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Mariella S. Castillo, MD, MSc Maternal Child Health Team WHO Philippines WomenDeliver Philippines Conference 15 Septe

The problem The evidence: What can save newborns from dying?The Philippine situationThe response Next steps. Outline. . Office of the WHO Representative in the Philippines. <5 Yr Old mortality decreased 40% (1988-1998)Past 10 years, declined by 20%Slow decline since neonatal mortality hasn't improved.

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Mariella S. Castillo, MD, MSc Maternal Child Health Team WHO Philippines WomenDeliver Philippines Conference 15 Septe

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    1. Essential Newborn Care (ENC) and Breastfeeding Read slideRead slide

    2. The problem The evidence: What can save newborns from dying? The Philippine situation The response Next steps

    3. Need to update this with 2008 DHSNeed to update this with 2008 DHS

    4. 82,000 Filipino children die annually, most could have lived CHERG – means child health epidemiologist and research groups We are ranked #29 of all countries in number of U5 deaths. Read the slide…Note header, footnote and particular Neonatal deaths. CHERG – means child health epidemiologist and research groups We are ranked #29 of all countries in number of U5 deaths. Read the slide…Note header, footnote and particular Neonatal deaths.

    5. Majority of newborns die due to stressful events or conditions during labor, delivery and the immediate postpartum period. Read slide. Read slide.

    6. The problem The evidence: What can save newborns from dying? The Philippine situation The response Next steps

    7. What can we do to save newborn lives anyway? Practitioners know how to save lives. With 23 interventions we can prevent 6 million of the 10 million global under five deaths. Notice that good nutrition through breastfeeding, appropriate complementary feeding, supplementation/fortification can prevent 3 millionPractitioners know how to save lives. With 23 interventions we can prevent 6 million of the 10 million global under five deaths. Notice that good nutrition through breastfeeding, appropriate complementary feeding, supplementation/fortification can prevent 3 million

    9. Delaying Initiation of breastfeeding increases risk of infection-related death, Nepal 2008, 22,838 breastfed babies

    10. Prevents HYPOTHERMIA which can lead to infection, coagulation defects, acidosis, delayed fetal to newborn circulatory adjustment, hyaline membrane disease, brain hemorrhage Dangers of early bathing: Infection Removes vernix Prevents maternal bacterial colonization Undermines breastfeeding Tunell R., in Improving Newborn Health in Developing Countries, A. Costello and D. Manandhar, Editors. 2000, Imperial College Press: London, UK. p. 207-220; Tollin M, et al.. Cell Mol Life Sci 2005; 62:2390-99; Righard L, Alade M. Lancet 1990; 336: 1105-07.

    11. Skin-to-Skin Contact Skin-to-skin care (SSC) was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants (RR 0.09; 95% CI 0.01, 0.64). Less well appreciated are its contributions to Overall success of breastfeeding/colostrum feeding Stimulation of the mucosa-associated lymphoid tissue system Protection from hypoglycemia Colonization with maternal skin flora Read the slide Emphasize that for every 2 preterm babies where cord clamping is delayed, one will be saved of a brain hemorrhage. Note Delayed cord clamping is completely safe for mothers as well as babies. 1) Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: A randomized, controlled trial. Pediatrics 2006; 17;e779-e786. 2)Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. 3) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2.4) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252.5) Kugelman A, et al. Immediate versus delayed umbilical cord clamping in premature neonates born <35 weeks: A prospective, randomized, controlled study. Amer J Perinatol. 2007. 24(5):307-315. 6) van Rheenen PF, et al. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67. 2006; 333:954-958. 7) van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ 2006; 333:954-958 Read the slide Emphasize that for every 2 preterm babies where cord clamping is delayed, one will be saved of a brain hemorrhage. Note Delayed cord clamping is completely safe for mothers as well as babies. 1) Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: A randomized, controlled trial. Pediatrics 2006; 17;e779-e786. 2)Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. 3) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2.4) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252.5) Kugelman A, et al. Immediate versus delayed umbilical cord clamping in premature neonates born <35 weeks: A prospective, randomized, controlled study. Amer J Perinatol. 2007. 24(5):307-315. 6) van Rheenen PF, et al. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67. 2006; 333:954-958. 7) van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ 2006; 333:954-958

