Welcome to read the article on stem cells by Cass McNamara
Cord blood…no such thing
We all know that there is no such thing as ‘cord blood’. What is referred to as cord blood is of course the baby’s circulating blood, via its umbilical cord to the placenta and back, at the time of its birth. Many of the private, and public (NHS) cord blood banking services, will state that this circulating blood from the baby is a waste product that can be harvested without any impact on the health and wellbeing of the baby, but we know that this is not true. The blood still circulating via the cord to the placenta and back to baby in the minutes following birth continues to supply oxygen while the infants body systems adjust to extra uterine life. This same life support system has kept the baby alive in utero throughout pregnancy and it is designed to continue doing this until natural physiology brings it to an end when the baby aerates its lungs and increases its cardiac output through spontaneous breathing. Cardiac output is dependent on blood volume as well as oxygen, decreased cardiac output occurs with decreased blood volume making it more difficult for the baby to oxygenate itself sufficiently. Mother nature evolved the foetal/neonatal circulatory system this way for a reason; the baby needs its blood; it needs the optimal volume of blood, rich in oxygen, stem cells, immune cells and iron cells for the best chance of survival at birth and in infancy. Rather than ‘extra’, blood that the baby is not supposed to have the majority of the blood circulating via the cord and placenta will transfuse back into the baby, this is normal and necessary physiology for the baby and the mother. The unnatural intervention is clamping and cutting of the umbilical cord before this process is complete, depriving the baby of its own blood.
Fortunately, largely due to the persistence and campaigning of people like Amanda Burliegh, David Hutcheon and Hannah Tizard, there is a growing body of evidence that shows the very important advantages for the baby (and the mother) if clamping of the umbilical cord is not done prematurely (before the baby has received back into its body the circulating blood from the placenta through the cord). Many healthy babies will tolerate not getting their optimal blood volume at birth without any obvious problems, others may have noticeable symptoms right away including respiratory distress, poor feeding, anaemia and even in extreme situations hypovolemic shock requiring resuscitation. Still others will have iron deficient anaemia in infancy that can lead to neurological impairment and behavioural problems. Realistically there may be other subtle impacts this intervention has on unique individuals that we are not yet aware of because the exact length of time this normal placental transfusion takes is unique to each individual baby and birth. However on average the 30% of the baby’s blood volume that is circulating through the cord and placenta is transfused back into the baby by 3 minutes following birth. Immediate (physiologically premature) cord clamping prevents this blood from being returned to the baby. In a recently-published study on the timing of umbilical cord clamping/cutting, presented by the Cochrane Summaries, evidence suggests that premature cord clamping can lead up to 50% loss of blood cells for infants in foetal stress, and up to 30% in normal births.
Stem Cells and the Future
The rationale behind collecting blood from the umbilical cord is that it is a very rich source of haematopoietic stem cells (HSCs). Because HSCs can transform into any type of blood cell, they are used in stem cell treatments for various blood cancers and disorders. This includes leukaemia, lymphoma and myeloma. To date stem cell therapy is recognized as a treatment in over 80 diseases and they are also considered to be a cornerstone of developments in regenerative medicine. In the future it is likely that stem cell treatments will become even more common and provide cures for a range of conditions such as heart disease, Alzheimer’s, and Diabetes. For increasing numbers of parents this is a good reason to choose to ‘bank’ their baby’s stem cells harvested from their blood at birth as a reserve should the baby be unfortunate enough to require them as a treatment in the future. It is known that the cells taken from the blood in the umbilical cord of the new-born are the richest source of stem cells followed by cells from bone marrow. Stem cells can also be harvested from dental pulp and adipose tissue, however unlike stem cells taken from the blood of a new-born there are currently no established medical uses for cells extracted from these types of tissue.
Donating and Storing stem cells. A personal choice
There are many parents that have donated ‘cord blood’ to public cord blood banks believing that this blood is just a waste product that may benefit someone else; not for a moment thinking that the person to benefit most from their own blood, is their own baby. While no one would argue about how wonderful and important it is that lives can be saved from a stem cell transplant, would some of these mothers still be willing to let their new-born be a blood donor for a public cord blood bank if they knew that their own child has an increased chance of developing an immediate or long term problem because of this donation?
