Essential Newborn Care

1. Essential Newborn Care Sarah A. Murphy, MD Pediatric Critical Care Fellow MassGeneral Hospital for Children Boston, MA

2. 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

3. Presentation Outline: Part Two • Essential care for sick newborns: • Care of low birth weight babies • Management of newborn illnesses • Neonatal Resuscitation* • Review Questions

4. 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

5. Causes of Neonatal Death (WHO 2001)

6. 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 administration • Treating newborns Bellagio, Lancet Survival Series

7. 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 Mothers • Interventions for Newborns

8. Essential Antenatal Care for Pregnant Women • Tetanus Toxoid Immunization • Iron and Folate supplementation • Treatment of infections: especially Malaria, Syphilis

9. 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

11. Tetanus • The shortest peripheral nerves are affected first • facial distortion • back and neck stiffness • Generalizes in a descending fashion • Seizures may occur • Autonomic nervous system may also be affected

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

13. 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!

14. 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

15. 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

16. Treatment of Maternal Infections 1) Malaria 2) Syphilis

17. 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

18. 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!

19. Treatment of Malaria • Provide antimalarial drugs • Use insecticide-treated bed nets

20. 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.

21. 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

22. 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

23. 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

24. 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

25. 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

27. 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

28. 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*

29. 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

30. Cleanliness The six “cleans” of the WHO 1. Clean hands of the attendant 2. Clean surface 3. Clean blade 4. Clean cord tie 5. Clean towels to dry the baby and then wrap the baby 6. Clean cloth to wrap the mother

31. 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

32. 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!!!

33. Thermal Protection Normal temperature of a newborn is between 36.5 and 37.5 degrees Celsius

34. 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

35. 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

36. Mechanisms of Heat Loss in Babies

37. 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

38. Thermal Protection • Prevention: • Hyperthermia in an infant is environmental • Do not expose infant to high temperatures, sunlight, heaters, etc!! • Treatment: • Active cooling

39. 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!!!!

40. 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

41. 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

42. 1. Initiation of breastfeeding within one hour of birth colostrum continuous 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 newborns low birthweight or premature babies HIV-infected women sick or severely malnourished babies

43. 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

44. 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

45. 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

46. 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

47. Management of Sick Infant

48. 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

49. 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

50. 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