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Cord Blood Banking

A provider's education guide

Umbilical cord blood banking (UCBB) has been an increasingly popular topic in the last few decades and has been found as a potential treatment for numerous diseases.

Initially thought of as a waste product, this blood has been found to harbor hematopoietic stem cells that have the potential to develop into white cells, red cells or platelets.1 These cells are especially valuable to individuals in the same family as they are genetically related to the infant and that infant's biological family.

If a need for these cells is found, siblings of the same biological parents have a 25% chance of being a perfect match and a 50% chance of being a partial match. The biological parents are always a partial match.2

Many expecting families are faced with numerous decisions regarding the birth of their child. Among these decisions is the choice to donate or store their infant's umbilical cord blood (UCB). As healthcare providers it is important to know what cord blood is, what it treats, how it's collected and stored, and if it's safe.

Research has found that expecting mothers as well as healthcare providers are under informed in regards to UCBB. According to the Lubin et al.,3 only 18% of pediatricians feel that they possess the confidence of discussing the pros, cons and limitations of UCBB for private or public use.

Din and Sahin4 found that out of 334 pregnant women only 90 (27%) had some information about UCB and 65 (72%) of these women received their information from the media, which has widely misled the general public.

Due to marketing from private banking companies, the hype surrounding these cells has exceeded the research displaying potential clinical benefit.5 It is the job of healthcare providers to be educated on this in order to adequately educate their patients and allow them to make an informed non-biased decision.

Uses of UCB
More than 20,000 umbilical cord blood (UCB) transplant procedures have been performed over the last 20 years.6

According to Verter and Berseney,7 stem cell transplants from UCB are currently being used to treat leukemia, lymphomas, myelodysplastic syndromes (pre-leukemia), inherited metabolic disorders and select solid tumors that do not originate in the immune system or blood.

There are also numerous clinical trials researching new disease treatments. These include: neurologic injuries, auto-immune diseases, cardiovascular diseases, and inherited disorders.7

Collection & Safety
The collection of UCB is simple, safe and not painful for the mother or infant. Collection takes less than five minutes to obtain and has to be collected within 15 minutes of the birth of the infant. Collection does not interfere with delivery and is possible with both vaginal and cesarean deliveries.8

The collection is done in a sterile fashion. The umbilical vein is accessed with a 17-gauge needle and fed into a sterile collection bag by a closed system.9 The collection of this blood can be done while the placenta is delivered (in utero) or after (ex utero).

The main risk for in utero collection is the possibility of clamping the cord too soon, stripping the infant of important vascular nourishment. Ex utero minimizes this potential risk to the infant, but slightly increases the chances of contamination.10

Typically 50 to 200 ml of blood is collected to make a single unit of UCB. To treat a child or small adult, 50 to 100 ml of blood is needed. Additional doses may be needed for treatment; therefore, it is important to get as much UCB as possible because there is no way to acquire more stem cells from the original sample.11

UCB is discarded if the pregnant woman has a history of active genital herpes, group B streptococcus, chorioamnionitis or prolonged rupture of membranes.11 The mother's blood and UCB are tested after delivery for HLA type, and diseases which include Hepatitis B and C, HIV types I and II, West Nile, Syphilis and Chagas Disease. If any of these are found the UCB must be discarded.12

Storage Banks
There are two types of UCB storage banks: public and private banks.

Private banks are commercial, for-profit programs that collect payment from families who intend to use the UCB for later personal family use. These private banks typically charge a one-time fee for the collection and processing of the blood. A yearly storage fee is then expected.9 The American Pregnancy Association14 notes the initial cost can vary from $900 to $2,100 with an annual storage fee around $100. Over a 20 year span the total cost would potentially be between $2,999 and $4,675 depending on the company selected.15

Public banks on the other hand accept donations of UCB without charging any donation fees, but they do not save the units for the families personal use and dispense the units on an as-needed basis.11

SEE ALSO: Delayed Cord Clamping

Public banks are struggling to collect and store blood due to the enormous expense associated with the testing and storing. Currently they are supported through government grants, donations and the compensation they receive when releasing units to be used.5

A study by Keersmaekers et al.,16 found that out of the 7,839 UCB units they collected, only 2,539 units (32.4%) were viable samples. So in theory, a public blood bank is only able to retain 32.4% of the blood they spend numerous dollars testing. This makes it hard to accept unlimited donations that could potentially be matches for individuals in need.

Regulation
The Food and Drug Administration (FDA) regulates UCB for safety under the Code of Federal Regulations and the "Human Cells, Tissues, and Cellular and Tissue Based-Products" category.13

All public and private banks must follow good practice standards when storing UCB. In addition to these good practice standards, public banks are required to adhere to additional stricter standards in regard to the testing, collection, processing and banking of the UCB.

Private banks are encouraged to apply for accreditation and adhere to stricter standards. Two well-known accrediting agencies are the Foundation for Accreditation of Cellular Therapy and American Association of Blood Banks.13

Disadvantages
The major disadvantage of collecting blood for one's own use is its limited ability to actually treat the person from whom the UCB originated.

