Essential Newborn Care: From Evidence to Practice

Essential Intra-Partum and Newborn Care Scale-Up Program DOH/WHO

<5 year old and Neonatal Mortality

80 70

60 50 40 30
20 10 0

Under Five MR
Neonatal MR
1988 1993 1998 2003 2008

1988-1998: 40% 1998-2008: 20% Neonatal mortality hasnt improved

DHS 88, 93, 98, 03, 08

The Philippines is one of

42 countries

that account for of global under-five mortality

90%

82,000
Filipino children die annually Most could have lived

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

Majority of newborns die due to stressful events or conditions during labor, delivery and the immediate postpartum period
35

30

Number of deaths

25
20 15

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

10
5 0

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

Day of Life

NDHS 2003, special tabulations

Neonatal Mortality is high for Rich and Poor, NDHS 2003

25 20 15 10 5

0
Poorest 2nd 3rd 4th Least Poor

What Can We Do to Save Newborn Lives?

Preventive Interventions
Breastfeeding Insecticide-treated materials Complementary Feeding

13%
7% 6%

Zinc
Clean delivery Hib Vaccine Water sanitation, hygiene

4%
4% 4%

3% 3%
2% 2%

Antenatal Steroids
Newborn temperature management Vitamin A

Tetanus Toxoid Nevirapine and replacement feeding

Antibiotics for premature rupture of membranes Measles vaccine

2% 2%
1% 1% <1%
The Lancet Child Survival Series. Lancet 2003; 362: 6571

Antimalarial intermittent preventive treatment in pregnancy

Baguio General Hospital, 1970s

Period I: II: Neonates roomed-in were not with their mother rooming-in with their mother The hospital strongly promoted The hospital allowed breastfeeding policy formula

89% reduction Many cases of of neonates with neonatal sepsisclinical signs of sepsis

Clavano, J TropPed, 1982

Delaying Initiation of breastfeeding increases risk of infection-related death

Nepal 2008
12 11 10 9 8 7 6 5 4 3 2 1 0 <1 1-24 24-48 48-72 >72

N = 22,838 breastfed babies

Relative Risk

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
12 11 10 9 8 7 6 5 4 3 2 1 0 Within 1 h 1h-end Day 1 Day 2 Day 3 After Day 3

Relative Risk

Hours after Birth

Random Clinical Control Trial of Low Birth Weight Hospitalized Neonates comparing type of feeding vs. percentage with serious illness
50 45

45 33

% With Serious Illness

40 35 30 25 20 15 10 5 0

14.3

16

10.5

Raw Expressed BF

Pasteurized Expressed BF

Raw Expressed Pasteurized BF + Formula Expressed BF + Formula

Formula Only

The extent of neonatal death and sepsis in the Philippines

Nationwide home deliveries by nonhealth professionals Newborn Sepsis Not Studied 16.8/1000 Live Births

Nationwide Hospitals
6% 16.0/1000 Live Births

Newborn Mortality * Maternal Mortality

162/100,000 +

234/100,000

+ FPS 2006, Sobel, Silvestre, Mantaring 2009

* Sobel, Oliveros, Nyunt-U 2009

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 unreliable

Prednisone, methylprednisolone, cortisol are

Antenatal Steroids

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

A B C D

Clamp and cut the cord

Dry the baby

Suction the babys mouth and nose

Do foot printing

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

A B C D

Clamp and cut the cord

Dry the baby

Suction the babys mouth and nose

Do foot printing

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippine Hospitals (2009)
Intervention
Drying Put on cold surface Not dried
Head not dried

Percentage and Median Time

97% at 1 min 12% 2.5%
6.2%

WHO Standard
100% Immediately None None
None

Sobel, Silvestre, Mantaring, Oliveros, 2009

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 28C

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:

Action Suctioning Bag and Mask
Slapping back

N (%) 24 (92.3%) 12 (46.1%) at 120 seconds

7 (26.9%)

Intubation
Chest compressions/ Epi

2 (7.7%) at 3 and 6 min

2 (7.7%) at 4 min

Drying ***

1 (3.8%)

Sobel, Silvestre, Mantaring, Oliveros, 2009

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?

A B C D

Suction the babys mouth and nose Clamp and cut the cord

Do skin-to-skin contact

Do early latching on

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

What is your next action?

A B C D

Suction the babys mouth and nose Clamp and cut the cord

Do skin-to-skin contact

Do early latching on

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippine Hospitals (2009)
Intervention
Immediate Skin-to-Skin Contact

Percentage and Median Time

9.6% at 5 min

WHO Standard
>90% (except those needing resuscitation)

Sobel, Silvestre, Mantaring, Oliveros, 2009

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;964:1345

Early Skin-to-Skin Contact

If newborn is breathing

or crying:
Position the newborn

prone on the mothers abdomen or chest Cover the newborns back with a dry blanket Cover the newborns head with a bonnet

Use a warm cover if

room temp <25C

When should the cord be clamped after birth?

A B C D

When the cord pulsations stop

Between 1 and 3 minutes Between 30 secs - 1 minute in preterms All of the above are appropriate

When should the cord be clamped after birth?

A B C D

When the cord pulsations stop

Between 1 and 3 minutes Between 30 secs - 1 minute in preterms All of the above are appropriate

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippine Hospitals (2009)
Intervention Cord Clamp

Percentage and Median Time 12 sec 99% in < 1 min

WHO Standard

Until pulsations stop (1-3 mins)

Sobel, Silvestre, Mantaring, Oliveros, 2009

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)
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

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

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

2cm

3cm

BABY

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)
Intervention
Wash Temp taken before

Percentage and Median Time

84% at 8 min 17%

WHO Standard
>6 hours All

Sobel, Silvestre, Mantaring, Oliveros, 2009

What is the approximate capacity of a newborns stomach?

A B C D

What is the approximate capacity of a newborns stomach?

A B C D

How long after birth is a newborn ready to breastfeed?

A B C D

immediately 5-10 minutes 10-20 minutes 20-60 minutes

How long after birth is a newborn ready to breastfeed?

A B C D

immediately 5-10 minutes 10-20 minutes 20-60 minutes

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)
Intervention
Breast feed

Percentage and Median Time

69.3% at10min

WHO Standard
Within 1 hour (but when baby shows signs)

Separatedfrom mother Weigh Exam

Hepatitis B Vaccine Nursery Rooming in

92.9% at12 min 100% at 13 min 75.7% at 17 min

69.4% at 20 min 52% at 19 min 83% (155 min)

>1 hour > 1 hour > 1 hour

>1 hour Never Immediately with mother
Sobel, Silvestre, Mantaring, Oliveros, 2009

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 mothers

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

Early and Appropriate Breastfeeding Initiation

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

Support Continued and Exclusive Breastfeeding

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
Newborns neck is not

flexed or twisted Newborn is facing the breast Newborn is close to mothers body Newborns whole body is supported

Support Continued and Exclusive Breastfeeding

Counsel on

attachment and suckling

Mouth wide open Lower lip turned outwards Babys chin touching breast Suckling is slow, deep with some pauses

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

Babys trunk is secure

beside mothers trunk

Side-Lying Position

Side-Lying Position

E.O. 51 and its rIRR: The DONTs DO NOT REQUEST or ACCEPT

from Milk Companies or their representatives:
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