Normal Newborn Care

Advances in Maternal and Neonatal Health

Session Objective

Define essential elements of early newborn care

Discuss best practices and technologies for promoting newborn health Use relevant data and information to develop appropriate essential newborn recommendations

Normal Newborn Care

Newborn Deaths

8.1 million infant deaths (1993)

3.9 million (48%) newborn deaths 2.8 million (67%) early newborn deaths Major causes of newborn deaths

Birth asphyxia: 21% Infections: 42% (tetanus, sepsis, meningitis, pneumonia, diarrhea)
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Newborn Deaths (continued)

Birth process was the antecedent cause of 2/3 of deaths due to infections

Lack of hygiene at childbirth and during newborn period Home deliveries without skilled birth attendants 3% of newborns suffer mild to moderate birth asphyxia Prompt resuscitation is often not initiated or procedure is inadequate or incorrect

Birth asphyxia in developing countries

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Newborn Deaths (continued)

Hypothermia and newborn deaths

Significant contribution to deaths in low birth weight infants and preterm newborns Social, cultural and health practices delaying care to the newborn

Countries with high STD prevalence and inconsistent prophylactic practices

Ophthalmia neonatorum is a common cause of blindness

Normal Newborn Care

Newborn Deaths (continued)

Low birth weight

An extremely important factor in newborn mortality At least 2 out 3 childbirths in developing countries occur at home Only half are attended by skilled birth attendants Strategies for improving newborn health should target Birth attendant, families and communities Healthcare providers within the formal health system

Place of childbirth

Normal Newborn Care

Essential Newborn Care Interventions

Clean childbirth and cord care

Prevent newborn infection Prevent and manage newborn hypo/hyperthermia Started within 1 hour after childbirth Early asphyxia identification and management

Thermal protection

Early and exclusive breastfeeding

Initiation of breathing and resuscitation

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Essential Newborn Care Interventions (continued)

Eye care

Prevent and manage ophthalmia neonatorum At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO)

Immunization

Identification and management of sick newborn Care of preterm and/or low birth weight newborn

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Cleanliness to Prevent Infection

Principles of cleanliness essential in both home and health facilities childbirths

Principles of cleanliness at childbirth

Clean hands

Clean perineum
Nothing unclean introduced vaginally Clean delivery surface Cleanliness in cord clamping and cutting

Cleanliness for cord care

Infection prevention/control measures at healthcare facilities

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Thermal Protection

Newborn physiology
Normal temperature: 36.537.5C Hypothermia: < 36.5C Stabilization period: 1st 612 hours after birth Large surface area Poor thermal insulation Small body mass to produce and conserve heat Inability to change posture or adjust clothing to respond to thermal stress Increase hypothermia

Newborn left wet while waiting for delivery of placenta Early bathing of newborn (within 24 hours)
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Hypothermia Prevention

Deliver in a warm room

Dry newborn thoroughly and wrap in dry, warm cloth Keep out of draft and place on a warm surface Give to mother as soon as possible

Skin-to-skin contact first few hours after childbirth Promotes bonding Enables early breastfeeding

Check warmth by feeling newborns feet every 15 minutes Bathe when temperature is stable (after 24 hours)

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Early and Exclusive Breastfeeding

Early contact between mother and newborn

Enables breastfeeding Rooming-in policies in health facilities prevents nosocomial infection Best practices

No prelacteal feeds or other supplement Giving first breastfeed within one hour of birth Correct positioning to enable good attachment of the newborn Breastfeeding on demand Psycho-social support to breastfeeding mother

WHO 1999.

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Breathing Initiation and Resuscitation

Spontaneous breathing (> 30 breaths/min.) in most newborns

Gentle stimulation, if at all Biologically plausible advantages clear airway

Effectiveness of routine oro-nasal suctioning is unknown

Potentially real disadvantages cardiac arrhythmia

Bulb suctioning preferred Fetal distress

Newborn resuscitation may be needed

Thick meconium staining

Vaginal breech deliveries Preterm
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Hamilton 1999.

