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© World Health Organization 2010 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate borde r lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organizati on be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Acknowledgments

This training package was developed by JSI/Ukraine and WHO Regional Office for Europe, Making Safer Programme with the financial support towards the preparation and production of this document provided by the Government of the Unites States of America and JSI.

Authors and contributors: Tengiz Asatiani, Nino Berdzuli, Atrem Chernov, Gianpaolo Chiaffoni, Dmytro Dobrianskyi, Pauline Glatleider, Gianfranco Gori, Daniela Iancu, Tamara Irkina, Dalia Jeckaite, Viacheslav Kabakov, Anna Karpushkina, Ivan Lejnev, Ketevan Nemsadze, Audrius Maciulevicius, Irina Matvienko, Natalia Podolchak, Liubov Pozdniakova, Igor Semenenko, Oleg Shvabski, Gelmius Siupsinskas, Elena Sofronova, Fabio Uxa.

Coordinators: Alberta Bacci, WHO, Regional Office for Europe, Helene Lefèvre -Cholay, Oleg Kuzmenko, JSI/Ukraine Contents

Module 1N. Complete Examination of a Newborn ...... 1MO-1 Module 2N. Post-Resuscitation Neonatal Care ...... 2MO -1 Module 3N. Breathing Difficulty in the Newborn ...... 3MO -1 Module 4N. Neonatal ...... 4MO -1 Module 5N. Neonatal Bacterial Infections ...... 5MO -1 Module 6N. Care of a Newborn with Birth Defects/Congenital Malformations or ...... 6MO-1 Module 7N. Low- Baby/Small Baby: Care and Feeding ...... 7MO -1 Module 1N

Complete Examination of a Newborn Effective perinatal care (EPC)

1N - 2 Module 1N

Slide 1N-1 Complete Examination of a Newborn

Upon completion of the module the participants will be able to perform a complete neonatal examination from “Head to Toes“ in order to: o Quickly identify any danger signs and organize the appropriate referral after pre-referral treatment o Assess the normal adaptations of a newborn after birth o Identify conditions requiring special care or follow-up observation o Identify any birth defect or birth trauma; o Monitor growth o Counsel the mother.

Medical personnel should understand the importance of examination for the mother and for the baby. The majority of newborn will be found strictly normal and need to stay with their mother, in case of danger signs or important birth defects the newborn needs to be referred to a higher level of care if the problem can not be solve in the maternity. The results of examination should be discussed in detail with mother/family.

Slide 1N-2 Main Objectives of Complete Newborn Examination

The purpose of the physical exam is to assess the baby’s condition and adaptation after birth and to identify any problem requiring treatment and special monitoring. In case of danger signs or major birth defects it is important to give immediate pre referral treatment and to organize safe transportation to a higher level of care if possible.

This comprehensive assessment will guide the health staff in counselling mother and family.

“The Newborn Examination Tool” will be used during the first months of life to assess the growth and development of the .

In case of child abuse or neglect the full examination will be an important tool to recognise it.

1N - 3 Effective perinatal care (EPC)

Slide 1N-3 When to Conduct a Complete Newborn Examination?

- In maternity: If a danger sign is found immediately after birth during the rapid assessment.

If the baby doesn’t need resuscitation the mother and the newborn stay together, without disturbing them and ideally, with skin to skin contact during the first 2 hours to support bonding and early . After 2 hours, when the mother is ready to leave the delivery room, the baby can be completely assessed.

- In case of home delivery when the baby is shown to a medical professional.

- Before hospital discharge and during each follow up visit for the 2 first months of life.

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

Slide 1N-4 Steps of Newborn Examination

The main steps of a newborn examination are: x Assess x Classify (normal signs, signs to be monitor, danger signs) x Treat if necessary x Counsel the family

It is important that the results of newborn assessment will be carefully recorded in the infant’s file. They should be explained to the mother/family.

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

Slide 1N-5 How and Where to Perform a Newborn Examination

A newborn examination needs to be a pleasant experience for the baby, the family and the health care provider.

The newborn should be examined naked in a warm and safe room in the presence of the mother/parent and at a time that’s convenient for the baby, mother and doctor.

1N - 4 Module 1N

Examination of a newborn should be done with a good light.

Overall environment influences the behaviour of the newborn during examination.

The baby’s hunger and state of alertness can affect the accuracy of the examination.

The health worker needs the ability to concentrate, to have enough time for the assessment and he /she needs to take the necessary time to discuss the results with the family. Privacy should always be observed, especially when discussing sensitive issues related to the newborn or the mother’s health.

Routine Examination of the Newborn. NHS Quality Improvement. Best Practice Statement. Scotland 2004

Slide 1N-6 Wash your Hands before Starting the Newborn Examination.

Before assessing or touching any newborn, the medical staff should carefully wash their hands which the most important recommendation to prevent infection.

This basic “Universal Precaution” needs to be completely respected.

Slide 1N-7 Always Check First for Danger Signs

Danger signs in newborn are often non specific. x Not feeding well x Fast breathing (60 breaths per minute or more) x Severe chest indrawing when breathing-in x Grunting when breathing-out x Convulsions x Movement only when stimulated or no movement even when stimulated x Temperature > 38ºC or < 35,5ºC x Jaundice in newborn younger than 24 hours or yellow palms and soles at any age

Assess for danger signs at the beginning of newborn examination so immediate care can be provided.

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

1N - 5 Effective perinatal care (EPC)

Slide 1N-8 Danger Signs are a Threat to the Infant’s Life

If a danger sign is founded, quickly complete the assessment, give immediate pre-referral treatment, prepare the newborn for a safe transport (keeping him/her warm, preventing low blood glucose by breastfeeding or IV glucose infusion ), and refer to higher level of care as soon as possible.

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

Slide 1N-9 Main Characteristics of a Health Newborn at Birth (1)

All medical health workers in charge of newborns should clearly know the physiologic characteristics of a healthy newborn in order to recognise any differences or .

