Managing Low Birth Weight and Sick Newborns

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Managing Low Birth Weight and Sick Newborns

• Advances in Maternal and Neonatal Health

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Session Objectives

• To define essential elements of the care of sick
  newborns, including neonatal resuscitation
• To discuss best practices and technologies

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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

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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

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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

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Immediate Care of the Newborn Warmth

• Lay newborn on mothers 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

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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

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Immediate Care of the Newborn

• Assess breathing
• Keep head in a neutral position
• IMMEDIATELY assess respirations and need for
  resuscitation

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Signs of Good Health at Birth

• Objective measures
• Breathing
• Heart rate above 100 beats/minute

• Subjective measures
• Vigorous cry
• Pink skin
• Good muscular tone
• Good reactions to stimulus

• Most important measure is whether newborn is
  breathing
• Assessing all of above delays resuscitation, if
  it is necessary.

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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

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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

WHO 1998.
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Assess Breathing
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Open Airway

• Position newborn on its back
• Place head in slightly extend position
• Suction mouth then nostrils

WHO 1998.
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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

WHO 1998.
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Evaluate
After ventilating for about 1 minute, stop and
look for spontaneous breathing
If no breathing, breathing is slow (lt 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
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Harmful and Ineffective Resuscitation Practices

• Practices to be avoided include
• Routine aspiration of the newborns mouth and
  nose as soon as the head is born
• Routine aspiration of the newborns 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

WHO 1998.
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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 newborns nose
• Sprinkling or soaking newborn with cold water
• Stimulating anus
• Slapping newborn

WHO 1998.
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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 bulbdifficult to clean, poses risk
  of cross infection
• Correct disposal of secretions

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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

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Post-Resuscitation TasksSuccessful 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

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Post-Resuscitation TasksUnsuccessful
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

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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

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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

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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

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Care of the Preterm Newborn

• Associated problems with prematurity
• Feeding
• Respiratory
• Jaundice
• Intracranial bleed

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Principles of Management for Low Birth Weight and
Preterm Newborns

• Warmth
• Feeding
• Detection and management of complications (e.g.,
  resuscitation, assisted respiration)

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Warmth

• As for all newborns
• Lay newborn on mothers 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

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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

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Feeding

• Early and exclusive breastfeeding
• Breastmilk best nourishment
• Already warm temperature
• Facilitated by kangaroo care

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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

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How to Use Kangaroo Care

• Newborns position
• Held upright (or diagonally) and prone against
  skin of mother, between her breasts
• Head is on its side under mothers chin, and
  head, neck and trunk are well extended to avoid
  obstruction to airways
• Newborns 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

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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

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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

Cattaneo et al 1998.
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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 mothers 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.
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Summary

• Skilled attendant
• Equipment available and working
• Begin resuscitation immediately
• Ventilate
• Reassess frequently
• Kangaroo care once successful

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References

• Cattaneo et al. 1998. Kangaroo mother care for
  low birthweight infants a randomized controlled
  trial in different settings. Acta Paediatr 87
  976985.
• de Leeuw R et al. 1991. Physiologic effects of
  kangaroo care in very small preterm infants.
  Biology of the Neonate 59 149155.
• Karlsson H. 1996. Skin-to-skin care heat
  balance. Arch Dis Child 75F130F132.
• Lamb ME. 1983. Early mother-neonate contact and
  mother-child relationship. J Child Psychol
  Psychiatry 24(3) 487494.
• Ludington-Hoe SM et al. 1994. Kangaroo care
  Research results, and practice implications and
  guidelines. Neonatal Network 13(1) 1927.
• Ross GS. 1980. Parental responses to infants in
  intensive care. The separation issue
  re-evaluated. Clin Perinatol 7 4760.
• World Health Organization (WHO). 1998. Basic
  Newborn Resuscitation A Practical Guide. WHO
  Geneva.