Essential Newborn Care

Sarah A. Murphy, MDPediatric Critical Care FellowMassGeneral Hospital for ChildrenBoston, MA

Presentation Outline: Part One

Background: the problem of neonatal mortality WHO “Essential Interventions” for Mothers

Tetanus Toxoid Immunization Iron and Folate supplementation Treatment of infections: especially Malaria, Syphilis

WHO “Essential Interventions” for Newborns Essential care for all newborns

Cleanliness Thermal protection Early and exclusive breast-feeding Eye Care Immunization

Presentation Outline: Part Two

Essential care for sick newborns: Care of low birth weight babies Management of newborn illnesses Neonatal Resuscitation*

Review Questions

Background: Neonatal Mortality Neonatal mortality: death < 28 days after birth 40% of all child deaths (<5 yo) are neonatal! Highest rates in sub-Saharan Africa Africa: > 1 million neonatal deaths every year 38% die of infections Most are low birthweight (LBW) & many preterm Liberia: very high rate – 6.6% die in first month

Causes of Neonatal Death (WHO 2001)

Birth Asphyxia31%

Complications of Prematurity

25%

Congenital Anomalies

11%

Infections33%

Background: Neonatal Mortality

325,000 deaths from sepsis & pneumonia in Africa . Simple preventive practices can save most!

Existing interventions can prevent 35-55% neonatal deaths worldwide

These interventions include:Treating pregnant women

for example, tetanus toxoid administrationTreating newborns

Bellagio, Lancet Survival Series

WHO Essential Interventions

This presentation will review the principles behind the “essential interventions” identified by the WHO as having the greatest potential to reduce newbown mortality:

Interventions for MothersInterventions for Newborns

Essential Antenatal Care for Pregnant Women

Tetanus Toxoid ImmunizationIron and Folate supplementationTreatment of infections: especially

Malaria, Syphilis

Tetanus Caused by Clostridium tetani G+, anaerobic bacterium sensitive to heat & oxygen Spores are very resilient and found in soil & animals

GI tract of horses, sheep, cattle, dogs, cats, chickens, others. Spore inoculation occurs through dirty wounds. Once inside, spores germinate and produce tetanospasmin

A very potent neurotoxin Tetanospasmin dissminates in lymph and blood to all

nerves Toxin blocks neurotransmitter release and causes

unopposed muscle contraction and painful muscle spasms

Tetanus

The shortest peripheral nerves are affected firstfacial distortionback and neck stiffness

Generalizes in a descending fashion Seizures may occur Autonomic nervous system may also be

affected

Tetanus cases reported worldwide (1990-2004). Ranging from strongly prevalent (in dark red) to very few cases (in light yellow) (gray, no data).

Tetanus

Tetanus kills an estimated 70,000 newborns in Africa each year six percent of all neonatal deaths

It is very hard to treat neonatal tetanus!! Preventing the disease by immunizing mothers

is critical!

Tetanus

Tetanus can be prevented through immunization with tetanus-toxoid (TT) -containing vaccines

Mothers should receive at least 2 TT vaccines during pregnancy!!

This protects the mother and - through a transfer of tetanus antibodies to the fetus - her baby

Iron and Folate Supplementation

Iron deficiency anemia affects almost half of all women

Maternal anemia contributes significantly to maternal mortality and causes an estimated 10,000 deaths per year

Newborns of mothers with anemia are more likely to have low birth weight, be born too early, or die shortly after birth

Also at greater risk for cognitive impairment

Folate supplements before and around conception can reduce the occurrence of neural tube defects in newborns

Treatment of Maternal Infections

1) Malaria2) Syphilis

Treatment of Maternal Malaria:

Malarial infection causes 400,000 cases of severe maternal anemia yearly

And responsible for 75,000-200,000 infant deaths

annually

Effects on fetus: fetal loss premature delivery intrauterine growth retardation low birth-weight infant

Treatment of Maternal Malaria

In high malaria areas, women have some immunity that wanes during pregnancy Malaria infection results in severe maternal anemia and

delivery of low birth-weight infants

In low malaria transmission areas, women have not developed immunity Malaria infection results in severe malaria disease, maternal

anemia, premature delivery, or fetal loss

Malaria is a major factor in low birth weight babies and amenable to intervention!

Treatment of Malaria

Provide antimalarial drugs Use insecticide-treated bed nets

WHO guidelines for the treatment of Malaria in

pregnancy Intermittent Preventive Treatment

All pregnant women in areas of stable malaria transmission should receive at least 2 doses of IPT after quickening

The World Health Organization recommends a schedule of 4 antenatal clinic visits, with 3 visits after quickening

The delivery of IPT with each scheduled visit after quickening will assure that a high proportion of women receive at least 2 doses

The most effective drug for IPT is sulfadoxine-pyrimethamine (SP) because of its safety for use during pregnancy, effectiveness in reproductive-age women, and feasibility for use

IPT-SP doses should not be given more frequently than monthly. Insecticide-Treated Nets

ITNs should be provided to pregnant women as early in pregnancy as possible.

