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Essential Newborn Care
Sarah A. Murphy, MDPediatric Critical Care FellowMassGeneral Hospital for ChildrenBoston, MA
Presentation Outline: Part One
Background: the problem of neonatal mortality WHO “Essential Interventions” for Mothers
Tetanus Toxoid Immunization Iron and Folate supplementation Treatment of infections: especially Malaria, Syphilis
WHO “Essential Interventions” for Newborns Essential care for all newborns
Cleanliness Thermal protection Early and exclusive breast-feeding Eye Care Immunization
Presentation Outline: Part Two
Essential care for sick newborns: Care of low birth weight babies Management of newborn illnesses Neonatal Resuscitation*
Review Questions
Background: Neonatal Mortality Neonatal mortality: death < 28 days after birth 40% of all child deaths (<5 yo) are neonatal! Highest rates in sub-Saharan Africa Africa: > 1 million neonatal deaths every year 38% die of infections Most are low birthweight (LBW) & many preterm Liberia: very high rate – 6.6% die in first month
Causes of Neonatal Death (WHO 2001)
Birth Asphyxia31%
Complications of Prematurity
25%
Congenital Anomalies
11%
Infections33%
Background: Neonatal Mortality
325,000 deaths from sepsis & pneumonia in Africa . Simple preventive practices can save most!
Existing interventions can prevent 35-55% neonatal deaths worldwide
These interventions include:Treating pregnant women
for example, tetanus toxoid administrationTreating newborns
Bellagio, Lancet Survival Series
WHO Essential Interventions
This presentation will review the principles behind the “essential interventions” identified by the WHO as having the greatest potential to reduce newbown mortality:
Interventions for MothersInterventions for Newborns
Essential Antenatal Care for Pregnant Women
Tetanus Toxoid ImmunizationIron and Folate supplementationTreatment of infections: especially
Malaria, Syphilis
Tetanus Caused by Clostridium tetani G+, anaerobic bacterium sensitive to heat & oxygen Spores are very resilient and found in soil & animals
GI tract of horses, sheep, cattle, dogs, cats, chickens, others. Spore inoculation occurs through dirty wounds. Once inside, spores germinate and produce tetanospasmin
A very potent neurotoxin Tetanospasmin dissminates in lymph and blood to all
nerves Toxin blocks neurotransmitter release and causes
unopposed muscle contraction and painful muscle spasms
Tetanus
The shortest peripheral nerves are affected firstfacial distortionback and neck stiffness
Generalizes in a descending fashion Seizures may occur Autonomic nervous system may also be
affected
Tetanus cases reported worldwide (1990-2004). Ranging from strongly prevalent (in dark red) to very few cases (in light yellow) (gray, no data).
Tetanus
Tetanus kills an estimated 70,000 newborns in Africa each year six percent of all neonatal deaths
It is very hard to treat neonatal tetanus!! Preventing the disease by immunizing mothers
is critical!
Tetanus
Tetanus can be prevented through immunization with tetanus-toxoid (TT) -containing vaccines
Mothers should receive at least 2 TT vaccines during pregnancy!!
This protects the mother and - through a transfer of tetanus antibodies to the fetus - her baby
Iron and Folate Supplementation
Iron deficiency anemia affects almost half of all women
Maternal anemia contributes significantly to maternal mortality and causes an estimated 10,000 deaths per year
Newborns of mothers with anemia are more likely to have low birth weight, be born too early, or die shortly after birth
Also at greater risk for cognitive impairment
Folate supplements before and around conception can reduce the occurrence of neural tube defects in newborns
Treatment of Maternal Infections
1) Malaria2) Syphilis
Treatment of Maternal Malaria:
Malarial infection causes 400,000 cases of severe maternal anemia yearly
And responsible for 75,000-200,000 infant deaths
annually
Effects on fetus: fetal loss premature delivery intrauterine growth retardation low birth-weight infant
Treatment of Maternal Malaria
In high malaria areas, women have some immunity that wanes during pregnancy Malaria infection results in severe maternal anemia and
delivery of low birth-weight infants
In low malaria transmission areas, women have not developed immunity Malaria infection results in severe malaria disease, maternal
anemia, premature delivery, or fetal loss
Malaria is a major factor in low birth weight babies and amenable to intervention!
Treatment of Malaria
Provide antimalarial drugs Use insecticide-treated bed nets
WHO guidelines for the treatment of Malaria in
pregnancy Intermittent Preventive Treatment
All pregnant women in areas of stable malaria transmission should receive at least 2 doses of IPT after quickening
The World Health Organization recommends a schedule of 4 antenatal clinic visits, with 3 visits after quickening
The delivery of IPT with each scheduled visit after quickening will assure that a high proportion of women receive at least 2 doses
The most effective drug for IPT is sulfadoxine-pyrimethamine (SP) because of its safety for use during pregnancy, effectiveness in reproductive-age women, and feasibility for use
IPT-SP doses should not be given more frequently than monthly. Insecticide-Treated Nets
ITNs should be provided to pregnant women as early in pregnancy as possible.