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004

Slide 1N-10 Main Characteristics of a Healthy Newborn at Birth (2)

A healthy newborn opens his mouth and turns his head to search for the nipple and sucks vigorously.

A healthy newborn passes urine within 24 hours after birth.

Essential Newborn Care Course Training Manual (Draft).WHO, Geneva. 2006

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004.

1N - 6 Module 1N

Slide 1N-11 Medical History and Initial Observation

Check the medical history files of the newborn and the mother to have all the necessary information about the pregnancy and birth. Ask the mother about the baby’s health status since the birth.

It is extremely important to ask the mother if she has any concerns about the baby’s health or behaviour. The mother is the best observer of the baby’s condition and development thus she has to be a part of the team in charge of observing the baby from the first medical assessment.

It is also important to observe the mother’s attitude toward her baby. Is she emphatic? Is she interested or is she distant and not interested in the newborn examination?

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

Slide 1N-12 Respiratory System

The newborn needs to be calm during this assessment. If possible count the respiratory rate while the baby is sleeping. The normal respiratory rate of a newborn is 30 to 60 breaths per minute with no severe chest indrawing when breathing in and not grunting when breathing out; however, Small babies (less than 2.5 kg at birth or born before 37 weeks gestation) may have some mild chest indrawing, and it is not abnormal for a baby to periodically stop breathing for a few seconds (apnoea).

When determining the respiratory rate, count the number of breaths taken during a full minute, as babies may breathe irregularly (up to 80 breaths per minute) for short periods of time. If unsure of the respiratory rate, repeat the count.

IMPAC/Managing Newborn Problems: A guide for doctors, nurses, and midvifes. WHO, 2003

1N - 7 Effective perinatal care (EPC)

Slide 1N-13 Cardiovascular System

It is recommended that the baby be calm when conducting a cardiac auscultation.

The cardiovascular system needs to be assessed completely, which includes counting the heartbeat and heart auscultation, but also assessing peripheral perfusion such as the refilling time. The methodology to check how quickly the skin regains colour, using the thumb, press the middle of sternum for 5 seconds (skin under the thumb must become pale or colourless).Then record how quickly the skin regains colour. Femoral pulses are normally strong and symmetrical on both sides. x Femoral pulses are weak or not felt in case of coarctation of the aorta.

Pediatric Clinical Practice Guidelines for Nurses in Primary Care. Ottawa, Canada. 2001

Slide 1N-14 Posture and Movements

The normal resting posture of a term newborn includes loosely clenched fists, flexed arms, hips, and knees.

The limbs may be extended in small babies (less than 2.5 kg at birth or born before 37 weeks gestation).

First Nations and Inuit Health Branch Pediatric Clinical Practice Guidelines for Nurses in Primary Care.Canada.2001.

Babies who were in a breech position may have fully flexed hips and knees and the feet may be near the mouth; alternatively, the legs and feet may be to the side of the baby.

Managing newborn problems: guide for doctors, nurses, midwives. WHO, 2003

Slide 1N-15 Newborn Resting Postures

The normal resting postures of preterm and full term babies.

Managing newborn problems: guide for doctors, nurses, midwives.WHO.2003

1N - 8 Module 1N Slide 1N-16 Skin and Colour

The vernix caseosa should not be removed as it has a protective function.

Some skin conditions are common and don’t need treatment .These include milia (white spots around the nose) typically seen on the first day or later, and erythema toxicum (red spots with tiny white centres) seen on the face, trunk and back on the second day or later.

It is also usual for newborn skin on the trunk, abdomen, and back to peel after a few days.

Managing newborn problems: guide for doctors, nurses, midwives. WHO. 2003

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

Slide 1N-17 Cranium (1)

Assess newborn skull by gentle palpation.

The normal newborn baby’s head may be moulded during birth; this will resolve spontaneously over a period of three to four weeks.

The skull could be assessed for birth trauma, the most frequent one is cephalohaematoma which doesn’t require any treatment such as ice or aspiration.

Check for fontanels, which are soft and could have different sizes.

Managing newborn problems: guide for doctors, nurses, midwives. WHO, 2003

Slide1N-18 Cranium (2)

Baby with unilateral cephalohaematoma and baby with moulding.

Managing newborn problems: guide for doctors, nurses, midwives. WHO, 2003

1N - 9 Effective perinatal care (EPC)

Slide1N-19 Face, Eyes and Mouth

Look for symmetry and for any dysmorphic signs.

Eyes assessment: - Check for pus discharge or redness of the cornea. Conjunctivitis can be caused by gonococci, chlamydia, staphylococci.

- Red reflex: use an ophthalmoscope. Check the red with +10 dioptre lens, 15–20 cm from the eye. Normally a newborn’s eye reflects red light, in case of black spots are seen. Mouth assessment: - Palate and lip assessment: If cleft palate or cleft lip is found the baby could have feeding problem. - Breastfeeding is possible using special positions such as dancer position, but if the defect is severe the baby needs to be fed with expressed using a spoon or syringe. - If there are white patches in the mouth it could be oral thrush, which needs to be treated with oral nystatin. - Check that the tongue is a normal size. Macroglossia indicates .

First Nations and Inuit Health Branch Pediatric Clinical Practice Guidelines for Nurses in Primary Care.Canada.2001

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

Slide 1N-20 Abdomen

Obvious congenital birth defects, such as omphalocele and/or gastroschisis are immediately recognisable. Baby needs to be urgently and safely referred. Safe referral: keeping baby warm and preventing low blood glucose.

The cord needs to be kept clean and dry. Nothing needs to be put on the cord, no ointment, no antiseptic, no alcohol, no antibiotic and no bandage.

The use of any of substances listed above will delay normal mummification of the cord.

Zupan J, Garner P, Omari AAA. Topical care at birth. Cochrane Database of Systematic Reviews 2004, 2007

If the umbilicus is draining pus or if the skin around the umbilicus is red, it is a sign of infection.

