1. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 1 |1 | Current Guidelines on Newborn Health of the World Health Organization Severin von Xylander WHO Department of Maternal, Newborn, Child and Adolescent Health (MCA)

2. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 2 |2 | Outline Focus on priority interventions Types of guidelines References materials and sources

3. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 3 |3 | Ending preventable deaths Labour and childbirth care Labour monitoring Childbirth care Essential newborn care Birth: drying, skin-to-skin First week: early/excl. BF, warmth, cord care, hygiene Obstruction/Fetal distress: CS, vacuum PT labour: corticosteroids, antibiotics for PPROM Preterm/LBW: Kangaroo Mother Care, BF support, immediate treatment of suspected infection Suspected sepsis: Early antibiotic treatment Not breathing at birth: Resuscitation CARE DURING PREGNANCY TREATMENT FOR PREGNANCY COMPLI- CATIONS PRE- CONCEPTION CARE REPRODUCTIVE CARE The time around childbirth and the first day of life: a critical window of opportunity to prevent and manage complications ACTION 1

4. We can reduce the main causes of death We can reduce the main causes of death Newborn Survival Solutions – 3 by 2 Preterm birth 1.Preterm labor management including antenatal corticosteroids* 2.Care including Kangaroo mother care, essential newborn care Birth complications (and intrapartum stillbirths) 1.Prevention with obstetric care * 2.Essential newborn care, and resuscitation* Neonatal infections 1.Prevention, essential newborn care especially breastfeeding, Chlorhexidine where appropriate* 2.Case management of neonatal sepsis * 1 2 3 * Prioritised by the UN Commission on Life Saving Commodities for Women and Children CHANGE 2 Over two-thirds of newborn deaths preventable – actionable now without intensive care

5. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 5 |5 | CRITICAL NEWBORN INTERVENTIONS 1.Management of pre-term birth 2.Skilled care at birth 3.Basic Emergency Obstetric Care 4.Comprehensive Emergency Obstetric Care 5.Basic Newborn Care 6.Neonatal resuscitation 7.Kangaroo mother care for premature and small babies 8.Treatment of severe infections 9.Inpatient supportive care for sick and small newborns

6. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 6 |6 | Types of WHO Guidelines Rapid advice guidelines: –response to a public health emergency Standard guidelines –guidance in relation to a change in practice or controversy in a single clinical or policy area Full guidelines –complete coverage of a health topic or disease Compilations of guidelines –contains current recommendations from WHO and other sources, but does not include any new recommendations

7. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 7 |7 | Guidance by Levels of Care Primary Level (PCPNC) Community: Preventive/Promotive, Follow-up (Care of Newborn at Home) 1 st Referral Level (MCPC, Pocket Book) 2 nd Referral Level (MNP) Low rik > 37 wks Risks 34 - 36 wks Risks < 34 wks

8. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 8 |8 | Management of Preterm Birth Birth preparedness Detection of complications and initial management Management of: –Use of antenatal corticosteroids –Pre-ecclampsia/ecclampsia –Preterm labour –(Preterm) prelabour rupture of membranes (p)PROM –C-sections Standard guidelines in development

9. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 9 |9 | Skilled Care at Birth Routine and emergency care for women and newborns during labour and delivery Use of the partograph

10. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 10 | Emergency Obstetric Care Basic EmOC: –routine and emergency care for women and newborns during pregnancy, labour and delivery, and postpartum Comprehensive EmOC : –Managing complications in pregnancy and childbirth –Assist vaginal delivery –C-sections

11. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 11 | Basic Newborn Care Routine and emergency care for women and newborns during labour and delivery, postpartum Focus on cleanliness, warmth, and feeding Standard guidelines: Care of the newborn immediately after birth –Immediate drying and additional stimulation –Cord clamping –Skin-to-skin contact in the first hour of life –Initiation of breastfeeding –Vitamin K prophylaxis

12. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 12 | What is new in postnatal care for the newborn? Timing of discharge from health facility after birth: 24 hours Number and timing of postnatal contacts: < 24 h, d3, d7-d14, 6 weeks Home visits for postnatal care: recommended Assessment of the baby: harmonization of danger signs Cord care: daily application of chlorhexidine after home deliveries Other postnatal care: bathing delayed until > 24 hrs.

13. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 13 | Timing of discharge What is recommended? –After an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. Weak recommendation, low quality evidence (provisional approval by WHO GRC) What has changed? –Before the recommendation was "not before 12 hrs.

14. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 14 | Number and timing of postnatal contacts What is recommended? –For facility births: postnatal care for at least 24 hours. –For is at home births: first postnatal contact as early as possible within 24 hours. –At least 3 additional postnatal contacts for all mothers and newborns, on day 3 (48-72 hours) and between day 7-14 after birth, and 6 weeks after birth. Strong recommendation, moderate quality evidence for newborn outcomes and low quality evidence for maternal outcomes (provisional approval by WHO GRC) What has changed? –Harmonization between post-partum and postnatal care

15. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 15 | Home visits for postnatal care What is recommended? –Home visits in the first week after birth are recommended for care of the mother and newborn. Strong recommendation, moderate quality evidence for newborn outcomes and low quality evidence for maternal outcomes (provisional approval by WHO GRC) What has changed? –Mothers are included

16. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 16 | Other Postnatal Care What is recommended? –Bathing should be delayed to after 24 hours of birth. If this is not possible at all due to cultural reasons, bathing should be delayed for at least 6 hours. Appropriate clothing of the baby for ambient temperature is recommended, this should be 1–2 layers more than adults and a hat. The mother and baby should not be separated and should stay in the same room 24 hours a day Strong situational recommendation, based on Guideline Development Group consensus (provisional approval by WHO GRC) What has changed? –Before bathing "not before 6 hours"

17. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 17 | Cord Care Daily chlorhexidine (4%) application to the umbilical cord stump during the first week of life is recommended for newborns who are born at home in settings with high neonatal mortality (neonatal mortality rate >30 per 1000). Clean, dry cord care is recommended for newborns born in health facilities, and at home in low neonatal mortality settings. Use of chlorhexidine in these situations may be considered only to replace application of a harmful traditional substance such as cow dung to the cord stump. Strong situational recommendation, moderate quality evidence (provisional approval by WHO GRC)

18. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 18 | Optimizing Health Worker Roles for Maternal and Newborn Health Who to do what

19. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 19 | Management of Newborn Problems Neonatal resuscitation Kangaroo mother care Treatment of severe infections Inpatient supportive care for sick and small newborns Standard guidelines in development: –Management of preterm birth (ANCS) & the prematurely born infant (KMC) –Sepsis management

20. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 20 | Antenatal Corticosteroids Management of preterm labour: If less than 34 weeks gestation, give corticosteroids to the mother to improve fetal lung maturity and chances of neonatal survival: Prelabour ruptures of membranes: If there are no signs of infection and the pregnancy is less than 37 weeks (when fetal lungs are more likely to be immature): Give corticosteroids to the mother to improve fetal lung maturity: –betamethasone 12 mg IM, two doses 24 hours apart; –OR dexamethasone 6 mg IM, four doses 12 hours apart. Note: Corticosteroids should not be used in the presence of frank infection.

21. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 21 | Kangaroo Mother Care What is recommended? –Low birth weight (LBW) neonates weighing < 2000 g who are clinically stable should be provided Kangaroo Mother Care (KMC) early in the first week of life. Strong recommendation, moderate quality evidence (Recommendations for management of common childhood conditions: evidence for technical update of pocket book recommendations. WHO 2012) The panel noted that although there is no evidence for KMC in babies > 2000 g, KMC may be beneficial in neonates who have temperature instability. However, implementation will require a description on how to provide KMC.

22. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 22 | Newborn Sepsis 1.Prophylactic antibiotics in newborns at risk of infection 2.Empirical antibiotics for suspected neonatal sepsis

23. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 23 | Prophylactic Antibiotics for Newborn Sepsis A neonate with risk factors for infection, i.e. –membranes ruptured > 18 hours before delivery, –mother had fever > 38 °C before delivery or during labour, or –amniotic fluid was foul smelling or purulent, should be treated with prophylactic antibiotics ampicillin (IM or IV) and gentamicin for at least 2 days. After 2 days, the neonate should be reassessed and treatment continued only if there are signs of sepsis (or a positive blood culture). (Weak recommendation, very low quality evidence)

24. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 24 | Empirical antibiotics for suspected neonatal sepsis Neonates with signs of sepsis should be treated with ampicillin (or penicillin) and gentamicin as the first line antibiotic treatment for at least 10 days (Strong recommendation, low quality of evidence) If a neonate with sepsis is at greater risk of staphylococcus infection (e.g. extensive skin pustules, abscess, or omphalitis in addition to signs of sepsis), should be given cloxacillin and gentamicin instead of penicillin and gentamicin. (Strong recommendation, quality of evidence not graded) Where possible, blood cultures should be obtained before starting antibiotics. If an infant does not improve in 2–3 days, antibiotic treatment should be changed, or the infant should be referred to a neonatologist for further management. (Strong recommendation, quality of evidence not graded)

25. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 25 | Newborn Health Recommendation Only GRC recommendations released after 2008

26. ENGAP Consultation | Kathmandu, Nepal | 30 Aug. - 1 Sep. 2013 26 | Thank you