Normal Newborn Care Advances in Maternal and Neonatal Health

2Normal Newborn Care Session Objective Define essential elements of early newborn care Discuss best practices and technologies for promoting newborn health Use relevant data and information to develop appropriate essential newborn recommendations

3Normal Newborn Care Newborn Deaths 8.1 million infant deaths (1993) 3.9 million (48%) newborn deaths 2.8 million (67%) early newborn deaths Major causes of newborn deaths Birth asphyxia: 21% Infections: 42% (tetanus, sepsis, meningitis, pneumonia, diarrhea)

4Normal Newborn Care Newborn Deaths (continued) Birth process was the antecedent cause of 2/3 of deaths due to infections Lack of hygiene at childbirth and during newborn period Home deliveries without skilled birth attendants Birth asphyxia in developing countries 3% of newborns suffer mild to moderate birth asphyxia Prompt resuscitation is often not initiated or procedure is inadequate or incorrect

5Normal Newborn Care Newborn Deaths (continued) Hypothermia and newborn deaths Significant contribution to deaths in low birth weight infants and preterm newborns Social, cultural and health practices delaying care to the newborn Countries with high STD prevalence and inconsistent prophylactic practices Ophthalmia neonatorum is a common cause of blindness

6Normal Newborn Care Newborn Deaths (continued) Low birth weight An extremely important factor in newborn mortality Place of childbirth At least 2 out 3 childbirths in developing countries occur at home Only half are attended by skilled birth attendants Strategies for improving newborn health should target –Birth attendant, families and communities –Healthcare providers within the formal health system

7Normal Newborn Care Essential Newborn Care Interventions Clean childbirth and cord care Prevent newborn infection Thermal protection Prevent and manage newborn hypo/hyperthermia Early and exclusive breastfeeding Started within 1 hour after childbirth Initiation of breathing and resuscitation Early asphyxia identification and management

8Normal Newborn Care Essential Newborn Care Interventions (continued) Eye care Prevent and manage ophthalmia neonatorum Immunization At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO) Identification and management of sick newborn Care of preterm and/or low birth weight newborn

9Normal Newborn Care Cleanliness to Prevent Infection Principles of cleanliness essential in both home and health facilities childbirths Principles of cleanliness at childbirth Clean hands Clean perineum Nothing unclean introduced vaginally Clean delivery surface Cleanliness in cord clamping and cutting Cleanliness for cord care Infection prevention/control measures at healthcare facilities

10Normal Newborn Care Thermal Protection Newborn physiology Normal temperature: 36.5–37.5°C Hypothermia: < 36.5°C Stabilization period: 1st 6–12 hours after birth –Large surface area –Poor thermal insulation –Small body mass to produce and conserve heat –Inability to change posture or adjust clothing to respond to thermal stress Increase hypothermia Newborn left wet while waiting for delivery of placenta Early bathing of newborn (within 24 hours)

11Normal Newborn Care Hypothermia Prevention Deliver in a warm room Dry newborn thoroughly and wrap in dry, warm cloth Keep out of draft and place on a warm surface Give to mother as soon as possible Skin-to-skin contact first few hours after childbirth Promotes bonding Enables early breastfeeding Check warmth by feeling newborn’s feet every 15 minutes Bathe when temperature is stable (after 24 hours)

12Normal Newborn Care Early and Exclusive Breastfeeding Early contact between mother and newborn Enables breastfeeding Rooming-in policies in health facilities prevents nosocomial infection Best practices No prelacteal feeds or other supplement Giving first breastfeed within one hour of birth Correct positioning to enable good attachment of the newborn Breastfeeding on demand Psycho-social support to breastfeeding mother WHO 1999.

13Normal Newborn Care Breathing Initiation and Resuscitation Spontaneous breathing (> 30 breaths/min.) in most newborns Gentle stimulation, if at all Effectiveness of routine oro-nasal suctioning is unknown Biologically plausible advantages – clear airway Potentially real disadvantages – cardiac arrhythmia Bulb suctioning preferred Newborn resuscitation may be needed Fetal distress Thick meconium staining Vaginal breech deliveries Preterm Hamilton 1999.