1N - 10 Module 1N

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives. 2004

First Nations and Inuit Health Branch Pediatric Clinical Practice Guidelines for Nurses in Primary Care.Canada.2001

Slide 1N-21 Genitalia and Anus

Genitals of the newborn should be thoroughly examined for any abnormalities, or sexual ambiguity.

Often the scrotum of a baby boy is large because of hydrocele (no treatment).

If the newborn didn’t urinate for 24 hours after the complete examination, this should be stated in the newborn’s medical file and followed by the midwife and the mother.

Do not insert any instruments or finger to inspect the anus.

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004

First Nations and Inuit Health Branch Pediatric Clinical Practice Guidelines for Nurses in Primary Care.Canada.2001

Slide 1N-22 Back

Examine carefully the newborn’s backbone for spinal defects.

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004

1N - 11 Effective perinatal care (EPC)

Slide 1N-23 Limbs and Extremities

Examine the extremities carefully for possible birth defect or birth trauma.

Check each newborn for possible detection of developmental dysplasia of the hip (DDH) using the Ortolani and Barlow tests.

If the is not confident about the results of these tests/manoeuvres, the baby needs to be referred to a specialist.

First Nations and Inuit Health Branch Pediatric Clinical Practice Guidelines for Nurses in Primary Care.Canada.2001

Slide 1N-24 Ortolani and Barlow Tests

In order to conduct the Ortolani and Barlow tests, the newborn must laid on a hard surface, but still be comfortable and warm.

If a positive Ortolani or Barlow sign is found, the newborn should be referred to a specialist . The Ortolani maneuver reduces a dislocated hip .The Barlow maneuver is a provocative test to detect those hips that are unstable

x Technique of conducting Ortolani maneuver and Barlow maneuver. The maneuvers are performed on one hip at a time.

x Ortolani Maneuver (symptom of sliding or “clunk”) reduces a dislocated hip ….”The examiner’s index and middle fingers placed along the greater trochanter with the thumb placed along the inner thigh. The hip is flexed to 90 degrees but not more, and the leg is held in neutral rotation. The hip is gently abducted while lifting the leg anteriorly” AAP, 2000, p 897. This reduces a dislocated hip and will produce a “clunk” sensation .This positive Ortolani sign is produced by the head of the femur sliding over the edge of the actetabulum and into the socket.

x Barlow Maneuver – displacement of femoral head during flexion of leg in hip joint (under 90° angle). The newborn is supine and the hips are flexed to 90 degrees. “…The leg is then gently adducted while posteriorly directed pressure is placed on the knee. A palpable clunk or sensation of movement is felt as the femoral head exits the acetabulum posteriorly. This is the positive Barlow sign.” P 897

David .E Hertz Care of the newborn. A handbook for primary care. 2005

Committee on Quality Improvement, Subcommittee on Developmental Dysplasia of the Hip. Clinical Practice Guideline: Early Detection of Developmental Dysplasia of the Hip.AAP.2000

1N - 12 Module 1N

First Nations and Inuit Health Branch Pediatric Clinical Practice Guidelines for Nurses in Primary Care.Canada.2001

Slide 1N-25 Neurobehavioral Status

A healthy newborn is alert, with moving limbs, and reacts to noise and light.

x Functions of the cranial nerves 1-12 I Smelling II Response to light, vision III Extrinsic ocular movements, response of the pupil to light, eyelid elevation IV Extrinsic ocular movements V Facial sensibility, sucking, biting VI Extrinsic ocular movements

VII Facial motility, taste VIII Hearing, vestibular responses IX & X Sucking, swallowing, vocalization, taste, gag reflex XI Head and neck movements XII Movements of the tongue

Assess the posture of the newborn, the baby’s reactions and muscle tone, as well as the symmetry of movements, character of crying and reflexes.

Reflexes are involuntary movements or actions that help identify normal brain and nerve activity. Some reflexes can only be observed for a short period in the newborn’s life and then disappear. Reflexes should be symmetrical.

Pediatric Clinical Practice Guidelines for Nurses in Primary Care.Canada.2001

Volpe JJ., of the newborn, 4th edition, Philadelphia, WB Saunders, 2001

Slide 1N-26 Body Measurements

When the full clinical examination is complete the newborn is weighted, measured and the temperature is taken again to be sure that the baby did not get cold during the assessment.

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004

1N - 13 Effective perinatal care (EPC)

Slide 1N-27 Newborn’s Growth

It is normal for a newborn to lose 5-10 % of birth weight during the first days of life. The weight loss should not exceed 10% of the birth weight. Birth weight should be restored within 14 days.

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004.

Slide 1N-28 Counsel the Mother (1)

The newborn examination is a very good time to speak with the mother and family. The newborn’s health is the focus of attention for parents and the medical team.

It is critical to discuss everything found during the examination with the mother.

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004

Slide 1N-29 Counsel the Mother (2)

Counselling the mother and the family about appropriate care for their newborn is an important part of the examination process. It is important to teach the parents to keep the baby warm, to promote exclusive breastfeeding and to plan further medical assessment and immunization with the family. Explain to the mother when it is important to seek care immediately.

IMPAC/Pregnancy, Childbirth, Postpartum and Newborn care: A guide for essential practice. WHO, Geneva, 2006

1N - 14 Module 1N

Slide 1N-30 Special Focus of Newborn Visits

1st day of life It is the newborn ‘s adaptation to the life outside of the uterus . - Keep the baby warm and support bonding: the baby needs special attention to prevent hypothermia and skin to skin contact is the best because it also supports early breastfeeding and mother-baby bonding. Practically all mothers need support to initiate breastfeeding within an hour after the birth. No other food or drinks should be given to the newborn. - Make sure that the umbilical cord is tightly clamped and there is no . - If the newborn is jaundiced the first day of life, this jaundice is a pathological jaundice.

During each other follow -up visits it is important to: 1. Ask the mother if she has any concern about her newborn; 2. Praise her for the good care she is providing to the baby; 3. Assess the baby and focus on any problem previously identified 4. Continue counselling l the mother and family on baby care.

