Essential Newborn Care

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Essential Newborn Care

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

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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

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Presentation Outline Part Two

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

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Background Neonatal Mortality

• Neonatal mortality death lt 28 days after birth
• 40 of all child deaths (lt5 yo) are neonatal!
• Highest rates in sub-Saharan Africa
• Africa gt 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

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Causes of Neonatal Death (WHO 2001)
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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

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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

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Essential Antenatal Care for Pregnant Women

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

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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

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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

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

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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!

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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

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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

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Treatment of Maternal Infections

• 1) Malaria
• 2) Syphilis

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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

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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!

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Treatment of Malaria

• Provide antimalarial drugs
• Use insecticide-treated bed nets

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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.

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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
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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

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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

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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

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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

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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

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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

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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

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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

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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
• Infants clothes and blanket should be kept clean
• If cord becomes dirty, it should be washed and
  then dried with clean cotton or gauze

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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!!!

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Thermal Protection

• Normal temperature of a newborn is between 36.5
  and 37.5 degrees Celsius

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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

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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

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Mechanisms of Heat Loss in Babies
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Thermal Protection

• Hyperthermia is a temperature gt 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

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Thermal Protection

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

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Early and Exclusive Breast-feeding

• Early and exclusive breastfeeding is one of the
  least expensive and most cost-effective
  interventions for saving childrens lives!!!!

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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

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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

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• 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

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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

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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

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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

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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

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Management of Sick Infant
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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

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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

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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

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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

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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 infants weight is good measure
  of over or under-hydration

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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

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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 38C)

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Recognizing Danger Signs

• Danger signs in a newborn
• Hypothermia (below 35.5C),
• 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

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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

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Emergency Treatment of Danger Signs

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

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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

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Emergency Treatment of Danger Signs

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

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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

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Serious Bacterial Illness

• Also look for signs of a local infection
• swollen joints
• many severe skin pustules
• bulging fontanelle
• redness around umbilicus
• pus from umbilicus

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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

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Convulsions

• Treatment
• Initial dose of Phenobarbital is 15mg/kg IM
• If convulsions continue, give 10mg/kg IM in
  repeat doses up to maximum of 40mg/kg
• Monitor for apnea or slowed breathing and assist
  breathing if needed
• Check for low blood sugar
• Continue daily Phenobarbital at 5mg/kg if needed

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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

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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

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Low Birth Weight Baby

• Birthweight 1.75 to 2.25kg
• Initiate Kangaroo Care for warmth
• Start feeding within 1 hr
• If infant is able to nurse, allow normal,
  frequent breast-feeding
• If infant cannot breast-feed, give expressed
  breast-milk by cup and spoon
• Monitor carefully for signs of infection

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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

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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

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Low Birth Weight Baby

• Birthweight less than 1.75 kg
• Monitor for signs of infection and begin
  antibiotic therapy if any sign prsent
• If 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

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Low Birth Weight Baby

• Kangaroo Care
• The baby is undressed except for cap, nappy, and
  socks
• Placed upright between the mothers breasts, with
  head turned to one side
• Then tied to the mothers chest with a cloth and
  covered with the mothers 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

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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

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Neonatal Resuscitation Prototcols

• See next lecture in the series