Their use should be encouraged for women throughout pregnancy and during the postpartum period.
Placental Infection
Malaria-infected human placenta examined under the microscope. The intervillous spaces (central area of the picture) are filled with red blood cells, most of which are infected with Plasmodium falciparum malaria parasites
Treatment of Maternal Syphilis
Provide screening and treatment in areas where syphilis is endemic Untreated syphilis can cause
malformation, illness, or death of a fetus or newborn
Treatment of Syphilis
Syphilis is a sexually transmitted disease caused by a spirochete ~ Treponema pallidum
Syphilis can cause miscarriages, premature birth, still-birth, or death of newborn babies: 40% of births to syphilitic mothers are stillborn 40-70% of the survivors will be infected 12% of these will subsequently die
Syphilis Some infants have symptoms at birth, most develop
symptoms later Late congenital syphilis occurs in children greater that 2
years of age: Hutchinson teeth Interstitial keratitis Deafness Frontal bossing Saddle nose Swollen knees Saber shins Short maxillae Protruding mandible
Sores on infected babies are infectious
Congenital Syphilis Failure to gain weight Fever Irritability No bridge to nose (saddle nose) Early rash -- small blisters on the palms and soles Later rash -- copper-colored, flat or bumpy rash on the face, palms,
soles Rash of the mouth, genitalia, and anus Severe congenital pneumonia Watery discharge from the nose Blindness Clouding of the cornea Decreased hearing or deafness Gray, mucous-like patches
Treatment of Syphilis
One dose of penicillin will cure a person who has had syphilis for less than a year
More doses are needed to cure someone who has had it for longer
A baby born with the disease needs daily penicillin treatment for 10 days
Essential Care for Newborns
Essential care for all newborns Cleanliness Thermal protection Early and exclusive breast-feeding Eye Care Immunization
Essential care for sick newborns Care of low birth weight babies Management of newborn illnesses Neonatal Resuscitation*
Routine Supportive Care for All Newborns after delivery
Keep baby dry and warm Keep baby with mother – room in Initiate breast-feeding within 1 hour Give Vitamin K Keep umbilical cord clean and dry Apply eye ointment to prevent infection Give oral polio, BCG, and hepatitis B
injections
Cleanliness
The six “cleans” of the WHO1. Clean hands of the attendant2. Clean surface3. Clean blade4. Clean cord tie5. Clean towels to dry the baby and then
wrap the baby6. Clean cloth to wrap the mother
Cleanliness Hygiene during delivery:
Clean hands, perineum, delivery surface Sterilized equipment
Clean cutting of umbilical cord Clean hands with soap and water, under the nails Sterile razor blade for cutting cord Sterile ties or gauze to tie cord off
Umbilical cord care Umbilical stump is main source of entry for infections Cord should be kept clean and dry, no dressings should be
applied if stump is able to be kept clean without them Infant’s clothes and blanket should be kept clean If cord becomes dirty, it should be washed and then dried with
clean cotton or gauze
Cleanliness
Prevention of hospital infections: Rooming-in with mother:
Allows micro-organisms from mother to be given to infant These tend to be non-pathogenic Mother can give antibodies to these organisms to the
baby through breast-milk Reduces risk of cross-infection when babies are not being
roomed together No over-crowding Clean water Importance of hospital staff hand-washing!!!
Thermal Protection
Normal temperature of a newborn is between 36.5 and 37.5 degrees
Celsius
Thermal Protection Hypothermia can be a sign of infection!!!
Hypothermia is temperature less than 36.5 degrees C Large surface area Poor insulation Small body mass to produce heat
Signs of hypothermia cool hands and feet less active or lethargic Hypotonic poor suck weak cry shallow breathing redness of face and skin
Thermal Protection
Preventing hypothermia: deliver infant in warm room dry thoroughly after birth, including drying the head, wrap in warm dry cloth give to mother as soon as possible for skin to skin
contact no washing in the 1st 6 hours after birth
Treatment: skin to skin contact warm water bottles loosely wrapped warm blanket
Mechanisms of Heat Loss in Babies
Thermal Protection
Hyperthermia is a temperature > 37.5 degrees C Signs:
Irritable Rapid respirations Rapid heart rate Hot and dry skin Lethargic Convulsions
Hyperthermia is often accompanied by dehydration and re-hydration should be considered if infant is showing any signs
Thermal Protection
Prevention: Hyperthermia in an infant is environmental Do not expose infant to high temperatures,
sunlight, heaters, etc!!
