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Study flow diagram.
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Figure 1

Study flow diagram.

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.1 Mortality during neonatal admission.
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Figure 2

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.1 Mortality during neonatal admission.

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.2 Need for intubation in delivery room.
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Figure 3

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.2 Need for intubation in delivery room.

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.3 Inotropic support for hypotension.
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Figure 4

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.3 Inotropic support for hypotension.

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.4 Peak haematocrit in first 24 hours [%].
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Figure 5

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.4 Peak haematocrit in first 24 hours [%].

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.5 Blood transfusion during neonatal admission.
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Figure 6

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.5 Blood transfusion during neonatal admission.

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.6 Phototherapy for hyperbilirubinaemia [days].
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Figure 7

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.6 Phototherapy for hyperbilirubinaemia [days].

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.7 Use of surfactant in the first 48 hours of life.
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Figure 8

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.7 Use of surfactant in the first 48 hours of life.

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.8 Bronchopulmonary dysplasia.
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Figure 9

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.8 Bronchopulmonary dysplasia.

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.9 Intraventricular haemorrhage (of any grade).
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Figure 10

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.9 Intraventricular haemorrhage (of any grade).

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Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.10 Severe intraventricular haemorrhage grade 3 or 4.
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Figure 11

Forest plot of comparison: 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, outcome: 1.10 Severe intraventricular haemorrhage grade 3 or 4.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 1 Mortality during neonatal admission.
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Analysis 1.1

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 1 Mortality during neonatal admission.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 2 Need for intubation in delivery room.
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Analysis 1.2

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 2 Need for intubation in delivery room.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 3 Inotropic support for hypotension.
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Analysis 1.3

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 3 Inotropic support for hypotension.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 4 Peak haematocrit in first 24 hours.
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Analysis 1.4

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 4 Peak haematocrit in first 24 hours.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 5 Blood transfusion during neonatal admission.
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Analysis 1.5

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 5 Blood transfusion during neonatal admission.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 6 Phototherapy for hyperbilirubinaemia.
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Analysis 1.6

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 6 Phototherapy for hyperbilirubinaemia.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 7 Use of surfactant in the first 48 hours of life.
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Analysis 1.7

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 7 Use of surfactant in the first 48 hours of life.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 8 Bronchopulmonary dysplasia.
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Analysis 1.8

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 8 Bronchopulmonary dysplasia.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 9 Intraventricular haemorrhage (of any grade).
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Analysis 1.9

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 9 Intraventricular haemorrhage (of any grade).

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 10 Severe intraventricular haemorrhage grade 3 or 4.
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Analysis 1.10

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 10 Severe intraventricular haemorrhage grade 3 or 4.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 11 Periventricular leukomalacia.
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Analysis 1.11

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 11 Periventricular leukomalacia.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 12 Necrotizing enterocolitis ≥ Bell's stage 2.
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Analysis 1.12

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 12 Necrotizing enterocolitis ≥ Bell's stage 2.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 13 Retinopathy of prematurity requiring treatment.
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Analysis 1.13

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 13 Retinopathy of prematurity requiring treatment.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 14 Sepsis.
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Analysis 1.14

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 14 Sepsis.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 15 Pharmacological treatment for patent ductus arteriosus.
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Analysis 1.15

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 15 Pharmacological treatment for patent ductus arteriosus.

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Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 16 Surgical ligation for patent ductus arteriosus.
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Analysis 1.16

Comparison 1 Respiratory support versus no respiratory support during delayed cord clamping in preterm infants, Outcome 16 Surgical ligation for patent ductus arteriosus.

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Summary of findings for the main comparison. Respiratory support compared with no respiratory support before cord clamping in preterm infants

Respiratory support compared with no respiratory support before cord clamping in preterm infants

Patient or population: preterm infants

Settings: undergoing delayed cord clamping

Intervention: respiratory support

Comparison: no respiratory support

Outcomes

Relative effect
(95% CI)

No of participants

Quality of the evidence
(GRADE)

Comments

Mortality ≤2 years after hospital discharge

RR 1.67 (0.41 to 6.73)

150

⊕⊕⊝⊝
Low1

Secondary study outcome.

Inotropic support for hypotension

RR 1.25 (0.63 to 2.49)

150

⊕⊕⊝⊝
Low1

‐

Peak haematocrit

MD 0.20 (‐1.85 to 2.25)

150

⊕⊕⊕⊝
Moderate3

Primary outcome.

Blood transfusion during neonatal admission

RR 1.03 (0.70 to 1.54)

150

⊕⊕⊕⊝
Moderate

40% with this outcome

Phototherapy for hyperbilirubinaemia

MD 0.20 (‐0.31 to 0.71)

150

⊕⊕⊕⊝
Moderate3

From unpublished data

Intraventricular haemorrhage (of any grade)

RR 1.50 (0.65 to 3.46)

150

⊕⊕⊝⊝
Low1

Secondary outcome.

Severe intraventricular haemorrhage grade 3 or 4

RR 1.33 (0.31 to 5.75)

150

⊕⊝⊝⊝
Very low2

Uncommon secondary outcome.

CI: confidence interval; MD: mean difference; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: we are very uncertain about the estimate.

In the published report, results were presented according to method of delivery. For categorical variables (e.g. mortality), the RR was calculated for the delayed cord clamping with ventilation support (intervention) and delayed cord clamping (control) groups as a whole. For continuous variables (e.g. haematocrit), the authors provided unpublished data that enabled whole group statistics to be determined.

1Downgraded one level due to lack of precision with wide confidence intervals.

2Downgraded two levels due to lack of precision (confidence intervals included both important benefit and harm). The optimal information size for a 30% risk reduction with 80% power and 95% confidence intervals was 3280 infants per group.

3Unpublished data.

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Summary of findings for the main comparison. Respiratory support compared with no respiratory support before cord clamping in preterm infants
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Comparison 1. Respiratory support versus no respiratory support during delayed cord clamping in preterm infants

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Mortality during neonatal admission Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.67 [0.41, 6.73]

2 Need for intubation in delivery room Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.55, 1.21]

3 Inotropic support for hypotension Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [0.63, 2.49]

4 Peak haematocrit in first 24 hours Show forest plot

1

150

Mean Difference (IV, Fixed, 95% CI)

0.20 [‐1.85, 2.25]

5 Blood transfusion during neonatal admission Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.03 [0.70, 1.54]

6 Phototherapy for hyperbilirubinaemia Show forest plot

1

150

Mean Difference (IV, Fixed, 95% CI)

0.20 [‐0.31, 0.71]

7 Use of surfactant in the first 48 hours of life Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.54, 1.28]

8 Bronchopulmonary dysplasia Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.1 [0.50, 2.43]

9 Intraventricular haemorrhage (of any grade) Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.5 [0.65, 3.46]

10 Severe intraventricular haemorrhage grade 3 or 4 Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.33 [0.31, 5.75]

11 Periventricular leukomalacia Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

3.0 [0.12, 72.49]

12 Necrotizing enterocolitis ≥ Bell's stage 2 Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

2.0 [0.19, 21.59]

13 Retinopathy of prematurity requiring treatment Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

2.0 [0.38, 10.59]

14 Sepsis Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.67 [0.41, 6.73]

15 Pharmacological treatment for patent ductus arteriosus Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

0.74 [0.40, 1.36]

16 Surgical ligation for patent ductus arteriosus Show forest plot

1

150

Risk Ratio (M‐H, Fixed, 95% CI)

1.0 [0.26, 3.85]
Figuras y tablas -
Comparison 1. Respiratory support versus no respiratory support during delayed cord clamping in preterm infants
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