Clearly the choices one makes are dependent on the circumstances and perspective you have. For example, as a parent myself, if I had been asked to donate my baby’s blood my answer would have been no because I would feel my priority would always be with the wellbeing of my own child and I would not have considered putting them at any risk unnecessarily. However, also as a parent, I would be eternally grateful for the generosity of families that have donated blood from their baby if any of my family needed this treatment and were provided with it from the NHS. As an individual I believe in the benefits of organ donation and in blood donation. Should anyone choose to store or donate their own tissue or use their own harvested cells (donating an organ, egg or sperm donation or storage, ovarian tissue storage, blood, etc..) then this is entirely their own choice. However, stem cells taken from a new-born who has had no say in this is a different matter. Or is it? Parents make choices based on what they believe to be in the best interests of their children every day, from conception until they reach adulthood, so is choosing to store or donate their stem cells any different? Donating for yourself or making the decision on behalf of your child is a complex and emotive subject. However, as a midwife my main concern is that for those parents who do want to bank or donate their baby’s stem cells that they are informed and supported to do so with no or at least minimal risk or harm posed to the baby.
Supporting choice
As health care professionals our obligation is to support parents to make their choices based on the available evidence, even when the choice they make is not one we would necessarily make for ourselves. An informed choice is one people make for themselves (or their children) based on knowledge and within the context of their own lives, views, and needs. Being able to make informed choices is a fundamental part of the parenting journey but it is increasingly difficult for parents to find trusted sources of information. The internet has a large part to play here and for many parents a simple google search of ‘cord blood banking’ will bring up numerous companies, as well as the NHS cord blood bank, promoting the benefits of their services without ever mentioning any negative side effects of allowing this procedure. What we do know is that harvesting a comparatively large volume of the baby’s blood at birth is detrimental to their health; with no guarantee that these stored cells will be of use to them in the future. But are we as HCPs making this information clear to parents and how many of the cord blood banking companies genuinely make parents aware of that? If parents only get to find out about potential benefits, but not risks, then they are being subjected to good old-fashioned marketing and not making an informed choice.
The NHS Public blood bank
The NHS has a large cord blood bank and according to their website 22,000 women have donated ‘cord blood’ to public banks believing that the blood donated is just a waste product that may benefit someone else. Routinely public banks keep samples of cord blood of 100mls and dispose of smaller samples. In effect women are being misled into letting their new-born be used as a blood donor for a public cord blood bank because they are not informed of the very real risk of hypoxia or ischemia that can result by removing this amount of blood from the baby’s circulatory system at birth. The average blood volume of a healthy term baby is around 280mls, removing 100mls is a very significant amount (around 36% of the baby’s total blood volume). For reference adults who have experienced a blood loss of between 30% - 40% are considered to have had a major haemorrhage that will require a blood transfusion and recommendations from the World Health Organisation state that no more that 2.5% of total blood volume should be taken at any one blood draw.
Supporting choice
I don’t believe that many parents would accept the real and significant risks to their baby’s cardiovascular system, immune system, neurological development, or iron stores at birth if they based their decision to donate this amount of blood on accurate, easily available knowledge. However, parents will make a decision based on many factors; but how do we as HCPs ensure that they understand how best to do so with minimum impact on the baby’s immediate wellbeing? The obvious answer includes providing information and discussing the importance of not clamping/cutting the cord for at least 3-5 minutes after birth or until the cord has collapsed and become white. There are some great online resources such as the bloodtobaby.com campaign and #waitforwhite that can help parents and healthcare professionals understand more about stem cell collection via cord blood donation. Or perhaps lobbying the private companies and the public NHS banks into being more honest and accurate on their websites about what they are really asking parents to do including listing the potential risks equally with the potential benefits both now and in the future for their baby. This supports parents’ ability to make a genuinely informed choice if they do choose to bank their baby’s stem cells. It was with that in mind that has made me look more closely at the cord blood banking industry in the UK and what information parents have access to.
