Thank you. We do appreciate these insightful comments. They are correct in observing that our recommendations show a preference for deferring cord clamping in babies who do not require resuscitation and that the decision-making process for clamping and associated resuscitation steps are not indicated on the algorithm. The decision not to place new steps or branches in the algorithm in 2020 was deliberate: the algorithm views neonatal resuscitation from a high level and remains a condensed version of practice that is detailed in the text.

In addition, the science of each resuscitation step and, in this case, cord management overlaps with practical and educational principles. The “Utstein Formula for Survival” clearly delineates how science, education, and practice are inextricably intertwined and need to be addressed both in sequence and independently.1  We believe that clinicians and educators who develop educational programs for neonatal resuscitation should contribute to the translation of evidence into practice. We have therefore resisted the temptation to pre-empt their recommendations. The American Heart Association and American Academy of Pediatrics recognized these steps of translating science into education and then into practice in the formation and membership of the Neonatal Life Support Writing Group as a bridge between the International Liaison Committee on Resuscitation (ILCOR) guidelines and the Neonatal Resuscitation Program (NRP).2,3 

We agree with Drs. Ghirardello and Katheria that cord management should be integrated into educational programs but have been cautious about prejudging how clinicians and educators will address the challenges that the science presents to them. We agree that the evidence provides us with a range of timing and approaches to cord management in low- and high-risk populations and eagerly anticipate new educational materials that promote effective training, assessments, and interventions. In regard to the question on “term gestation,” it is intended primarily to prepare the team for the next steps for care, not to guide cord management decisions. The recommendations, including those on cord management, will be incorporated into the Neonatal Resuscitation Program (NRP), 8th edition, which will be available in June 2021.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: None declared.