Their use should be encouraged for women throughout pregnancy and during the postpartum period.

Placental Infection

Malaria-infected human placenta examined under the microscope. The intervillous spaces (central area of the picture) are filled with red blood cells, most of which are infected with Plasmodium falciparum malaria parasites

Treatment of Maternal Syphilis

Provide screening and treatment in areas where syphilis is endemic Untreated syphilis can cause

malformation, illness, or death of a fetus or newborn

Treatment of Syphilis

Syphilis is a sexually transmitted disease caused by a spirochete ~ Treponema pallidum

Syphilis can cause miscarriages, premature birth, still-birth, or death of newborn babies: 40% of births to syphilitic mothers are stillborn 40-70% of the survivors will be infected 12% of these will subsequently die

Syphilis Some infants have symptoms at birth, most develop

symptoms later Late congenital syphilis occurs in children greater that 2

years of age: Hutchinson teeth Interstitial keratitis Deafness Frontal bossing Saddle nose Swollen knees Saber shins Short maxillae Protruding mandible

Sores on infected babies are infectious

Congenital Syphilis Failure to gain weight Fever Irritability No bridge to nose (saddle nose) Early rash -- small blisters on the palms and soles Later rash -- copper-colored, flat or bumpy rash on the face, palms,

soles Rash of the mouth, genitalia, and anus Severe congenital pneumonia Watery discharge from the nose Blindness Clouding of the cornea Decreased hearing or deafness Gray, mucous-like patches

Treatment of Syphilis

One dose of penicillin will cure a person who has had syphilis for less than a year

More doses are needed to cure someone who has had it for longer

A baby born with the disease needs daily penicillin treatment for 10 days

Essential Care for Newborns

Essential care for all newborns Cleanliness Thermal protection Early and exclusive breast-feeding Eye Care Immunization

Essential care for sick newborns Care of low birth weight babies Management of newborn illnesses Neonatal Resuscitation*

Routine Supportive Care for All Newborns after delivery

Keep baby dry and warm Keep baby with mother – room in Initiate breast-feeding within 1 hour Give Vitamin K Keep umbilical cord clean and dry Apply eye ointment to prevent infection Give oral polio, BCG, and hepatitis B

injections

Cleanliness

The six “cleans” of the WHO1. Clean hands of the attendant2. Clean surface3. Clean blade4. Clean cord tie5. Clean towels to dry the baby and then

wrap the baby6. Clean cloth to wrap the mother

Cleanliness Hygiene during delivery:

Clean hands, perineum, delivery surface Sterilized equipment

Clean cutting of umbilical cord Clean hands with soap and water, under the nails Sterile razor blade for cutting cord Sterile ties or gauze to tie cord off

Umbilical cord care Umbilical stump is main source of entry for infections Cord should be kept clean and dry, no dressings should be

applied if stump is able to be kept clean without them Infant’s clothes and blanket should be kept clean If cord becomes dirty, it should be washed and then dried with

clean cotton or gauze

Cleanliness

Prevention of hospital infections: Rooming-in with mother:

Allows micro-organisms from mother to be given to infant These tend to be non-pathogenic Mother can give antibodies to these organisms to the

baby through breast-milk Reduces risk of cross-infection when babies are not being

roomed together No over-crowding Clean water Importance of hospital staff hand-washing!!!

Thermal Protection

Normal temperature of a newborn is between 36.5 and 37.5 degrees

Celsius

Thermal Protection Hypothermia can be a sign of infection!!!

Hypothermia is temperature less than 36.5 degrees C Large surface area Poor insulation Small body mass to produce heat

Signs of hypothermia cool hands and feet less active or lethargic Hypotonic poor suck weak cry shallow breathing redness of face and skin

Thermal Protection

Preventing hypothermia: deliver infant in warm room dry thoroughly after birth, including drying the head, wrap in warm dry cloth give to mother as soon as possible for skin to skin

contact no washing in the 1st 6 hours after birth

Treatment: skin to skin contact warm water bottles loosely wrapped warm blanket

Mechanisms of Heat Loss in Babies

Thermal Protection

Hyperthermia is a temperature > 37.5 degrees C Signs:

Irritable Rapid respirations Rapid heart rate Hot and dry skin Lethargic Convulsions

Hyperthermia is often accompanied by dehydration and re-hydration should be considered if infant is showing any signs

Thermal Protection

Prevention: Hyperthermia in an infant is environmental Do not expose infant to high temperatures,

sunlight, heaters, etc!!