Private blood banks forcefully promote their service promising, "peace of mind" and, "a powerful medical resource used to treat many severe illnesses for your child and loved ones."9

These statements, although true, tend to be misleading to the general public. UCB may potentially treat "many severe illnesses," but the chance of their loved one having one of these illnesses and needing their own UCB is very low.

The probability an individual will get such an illness in his or her lifetime can range from 0.23% to 0.98% respectively for undergoing allogeneic (using one's own cord blood for personal use) or either autologous (using a donor's cord blood) or allogeneic transfusions.17

Professional Organizations' Recommendations
The American Academy of Pediatrics (AAP)18 discourages the use of privately banking UCB for later family or personal use, as most conditions that are potentially helped by UCB are already present in the infant's cord blood (i.e., premalignant changes in stem cells), unless a full sibling has a medical condition that could possibly be treated with the UCB.

They also discourage storing UCB for "biological insurance" to treat diseases later in life, but do encourage storage for public use.18 The American College of Obstetricians and Gynecologists (ACOG),8 has a recommendation stating that, "Balanced and accurate information regarding the advantages and disadvantages of public versus private banking should be provided. The remote chance of an autologous unit of UCB being used for a child or a member of the same family (approximately 1 in 2,700 individuals) should be disclosed."

ACOG8 also recommends only privately banking blood if there is a known diagnosis in an immediate family member that a stem cell transplant would be indicated for and not for potential future uses.

All pregnant women should be educated with accurate and non-biased information about UCBB. Information should be given about private versus public banking and the likelihood of using the blood for personal use as well as a list of conditions UCB can treat.8

Kami Peterson is a family nurse practitioner working in urgent care in Dickinson, N.D. Susan Clouse Smith is adjunct faculty in the Family Nurse Practitioner Program at the University of Mary, Bismarck, N.D.

References
1.      Cord Blood Stem Cell Transplantation. The Leukemia and Lymphoma Society. https://www.lls.org/content/nationalcontent/resourcecenter/
freeeducationmaterials/treatments/pdf/cordbloodstemcelltransplantation.pdf

2.      A Genetic Match. Cord Blood Registry. http://www.cordblood.com/benefits-cord-blood/umbilical-cord-stem-cells.

3.      To Bank or Not to Bank Cord Blood: A National Survey of Pediatrician Counseling Practices. American Academy of Pediatrics.
http://www.aap.org/en-us/professional-resources/Research/Pages/
To-Bank-or-Not-to-Bank-Cord-Blood-A-National-Survey-of-Pediatrician-Counseling-Practices.aspx
.

4.      Din HH, et al. Pregnant women's knowledge and attitudes about stem cells and cord blood banking. Int Nurs Rev. 2009;56(2):250-6. doi: 10.1111/j.1466-7657.2008.00689.x.

5.      Webb S. Banking on cord blood stem cells. Nat Biotechnol. 2013;31(7):585-8. doi: 10.1038/nbt.2629.

6.      Querol S, et al. Cord blood banking: current status. Hematology. 2012;17:185-188. doi:10.1179/102453312x13336169157013.

7.      Diseases Treated. Parents' Guide to Cord Blood Foundation. http://parentsguidecordblood.org/en/diseases

8.      The American College of Obstetricians and Gynecologists. Umbilical Cord Blood Banking.
http://www.acog.org/Resources-And-Publications/
Committee-Opinions/Committee-on-Genetics/Umbilical-Cord-Blood-Banking
.

9.      Kurtzberg Jet al. Untying the Gordian knot: Policies, practices, and ethical issues related to banking of UCB. J Clin Invest. 2005;115(10):2592-7.

10.  Navarrete C, et al. Cord blood banking: a historical perspective. British Journal of Haematlogy. Br J Haematol. 2009;147(2):236-45. doi: 10.1111/j.1365-2141.2009.07827.x.

11.  Waller-Wise R. UCB: Information for childbirth educators. J Perinat Educ. 2011;20(1):54-60. doi:  10.1891/1058-1243.20.1.54

12.  Cord Blood Collections. National Cord Blood Program. http://www.nationalcordbloodprogram.org/work/collections.html.

13.  Cooper CA, et al. Cord blood and tissue banking: supporting expectant parent's decision making. Int J Childbirth Educ. 2013;28(2):62-68.

14.  Cord blood banking. American Pregnancy Association. http://American

pregnancy.org/labor-and-birth/cord-blood-banking/.

15.  How Americord Compares With Other Banks. Americord. http://americordblood.com/product-comparison.

16.  Keersmaekers CL, et al. Factors affecting umbilical cord blood stem cell suitability for transplantation in an in utero collection program. Transfusion. 2014;54(3):545-9. doi: 10.1111/trf.12340.

17.  Nietfeld J, et al. Lifetime probabilities of hematopoietic stem cell transplantation in the U.S. biology of blood and marrow transplantation. Journal of the American Society for Blood and Marrow Transplantation. 2008;14(3):316-322.

18.  American Academy of Pediatrics. Cord blood banking for future potential transplantation. Pediatrics. 2007;119(1):165-170. doi: 10.1542/peds.2006-2901.

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