Managing Low Birth Weight and Sick Newborns

Advances in Maternal and Neonatal Health

2 Managing 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

3 Managing 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

4 Managing 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 at birth

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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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Immediate Care of the Newborn: Warmth

Lay newborn on mother’s abdomen or other warm surface

Immediately dry newborn with clean (warm) cloth or towel

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

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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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Immediate Care of the Newborn

Assess breathing

Keep head in a neutral position

IMMEDIATELY assess respirations and need for resuscitation

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Signs of Good Health at Birth

Objective measures

Breathing

Heart rate above 100 beats/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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Birth Asphyxia

Definition: Failure to initiate and sustain breathing at birth

Magnitude:

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

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

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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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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 resuscitation

Provide routine care

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Open Airway

Position newborn on its back

Place head in slightly extend position

Suction mouth then nostrils

WHO 1998.

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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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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/breathing spontaneously

Continue ventilating until spontaneous

cry/ 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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Harmful and Ineffective Resuscitation Practices

Practices to be avoided include:

Routine aspiration of the newborn’s mouth and nose as soon as the head is born

Routine aspiration of the newborn’s 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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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 newborn’s nose Sprinkling or soaking newborn with cold water Stimulating anus Slapping newborn

Harmful and Ineffective Resuscitation Practices (continued)

WHO 1998.

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Infection Prevention for Resuscitation

Handwashing

Use of gloves

Careful suctioning if using a mucus extractor operated by mouth

Careful cleaning and disinfection of equipment and supplies

Do not reuse bulb—difficult to clean, poses risk of cross infection

Correct disposal of secretions

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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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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 indrawing and grunting

Encourage breastfeeding within 1 hour after birth

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Inform patients fully

Provide counseling, as needed

If culturally appropriate, allow parents private time with dead newborn

Burial should be arranged according to regulations and parents’ wishes

Post-Resuscitation Tasks:Unsuccessful Resuscitation

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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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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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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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Care of the Preterm Newborn

Associated problems with prematurity:

Feeding Respiratory Jaundice Intracranial bleed

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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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Warmth

As for all newborns:

Lay newborn on mother’s 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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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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Feeding

Early and exclusive breastfeeding

Breastmilk = best nourishment

Already warm temperature

Facilitated by kangaroo care

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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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How to Use Kangaroo Care

Newborn’s position:

Held upright (or diagonally) and prone against skin of mother, between her breasts

Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways

Newborn’s 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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How to UseKangaroo 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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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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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 mother’s 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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Summary

Skilled attendant

Equipment available and working

Begin resuscitation immediately

Ventilate Reassess frequently Kangaroo care once successful

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References

Cattaneo et al. 1998. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 87: 976–985.

de Leeuw R et al. 1991. Physiologic effects of kangaroo care in very small preterm infants. Biology of the Neonate 59: 149–155.

Karlsson H. 1996. Skin-to-skin care: heat balance. Arch Dis Child 75:F130–F132.

Lamb ME. 1983. Early mother-neonate contact and mother-child relationship. J Child Psychol Psychiatry 24(3): 487–494.

Ludington-Hoe SM et al. 1994. Kangaroo care: Research results, and practice implications and guidelines. Neonatal Network 13(1): 19–27.

Ross GS. 1980. Parental responses to infants in intensive care. The separation issue re-evaluated. Clin Perinatol 7: 47–60.

World Health Organization (WHO). 1998. Basic Newborn Resuscitation: A Practical Guide. WHO: Geneva.