CARE OF THE NEWBORN

ALELI PAGULAYAN-SUDIACAL, MD, MPH

National Center for Disease Prevention and Control DEPARTMENT OF HEALTH

Outline
Newborn

Mortality in the Philippines Evidence Based Interventions Newborn Care Practices: Our Report Card DOH-WHO Newborn Care Protocol DOH Administrative Order

Definitions
Newborn Period - birth up to the 27th completed day (total of 28 days) Essential Newborn Care Course - Covers essential interventions in the 1st hours after birth until the first week of life - Emphasizes the need for a package /bundle of interventions

<5 year old and Neonatal Mortality, 1988 to 2008

<5 Yr Old mortality decreased 40% (1988-1998) Past 10 years, declined by 20%

Slow decline since neonatal mortality hasnt improved

80 70 60 50 40 30 20 10 0
DHS 88, 93, 98, 03, 08

Under Five Mortality Rate

Neonatal MR
1988 1993 1998 2003 2008

Causes of death in children

Undernutrition

53%

Source: CHERG estimates of under-five deaths, 2000-03

The Philippines is one of the 42 countries that account for 90% of global under five mortalities

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

Number of deaths

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

Day of Life
NDHS 2003, special tabulations

Deaths of Neonates by day of life, Philippines 1998-2003

35 30

Number of deaths

25

50% of neonatal deaths occur in the first two days of life

20

15

10

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

Children are Dying

Mortality Rates Under Five 42 Under One 29 Newborn (< 28 days) 16
(NDHS 2008)

National *

17
(NDHS 2003)

* NDHS 2008

What Immediate Newborn Care Practices will save lives?

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

Immediate Thorough Drying

Immediate drying

Stimulates breathing Prevents hypothermia

Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000, Imperial College Press: London, UK. p. 207-220; Tollin M, et al.. Cell Mol Life Sci 2005

Hypothermia which can lead to

Infection Coagulation defects Acidosis Delayed fetal to newborn circulatory adjustment Hyaline membrane disease Brain hemorrhage

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

What are the benefits of immediate skin-to-skin contact?

A. Provides warmth B. Increases overall duration of exclusive breastfeeding C. Allows colonization with good bacteria D. All of the above

What are the benefits of immediate skin-to-skin contact (SSC)?

A. Provides warmth B. Increases overall duration of exclusive breastfeeding C. Allows colonization with good bacteria D. All of the above

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 Acad Sci 2002;964:1345

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

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) RR 0.49 (95% CI 0.3, 0.81) NNT 3 (1.6 - 29.6) RR 0.59 (95% CI 0.35, 0.92) NNT 2 (1.4 - 9.8)
1) Ceriani Cernadas ,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

Preterms: less intraventricular hemorrhage

No significant impact on incidence of Post-Partum Hemorrhage

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.

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 washing until at least 6 hours

Delaying Initiation of breastfeeding increases risk of infection-related death,

RR
14 12 10 8 6 4 2 0 <1 1-24 24-48 48-72 >72
Mullany LC, et al. J Nutr, 2008; 138(3):599-603.

Nepal 2008, 22,838 breastfed babies

Hours after Birth

The evidence is solid:

The following Newborn Care Practices will save lives: Immediate and Thorough Drying Early Skin-to-Skin Contact

Properly Timed Cord Clamping

Non-separation of Newborn from Mother for Early Breastfeeding

Current State of Newborn Care Practices in Philippine Hospitals

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippines Hospitals (2009) Intervention Percentage and Median Time WHO Standard

Cord Clamp
Drying

12 sec 99% in < 1 min

97% at 1 min

Until pulsations stop (1-3 mins)

100% Immediately

Immediate Skin-to-skin contact

Put on cold surface Not dried Head not dried Wash Temp taken before

9.6% at 5 min
12% 2.5% 6.2% 84% at 8 min 17%

>90% (except those

needing resuscitation)

None None None >6 hours All

Sobel, Silvestre, Mantaring, Oliveros, 2009

A Minute-by-Minute Assessment of Newborn Care within the First Hour of Life in Philippines Hospitals (2009) Intervention Breast feed Median Time or Percentage 69.3% at 10 min WHO Standard Within 1 hour (but when baby shows signs) >1 hour > 1 hour

