Managing Low Birth Weight and Sick Newborns

1. Managing Low Birth Weight and Sick Newborns Advances in Maternal and Neonatal Health

2. Session Objectives • To define essential elements of the care of sick newborns, including neonatal resuscitation • To discuss best practices and technologies Managing Low Birth Weight and Sick Newborns

3. Management of Newborn Illness • Education of mothers to recognize danger signals • Working with families to develop complication plan for newborns • Early recognition and appropriate management of newborn illness Managing Low Birth Weight and Sick Newborns

4. Minimum Preparation for ANY Birth The following should be available and in working order: • Heat source • Mucus extractor • Self-inflating bag of newborn size • 2 masks (for normal and small newborns) • 1 clock • At least one person skilled in newborn resuscitation present at birth Managing Low Birth Weight and Sick Newborns

5. Essential Care for All Newborns Most newborns breathe as soon as they are born and only need: • A clean and warm welcome • Vigilant observation • Warmth • To be observed for breathing • To be given to the mother for warmth and breastfeeding Managing Low Birth Weight and Sick Newborns

6. Immediate Care of the Newborn: Warmth • Lay newborn on mother’s abdomen or other warm surface • Immediately dry newborn with clean (warm) cloth or towel • Remove wet towel and wrap/cover newborn, except for face and upper chest, with a second towel/cloth Managing Low Birth Weight and Sick Newborns

7. Immediate Care of the Newborn: Warmth (continued) • Blood on newborn is not a risk to newborn, but is a risk to caregiver • Bathe after 24 hours • In areas with high HIV prevalence, consider bathing earlier to reduce risk of maternal-fetal transmission, and to reduce risk to caregiver and to other newborns Managing Low Birth Weight and Sick Newborns

8. Immediate Care of the Newborn • Assess breathing • Keep head in a neutral position • IMMEDIATELY assess respirations and need for resuscitation Managing Low Birth Weight and Sick Newborns

9. Objective measures Breathing Heart rate above 100 beats/minute Subjective measures Vigorous cry Pink skin Good muscular tone Good reactions to stimulus Signs of Good Health at Birth • Most important measure is whether newborn is breathing • Assessing all of above delays resuscitation, if it is necessary. Managing Low Birth Weight and Sick Newborns

10. Birth Asphyxia • Definition: Failure to initiate and sustain breathing at birth • Magnitude: • 3% of 120 million newborns each year in developing countries develop birth asphyxia and require resuscitation • An estimated 900,000 of these newborns die as a result of asphyxia Managing Low Birth Weight and Sick Newborns

11. Steps in Resuscitation • Anticipate need for resuscitation at every birth, be prepared with equipment in good condition • Prevent of heat loss (dry newborn and remove wet clothes) • Assess breathing • Resuscitate: • Open airway • Position newborn • Clear airway • Ventilate • Evaluate Managing Low Birth Weight and Sick Newborns WHO 1998.

12. Newborn crying? Yes No • Chest is rising symmetrically • Frequency >30 breaths/min. • Not breathing/ gasping • Breathing < 30 or > 60 breaths/ min. Provide routine care Immediately start resuscitation Provide routine care Assess Breathing Managing Low Birth Weight and Sick Newborns

13. Open Airway • Position newborn on its back • Place head in slightly extend position • Suction mouth then nostrils Managing Low Birth Weight and Sick Newborns WHO 1998.

14. Ventilate • Select appropriate mask size to cover chin, mouth and nose with a good seal • Squeeze bag with two fingers or whole hand, look for chest to rise • If chest not rising: • Reposition head and mask • Increase ventilation • Repeat suctioning Managing Low Birth Weight and Sick Newborns WHO 1998.

15. Evaluate After ventilating for about 1 minute, stop and look for spontaneous breathing If no breathing, breathing is slow (< 30 breaths/ min.) or is weak with severe indrawing If newborn starts crying/breathing spontaneously • Stop ventilating • Do not leave newborn • Observe breathing • Put newborn skin-to-skin with mother and cover them both Continue ventilating until spontaneous cry/ breathing begins Managing Low Birth Weight and Sick Newborns

16. Harmful and Ineffective Resuscitation Practices Practices to be avoided include: • Routine aspiration of the newborn’s mouth and nose as soon as the head is born • Routine aspiration of the newborn’s stomach at birth • Stimulation of the newborn by slapping or flicking the soles of her/his feet: only enough stimulation for mildly depressed-delays resuscitation • Postural drainage and slapping the back: dangerous Managing Low Birth Weight and Sick Newborns WHO 1998.

17. Harmful and Ineffective Resuscitation Practices (continued) • Squeezing the chest to remove secretions from the airway • Routine giving of sodium bicarbonate to newborns who are not breathing • Intubation by an unskilled person • Some traditional practices: • Putting alcohol in newborn’s nose • Sprinkling or soaking newborn with cold water • Stimulating anus • Slapping newborn Managing Low Birth Weight and Sick Newborns WHO 1998.

