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)
Normal Newborn Care 1
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 3% of newborns suffer mild to moderate birth asphyxia Prompt resuscitation is often not initiated or procedure is inadequate or incorrect
Significant contribution to deaths in low birth weight infants and preterm newborns Social, cultural and health practices delaying care to the newborn
An extremely important factor in newborn mortality 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
Place of childbirth
Prevent newborn infection Prevent and manage newborn hypo/hyperthermia Started within 1 hour after childbirth Early asphyxia identification and management
Thermal protection
Eye care
Prevent and manage ophthalmia neonatorum At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO)
Immunization
Identification and management of sick newborn Care of preterm and/or low birth weight newborn
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
Thermal Protection
Newborn physiology Normal temperature: 36.537.5C Hypothermia: < 36.5C 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)
Normal Newborn Care 8
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)
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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Gentle stimulation, if at all Biologically plausible advantages clear airway Potentially real disadvantages cardiac arrhythmia Bulb suctioning preferred Fetal distress Thick meconium staining Vaginal breech deliveries Preterm
Normal Newborn Care 11
Hamilton 1999.
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 N. gonorrhea More severe and rapid development of complications 3050% mother-newborn transmission rate C. trachomatis
Etiology
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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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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 < 0.05), erythromycin: not significant
Chen 1992.
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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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Silver nitrate vs. no prophylaxis: Hazard ratio 0.61 (0.390.97) 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.
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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 < 0.001 More infections in erythromycin OR 1.38, p=0.001
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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
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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
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Summary
The essential components of normal newborn care include:
Clean delivery and cord care Thermal protection Early and exclusive breastfeeding Monitoring Eye care Immunization
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