2-3rd day of life - Breastfeeding: mother and newborn are getting use to each other and breastfeeding is normally well established. At this time the breasts can swell causing discomfort and difficulties during breastfeeding. It is crucial that no other food or drinks be given to the newborn. - Check for danger signs and signs of local infections. - Check for the localisation of jaundice and its intensity. - Weight loss should not exceed 10% of the birth weight.

7th day of life - Breastfeeding: the newborn is getting used to breastfeeding. - Newborns usually start to gain weight and will restore it no later than day 14th. - Check for danger signs and signs of local infections. - Check for the localisation of jaundice and its intensity. - Immunize according to national guidelines.

Diana Beck, et al. Care of the Newborn. Reference Manual. Saving newborn lives.2004

1N - 15 Effective perinatal care (EPC)

1N - 16 Module 2N

Post-Resuscitation Neonatal Care

Effective Perinatal Care (EPC)

2N - 2 Module 2N

Slide 2N-1 Post-Resuscitation Neonatal Care

Module objectives At the end of the module participants will be able to: x Assess an infant after neonatal resuscitation x Decide if after resuscitation the baby can stay with his/her mother or should be transfer to a special neonatal or paediatric department x Know how to care for a newborn after neonatal resuscitation x Know how to monitor the infant’s condition after neonatal resuscitation x Know the main modes of treatment in the neonatal care unit x Know when the infant is ready for discharge.

Slide 2N-2 Main Problems That Occur in the Post-Resuscitation Period

After resuscitation a newborn can have several problems.

It is necessary to categorise the problems and to treat the most problems first such as temperature less than 32°C, convulsions, unconsciousness).

Evaluate indicators such as preterm delivery and birth defects to make additional decisions about further care.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 2N-3 How to Assess a Newborn after Neonatal Resuscitation

After resuscitation each newborn should be carefully assessed on a warm surface, under a radiant heater and in good light.

Assess the baby for emergency signs (fast breathing, low breathing, heart beat rate <100 min, central cyanosis, pallor, convulsions, or lethargy). If emergency signs are identified, treat the baby immediately and transfer him/her to the neonatal or paediatric unit or to the NICU.

2N - 3 Effective Perinatal Care (EPC)

The normal adaptations after birth are: x Respiratory rate 30-60 per min, no severe chest in-drawing when breathing in , no grunting when breathing out x Normal heartbeat rate 100-160 per min x Skin and mucous membranes should be pink. x Baby is alert, with a good muscle tone. The normal resting posture of a term newborn includes loosely clenched fists and flexed arms, hips and knees; the limbs may be extended in small babies x The body temperature is 36.5°C-37.5°C. All newborns need help controlling their body temperature and must be kept warm, especially babies who are resuscitated.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 2N-4 1st Case: Good Clinical Status after Neonatal Resuscitation

After resuscitation if the newborn is alert, if respiratory rate stabilizes, if heart beat rate >100 and skin turning pink give the baby to the mother and stay with mother and bay in the delivery room.

These newborns don’t need any routine special tests or interventions; however, they need careful monitoring, in order to timely detect potential problems. They also need essential newborn care which includes keeping baby warm, starting breastfeeding early and proper cord management.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. World Health Organization, Geneva, 2006

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 2N-5 Care in the Birth Room

Once the baby is in good general condition after resuscitation start skin-to skin contact with mother immediately. At the same time closely monitor the baby’s temperature. If newborn’s body temperature is less than 36.5°ɋ, start warming him/her immediately.

Respiratory rate and signs of difficult breathing need to be monitored very strictly over a 2 hour period.

Initiate breastfeeding within the first hour if the baby is ready. Help the mother

2N - 4 Module 2N attach the baby correctly and counsel her on the correct position. Make sure that the baby is securely latched to the breast and suckling well.

Provide a complete examination 2 hours after birth or immediately in case of any problems are present.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. World Health Organization, Geneva, 2006

Slide 2N-6 Care in the Postpartum Unit

Newborns that have experienced resuscitation, once they are in good condition, need to be room with their mother 24 hours a day. The same requirement as all other newborn.

It is important to reassure the mother. Explain that the baby had some difficulty at birth. Tell her the problem is solved but the baby still needs careful monitoring. Explain her role caring for and observing the baby; train her to recognise danger signs and to tell her how to call for help. Support exclusive breastfeeding during the day and night.

These newborns may have problems maintaining their body temperature. Ensure that the baby does not become cold (hypothermic) or overheated. In case of hypothermia it is necessary to warm the baby immediately.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. World Health Organization, Geneva, 2006

Slide 2N-7 Monitoring in the Postpartum Unit

Breathing difficulties indicate the baby is in distress It is important to check for fast breathing > 60 per min and other signs of breathing difficultly (severe chest in drawing when breathing in, apnoea, grunting on expiration). Monitor breathing rate at least every hour during a 4 hour period and then every 2 hours during the first day of life. Record the results on the monitoring form.

If on the second day the baby is stable continue to assess daily and remind the mother to seek care if she has any concerns or if she sees a danger sign.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. World Health Organization, Geneva, 2006

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

2N - 5 Effective Perinatal Care (EPC)

Slide 2N-8 2nd Case: Poor Clinical Status after Extensive Resuscitation and/or after Post Resuscitation

If the newborn was intubated, received chest compression or adrenaline during the resuscitation, and/or his/her clinical condition is poor once adequate ventilation and circulation are established, the infant should be transferred to a place where close monitoring and anticipatory care can be provided.

The newborn’s clinical status should be assessed carefully by a complete examination.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

European Resuscitation Council Guidelines for Resuscitation. Section 6: Paediatric life support, Resuscitation of babies at birth, 2005:S115-S133

Slide 2N-9 Care in the Delivery Room

Before transferring the newborn to an appropriate unit, it is necessary to maintain an adequate ventilation and circulation. The experienced doctor (preferably neonatologist or anaesthesiologist) will prepare the baby for transfer establishing and /or maintaining IV lines (if needed) and monitor breathing and heart functions.

