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Surviving the First Month of Life

Surviving the First Month of Life. Lily Kak, USAID Indira Narayanan, BASICS Mini-University, George Washington University October 27, 2006. Four Million Newborn Deaths: Where?. 99% of newborn deaths are in low/middle income countries 66% in Africa and Southeast Asia.

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Surviving the First Month of Life

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  1. Surviving the First Month of Life Lily Kak, USAID Indira Narayanan, BASICS Mini-University, George Washington University October 27, 2006

  2. Four Million Newborn Deaths: Where? 99% of newborn deaths are in low/middle income countries 66% in Africa and Southeast Asia

  3. Stagnating Trends in Neonatal Mortality Sub-Saharan Africa Global Asia and Middle East Latin America and Caribbean Source: DHS and RHS estimates for countries receiving USAID support Number of countries: Global-35; ANE -8; Africa – 17; LAC: 9

  4. Neonatal Deaths and the Millennium Development Goals 150 Under-5 mortality rate 100 Global mortality per 1000 births 50 0 1960 1980 2000 2020 Year Millennium Development Goal 4 can only be achieved if neonatal deaths are addressed 1-60 mo. mortality < 1 mo. mortality (NMR) Present trend  MDG Source: Neonatal Lancet, 2005

  5. Only 50% of deliveries are attended by skilled birth attendants Coverage of Newborn Care During the Most Critical Period Up to 50% of neonatal deaths are in the first 24 hours Only 21% receive postnatal care within 7 days 75% of neonatal deaths are in the 7 days

  6. Newborn Care in Sub-Saharan Africa: the Weakest Link NIB: Non-Institutional Birth Source of data: 1999-2005 DHS; State of the World’s Children, 2006

  7. The Lancet Child and Neonatal Survival Series identified newborn survival as a priority, lacking information and action • The World Health Report advocates the repositioning of MCH as MNCH (maternal, newborn and child health) Newborn Health: No longer Falling Through the Cracks

  8. Evidence Based Interventions for • Syphilis Control • Folate Supplementation • Tetanus Toxoid Immunization of Mother • Clean Delivery • Cord Care • Early & Exclusive • Breastfeeding • Antibiotics for mother and baby Malaria Control Antenatal Corticosteriod Treatment of bacteriuria • Kangaroo Mother Care • Birth Spacing • Maternal Nutrition • Warming • Resuscitation • Skilled Birth Attendants Major Causes of Neonatal Mortality Cong. Anom 7% Infection 36% Sepsis/Pneumonia Tetanus Diarrhea Complications of Prematurity 27% Other 7% Asphyxia 23% Low birth weight is a significant contributor in 60–80% of neonatal deaths. Adapted from Lancet 2005

  9. Prophylactic Eye care Special care for LBW Iron and folate Other Essential Interventions Family planning Adequate nutrition Emergency Obstetric and Newborn Care Immunization Iodine Syphilis detection and treatment Prevention of Mother-to-Child Transmission of HIV Intermittent presumptive treatment for malaria Context-Specific Package • Minimum activities: Community • ANC • Birth preparedness • Tetanus Toxoid • Safe Birth • Clean delivery • Referral link for obstetric& newborn complications • Postpartum • Cord care • Thermal Care • Immediate & excl Breastfeeding • Infection recognition & referral/treatment • Minimum activities: Facility • ANC • Birth preparedness • Tetanus toxoid • Safe Birth with Skilled Attendance • Partograph • Infection prevention • Active mgt of 3rd stage of labor • Newborn resuscitation • Postpartum • Cord care • Thermal care • Immediate & excl breastfeeding • Infection Treatment Essential Maternal & Newborn Care USAID October, 2006

  10. Shivgarh, India Saksham LOGO A community based and community driven essential newborn care program Source: Global Research Activities, Johns Hopkins University

  11. Neonatal Mortality Rate, Shivgarh, India Source: Global Research Activities, Johns Hopkins University

  12. Sylhet, Bangladesh Projahnmo… Projahnmo A community based essential newborn care program Source: Global Research Activities, Johns Hopkins University

  13. Neonatal Mortality RatesSylhet, Bangladesh Projahnmo… Significant reduction in neonatal mortality with home-based care Source: A Community-based Effectiveness Trial to Improve Newborn Health in Sylhet District of Bangladesh, GRA/JHU, 2006

  14. Pearl # 1 All newborns need essential newborn care

  15. USAID’s Global Priorities • Introduce and expand community-based essential newborn care globally • Focus on major killers to reduce mortality: low birth weight, infections, asphyxia

  16. Management of Low Birth Weight Globally, 60-80% Neonatal Deaths occur in Babies below 2500 Gm (LBW) LBW Based on Vital Registration data for 45 countries (N = 96797). and modeled estimates for 146 countries (N = 13,685) - Lawn JE, Cousens SN. Zupan J, Lancet 2005

  17. Low Birth Weight Infants • Global burden: 21 million, 96% in developing countries • Global incidence: 16% c

  18. Distribution of 21 million LBW WHO, UNICEF. Country, regional and global estimates. 2004

  19. Priority Intervention The priority from a public health point of view is the group of larger / more mature LBW infantsCurrently, there is more evidence and experience on management than prevention of LBW infants Bang 2005

  20. Outcome of LBW babies with extra care at first referral level facility Category n Died/referred Discharged <1500g 101 28% 72% 1501-1999g 264 7% 93% 2000-2499g 1744 1% 99% All LBW 2109 3% 97% Paul VK- Ballafgarh Hospital (1994-1999)