What’s out there?
For obvious reasons many healthcare professionals, particularly midwives, have reservations about the cord blood banking industry. A quick google search will bring up numerous websites that provide the service of cord blood banking. Looking through them there is little regard given to the importance of not clamping the umbilical cord prematurely at birth. The emphasis is firmly placed on the possible benefits that might be gained in the future rather than on any risks associated with collecting babies blood at birth, or the certain benefits of the baby receiving all his or her own necessary stem cells right away as nature intended. Some explicitly state that blood in the umbilical cord is extra or additional blood, implying that the baby doesn’t really need it or that it is not their blood but the cords, or even describe it as “waste that is usually thrown away”. I have no issue at all with companies selling a service that some parents may want or with parents making an informed decision to store their baby’s stem cells. But I do care that during their decision-making process parents are given accurate, balanced, and honest information. I would like to challenge these companies, and the NHS public bank, to change their focus to making sure that facilitating true informed choice is their fundamental and abiding standard.
Could there be light at the end of the tunnel?
Like most midwives I am always keen to find out more about anything that reports to be useful to mothers or babies and in February 2017 I attended an exhibition where I came across a company called Cells4Life. My initial thoughts were more on the wary/dubious/profiteering vampires theme! but you can’t judge what you don’t know so I decided to have a good chat about cord blood banking with them to see if they had anything different to offer. What really struck me was just how open and interested they were in discussing the issues health care professionals have with cord blood banking companies. Genuine interest and curiosity rather than defensive, or worse dismissive marketing nonsense. In the past I have been told by cord blood banking representatives that midwives just don’t understand what they are doing (we understand too well) or that they are promoting choice (bearing in mind most promote a very biased version of choice around why parents should use their service, not a truly informed choice). This type of response is disingenuous because of course not all products or services can assure no risk or any negative aspects to their customers, especially in healthcare! So why not just be honest and open with customers. If they want to claim to support informed choice, meaning disclosure of ALL information about benefits and risks, then why not just do that? But I digress….
The team from Cells4life agreed that taking comparatively large volumes of the baby’s blood at birth was not in the baby’s best interest and this was why they were launching their new process, TotiCyte, that enables stem cell banking with very small volumes of blood.
TotiCyte typically requires between 5-15mls from the residual blood left in the umbilical cord or placenta after delayed and optimal cord clamping or severance. This is a truly transformational area of technology that could mean the end of private or public blood banks taking 30-40% of a new-borns blood and instead get enough stem cells from 2-5% of the same blood! Imagine if parents who do choose to store their baby’s stem cells could do so in the knowledge that this small amount is much less likely to harm their baby and that optimal, delayed cord clamping is in no way compromised? Imagine if 20 people could have stem cell treatment from 100mls of blood (gathered from different babies!) as opposed to the one currently treated by the NHS?
TotiCyte has transformed stem cell retention both during the processing procedure and in cryopreservation and it is the highest performing cord blood processing system in the world. According to their website TotiCyte delivers 100% – 400% more stem cells than any other method that was tested at the point of treatment. If parents are choosing to bank stem cells then at least the negative impact on the baby at the time of its birth is greatly decreased.
I feel that this could play an important part in promoting optimal cord clamping with all of the significant benefits for babies this provides while meeting the needs of parents who do choose to bank or donate their babies stem cells. Medicine continues to advance and there is no doubt that the future will in a large part be based around regenerative medicine using human stem cells. The challenge now is to develop methods that will provide these stem cells without harming our new borns and to promote practices that support optimal physiology whenever possible, I do believe that TotiCyte is a really interesting and positive step towards achieving this. Stem cell use is not going to go away, it is going to increase into the future. Let’s support ways to get stem cells without harming babies by promoting optimal cord clamping and ‘wait for white’ whenever possible.