Treatment: Active cooling

Early and Exclusive Breast-feeding

Early and exclusive breastfeeding is one of the least expensive and most cost-effective interventions for saving children’s lives!!!!

Early and Exclusive Breastfeeding

Exclusive breastfeeding for six months and continued breastfeeding for the first year could avert 13 percent of the more than 10 million deaths among children

Benefits: including improved cognitive development reduced risk of infections better overall chances of survival

Early and Exclusive Breastfeeding

Formula feeding raises risk of illness by depriving infants of infection-fighting components of human milk

Bottle feeding carries risks of possible contamination of water and formula

In areas with a high level of infectious disease and unsafe water, an infant who is not breastfed during the first 2 months of life is up to 23 times more likely to die from diarrhea

1. Initiation of breastfeeding within one hour of birthcolostrumcontinuous skin-to-skin contact

2. Exclusive breastfeeding for six months

3. Assess for good attachment and positioning

4. Prompt treatment of breast conditions

5. Frequent breastfeeds, day and night (8-12 times per 24 hours)

6. Continuation of breastfeeding when mother or newborn is ill

7. Extra support for feeding more vulnerable newbornslow birthweight or premature babiesHIV-infected womensick or severely malnourished babies

Early and Exclusive Breast-feeding

Breast-feeding and HIV: Exclusive breastfeeding recommended for all

mothers in HIV-endemic areas, including HIV-positive mothers where

alternatives are not acceptable, feasible, affordable, sustainable, and safe

This applies to much of sub-Saharan Africa and South Asia, among other places.

Exclusive breastfeeding is associated with two to four times lower rates of mother to child transmission of HIV compared to non-exclusive breastfeeding

Eye Care: application of topical antibiotic

Tetracycline eye ointment Prevents infection of tissues surrounding

the eyes caused by bacteria from the birth canal The most significant of these bacteria are

gonorrhea and chlamydia Also helps prevent infection with other bacteria Untreated, gonorrhea and chlamydia can cause

permanent visual impairment and also spread to other parts of the body such as the lungs causing pneumonia

Immunization

Each year, over four million African children die before their fifth birthday, many from vaccine-preventable diseases

Immunizations will be covered in later lecture But, notably, there are a number of vaccines

given to babies just after birth to be aware of:• BCG vaccination to reduce the risk of tuberculosis• Hepatitis B vaccination to prevent hepatitis B infection• OPV to prevent polio infection

Supportive Care for All Newborns after delivery: KEY

POINTS!!! Keep baby dry and warm Keep baby with mother – room in Initiate breast-feeding within 1 hour Give Vitamin K Keep umbilical cord clean and dry Apply eye ointment to prevent infection Give oral polio, BCG, and hepatitis B

injections

Management of Sick Infant

Management of Sick Infant: Outline

Care for ALL sick infants Recognizing danger signs Treating serious bacterial infection Treating convulsions Treating low birth weight baby Review of key points

Management of Newborn Illness

Neonates and young infants present with non-specific symptoms which may indicate a serious illness or serious bacterial illness

It is imperative to monitor for and recognize these danger signs to initiate treatment early

Treatment is aimed at stabilizing child and preventing deterioration

General principles of management of all sick

infants:Keep infant dry and warm

Wrap infant Cap Kangaroo infant with mother if possible

Follow temperature closely

General principles of management of sick infants:Encourage frequent breast-feeding if

infant is alert If baby is lethargic or having frequent

convulsions, avoid oral feeding

General principles of management of sick infants: If giving IV fluids, follow the TOTAL amount of

fluids given to infant This includes oral and IV fluid WHO recommends:

60cc/kg/day on Day 1 90cc/kg/day on Day 2 120cc/kg/day on Day 3 150cc/kg/day thereafter

Note: Infant may need more fluids if kept under radiant warmer

Note: Following infant’s weight is good measure of over or under-hydration

General principles of management of sick infants:

Oxygen should be given by nasal prongs at initial flow rate of 0.5L/min

If able to follow pulse oximeter, goal is oxygen saturation greater than 90%

Recognizing Danger Signs

Danger signs in a newborn:• Convulsions• Drowsy or unconscious• Not feeding well• Fast breathing (more than 60 breaths per

minute)• Slow breathing (less than 20 breaths per

minute or not breathing)• Grunting or severe chest in-drawing• Fever (above 38°C)

