managing low birth weight and sick newborns

1. Managing Low Birth Weight and Sick Newborns Advances in Maternal and Neonatal Health The purpose of this presentation is to discuss experiences with low birth weight newborns. WHO estimates that almost half of newborn mortality is associated with preterm or low birth weight babies (Child Health Research Project and Maternal and Neonatal Health Program 1999). Note: In this presentation, the term “newborn” refers to a baby between birth and one month old.The purpose of this presentation is to discuss experiences with low birth weight newborns. WHO estimates that almost half of newborn mortality is associated with preterm or low birth weight babies (Child Health Research Project and Maternal and Neonatal Health Program 1999). Note: In this presentation, the term “newborn” refers to a baby between birth and one month old.

2. 2 Managing Low Birth Weight and Sick Newborns

3. 3 Managing Low Birth Weight and Sick Newborns Management of Newborn Illness Education of mothers to recognize danger signals Working with families to develop complication plan for newborns Early recognition and appropriate management of newborn illness

4. 4 Managing Low Birth Weight and Sick Newborns Minimum Preparation for ANY Birth The following should be available and in working order: Heat source Mucus extractor Self-inflating bag of newborn size 2 masks (for normal and small newborns) 1 clock At least one person skilled in newborn resuscitation present at birth Alternative devices in place of self-inflating bag are now being developed that are safe and effective. Milner A et al. 1990. A device for domiciliary neonate resuscitation. Lancet 335: 273-275. Alternative devices in place of self-inflating bag are now being developed that are safe and effective. Milner A et al. 1990. A device for domiciliary neonate resuscitation. Lancet 335: 273-275.

5. 5 Managing Low Birth Weight and Sick Newborns Essential Care for All Newborns Most newborns breathe as soon as they are born and only need: A clean and warm welcome Vigilant observation Warmth To be observed for breathing To be given to the mother for warmth and breastfeeding The most crucial aspects of essential newborn care are warmth and breathing. Placing the newborn on a warm surface and drying the newborn helps maintain body temperature and prevent hypothermia.The most crucial aspects of essential newborn care are warmth and breathing. Placing the newborn on a warm surface and drying the newborn helps maintain body temperature and prevent hypothermia.

6. 6 Managing Low Birth Weight and Sick Newborns Immediate Care of the Newborn: Warmth Lay newborn on mother’s abdomen or other warm surface Immediately dry newborn with clean (warm) cloth or towel Remove wet towel and wrap/cover newborn, except for face and upper chest, with a second towel/cloth Warmth is essential for newborns, to help maintain body temperature. The best source of warmth is the mother’s skin. To avoid heat loss, the newborn must also be dry.Warmth is essential for newborns, to help maintain body temperature. The best source of warmth is the mother’s skin. To avoid heat loss, the newborn must also be dry.

7. 7 Managing Low Birth Weight and Sick Newborns Immediate Care of the Newborn: Warmth (continued) Blood on newborn is not a risk to newborn, but is a risk to caregiver Bathe after 24 hours In areas with high HIV prevalence, consider bathing earlier to reduce risk of maternal-fetal transmission, and to reduce risk to caregiver and to other newborns Avoid bathing too early (within 24 hours) to prevent heat loss (except in areas with high HIV prevalence, where bathing may help reduce maternal-fetal transmission.Avoid bathing too early (within 24 hours) to prevent heat loss (except in areas with high HIV prevalence, where bathing may help reduce maternal-fetal transmission.

8. 8 Managing Low Birth Weight and Sick Newborns Immediate Care of the Newborn Assess breathing Keep head in a neutral position IMMEDIATELY assess respirations and need for resuscitation The most important vital sign to assess is respiration. Do not hesitate to begin resuscitation is needed.The most important vital sign to assess is respiration. Do not hesitate to begin resuscitation is needed.

9. 9 Managing Low Birth Weight and Sick Newborns Signs of Good Health at Birth Objective measures Breathing Heart rate above 100 beats/minute Subjective measures Vigorous cry Pink skin Good muscular tone Good reactions to stimulus Objective measures are most useful in determining whether a newborn needs to be resuscitated. Of these measures, breathing is the most important. If a newborn does not start or keep breathing, resuscitation should be started immediately. Do not delay to assess muscular tone, skin color, etc. Objective measures are most useful in determining whether a newborn needs to be resuscitated. Of these measures, breathing is the most important. If a newborn does not start or keep breathing, resuscitation should be started immediately. Do not delay to assess muscular tone, skin color, etc.

10. 10 Managing Low Birth Weight and Sick Newborns Birth Asphyxia Definition: Failure to initiate and sustain breathing at birth Magnitude: 3% of 120 million newborns each year in developing countries develop birth asphyxia and require resuscitation An estimated 900,000 of these newborns die as a result of asphyxia

11. 11 Managing Low Birth Weight and Sick Newborns Steps in Resuscitation Anticipate need for resuscitation at every birth, be prepared with equipment in good condition Prevent of heat loss (dry newborn and remove wet clothes) Assess breathing Resuscitate: Open airway Position newborn Clear airway Ventilate Evaluate The steps in resuscitation are to: Open the airway: Slightly extend the head and clear the airway Begin ventilation: Use a size 0 (small newborn) or 1 (normal newborn) mask. Ensure a good seal around the nose and mouth so that the airways are properly getting air. Continually assess the newborn’s progress. The steps in resuscitation are to: Open the airway: Slightly extend the head and clear the airway Begin ventilation: Use a size 0 (small newborn) or 1 (normal newborn) mask. Ensure a good seal around the nose and mouth so that the airways are properly getting air. Continually assess the newborn’s progress.

