~Eva
Introduction
I want to introduce the topic of cord blood banking via a short illustrative piece about breast feeding - please indulge me and hopefully you will see the point!
Colostrum and Breast Feeding - there is a connection!
I first learned about the importance of colostrum to the new born as a farmer's daughter - colostrum has always been highly prized and surplus supplies are routinely collected and stored frozen on the farm for any sickly newborn animals who may need a therapeutic dose. However, it has taken much longer to convince the medical profession of the crucial health benefits and potentially life- saving properties of human colostrum! Lots of babies, including the most sick and vulnerable, still go without the precious first dose of this highly specialised living complex of cells, antibodies, 'good bacteria', growth factors, nutrients and hormones, all specifically designed to prepare the immune system, the digestive tract and other organ systems for life in the outside world.
As a midwife, I have always supported women and babies to successfully breastfeed. I've also helped other mothers in their battles to ensure their premature / special care babies receive the benefit of colostrum and breast milk, even if this had to be donated from another breast feeding mum. It is wonderful that through the hard work of a local campaign and public fundraising a local breast milk bank has now been established but nationally, provision remains patchy.
What's the link?
Like breast milk, umbilical cord blood is a highly specialised and complex living system of cells and blood components, with unique and extraordinary properties and functions, specifically designed to meet the needs of a developing human being. Cord blood is especially rich in stem cells, the building blocks needed to grow, restore and repair the human body; and like colostrum, its unique qualities and functions are still being actively researched and until recently, its importance has been poorly understood and undervalued.
Natural Physiology
After the birth of a human baby, the umbilical cord remains intact - (unlike in many hoofed mammals where the cord is designed to break naturally as the baby animal is born). Immediately after birth, the human umbilical cord can be seen to pulsate and the blood continues to flow back and forth for a short time (a few seconds to a few minutes in some cases). During this time the baby continues to receive oxygenated blood from the placenta which helps as he/she adjusts to breathing air for the first time. It also allows for the correct amount of cord blood to be transferred to the baby for a healthy transition to life outside the womb.
Recently, the obstetric community have acknowledged that the traditional policy of clamping and cutting the cord immediately after birth could actually deprive babies of the amount of the blood they actually need - a fact already recognised by those of us who trust and practice natural birth. Delayed cord clamping is now recommended in most circumstances.
Stem Cell Treatments
After the baby's cord has been clamped and cut, the placenta and remaining cord are routinely discarded as waste products. However, there is often a significant amount of surplus cord blood still left inside the cord and placenta and upto 45,000 litres of this left over cord blood is discarded every year in the UK alone1. This is despite the fact that cord blood stem cells are already highly valued for their application in a significant number of treatments and therapies.
For example, each year, hundreds of thousands of people are diagnosed with leukaemia, lymphoma, bone marrow failure or other immune system or genetic metabolic and blood disorders such as Sickle Cell Anaemia; many of these are children. These disorders may be treated with a transplant of cord blood or bone marrow, but in many cases the unique qualities of cord blood make it the better choice. Even though a closely matched cord blood unit is preferred, clinical studies have shown that the match doesn't need to be as close for cord blood as compared to bone marrow or adult blood transfusions and it is generally less likely to cause complications associated with rejection (graft versus host disease)2.
Regenerative Medicine
The unique properties of cord blood stem cells together with the stem cells from the cord tissue itself, have also made them an increasing focus for research into regenerative medicine. These exciting treatments are designed to repair or re-grow damaged tissue in the body using a transfusion or application of a person's own perfectly matched stem cells. Also, whereas stem cell transplants often require large cord blood collections, the emerging therapies can be successful with small collections.
The use of cord blood stem cells is already being tested in humans in the treatment of conditions such as brain injury and Type 1 Diabetes. Earlier stage research is being conducted in a wide range of conditions including stroke, hearing loss, Alzheimer's and cardio-vascular disease.
The cord tissue itself (Wharton's Jelly) is rich in stem cells designed to differentiate into bone, cartilage and connective tissue; they are also very effective at mediating the body's inflammatory response to damaged or injured cells. Numerous potential treatments using this type of stem cell are now being studied in adult volunteers using stem cells derived from their bone marrow e.g. heart disease, stroke, bone disease and injury, neuro degenerative disorders, auto immune diseases such as Multiple Sclerosis and Crohn's Disease, Type 1 Diabetes and arthritis. Lung Cancer, Liver Diease, Parkinson's Disease, Rheumatoid Arthritis and sports injuries to cartilage are just some of the other conditions being studied in stem cell therapies in animal models3.