Treatment: Active cooling
Early and Exclusive Breast-feeding
Early and exclusive breastfeeding is one of the least expensive and most cost-effective interventions for saving children’s lives!!!!
Early and Exclusive Breastfeeding
Exclusive breastfeeding for six months and continued breastfeeding for the first year could avert 13 percent of the more than 10 million deaths among children
Benefits: including improved cognitive development reduced risk of infections better overall chances of survival
Early and Exclusive Breastfeeding
Formula feeding raises risk of illness by depriving infants of infection-fighting components of human milk
Bottle feeding carries risks of possible contamination of water and formula
In areas with a high level of infectious disease and unsafe water, an infant who is not breastfed during the first 2 months of life is up to 23 times more likely to die from diarrhea
1. Initiation of breastfeeding within one hour of birthcolostrumcontinuous skin-to-skin contact
2. Exclusive breastfeeding for six months
3. Assess for good attachment and positioning
4. Prompt treatment of breast conditions
5. Frequent breastfeeds, day and night (8-12 times per 24 hours)
6. Continuation of breastfeeding when mother or newborn is ill
7. Extra support for feeding more vulnerable newbornslow birthweight or premature babiesHIV-infected womensick or severely malnourished babies
Early and Exclusive Breast-feeding
Breast-feeding and HIV: Exclusive breastfeeding recommended for all
mothers in HIV-endemic areas, including HIV-positive mothers where
alternatives are not acceptable, feasible, affordable, sustainable, and safe
This applies to much of sub-Saharan Africa and South Asia, among other places.
Exclusive breastfeeding is associated with two to four times lower rates of mother to child transmission of HIV compared to non-exclusive breastfeeding
Eye Care: application of topical antibiotic
Tetracycline eye ointment Prevents infection of tissues surrounding
the eyes caused by bacteria from the birth canal The most significant of these bacteria are
gonorrhea and chlamydia Also helps prevent infection with other bacteria Untreated, gonorrhea and chlamydia can cause
permanent visual impairment and also spread to other parts of the body such as the lungs causing pneumonia
Immunization
Each year, over four million African children die before their fifth birthday, many from vaccine-preventable diseases
Immunizations will be covered in later lecture But, notably, there are a number of vaccines
given to babies just after birth to be aware of:• BCG vaccination to reduce the risk of tuberculosis• Hepatitis B vaccination to prevent hepatitis B infection• OPV to prevent polio infection
Supportive Care for All Newborns after delivery: KEY
POINTS!!! Keep baby dry and warm Keep baby with mother – room in Initiate breast-feeding within 1 hour Give Vitamin K Keep umbilical cord clean and dry Apply eye ointment to prevent infection Give oral polio, BCG, and hepatitis B
injections
Management of Sick Infant
Management of Sick Infant: Outline
Care for ALL sick infants Recognizing danger signs Treating serious bacterial infection Treating convulsions Treating low birth weight baby Review of key points
Management of Newborn Illness
Neonates and young infants present with non-specific symptoms which may indicate a serious illness or serious bacterial illness
It is imperative to monitor for and recognize these danger signs to initiate treatment early
Treatment is aimed at stabilizing child and preventing deterioration
General principles of management of all sick
infants:Keep infant dry and warm
Wrap infant Cap Kangaroo infant with mother if possible
Follow temperature closely
General principles of management of sick infants:Encourage frequent breast-feeding if
infant is alert If baby is lethargic or having frequent
convulsions, avoid oral feeding
General principles of management of sick infants: If giving IV fluids, follow the TOTAL amount of
fluids given to infant This includes oral and IV fluid WHO recommends:
60cc/kg/day on Day 1 90cc/kg/day on Day 2 120cc/kg/day on Day 3 150cc/kg/day thereafter
Note: Infant may need more fluids if kept under radiant warmer
Note: Following infant’s weight is good measure of over or under-hydration
General principles of management of sick infants:
Oxygen should be given by nasal prongs at initial flow rate of 0.5L/min
If able to follow pulse oximeter, goal is oxygen saturation greater than 90%
Recognizing Danger Signs
Danger signs in a newborn:• Convulsions• Drowsy or unconscious• Not feeding well• Fast breathing (more than 60 breaths per
minute)• Slow breathing (less than 20 breaths per
minute or not breathing)• Grunting or severe chest in-drawing• Fever (above 38°C)
Recognizing Danger Signs