Separated from mother Weigh

92.9% at 12 min 100% at 13 min

Exam
Hepatitis B Vaccine Nursery Rooming in

75.7% at 17 min
69.4% at 20 min 52% at 19 min 83% (155 min)

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

Resuscitation action of 26 infants with apnea:

Action Suctioning Bag and Mask Slapping back Intubation 24 (92.3%) 12 (46.1%) at 120 seconds 7 (26.9%) 2 (7.7%) at 3 and 6 min N (%)

Chest compressions/ Epi

Drying ***

2 (7.7%) at 4 min
1 (3.8%)

*** Should be first action, immediately, for full 30 seconds, unless both floppy/limp and apneic Sobel, Silvestre, Mantaring, Oliveros, 2009

Unnecessary Resuscitation
Of

the 455 who were already breathing 94.9% suctioned once 84.0% suctioned more than once

Sobel, Silvestre, Mantaring, Oliveros, 2009

Newborn Care Practices in 51 Philippine Hospitals, 2009

Performance

and timing of evidencebased interventions in immediate newborn care are below essential newborn care standards recommended by the WHO. Hospital practices prevented Philippine newborns from benefiting from their mothers natural protection in the first hour of life.
Sobel HL, Silvestre MA, Mantaring JB III. DOH/WHO Commissioned Study on Newborn Care Practices, 2009

Differences in Practices
There

was minimal difference in timing or performance of immediate newborn interventions regardless of whether the attendant at delivery was a pediatrician, nurse or midwife

Sobel, Silvestre, Mantaring, Oliveros, 2009

Indications that a guideline is needed:

Wide

variation in practices Reports of inappropriate care High health care costs All of these indicate the Essential Newborn Care Protocol is needed in the Philippines.

Essential Newborn Care Protocol was developed to address these issues

Newborn Care Protocol

- Simple, to-the-point, user-friendly, evidencebased protocol for essential newborn care focusing on the 1st week of life - Emphasizes a core sequence of actions or steps - Need for a package/bundle of interventions - Some time-bound but doable even by a single health worker caring for both mother and newborn

Estimations of NMR impact

With 99% coverage of a selected set of: Antenatal interventions
Intrapartum interventions (including immediate newborn care)

Potential reduction in NMR 7-12%

18-35%

Postnatal interventions

17-39%

Next Steps

Dissemination Implementation Monitoring

Time Band: Prepare for the Delivery

Check temperature of the delivery room

25 - 28 o C Free of air drafts

Notify appropriate staff Arrange needed supplies in linear fashion Check resuscitation equipment Wash hands with clean water and soap Double glove just before delivery

Four Core Steps of Essential Newborn Care

Immediate

and thorough drying Early skin-to-skin contact Properly timed cord clamping Non-separation of the newborn and mother for early initiation of breastfeeding

Time Band: Within 1st 30 secs Immediate Thorough Drying

Call

out the time of birth Dry the newborn thoroughly for at least 30 seconds

Wipe the eyes, face, head, front and back, arms and legs

Remove

the wet cloth

Time Band: Within 1st 30 secs Immediate and Thorough Drying

Do a quick check of breathing while drying Notes: During the 1st secs: Do not ventilate unless the baby is floppy/limp and not breathing Do not suction unless the mouth/nose are blocked with secretions or other material

Time Band: 0 3 mins After 30 secs of drying 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 Place identification band on ankle (not wrist)

Time Band: 1 - 3 mins Properly - timed cord clamping

Remove

the first set of gloves After the umbilical pulsations have stopped, clamp the cord using a sterile plastic clamp or tie at 2 cm from the umbilical base Clamp again at 5 cm from the base Cut the cord close to the plastic clamp

Time Band: 1 - 3 mins Properly - timed cord clamping

Notes:

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 Do not apply any substance onto the cord

Time Band: Within 90 mins Non-separation of Newborn from Mother for Early Breastfeeding

Leave the newborn in skin-to-skin contact Observe for feeding cues, including tonguing, licking, rooting Point these out to the mother and encourage her to nudge the newborn towards the breast