One of the most well-known emerging therapy trials involves treating children with Cerebral Palsy with their own cord blood stem cells. Since 2005, several hundred children world-wide have received this treatment for Cerebral Palsy and similar acquired neurological disorders4. However, at present, Doctors and researchers will only perform potential new cord blood therapies on children who have their own stem cells available.
As more people have access to their own stored cord blood and additional cord blood stem cell treatments and applications are tested, regenerative medicine is expected to continue to advance rapidly and to revolutionize medicine in the future. As medicine advances towards harnessing the body's own restorative properties, children whose cord blood was stored at birth could be among the first to benefit from new treatments as they become available. Current estimates indicate that approximately 1 in 3 Americans could benefit from regenerative medicine5.
Cord Blood Banks
Stored cord blood is also readily available, it can be selected and delivered to a transplant centre in a matter of days rather than waiting for several months or more for a suitably matched blood or bone marrow donor and it is well used. On average, every year 1 in a 100 cord blood units collected will be used for transplantation compared to only 1 in 1000 of adult bone marrow donations1. Through an international network of cord blood banks and registries, more than 20,000 stem cell transfusions have now taken place - some of them life saving, all from stem cells derived from a newborn baby's surplus cord blood6.
The UK's NHS Cord Blood Bank opened in 2006 but it collects far less cord blood than other countries like Spain, France, Germany, Italy and the USA, where there are government funded national collection programmes. Unfortunately the UK's public cord blood bank is woefully undersupplied to meet current demand for stem cell transplants. There is only a 38% chance of attaining a match for a Caucasian patient from the NHS cord bank today and it is far less for those from an ethnic minority7. As a result, in 2011/12 over 80% of the cord blood units used by UK transplant centres came from cord banks overseas and 2 people still miss out on a transplant every day1.
Patients from racially or ethnically diverse communities are particularly poorly served. Blood disorders such as Sickle Cell Anaemia are more prevalent within the minority populations but their blood and tissue types are relatively uncommon and significantly under represented within the public bone marrow and blood banks, making it very hard to find matched transfusions for this group. As a result, more than 40% of these transplant patients rely soley on cord blood because the unique properties of cord blood stem cells mean they can often be successfully transfused even when the donor and recipient blood types are not perfectly matched.
[It's worth noting at this point that despite almost 10 million bone marrow donors registered worldwide, only 50% of white patients needing stem cells will find a suitable match, a figure that has remained constant for almost 20 years]1 8.
The NHS cord blood bank currently collects donated cord blood from only 6 London Maternity Hospitals7. The Anthony Nolan Trust collects cord blood from another 5 hospitals for public use (2 more in London, 1 in Birmingham and 2 more in Leicester)1. If you have a baby in one of these hospitals, you will receive literature about the potential life saving benefits of cord blood transplant and treatments and you will be strongly encouraged to consider donating your baby's cord blood for storage and future therapeutic use.
However, outside of these 11 hospitals there is limited information about cord blood banking available and no means of freely donating your baby's surplus cord blood to the public banks. Public bank donations are also anonymous and a donor baby and family has no personal right or access to their stored stem cells in the future i.e. should your own baby or another family member, require a cord blood transplant at a later date, although the closest matched blood would be selected - your own baby's sample may no longer be available.
There is one situation that is different - that is if you already have a child currently diagnosed with a disease or condition for which a cord blood transplant is a viable treatment option. If recommended by your child's doctor, the NHS can arrange for a cord blood collection to be taken from your next baby's cord and placenta after birth, in the hope that this will be a close enough match to treat the affected older sibling. In this case the cord blood collection is organised by the NHS and if suitably matched, it is transported directly for immediate transfusion. If you are in this situation, do ask about the possibility of a cord blood transplant - some families have missed out on this opportunity unnecessarily.
Ideally, there should be a national cord blood collection service, however, present funding doesn't even guarantee a round the clock collection service in the few participating hospitals we do have.
Private Storage
If you want to save and store your own baby's cord blood for your family's exclusive use, you will have to arrange and pay for this privately through one of the independent cord blood banks. Private cord banks, just like the public banks, are all regulated and licensed by The Human Tissue Authority8. The collection of cord blood can only be undertaken by trained and licensed clinical staff. In most cases, a specialist phlebotomist will attend the hospital to undertake the collection, in some cases it can be done by a member of the hospital staff. A private bank will store individual cord blood units for the future, sole use of the donor baby and/or other family members who prove to be sufficiently closely matched e.g. siblings, parents and grandparents, so you are guaranteed to have this blood available should you need it. Often the grandparents will gift the cost of collection and storage as an 'insurance policy' that the whole family could potentially benefit from.
