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Healthcare – a hidden goldmine that can lift clinical research

Ola Andersson, överläkare i neonatologi vid Skånes universitetssjukhus och forskare vid Lunds universitet.

Ola Andersson is a consultant neonatologist at Skåne University Hosptail, and a researcher at Lund University. His research into the advantages of delayed cord clamping of newborns has had global impact, and changed the guidelines and procedures in obstetrics the world over. Now he is building up his own research team, with doctoral students who carry the research forward.

 

It is early afternoon when the train rolls into the station in Halmstad. Ola Andersson, who is meeting us in a car, has taken a few hours off to tell us more about his research and what drives him. A few hours later, he is catching the train to Lund, where he is a consultant within the child surgery and neonatal care operational area at Skåne University Hospital in Malmö.

– I have lived in Halmstad for several years, and commute to Lund a couple of times per week during my research weeks. It is working better than expected; you can get a lot done on a train, and it is also great to take a break from everyday stresses and obligations.

Ended up doing research by chance

At a café with a view across river Nissan, Ola Andersson tells us that he had in fact not planned to do research; instead, he was aiming to become a good clinician, and to work in teams close to patients. But when he saw the needs and the opportunities to improve the prerequisites for newborns, he chose to combine being a physician with research.

– My former partner was a midwife. She and her colleagues were very doubtful about the practice of clamping the umbilical cord of newborns immediately, in conjunction with delivery. I became interested in the midwives’ discussions, and wanted to learn more. About then, I also read an article in the scientific periodical Paediatrics, where a randomised study showed the advantages of delaying clamping the umbilical cord.

At that time, the normal practice at the majority of Sweden’s delivery units to cut the umbilical at an early stage, that is 10–30 seconds after the baby is born. The prime reasons were that it was thought that this could reduce the mother’s bleeding, and that the blood gas analysis carried out in conjunction with delivery would otherwise be of reduced quality.

– The problem with early cord clamping is that the child loses out on getting the added oxygen- and iron-saturated blood from the placenta; it can amount to around 30 per cent of the child’s blood volume, or around 100 ml for a child weighing around 3.5 kg. This equals around 2 litres of blood in an adult.

Benefits of delayed cord clamping

When Ola Andersson read the available research and wrote a summary in Läkartidningen, he met with objections.

– I felt that people were not listening, and I realised I needed a scientific basis, and decided to start conducting research. I wrote a project plan to conduct an umbilical cord study. My driver was to supply evidence for delaying clamping the cord.

The study became the start of a large research project, resulting in a thesis. In 2013, Ola Andersson was awarded a doctoral degree from Uppsala University, based on a thesis entitled “Effects of Delayed versus Early Cord Clamping on Healthy Term Infants”.

– The work for my thesis covered 400 children, and I wanted to investigate whether the timing for clamping the cord impacts on the child’s health during the first year of life.

In brief, the thesis shows that children whose cord is clamped late (after three minutes) have a clearly better iron store, and less red blood cell or haemoglobin deficiency anaemia at four months’ age, without any demonstrable negative consequences.

– The first study was published in 2011 in the British Journal of Medicine, it showed that haemoglobin deficiency reduced by 90 per cent at four months’ age.

It was previously claimed that delayed cord clamping raised the risk of the child suffering from jaundice, impaired breathing and haemostasis.

– This turned out to be untrue. Instead, we could show that there were several advantages of delaying cord clamping, and that it is a safe method. Infants who can retain their umbilical cord for the first few minutes after birth can absorb the oxygenated and nutritious blood that remains in the placenta, and benefit from the positive effects.

Research that has changed practice

Today, Ola Andersson lives in Halmstad, but works half-time at Skåne University Hospital as a neonatologist and half-time as a researcher at Lund University. His research has had a global impact, and has changed practices and guidelines in both Europe and USA. It is not just the western world and countries with high living standards that can benefit from the research findings, instead, countries with high infant mortality could also prevent thousands of deaths through delaying cord clamping. Anaemia occurs in around 40 per cent of all children under the age of 5 around the world, and affects both mental and physical performance. In around half of these cases, the anaemia is caused by a lack of iron.

– When I had finished my thesis, I chose to do my postdoc at an obstetrics hospital in Kathmandu in Nepal. There, around 70 per cent of all children under the age of 1 suffer from anaemia. I wanted to see if iron deficiency could be prevented, and if more more children could survive through delayed cord clamping.

According to Ola Andersson, delayed cord clamping can be a matter of life and death for children growing up in low income countries with shortages in access to nutritious food. The results of the Nepal studies confirmed previous studies: delaying cord clamping until three minutes after birth reduced iron deficiency by 42 per cent at the age of 8 months. After 12 months, the delayed cord clamping group had 9 per cent fewer cases of anaemia, which is associated with improved social development and well-being.

– Delayed cord clamping is a simple and cost-free method, that results in more iron in the body without any apparent side effects. We are now continuing to collect the results from the studies, and to date 2 500 children and their parents have taken part in our research in Sweden and Nepal.

The SAVE study

As a next step, Ola Andersson wants to study whether the delayed cord clamping method can also be used when children are born lifeless. Today, the umbilical cord is cut straight away, before the child is taken care of with artificial respiration and cardiopulmonary resuscitation. In Nepal, the method was tested in a pilot project, with good results. The research team is now progressing with a larger research project. This autumn, the SAVE study (Sustained cord clamping Awaiting Ventilation) will be starting in Malmö, to evaluate what happens if the cord is clamped straight away compared to delaying cord clamping in cases where the infant needs resuscitation.

– We want to see how the child develops if we delay cutting the umbilical and instead carry out the resuscitation right next to the mother, while the child can still receive support from oxygenation via the placenta. For the infant, the connection to the mother via the placenta means that it is linked up to a well-functioning heart-lung machine.

Healthcare a goldmine

It was everyday healthcare that gave rise to Ola Andersson’s research. There are many good ideas among healthcare personnel that could be captured in a much better way than is now done, he thinks.

– Those who see the patients usually see the problems and the needs, but also the development possibilities and solutions. “I should like to see more people working on the ground being part of various research networks, in order to highlight questions that perhaps wouldn’t be asked otherwise. Hospital clinics and medical centres are a hidden goldmine, with great potential for lifting clinical research, says Ola Andersson.

He is himself in the middle of an intensive phase right now, building up his own research team with doctoral students.

– It is stimulating to inspire others to feel the same commitment to research that I have done, and do. It is fantastic to be able to make an impact and change the practice in a way that leads to fewer children being born with iron and haemoglobin deficiency anaemia.