12. 12 Managing Low Birth Weight and Sick Newborns Assess Breathing

13. 13 Managing Low Birth Weight and Sick Newborns Open Airway Position newborn on its back Place head in slightly extend position Suction mouth then nostrils

14. 14 Managing Low Birth Weight and Sick Newborns Ventilate Select appropriate mask size to cover chin, mouth and nose with a good seal Squeeze bag with two fingers or whole hand, look for chest to rise If chest not rising: Reposition head and mask Increase ventilation Repeat suctioning If ventilation does not work, it may be due to a technical problem. Reposition the newborn’s head and mask first, then try increasing the pressure with which air is ventilated. Also, repeat suctioning to clear the airway.If ventilation does not work, it may be due to a technical problem. Reposition the newborn’s head and mask first, then try increasing the pressure with which air is ventilated. Also, repeat suctioning to clear the airway.

15. 15 Managing Low Birth Weight and Sick Newborns Evaluate

16. 16 Managing Low Birth Weight and Sick Newborns Harmful and Ineffective Resuscitation Practices Practices to be avoided include: Routine aspiration of the newborn’s mouth and nose as soon as the head is born Routine aspiration of the newborn’s stomach at birth Stimulation of the newborn by slapping or flicking the soles of her/his feet: only enough stimulation for mildly depressed-delays resuscitation Postural drainage and slapping the back: dangerous These practices may be dangerous, but also delay the initiation of effective resuscitative measures. Slapping or flicking the soles of the feet is only useful for mildly depressed newborns, and only results in delaying effective resuscitative efforts in newborns who are asphyxiated. Using postural drainage or slapping the newborn’s back may cause trauma, as can squeezing the chest. Aspiration of the nose, mouth and stomach can cause brachycardia. Study by Takroni et al 1998 suggests heavy meconium should be aspirated on the perineum, but intubation only called for if signs of asphyxia are present. Vigorous newborns do not need intubation to prevent MAS. Bulb aspiration vs Delee equally effective. Locus et al 1990.These practices may be dangerous, but also delay the initiation of effective resuscitative measures. Slapping or flicking the soles of the feet is only useful for mildly depressed newborns, and only results in delaying effective resuscitative efforts in newborns who are asphyxiated. Using postural drainage or slapping the newborn’s back may cause trauma, as can squeezing the chest. Aspiration of the nose, mouth and stomach can cause brachycardia. Study by Takroni et al 1998 suggests heavy meconium should be aspirated on the perineum, but intubation only called for if signs of asphyxia are present. Vigorous newborns do not need intubation to prevent MAS. Bulb aspiration vs Delee equally effective. Locus et al 1990.

17. 17 Managing Low Birth Weight and Sick Newborns Squeezing the chest to remove secretions from the airway Routine giving of sodium bicarbonate to newborns who are not breathing Intubation by an unskilled person Some traditional practices: Putting alcohol in newborn’s nose Sprinkling or soaking newborn with cold water Stimulating anus Slapping newborn Harmful and Ineffective Resuscitation Practices (continued) These practices may be dangerous, but also delay the initiation of effective resuscitative measures. Sprinkling cold water on the newborn can result in hypothermia. Intubation by unskilled personnel can injure the respiratory or alimentary tract.These practices may be dangerous, but also delay the initiation of effective resuscitative measures. Sprinkling cold water on the newborn can result in hypothermia. Intubation by unskilled personnel can injure the respiratory or alimentary tract.

18. 18 Managing Low Birth Weight and Sick Newborns Infection Prevention for Resuscitation Handwashing Use of gloves Careful suctioning if using a mucus extractor operated by mouth Careful cleaning and disinfection of equipment and supplies Do not reuse bulb—difficult to clean, poses risk of cross infection Correct disposal of secretions Infection prevention is very important.Infection prevention is very important.

19. 19 Managing Low Birth Weight and Sick Newborns Documentation Details of the resuscitation to be recorded include: Identification of newborn Condition at birth Procedures necessary to initiate breathing Time from birth to initiation of spontaneous breathing Clinical observations during and after resuscitation Outcome of resuscitation In case of failed resuscitation, possible reasons for failure Names of healthcare providers involved

20. 20 Managing Low Birth Weight and Sick Newborns Post-Resuscitation Tasks:Successful Resuscitation Do not separate mother and newborn Leave newborn skin-to-skin with mother (kangaroo care) Measure temperature, count breaths, observe for indrawing and grunting Encourage breastfeeding within 1 hour after birth

