What do clinical practice guidelines suggest for deferred cord clamping for preterm and term infants and how evidence-based are they? A systematic review

Objectives To systematically review guidelines on deferred cord clamping (DCC) to identify consensus, variation and gaps in guidance and appraise their quality. Methods We searched 10 medical and guideline databases from January 1, 2010 to July 17, 2019. Recommendations and whether guidelines reported a mortality related benefit of DCC in preterm infants was extracted, as clinicians are most likely to change practice based on beneficial outcomes like decreased mortality. We appraised quality with a modified Appraisal of Guidelines for REsearch & Evaluation II (AGREE-II) and the AGREE-Recommendation EXcellence (AGREE-REX) tools. Results We included 43 clinical practice guidelines, position statements and consensus statements (collectively, “Statements” hereafter) from 34 organizations. While all endorsed DCC, only 33 Statements specified an optimal duration with the most common duration being at least 60 seconds but including: at least 30 seconds, less than 60 seconds, 30–120 seconds, 30–180 seconds, until cord pulsations cease, until the placenta delivers, or beyond 5 minutes. Only 3 out of 37 Statements recommending DCC for preterm populations cited a mortality benefit with DCC. Roughly two thirds of Statements were considered high quality in the AGREE-II clarity of presentation domain. However, more than three fourths of them were considered moderate/low quality recommendations for being clinically credible and implementable using the AGREE-REX tool. Conclusions Worldwide, evidence on the mortality and morbidity related benefits of DCC are reflected in official Statements with differing levels of granularity. While the majority of Statements had clear recommendations, credibility and implementability would benefit from improvement.