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Essential "nutrition-related" delivery care practices for short- and long-term infant and maternal health and

Essential "nutrition-related" delivery care practices for short- and long-term infant and maternal health and nutrition. AMTSL and the newborn – an immediate postpartum care package: new directions and collaborative efforts POPPHI PPH Working Group, March 20, 2008 Camila M Chaparro, PhD

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Essential "nutrition-related" delivery care practices for short- and long-term infant and maternal health and

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  1. Essential "nutrition-related" delivery care practices for short- and long-term infant and maternal health and nutrition AMTSL and the newborn – an immediate postpartum care package: new directions and collaborative efforts POPPHI PPH Working Group, March 20, 2008 Camila M Chaparro, PhD Pan American Health Organization

  2. What are the practices? • Delayed umbilical cord clamping • Immediate mother to newborn skin-to-skin contact • Early initiation of exclusive breastfeeding

  3. Why are they important? • Delayed cord clamping: • Evidence that a minimum delay of 2 minutes: • Improves infant hematological and iron status through 6 months of age in full-term infants • Preterm infants: delay of 30-45 seconds shows immediate benefits: prevention of late-onset sepsis, intraventricular hemorrhage; decreased blood transfusions, increased hematocrit

  4. Infant iron status • Iron deficiency is the most common nutritional deficiency worldwide, the most common cause of anemia • Up to 50% of infants in developing countries are estimated to become anemic by age 1 • IDA in young children associated with impaired cognitive, motor and behavioral development • Some effects may be irreversible even after treatment, and many years later negative effects still evident

  5. Prevalence of anemia:6-9 mo

  6. Iron deficiency during infancy: Preventive interventions? • Particularly in developing countries there may be few feasible and affordable interventions to prevent iron deficiency in infants • One intervention to improve infant iron status is delayed umbilical cord clamping (DC) (Chaparro CM et al, Lancet 2006)

  7. DC significantly increased infant body storage iron at 6 months of age1 p = 0.0003 65 57.6 56 27 mg Fe = 1.25 mo Fe requirements EC 47 Body storage iron (mg) DC 38 30.7 29 20 1 Adjusting for maternal ferritin and employment

  8. DC increases body iron more in infants born to ID mothers1 p = 0.008 for interaction term 50 48.6 47.5 46.7 47 44 Infant Body Iron (mg/kg) 42.1 EC 41 DC 38 35 Iron-replete mothers Iron deficient mothers ID = ferritin < 12µg/L

  9. DC increases body iron more in infants with birth weight ≤ 3000 g p = 0.04 for interaction term 50 48.3 47.7 47 45.2 44 Infant body iron (mg/kg) EC 41.2 41 DC 38 35 Birth weight > 3000 g Birth weight 2500 to 3000 g

  10. Why are they important? • Skin-to-skin contact: • Improves time to effective breastfeeding, as well as more "successful" breastfeeding on the first latch • breastcrawl.org • Positively associated with breastfeeding status at 1-4 months postpartum and a longer breastfeeding duration

  11. Why are they important? • Early initiation of exclusive breastfeeding • Reduces neonatal and infant morbidity and mortality • Initiation of breastfeeding within the first hour could reduce 22% of all-cause mortality (Edmond et al Pediatrics, 2006) • Single most effective intervention for preventing under-5 mortality (13%) (Lancet, 2005) • Nutritionally ideal food • Long-term health benefits for mother and infant

  12. Are they being done? • Delayed cord clamping • POPPHI data: % of deliveries where cord clamped ≤ 1 min • Ethiopia: 93% • Tanzania: 75% • El Salvador: 71% • Guatemala: 90% • Honduras: 88% • Nicaragua: 94% • Indonesia: 96% • Indonesia (domiciliary deliveries): 86%

  13. Are they being done? • Skin-to-skin contact • ? • Early initiation of exclusive breastfeeding • DHS data

  14. Why not? • Lack of research on benefits/risks • Barriers to "evidence-based" clinical practice: habit, convenience, little access to medical literature, outdated guidelines/curricula/clinical norms • Other barriers: cultural • Lack of integrated nature of guidelines for maternal and newborn care (perceived incompatibility between maternal and newborn care practices)

  15. Philip AGS, Saigal S. NeoReviews 2004;5:142-154.

  16. Presents the evidence base for the three practices • Recommendations for each practice • Suggested steps to ensure integration within the context of other programs • Addresses "common concerns/FAQs" with delayed cord clamping

  17. Briefly presents the evidence supporting the three practices plus AMTSL Presents a suggested sequence of steps for integration of the practices

  18. What can be done? • Simple, safe, effective and no-cost practices to improve infant nutrition, with potential long-term implications for health and development • Greater awareness of revised AMTSL guidelines (WHO/FIGO/ICM) recommending delayed cord clamping • Coordination between obstetric and pediatric programs to bridge the divide between "maternal" and "newborn" care

  19. What can be done? • Re-emphasis on importance of delivery care practices/hospital routines for infant nutrition and health • Renewed emphasis on BFHI certification, and importance of re-certification

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