  21. Outcome with Extra Care at Community Level With intervention, 95% LBW survived Bang 2005

  22. Extra Care for LBW Babies • Extra focus on essential newborn care especially • Temperature maintenance • Prevention of infection • More frequent breastfeeding and/or use of breast milk • Kangaroo Mother Care - major components • Skin to skin contact • Position • Nutrition • Support to mother and baby • Discharge & follow-up policy

  23. Kangaroo Mother Care (KMC) • Baby wears only a diaper (cap and socks where needed) • Placed vertically in between the mother’s breasts • Wrapped firmly / securely on to the mother’s chest • Can also be carried out by other family members

  24. KMC - Advantages • Thermal control—mother’s temperature adjusts for baby • Vital signs better—breathing more regular—less ‘periodic breathing’; less apnea • Less crying—less stress—even in term babies after delivery—salivary cortisol twice as high in control infants with standard care than with skin-to-skin contact 1 hr. post birth. • Better breastfeeding • Bonding

  25. KMC - Conclusions • Simple, effective, low cost intervention • At facility level and at home • Has global applications—both for advanced and developing countries. May be the only alternative in resource-poor situations • Other practical applications: • Just after birth for all babies (without problems needing immediate attention) • During transport of sick & LBW babies

  26. Pearl # 2 Kangaroo Mother Care is for humans too!

  27. Causes of Neonatal Mortality 7 % Others Complications of Prematurity 27% Neonatal tetanus 7% Low Birthweight Sepsis / Pneumonias 26 % Infections 36 % Congenital malformations 7 % Diarrhea 3% Birth asphyxia & trauma 23 %

  28. Neonatal Sepsis Timing of Deaths and Interventions Clean delivery Cord care Colostrum and exclusive breastfeeding Identify signs of illness- algorithms / Antibiotics Source: South Asia Newborn Health Investigators Group (Unpublished courtesy Steve Wall )

  29. Types of Infections • Minor Infections: • Thrush • Conjunctivitis • Skin infections • Umbilical infection ( localized) • Major Infections • Specific entities such as pneumonia, diarrhea, septicemia and meningitis difficult to diagnose in the newborn . Hence catch-all term “sepsis” is used in public health • Easy spread and rapid progression of disease • High case fatality • Specific infections such as syphilis, HIV/AIDS, Hepatitis B, tetanus, and malaria

  30. Timing of Infections • Early onset of infection (0-3d) is usually acquired from maternal risk factors and during delivery such as: • Maternal fever • Premature rupture of the membranes (>12-18-24 hr) • Unhygienic delivery practices • Poor cord care • Late onset of infection (4-30d) are usually acquired from the environment (most likely acquired in the home or facility - nosocomial) due to factors such as: • Unhygienic newborn care practices (i.e., lack of hand washing) • Excessive invasive procedures Trotman Ann. Tropical Paediatrics 2006 and Robillard West Indian Medical Journal 2001

  31. Neonatal Sepsis Key Components Of Prevention • Antenatal period: • Addressing tetanus, STD, HIV/AIDS and malaria • Delivery: • Clean delivery practices, preventive Essential Newborn Care (ENC) –hygiene-clean cord and skin care, breastfeeding • Postnatal period: • Preventive maternal and newborn care – clean cord and skin care, breastfeeding

  32. Newborn Care: Impact of Options on Mortality - Community Level Fall in NMR 23.1% Percentage Fall in NMR 62.2% Preventive ENC+HBC of sick babies PreventiveENC Bang et al Pratinidhi et al

  33. Neonatal Sepsis: Clinical Characteristics • Newborns, notably LBW infants are at high risk for infection • Easy spread to other organs and rapid progression of disease • Specific diagnosis difficult in major infections – hence catch-all term “sepsis” is used • High case fatality • Susceptible to special germs that do not affect normal older infants • Most require injectable antibiotics • Organisms vary by region, over time and with long term use of antibiotics All these have public health implications

  34. Neonatal Sepsis :Danger Signs • Numbers vary (1st 4 or 5 most important) • refusal to feed/suck/poor feeding • inactivity/lethargy/ ‘limp limbs’ • body hot/cold • Rapid breathing /difficulty in breathing • chest in-drawing, grunting/nasal flaring • weak/no cry • vomiting/abdominal distention • periumbilical redness/pus discharge Based on Bang et al, BASICS country programs • IMCI – 11-15 signs

  35. Neonatal Sepsis:Needed Government Policies • Availability of drugs, supplies, and equipment Need for appropriate • Antibiotics, including required strengths • Supplies and equipment including suitable sizes • Quality of services at the facility • Policies of administration of antibiotics by less qualified health workers in special situations

  36. Neonatal Sepsis: Link with IMCI • Conventional IMCI addresses babies older than 1 week • Now newborns included by WHO and by some countries • One prominent example is IMNCI-India • Includes 0-6 days of age • 50% of training time on infants 0-2 months of age • Home-based care of young infants by workers added • In severe illness administration of first dose of oral antibiotics before referral • Requires training, supervision, and suitable drugs and supplies • Needs to be applied at facility and community level

  37. Neonatal Sepsis: Major Infections • Major infections: • Early stage: Baby can accept feeds and maintain temperature with simple aids • Late stage: Baby cannot feed and/or maintain temperature with simple aids • Influences level of treatment

  38. Management of Neonatal Infections

  39. Pearls for Today All newborns need … Kangaroo mother care is for…

  40. Care of the sick newborn is challengingbut will improve mortality outcomes to better achieve MDG #4Babies are worth itWe need to act NOW!

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