Danger signs in a newborn:• Hypothermia (below 35.5°C),• Very small baby (less than 1500 grams or born
more than two months early)• Bleeding• Severe jaundice• Severe abdominal distension• Bulging fontanelle• Signs of local infection (ex: swollen joints, skin
pustules or redness)• Central cyanosis
Emergency Treatment of Danger Signs
Give oxygen by nasal prongs or catheter to any ill-appearing infant
Especially if having respiratory symptoms
Provide bag and mask ventilation if breathing is too slow or labored
With oxygen if available, or room air
Emergency Treatment of Danger Signs
Give penicillin/ampicillin and gentamicin as soon as possible to any infant presenting with signs of illness
Emergency Treatment of Danger Signs
If convulsing, give Phenobarbital (IM 15mg/kg)
If patient is drowsy, unconscious, or convulsing:
Check blood sugar if possible, give IV glucose if blood sugar is low
If unable to check blood sugar, give IV glucose If unable to give IV glucose, give either
expressed breast-milk or glucose through a nasogastric tube
Emergency Treatment of Danger Signs
Give vitamin K injection to all sick newborns if they have not already received it
Serious Bacterial Illness
Serious bacterial infection should be suspected if an infant presents with any DANGER SIGN
Risks for serious bacterial infection include: maternal fever rupture of membranes for more than 24 hours foul-smelling amniotic fluid
Serious Bacterial Illness
Also look for signs of a local infection: swollen jointsmany severe skin pustulesbulging fontanelleredness around umbilicuspus from umbilicus
Serious Bacterial Illness
Treatment of suspected serious bacterial illness: Admit to Hospital Send blood cultures if possible Ampicillin/Penicillin and Gentamicin for 10 days If no improvement in 2-3 days consider changing
antibiotics If extensive skin infection consider giving
Cloxacillin if available instead of Penicillin for staph aureus coverage
Convulsions
Treatment:Initial dose of Phenobarbital is 15mg/kg IMIf convulsions continue, give 10mg/kg IM
in repeat doses up to maximum of 40mg/kgMonitor for apnea or slowed breathing and
assist breathing if neededCheck for low blood sugarContinue daily Phenobarbital at 5mg/kg if
needed
Low Birth Weight Baby
Most newborn deaths are among low birthweight babies
Low birth weight is baby weighing less than 2500 grams
Simple care of these small babies, close monitoring and early treatment of problems could save many newborn lives
Low Birth Weight Baby
Birthweight of 2.25-2.5kg These infants normally do well with routine
newborn care Monitor carefully Ensure proper warmth and infection control
Low Birth Weight Baby
Birthweight 1.75 to 2.25kgInitiate Kangaroo Care for warmthStart feeding within 1 hrIf infant is able to nurse, allow normal,
frequent breast-feedingIf infant cannot breast-feed, give
expressed breast-milk by cup and spoonMonitor carefully for signs of infection
Low Birth Weight Baby
Birthweight less than 1.75 kg These infants need to be admitted to special care
nursery for extra care Give oxygen by nasal prongs or nasal catheter if
there are any signs of difficulty breathing, fast breathing rate or cyanosis
Maintain temperature of 36-37 deg C Kangaroo Care Humidicrib if available Hot water bottle wrapped in a towel if no heating source
Low Birth Weight Baby
Birthweight less than 1.75 kg If possible, give IV fluids Give 2-4ml of expressed breastmilk every 2
hours by nasogastric tube IF: baby looks well no abdominal distension bowel sounds present baby has passed meconium,
If baby is tolerating these feeds, increase volume slowly
Low Birth Weight Baby
Birthweight less than 1.75 kgMonitor for signs of infection and begin
antibiotic therapy if any sign prsentIf infant has apnea, treat:
caffeine citrate 20mg/kg PO or IV x 1, then daily 5mg/kg
OR aminophylline 10mg/kg x 1, then 2.5 - 4 mg/kg q 12 hours
Low Birth Weight Baby Kangaroo Care:
The baby is undressed except for cap, nappy, and socks Placed upright between the mother’s breasts, with head
turned to one side Then tied to the mother’s chest with a cloth and covered with
the mother’s clothes If the mother is not available, the father or any adult can
provide skin-to-skin care
Provides warmth, breastfeeding, protection from infection, stimulation, and love
Effective way to care for a small baby weighing between 1,000 and 2,000 grams who has no major illness
Low Birth Weight Baby
Kangaroo Care:This care is continued until the infant no
longer accepts it, usually when the weight exceeds 2,000 grams
Research has shown that for preterm babies, KMC is at least as effective as an incubator
Shorter average stay in hospital compared to conventional care, have fewer infections, and gain weight more quickly
Neonatal Resuscitation Prototcols
See next lecture in the series
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