Infant anemia (William Windle)
Windle (1940) presented a paper at a "Round Table
Discussion on Anemias of Infancy" as part of the tenth
annual American Academy of Pediatrics [1]. In his
talk Windle began by summarizing research on
development of red blood cells, which begins in the
wall of the embryonic yolk sac. Blood vessels begin
to form during the fifth week, and after sufficient
development of the liver, blood cell formation
becomes one of the fetal liver's primary functions.
With development of the fetal spleen and bone
marrow, these take over as the major sites for blood
cell formation.
How essential oxygen delivery is, that red cells, blood
vessels, and circulation powered by the fetal heart
(the earliest functioning organ) follow such an elegant
maturational plan! This knowledge remains current [2-
4]. Why is it not incorporated into the education of
most obstetricians, in whom we place our trust for
safe delivery of our children into this world?
Windle continued with a detailed description of how
oxygen is transferred across the placenta, and how
fetal hemoglobin is designed to readily take up
oxygen at low partial pressures on the maternal side
of the placenta, again emphasizing the importance of
maintaining full aerobic activity. Placental blood is fully
part of the fetal circulatory system, and found by
many investigators to contain one-fifth to one-fourth
of the total fetal blood at birth. Windle pointed out
that this placental blood does not pass into the infant
at birth until uterine contractions have a chance to
compress the placenta, and he stated:
"... The rather common practice of promptly
clamping the cord at birth should be
condemned. Of course, this will make it
imposible to salvage placental blood for 'blood
banks.' However, the collection of usable
quantities of placental blood robs the newborn
infant of blood which belongs to him and which
he retrieves under natural conditions...
Immediate clamping of the cord is comparable to
submitting the infant to a rather severe
hemorrhage." [1, p546]
Windle with DeMarsh, Wilson, and Alt (1941, 1942,
1948), and like many before and since, did research
with human infants, assigning them to groups for
immediate or delayed clamping of the cord [5-8]. I am
not sure I understand why any more "randomized
controlled trials" need to be done. Clamping of the
cord had been adopted by some obstetricians during
the 1930s, as described above, for the purpose of
banking placental blood. Thus immediate effects of
cord clamping appeared to do no harm, but this
illustrates the hardiness of most newborn infants. It
seems clear that newborn infants have the capacity to
adapt to adverse situations, but this should not be
confused with what provides the healthiest start in
life.
In any case, Windle and his colleagues found
increased erythropoiesis (more active blood
formation) in infants when the cord was clamped early
that when it was clamped late. Early clamping of the
umbilical cord leaves the infant in an anemic state.
The main reason immediate clamping of the cord has
gained favor, is the thinking that fewer red cells leads
to less likelihood of developing jaundice, with the aim
of preventing kernicterus (yellow staining of nuclei in
the subcortical motor system. This goal has not been
accomplished. Sadly, kernicterus is still prevalent.
Windle would during the 1950s begin doing research
with monkeys, which many now would find unethical.
If it's unethical to do experiment with animals, how can
random assignment of human infants to groups for
immediate or delayed clamping of the umbilical cord
at birth be ethical? Is it ethical to ignore all of the
research of past decades that provide clear evidence
that immediate clamping of the cord at birth is
potentially harmful?
- Windle WF (1940) Round
table discussion on anemias
of infancy .
- Mäkikallio K et al. (1999) Yolk
sac and umbilicoplacental
hemodynamics during early
human embryonic
development.
- FitzGerald MJT, FitzGerald M
(1994) Human Embryology.
- Brezinka C (2001) Fetal
hemodynamics.
- Wilson EE et al. (1941)
Deprivation of placental blood
as a cause of iron deficiency
in infants.
- DeMarsh QB et al. (1941) The
effect of depriving the infant of
its placental blood; on the
blood picture during the first
week of life.
- DeMarsh QB et al.(1942)
Blood volume of newborn
infant in relation to early and
late clamping of umbilical
cord. Am J Dis Child 63:1123-
1129.
- DeMarsh QB et al. (1948)
Factors incluencing the blood
picture of the newborn;
studies on sinus blood on the
first and third days.
- Windle WF (1940) Round table discussion on anemias of infancy (from the
proceedings of the tenth annual meeting of the American Academy of
Pediatrics) Journal of Pediatrics 18:538-547.
- Mäkikallio K, Tekay A, Jouppila P (1999) Yolk sac and umbilicoplacental
hemodynamics during early human embryonic development. Ultrasound in
Obstetrics and Gynecology 14:175-179.
- FitzGerald MJT, FitzGerald M (1994) Human Embryology. Baillière Tindall,
London.
- Brezinka C (2001) Fetal hemodynamics. J Perinat Med 29:371-380.
- Wilson EE, Windle WF, Alt HL (1941) Deprivation of placental blood as a
cause of iron deficiency in infants. Am J Dis Child 62:320-327.
- DeMarsh QB, Alt HL, Windle WF, Hillis DS (1941) The effect of depriving the
infant of its placental blood; on the blood picture during the first week of life.
JAMA 116:2568-2573.
- DeMarsh QB, Windle WF, Alt HL (1942) Blood volume of newborn infant in
relation to early and late clamping of umbilical cord. Am J Dis Child 63:1123-
1129.
- DeMarsh QB Alt HL, Windle WF (1948) Factors incluencing the blood
pictureof the newborn; studies on sinus blood on the first and third days.
AmericanJournal of Diseases of Children 75:860-871.