Recognizing Danger Signs

Danger signs in a newborn:• Hypothermia (below 35.5°C),• Very small baby (less than 1500 grams or born

more than two months early)• Bleeding• Severe jaundice• Severe abdominal distension• Bulging fontanelle• Signs of local infection (ex: swollen joints, skin

pustules or redness)• Central cyanosis

Emergency Treatment of Danger Signs

Give oxygen by nasal prongs or catheter to any ill-appearing infant

Especially if having respiratory symptoms

Provide bag and mask ventilation if breathing is too slow or labored

With oxygen if available, or room air

Emergency Treatment of Danger Signs

Give penicillin/ampicillin and gentamicin as soon as possible to any infant presenting with signs of illness

Emergency Treatment of Danger Signs

If convulsing, give Phenobarbital (IM 15mg/kg)

If patient is drowsy, unconscious, or convulsing:

Check blood sugar if possible, give IV glucose if blood sugar is low

If unable to check blood sugar, give IV glucose If unable to give IV glucose, give either

expressed breast-milk or glucose through a nasogastric tube

Emergency Treatment of Danger Signs

Give vitamin K injection to all sick newborns if they have not already received it

Serious Bacterial Illness

Serious bacterial infection should be suspected if an infant presents with any DANGER SIGN

Risks for serious bacterial infection include: maternal fever rupture of membranes for more than 24 hours foul-smelling amniotic fluid

Serious Bacterial Illness

Also look for signs of a local infection: swollen jointsmany severe skin pustulesbulging fontanelleredness around umbilicuspus from umbilicus

Serious Bacterial Illness

Treatment of suspected serious bacterial illness: Admit to Hospital Send blood cultures if possible Ampicillin/Penicillin and Gentamicin for 10 days If no improvement in 2-3 days consider changing

antibiotics If extensive skin infection consider giving

Cloxacillin if available instead of Penicillin for staph aureus coverage

Convulsions

Treatment:Initial dose of Phenobarbital is 15mg/kg IMIf convulsions continue, give 10mg/kg IM

in repeat doses up to maximum of 40mg/kgMonitor for apnea or slowed breathing and

assist breathing if neededCheck for low blood sugarContinue daily Phenobarbital at 5mg/kg if

needed

Low Birth Weight Baby

Most newborn deaths are among low birthweight babies

Low birth weight is baby weighing less than 2500 grams

Simple care of these small babies, close monitoring and early treatment of problems could save many newborn lives

Low Birth Weight Baby

Birthweight of 2.25-2.5kg These infants normally do well with routine

newborn care Monitor carefully Ensure proper warmth and infection control

Low Birth Weight Baby

Birthweight 1.75 to 2.25kgInitiate Kangaroo Care for warmthStart feeding within 1 hrIf infant is able to nurse, allow normal,

frequent breast-feedingIf infant cannot breast-feed, give

expressed breast-milk by cup and spoonMonitor carefully for signs of infection

Low Birth Weight Baby

Birthweight less than 1.75 kg These infants need to be admitted to special care

nursery for extra care Give oxygen by nasal prongs or nasal catheter if

there are any signs of difficulty breathing, fast breathing rate or cyanosis

Maintain temperature of 36-37 deg C Kangaroo Care Humidicrib if available Hot water bottle wrapped in a towel if no heating source

Low Birth Weight Baby

Birthweight less than 1.75 kg If possible, give IV fluids Give 2-4ml of expressed breastmilk every 2

hours by nasogastric tube IF: baby looks well no abdominal distension bowel sounds present baby has passed meconium,

If baby is tolerating these feeds, increase volume slowly

Low Birth Weight Baby

Birthweight less than 1.75 kgMonitor for signs of infection and begin

antibiotic therapy if any sign prsentIf infant has apnea, treat:

caffeine citrate 20mg/kg PO or IV x 1, then daily 5mg/kg

OR aminophylline 10mg/kg x 1, then 2.5 - 4 mg/kg q 12 hours

Low Birth Weight Baby Kangaroo Care:

The baby is undressed except for cap, nappy, and socks Placed upright between the mother’s breasts, with head

turned to one side Then tied to the mother’s chest with a cloth and covered with

the mother’s clothes If the mother is not available, the father or any adult can

provide skin-to-skin care

Provides warmth, breastfeeding, protection from infection, stimulation, and love

Effective way to care for a small baby weighing between 1,000 and 2,000 grams who has no major illness

Low Birth Weight Baby

Kangaroo Care:This care is continued until the infant no

longer accepts it, usually when the weight exceeds 2,000 grams

Research has shown that for preterm babies, KMC is at least as effective as an incubator

Shorter average stay in hospital compared to conventional care, have fewer infections, and gain weight more quickly

Neonatal Resuscitation Prototcols

See next lecture in the series