    12. Skin-to-Skin Contact: Effect on Breastfeeding Meta-analysis 30 quasi-/randomized trials comparing early SSC with usual hospital care (n=1925 mother-infant dyads) Statistically significant & positive effects of early SSC on Breastfeeding at 1-4 mos post-birth OR 1.82, 95% CI 1.08, 3.07), (10 trials; 552 dyads); and Breastfeeding duration WMD 42.55, 95% CI -1.69, 86.79) (7 trials; 324 dyads)

    13. Properly-Timed cord clamping Term babies: less anemia in the newborn 24-48 hrs after birth RR 0.2 (95% CI 0.06, 0.6) NNT 7, (4.5- 20.8) Preterms: less infant anemia RR 0.49 (95% CI 0.3, 0.81) NNT 3 (1.6 - 29.6) Preterms: less intraventricular hemorrhage RR 0.59 (95% CI 0.35, 0.92) NNT 2 (1.4 - 9.8) No significant impact on incidence of Post-Partum Hemorrhage Read the slide Emphasize that for every 2 preterm babies where cord clamping is delayed, one will be saved of a brain hemorrhage. Note Delayed cord clamping is completely safe for mothers as well as babies. 1) Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: A randomized, controlled trial. Pediatrics 2006; 17;e779-e786. 2)Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. 3) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2.4) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252.5) Kugelman A, et al. Immediate versus delayed umbilical cord clamping in premature neonates born <35 weeks: A prospective, randomized, controlled study. Amer J Perinatol. 2007. 24(5):307-315. 6) van Rheenen PF, et al. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67. 2006; 333:954-958. 7) van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ 2006; 333:954-958 Read the slide Emphasize that for every 2 preterm babies where cord clamping is delayed, one will be saved of a brain hemorrhage. Note Delayed cord clamping is completely safe for mothers as well as babies. 1) Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: A randomized, controlled trial. Pediatrics 2006; 17;e779-e786. 2)Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. 3) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2.4) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252.5) Kugelman A, et al. Immediate versus delayed umbilical cord clamping in premature neonates born <35 weeks: A prospective, randomized, controlled study. Amer J Perinatol. 2007. 24(5):307-315. 6) van Rheenen PF, et al. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67. 2006; 333:954-958. 7) van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ 2006; 333:954-958

    14. Non-separation of Newborn from Mother for Early Breastfeeding Weighing, bathing, eye care, examinations, injections should be done AFTER the first full breastfeed is completed Postpone bathing until at least 6 hours Read the slide Emphasize that for every 2 preterm babies where cord clamping is delayed, one will be saved of a brain hemorrhage. Note Delayed cord clamping is completely safe for mothers as well as babies. 1) Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: A randomized, controlled trial. Pediatrics 2006; 17;e779-e786. 2)Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. 3) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2.4) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252.5) Kugelman A, et al. Immediate versus delayed umbilical cord clamping in premature neonates born <35 weeks: A prospective, randomized, controlled study. Amer J Perinatol. 2007. 24(5):307-315. 6) van Rheenen PF, et al. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67. 2006; 333:954-958. 7) van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ 2006; 333:954-958 Read the slide Emphasize that for every 2 preterm babies where cord clamping is delayed, one will be saved of a brain hemorrhage. Note Delayed cord clamping is completely safe for mothers as well as babies. 1) Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: A randomized, controlled trial. Pediatrics 2006; 17;e779-e786. 2)Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No. CD003248. DOI: 10.1002/14651858.CD003248.pub2. 3) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No. CD004074. DOI:10.1002/14651858.CD004074.pub2.4) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates. Systematic review and meta-analysis of controlled trials. JAMA. 2007; 297:1241-1252.5) Kugelman A, et al. Immediate versus delayed umbilical cord clamping in premature neonates born <35 weeks: A prospective, randomized, controlled study. Amer J Perinatol. 2007. 24(5):307-315. 6) van Rheenen PF, et al. Delayed umbilical cord clamping for reducing anaemia in low birthweight infants: implications for developing countries. Ann Trop Paediatr. 2006 Sep;26(3):157-67. 2006; 333:954-958. 7) van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. BMJ 2006; 333:954-958