18. Infection Prevention for Resuscitation • Handwashing • Use of gloves • Careful suctioning if using a mucus extractor operated by mouth • Careful cleaning and disinfection of equipment and supplies • Do not reuse bulb—difficult to clean, poses risk of cross infection • Correct disposal of secretions Managing Low Birth Weight and Sick Newborns

19. Documentation Details of the resuscitation to be recorded include: • Identification of newborn • Condition at birth • Procedures necessary to initiate breathing • Time from birth to initiation of spontaneous breathing • Clinical observations during and after resuscitation • Outcome of resuscitation • In case of failed resuscitation, possible reasons for failure • Names of healthcare providers involved Managing Low Birth Weight and Sick Newborns

20. Post-Resuscitation Tasks:Successful Resuscitation • Do not separate mother and newborn • Leave newborn skin-to-skin with mother (kangaroo care) • Measure temperature, count breaths, observe for indrawing and grunting • Encourage breastfeeding within 1 hour after birth Managing Low Birth Weight and Sick Newborns

21. Post-Resuscitation Tasks:Unsuccessful Resuscitation • Inform patients fully • Provide counseling, as needed • If culturally appropriate, allow parents private time with dead newborn • Burial should be arranged according to regulations and parents’ wishes Managing Low Birth Weight and Sick Newborns

22. Policy Decisions for Resuscitation • Guidelines on when to start: • Apparently stillborn newborn • Malformations: • Lethal • Less severe malformations • Extremely low gestational age • Guidelines on when to stop: • 20 minutes Managing Low Birth Weight and Sick Newborns

23. Principles of Success • Readily available personnel • Skilled providers • Coordinated team • Resuscitation tailored to newborn response • Available and functioning equipment • Avoidance of harmful and ineffective practices • Follow rules for infection prevention Managing Low Birth Weight and Sick Newborns

24. Care of the Low Birth Weight Newborn • Birth weight = Gestation duration + intrauterine growth • Most low birth weight newborns in developing countries are term or near term (Small for gestation age) • Increased risk of hypothermia and poor growth Managing Low Birth Weight and Sick Newborns

25. Care of the Preterm Newborn • Associated problems with prematurity: • Feeding • Respiratory • Jaundice • Intracranial bleed Managing Low Birth Weight and Sick Newborns

26. Principles of Management for Low Birth Weight and Preterm Newborns • Warmth • Feeding • Detection and management of complications (e.g., resuscitation, assisted respiration) Managing Low Birth Weight and Sick Newborns

27. Warmth As for all newborns: • Lay newborn on mother’s abdomen or other warm surface • Dry newborn with clean (warm) cloth or towel • Remove wet towel and wrap/cover with a second dry towel • Bathe after temperature is stable Managing Low Birth Weight and Sick Newborns

28. Warmth: Problem with Incubators • Potential source of infection • Often temperature controls malfunction • Often share incubator for more than one newborn Need alternative method: kangaroo care Managing Low Birth Weight and Sick Newborns

29. Feeding Early and exclusive breastfeeding • Breastmilk = best nourishment • Already warm temperature • Facilitated by kangaroo care Managing Low Birth Weight and Sick Newborns

30. Definition of Kangaroo Care • Early, prolonged and continuous skin-to-skin contact between a mother and her newborn • Could be in hospital or after early discharge Managing Low Birth Weight and Sick Newborns

31. How to Use Kangaroo Care • Newborn’s position: • Held upright (or diagonally) and prone against skin of mother, between her breasts • Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways • Newborn’s clothing: • Usually naked except for nappy and cap • May be dressed in light clothing • Mother covers newborn with her own clothes and added blanket or shawl Managing Low Birth Weight and Sick Newborns

32. How to UseKangaroo Care (continued) • Newborn should be: • Breastfed on demand • Supervised closely and temperature monitored regularly • Mother needs lots of support because kangaroo care: • Is very tiring for her • Restricts her freedom • Requires commitment to continue Managing Low Birth Weight and Sick Newborns

33. Effectiveness of Kangaroo Care • Randomized controlled trial • Conducted in three tertiary and teaching hospitals in Ethiopia, Indonesia and Mexico • Study effectiveness, feasibility, acceptability and cost of kangaroo mother care when compared to conventional methods of care Managing Low Birth Weight and Sick Newborns Cattaneo et al 1998.

34. Benefits of Kangaroo Care • Is efficient way of keeping newborn warm • Helps breathing of newborn to be more regular; reduce frequency of apneic spells • Promotes breastfeeding, growth and extra-uterine adaptation • Increases the mother’s confidence, ability and involvement in the care of her small newborn • Seems to be acceptable in different cultures and environments • Contributes to containment of cost— salaries, running costs (electricity, etc.) deLeeuw et al 1991; Karlsson 1996; Lamb 1983; Ludington-Hoe et al 1993; Ross 1980. Managing Low Birth Weight and Sick Newborns

35. Summary • Skilled attendant • Equipment available and working • Begin resuscitation immediately • Ventilate • Reassess frequently • Kangaroo care once successful Managing Low Birth Weight and Sick Newborns

36. References Cattaneo et al. 1998. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 87: 976–985. de Leeuw R et al. 1991. Physiologic effects of kangaroo care in very small preterm infants. Biology of the Neonate 59: 149–155. Karlsson H. 1996. Skin-to-skin care: heat balance. Arch Dis Child 75:F130–F132. Lamb ME. 1983. Early mother-neonate contact and mother-child relationship. J Child Psychol Psychiatry 24(3): 487–494. Ludington-Hoe SM et al. 1994. Kangaroo care: Research results, and practice implications and guidelines. Neonatal Network 13(1): 19–27. Ross GS. 1980. Parental responses to infants in intensive care. The separation issue re-evaluated. Clin Perinatol 7: 47–60. World Health Organization (WHO). 1998. Basic Newborn Resuscitation: A Practical Guide. WHO: Geneva. Managing Low Birth Weight and Sick Newborns