Essential newborn care: It’s about time!

Susan Niermeyer, MD, MPH, FAAPUniversity of Colorado School of Medicine and Colorado School of Public Health

Aurora, Colorado, USA

• No relevant financial relationships with any commercial interests.

• Editor, Helping Babies Breathe, American Academy of Pediatrics and technical advisor to World Health Organization for development of educational materials

• Content expert, ILCOR Neonatal Life Support – cord management

• Senior Medical Advisor for Newborn Health, USAID The views and opinions expressed in this presentation are those of the author and not necessarily the views and opinions of the United States Agency for International Development

COI - Susan Niermeyer

Learning objectives

• Review recent evidence supporting livesavingactions in essential newborn care• Thorough drying and immediate skin-to-skin

care, delayed umbilical cord clamping, early initiation of breastfeeding

• Basic resuscitation• Kangaroo mother and father care, family-

integrated care• Discuss initiatives to strengthen systems of care to

improve global neonatal outcomes• Appreciate the relevance of essential newborn care

to both resource-limited and resource-rich settings

Essential newborn care: increasing survival, improving outcome, eliminating disparities

Causes of neonatal mortality—The Big Three

SevereInfections

Intrapartum-related complications

Complications from preterm birth

Liu L et al. Lancet 2012

Evidence-based interventions3 major causes of neonatal mortality

Maternal tetanus immunizationDx/rx bacteruriaHygieneImmediate skin-to-skinExclusive breastfeedingRecognition of Danger Signs- coordinated postnatal care

Improved fetal monitoringAccess to C-sectionNeonatal resuscitationDelayed umbilical cord

clamping

Dx/rx pre-eclampsiaAntenatal steroids and tocolyticsAntibiotics for PROMKangaroo mother careFamily-centered care

http://www.who.int/pmnch/knowledge/publications/201112_essential_interventions/en/

Preterm birth

• Antenatal corticosteroids, preterm labor management

• Care including essential newborn care + Kangaroo mother care

Birth complications

(and intrapartum stillbirths)

• Prevention by skilled attendance and obstetrics

• Care including essential newborn care + resuscitation

Neonatal infections

• Prevention, essential newborn care especially breastfeeding, chlorhexidine where appropriate

• Case management of neonatal sepsis with antibiotics

1

2

* Prioritised by the UN Commission on Life Saving Commodities for Women and Children

71% of newborn deaths preventable

actionable now without intensive care

3

Three main causes of newborn deaths all have effective and feasible interventions = 3 by 2

EVERY NEWBORN ACTION PLAN: NEONATAL MORTALITY GOAL

Unless we greatly accelerate newborn survival efforts, goal to end preventable

child deaths by 2035 unreachable

Every Newborn Action Plan

Implementation of best practices

patient survival is the product of three important factors

Søreide E et al. Resuscitation 2013;84:1487-93

Medical

Science

Educational

Efficiency

Local

ImplementationSurvival

The Formula for Survival

Implementation of best practices: basic stabilization and resuscitation

Drying to provide stimulation of breathing

and prevent hypothermia

Immediate skin-to-skin contact to promote early

breastfeeding and prevent hypothermia

Delayed umbilical cord clamping to promote

cardiovascular stability

Early initiation of breastfeeding to avoid

hypoglycemia

Clearing the airway only if necessary

Specific stimulation to breathe

Ventilation within one minute after birth, The Golden Minute

Improved ventilation

Implementation of best practices: drying and immediate skin-to-skin contact

Advantages of immediate skin-to-skin contact

• Promotes physiological stability of infant – stimulates breathing, maintains temperature and decreases stress

• Improves breastfeeding outcomes to 6 months

• Facilitates maternal-infant attachment

o Preparation of mothero Presence of companiono Adjustment of workflow

www.Cochrane.org/CD003519, 2016

Skin-to-skin contact and importance of normal temperaturehypothermia is common – especially in small or preterm infants

N=8782 infants < 1500 grams

Miller S et al. J Perinatology 2011; 31:S49

Skin-to-skin contact and importance of normal temperature

• Temperature < 36⁰C at birth is an independent risk factor for death in premature infants• Evidence from 36 observational studies

• Low quality evidence upgraded to moderate due to effect size, dose-effect relationship, single direction of evidence