By Cass McNamara, Midwife and the Founder of the MaMa Conference
Cord blood…no such thing
We all know that there is no such thing as ‘cord blood’. What is referred to as cord blood is of course the baby’s circulating blood, via its umbilical cord to the placenta and back, at the time of its birth. Many of the private, and public (NHS) cord blood banking services, will state that this circulating blood from the baby is a waste product that can be harvested without any impact on the health and wellbeing of the baby, but we know that this is not true. The blood still circulating via the cord to the placenta and back to baby in the minutes following birth continues to supply oxygen while the infants body systems adjust to extra uterine life. This same life support system has kept the baby alive in utero throughout pregnancy and it is designed to continue doing this until natural physiology brings it to an end when the baby aerates its lungs and increases its cardiac output through spontaneous breathing. Cardiac output is dependent on blood volume as well as oxygen, decreased cardiac output occurs with decreased blood volume making it more difficult for the baby to oxygenate itself sufficiently. Mother nature evolved the foetal/neonatal circulatory system this way for a reason; the baby needs its blood; it needs the optimal volume of blood, rich in oxygen, stem cells, immune cells and iron cells for the best chance of survival at birth and in infancy. Rather than ‘extra’, blood that the baby is not supposed to have the majority of the blood circulating via the cord and placenta will transfuse back into the baby, this is normal and necessary physiology for the baby and the mother. The unnatural intervention is clamping and cutting of the umbilical cord before this process is complete, depriving the baby of its own blood.
Fortunately, largely due to the persistence and campaigning of people like Amanda Burliegh, David Hutcheon and Hannah Tizard, there is a growing body of evidence that shows the very important advantages for the baby (and the mother) if clamping of the umbilical cord is not done prematurely (before the baby has received back into its body the circulating blood from the placenta through the cord). Many healthy babies will tolerate not getting their optimal blood volume at birth without any obvious problems, others may have noticeable symptoms right away including respiratory distress, poor feeding, anaemia and even in extreme situations hypovolemic shock requiring resuscitation. Still others will have iron deficient anaemia in infancy that can lead to neurological impairment and behavioural problems. Realistically there may be other subtle impacts this intervention has on unique individuals that we are not yet aware of because the exact length of time this normal placental transfusion takes is unique to each individual baby and birth. However on average the 30% of the baby’s blood volume that is circulating through the cord and placenta is transfused back into the baby by 3 minutes following birth. Immediate (physiologically premature) cord clamping prevents this blood from being returned to the baby. In a recently-published study on the timing of umbilical cord clamping/cutting, presented by the Cochrane Summaries, evidence suggests that premature cord clamping can lead up to 50% loss of blood cells for infants in foetal stress, and up to 30% in normal births.
Stem Cells and the Future
The rationale behind collecting blood from the umbilical cord is that it is a very rich source of haematopoietic stem cells (HSCs). Because HSCs can transform into any type of blood cell, they are used in stem cell treatments for various blood cancers and disorders. This includes leukaemia, lymphoma and myeloma. To date stem cell therapy is recognized as a treatment in over 80 diseases and they are also considered to be a cornerstone of developments in regenerative medicine. In the future it is likely that stem cell treatments will become even more common and provide cures for a range of conditions such as heart disease, Alzheimer’s, and Diabetes. For increasing numbers of parents this is a good reason to choose to ‘bank’ their baby’s stem cells harvested from their blood at birth as a reserve should the baby be unfortunate enough to require them as a treatment in the future. It is known that the cells taken from the blood in the umbilical cord of the new-born are the richest source of stem cells followed by cells from bone marrow. Stem cells can also be harvested from dental pulp and adipose tissue, however unlike stem cells taken from the blood of a new-born there are currently no established medical uses for cells extracted from these types of tissue.
Donating and Storing stem cells. A personal choice
There are many parents that have donated ‘cord blood’ to public cord blood banks believing that this blood is just a waste product that may benefit someone else; not for a moment thinking that the person to benefit most from their own blood, is their own baby. While no one would argue about how wonderful and important it is that lives can be saved from a stem cell transplant, would some of these mothers still be willing to let their new-born be a blood donor for a public cord blood bank if they knew that their own child has an increased chance of developing an immediate or long term problem because of this donation?
