NEONATAL AND CHILD HEALTH CARE

Introduction

• Neonate : first 28 day of life

• Infant : from birth through first year of life

• Fetal death : death of fetus after 22 WOG

• IMR : death of infants per 1000 live birth

The ‘Two Third Rule’ on global infant mortality

• Almost 2/3rd of infant deaths occur in the first month of life

• Among those who die in the first month of life, about 2/3rd die in the first week of life

• Among those who die within the first week, 2/3rd die in the first 24 hours of life

Where do newborn babies die?

• High income countries - 4/1000

• Low and middle income countries – 44/1000

• WHO region:

• Africa - 44/1000

• America - 12/1000

• East Mediterranean- 40/1000

• Europe- 11/1000

• South East Asia- 38/1000

• Western pacific- 19/1000

• Overall- 30/1000

Trend of Child Mortality in Nepal

50

39

33

33

79

64

48

46

118

91

61

54

0

20

40

60

80

100

120

140

1996 NFHS 2001 NDHS 2006 NDHS 2011 NDHS

Neonatal Mortality Rate Infant Mortality Rate Under 5 Mortality Rate

Trend of Nutritional Status of under 5 Children

57

49

4143

39

29

1113

11

0

10

20

30

40

50

60

2001 NDHS 2006 NDHS 2011 NDHS

Stunting (Ht/Age) Underweight (Wt/Age) Wasting (Wt/Ht)

Combined infection, 60%

Diarrhea, 13.20%

Injury, 10.70%

ARI and diarrhea ,

7.50%

Others, 8.60%

Causes of under five mortality in Nepal

DHS-2006

Leading causes death of children in developing world

• Perinatal Condition 23.1%

• Lower reparatory condition 18.1%

• Diarroheal diseases 15.2%

• Malaria 10.7%

• Measles 5.4%

• Congenital abnormalities 3.8%

• HIV/AIDS 3.6%

• Pertusis 2.9%

• Tetanus 1.8%

• PEM 1.3%

• Others 14%

Source; World health report 2003

Millenium Development Goal

• GOAL 4 : Reduce Child Mortality

• Targtets

– 4 A : Reduce U5MR by 2/3rd between 1990-2015

• Indicators

– 4.1 : U5MR

– 4.2 : IMR

Progress

• Child Survival

– Global U5 deaths dropped from 12 million in 1990 to <9 million in 2008

• Micronutrient Supplementation

– 2 doses of Vit A increased from 16% to 62%

• Routine Immunization

– 3 doses of DPT increased from 75% in 1990 to 81% in 2007

• Vaccines

– Decreased global measles death by 74% since 2000

• Malaria prevention

– Use of insecticide treated nets risen sharply

• Improved drinking water

– More than 1.6 billion have gained access between 1990 & 2006

• Primary school enrollment

– No. of chlidren out of school decreased from 115 million in 2000 to 101 million in 2007

IMCI Implementation

CDD program started 1982

ARI program started 1986/87

ARI strengthening program at community focused on pneumonia treatment as a pilot in 4 districts

1995

Evaluation of ARI pilot program 1997

Scale up Pneumonia treatment program at community with CBAC 1998/1999

IMCI piloted in Mahottari 1997

Merged Community component and program management component in IMCI in and named as CB-IMCI.

1999/2000

Initially expanded in CB-IMCI in three districts 1999/2000

Revised the package and incorporated zinc 2006

Scaled up through out the country in 2010 2010

Causes of deaths of under five children

DISEASE PREVALANCE

PNEUMONIA 19%

DIARRHOEA 17%

MALARIA 8%

MEASLES 4%

HIV/AIDS 3%

INJURIES 3%

OTHERS 10%

CHERG estimates as presented in WHO,World Helath Report 2005

Neonatal(36%)

Pre term birth(10%)

Severe infection(mainly pneumonia and sepsis)(10%)

Birth asphyxia(8%)

Congenital anomalies(3%)

Tetanus(2%)

Neonatal diarrheal diseases(1%)

Others (2%)

Pneumonia

• kills 2 million children each year

• 1 in 5 deaths under 5 years of age.

• Around 6 lakhs children’s life could be saved

• Number of saved life could be doubled to 1.3 million by both prevention and treatment

Diarrhea

• Causes dehydration and kills 1.9 mi children under 5

• 88% or 1.5 mi deaths each year are due to unsafe drinking water ,inadequate availability of water for hygiene and lack of assess to sanitation

• Related illness indirectly kill many more

Malaria • Kill over 1 mi and sickens 350 to 5oo mi people

each year• 8/10 deaths in sub-Saharan Africa. Malaria kill a

child in every 40 seconds• Particularly damaging to pregnant women and

their newborn• Maternal anemia and low birth weightMeasles• A highly contagious disease• Although vaccination since 1960,454000 under 5

deaths in 2004 • Survivor are left with lifelong disabilities-

blindness and brain damage.

