Dr. Greene at TEDxBrussels on TICC TOCC – Transitioning Immediate Cord Clamping To Optimal Cord Clamping

At TEDx Brussels, Dr. Greene delivers a passionate talk about the optimal time after a baby's birth for umbilical cord clamping.

The TICC TOCC Campaign

Improving the health of billions by strategically spreading a simple idea.

The Problem

Anemia hinders a quarter of the global population, and is disproportionately concentrated in low-income groups. Iron deficiency is the leading cause of anemia – but with iron deficiency, anemia is just the tip of the iceberg. Even when iron deficiency is not severe enough to cause anemia, it has been linked to lasting damage to the developing brain. Infancy is thus both one of the most important as well as most common life cycle windows for iron deficiency. The World Health Organization estimates that solving iron deficiency in a developing nation would increase productivity by 20 percent.

The Question

Given that human milk is the ideal food for human infants, why is breast milk relatively low in iron, and why are exclusively breastfed infants at risk for iron deficiency? Perhaps, infants are designed to also receive iron from their mothers in another way.

The Physiology

At the moment of birth, about 2/3 of the baby’s blood (the fetal circulation) is in the baby. The remaining third is still in the umbilical cord and placenta. During the third stage of labor, which lasts from the delivery of the baby to the delivery of the placenta, the cord actively pumps iron-rich, oxygen-rich, stem-cell-rich blood into the baby.

The History

Immediately clamping the umbilical cord was popularized in 1913 as one of three pillars of active management of the third stage of labor. While this intervention began in the West, we exported this technique to developing nations around the world. Today, in some low-income countries as many as 95 percent of delivery clinicians surveyed practice immediate cord clamping. Immediate cord clamping results in up to 10x the risk of developing iron deficiency anemia.

The Solution

Alan Greene at TEDxBrussels for Ticc Tocc

Wait until the cord stops actively pumping fetal blood into the baby, unless there is a strong reason otherwise. This has been studied in countries such as Argentina, Australia, Bangladesh, Canada, India, Libya, Mexico, Pakistan, United Kingdom, USA, and Zambia. Optimal cord care (a more accurate term than the more frequent ‘delayed’ cord clamping) has been shown to be both safe and effective at significantly reducing the risk of iron deficiency. Other benefits may include reducing birth asphyxia (inadequate oxygen to the brain) and cerebral palsy. The health benefits from receiving the cord’s pluripotent stem cells may be the most significant impact, but has yet to be understood.

Immediate cord clamping is an active medical intervention with unproven benefit. The WHO no longer recommend immediate cord clamping.

TICC TOCC (Transitioning Immediate Cord Clamping to Optimal Cord Care)

Modeled on the success of the WhiteOut Now campaign to end the introduction of processed white flour rice cereal to babies, TICC TOCC will leverage existing networks to spread the word to mothers and those who assist them in giving birth.

Spreading an idea that makes intuitive sense is cost effective and a simple first step to addressing a major global health problem. Moreover, it can be expected to amplify the benefits of existing nutrition and supplement programs.

Not only have people around the world traditionally waited for the cord to stop pulsing until the 20th century innovation, every other mammal studied instinctively waits for the cord to stop pulsing as well.

More than a quarter million babies will be born today. The clock is ticking.

References and Resources

Andersson, O., Hellstrom-Westas, L., Andersson, D., & Domellof, M. (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. Bmj, 343 (nov15 1), d7157-d7157. doi:10.1136/bmj.d7157

Arroyo, P., Pardío, J., & Loria, A. (2011). Special issue: Iron deficiency and iron deficiency anemia in early infancy; etiology, consequences, prevalence, and prevention. Foreword. Nutrition reviews, 69 Suppl 1(Id), S1-2. doi:10.1111/j.1753-4887.2011.00427.x

Balarajan, Y., Ramakrishnan, U., Ozaltin, E., Shankar, A. H., & Subramanian, S. V. (2011). Anaemia in low-income and middle-income countries. Lancet, 378(9809), 2123-35. Elsevier Ltd. doi:10.1016/S0140-6736(10)62304-5

Beard, J. L. (2008). Why Iron Deficiency Is Important in Infant Development. Experimental Biology, (2), 2534-2536.

