CARE Booklet B

8/8/2019 CARE Booklet B

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B. Newborn Care at the Community Level

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THE PROBLEM:TOO MANYNEWBORN INFANTSDIE IN INDIA

FIGURE 2Neonatal Mortality Rate in South Asian Countries (1995-2000)

N M R / 1 0 0 0 L i v e

B i r t h s

Source: State of the World s Newborns, Save the Children, 2001.

Sri Lanka Pakistan Nepal India Bangladesh

60

50

40

30

20

10

0

When an infant dies before completing

28 days of life, we call it neonatal or

newborn death. Each year, about 40

lakh babies die all over the world

before they are 28 days old. Of these,

about 10 lakhs are Indian (Figure 1).

Currently, of every 1000 live births in

India, about 40-60 do not survive

beyond 28 days after birth. This is what

we call the neonatal mortality rate

(NMR). In 2000, the average neonatal

mortality rate for India was 43/1000

live births. We can compare this with

some of our neighbours (Figure 2).

Within India, the NMR varies from a

high of over 60 per 1000 live births in

states like Orissa and Madhya Pradesh

to a low of around 11 per 1000 live

births in Kerala. The difference

between the states with the highest

and lowest NMRs is more than 5 times,

which indicates how much has yet to be

achieved. Clearly the example of Kerala

suggests that it is possible in India to

reduce NMR substantially.

In general, states, where deliveries

conducted by skilled health workers are

more frequent are also the states where

neonatal mortality is lower (Figure 3).

Why do newborn babies die?

They die of three main causes

asphyxia, prematurity and infections

Based on data from different studies in

a number of countries, WHO estimatesthat of all newborn deaths:

about 32% are caused by

infections, including tetanus

29% die of asphyxia (inability to

establish normal breathing at birth)

24% die due to complications

of being born prematurely

the remaining 15% from other

causes such as birth defects.

These figures are averages of figures

from many different settings, and

actual proportions for a given country

or state are likely to vary.

FIGURE 1Global Burden of Newborn Deaths

India

Rest of the world

Rest ofthe world

India10 lakhs

(25%)

30 lakhs (75%)

Roughly two-thirds of infantdeaths are neonatal deaths.Of these, almost two-thirdsoccur in the first week, andtwo-thirds of these on thefirst day after birth.

Source: State of the World s Newborns,Save the Children, 2001.

20

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FIGURE 3NMR and Trained Healthworker Assisted Deliveries, Selected States, 1999

70

60

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40

30

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Source: Sample Registration Systems Statistical Report, 1999; NFHS 1998-99.

NMR Assisted Deliveries %

N M R / 1 0 0 0 L i v e B

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A s s

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a l s %

100

90

80

70

60

50

40

30

20

10

0West

Bengal

Madhya

Pradesh

Andhra

Pradesh

Uttar

Pradesh

OrissaRajasthanKerala Bihar

FIGURE 4Causes of Neonatal Mortality

in a Rural Indian Study

Asphyxia20 %

Un-known10 %

Other3 %

Prematurity15 %

A study of newborn deaths in rural

Maharashtra (Figure 4) showed that

these causes were responsible for

about 88% of newborn deaths, of which

52% died due to infections.

Low birth weight (LBW) is an important

determinant of child mortality. The

lower the birth weight, the greater the

risk of death. In the Maharashtra study,

at least 90% of newborn deaths

occurred in neonates with a birth

weight less than 2.5 kg. (see Figure 4

and Table 1 on page 8) .

This has important implications on

programs aiming to reduce neonatal

mortality. Such programs must focus

primarily on reducing deaths from

these three specific causes: asphyxia,

prematurity and infections.

Newborn deaths occur due to lack

of care

Women in rural areas have poor access

to adequate nutrition and health care

before and during pregnancy. Children

born to such women are more likely to

be born with low birth weight and die

from common causes early in infancy.

Only about one-third of births in India

are attended by trained personnel,

even fewer in rural areas. This means,

most newborn babies do not get the

care they need at birth.

Most rural areas and many urban areas

do not have easy access to specialist

neonatal care hospitals. General

Low

Birthweight90 %

Sepsis52 %

Source: Bang AT et al, 1999.

hospitals, both in the public and private

sectors, are sometimes unable to

provide adequate care even for normal

newborn babies, and most do not have

the capability of taking care of

premature or sick newborns.

Often, family members are reluctant to

take newborn babies to available health

care facilities. Also families may not

recognize symptoms of illness early

enough for referral to be effective.

Unless adequate care is provided to

mothers before and during pregnancy,

to newborn infants at and after birth,

neonatal mortality will remain high.

What can be done to preventnewborn deaths?

Newborn deaths can be prevented by

addressing the major reasons for

newborn deaths:

A. Addressing issues related to lack of

adequate care

B. Addressing specific causes of

newborn death

Unhealthy Babies MakeUnhealthy Adults

While it is common sense that anunhealthy childhood can lead toan unhealthy adult life, a lot of

evidence is accumulating thatshows specific linkages betweenbabies with an unhealthy start inlife (such as those with low birthweight, asphyxia or sepsis), andlong term disability and disease.For instance, babies who areborn with low birth-weight aremore likely to develop diabetesand hypertension in later life.Such babies are also much lesslikely to reach their educationalor economic potential.