Considering that the cause of most cancers is unknown and that the science of stem cell therapy is expanding rapidly, it is difficult to accurately calculate the odds that a family will use the cord blood or benefit from new treatments. Actual rates of stem cell transplantation in the US were last published in 2008 and demonstrate that the probability that a person will have some type of stem cell transplant by age 70, either from their own cells or from a donor, is approximately 1 in 2009. This is the same probability that the newborn or a family member may benefit from banked cord blood. The odds that a child will someday need to use his or her own newborn stem cells for current treatments are estimated at 1 in 40010.
All of the figures above are based on statistics drawn from current rates of stem cell transplant. They do not reflect the potential use of newborn stem cells in the emerging regenerative therapies, all of which treat conditions that a child is actually much more likely to experience than the need for a stem cell transplant. As advances continue in this area of medicine the likelihood of use will undoubtedly increase throughout a child's lifetime.
You will have to do your own research about the option of private banking as it is unlikely that NHS staff are well informed about this choice. However, this is set to change as the latest All Party Parliamentary Committee on Stem Cell Transplantation has made a commitment to ensure the general public and specifically pregnant women do all have access to information about the potential benefits of cord blood banking and all of the choices currently available.
I have always been an advocate for informed choice within maternity care. Information should be evidence based, up to date and available to everyone - regrettably, this is not the case currently in the area of cord blood banking. Some pregnant women are given good information and actively encouraged to have their baby's cord blood collected, some are actively discouraged or put off through lack of information or misinformation about the available options, most don't have any information at all.
As a midwife and having worked as both a cord blood phlebotomist and a specialist trainer in the field (I continue to train and update both NHS and independent phlebotomy staff nation-wide), I have a thorough understanding and practical experience of how this service can operate well within the clinical setting. I currently hold a clinical liaison role for Cells4Life, the largest independent cord blood bank in the UK and I work with hospitals providing a range of cord banking services, using both NHS and external agencies.
As an increasing number of parents ask for information about cord blood storage and go onto to choose this option, I want to ensure there is both accurate information available and access to locally available services designed to meet the needs of everyone involved in the process.
Jo Taylor RM
Clinical Liaison and Trainer Cells4Life
References
1. www.anthonynolan.org/cord-blood The Anthony Nolan charity collects for its own public cord bank from 5 hospitals: The Royal Free and King's College Hospitals in London; The Birmingham Women's Hospital; The Leicester Royal Infirmary and the Leicester General.
2. Sager, J., Chaib, B., Sales,K., Winslet,M. and Seifalian, A. 2007. Role of Stem Cells in Cancer Therapy and Cancer Stem Cells: A Review. Cancer Cell Int. (2007). 7(9)
3. Giordano A, etal.; Galderisi, U; Marino, IR (2007). "From the laboratory bench to the patient's bedside: An update on clinical trials with mesenchymal stem cells". Exp. Hematol. 211 (1): 27–35.
4. Verter, F & JJ Nietfeld, Cytotherapy 2010;12:Suppl.1, abstract#157
5. Harris DT, et al. (2007). "The potential of cord blood stem cells for use in regenerative medicine". Expert Opin. Biol. Ther. 7 (9): 1311–1322.
6. Rocha, V & E Gluckman, Brit. J. Haematology 2009;147:262-274
7. www.nhsbt.nhs.uk/cordblood/howtodonate/wherecanidonate/ The NHS Cord Blood Bank collects from the following 6 Greater London hospitals: Barnet General; Luton and Dunstable; St George's; Northwick Park; Watford General and University College Hospital. It currently holds 19,000 cord blood units and there is a 1:500 chance of a match for a white patient.
8. The Human Tissue Authority - controls, regulates and licenses the collection, use and storage of human blood and tissue in the UK. www.hta.gov.uk/
9. Pasquini M.C., Logan B.R.,Verter F., et al. The Likelihood of Haematopoietic Stem Cell Transplantation (HCT) in the United States: Implications for Umbilical Cord Blood Storage. Blood. 2005;106(11)
10. Confer, D. L. 1997 Unrelated Bone Marrow Registries. Curr Opin Haematol. (1997) 4; 408-412
Further Sources of Information
Parents Guide to Cord Blood Foundation - US website with up to date information and statistics on all options for cord blood banking www.parentsguidecordblood.org
Make your baby proud - as above www.makeyourbabyproud.com
Anthony Nolan Trust www.anthonynolan.org This charity set up the first bone marrow donor register (now a world wide network) and its own public cord blood bank in 2008, works in partnership with the NHS Cord Blood Bank
NHS Cord Blood Bank www.nhsbt.nhs.uk
Cells4Life www.cells4life.com Largest UK based Private Cord Blood Bank
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