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Managing Low Birth Weight and Sick

Newborns

Advances in Maternal and Neonatal Health

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2Managing Low Birth Weight and Sick Newborns

Session Objectives

To define essential elements of the care of sick newborns,

including neonatal resuscitation

To discuss best practices and technologies

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3Managing Low Birth Weight and Sick Newborns

Management of Newborn Illness

Education of mothers to recognize danger signals

Working with families to develop complication plan for

newborns

Early recognition and appropriate management of newborn

illness

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4Managing Low Birth Weight and Sick Newborns

Minimum Preparation for ANY Birth

The following should be available and in working order:

Heat source

Mucus extractor

Self-inflating bag of newborn size

2 masks (for normal and small newborns)

1 clock

At least one person skilled in newborn resuscitation present atbirth

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5Managing Low Birth Weight and Sick Newborns

Essential Care for All Newborns

Most newborns breathe as soon as they are born and only need:

A clean and warm welcome

Vigilant observation

Warmth

To be observed for breathing

To be given to the mother for warmth and breastfeeding

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6Managing Low Birth Weight and Sick Newborns

Immediate Care of the Newborn:

Warmth

Lay newborn on mothers abdomen or other warm surface

Immediately dry newborn with clean (warm) cloth or towel

Remove wet towel and wrap/cover newborn, except for faceand upper chest, with a second towel/cloth

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7Managing Low Birth Weight and Sick Newborns

Immediate Care of the Newborn:

Warmth (continued)

Blood on newborn is not a risk to newborn, but is a risk to

caregiver

Bathe after 24 hours

In areas with high HIV prevalence, consider bathing earlier to

reduce risk of maternal-fetal transmission, and to reduce risk

to caregiver and to other newborns

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8Managing Low Birth Weight and Sick Newborns

Immediate Care of the Newborn

Assess breathing

Keep head in a neutral position

IMMEDIATELY assess respirations and need for resuscitation

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9Managing Low Birth Weight and Sick Newborns

Signs of Good Health at Birth

Objective measures

Breathing

Heart rate above 100beats/minute

Subjective measures

Vigorous cry

Pink skin

Good muscular tone

Good reactions to stimulus

Most important measure is whether newborn is breathing

Assessing all of above delays resuscitation, if it is necessary.

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10Managing Low Birth Weight and Sick Newborns

Birth Asphyxia

Definition: Failure to initiate and sustain breathing at birth

Magnitude:

3% of 120 million newborns each year in developingcountries develop birth asphyxia and require resuscitation

An estimated 900,000 of these newborns die as a result of

asphyxia

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11Managing Low Birth Weight and Sick Newborns

Steps in Resuscitation

Anticipate need for resuscitation at every birth, be prepared

with equipment in good condition

Prevent of heat loss (dry newborn and remove wet clothes)

Assess breathing

Resuscitate:

Open airway

Position newborn

Clear airway

Ventilate

Evaluate

WHO 1998.

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12Managing Low Birth Weight and Sick Newborns

Assess Breathing

Newborn crying?

Yes No

Provide routine

care

Chest is rising

symmetrically

Frequency >30

breaths/min.

Not breathing/

gasping

Breathing < 30

or > 60 breaths/

min.

Immediately start

resuscitationProvide routine

care

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13Managing Low Birth Weight and Sick Newborns

Open Airway

Position newborn on its back

Place head in slightly extend position

Suction mouth then nostrils

WHO 1998.

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14Managing Low Birth Weight and Sick Newborns

Ventilate

Select appropriate mask size to cover chin, mouth and nose

with a good seal

Squeeze bag with two fingers or whole hand, look for chest to

rise

If chest not rising:

Reposition head and mask

Increase ventilation

Repeat suctioning

WHO 1998.

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15Managing Low Birth Weight and Sick Newborns

Evaluate

After ventilating for about 1 minute, stop

and look for spontaneous breathing

If no breathing, breathing

is slow (< 30 breaths/min.) or is weak with

severe indrawing

If newborn starts

crying/breathingspontaneously

Continue ventilating

until spontaneouscry/ breathing begins

Stop ventilating

Do not leave newborn

Observe breathing

Put newborn skin-to-skin

with mother and cover them

both

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16Managing Low Birth Weight and Sick Newborns

Harmful and Ineffective

Resuscitation Practices

Practices to be avoided include:

Routine aspiration of the newborns mouth and nose as soon

as the head is born

Routine aspiration of the newborns stomach at birth

Stimulation of the newborn by slapping or flicking the soles of

her/his feet: only enough stimulation for mildly depressed-

delays resuscitation

Postural drainage and slapping the back: dangerous

WHO 1998.

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17Managing Low Birth Weight and Sick Newborns

Squeezing the chest to remove secretions from the airway

Routine giving of sodium bicarbonate to newborns who are not

breathing

Intubation by an unskilled person

Some traditional practices:

Putting alcohol in newborns nose

Sprinkling or soaking newborn with cold water

Stimulating anus

Slapping newborn

Harmful and Ineffective

Resuscitation Practices (continued)

WHO 1998.

