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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 on theme: "Essential Newborn Care Sarah A. Murphy, MD Pediatric Critical Care Fellow MassGeneral Hospital for Children Boston, MA."— Presentation transcript:

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

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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 ( ). 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 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

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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 1 st 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

51 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

52 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 infant’s weight is good measure of over or under- hydration

53 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%

54 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 38°C)

55 Recognizing Danger Signs Danger signs in a newborn: Hypothermia (below 35.5°C), 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

56 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

57 Emergency Treatment of Danger Signs  Give penicillin/ampicillin and gentamicin as soon as possible to any infant presenting with signs of illness

58 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

59 Emergency Treatment of Danger Signs  Give vitamin K injection to all sick newborns if they have not already received it

60 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

61 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

62 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

63 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

64 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

65 Low Birth Weight Baby Birthweight of kg  These infants normally do well with routine newborn care  Monitor carefully  Ensure proper warmth and infection control

66 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

67 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 deg C Kangaroo Care Humidicrib if available Hot water bottle wrapped in a towel if no heating source

68 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

69 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 mg/kg q 12 hours

70 Low Birth Weight Baby Kangaroo Care:  The baby is undressed except for cap, nappy, and socks  Placed upright between the mother’s breasts, with head turned to one side  Then tied to the mother’s chest with a cloth and covered with the mother’s 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

71 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

72 Neonatal Resuscitation Prototcols See next lecture in the series


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