Explain to the mother/family the reason for transferring the baby.

Coordinate with the “receiving department”. Ask them to prepare a safe, warm place with good light, resuscitation equipment and a source of oxygen if possible.

While transporting the baby keep her/him baby warm preferably with an incubator or heated cradle. Avoid having staff carry baby though cold corridors.

If the baby is receiving oxygen during transfer, check the oxygen flow and tubing

If any problems occur during the transfer stop immediately and stabilise the newborn.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

2N - 6 Module 2N

Slide 2N-10 Principles of Newborn Care in the Neonatal Unit

Ensure an optimum temperature in the room or department. The room temperature should not be less then 25°ɋ but avoid making it too cold or too warm. Put the sick newborn in a comfortable position. Create a ‘nest’, position hands and legs comfortably (no tight swaddling).

Follow the principles of ‘minimum handling’: x Avoid too much light in the room (cover the incubators, use sources

of concentrated light) x Avoid noise (speak quietly; do not slam room doors or incubator doors, etc.) x Minimize routine procedures by grouping them, and refuse ‘planned’ interventions such as routine aspiration of mucous from nasopharynx or trachea) x Install a venous catheter (but not a routine umbilical catheter) if frequent blood tests are needed x Avoid useless and frequent examinations of neonates. It is necessary to use non- invasive monitoring with newborns

Ensure adequate pain relief: the best is skin-to-skin contact with the mother and breastfeeding. If that contact is impossible stimulate the sucking reflex. Sucking is a powerful sense stimulant for the newborn which relieves pain. Sucking also increases the newborn’s ability to regulate pain allowing him/her to focus on sucking as the more pleasant activity. Use both methods to improve pain relief.

Encourage the mother or family to stay with baby and provide simple care such as speaking to the baby, touching the baby and changing and feeding the baby.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Anand KJ. Prevention and Management of Pain in the Neonate: An Update. Vol. 118 ʋ 5, November 2006, pp. 2231-2241

Carbajal R, Chauvet X, Couderc S, Olivier-Martin M. Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates. BMJ 1999; 319: 1393-1397

Slide 2N-11 “Nesting” Newborns in the Neonatal Unit

Photographs show a comfortable position. The are in a ‘nest’, hands and legs positioned comfortably (no tight swaddling).

2N - 7 Effective Perinatal Care (EPC)

Slide 2N-12 Care in the Neonatal Unit

Ensure a regular complete assessment: examine the baby under a radiant heater or in an incubator and allow the mother to be present during the examination. Explain your findings to the mother in simple terms.

x Keep the baby warm. Do not allow the baby to become too cold or overheated x Provide supportive ventilation or oxygenation if there is breathing difficulty x Prevent or treat hypoglycaemia or any metabolic imbalances by proper feeding and/or the IV administration of fluids x Prevent infections, wash your hands before touching the baby, restrict invasive interventions and involve the mother in the care of her baby x Isolate infected babies.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. World Health Organization, Geneva, 2006

Slide 2N-13 Monitoring in the Neonatal Unit

Monitor the indicators mentioned every hour in a 4 hour period, then every two hours for the next 24 hours, then every 3 hours until the baby no longer requires oxygen. Then for an additional 24 hour and continue as the newborn’s condition requires. If baby’s condition worsens monitor the baby more often.

x Look for central cyanosis or pallor and remember that central cyanosis is a very late clinical sign x Check for convulsions or lethargy and remember that between convulsions or lethargy the baby may appear normal x Check for baby’s response to feeding: Is the baby digesting his/her food? Is the baby vomiting? In this case aspirate gastric content x Check to see if the baby has more difficulty breathing after feeding x Check for urine and stool output (quantity) and assess presence of mucus or blood in the stool.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

2N - 8 Module 2N

Slide 2N-14 Promoting Feeding

A newborn after resuscitation often has feeding problems.

Poor suckling reflex, vomiting, poor digestion or necrotizing enterocolitis are the most common manifestations of this problem. The sucking reflex, or the coordination of sucking swallowing, and breathing may be impaired because of central nervous system damage. In these cases, intravenous fluid administration should be given until the baby improves.

Once the baby’s condition improves begin the enteral feeding. Give expressed milk using an alternative feeding method. If the baby tolerates it and there are no problems, continue to increase the volume of expressed milk while decreasing the volume of IV fluid to maintain the total daily volume according to the baby’s daily requirement. Feed the baby every three hours or more frequently if necessary.

Discontinue the IV fluid when the baby receives more than two-thirds of the daily fluid volume by mouth and the abdomen is not distended and there is no vomiting.

Help the mother to express breast milk and feed her baby. Encourage the mother to breastfeed exclusively as soon as the baby receives 100% of daily fluid volume by mouth.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 2N-15 Giving Oxygen When There is Difficulty Breathing

Give oxygen if the baby has difficulty breathing.

Carefully review the methods of administration, the instructions and the advantages and disadvantages. The flow and concentration of oxygen depends on the severity of the breathing difficulty and on the method of administration.

During the oxygen it is necessary to closely monitor the response to oxygen. Use the oximeter according to the manufacturer’s instructions to ensure that the baby receives an adequate concentration of oxygen. If an oximeter is not available, monitor the signs of oxygenation by assessing signs of breathing difficulty in the baby or look for central cyanosis (blue tongue and lips).

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

2N - 9 Effective Perinatal Care (EPC)

Slide 2N-16 Giving Fluids when there is Difficulty Breathing, Convulsions or Signs of Shock

Give IV fluids to ensure that the baby receives the necessary fluids, minimum calories and electrolytes. Use an infusion set with a microdropper if possible (1ml=60 micro drops).

Determine the required volume of fluid according to the baby’s age and weight.