HIV/AIDS• Directly affecting mi of children adolescents and young

people.• In 2005,2.3 million children under 15 were living with

AIDS.Under-nutrition• Underlying cause of 53%of child's death each year• Leave children mentally and physically impaired • Illness, insufficient breastfeeding and shortfalls of food

and micronutrient• Universal iodination of salt Vit A supplementation-

spectacular results• Powerful tool-promoting exclusive breastfeeding in 1st

6 months of life• Policies-better nutrition knowledge in family and

community, disease control, safe water and basic sanitation.

Cause of under five deaths in NepalCause of death Male Female Total

Possible ARI and possible Diarrhea

26.4 29.4 27.9

Birth injury 10.7 8.6 9.7

ARI 22 24.1 23.1

Birth asphyxia 6.3 9.2 7.8

Congenital abnormality 4 4.4 4.2

Preterm/LBW 3.8 2.3 3.1

Tetanus 2.3 0.1 1.2

Diarrhea 5.6 4.0 4.8

ARI and Diarrhea 2.6 2.2 2.4

Malnutrition 3.2 3.1 3.2

Injury 5.5 0.8 3.1

measles 0.2 0.0 0.1

Measles followed by ARI 0.4 0.0 0.2

Cause not identified 6.8 11.5 9.1

total 100 100 100

Global strategy for women’s and children health

22 September 2010:Ban ki-moon launched Global strategy for women’s and children health

Key elements of the global strategy:

• Country led health plans

• A comprehensive, integrated package of essential interventions and services

• Integrated care

• Health system strengthening

• Health workforce capacity building

• Coordinated research and innovation

Neonatal health• Critical stage of life

• The first 4 week of life-the neonatal period caries highest risks of life

• Neonates-major focus for mortality and morbidity reduction

• There was widespread mistaken assumption that problems of newborns being addressed by safe motherhood and child survival programs

• MDG stimulated the importance of newborn survival globally and has aimed to reduce under 5 mortality by 2/3 rd.

Increasing attention on newborn health• An estimated 3.1 million deaths before 1

month,98% in poor countries at home in absence of any skilled health care

• MDG 4 and MDG 5

• Most neonatal deaths are preventable via,immunization,medications,care during and after delivery,keeping baby warm,cutting umbilical cord clean,breast feeding & famliy planning practices.

• Neonatal deaths- 2/3rd all deaths in first year of life & 40% of deaths before age of five

• “Two third rule” on global IMRDeaths in 1st months of lifeAmong those deaths in 1st months of life, about

2/3rd die in 1st week of lifeAmong those who die in 1st week of life die in

first 24 hours of life• Marked variation of neonatal deaths between

high income and low income countries.• Healthy newborns are likely to enjoy better

health in childhood and in late life; growing evidence for and interest in the influence of in-utero health on future cognitive development

• Related evidence that when a newborn dies,many mothers are inclined to enter more quickly into another pregnancy to provide replacement baby.

For above reasons, recently government international NGOs,donors and health institutions are putting a lot of efforts and resources in improving neonatal health.

Cause of neonatal deaths

• It is difficult to find out the causes of neonatal deaths in developing countries. Because most of the deaths occur at home there is lack of well registration system. Families are reluctant to seek outside help for sick child.

Following are main causes of neonatal deaths

a) Severe infections (tetanus, sepsis, pneumonia, diarrhea)

b) Asphyxia

c) Preterm birth

d) Congenital anomalies

e) Indirect causes

Severe infections

• It accounts for 36% of all new born deaths• Four most common infections are tetanus, sepsis,

pneumonia and diarrhea • Other infections include infection of skin,

umbilical cord, lungs, GI tract etc.• Severe infection can occur any point during 1st

month of life• Providing TT for mother clean delivery practice

maintaining clean cord and exclusive breast feeding reduce most of infection.

Asphyxia

• Difficulty in breathing after birth due to inadequate supply of oxygen immediately before during or just after birth

• It accounts 23% of new born deaths

• Can be prevented by improved care during labor and delivery, conduction of delivery by trained health worker who is able to detect the sign and resuscitate the new born.

Pre term birth

• A baby born before 37 completed weeks of gestation calculating from the first day of the last menstrual period.