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18Managing Low Birth Weight and Sick Newborns

Infection Prevention for Resuscitation

Handwashing

Use of gloves

Careful suctioning if using a mucus extractor operated bymouth

Careful cleaning and disinfection of equipment and supplies

Do not reuse bulbdifficult to clean, poses risk of cross

infection

Correct disposal of secretions

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19Managing Low Birth Weight and Sick Newborns

Documentation

Details of the resuscitation to be recorded include:

Identification of newborn

Condition at birth

Procedures necessary to initiate breathing

Time from birth to initiation of spontaneous breathing

Clinical observations during and after resuscitation

Outcome of resuscitation

In case of failed resuscitation, possible reasons for failure

Names of healthcare providers involved

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20Managing Low Birth Weight and Sick Newborns

Post-Resuscitation Tasks:

Successful Resuscitation

Do not separate mother and newborn

Leave newborn skin-to-skin with mother (kangaroo care)

Measure temperature, count breaths, observe for indrawingand grunting

Encourage breastfeeding within 1 hour after birth

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21Managing Low Birth Weight and Sick Newborns

Inform patients fully

Provide counseling, as needed

If culturally appropriate, allow parents private time with deadnewborn

Burial should be arranged according to regulations and

parents wishes

Post-Resuscitation Tasks:

Unsuccessful Resuscitation

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22Managing Low Birth Weight and Sick Newborns

Policy Decisions for Resuscitation

Guidelines on when to start:

Apparently stillborn newborn

Malformations: Lethal

Less severe malformations

Extremely low gestational age

Guidelines on when to stop:

20 minutes

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23Managing Low Birth Weight and Sick Newborns

Principles of Success

Readily available personnel

Skilled providers

Coordinated team

Resuscitation tailored to newborn response

Available and functioning equipment

Avoidance of harmful and ineffective practices Follow rules for infection prevention

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24Managing Low Birth Weight and Sick Newborns

Care of the Low Birth Weight Newborn

Birth weight = Gestation duration + intrauterine growth

Most low birth weight newborns in developing countries

are term or near term (Small for gestation age)

Increased risk of hypothermia and poor growth

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25Managing Low Birth Weight and Sick Newborns

Care of the Preterm Newborn

Associated problems with prematurity:

Feeding

Respiratory Jaundice

Intracranial bleed

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26Managing Low Birth Weight and Sick Newborns

Principles of Management for Low Birth

Weight and Preterm Newborns

Warmth

Feeding

Detection and management of complications (e.g.,resuscitation, assisted respiration)

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27Managing Low Birth Weight and Sick Newborns

Warmth

As for all newborns:

Lay newborn on mothers abdomen or other warm surface

Dry newborn with clean (warm) cloth or towel

Remove wet towel and wrap/cover with a second dry towel

Bathe after temperature is stable

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28Managing Low Birth Weight and Sick Newborns

Warmth: Problem with Incubators

Potential source of infection

Often temperature controls malfunction

Often share incubator for more than one newborn

Need alternative method: kangaroo care

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29Managing Low Birth Weight and Sick Newborns

Feeding

Early and exclusive breastfeeding

Breastmilk = best nourishment

Already warm temperature

Facilitated by kangaroo care

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30Managing Low Birth Weight and Sick Newborns

Definition of Kangaroo Care

Early, prolonged and continuous skin-to-skin contact between

a mother and her newborn

Could be in hospital or after early discharge

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31Managing Low Birth Weight and Sick Newborns

How to Use Kangaroo Care

Newborns position:

Held upright (or diagonally) and prone against skin of

mother, between her breasts

Head is on its side under mothers chin, and head, neck

and trunk are well extended to avoid obstruction to airways

Newborns clothing:

Usually naked except for nappy and cap

May be dressed in light clothing Mother covers newborn with her own clothes and added

blanket or shawl

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32Managing Low Birth Weight and Sick Newborns

How to Use

Kangaroo Care (continued)

Newborn should be:

Breastfed on demand

Supervised closely and temperature monitored regularly Mother needs lots of support because kangaroo care:

Is very tiring for her

Restricts her freedom

Requires commitment to continue

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33Managing Low Birth Weight and Sick Newborns

Effectiveness of Kangaroo Care

Randomized controlled trial

Conducted in three tertiary and teaching hospitals in Ethiopia,

Indonesia and Mexico

Study effectiveness, feasibility, acceptability and cost of

kangaroo mother care when compared to conventional

methods of care

Cattaneo et al 1998.

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34Managing Low Birth Weight and Sick Newborns

Benefits of Kangaroo Care

Is efficient way of keeping newborn warm

Helps breathing of newborn to be more regular; reduce

frequency of apneic spells

Promotes breastfeeding, growth and extra-uterine adaptation

Increases the mothers confidence, ability and involvement in

the care of her small newborn

Seems to be acceptable in different cultures and environments

Contributes to containment of cost salaries, running costs

(electricity, etc.)

deLeeuw et al 1991; Karlsson 1996; Lamb 1983; Ludington-Hoe et al 1993; Ross 1980.

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35Managing Low Birth Weight and Sick Newborns

Summary

Skilled attendant

Equipment available and working

Begin resuscitation immediately

Ventilate

Reassess frequently

Kangaroo care once successful

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36Managing Low Birth Weight and Sick Newborns

References

Cattaneo et al. 1998. Kangaroo mother care for low birthweight infants: a

randomized controlled trial in different settings. Ac ta Paediatr87: 976985.

de Leeuw R et al. 1991. Physiologic effects of kangaroo care in very small

preterm infants. Biolog y of the Neonate59: 149155.

Karlsson H. 1996. Skin-to-skin care: heat balance. Arch Dis Chi ld75:F130F132.

Lamb ME. 1983. Early mother-neonate contact and mother-child relationship. J

Chi ld Psychol Psychiatry24(3): 487494.

Ludington-Hoe SM et al. 1994. Kangaroo care: Research results, and practice

implications and guidelines. Neonatal Networ k13(1): 1927.

Ross GS. 1980. Parental responses to infants in intensive care. The separationissue re-evaluated. Clin Perinatol7: 4760.

World Health Organization (WHO). 1998. Basic Newborn Resusci tat ion: A

Practical Guide. WHO: Geneva.