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A. Addressing issues related tolack of adequate care

Ensuring the health and nutrition of

future and current mothers

Newborn health cannot be separatedfrom the health and health care of

women. Small girls grow into small

women, who develop into underweight

mothers who have undernourished

babies this is a vicious cycle of ill

health and high death rates. In turn,

the health and nutrition of mothers,

and the outcomes in terms of child

health are closely associated with the

status of women in society

opportunities for education, her roleand position in marriage and sexual

life, her contribution to decision

making at home, the degree of control

over family income, the willingness of

other family members to share routine

chores including child-care, access to

health care services are all related

to the place she is given in society, and

to how she demands her rights, and

exercises them. Ultimately, it is thecorrection of these distortions that will

help improve the care of women before

and during pregnancy.

Many of the conditions that cause

complications for the mother in

pregnancy, during delivery and after

delivery, also result in complications for

the baby. For instance maternal

reproductive tract infections may lead

to prematurity or still-birth, obstructedlabour can lead to asphyxia, and

hypertension in pregnancy (toxemia)

can lead to prematurity, still-birth and

asphyxia (as discussed later).

Addressing such specific maternal

problems will lead to better outcomes

for newborns. Specifically, certain

timely health interventions can make a

significant difference to the health of

the future mother, and thus to thechild (see Box below).

The Elements of Essential Newborn Care

A. Helping establish breathing at birth, with simple interventionsi. In case the baby has not cried, using simple physical stimuli for

inducing breathing/crying, like rubbing/flicking the palms and solesor rubbing the back of the baby

B. Ensuring adequate warmth from the moment of birthi. Immediately at birth, using a clean and dry cloth to wipe the baby,

and then using multiple layers of another cloth to wrap the babyfrom head to toe, keeping only the face exposed;

ii. Avoiding bathing for the first few days after birth;iii. Keeping the child adequately warm all the time particularly during

the first month

C. Ensuring adequate nutritioni. Breastfeeding the baby early and exclusivelyii. Detecting and managing common breastfeeding problems

D. Practicing clean handling to prevent infectionsi. Clean delivery by a trained attendant e.g. clean hands, clean

surface, clean blade, clean cord tie, and clean cord stumpii. Minimizing handling, and washing hands frequently before handling

the baby for the first few weeks

In addition, vaccines that are due at birth (BCG and OPV-0) are given asapplicable in the program. The care of babies with any special conditions(low birth-weight, asphyxia, sepsis, babies of HIV+ mothers, etc.) is dealtwith in separate sections.

Care of future mothersImprove the nutritional statusof girls. This should include theprevention or treatment ofanemia.Discourage early marriages andearly childbearing.Promote safer sexual practicesand birth spacing.

Care during pregnancyImprove the nutrition ofpregnant women, includingeating more food, and takingiron tablets to prevent ortreat anemia.Ensure tetanus immunizationScreen and treat infections(especially syphilis and malaria).Provide prophylaxis for malaria,if in a malaria endemic area.Ensure antenatal examinationsto detect maternal conditionssuch as anemia and toxemia, orcomplications related to thefetus or placenta. Ensureadequate action for anyproblems detected.Ensure birth preparedness:encourage planning for where todeliver, and to prepareadequately for home delivery,including for potentialemergencies. Encouragepreparedness for immediatecare of the newborn at birth.

Special attentionPromote voluntary counselingand testing for HIV (see sectionon HIV).Reduce the risk of mother-to-child transmission of HIV (seesection on HIV).


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Essential Newborn Care

Essential newborn care is often defined

differently by different programs.

Here, it is used to denote basic care

that can be provided to every newborn

in any setting, in the periodimmediately after birth and for the

duration of the newborn period (the

first month of life). This includes all

the basic care that any healthy

newborn needs to ensure its health and

survival.

The commonest reason for failure to

provide basic care to newborn babies is

lack of awareness among care-givers,

including family members, about whatis best for the health and survival of

the newborn. Many, but not all,

traditional newborn care practices are

beneficial to the baby, and a program

that reaches out to communities must

take these into account. (For specific

elements of essential newborn care,

see Box on page 4).

Any program that aims to improve

newborn health and survival must

ensure that essential newborn care is

made available to all babies,

irrespective of where the baby is born.

B. Addressing specific causes of newborn death

Since asphyxia, low birth-weight/

prematurity and infections account for

around 90% of all deaths, interventions

that can deal effectively with these

causes should help reduce neonatal

deaths to a large extent.

Asphyxia and birth trauma

What is asphyxia?

Asphyxia is absent or depressed

breathing at birth. This is easily

recognized as a newborn baby who

does not cry at birth.

Birth trauma or injury, particularly to

the brain during birth, often results in

asphyxia. Hence, they are considered

together.

What causes asphyxia?Prolonged or obstructed labour.

Asphyxia is more likely to occur under

certain circumstances:

Multiple births, such as twins

The baby presenting abnormally

that is, emerging from the birth

canal in an abnormal position

First pregnancy of a woman

Short stature of the mother

Premature birth

How can asphyxia be prevented?

Some cases of asphyxia can be

prevented by careful monitoring of

labour, and timely intervention to

hasten delivery, such as by cesarean

section. This requires skilledattendance, at a hospital where

surgery is possible.