Time Band: Within 90 mins Non-separation of Newborn from Mother for Early Breastfeeding

Counsel on positioning

Newborns neck is not flexed nor twisted Newborn is facing the breast Newborns body is close to mothers body Newborns whole body is supported

Time Band: Within 90 mins Non-separation of Newborn from Mother for Early Breastfeeding

Counsel on attachment and suckling

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

Time Band: Within 90 mins Non-separation of Newborn from Mother for Early Breastfeeding

Notes:

Minimize handling by health workers Do not give sugar water, formula or other prelacteals Do not give bottles or pacifiers Do not throw away colostrum

Time Band: Within 90 minutes Non-separation of Newborn from Mother for Early Breastfeeding

Weighing, eye care, examinations, injections (hepatitis B, BCG) should be done after the first full breastfeed is completed Postpone washing until at least 6 hours

Adopting New Policies and Protocol on Essential Newborn Care (Administrative Order # 2009 - 0025)

Scope of Application
Whole

hierarchy of the DOH and its attached agencies Public and private providers Development partners involved in the MNCHN strategy All health practitioners involved in maternal and newborn care

Time-Bound Interventions
Within 30 Seconds Objective: To provide warmth, prevent hypothermia After thorough drying Objective: To facilitate bonding through STS (infection, hypoglycemia) Up to 3 minutes Post-delivery Objective: To reduce incidence anemia in term and IVH in preterm Within 90 minutes Of age Objective: To facilitate initiation of breastfeeding through sustained contact

-Put on double Gloves -Dry thoroughly -Remove wet cloth -Quick check of NBsbreathing

-Put prone on chest/ abdomen in STS -Cover w/ blanket, bonnet -Place identification on ankle -Do not separate -Do not remove vernix

-Remove 1st set of gloves -Clamp and cut cord after cord pulsations (1-3 mins) -Do not milk cord -Active management of labor

-Leave the NB on STS contact -Observe NB for feeding cues -Counsel on positioning and attachment ** Do eye care

Non-Immediate Interventions
Vit.

K Hepatitis B BCG Re-Examination of the NB

-

Weigh Look for malformations, etc. Feeding difficulties

NB Resuscitation
Not

breathing or gasping after 30 secs of drying and stimulation or before 30 secs if floppy and not breathing Clamp and cut Call for help Transfer, provide warmth Inform the mother
Silvestre MA April 2009

Care for a small baby or twin - preterm or 1-2 months early or weighing 1,500 2,499 g
Kangaroo

Mother Care More warmth More support for breastfeeding Weigh daily Discharge planning
-

Breastfeeding well and gaining weight for past 3 days Normal temperature for past 3 days Able and confident to care for NB

Unnecessary Procedures
Routine suctioning Early bathing/washing Footprinting Giving sugar water, prelacteals, formula and using bottles and pacifiers Application of alcohol, other subs on the cord stump and bandaging the stump/ abdomen

Discharge Instructions
When to return: jaundice of the soles or any of the following are present; difficulty of feeding, convulsions, movement only when stimulated; fast or slow or difficult breathing, temp >37.5 or <35.5 C Post natal Visits: 48 72 hrs, 7 days, immunization at 6 weeks Additional Visits: 2 days, 7 days NBS

The evidence is solid:

The following Newborn Care Practices will save lives: Immediate and

Thorough Drying
Early Skin-to-Skin Contact

Properly Timed Cord Clamping

Non-separation of Newborn from Mother for Early Breastfeeding

How can I contribute to implementing ENC?

Enable

the environment for ENC

the environment that hinders

Disable

ENC
Join

us to bring Unang Yakap to your membership and every mother, father that they can influence.

CLOSING THOUGHTS

The current state of newborn care needs urgent action Evidence-based interventions are not practiced sufficiently. ENC Protocol provides an evidence-based, low cost, low technology package of interventions that will save tens of thousands of lives.
Each of us, as individuals and as organizations, have to look inward to find ways to implement ENC Join us to bring Unang Yakap to your membership and every person they can influence.

THANK YOU FOR LISTENING!