Eye Care To Prevent or Manage Ophthalmia Neonatorum

Ophthalmia neonatorum

Conjunctivitis with discharge during first 2 weeks of life Appears usually 25 days after birth Corneal damage if untreated

Systemic progression if not managed

N. gonorrhea More severe and rapid development of complications 3050% mother-newborn transmission rate C. trachomatis

Etiology

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Eye Care To Prevent or Manage Ophthalmia Neonatorum (continued)

Prophylaxis

Clean eyes immediately 1% Silver nitrate solution Not effective for chlamydia 2.5% Povidone-iodine solution 1% Tetracycline ointment Not effective vs. some N. gonorrhea strains Common causes of prophylaxis failure

Giving prophylaxis after first hour Flushing of eyes after silver nitrate application Using old prophylactic solutions

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Efficacy of Prophylaxis for Conjunctivitis in China

Objective: To assess etiology of newborn conjunctivitis and evaluate the efficacy of regimens in China
Design: November 1989 to October 1991 rotated regimens monthly: tetracycline, erythromycin, silver nitrate 302 (6.7%) infants developed conjunctivitis, most S. aureus (26.2%) and chlamydia (22.5%) Silver nitrate, tetracycline: fewer cases than no prophylaxis (p < 0.05), erythromycin: not significant

Chen 1992.

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Prophylaxis for Conjunctivitis: Objective and Design

Objective: To compare efficacy in prevention of nongonococcal conjunctivitis

Design: Randomized control trial to compare erythromycin, silver nitrate, no prophylaxis

Examined with test for leukocyte esterase and chlamydia trachomatis antibody probe 3048 hours postpartum, 1315 days later, and telephone contact up to 60 days of life

Main outcome measured: conjunctivitis within 60 days of life and nasolacrimal duct patency

Bell 1993.

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Prophylaxis for Conjunctivitis: Results and Conclusion

Results: 630 infants

109 with conjunctivitis

Silver nitrate vs. no prophylaxis: Hazard ratio 0.61 (0.390.97)

Chemical conjunctivitis with silver nitrate resolves within 48 hours Erythromycin vs. no prophylaxis: Hazard ratio 0.69 (not significant)

Conclusion: Parental choice of prophylaxis, including no prophylaxis, is reasonable IF antenatal care and STD screening

Bell 1993.

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Povidone-Iodine for Conjunctivitis: Objective and Design

Objective: To determine incidence and type of conjunctivitis after povidone-iodine in Kenya

Design: Rotate regimen weekly: erythromycin, silver nitrate, povidone iodine Results:

Conjunctivitis: Chlamydia in 50.5% S. aureus in 39.7% More infections in silver nitrate than povidone-iodine, OR 1.76, p < 0.001 More infections in erythromycin OR 1.38, p=0.001

Isenberg, Apt and Wood 1995.

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Povidone-Iodine for Conjunctivitis: Conclusion

Povidone-iodine:

Is good prophylaxis Has wider antibacterial spectrum Causes greater reduction in colony-forming units and number of bacterial species Is active against viruses Is inexpensive

Isenberg, Apt and Wood 1995.

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Immunization

BCG vaccinations in all population at high risk of tuberculosis infection

Single dose of OPV at birth or in the two weeks after birth HBV vaccination as soon as possible where perinatal infections are common

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Summary
The essential components of normal newborn care include:

Clean delivery and cord care Thermal protection Early and exclusive breastfeeding Monitoring Eye care Immunization

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References
Bell TA et al. 1993. Randomized trial of silver nitrate, erythromycin and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics 92: 755760. Chen J. 1992. Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin, and no prophylaxis. Pediatr Infect Dis J 11: 10261030. Child Health Research Project and Maternal and Neonatal Health Program. 1999. Reducing Perinatal and Neonatal Mortality. Report of a meeting in Baltimore, Maryland, 1012 May, 1999. Hamilton P. 1999. Care of the newborn in the delivery room. Br Med J 318: 14031406. Isenberg SJ, L Apt and M Wood. 1995. A controlled trial of povidoneiodine as prophylaxis against ophthalmitis neonatorum. N Engl J Med 332: 562566. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. WHO: Geneva.
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