In rural homes, where most home

deliveries are attended by TBAs,

expecting close monitoring of labour

for asphyxia and quick action is

unrealistic.

Even in institutions, all asphyxia

cannot be prevented, and so personnelskilled in treatment of asphyxia must

be available at the moment of

childbirth.

How can asphyxia be treated?

When a newborn baby does not cry at

birth, it is an emergency situation.

Unless the baby can be helped to

breathe within a few minutes, the

baby s brain can be damaged by lack of

oxygen. The baby can even die.

Very few studies have investigated in detail the effectiveness of acomprehensive package of newborn care services delivered at the communitylevel. The few studies that have done so are all Indian.

A study conducted by an NGO called SEARCH in Gadchiroli district in ruralMaharashtra has shown that it is possible to train village health workers (villagewomen volunteers) to effectively reduce mortality from neonatal sepsis. Theworkers were intensively trained and supervised, and provided comprehensiveneonatal care in addition to antenatal care. The neonatal mortality rate in the

study dropped by about 62% and infant mortality by nearly half, over a periodof three years, most of the effect being due to a reduction in mortality due tosepsis. The incidence of sepsis and the mortality from sepsis were bothsubstantially reduced. The mortality from asphyxia and prematurity was alsoreduced, though less dramatically. Table 1 on page 8 shows the reduction inmortality pre and post intervention, i.e. following training of health workers indelivering neonatal care (Bang et al, 1999).

Newborn baby.

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When all facilities are available, such

babies can be resuscitated (see Box

below).

However, in the case of home deliveries

in rural areas:There are usually no facilities for

resuscitation.

Death or serious brain damage

occurs within minutes after birth.

The best time to refer is therefore

during or before labour if the

attendant can detect distress in a

baby still in the womb (see Box

alongside).

Since TBAs usually do not have

these skills, only the simplest ofcare can be given at home, as

described below.

Referral after a home delivery can

take time, and even if the baby

eventually survives, it may have

suffered considerable brain damage

by the time it is revived in a

hospital. Hence it is always

preferable to deliver in an

institution where facilities for

resuscitation are available.

Most deaths and disability from asphyxia

will be difficult to prevent, unless

deliveries take place in institutions able

to provide skills and equipment for

effective management of asphyxia.

However, the following steps can be

taken at all home deliveries, even if

attended by only a trained TBA:

As soon as a baby is born, it is

received in a sheet of clean, dry

cloth.

The baby is wiped dry with the

sheet of cloth. If the baby has not

cried by then, the stimulation

provided by rubbing the back and

limbs firmly with the cloth may beenough to make the baby cry.

A baby who still does not cry is

wrapped in another dry cloth to

maintain warmth, and the soles

and palms are rubbed firmly.

The baby is turned over on its side

or onto its face, which helps drain

out any liquid that is blocking its

airway in the throat or nose.

In addition, where such equipment and

training have been provided, the

attendant may take these steps:

Use a mucous sucker to suck out

any liquid from the throat of the

baby that is not crying or breathing.

Provide artificial respiration, either

tube and mask, or bag and mask,

depending on the equipment

available.

Detecting a baby in distress

When a baby is distressed inside the uterus, it becomes restless andpasses stool. The first stools, called meconium, are of a dark green color.This can be easily detected by the birth attendant when the water thatcomes out as the membranes burst is observed to be green. However,birth often occurs within minutes after passage of the water, and sothere may not be enough time to move the mother to the hospital.The distressed baby s movements may become excessively frequent orinfrequent, and the mother can often feel this. This is not alwaysreliable, but quickly reaching a hospital can help confirm suspicion.The heart rate of the baby in the womb shows characteristic patternswhen in distress. This can be reliably detected by closely monitoringthe labour. However, this is usually possible only by well-trained staffin a well-equipped hospital.Distress is not easy to detect in the case of home deliveries.

Resuscitating an asphyxiated newborn in institutions

Stimulating the baby by rubbing its back, soles or palms can get manybabies to start crying. This happens naturally when wiping a baby dryat birth.If this is not enough, the first step is to make sure that the airway(the passage for air to enter the lungs) is not blocked. A block is usuallydue to liquid and mucus, and this must be cleared by sucking it out.This requires simple equipment for suctioning, but suctioning is mosteffectively done while directly visualizing the airway with alaryngoscope.

If the baby still does not breathe, a small tube is inserted into thetrachea (windpipe) through the mouth and artificial respiration isinitiated. This requires special training and highly skilled care, which isavailable only in hospitals that specialize in neonatal care.In the absence of highly skilled personnel, artificial respiration can beprovided with a bag and mask or a tube and mask. However, this tooneeds considerable training, and is not as effective as using a tube inthe airway as described above.

What not to do:Do not hang the baby upside

down by its feet.

Do not slap the baby on its

back or chest.

Do not splash cold water on

the baby.


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Low Birth Weight and Prematurity

What is low birth weight?

By convention, a baby who is less than

2.5 kg at birth is considered a low birth

weight (LBW) baby.

Most births in India occur in rural

homes, and most such babies are not

weighed at birth. Therefore, we do not

have reliable estimates of the

proportion of LBW babies. It is believed

that India (along with other South Asian

countries) has the highest proportion of

LBW babies in the world. The rates are

probably as high as 30-40%.