14Normal Newborn Care Eye Care To Prevent or Manage Ophthalmia Neonatorum Ophthalmia neonatorum Conjunctivitis with discharge during first 2 weeks of life Appears usually 2–5 days after birth Corneal damage if untreated Systemic progression if not managed Etiology N. gonorrhea –More severe and rapid development of complications –30–50% mother-newborn transmission rate C. trachomatis

15Normal Newborn Care Eye Care To Prevent or Manage Ophthalmia Neonatorum (continued) Prophylaxis Clean eyes immediately 1% Silver nitrate solution –Not effective for chlamydia 2.5% Povidone-iodine solution 1% Tetracycline ointment –Not effective vs. some N. gonorrhea strains Common causes of prophylaxis failure Giving prophylaxis after first hour Flushing of eyes after silver nitrate application Using old prophylactic solutions

16Normal Newborn Care Efficacy of Prophylaxis for Conjunctivitis in China Objective: To assess etiology of newborn conjunctivitis and evaluate the efficacy of regimens in China Design: November 1989 to October 1991 rotated regimens monthly: tetracycline, erythromycin, silver nitrate 302 (6.7%) infants developed conjunctivitis, most S. aureus (26.2%) and chlamydia (22.5%) Silver nitrate, tetracycline: fewer cases than no prophylaxis (p < 0.05), erythromycin: not significant Chen 1992.

17Normal Newborn Care Prophylaxis for Conjunctivitis: Objective and Design Objective: To compare efficacy in prevention of nongonococcal conjunctivitis Design: Randomized control trial to compare erythromycin, silver nitrate, no prophylaxis Examined with test for leukocyte esterase and chlamydia trachomatis antibody probe 30–48 hours postpartum, 13–15 days later, and telephone contact up to 60 days of life Main outcome measured: conjunctivitis within 60 days of life and nasolacrimal duct patency Bell 1993.

18Normal Newborn Care Prophylaxis for Conjunctivitis: Results and Conclusion Results: 630 infants 109 with conjunctivitis Silver nitrate vs. no prophylaxis: Hazard ratio 0.61 ( ) –Chemical conjunctivitis with silver nitrate resolves within 48 hours Erythromycin vs. no prophylaxis: Hazard ratio 0.69 (not significant) Conclusion: Parental choice of prophylaxis, including no prophylaxis, is reasonable IF antenatal care and STD screening Bell 1993.

19Normal Newborn Care Povidone-Iodine for Conjunctivitis: Objective and Design Objective: To determine incidence and type of conjunctivitis after povidone-iodine in Kenya Design: Rotate regimen weekly: erythromycin, silver nitrate, povidone iodine Results: Conjunctivitis: –Chlamydia in 50.5% –S. aureus in 39.7% More infections in silver nitrate than povidone-iodine, OR 1.76, p < More infections in erythromycin OR 1.38, p=0.001 Isenberg, Apt and Wood 1995.

20Normal Newborn Care Povidone-Iodine for Conjunctivitis: Conclusion Povidone-iodine: Is good prophylaxis Has wider antibacterial spectrum Causes greater reduction in colony-forming units and number of bacterial species Is active against viruses Is inexpensive Isenberg, Apt and Wood 1995.

21Normal Newborn Care Immunization BCG vaccinations in all population at high risk of tuberculosis infection Single dose of OPV at birth or in the two weeks after birth HBV vaccination as soon as possible where perinatal infections are common

22Normal Newborn Care Summary The essential components of normal newborn care include: Clean delivery and cord care Thermal protection Early and exclusive breastfeeding Monitoring Eye care Immunization

23Normal Newborn Care References Bell TA et al Randomized trial of silver nitrate, erythromycin and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics 92: 755–760. Chen J Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin, and no prophylaxis. Pediatr Infect Dis J 11: 1026–1030. Child Health Research Project and Maternal and Neonatal Health Program Reducing Perinatal and Neonatal Mortality. Report of a meeting in Baltimore, Maryland, 10–12 May, Hamilton P Care of the newborn in the delivery room. Br Med J 318: 1403–1406. Isenberg SJ, L Apt and M Wood A controlled trial of povidone- iodine as prophylaxis against ophthalmitis neonatorum. N Engl J Med 332: 562–566. World Health Organization (WHO) Care in Normal Birth: A Practical Guide. WHO: Geneva.