Essential Newborn Care (ENC) and Breastfeeding

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Essential Newborn Care (ENC) and Breastfeeding
Mariella S. Castillo, MD, MSc Maternal Child
Health Team WHO Philippines WomenDeliver
Philippines Conference 15 September 2010
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Outline

• The problem
• The evidence What can save newborns from dying?
• The Philippine situation
• The response
• Next steps

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Philippines
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lt5 year old and Neonatal Mortality, 1988 to 2008

• lt5 Yr Old mortality decreased 40 (1988-1998)
• Past 10 years, declined by 20
• Slow decline since neonatal mortality hasnt
  improved

Under Five Mortality Rate
Neonatal MR
DHS 88, 93, 98, 03, 08
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82,000 Filipino children die annually, most
could have lived
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 mortality
Office of the WHO Representative in the
Philippines
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Majority of newborns die due to stressful events
or conditions during labor, delivery and the
immediate postpartum period.
3 out of 4 newborn deaths occur in the week of
life
Number of deaths
Day of Life
NDHS 2003, special tabulations
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Philippines
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Outline

• The problem
• The evidence What can save newborns from dying?
• The Philippine situation
• The response
• Next steps

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Philippines
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What can we do to save newborn lives anyway?
The Lancet Child Survival Series (2003) Gave
Clear Estimates of 23 Interventions Needed to
Prevent 2/3rds of Under 5 Child Deaths
Lancet 2003 362 6571
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Baguio General Hospital, 1970s
Period I Neonates were not rooming-in with
their mother The hospital allowed formula Many
cases of neonatal sepsis
Period II Neonates roomed-in with their
mother The hospital strongly promoted
breastfeeding policy 89 reduction of neonates
with clinical signs of sepsis
Clavano, J Trop Ped, 1982
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Delaying Initiation of breastfeeding increases
risk of infection-related death, Nepal 2008,
22,838 breastfed babies
RR
Mullany LC, et al. J Nutr, 2008 138(3)599-603.
Hours after Birth
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Philippines
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Immediate drying

• Prevents HYPOTHERMIA which can lead to
• infection, coagulation defects, acidosis, delayed
  fetal to newborn circulatory adjustment, hyaline
  membrane disease, brain hemorrhage
• Dangers of early bathing
• Infection
• Removes vernix
• Prevents maternal bacterial colonization
• Undermines breastfeeding
• 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 622390-99 Righard L, Alade
  M. Lancet 1990 336 1105-07.

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Philippines
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Skin-to-Skin Contact

• Skin-to-skin care (SSC) was shown to be effective
  in reducing the risk of hypothermia when compared
  to conventional incubator care for infants (RR
  0.09 95 CI 0.01, 0.64).
• 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
20029641345 McCall EM, et al. Cochrane
Database of Systematic Reviews 2010, Issue 3.
Art. No. CD004210. DOI10.1002/14651858.CD004210
.pub4.
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Philippines
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Skin-to-Skin Contact Effect on Breastfeeding

• Meta-analysis 30 quasi-/randomized trials
  comparing early SSC with usual hospital care
  (n1925 mother-infant dyads)
• Statistically significant positive effects of
  early SSC on
• Breastfeeding at 1-4 mos post-birth
• OR 1.82, 95 CI 1.08, 3.07), (10 trials 552
  dyads) and
• Breastfeeding duration
• WMD 42.55, 95 CI -1.69, 86.79) (7 trials 324
  dyads)

Moore E, et al. Cochrane Rev. 2007 Jul
18(3)CD003519
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Philippines
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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)
• Preterms less infant anemia
• RR 0.49 (95 CI 0.3, 0.81)
• NNT 3 (1.6 - 29.6)
• Preterms less intraventricular hemorrhage
• RR 0.59 (95 CI 0.35, 0.92)
• NNT 2 (1.4 - 9.8)
• No significant impact on incidence of Post-Partum
  Hemorrhage