A baby may have low birth-weight dueto one or both of the following reasons:

Premature birth: Babies born too

early, before they have had a

chance to put on enough weight

Failure to put on adequate weight

while in the womb: Babies who

have not gained as much weight as

expected for their age. For

instance, a baby born at the end of

a pregnancy of normal duration

may weigh less than 2 kg at birth.

Such babies are said to have

A summary of what can and cannot be done for the preventionand treatment of asphyxia at the home level

What can work at the home level:Antenatal check-ups, particularly in the last three months, may detectconditions that predispose to asphyxiaEnsuring that the delivery is conducted by a trained attendantSimple stimulation of the baby to induce breathing/cryingUsing simple suction devices and equipment like a bag and maskProviding training and supervision of the birth attendants that isadequate.

What cannot work at the home level:Prevention of all or most cases of asphyxiaSophisticated resuscitation of the kind possible in institutional deliveries.Referral to institutions after birth, since it may not be effectiveenough to save lives or prevent disability.

suffered growth retardation while

in the womb (intra-uterine growth

retardation).

Some babies may be both, premature,as well as growth-retarded.

What is prematurity?

A normal pregnancy usually lasts about

40 weeks (i.e. 10 lunar or traditional

calendar months, or 9 modern calendar

months and 7 days). A pregnancy that

ends after 37 completed weeks but

before 42 completed weeks is

considered full-term . A baby born

before 37 weeks of pregnancy are

completed is considered premature or

preterm . A birth

after 42 completed

weeks is post-

term .

On an average,about 10% of all

pregnancies end in

premature births.

In general, the

more premature

the baby, the greater the risk of death

(see Table 1 on page 8).

Why is LBW dangerous?

LBW is a major contributing factor forneonatal death and birth weight is one

of the important predictors of neonatal

mortality (see Table 1 on page 8). This

is because both, premature babies and

growth-retarded babies are more likely

to die than normal babies.

Why premature babies are more likely

to die

As a baby grows inside the womb, each

organ continues to mature throughout

pregnancy. A baby who is born after 37

weeks is sufficiently mature to perform

certain critical functions that allow

them to survive on their own, with

normal care from the mother:

The ability to breath normally

The ability to suck at the breast

and swallow milk without choking

The ability to maintain a steady

body temperature even when the

outside temperature is low or high

The ability to fight infections

Babies born before completing 37

weeks of pregnancy are not sufficiently

mature to perform these functions

normally. The earlier the birth, the less

mature these body systems will be.

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Low birth weight baby.


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With adequate care from the family, it

is possible to maintain temperature

and to minimize infection. However,

the baby must still be able to breathe

normally, and suck and swallow milk,

in order to survive at home.

Almost all babies become sufficiently

mature to be able to perform these

critical functions independently by

about 34 weeks of pregnancy. Any baby

born after these functions mature has

a fair chance of survival even if it is

cared for at home.

Babies who are born before these

functions become mature need very

special care that is available only in

specialist neonatal care hospitals. Less

the maturity, the greater the intensity

of care needed.

Why growth retarded babies are more

likely to die

As discussed below, failure to gain

weight adequately in the womb is often

due to maternal ill-health. This affects

the baby s health as well, and such

babies are more susceptible to die from

causes such as asphyxia and sepsis, as

well as hypoglycemia and hypothermia

(which are discussed later).

What causes low birth weight?

Prematurity or a failure to gain weight

in the womb can be due to numerous

causes. The pre-pregnant nutritional

status of the mother (i.e. mother s

height and weight), as well as the

nutrition and weight gain of mothers

during pregnancy are crucial factors.

Demanding physical work, short

spacing between pregnancies and

adolescent pregnancies are all

associated with prematurity and LBW.

Smoking mothers tend to have lighter

babies.

Most of the weight gain of the baby in

the womb occurs in the last three

months of pregnancy. Maternal

conditions like toxemia (pre-

eclampsia), malaria, certain other

maternal infections and any condition

that affects the health of the placenta

adversely affects the growth of the

baby in these months.

This table illustrates that:1. The likelihood of death is more when the birth weight is less, or when the maturity is lower.2. After intervention, the greatest reductions in death rates were among newborn babies born with a low birth weight,

and with moderate prematurity (between 34 and 37 weeks). This is the group that programs are likely to affect the most.3. The proportion of premature babies, or babies with a weight less than 2 kg is likely to be around 10% (or less) of all births

this is the proportion of newborn who will need special care

TABLE 1Likelihood of death by birthweight and maturity, pre and post intervention, Gadchiroli district study, 1995-1998

Source: Adapted from Bang et al, Lancet, 1999

1995-96 (baseline) 1997-98 (after intervention)

Number of live % of births Number Number of live % of births Numbernewborns in this category dying % newborns in this category dying %

Birth Weight

< 2 kg 74 8 27 36 63 6 9 14

2-2.5 kg 246 32 9 4 258 28 4 2

>2.5 kg 417 54 1 < 1 574 62 5 1

Unknown 26 3 3 12 18 1 4 22

Gestation

37 weeks 673 88.2 14 2 801 82 11 1

Unknown 15 1.9 1 7 19 2 2 11

Total 763 100 40 5 913 100 22 2


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A number of other conditions are

known to cause early labour:

Twins or multiple pregnancy

Incompetent cervix (mouth of

uterus not tight enough to hold

the growing baby)Obstetric complications such as

placenta praevia (low lying

placenta that blocks the cervix),

placental abruption (placenta

separating from the uterus before

baby is delivered)

Urinary or reproductive tract

infections in the mother.

