Einc Newborn Mar 2011

Essential Newborn Care:

From Evidence to Practice

Essential Intra-Partum and

Newborn Care Scale-Up Program

DOH/WHO

0

10

20

30

40

50

60

70

80

1988 1993 1998 2003 2008

• 1988-1998: 40%

• 1998-2008: 20%

• Neonatal mortality hasn’t improved

Under Five MR

Neonatal MR

•DHS 88, 93, 98, 03, 08

<5 year old and Neonatal Mortality

The Philippines is one of 42 countries

that account for90% of global

under-five mortality

Most could have lived

82,000 Filipino children die annually

Under Five Year Old Deaths, 2008

Source: Child Health Epidemiology Reference Group (CHERG)

Global, Regional and National Causes of Child Mortality: a systematic analysis. The Lancet May 2010; 375: 1969-1987

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

3 out of 4 newborn deaths occur in the 1st week of life

Day of Life

Nu

mb

er o

f d

eath

s

NDHS 2003, special tabulations

Majority of newborns die due to stressful events or conditions during labor, delivery and the immediate

postpartum period

Neonatal Mortality is high

for Rich and Poor, NDHS 2003

0

5

10

15

20

25

Poorest 2nd 3rd 4th Least Poor

Preventive Interventions

Breastfeeding 13%

Insecticide-treated materials 7%

Complementary Feeding 6%

Zinc 4%

Clean delivery 4%

Hib Vaccine 4%

Water sanitation, hygiene 3%

Antenatal Steroids 3%

Newborn temperature management 2%

Vitamin A 2%

Tetanus Toxoid 2%

Nevirapine and replacement feeding 2%

Antibiotics for premature rupture of membranes 1%

Measles vaccine 1%

Antimalarial intermittent preventive treatment in pregnancy

<1% The Lancet Child Survival Series.

Lancet 2003; 362: 65–71

What Can We Do to Save Newborn Lives?

Baguio General Hospital, 1970’s

Period I: •Neonates were not rooming-in with their mother

•The hospital allowed formula

•Many cases of neonatal sepsis

Clavano, J TropPed, 1982

Period II: •Neonates roomed-in with their mother

•The hospital strongly promoted breastfeeding policy

•89% reduction of neonates with clinical signs of sepsis

Delaying Initiation of breastfeeding increases risk of infection-related death

Nepal 2008 N = 22,838 breastfed babies

0

1

2

3

4

5

6

7

8

9

10

11

12

<1 1-24 24-48 48-72 >72

Rel

ativ

e R

isk

Hours after Birth

Mullany LC, et al. JNutr, 2008; 138(3):599-603.

Delaying Initiation of breastfeeding increases risk of infection-related death Ghana 2004 N = 10,947 breastfed infants

0

1

2

3

4

5

6

7

8

9

10

11

12

Within 1 h 1h-end Day 1 Day 2 Day 3 After Day 3

Rel

ativ

e R

isk

Hours after Birth

Random Clinical Control Trial of Low Birth Weight Hospitalized Neonates comparing type of feeding

vs. percentage with serious illness

10.5 14.3 16

33

45

0

5

10

15

20

25

30

35

40

45

50

Raw ExpressedBF

PasteurizedExpressed BF

Raw ExpressedBF + Formula

PasteurizedExpressed BF +

Formula

Formula Only

% W

ith

Ser

iou

s Ill

nes

s

The extent of neonatal death and

sepsis in the Philippines

+ FPS 2006, § Sobel, Silvestre, Mantaring 2009 * Sobel, Oliveros, Nyunt-U 2009

Nationwide home deliveries by non-

health professionals

Nationwide

Hospitals

Newborn Sepsis § Not Studied 6%

Newborn Mortality * 16.8/1000

Live Births

16.0/1000

Live Births

Maternal Mortality 162/100,000 + 234/100,000§

Essential Newborn

Care Protocol was

developed to address these

issues

What Immediate Newborn Care

Practices Save Lives?