Clearly the choices one makes are dependent on the circumstances and perspective you have. For example, as a parent myself, if I had been asked to donate my baby’s blood my answer would have been no because I would feel my priority would always be with the wellbeing of my own child and I would not have considered putting them at any risk unnecessarily. However, also as a parent, I would be eternally grateful for the generosity of families that have donated blood from their baby if any of my family needed this treatment and were provided with it from the NHS. As an individual I believe in the benefits of organ donation and in blood donation. Should anyone choose to store or donate their own tissue or use their own harvested cells (donating an organ, egg or sperm donation or storage, ovarian tissue storage, blood, etc..) then this is entirely their own choice. However, stem cells taken from a new-born who has had no say in this is a different matter. Or is it? Parents make choices based on what they believe to be in the best interests of their children every day, from conception until they reach adulthood, so is choosing to store or donate their stem cells any different? Donating for yourself or making the decision on behalf of your child is a complex and emotive subject. However, as a midwife my main concern is that for those parents who do want to bank or donate their baby’s stem cells that they are informed and supported to do so with no or at least minimal risk or harm posed to the baby.
Supporting choice
As health care professionals our obligation is to support parents to make their choices based on the available evidence, even when the choice they make is not one we would necessarily make for ourselves. An informed choice is one people make for themselves (or their children) based on knowledge and within the context of their own lives, views, and needs. Being able to make informed choices is a fundamental part of the parenting journey but it is increasingly difficult for parents to find trusted sources of information. The internet has a large part to play here and for many parents a simple google search of ‘cord blood banking’ will bring up numerous companies, as well as the NHS cord blood bank, promoting the benefits of their services without ever mentioning any negative side effects of allowing this procedure. What we do know is that harvesting a comparatively large volume of the baby’s blood at birth is detrimental to their health; with no guarantee that these stored cells will be of use to them in the future. But are we as HCPs making this information clear to parents and how many of the cord blood banking companies genuinely make parents aware of that? If parents only get to find out about potential benefits, but not risks, then they are being subjected to good old-fashioned marketing and not making an informed choice.
The NHS Public blood bank
The NHS has a large cord blood bank and according to their website 22,000 women have donated ‘cord blood’ to public banks believing that the blood donated is just a waste product that may benefit someone else. Routinely public banks keep samples of cord blood of 100mls and dispose of smaller samples. In effect women are being misled into letting their new-born be used as a blood donor for a public cord blood bank because they are not informed of the very real risk of hypoxia or ischemia that can result by removing this amount of blood from the baby’s circulatory system at birth. The average blood volume of a healthy term baby is around 280mls, removing 100mls is a very significant amount (around 36% of the baby’s total blood volume). For reference adults who have experienced a blood loss of between 30% - 40% are considered to have had a major haemorrhage that will require a blood transfusion and recommendations from the World Health Organisation state that no more that 2.5% of total blood volume should be taken at any one blood draw.
Supporting choice
I don’t believe that many parents would accept the real and significant risks to their baby’s cardiovascular system, immune system, neurological development, or iron stores at birth if they based their decision to donate this amount of blood on accurate, easily available knowledge. However, parents will make a decision based on many factors; but how do we as HCPs ensure that they understand how best to do so with minimum impact on the baby’s immediate wellbeing? The obvious answer includes providing information and discussing the importance of not clamping/cutting the cord for at least 3-5 minutes after birth or until the cord has collapsed and become white. There are some great online resources such as the bloodtobaby.com campaign and #waitforwhite that can help parents and healthcare professionals understand more about stem cell collection via cord blood donation. Or perhaps lobbying the private companies and the public NHS banks into being more honest and accurate on their websites about what they are really asking parents to do including listing the potential risks equally with the potential benefits both now and in the future for their baby. This supports parents’ ability to make a genuinely informed choice if they do choose to bank their baby’s stem cells. It was with that in mind that has made me look more closely at the cord blood banking industry in the UK and what information parents have access to.