How far can low birth-weight be

prevented? How far can labour bedelayed to prevent premature birth?

Some of these conditions, if detected

early, can be controlled to a certain

extent. However, premature labour is

difficult to prevent even in hospitals.

Even in developed countries,

prematurity is likely to remain the

leading cause of neonatal morbidity

and mortality for many years to come.

Protein and energy supplements in

pregnancy can reduce the incidence of

intrauterine growth retardation and

improve birthweight, with an average

increase of about 100 grams. Increases

in birth weight are particularly

observed in moderately and severely

malnourished mothers. A recent

community-based trial found that

supplements delivered to pregnant

women in Gambia through a primary

health care system resulted in

significant increase in mean

birthweight. This effect was particularly

marked in the hungry season, when the

rate of LBW was reduced by 33 percent.

However, particularly in the context of

home deliveries, even with the best of

antenatal care and counselling for

better nutrition, it is difficult to

reduce the proportion of LBW babies.

What can be done to help LBW babies

survive?

Low birth-weight babies born in well-

equipped and staffed institutions will

receive adequate care at the

institution. However, since a large

proportion of births in rural India still

take place in homes (or in ill-equipped

hospitals), far from institutions

capable of taking care of newborn

babies, it is important to focus on what

can be done under such circumstances.

For many such babies, it may be

difficult to have a reliable estimate of

either gestational age or birth weight,

and so even identification of low birth-

weight or prematurity may not be

easy. Based on wide-ranging

experience from community and

The relationship between maturity and birth weight

A premature baby is often LBW by definition (less than 2.5 kg), even ifit has put on weight adequately for the duration of its pregnancy. Forinstance, the average expected weight for a gestational age of 20 weeksis 300g, at 32 weeks it is 1700g and at 37 weeks it is around 2900g.Maturity of systems is linked closely to the duration of pregnancy,rather than to birth weight.Since failure to put on adequate weight in the womb is so common inIndia, it is common to find a fully mature baby weighing less than2.0 kg, and a grossly premature baby of the same weight.For any given level of maturity, a lower birth weight carries a higherrisk of death.

Weighing babies.

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C A R E I n d i a


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hospital studies criteria for identifying

a baby likely to need special care are

suggested in the Box above. Depending

on feasibility in terms of complexity

that service providers can handle, other

indicators of maturity can be added.

Ideally, premature and LBW babies

would be cared for in hospitals specially

set up for such babies. However, such

special hospitals are found only in a few

large cities. Most babies born in rural

homes do not have access to these

special hospitals. In any case, it is

difficult to persuade rural families to

take sick newborn babies to these

hospitals across long distances and at

considerable cost. Until specialist

hospitals become more generally

accessible, we need a simple protocol

that can be followed by the family and

health workers to care for these LBW

babies at home. Based on the

experience of a handful of small

studies, the following steps are

suggested. They will need validationand adaptation to different settings.

A. Assessment of all newborn babies

to identify those who need special

care, and provision of simple care

at home.

a. A baby needing special care can be

identified using the criteria in the

box alongside.

b. In specialist neonatal care

hospitals, premature or weakbabies are nursed at constant

temperature and fed breast milk

or a suitable alternative by highly

skilled nurses. Strict discipline

among handlers minimizes risk of

transmitting infection to the baby.

If needed, respiration is supported

by various means. When cared for

at home, however, such equipment

and skilled nursing are not

available, but the same principles

can be followed to the extent

possible at home:

Providing adequate warmth,

preferably by placing the

baby in skin-to-skin contact

with the mother, popularly

called kangaroo mother care,

or by adequately wrapping up

in enough warm clothing.

Minimizing risk of infection

from handlers by minimizing

handling, and frequent hand-

washing. Clean birthing and

handling practices are

applicable to all newborn

babies. These practices are

particularly important in the

case of premature/LBW babies.

Frequent feeding of breast

milk, either directly from the

breast, or expressed with a

cup or spoon. Babies who

thrive well with this simplemanagement can be taken

care of at home. They will

continue to need special care

for a week or two until they

grow strong enough to feed

well and maintain their body

temperature well. They will,

however, need to be carefully

protected from infection until

many weeks later.

B. Assessment of all babies needing

special care to determine if they

cannot be cared for at home, and

referral to appropriate institutions.

Simple ways to tell which babies cannot

be taken care of at home include:

a. A baby who is unable to feed even

with a cup or spoon, because it

either chokes while feeding, or

does not have the strength even to

sip and swallow from the cup or

spoon. Such babies are probably

too premature to be fed orally, and

need much more intensive care

than is possible at home.

b. A baby who becomes sick with such

an infection cannot be cared for at

home.