Antenatal Steroids: The Evidence

Overall reduction in neonatal death RR 0.69 (95% CI 0.58 – 0.81)

Reduction in RDS RR 0.66 (95% CI 0.59 to 0.73)

Reduction in cerebroventricular hemorrhage RR 0.54 (95% CI 0.43 to 0.69)

Reduction in sepsis in the first 48 hours of life RR 0.56 (95% CI 0.38 to 0.85)

Does not increase risk of death, chorioamnionitis or puerperal sepsis in the mother

Roberts D, Dalziel SR. Cochrane Database of Systematic Reviews 2006, Issue 3.

Antenatal Steroids Betamethasone

12 mg IM q 24 hrs x 2 doses May be the preferred drug – less PVL

Dexamethasone 6 mg IM q 12 hrs x 4 doses

Have dexamethasone available in the E-cart

No additional benefit to using higher or more frequent doses

Prednisone, methylprednisolone, cortisol are unreliable

Antenatal Steroids

After a baby is born, what should be the first action performed?

• Clamp and cut the cord A

• Dry the baby B

• Suction the baby’s mouth and nose C

• Do foot printing D

After a baby is born, what should be the first action performed?

• Clamp and cut the cord A

• Dry the baby B

• Suction the baby’s mouth and nose C

• Do foot printing D

A Minute-by-Minute Assessment of Newborn Care within the First Hour of

Life in Philippine Hospitals (2009)

Sobel, Silvestre, Mantaring, Oliveros, 2009

Intervention Percentage and

Median Time WHO Standard

Drying 97% at 1 min 100% Immediately

Put on cold surface 12% None

Not dried 2.5% None

Head not dried 6.2% None

Every Newborn Has Needs

To breathe normally

To be warm

To be protected

To be fed

Providing Warmth: Check the Environment

Check temperature of the delivery room

Ideal temp: 25 – 28°C

Check for air drafts

Turn air conditioner off at time of delivery

Immediate Thorough Drying Immediate drying: Stimulates Breathing

Prevents hypothermia

Hypothermia can lead to Infection

Coagulation defects

Acidosis

Delayed fetal to newborn circulatory adjustment

Hyaline membrane disease

Brain hemorrhage Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000, Imperial College Press: London,

UK. p. 207-220; TollinM,etal.. Cell Mol Life Sci 2005

Drying should be the first action,

IMMEDIATELY for a full 30 seconds

unless the infant is both floppy/limp and apneic

Resuscitation action of 26 infants with apnea:

Sobel, Silvestre, Mantaring, Oliveros, 2009

Action N (%)

Suctioning 24 (92.3%)

Bag and Mask 12 (46.1%) at 120 seconds

Slapping back 7 (26.9%)

Intubation 2 (7.7%) at 3 and 6 min

Chest compressions/ Epi 2 (7.7%) at 4 min

Drying *** 1 (3.8%)

Immediate Thorough Drying

Dry the newborn thoroughly for at least 30 seconds

Follow an organized sequence Wipe eyes, face, head

Front and back

Arms and legs

Wipe gently, do not wipe off the vernix

Remove the wet cloth, replace with a dry one

Immediate Thorough Drying

Do a quick check of breathing while drying 90% of newborns breathe normally after birth

If a baby is not breathing; Stimulate by drying thoroughly

Do not slap the baby

Do not shake the baby

Do not rub the baby vigorously

Immediate Thorough Drying Do not ventilate unless

the baby is floppy/limp and not breathing

Do not suction unless the mouth/nose are blocked by secretions

Unnecessary Suctioning

Of the 455 who were already breathing

94.9% suctioned once

84.0% suctioned more than once

Those trained in neonatal resuscitation were 2.5 (1.1-5.7) and in pediatric resuscitation 2.2 (0.96-5.2) times more likely to unnecessarily suction babies who were already breathing.

Sobel, Silvestre, Mantaring, Oliveros, 2009

During drying and stimulation of the baby, your rapid assessment shows that the baby is crying.

What is your next action?

• Suction the baby’s mouth and nose A

• Clamp and cut the cord B

• Do skin-to-skin contact C

• Do early latching on D

During drying and stimulation of the baby, your rapid assessment shows that the baby is crying.

What is your next action?