Give only 10% glucose for the first three days of life. On the fourth day if urine output is well established, give 10% glucose with 3 mmol/kg body weight of sodium and 2 mmol/kg body weight of potassium.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 2N-17 Maintaining Hemodynamic

It is necessary to control the heartbeat rate and arterial pressure in newborns after resuscitation until there is stabilization of arterial pressure and peripheral perfusion. If the baby has low blood pressure or shows sign of shock (e.g. cold to the touch, heart rate more than 180 beats per minute, unconscious or nearly unconscious etc), but no sign of bleeding give a normal saline IV.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Royal Women Hospital, NETS Neonatal Handbook, Clinical Practice Guidelines. Last Updated 03-Jan-2007

2N - 10 Module 2N

Slide 2N-18 Preventing Metabolic Imbalances by Promoting Feeding and/or with IV Fluids

Control blood glucose level soon after resuscitation.Continue monitoring depending on the results and the infant’s conditions as well as correcting problems in time.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Royal Women Hospital, NETS Neonatal Handbook, Clinical Practice Guidelines. Last Updated 03-Jan-2007

Slide 2N-19 Managing Convulsions

1. If the baby has convulsion check the blood glucose level: x If blood glucose level is less than 2.6 mmol/l or 45 mg/dl, give a bolus of 2 ml /kg body weight of 10% glucose IV slowly over 5 minutes x Infuse 10% glucose at the daily maintenance volume according to the baby’s age e.g. Day 1 = 60 ml/kg body weight; Day 2 = 80 ml/kg body weight x Measure blood glucose 30 min after the bolus of glucose and then every 3 hours: o If the level is less than 1.4 mmol/L or 25 mg/dl, repeat the bolus of glucose of 2 ml /kg body weight IV slowly over 5 minutes and continue the infusion. continue the blood glucose measurement until blood glucose is 2.6 mmol/l or 45 mg/dl or more after two consecutive measurements o If the blood glucose is less than 2.6 mmol/l or 45 mg/dl but is more than 1. 4 mmol/L or 25 mg/dl, continue the infusion and repeat the blood glucose measurement every three hours until the blood glucose is 2.6 mmol/l or 45 mg/dl or more after two consecutive measurements. x Within the next few days measure blood glucose levels every 12 hours x Increase measurement frequency if clinical symptoms of hypoglycaemia persist.

2. If blood glucose level is in normal ranges, or convulsions continue after IV glucose administration, give : x Give Phenobarbital 20 mg/kg body weight IV slowly over 5 minutes x If IV line has not yet been established give Phenobarbital 20 mg/kg as a single IM injection x If convulsions do not stop within 30 minutes, repeat administration of Phenobarbital 10 mg/kg IV slowly over 5 min. x Repeat one more time after 30 minutes, if necessary

3. If convulsions continue or if they recur within six hours, give Phenytoin:

2N - 11 Effective Perinatal Care (EPC)

x Give Phenytoin 20 mg/kg body weight IV only x Mix the total dose of phenytoin with 15 ml of normal saline and infuse at the rate of 0,5 ml/min over 30 min).

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 2N-20 Drugs Not Recommended Drugs for Routine Use after Resuscitation of the Newborn

A one dose comparison trial has been performed in newborn infants showing that MgSO4 (400 mg/kg) has an unacceptable risk of hypotension; 250 mg/kg MgSO4 was not associated with hypotension although respiratory depression can occur. Trials comparing MgSO4 to placebo are required before it can be recommended.

Levene M, Blennow M, Whitelaw A, Hanko E, Fellman V, Hartley R.. Acute effects of two different doses of magnesium sulphate in infants with birth asphyxia. Arch Dis Child Fetal Neonatal Ed. 1995 Nov;73(3):F174-7

There is no data to support the use of prophylactic barbiturates or other drugs especially for HIE: the symptomatic treatment should be provided only.

Volpe JJ. Neurology of the Newborn. Philadelphia, Pa: WB Saunders Company; 2001

Slide 2N-21 Criteria for Discharge from Hospital

Examine the baby and confirm that the baby meets the requirements for discharge: x Baby is breathing well and doesn’t have other problems which cannot be managed on an outpatient basis x Baby’s body temperature is stable (36.5-37.5°C) x Baby is breastfeeding well or mother is confident using an alternative feeding method x Baby is gaining weight.

Advise the mother to return immediately with the baby if the baby has any problems (e.g. feeding or breathing difficulties, convulsions, abnormal body temperature, etc.).

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

2N - 12 Module 2N

Slide 2N-22 Preparation for Discharge from Hospital

Advise the mother on home care: x How to keep the baby warm x Breastfeeding on demand and exclusively x Providing dry cord care x Providing standard hygienic care x The back sleeping position x Observing the baby and immediately returning to hospital if any danger signs occur x Ensure the baby has regular medical surveillance and care.

Give the mother a sufficient supply of drugs to complete any treatment at home, or give prescriptions for the drugs.

Complete the baby’s clinical record with full information.

Plan at least one follow-up visit after discharge to: x Assess the baby for the any specific problem identified before discharge and which required additional observation. Make sure that the problem is solved or under control x Assess the general condition of the newborn x Weigh the infant and assess growth x Counsel the mother and/or help her to solve any problems that she might have x If there are feeding difficulty assess breastfeeding or alternative feeding methods and counsel the mother to breastfeed exclusively x Remind to the parents of the danger signs and essential newborn care.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 2N-23 Conclusion

The effective management of post- resuscitated newborns can decrease the neonatal mortality by 15-50%.

Gary L Darmstadt et al. Evidence-based, cost effective interventions: how many newborn babies can we save? Lancet, March 3, 2005, 19-30

Mother and baby should not be separated if the baby is in good clinical condition after neonatal resuscitation.

When preparing for discharge, the mother should receive advice on how to monitor and care for her baby.

Case Study

2N - 13 Effective Perinatal Care (EPC)

Maria, a full term newborn, is Galina’s first baby. It was a normal pregnancy.

At birth she was cyanotic with irregular breathing. The neonatologist resuscitated her with bag and mask.

Immediately after resuscitation she assessed Maria’s condition: the baby was active; her breathing rate was 40 per min; her heart rate was 140 beats per min; no severe chest indrawing no grunting; skin and mucous were pink. Apgar score was 6-7 points.