Identifying the newborn inneed of extra care

(the weak newborn)

A baby with a birth weight of less than 2000 g, (if birth

weight is available). While acut-off of 2.5 kg would includeall LBW babies, babies of lessthan 2 kg are at a much higherrisk of disease and death.A baby born more than a monthbefore the expected date of delivery (if the expected dateof delivery can be determined).A baby is premature bydefinition if < 37 completedweeks. However, this is difficultto measure exactly under field

conditions.A baby who does not suckvigorously at the breast fromthe time of birth . In theabsence of birth-weight andestimate of maturity, thisindicator will detect thosebabies who definitely needspecial care.

Kangaroo mother care.


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Potentially fatal infections,

or sepsis

Infections are responsible for more

than a third of deaths in the newborn

period. In the study of neonatal deaths

in Gadchiroli district of Maharashtra,52% of newborn deaths were due to

such infections.

What is sepsis?

The term sepsis is usually used to

indicate a bacterial infection.

When the immune system is not

sufficiently effective, an infection

tends to easily spread to other parts of

the body, usually through the bloodstream. This is called septicemia .

Since their immune systems are not

fully developed, newborn babies are

particularly vulnerable to septicemia

from even minor infections. The less

mature the baby, the greater the risk

of septicemia.

Tetanus is a specific, highly fatal

bacterial disease that is entirely

preventable using tetanus toxoid

vaccine during pregnancy, and by

ensuring clean delivery and cord care.

Tetanus does not cause septicemia.

What is the source of the bacteria in

potentially fatal infections?

The source of bacteria causing sepsis is

usually either the mother or a care-

giver. Table 2 on page 12 summarizes

the likely routes of infection.

How can infection be prevented?

Most infections can be prevented by

following these simple procedures:

Use of clean materials (cord-tie,

blade, cloth) at childbirth.

Close attention to adequate hand-

washing at birth (keeping nails

short and clean, use of soap and

water in enough quantity,

scrubbing adequately, and air-

drying hands).

Proper cord care until the cord

falls off (keeping cord stump clean

and dry after birth, applying

nothing and leaving it open), and

appropriate care of the umbilicus

until it is dry (applying nothing

and leaving it open).

Minimal handling after birth

(restricting the number of persons

who handle the baby) and

handling the baby only when

necessary.

Adequate hand-washing each

time before handling the baby

for several weeks after birth.

Avoidance of all feeds other than

breast milk (until the baby is

about six months old).

A summary of what can and cannot be done to prevent and treatLBW and prematurity at the home level

What can work at the home level:Adequate antenatal care, particularly in the last three months,including:o adequate diet and rest, may increase birth weighto regular check ups to detect potential causes of LBWo malaria chemoprophylaxis and treatment where indicatedReferral of premature labour for institutional deliveryRecognition of weak babies who can be cared for at home andadequate care of such weak babies, including ensuring warmth(kangaroo mother care), support for breastfeeding, cleanliness, earlyidentification and management of illnessRecognition of premature babies who are too premature to be caredfor at home and referral of such babies to appropriate institutions

What cannot work at the home level:Prevention of most premature birthsCare of premature babies who cannot safely swallow milk.

Five cleans.


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If the baby is not born for more than 6

hours after the membranes have

ruptured, antibiotics may help reduce

the risk of infection. Such a mother

usually needs referral to an institution

for completing the delivery.

After birth, breastfeeding the baby

immediately reduces the risk of serious

infection, since breast milk, especially

the first milk or colostrum , is rich in

immune components that are

extremely useful in fighting infection.

Breast milk itself is free of disease-

causing bacteria.

Tetanus toxoid vaccine administered to

the mother before or during pregnancy

can effectively eliminate chances of

tetanus in the newborn baby.

With the simple measures outlined

above, a large proportion of infections

can be prevented. However, some

babies will still acquire infections, and

such babies can be treated if

recognized and referred early.

How do we recognize severe

infections in a newborn baby?

The symptoms of infection that are

common in older children, like fever,

pain and swelling, or typical symptoms

of specific infections like meningitis

(infection of the coverings of the

brain), are often absent in newborn

babies. This is mainly because the

immune system is not mature enough

to fight infections as adults do, and to

produce these symptoms.

Even where specific symptoms of

serious infections like pneumonia or

meningitis are seen, infection tends to

spread so rapidly that in a matter of a

few hours, the specific symptoms may

disappear or get replaced by general

symptoms of septicemia.

Based on the findings of the

Maharashtra study on neonatal deaths,

the authors have recommended a set of

criteria to be used for suspecting

neonatal sepsis and referral (See Box on

page 13).

Specific symptoms may be seen in some

cases:

Pneumonia will cause increased

respiratory rate, and in-drawing of

inter-costal spaces (spaces

between ribs) during rapid

breathing.

Meningitis may cause vomiting or

convulsions and a bulging

fontanelle (the soft spot at the

center of the head in newborn

babies).

Neonatal tetanus makes the

baby s body spasm on touch or on

crying, and the jaw to become

stiffand locked . Unlike the

convulsions of meningitis, the baby

Causes How Infection is Transmitted

A. Non intact membranes In the womb, the baby floats in water inside a sac made of thin membranes.Bacterial infection of the baby in the womb is rare in the presence of intactmembranes. When membranes rupture but birth is delayed (by more than 6

hours), the baby has a high chance of being infected.

B. Childbirth and delivery Infection acquired during childbirth can come from the mother s reproductivetract, the unclean hands of the person assisting the delivery, or an uncleanpiece of equipment.