• Suction the baby’s mouth and nose A

• Clamp and cut the cord B

• Do skin-to-skin contact C

• Do early latching on D

A Minute-by-Minute Assessment of Newborn Care within the First Hour of

Life in Philippine Hospitals (2009)

Sobel, Silvestre, Mantaring, Oliveros, 2009

Intervention Percentage and

Median Time WHO Standard

Immediate Skin-to-Skin Contact

9.6% at 5 min >90% (except those needing

resuscitation)

Skin-to-Skin Contact Generally perceived to be an intervention for

provision of warmth and bonding

Less well appreciated are its contributions to

Overall success of breastfeeding/colostrum feeding

Stimulation of the mucosa-associated lymphoid tissue system

Protection from hypoglycemia

Colonization with maternal skin flora

Moore E, et al. Cochrane Rev. 2007 Jul 18;(3). Anderson GC, et al. Cochrane Rev 2003;(2).

Brandtzaeg P. Ann N Y AcadSci 2002;964:13–45

Early Skin-to-Skin Contact If newborn is breathing

or crying: Position the newborn

prone on the mother’s abdomen or chest

Cover the newborn’s back with a dry blanket

Cover the newborn’s head with a bonnet

Use a warm cover if room temp <25°C

When should the cord be clamped after birth?

• When the cord pulsations stop A

• Between 1 and 3 minutes B • Between 30 secs - 1 minute in

preterms C

• All of the above are appropriate D

When should the cord be clamped after birth?

• When the cord pulsations stop A

• Between 1 and 3 minutes B • Between 30 secs - 1 minute in

preterms C

• All of the above are appropriate D

A Minute-by-Minute Assessment of Newborn Care within the First Hour of

Life in Philippine Hospitals (2009)

Sobel, Silvestre, Mantaring, Oliveros, 2009

Intervention Percentage and

Median Time WHO Standard

Cord Clamp 12 sec

99% in < 1 min Until pulsations stop

(1-3 mins)

Properly-Timed Cord Clamping Term babies: less anemia in the newborn

24-48 hrs after birth RR 0.2 (95% CI 0.06, 0.6) NNT 7 (4.5 - 20.8)

Preterms: less infant anemia RR 0.49 (95% CI 0.3, 0.81) NNT 3 (1.6 - 29.6)

Preterms: less intraventricular hemorrhage RR 0.59 (95% CI 0.35, 0.92) NNT 2 (1.4 – 9.8)

No significant impact on incidence of Post-Partum Hemorrhage

1) CerianiCernadas ,et al.

2006;

2) Rabe H, et al. 2004;

3) McDonald SJ, et al. 2008;

4) Hutton EK, et al. 2007;

5) Kugelman A, et al. 2007

6) Van Rheenen PF, et al.

2006

7) Van Rheenen PF & Brabin

BJ. 2006

Properly-Timed Cord Clamping

When preparing for delivery, don 2 pairs of gloves after thorough handwashing

Remove the first set of gloves

Palpate the umbilical cord

After cord pulsations have stopped, clamp the cord using a sterile plastic clamp or tie at 2 cm from the umbilical base

Properly-Timed Cord Clamping

Clamp again at 5 cm from the base

Cut the cord close to the plastic clamp

BABY

3cm 2cm

Properly-Timed Cord-Clamping Do not milk the cord

towards the baby

After the 1st clamp, you may “strip” the cord of blood before applying the 2nd clamp

Cut the cord close to the plastic clamp so that there is no need for a 2nd trim

Care of the Cord Do not use a binder or “bigkis”

Do not apply any substance onto the cord

Observe for the oozing of blood. If blood oozes, place a second tie between the skin and the clamp

Washing the Baby in the First 6 Hours is Protective.

TRUE FALSE

Washing the Baby in the First 6 Hours is Protective.

TRUE FALSE

Early Washing Can Lead To: Hypothermia which can lead to

Infection, coagulation defects, acidosis, delayed fetal to newborn circulatory adjustment, hyaline membrane disease, brain hemorrhage

Infection The vernix is a protective barrier to bacteria such as

E.coli and Group B Strep; so is maternal bacterial colonization

No crawling reflex

Tunell R., Cell Mol Life Sci 2005; 62:2390-99; Righard L, Alade M. Lancet 1990; 336: 1105-07.