21. 21 Managing Low Birth Weight and Sick Newborns Inform patients fully Provide counseling, as needed If culturally appropriate, allow parents private time with dead newborn Burial should be arranged according to regulations and parents’ wishes Post-Resuscitation Tasks:Unsuccessful Resuscitation

22. 22 Managing Low Birth Weight and Sick Newborns Policy Decisions for Resuscitation Guidelines on when to start: Apparently stillborn newborn Malformations: Lethal Less severe malformations Extremely low gestational age Guidelines on when to stop: 20 minutes

23. 23 Managing Low Birth Weight and Sick Newborns Principles of Success Readily available personnel Skilled providers Coordinated team Resuscitation tailored to newborn response Available and functioning equipment Avoidance of harmful and ineffective practices Follow rules for infection prevention

24. 24 Managing Low Birth Weight and Sick Newborns Care of the Low Birth Weight Newborn Birth weight = Gestation duration + intrauterine growth Most low birth weight newborns in developing countries are term or near term (Small for gestation age) Increased risk of hypothermia and poor growth Low birth weight newborns have low body mass and more body surface area, and therefore have a greater tendency to lose heat. Thermal protection is, therefore, even more important.Low birth weight newborns have low body mass and more body surface area, and therefore have a greater tendency to lose heat. Thermal protection is, therefore, even more important.

25. 25 Managing Low Birth Weight and Sick Newborns Care of the Preterm Newborn Associated problems with prematurity: Feeding Respiratory Jaundice Intracranial bleed

26. 26 Managing Low Birth Weight and Sick Newborns Principles of Management for Low Birth Weight and Preterm Newborns Warmth Feeding Detection and management of complications (e.g., resuscitation, assisted respiration)

27. 27 Managing Low Birth Weight and Sick Newborns Warmth As for all newborns: Lay newborn on mother’s abdomen or other warm surface Dry newborn with clean (warm) cloth or towel Remove wet towel and wrap/cover with a second dry towel Bathe after temperature is stable

28. 28 Managing Low Birth Weight and Sick Newborns Warmth: Problem with Incubators Potential source of infection Often temperature controls malfunction Often share incubator for more than one newborn Need alternative method: kangaroo care

29. 29 Managing Low Birth Weight and Sick Newborns Feeding Early and exclusive breastfeeding Breastmilk = best nourishment Already warm temperature Facilitated by kangaroo care

30. 30 Managing Low Birth Weight and Sick Newborns Definition of Kangaroo Care Early, prolonged and continuous skin-to-skin contact between a mother and her newborn Could be in hospital or after early discharge Included Small for gestational age/low birth weight No gestational age limits No oxygen or IV fluids needed, partly able to feed No visible malformations Included Small for gestational age/low birth weight No gestational age limits No oxygen or IV fluids needed, partly able to feed No visible malformations

31. 31 Managing Low Birth Weight and Sick Newborns How to Use Kangaroo Care Newborn’s position: Held upright (or diagonally) and prone against skin of mother, between her breasts Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways Newborn’s clothing: Usually naked except for nappy and cap May be dressed in light clothing Mother covers newborn with her own clothes and added blanket or shawl

32. 32 Managing Low Birth Weight and Sick Newborns How to UseKangaroo Care (continued) Newborn should be: Breastfed on demand Supervised closely and temperature monitored regularly Mother needs lots of support because kangaroo care: Is very tiring for her Restricts her freedom Requires commitment to continue

33. 33 Managing Low Birth Weight and Sick Newborns Effectiveness of Kangaroo Care Randomized controlled trial Conducted in three tertiary and teaching hospitals in Ethiopia, Indonesia and Mexico Study effectiveness, feasibility, acceptability and cost of kangaroo mother care when compared to conventional methods of care

34. 34 Managing Low Birth Weight and Sick Newborns Benefits of Kangaroo Care Is efficient way of keeping newborn warm Helps breathing of newborn to be more regular; reduce frequency of apneic spells Promotes breastfeeding, growth and extra-uterine adaptation Increases the mother’s confidence, ability and involvement in the care of her small newborn Seems to be acceptable in different cultures and environments Contributes to containment of cost— salaries, running costs (electricity, etc.)

35. 35 Managing Low Birth Weight and Sick Newborns Summary Skilled attendant Equipment available and working Begin resuscitation immediately Ventilate Reassess frequently Kangaroo care once successful

36. 36 Managing Low Birth Weight and Sick Newborns References Cattaneo et al. 1998. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 87: 976–985. de Leeuw R et al. 1991. Physiologic effects of kangaroo care in very small preterm infants. Biology of the Neonate 59: 149–155. Karlsson H. 1996. Skin-to-skin care: heat balance. Arch Dis Child 75:F130–F132. Lamb ME. 1983. Early mother-neonate contact and mother-child relationship. J Child Psychol Psychiatry 24(3): 487–494. Ludington-Hoe SM et al. 1994. Kangaroo care: Research results, and practice implications and guidelines. Neonatal Network 13(1): 19–27. Ross GS. 1980. Parental responses to infants in intensive care. The separation issue re-evaluated. Clin Perinatol 7: 47–60. World Health Organization (WHO). 1998. Basic Newborn Resuscitation: A Practical Guide. WHO: Geneva.