C. Immediate postnatal period The baby can become infected at any time after birth until the baby becomesmore resistant to infection. Such infections can be transmitted by touch,feeds, or air; invariably the source of infection is either the mother or otherhandlers.

D. Unhygienic practices Cowdung or other unclean substances applied to the umbilical stump canlead to serious infections, including tetanus.

E. Inadequate facilities Babies born in hospitals with inadequate facilities or inadequately trained

staff for the conduct of clean deliveries, run the risk of potentially fatalinfections from other patients.

The bacteria affecting newborns in developing countries like India include Pneumococcus, E. coli, Staphylococcus and Clostridium tetani(organism causing tetanus). However in the developed world, group B Streptococcus is the major organism causing neonatal sepsis.

TABLE 2: Likely routes of infection


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usually remains awake during a

spasm, and continues to cry.

Umbilical abscess can present as

a red, painful swelling of the

abdominal wall around the

umbilicus, and needs immediatetreatment. However, the more

common symptoms of discharge of

a pus like liquid from the

umbilical stump are usually not

serious, in the absence of swelling.

Gastrointestinal infections can

present with diarrhea and vomiting.

Diarrhea is often difficult to

distinguish from the normally high

frequency of stools that a normal

newborn passes, and normalregurgitation of milk can be easily

mistaken for vomiting. Hence,

these are not reliable signs of

serious disease.

Skin conditions appearing to be

pustules are common in the first

few days after birth. Most of these

are not infections, and even true

pustules do not often lead to

serious disease.

Eye infections usually present as

a small discharge from the corners

of the eyes, and are usually

benign. Serious eye infections

present as sudden red swellings of

the eyelids, with pus discharge,and need emergency treatment to

save the eyes.

However, none of these symptoms is

necessary for suspecting sepsis.

What is the treatment of potentially

fatal infections?

The only confirmative test for

septicemia is a positive blood culture.

Since it usually takes at least 48 hoursto get a blood culture result, and since

death can occur within a few hours

after onset of symptoms if untreated,

treatment is begun immediately on

suspicion of septicemia or other major

infection, without waiting for

laboratory test results.

Irrespective of the source or site of

infection, all serious infections are

usually treated as septicemia. Two

antibiotics administered parenterally

(as injections) in recommended doses

for at least one week is the minimum

treatment. In addition, depending on

the condition of the baby, othersupportive treatment may be needed.

Since this treatment needs well-trained

personnel, it is best administered in a

hospital having staff trained in treating

serious neonatal disease.

Tetanus is very difficult to treat, even

in the best of institutions, and most

babies will probably die before

reaching such institutions.

Where can neonatal sepsis be treated?

Only those hospitals that have trained

staff and equipment to handle serious

neonatal illnesses can reliably treat

sepsis. At present, most areas in rural

India do not have ready access to such

centers.

The Government of India and the

National Neonatology Forum are taking

steps to increase the availability of

centers where such treatment can be

provided.

Until reliable centers are established,

referral of suspected sepsis will

continue to be at the nearest and best

centers that the family can afford. It is

therefore important to use a set of

criteria for referral that does not

excessively over-diagnose septicemia.

Other causes of neonatal death

Birth defects

Since preventable deaths are not

common in developed countries, it is

birth defects that are the major cause

of neonatal deaths in these countries.

Criteria to be used for suspecting septicemiaat the community level

1. A baby who is feeding poorly, or has stopped breastfeeding, after earlierfeeding well (i.e. any baby whose vigor of feeding has deteriorated).

2. A baby who is drowsy/unconscious (or inactive or lethargic after beingnormally active earlier). This is a baby, who is difficult to awaken, or ababy whose limbs are limp or loose , or a baby who does not cry aswell as before.

3. A baby who is cold to touch.4. A baby who is breathing very fast. Newborn babies normally breathe

quite fast. Fast breathing without pause, or a breathing rate greaterthan 60 per minute is likely to be pneumonia.

5. A baby who has chest in-drawing while breathing. This is often expressedas seeing pits in the lower chest wall, and locals may have a specificexpression for describing this sign of pneumonia.

The presence of even one of these signs is sufficient reason for suspectingsepsis.


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In the developing countries, however,

they cause less than 10% of newborn

deaths. There are numerous causes of

congenital or birth defects, a few of

which are preventable:

Neural tube defects that show upas soft, fluid-filled swellings on

the back over the spine often

associated with brain defects and

paralysis. These are partly

preventable by folic acid

supplementation for the mother in

the period around conception.

Iodine deficiency disorders,

including different degrees of

mental retardation. These are

preventable by regular maternalintake of iodized salt.

Congenital rubella syndrome,

which can cause severe eye, heart

and other organ defects if the

mother gets rubella (a mild viral

infection, also called German

measles) during early pregnancy.

This is preventable by rubella

immunization of the mother well

before pregnancy.

Hypothermia

Hypothermia is defined as a core body

temperature of less than 36o

C. Human

adults can maintain a steady body

temperature of around 37o

C,

irrespective of what the external

environmental temperature is. For

various reasons, newborn babies are

unable to do this effectively, and the

less mature a baby, the less it is able to

do so. Once body temperature drops,

the baby becomes more prone to

infections and other metabolic

disturbances. Unless quickly corrected,

death can occur. It is much easier to

prevent hypothermia, using simple

ways of keeping the baby warm, than to

treat it. It should be noted that it is

probably more common to find

hypothermia as a consequence of sepsis

or asphyxia, rather than as a cause.