• It causes 28% of new born deaths• Most of preterm baby weigh 2.5 kg or less• It is difficult to feed maintain body temperature and

prevent from infection • Commonly seen complications are asphyxia,

hypothermia, pulmonary syndrome like pulmonary edema, intra alveolar hemorrhage, Idiopathic respiratory distress syndrome, cerebral hemorrhage etc.

Congenital anomalies

• It includes neural tube defects, cretinism and congenital rubella syndrome

• It causes 8% of new born deaths

• To prevent neural tube defects mothers can be given folic acid during 1st trimester of pregnancy, to prevent cretenism mothers can be provided with adequate iodine and congenital rubella syndrome can be prevented by immunizing mothers against rubella

Indirect causes

• Low birth weight

• Gender bias

• Poverty

• Poor maternal health status

• Poor coverage of health service

Causes of neonatal deaths in Nepal

Cause of death % of neonatal deaths

Other serious infections 20.6

Birth injury 18.5

ARI 18.1

Birth asphyxia 14.9

Congenital abnormality 8.1

Pre term birth/low birth weight 5.9

Tetanus 2.3

Diarrhea 0.8

ARI and diarrhea 0.5

Cause not identified 10.1

Continuum care for maternal neonatal and child health

• World health report defines

• “the core principle underline the strategies to develop MNCH programs is the continuum of care. This expressions has two meanings first it means care has to be provided as a continuum throughout the life cycle including adolescence, pregnancy, childbirth and childhood. Second it indicates that care has to be provided in a seamless continuum that spans the home community health centre and hospital.”

Principles of continuum of care

• Actions to improve the health of women, new borns and children are most effective and sustainable when they are integrated and delivered in convenient, cost effective packages to communities and families

• Health systems are most useful when they integrate dynamically the different modes of care – facility based, outreach and out patient services and community and family care

• Strengthening health system to improve health outcomes for mothers and children requires combining and integrating the strength of vertical and horizontal approaches to health services delivery, rather than choosing either approach in isolation

• A result oriented approach to health system development, centered on effective and evidence based interventions is useful in setting agendas and policies and in monitoring and evaluating progress

• Results are best achieved through collaborative action between programs, policies and partnerships working towards improving maternal, newborn and childcare

Ways to improve neonatal and child health

• Status of neonatal and child health depends on many factors, health system, culture, education, economic, political commitment, support from donor international partners

Basic practices for community based health care intervention

Exclusive breast feeding -: up to 6 month

Complementary feeding -: starting about at 6 months, feeding children with energy and nutrient rich foods while continuing to breast feed for at least 2 years

Micronutrient supplement -: improving the intake of vitamin A in communities where it is deficient

Hygiene

Immunization -: full course immunization (BCG, Diphtheria, Pertusis, TT, Polio and measles) before 1st birth day

Malaria prevention -: in the malaria endemic areas

Psychosocial care and development-: it is done by talking playing and providing stimulating environment to the child

Feeding and fluids for sick childrenHome treatment Care seeking -: recognize when sick children need

treatment outside home and seek care from appropriate providers

Appropriate practices -: follow the health workers advice about treatment, follow-up and referral

Antenatal care -: at least 4 antenatal visits with appropriate health care provider and receiving recommended doses of TT along with support from family and community

Essential care for new born health

Care of future mothers

Improve health and status of women

Discourage early marriage and early child bearing

Promotes safer sexual practice

Provide female education

Care during pregnancy

Improve nutrition of pregnant woman

Immunize against tetanus

Screen and treat infection specially syphilis and malaria

Improve communication and counseling

Special attention

Monitor and treat pregnancy complications such as anemia preeclampsia and bleeding

Promote voluntarily counseling and testing for HIV

Reduce the risk of mother to child transmission of HIV

Care at time of birth

Ensure skilled care at delivery

Provide for clean delivery -: clean hands, clean delivery surfaces, clean cutting, tying and stump care and clean clothes

Keep the new born warm

Initiate the immediate, exclusive breast feeding at least with in one hour

Give prophylactic eye care

Special attention

Recognize danger sings in both mother and baby and avoid delay in seeking care and referral

Recognize and resuscitate asphyxiated baby immediately

Pay special attention to warmth feeding and hygiene practices for pre term and LBW babies

Care after birth

Ensure early postnatal contact

Promote continued exclusive breast feeding

Maintain hygiene to prevent infections, ensure clean cord care and counsel mother on general hygiene

Provide immunization such as BCG, OPV and HepB

Special attention

Recognize danger sign in both mother and new born particularly of infection and avoid delay in seeking care and referral

Support HIV positive mother to make appropriate, sustainable choices about feeding

Continue to pay special attention to warmth, feeding and hygienic practices for LBW babies