Maria was weighed and measured, her weight was 3, 400 g.

After Maria was resuscitated she was transferred to the neonatal unit for monitoring.

Immediately after admission blood test results showed: red cells: 5.4 ɯ 1012; Hb: 210 g/L; white cells: 24 ɯ 109; Ht: 50%.

The neonatologist decided to feed Maria 5 ml of 5% glucose orally.

Two hours after birth Maria’s temperature was 36.60ɋ. As Maria was in good condition the neonatologist allowed Maria to room in with her mother.

The next morning (16 hours after birth ) Maria’s temperature was 36.40ɋ; she was breathing irregularly and her respiratory rate 46 per min; heart rate 130 beats per min; and she was little hypotonic . Maria’s mother said that Maria did not eat at night because she refused the breast and in the morning only sucked for 10 min 2 times and then refused to feed.

The doctor weights Maria. Her weight was 3, 250g and she decides to put the baby in an incubator and checks the temperature after 1 hour: the temperature is 36.60ɋ.

The doctor recommends checking the temperature again in the evening. Due to the 150 g weight loss in a few hours, the neonatologist prescribed baby formula on 10 ml per each feeding 6 times a day.

1st Question: What are the basic principles of management of resuscitated newborns in the delivery room? Explain your answer and compare with what was done in Maria’s case.

2nd Question: What are the basic principles of management of resuscitated newborns in the postpartum department? Explain your answer and compare with what was done in Maria’s case.

3rd Question: When can Maria be discharged from the hospital? Explain your answer.

2N - 14 Module 3N

Breathing Difficulty in the Newborn Effective perinatal care (EPC)

3N - 2 Module 3N

Slide 3N-1 Breathing Difficulty in the Newborn

By the end of this module participants will: x Know how to quickly resuscitate a baby who is gasping or not breathing x Be able to recognize the clinical signs of breathing difficulty x Be able to classify the severity of breathing difficulty x Know how to manage a newborn with breathing difficulty x Know general and specific treatments for breathing difficulty x Know the basic principles of oxygen therapy x Know when a baby who experienced breathing difficulty can be discharged.

Slide 3N-2 Resuscitate the Baby Immediately Using a Bag and Mask

If the baby is not breathing even when stimulated or is gasping or breathing less than 20 times per minute, it is an emergency; this baby could die if he is not resuscitated immediately. Move the baby quickly to an appropriate place, and immediately start the resuscitation with a bag and mask.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-3 Position the Baby Correctly and Clean the Airways

Act quickly and constantly check the time using a clock with a second hand.

Position the baby correctly: x Place the newborn on his/her back with the head in a "sniffing" position to open the airway x Place a 2-cm thick towel under the baby’s shoulder

Clean the airways if they are blocked by mucus, blood or vomit x Suction is needed only if there is particulate matter or blood obstructing the airway x Sequence of suctioning: First from the mouth, then from the nostrils.

3N - 3 Effective perinatal care (EPC)

x Perform this procedure gently and softly: no deeper than 5 cm from the lip edge and 3 cm from the nostril edge x Do not aspirate more than twice

Suction may initiate spontaneous breathing.

If after aspiration the baby is still not breathing ventilate with bag and mask.

Equipment for newborn resuscitation in good working condition should be available at any time in the department/room where newborns with breathing difficulties are managed. The equipment must be disinfected after each use.

Equipment x Bag: it is recommended to use a self-inflating bag for neonatal resuscitation with a volume 240 ml. The bag compression must generate the pressure of at least 45 cm water. The bag must be convenient for use and disinfected after every use. x Masks in 2 sizes: 0 for preterm newborn, 1- for full-term newborn x Equipment for suctioning: mucus extractor, bulb or catheter x Intubation equipment: laryngoscope with blades for newborns, intubation tubes of different sizes, adapter for suctioning, wire, Magill forceps x Source of oxygen (if available) x Drugs (adrenaline and normal saline) and sterile syringes

Procedure x All the necessary equipment should be prepared in advance x Connect source of oxygen and mask with self-inflating bag x Wash your hands x Check the bag: press a mask hermetically to your palm and squeeze the bag: o If the bag makes an adequate pressure you can feel it on your palm o The bag is in working condition if it re-inflates when you release x Complete all steps listed on the slide in proper order.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Basic Newborn Resuscitation: a practical guide. World Health Organisation, Geneva, 1997

Slide 3N-4 Ventilate with Bag and Mask

- If the source of oxygen is not available start to ventilate with a room air - Carefully fit the mask to the infant’s face - Squeeze the bag with a frequency of 40- 60 as per ERC and AHA/AAP NNR guidelines. squeezes per minute and monitor the chest wall movements when squeezed: x If the chest wall movements are present continue the ventilation with bag and mask x If the chest wall movements are not present re-position the baby’s head; check if the mask is correctly positioned; squeeze the bag harder, using the whole hand

3N - 4 Module 3N

x In case of blood or meconium-stained amniotic fluid, re-aspirate from the mouth and the nose - Ventilate for one minute and then stop and quickly determine if the baby is breathing spontaneously: x If the respiratory rate is normal (30 to 60 breaths per minute), stop ventilating; x If there is central cyanosis (blue tongue and lips), chest indrawing or grunting on expiration, or the respiratory rate is 20 to 30 or more than 60 breaths per minute, treat for breathing difficulty. x If the baby is gasping or not breathing, or the respiratory rate is less than 20 breaths per minute, continue ventilating.

