Normal Newborn Care

1
Normal Newborn Care

• Advances in Maternal and Neonatal Health

2
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

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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)

4
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

5
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

6
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

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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

8
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

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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

10
Thermal Protection

• Newborn physiology
• Normal temperature 36.537.5C
• Hypothermia
• Stabilization period 1st 612 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)

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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 newborns feet every 15
  minutes
• Bathe when temperature is stable (after 24 hours)

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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.
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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.
14
Eye Care To Prevent or Manage Ophthalmia
Neonatorum

• Ophthalmia neonatorum
• Conjunctivitis with discharge during first 2
  weeks of life
• Appears usually 25 days after birth
• Corneal damage if untreated
• Systemic progression if not managed
• Etiology
• N. gonorrhea
• More severe and rapid development of
  complications
• 3050 mother-newborn transmission rate
• C. trachomatis

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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

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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 significant

Chen 1992.
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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 3048 hours
  postpartum, 1315 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.
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Prophylaxis for Conjunctivitis Results and
Conclusion

• Results 630 infants
• 109 with conjunctivitis
• Silver nitrate vs. no prophylaxis Hazard ratio
  0.61 (0.39-0.97)
• 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.
19
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, p0.001

Isenberg, Apt and Wood 1995.
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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.
21
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

22
Summary

• The essential components of normal newborn care
  include
• Clean delivery and cord care
• Thermal protection
• Early and exclusive breastfeeding
• Monitoring
• Eye care
• Immunization

23
References

• Bell TA et al. 1993. 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 755760.
• Chen J. 1992. Prophylaxis of ophthalmia
  neonatorum comparison of silver nitrate,
  tetracycline, erythromycin, and no prophylaxis.
  Pediatr Infect Dis J 11 10261030.
• Child Health Research Project and Maternal and
  Neonatal Health Program. 1999. Reducing Perinatal
  and Neonatal Mortality. Report of a meeting in
  Baltimore, Maryland, 1012 May, 1999.
• Hamilton P. 1999. Care of the newborn in the
  delivery room. Br Med J 318 14031406.
• Isenberg SJ, L Apt and M Wood. 1995. A controlled
  trial of povidone-iodine as prophylaxis against
  ophthalmitis neonatorum. N Engl J Med 332
  562566.
• World Health Organization (WHO). 1999. Care in
  Normal Birth A Practical Guide. WHO Geneva.