Benton, D. (2010). The influence of dietary status on the cognitive performance of children. Molecular nutrition & food research, 54(4), 457-70. doi:10.1002/mnfr.200900158

Berger, J., Wieringa, F. T., Lacroux, A., & Dijkhuizen, M. a. (2011). Strategies to prevent iron deficiency and improve reproductive health. Nutrition reviews, 69 Suppl 1, S78-86. doi:10.1111/j.1753-4887.2011.00436.x

Bimbashi, A., Ndoni, E., Dokle, A., & Duley, L. (2010). Care during the third stage of labour: obstetricians views and practice in an Albanian maternity hospital. BMC pregnancy and childbirth, 10, 4. doi:10.1186/1471-2393-10-4

Cameron, B. M., & Neufeld, L. M. (2011). Estimating the prevalence of iron deficiency in the first two years of life: technical and measurement issues. Nutrition reviews, 69 Suppl 1, S49-56. doi:10.1111/j.1753-4887.2011.00433.x

Ceriani Cernadas, J. M., Carroli, G., Pellegrini, L., Otaño, L., Ferreira, M., Ricci, C., Casas, O., et al. (2006). The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics, 117(4), e779-86. doi:10.1542/peds.2005-1156

Cernadas, C., Carroli, G., Pellegrini, L., Ferreira, M., Ricci, C., Casas, O., Lardizabal, J., et al. (2010). Efecto del clampeo demorado del cordón umbilical en la ferritina sérica a los seis meses de vida . Estudio clínico controlado aleatorizado. Group, 108 (3), 201-208.

Chaparro, C. M. (2011). Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutrition reviews, 69 Suppl 1, S30-6. doi:10.1111/j.1753-4887.2011.00430.x

Chaparro, C. M., Neufeld, L. M., Tena Alavez, G., Eguia-Líz Cedillo, R., & Dewey, K. G. (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet, 367 (9527), 1997-2004. doi:10.1016/S0140-6736(06)68889-2

Cm, B., Gml, G., Devane, D., Mcguire, W., & Weeks, A. (2011). Active versus expectant management for women in the third stage of labour ( Review ). Assessment, (11).

Davis, P. G., & Dawson, J. A. (2012). New concepts in neonatal resuscitation. Current opinion in pediatrics, 24(2), 147-53. doi:10.1097/MOP.0b013e3283504e11

Georgieff, M. K. (2011). Long-term brain and behavioral consequences of early iron deficiency. Nutrition reviews, 69 Suppl 1, S43-8. doi:10.1111/j.1753-4887.2011.00432.x

Gülmezoglu, a M., Lumbiganon, P., Landoulsi, S., Widmer, M., Abdel-Aleem, H., Festin, M., Carroli, G., et al. (2012). Active management of the third stage of labour with and without controlled cord traction: a randomised, controlled, non-inferiority trial. The Lancet, 6736 (12), 1-7. doi:10.1016/S0140-6736(12)60206-2

Hutton, E. K., & Hassan, E. S. (2007). CLINICIAN ‘ S CORNER Late vs Early Clamping of the Umbilical Cord in Full-term Neonates Systematic Review and Meta-analysis of Controlled Trials. Main, 297 (11), 1241-1252.

Jaleel, R., Deeba, F., & Khan, A. (n.d.). Original Article Timing of umbilical cord clamping and neonatal haematological status. American Journal of Obstetrics and Gynecology, 468-470.