    15. The problem The evidence: What can save newborns from dying? The Philippine situation The response Next steps

    16. This is a study conducted in 51 hospitals in the Philippines. It helped us to determine where Philippines newborn practices fell short of WHO standards. Salient points: 1. All interventions fell short of WHO standards 2. Cords were clamped at a median of 12 seconds, far too soon 3. Less than 1 in 10 babies was placed in direct skin-to-skin contact. 4. Many were exposed to cold by not being dried immediately and thoroughly, being put on cold surfaces, and being washed. This is a study conducted in 51 hospitals in the Philippines. It helped us to determine where Philippines newborn practices fell short of WHO standards. Salient points: 1. All interventions fell short of WHO standards 2. Cords were clamped at a median of 12 seconds, far too soon 3. Less than 1 in 10 babies was placed in direct skin-to-skin contact. 4. Many were exposed to cold by not being dried immediately and thoroughly, being put on cold surfaces, and being washed.

    17. Let us review the Salient points: Breastfeeding far before any newborn is ready to breastfeed (typical range 20 – 120 minutes for time from birth to onset of feeding behaviors) Separation prevented babies from getting colostrum (only two minutes was allowed for breastfeeding) Weighing, exam and HBV all ok, but interrupted natural protections. Half went to a nursery which exposes them to infection Rooming in too lateLet us review the Salient points: Breastfeeding far before any newborn is ready to breastfeed (typical range 20 – 120 minutes for time from birth to onset of feeding behaviors) Separation prevented babies from getting colostrum (only two minutes was allowed for breastfeeding) Weighing, exam and HBV all ok, but interrupted natural protections. Half went to a nursery which exposes them to infection Rooming in too late

    18. The problem The evidence: What can save newborns from dying? The Philippine situation The response Next steps

    19. Dissemination Launched on Dec 7, 2009 Meetings held with professional societies, academe, regional directors Still to come Implementation Monitoring Essential Newborn Care Protocol was developed to address these issues Read the slidesRead the slides

    20. The evidence is solid. The following Newborn Care Practices will save lives: 1. Immediate and Thorough Drying 2. Early Skin-to-Skin Contact 3. Properly Timed Cord Clamping 4. Non-separation of Newborn from Mother for Early Breastfeeding

    21. Implementation of ENC at QMMC, Nov 2008 to Feb 2010

    22. Neonatal Mortality and Sepsis, QMMC, 2001 - 2010

    23. Appropriate BF within first 90 minutes OR 2.31 (95%CI 1.4-3.8) if skin-to-skin contact OR 0.12 (95% CI .05-0.27) if suctioned EBF at 28 days OR 1.99 (95% CI 1.5-2.7) if breastfed within first 90 minutes Exclusive breastfeeding rates 69% at 28 days

    25. The problem The evidence: What can save newborns from dying? The Philippine situation The response Next steps

    26. Incorporation of ENC Protocol, improved maternal care and related-hospital infection control practices as flagship interventions for hospital reform agenda within the next phase of the health sector reform agenda Read the slideRead the slide

    27. Incorporation of ENC Protocol and improved maternal care and related-hospital infection control practices into the pre-service and in-service curriculum including training materials development Read the slideRead the slide

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