Hypoglycemia

Hypoglycemia is defined as blood sugar

less than 70 mg/100 ml. Severe

hypoglycemia increases the risk of

death, even moderate hypoglycemia

Criteria to identifyinstitutions for referral of the

weak or sick newborn

1. Availability of trained

pediatrician/neonatologist

at the hospital

2. Availability of basic

equipment for neonatal care

such as a radiant warmer.

3. Availability of nursing staff

trained in neonatal care

4. Distance from village and

access to transportation

5. Cost of care

A summary of what can and cannot be done at home to preventor treat sepsis

What can work at the home levelTetanus toxoid vaccine to the mother before and during pregnancyAttendance by a trained birth attendant who follows procedures forclean delivery *Early and exclusive breastfeedingClean cord and umbilical careMinimal handl ingClean handling by a few care-givers, including frequent handwashingSuspicion of sepsis using easily understood danger signs, and referral tothe best available institution for treatment

What cannot work at the home levelUse of appropriate antibiotics for treatment of suspected sepsis, unlessintensive training of health workers is possibleTreatment of tetanus

* Clean hands, clean surface, clean blade, clean cord tie, and clean cord

stump, often referred to as the 5 cleans

may cause long term reduction in

intelligence. Hypoglycemia often

occurs as a result of other neonatal

conditions such as sepsis or asphyxia.

Hypoglycemia can be prevented in the

community setting by early, exclusive

and frequent breastfeeding.

Jaundice

In the neonatal period jaundice

(yellow colour of skin) is common.

In most cases, it is mild, appears

around the third day after birth, and

disappears before the end of the first

week. This is called physiological

jaundice, and is one consequence of

the many adjustments that a baby has

to make when shifting from life within

the womb, to an independent

existence outside. This does not need

any treatment. In a very few cases,

babies can have deep yellow

jaundice, that can be easily seen all

over the body. Such severe jaundice

is usually because of some infection

or disease, and needs urgent

treatment in a specialist hospital.


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The National Population Policy of 2001 recognizes the link between high infant mortality and excessive population growth.

The Policy commits the nation to a reduction of the infant mortality rate to under 30 per 1000 live births by the year 2010.This necessitates a rapid reduction in neonatal deaths which form a major component of infant mortality.

The Policy also aims to achieve 80% deliveries in institutions and 100% deliveries by trained personnel by the year 2010.

Newborn care at district and sub-district levels is being operationalized by the Ministry of Health and Family Welfare withthe technical assistance of the National Neonatology Forum.

What interventions are likely to be feasible and effectivein reducing neonatal mortality at the community level?

A. Adequate antenatal care:1. Tetanus toxoid vaccine, one or two doses, depending on the previous

vaccination status2. Adequate diet and rest

3. Iron and folate supplements4. Regular check-ups and appropriate follow up (using home visits) on

detection of problems5. Planning for birth, including for emergencies at childbirth6. Recognition of danger signs in the mother and referral to an appropriate

institution

B. Appropriate delivery care:1. Delivery according to plan2. Attendance by a trained TBA or nurse3. Use of disposable delivery kit / 5 cleans

C. Essential care for all newborns:1. Ensuring breathing with simple interventions2. Ensuring adequate warmth3. Ensuring adequate nutrition4. Preventing infections

D. Special care for the premature/weak newborn:1. Recognition of a premature/weak baby who can be taken care of at home2. Extra warmth, more frequent feeds, feeding expressed breast milk with

a cup if need be, extra care to prevent infections3. Kangaroo mother care wherever acceptable

E. Recognition and referral of suspected septicemia1. Using easily recognizable danger signs for suspecting sepsis2. Immediate referral to an appropriate institution.

Newborn health is a high priority of the Government of India

Further Reading

1. Bang AT, et al. Effect of home-basedneonatal care and management of sepsison neonatal mortality: field trial in ruralIndia, Lancet 1999; 354:1955-1961.

2. National Family Health Survey (NFHS-2),India; 1998-1999.

3. Newborn Health Key to Child Survival.Present scenario, current strategies andfuture directions for Newborn Health inIndia, Child Health Division, Departmentof Family Welfare, Ministry of Healthand Family Welfare, Government of India; 2001.

4. Paul VK. Newborn care in India Apromising beginning, but a long way togo. Newborn Care in the South-East AsiaRegion Current Status and Priorities.Report of the Regional Expert GroupMeeting, Nov 16-17; 1998.

5. Pratinidhi A, Shah U, Shrotri A, Bodhani N.Risk-approach strategy in neonatal care.Bulletin of the World Health Organization1986; 64:291-297.

6. Saving Newborn Lives. State of theWorld s Newborns . Washington, DC, Savethe Children Federation-US; 2001:1-49.

7. Stoll BJ. The global impact of neonatalinfection. Clinical Perinatol 1997;24:1-21.

8. The Healthy Newborn: A ReferenceManual for Program Managers. The CARE/

CDC Collaborative Health Initiative; 2001.


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CARE Booklet B

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