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Essential Newborn Care (ENC) and Breastfeeding

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Essential Newborn Care (ENC) and Breastfeeding Mariella S. Castillo, MD, MSc Maternal & Child Health Team WHO Philippines WomenDeliver Philippines Conference – PowerPoint PPT presentation

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Title: Essential Newborn Care (ENC) and Breastfeeding


1
Essential Newborn Care (ENC) and Breastfeeding
Mariella S. Castillo, MD, MSc Maternal Child
Health Team WHO Philippines WomenDeliver
Philippines Conference 15 September 2010
2
Outline
  • The problem
  • The evidence What can save newborns from dying?
  • The Philippine situation
  • The response
  • Next steps

Office of the WHO Representative in the
Philippines
3
lt5 year old and Neonatal Mortality, 1988 to 2008
  • lt5 Yr Old mortality decreased 40 (1988-1998)
  • Past 10 years, declined by 20
  • Slow decline since neonatal mortality hasnt
    improved

Under Five Mortality Rate
Neonatal MR
DHS 88, 93, 98, 03, 08
4
82,000 Filipino children die annually, most
could have lived
Source CHERG estimates of under-five deaths,
2000-03
The Philippines is one of the 42 countries that
account for 90 of global under-five mortality
Office of the WHO Representative in the
Philippines
5
Majority of newborns die due to stressful events
or conditions during labor, delivery and the
immediate postpartum period.
3 out of 4 newborn deaths occur in the week of
life
Number of deaths
Day of Life
NDHS 2003, special tabulations
Office of the WHO Representative in the
Philippines
6
Outline
  • The problem
  • The evidence What can save newborns from dying?
  • The Philippine situation
  • The response
  • Next steps

Office of the WHO Representative in the
Philippines
7
What can we do to save newborn lives anyway?
The Lancet Child Survival Series (2003) Gave
Clear Estimates of 23 Interventions Needed to
Prevent 2/3rds of Under 5 Child Deaths
Lancet 2003 362 6571
8
Baguio General Hospital, 1970s
Period I Neonates were not rooming-in with
their mother The hospital allowed formula Many
cases of neonatal sepsis
Period II Neonates roomed-in with their
mother The hospital strongly promoted
breastfeeding policy 89 reduction of neonates
with clinical signs of sepsis
Clavano, J Trop Ped, 1982
9
Delaying Initiation of breastfeeding increases
risk of infection-related death, Nepal 2008,
22,838 breastfed babies
RR
Mullany LC, et al. J Nutr, 2008 138(3)599-603.
Hours after Birth
Office of the WHO Representative in the
Philippines
10
Immediate drying
  • 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 622390-99 Righard L, Alade
    M. Lancet 1990 336 1105-07.

Office of the WHO Representative in the
Philippines
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

Moore E, et al. Cochrane Rev. 2007 Jul 18(3).
Anderson GC, et al. Cochrane Rev
2003(2). Brandtzaeg P. Ann N Y Acad Sci
20029641345 McCall EM, et al. Cochrane
Database of Systematic Reviews 2010, Issue 3.
Art. No. CD004210. DOI10.1002/14651858.CD004210
.pub4.
Office of the WHO Representative in the
Philippines
12
Skin-to-Skin Contact Effect on Breastfeeding
  • Meta-analysis 30 quasi-/randomized trials
    comparing early SSC with usual hospital care
    (n1925 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)

Moore E, et al. Cochrane Rev. 2007 Jul
18(3)CD003519
Office of the WHO Representative in the
Philippines
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
  • Ceriani Cernadas ,et al. 2006
  • Rabe H, et al. 2004
  • McDonald SJ, et al. 2008
  • Hutton EK, et al. 2007
  • Kugelman A, et al. 2007
  • Van Rheenen PF, et al. 2006
  • Van Rheenen PF Brabin BJ. 2006

Office of the WHO Representative in the
Philippines
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

Office of the WHO Representative in the
Philippines
15
Outline
  • The problem
  • The evidence What can save newborns from dying?
  • The Philippine situation
  • The response
  • Next steps

Office of the WHO Representative in the
Philippines
16
A Minute-by-Minute Assessment of Newborn Care
within the First Hour of Life in Philippines
Hospitals (2009)
Intervention Percentage and Median Time WHO Standard
Cord Clamp 12 sec 99 in lt 1 min Until pulsations stop (1-3 mins)
Drying 97 at 1 min 100 Immediately
Immediate Skin-to-skin contact 9.6 at 5 min gt90 (except those needing resuscitation)
Put on cold surface 12 None
Not dried 2.5 None
Head not dried 6.2 None
Wash 84 at 8 min gt6 hours
Temp taken before 17 All
Sobel, Silvestre, Mantaring, Oliveros, 2009
17
A Minute-by-Minute Assessment of Newborn Care
within the First Hour of Life in Philippines
Hospitals (2009)
Intervention Median Time or Percentage WHO Standard
Breast feed 69.3 at 10 min Within 1 hour (but when baby shows signs)
Separated from mother 92.9 at 12 min gt1 hour
Weigh 100 at 13 min gt 1 hour
Exam 75.7 at 17 min gt 1 hour
Hepatitis B Vaccine 69.4 at 20 min gt1 hour
Nursery 52 at 19 min Never
Rooming in 83 (155 min) Immediately with mother
Sobel, Silvestre, Mantaring, Oliveros, 2009
18
Outline
  • The problem
  • The evidence What can save newborns from dying?
  • The Philippine situation
  • The response
  • Next steps

Office of the WHO Representative in the
Philippines
19
Essential Newborn Care Protocol was developed to
address these issues
  • Guideline Development Process
  • Convened Technical Committee
  • Identified problems in newborn care incl.
    observational studies
  • Appraised evidence for effective interventions
    including WHO Guidelines
  • GRADE methodology
  • Evidence-based draft developed
  • Individual and en banc panel stakeholder and
    expert review
  • Protocol finalized
  • Administrative Order issued
  • Dissemination
  • Launched on Dec 7, 2009
  • Meetings held with professional societies,
    academe, regional directors
  • Still to come
  • Implementation
  • Monitoring

20
The evidence is solid. The following Newborn
Care Practices will save lives 1. Immediate
and Thorough Drying2. Early Skin-to-Skin
Contact3. Properly Timed Cord Clamping4.
Non-separation of Newborn from Mother for Early
Breastfeeding
21
Implementation of ENC at QMMC, Nov 2008 to Feb
2010
Weekly team assess and improve
ENC Trn
Initial ENC work of Dr Vitangcol, et al.
22
Neonatal Mortality and Sepsis, QMMC, 2001 - 2010
23
Implementation at Pilot Hospital
  • Appropriate BF within first 90 minutes
  • OR 2.31 (95CI 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

Office of the WHO Representative in the
Philippines
24
ORs for Mortality, Sepsis Severe Disease
Risk of Harm
Protection
Intervention
0.10 1.0 10.0
25
Outline
  • The problem
  • The evidence What can save newborns from dying?
  • The Philippine situation
  • The response
  • Next steps

Office of the WHO Representative in the
Philippines
26
4 Strategies to Scale Up ENC
  • 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
  • Development of a network of centers of excellence
    to fully implement the ENC Protocol, improved
    maternal care and related-hospital infection
    control practices

Office of the WHO Representative in the
Philippines
27
4 Strategies to Scale Up ENC
  • 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
  • Social Marketing Campaign

Office of the WHO Representative in the
Philippines
28
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