uncertainty about how much people value the main outcomes? Are the desirable anticipated effects large? included studies Very low Low XX High Important uncertainty or Possibly important uncertainty or XX Probably no important uncertainty of important uncertainty of known undesirable Very low quality evidence from one non-rct; Low to moderate quality of evidence from 4 RCTs. Outcome (relevance) Death-9 Neurodevelopmental outcome-8 Cardiovascular stability-8 Quality of evidence (OR 0.76, ) None available Low (pressor use: OR 0.44, 95% CI ) (increased initial mean BP: 5.43 References

2 Are the undesirable anticipated effects small? Are the desirable effects large relative to undesirable effects? ICH-6 Temperature at admission-6 Hematologic indices- 5 Hyperbilirubinemia-3 mm Hg ( mm Hg)) (any ICH OR 0.37, 95% CI ; severe ICH OR 0.44, ) Low (no difference) (initial hemoglobin increased 2.27 g/dl, ) High (decreased need for transfusion OR 0.2, ) (no difference) (2014) (2013)

3 Resource use Are the resources required small? Is the incremental cost small relative to the net benefits? There are no resources required for this intervention. There is little to no cost to perform umbilical cord milking. Equity What would be the impact on health inequities? Increased Probably increased XX Probably reduced Reduced Cord milking is likely to decrease morbidity for VLBW infants, regardless of other resources available.

4 Acceptability Is the acceptable to key stakeholders? Given the speed and low cost and apparent safety of the intervention there is general acceptance of this intervention. Feasibility Is the feasible to implement? Recommendation Balance of consequences Undesirable consequences clearly outweigh desirable Undesirable consequences probably outweigh desirable The balance between desirable and undesirable consequences is closely balanced or uncertain Desirable consequences probably outweigh undesirable consequences in most Desirable consequences clearly outweigh undesirable XX Type of recommendation We recommend against offering this We suggest not offering this We suggest offering this We recommend offering this

5 XX Recommendation When delayed cord clamping cannot be accomplished, we suggest that cord milking be performed at delivery for VLBW infants as opposed to immediate cord clamping. Justification Low to moderate evidence shows benefit without evidence of harm, particularly in the outcomes of cardiovascular stability, ICH and hematologic indices. Subgroup considerations Implementation considerations All studies included in this review used the same milking procedure: milk 20 cm of umbilical cord toward the umbilicus 3 times while the infant is held at the level of the introitus or below the level of the placenta. Other methodologies are not included in this review. Monitoring and evaluation Research possibilities Delayed cord clamping compared to cord milking; Neurodevelopmental outcomes