• Ceriani Cernadas ,et al. 2006
• Rabe H, et al. 2004
• McDonald SJ, et al. 2008
• Hutton EK, et al. 2007
• Kugelman A, et al. 2007
• Van Rheenen PF, et al. 2006
• Van Rheenen PF Brabin BJ. 2006

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Philippines
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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 bathing until at least 6 hours

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Philippines
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Outline

• The problem
• The evidence What can save newborns from dying?
• The Philippine situation
• The response
• Next steps

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Philippines
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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 12 sec 99 in lt 1 min Until pulsations stop (1-3 mins)
Drying 97 at 1 min 100 Immediately
Immediate Skin-to-skin contact 9.6 at 5 min gt90 (except those needing resuscitation)
Put on cold surface 12 None
Not dried 2.5 None
Head not dried 6.2 None
Wash 84 at 8 min gt6 hours
Temp taken before 17 All
Sobel, Silvestre, Mantaring, Oliveros, 2009
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A Minute-by-Minute Assessment of Newborn Care
within the First Hour of Life in Philippines
Hospitals (2009)
Intervention Median Time or Percentage WHO Standard
Breast feed 69.3 at 10 min Within 1 hour (but when baby shows signs)
Separated from mother 92.9 at 12 min gt1 hour
Weigh 100 at 13 min gt 1 hour
Exam 75.7 at 17 min gt 1 hour
Hepatitis B Vaccine 69.4 at 20 min gt1 hour
Nursery 52 at 19 min Never
Rooming in 83 (155 min) Immediately with mother
Sobel, Silvestre, Mantaring, Oliveros, 2009
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Outline

• The problem
• The evidence What can save newborns from dying?
• The Philippine situation
• The response
• Next steps

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Philippines
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Essential Newborn Care Protocol was developed to
address these issues

• Guideline Development Process
• Convened Technical Committee
• Identified problems in newborn care incl.
  observational studies
• Appraised evidence for effective interventions
  including WHO Guidelines
• GRADE methodology
• Evidence-based draft developed
• Individual and en banc panel stakeholder and
  expert review
• Protocol finalized
• Administrative Order issued

• Dissemination
• Launched on Dec 7, 2009
• Meetings held with professional societies,
  academe, regional directors
• Still to come
• Implementation
• Monitoring

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The evidence is solid. The following Newborn
Care Practices will save lives 1. Immediate
and Thorough Drying2. Early Skin-to-Skin
Contact3. Properly Timed Cord Clamping4.
Non-separation of Newborn from Mother for Early
Breastfeeding
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Implementation of ENC at QMMC, Nov 2008 to Feb
2010
Weekly team assess and improve
ENC Trn
Initial ENC work of Dr Vitangcol, et al.
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Neonatal Mortality and Sepsis, QMMC, 2001 - 2010
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Implementation at Pilot Hospital

• Appropriate BF within first 90 minutes
• OR 2.31 (95CI 1.4-3.8) if skin-to-skin contact
• OR 0.12 (95 CI .05-0.27) if suctioned
• EBF at 28 days
• OR 1.99 (95 CI 1.5-2.7) if breastfed within
  first 90 minutes
• Exclusive breastfeeding rates
• 69 at 28 days

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Philippines
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ORs for Mortality, Sepsis Severe Disease
Risk of Harm
Protection
Intervention
0.10 1.0 10.0
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Outline

• The problem
• The evidence What can save newborns from dying?
• The Philippine situation
• The response
• Next steps

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Philippines
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4 Strategies to Scale Up ENC

• Incorporation of ENC Protocol, improved maternal
  care and related-hospital infection control
  practices as flagship interventions for hospital
  reform agenda within the next phase of the health
  sector reform agenda

• Development of a network of centers of excellence
  to fully implement the ENC Protocol, improved
  maternal care and related-hospital infection
  control practices

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Philippines
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4 Strategies to Scale Up ENC

• Incorporation of ENC Protocol and improved
  maternal care and related-hospital infection
  control practices into the pre-service and
  in-service curriculum including training
  materials development

• Social Marketing Campaign

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Philippines
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