What’s out there?
For obvious reasons many healthcare professionals, particularly midwives, have reservations about the cord blood banking industry. A quick google search will bring up numerous websites that provide the service of cord blood banking. Looking through them there is little regard given to the importance of not clamping the umbilical cord prematurely at birth. The emphasis is firmly placed on the possible benefits that might be gained in the future rather than on any risks associated with collecting babies blood at birth, or the certain benefits of the baby receiving all his or her own necessary stem cells right away as nature intended. Some explicitly state that blood in the umbilical cord is extra or additional blood, implying that the baby doesn’t really need it or that it is not their blood but the cords, or even describe it as “waste that is usually thrown away”. I have no issue at all with companies selling a service that some parents may want or with parents making an informed decision to store their baby’s stem cells. But I do care that during their decision-making process parents are given accurate, balanced, and honest information. I would like to challenge these companies, and the NHS public bank, to change their focus to making sure that facilitating true informed choice is their fundamental and abiding standard.
Could there be light at the end of the tunnel?
Like most midwives I am always keen to find out more about anything that reports to be useful to mothers or babies and in February 2017 I attended an exhibition where I came across a company called Cells4Life. My initial thoughts were more on the wary/dubious/profiteering vampires theme! but you can’t judge what you don’t know so I decided to have a good chat about cord blood banking with them to see if they had anything different to offer. What really struck me was just how open and interested they were in discussing the issues health care professionals have with cord blood banking companies. Genuine interest and curiosity rather than defensive, or worse dismissive marketing nonsense. In the past I have been told by cord blood banking representatives that midwives just don’t understand what they are doing (we understand too well) or that they are promoting choice (bearing in mind most promote a very biased version of choice around why parents should use their service, not a truly informed choice). This type of response is disingenuous because of course not all products or services can assure no risk or any negative aspects to their customers, especially in healthcare! So why not just be honest and open with customers. If they want to claim to support informed choice, meaning disclosure of ALL information about benefits and risks, then why not just do that? But I digress….
The team from Cells4life agreed that taking comparatively large volumes of the baby’s blood at birth was not in the baby’s best interest and this was why they were launching their new process, TotiCyte, that enables stem cell banking with very small volumes of blood.
TotiCyte typically requires between 5-15mls from the residual blood left in the umbilical cord or placenta after delayed and optimal cord clamping or severance. This is a truly transformational area of technology that could mean the end of private or public blood banks taking 30-40% of a new-borns blood and instead get enough stem cells from 2-5% of the same blood! Imagine if parents who do choose to store their baby’s stem cells could do so in the knowledge that this small amount is much less likely to harm their baby and that optimal, delayed cord clamping is in no way compromised? Imagine if 20 people could have stem cell treatment from 100mls of blood (gathered from different babies!) as opposed to the one currently treated by the NHS?
TotiCyte has transformed stem cell retention both during the processing procedure and in cryopreservation and it is the highest performing cord blood processing system in the world. According to their website TotiCyte delivers 100% – 400% more stem cells than any other method that was tested at the point of treatment. If parents are choosing to bank stem cells then at least the negative impact on the baby at the time of its birth is greatly decreased.
I feel that this could play an important part in promoting optimal cord clamping with all of the significant benefits for babies this provides while meeting the needs of parents who do choose to bank or donate their babies stem cells. Medicine continues to advance and there is no doubt that the future will in a large part be based around regenerative medicine using human stem cells. The challenge now is to develop methods that will provide these stem cells without harming our new borns and to promote practices that support optimal physiology whenever possible, I do believe that TotiCyte is a really interesting and positive step towards achieving this. Stem cell use is not going to go away, it is going to increase into the future. Let’s support ways to get stem cells without harming babies by promoting optimal cord clamping and ‘wait for white’ whenever possible.
By Cass McNamara, Midwife and the Founder of the MaMa Conference