• Hypothermia is associated with morbidities• Respiratory distress

• Metabolic derangements - hypoglycemia

• Intraventricular hemorrhage

• Late-onset sepsis

hypothermia is associated with mortality and morbidity in premature infants

Mullany LC et al. Arch Pediatr Adolesc Med 2010;164:650Laptook AR et al Pediatrics 2007119:e643

Skin-to-skin contact and importance of normal temperature

Lyu Y et al. JAMA Pediatrics 2015; 169(4)

hypothermia and hyperthermia are associated with mortality and morbidity in premature infants

N = 9833 infants < 33 weeks

Implementation of best practices: physiological umbilical cord clamping

Advantages of delayed umbilical cord clamping• Smoother cardiopulmonary

transition at birth• Improved placental

transfusion – reduction of anemia, higher BP and temperature

• Feasibility at vaginal or C-section birth

• Resuscitation with cord intact (option)

o Physical space for infanto Communication among providerso Preparation of mother

Ersdal H et al. Pediatrics 2014; DOI: 10.1542/peds.2014-0467

Physiologic umbilical cord clamping reduces in-hospital mortality < 37 weeks

Fogarty M et al. AJOG 2017

Implementation of best practices: early initiation of breastfeeding (1st hour)

Advantages of early initiation of breastfeeding

• Reduced hypoglycemia

• Improved success with latch/suckling in first days

• Timely switch from colostrum to milk production

• Improved milk volume at 4 days, 4 weeks, 4 months

• Lower mortality

o Preparation of mothero Skin-to-skin contacto Undisturbed first houro Adjustment of workflow

www.who.int/elena/titles/early_breastfeeding/en/

Implementation of best practices: basic resuscitation (Helping Babies Breathe)

Dol J. JBI Database of Sys Rev and Impl Rep 2018

Fresh stillbirth

First-day mortality

Essential Care for Every Baby

Essential Care for Small Babies

Implementation of best practices: family-integrated care

Advantages of family-integrated care

• Capacity-building of caregivers• Hygiene – handwashing, equipment• Bathing/cleaning the baby• Breastfeeding/expression and feeding of breastmilk• Skin-to-skin care• Developmentally supportive care• Recognition of Danger Signs and seeking medical help

• Improved infant and parent outcomes• Improved weight gain, exclusive breastfeeding• Reduced parental stress and anxiety

• Improved patient-staff interactiono Change in policies and staff roleso Continuous support and

supervisiono Physical facilities and services O’Brien K et al. Lancet Child Adolesc Health 2018

Verma A, et al. Indian Pediatrics 2017; 54:455

Implementation of best practices: Kangaroo mother (and father) care

Advantages of kangaroo care

• Improved survival of LBW in resource-limited settings

• Support of breastfeeding/ breast milk feeding

• Improved growth

• Infection prevention

• Thermal stability

• Shorter facility stay

o Preparation of mother/familyo Flexible use of available bedspaceo Facilities/services for families –

sleeping space, toilet, water and food

https://www.healthynewbornnetwork.org/hnn-content/uploads/ PA-KMC-Joint-Statement_final_2017.pdf

Implementation of best practices: developmentally supportive care

Optimizing nutritionProtecting skin

Safeguarding sleep

Minimizing stress and pain

Positioning and interacting

PARENTS/FAMILY

CARE PROVIDERS

Altimier L, Phillips R. Newborn & Infant Nsg Rev 2016; 16:230

10 steps for Helping Babies and Mothers Survive 1. Secure Ministry of Health buy-in

2. Form a working group for planning, training and monitoring

3. Develop national roll-out plan for pre-service and in-service

training, in both public and private sector

4. Provide learning materials & equipment at time of training

5. Identify and support local leaders and champions

6. Establish Low-Dose High-Frequency refresher training

7. Establish facility level quality improvement teams

8. Monitor performance

9. Establish a system for reporting and feedback

10.Engage health providers, families and the broadercommunity

http://journals.plos.org/plosone/article?id=10.1371/journal.pone.10178073

Implementation of best practices: strengthening systems

WHOEssential Newborn Care educational materials

WHO Quality Framework for Maternal and Newborn Health

Essential newborn care – lifesaving in every setting

WHO Western Pacific Region, Early Essential Newborn Care