Matar, H. E., Almerie, M. Q., Alsabbagh, M., Jawoosh, M., Almerie, Y., Abdulsalam, A., & Duley, L. (2010). Policies for care during the third stage of labour: a survey of maternity units in Syria. BMC pregnancy and childbirth, 10, 32. doi:10.1186/1471-2393-10-32

Mercer, J. S. (2001). Current best evidence: a review of the literature on umbilical cord clamping. Journal of midwifery & women’s health, 46 (6), 402-14. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/11783688

Mercer, J. S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics, 117 (4), 1235-42. doi:10.1542/peds.2005-1706

Mercer, J., & Erickson-Owens, D. (2006). Delayed cord clamping increases infants’ iron stores. Lancet, 367 (9527), 1956-8. doi:10.1016/S0140-6736(06)68858-2

Miller, E. M. (2010). Maternal hemoglobin depletion in a settled northern Kenyan pastoral population. American journal of human biology : the official journal of the Human Biology Council, 22 (6), 768-74. doi:10.1002/ajhb.21078

Oh, W. (2007). Timing of umbilical cord clamping at birth in full-term infants. JAMA : the journal of the American Medical Association, 297 (11), 1257-8. doi:10.1001/jama.297.11.1257

Rabe, H., Reynolds, G., & Diaz-Rossello, J. (2008). A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology, 93 (2), 138-44. doi:10.1159/000108764

Sommers, R., Stonestreet, B. S., Oh, W., Laptook, A., Yanowitz, T. D., Raker, C., & Mercer, J. (2012). Hemodynamic effects of delayed cord clamping in premature infants. Pediatrics, 129 (3), e667-72. doi:10.1542/peds.2011-2550

Ultee, C. a, van der Deure, J., Swart, J., Lasham, C., & van Baar, a L. (2008). Delayed cord clamping in preterm infants delivered at 34 36 weeks’ gestation: a randomised controlled trial. Archives of disease in childhood. Fetal and neonatal edition, 93 (1), F20-3. doi:10.1136/adc.2006.100354

van Rheenen, P. (2011). Delayed cord clamping and improved infant outcomes. Bmj, 343 (nov15 1), d7127-d7127. doi:10.1136/bmj.d7127

Published on: November 18, 2012
About the Author
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Dr. Greene is a practicing physician, author, national and international TEDx speaker, and global health advocate. He is a graduate of Princeton University and University of California San Francisco.
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Recent Comments

Hi Sara,

So sorry you’re going through this. It sounds horrible.

I noticed you left this comment on an unrelated article. I’m not sure what you are referring to “told me something completely differently”.

Here is Dr. Greene’s article on Mono. Perhaps it will help, but either way, what a rough time for you. So sorry!

Best, @MsGreene
Note: I am the co-founder of DrGreene.com, but I am not Dr. Greene and I am not a doctor. Please keep that in mind when reading my comments and replies.

I have mono and I am 38. The doctors that I see they told me something completely differently. One tiredness/fever could last months/years and no diseases before hand, two regardless the age your liver could be affected, three if kids or adults have a weak immune system it can affect those people. Four mothers please try to avoid changing the liter box. I’m sure I am missing more from what they told me in the hospital. Overwhelming at times for parents and adults that have it. I go to infectious disease doctor, and I am pretty sure he knows what he’s talking about. I apologize for being rude. Just trying to give some facts about the illness. Do not mean to be rude, this is coming from someone that has it.

Hi Sara,

So sorry you’re going through this. It sounds horrible.

I noticed you left this comment on an unrelated article. I’m not sure what you are referring to “told me something completely differently”.

Here is Dr. Greene’s article on Mono. Perhaps it will help, but either way, what a rough time for you. So sorry!

Best, @MsGreene
Note: I am the co-founder of DrGreene.com, but I am not Dr. Greene and I am not a doctor. Please keep that in mind when reading my comments and replies.

Thanks Kirsty. There’s a nice bibliography on the topic at the bottom of this article TICC TOCC.

Good luck with your dissertation.

Hi , I am very interested to have come across your campaign- I am currently writing my dissertation for my Midwifery degree in the UK on optimal cord clamping and creating an audit proposal for the local trust. Any further info is greatly received.

Thanks Kirsty. There’s a nice bibliography on the topic at the bottom of this article TICC TOCC.

Good luck with your dissertation.