A Minute-by-Minute Assessment of Newborn Care within the First Hour of

Life in Philippine Hospitals (2009)

Sobel, Silvestre, Mantaring, Oliveros, 2009

Intervention Percentage and

Median Time WHO Standard

Wash 84% at 8 min >6 hours

Temp taken before 17% All

What is the approximate capacity of a

newborn’s stomach?

A

B C

D

What is the approximate capacity of a

newborn’s stomach?

A

B C

D

How long after birth is a newborn ready to breastfeed?

•immediately A

•5-10 minutes B

•10-20 minutes C

•20-60 minutes D

How long after birth is a newborn ready to breastfeed?

•immediately A

•5-10 minutes B

•10-20 minutes C

•20-60 minutes D

Non-separation of Newborn from Mother for Early Breastfeeding

Weighing, bathing, eye care, examinations, injections should be done after the first full breastfeed is completed

Postpone bathing until at least 6 hours

A Minute-by-Minute Assessment of Newborn Care within the First Hour of

Life in Philippine Hospitals (2009)

Sobel, Silvestre, Mantaring, Oliveros, 2009

Intervention Percentage and

Median Time WHO Standard

Breast feed 69.3% at10min Within 1 hour (but when baby shows signs)

Separatedfrom mother 92.9% at12 min >1 hour

Weigh 100% at 13 min > 1 hour

Exam 75.7% at 17 min > 1 hour

Hepatitis B Vaccine 69.4% at 20 min >1 hour

Nursery 52% at 19 min Never

Rooming in 83% (155 min) Immediately with mother

Non-separation of Newborn from

Mother

Never leave the mother and baby unattended

Monitor mother and baby q15 minutes in the first 1-2 hrs. Assess breathing and warmth

Breathing: listen for grunting, look for chest in-drawing and fast breathing

Warmth: check to see if feet are cold to touch if no thermometer

Early and Appropriate

Breastfeeding Initiation

Leave the newborn between the mother’s breasts in continuous skin-to-skin contact

The baby may want to rest for 20-30 mins and even up to 120 minutes before showing signs of readiness to feed

Early and Appropriate Breastfeeding Initiation

Health workers should not touch the newborn unless there is a medical indication

Do not give sugar water, formula or other prelacteals

Do not give bottles or pacifiers

Do not throw away colostrum

Let the baby feed for as long as he/she wants on both breasts

Help the mother and baby into a comfortable position

Observe the newborn

Once the newborn shows feeding cues, ask the mother to encourage her newborn to move toward the breast

Early and Appropriate Breastfeeding Initiation

After delivery, mother is moved onto a stretcher with her baby and transported to Recovery Room, mother-baby ward or private room

Breastfeeding support is continued

Support Continued and Exclusive Breastfeeding

Counsel on positioning

Newborn’s neck is not flexed or twisted

Newborn is facing the breast

Newborn is close to mother’s body

Newborn’s whole body is supported

Support Continued and Exclusive Breastfeeding

Counsel on attachment and suckling Mouth wide open

Lower lip turned outwards

Baby’s chin touching breast

Suckling is slow, deep with some pauses

Support Continued and Exclusive Breastfeeding

Proper Breastfeeding Hold

Look for a quiet place

Find most relaxed position for mother

Provide adequate back support

Support feet

Do not hunch shoulders

Do not “scissor” the breast

Underarm Hold

Football hold

Baby is held like a clutch bag

Nose further away from the breast

Baby’s trunk is secure beside mother’s trunk

Side-Lying Position

Side-Lying Position

E.O. 51 and its rIRR: The DON’Ts

Gifts of any sort Samples or products covered under the Milk Code Posters, other promotional materials or direct

promotions of products covered under the code within your Health Facility, Community, Barangays, Events, etc.

Sponsorships without permission from FDA Endorsements of products covered by the Milk Code

DO NOT REQUEST or ACCEPT from Milk Companies or their representatives: