What is the treatment for the milking phenomenon?

Treatment of Umbilical Cord Milking Phenomenon

For preterm infants <28 weeks' gestational age, umbilical cord milking should be avoided due to potential increased risk of severe intraventricular hemorrhage compared to delayed cord clamping. 1

Recommendations Based on Gestational Age

Preterm Infants <28 Weeks' Gestational Age

• Avoid intact cord milking due to increased risk of severe intraventricular hemorrhage 1
• Defer cord clamping for at least 60 seconds instead, as this is associated with reduced mortality 1
• If immediate resuscitation is required, individualized decisions should be made based on clinical status 1

Preterm Infants 28+0 to 33+6 Weeks' Gestational Age

• Intact cord milking can be considered as a reasonable alternative when delayed cord clamping is not feasible 1
• Cord milking improves hematologic outcomes including higher hemoglobin and hematocrit levels 1
• Reduces need for inotropic support for hypotension (125 fewer infants per 1000 require support) 1
• Decreases blood transfusion requirements (167 fewer infants per 1000 receive transfusions) 1

Preterm Infants 34-36+6 Weeks' Gestational Age

• Defer cord clamping for at least 60 seconds as the primary approach 1
• Cord milking can be considered if delayed cord clamping is not possible 1

Technique for Umbilical Cord Milking

When performing intact cord milking (when appropriate based on gestational age):

• Milk approximately 20 cm of umbilical cord toward the umbilicus 1
• Repeat this process 3 times 1
• Hold the infant at or below the level of the placenta during the procedure 1
• Complete the procedure before cord clamping 1

Safety Considerations

• Intact cord milking in infants <28 weeks has been associated with increased risk of severe intraventricular hemorrhage 1
• One trial was stopped early due to this finding in the <28 weeks gestational age group 1
• No evidence of adverse effects has been found when used in infants ≥28 weeks gestational age 1, 2
• No significant difference in maternal outcomes including severe postpartum hemorrhage has been observed 1

Clinical Decision-Making Algorithm

1. Determine gestational age of infant
2. If <28 weeks: Avoid cord milking and use delayed cord clamping (≥60 seconds) 1
3. If 28+0 to 36+6 weeks:
   • First choice: Defer cord clamping for ≥60 seconds 1
   • If delayed clamping not feasible: Consider intact cord milking 1
4. If immediate resuscitation required: Make individualized decision based on clinical status 1

Common Pitfalls to Avoid

• Using intact cord milking in extremely preterm infants (<28 weeks) due to increased risk of intraventricular hemorrhage 1
• Failing to document exact timing and technique of cord management 1
• Not discussing the plan for cord management between maternity and neonatal teams before delivery 1
• Assuming that cord milking provides the same physiological benefits as delayed cord clamping in all gestational age groups 1

The evidence supporting these recommendations is of moderate to low certainty, with the strongest evidence being against cord milking in extremely preterm infants (<28 weeks) and for delayed cord clamping as the preferred approach when possible 1.