If the newborn starts crying stop ventilating and observe the baby’s respiratory rate breathing for 5 minutes and assess as above.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-5 Signs of Breathing Difficulty

The signs of breathing difficulty are listed on the slide.

x Nevertheless a “small baby” less than 2500g or preterm newborns (born before 37 week) could present “normally” mild chest indrawing at birth as well as spontaneous cessation of breathing for a few seconds. These conditions need to be monitored but don’t need any treatment. x Apnoea is the spontaneous cessation of breathing for not more then 20 seconds x Central cyanosis (tongue and lips are blue (cyanotic) is a late sign of a problem x The assessment of respiratory rate requires counting breaths during one full minute because newborns breathe irregularly, they could sometimes pause for a few seconds and then start to breathe faster. Counting breaths for less than 1 minute may be the cause of a false reading. If you are not sure whether the count is correct, repeat it again.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World health Organisation, Geneva, 2003

3N - 5 Effective perinatal care (EPC)

Slide 3N-6 General Management of Breathing Difficulty

1. Give oxygen at a moderate flow

2. Measure blood glucose, if < 45 mg/dl (2.6 mmol/l) treat for low blood glucose per protocol.

3. Look for other clinical signs in addition to signs of breathing difficulty to determine if the baby’s problems are due to small size, or if the baby has asphyxia, , or congenital syphilis, and continue to treat breathing difficulty

4. Classify the breathing difficulty and manage accordingly.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-7 Classification of Breathing Difficulty

This simple classification may help the health providers (doctors as well as nurses or midwives) to quickly assess the severity of breathing difficulties and to act immediately.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-8 Management of Apnoea

Apnoea for a full-term baby is always a pathological sign.

Small babies < 2500g and very small babies < 1500g are predisposed to episodes of apnoea. The frequency of apnoea episodes decreases as baby grows.

Management of preterm baby with apnoea: x Teach mother to observe baby closely for further episodes of apnoea x If the baby stops breathing: o Stimulate the baby to breathe by rubbing the baby’s back for 10 seconds

3N - 6 Module 3N

o If the baby does not begin to breathe immediately, resuscitate him with bag and mask x Review general principles of feeding and fluid administration to the small baby calculate the necessary quantities of feeding/fluid according to age and severity of baby condition; monitor the baby’s temperature and blood glucose. x Encourage the use of continuous kangaroo mother care. Babies cared for in this way have fewer apnoeic episodes and the mother is able to observe the baby closely. x If the apnoeic episodes become more frequent, treat for sepsis. x Baby can be discharged if he/she has not had an episode of apnoea for seven days, suckles well or alternative feeding is established and doesn’t need further hospitalization related to other problems.

Management of full-term baby with apnoea: x If full-term baby had a single episode of apnoea: o Observe baby closely for further episodes of apnoea for 24 hours, and teach mother to recognise them. ƒ Monitor the baby’s temperature, blood glucose and assess feeding o If the baby does not have an apnoeic episode in 24 hours, is feeding well, and has no other problems requiring hospitalization, discharge the baby. x If full-term baby has multiple episodes of apnoea: o Treat for sepsis o Monitor blood glucose levels o In case of concomitant diseases provide appropriate treatment and examination o Baby can be discharged if he/she has not had an episode of apnoea for seven days, is sucking well or alternative feeding is established and doesn’t need further hospitalization related to other problems x In case of recurrent apnoea transfer the baby to NICU.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003 .

Slide 3N-9 Suspected Congenital Heart Abnormality

In some case when breathing difficulties are associated with central cyanosis but without signs of grunting when breathing out or severe chest indrawing, congenital heart abnormality must be suspected.

If congenital heart abnormality is suspected organise transfer and refer the baby to a tertiary hospital or specialized centre for further evaluation.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

3N - 7 Effective perinatal care (EPC)

Slide 3N-10 Monitor Baby with Breathing Difficulty

Monitor breathing every three hours for: x Breathing rate less than 30 or more than 60 breaths per minute; x Severe chest indrawing; x Grunting when breathing out Monitor colour of skin and mucosa for: x Pallor x Central cyanosis Monitor feeding for: x Frequency x Volume of food x Suckling reflex: presence, activeness Monitor temperature: x If the temperature is stable 4 times per day x If the temperature is unstable every hour Monitor blood glucose level: x Routinely every 12 hours until the baby no longer requires therapy and begins to receive needed volume of food x If hypoglycaemia provide treatment Monitor Urine (quantity) Monitor O2 saturation (if possible) Monitor Blood pressure (if possible).

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-11 Ensure Essential Care for Every Newborn

Every newborn whether sick or healthy needs essential newborn care 1. Implement universal precautions, emphasize careful hand washing and clean clothes.

2. Keep baby warm: if skin to skin contact is not possible due to baby’s severe condition other methods should be implemented: heated cradle, incubator, radiant heater. o If baby’s temperature <36.5°C, he/she is hypothermic and needs to be rewarmed immediately o Rewarm baby until his/her temperature becomes normal >36.5°C o Measure the baby’s temperature every hour. o If the baby’s temperature is increasing at least 0.5°C per hour over the last three hours, rewarming is successful. Continue measuring the baby’s temperature every two hours.

3N - 8 Module 3N

o If the baby’s temperature does not rise or is rising more slowly than 0.5°C per hour, ensure that the temperature of the warming devise is set correctly AND look for signs of sepsis e.g. poor feeding, vomiting, breathing difficulty. o Once the baby’s temperature is normal, measure the baby’s temperature every three hours for 12 hours. o If the baby’s temperature remains within the normal range, discontinue measurements.

In case of moderate hypothermia (from 32°C to 36.4°C) use “Skin to skin” contact, radiant heater, heated cradle or incubator to warm baby.

In case of severe hypothermia (<32°C) x Warm the baby immediately using a prewarmed radiant warmer or another method if necessary (warm incubator or warm heated cradle). x Remove cold or wet clothing, if present. Dress the baby in warm clothes and a hat; cover with a warm blanket x Treat for sepsis and keep the tubing of the IV line under the radiant warmer to warm the fluid. x Measure blood glucose; if less than 45 mg/dl, treat for low blood glucose per protocol x Assess the baby every hour for emergency signs e.g. respiratory rate less than 20 breaths per minute, gasping, not breathing, shock. x Measure temperature every hour as above x If the baby’s respiratory rate is more than 60 breaths per minute or the baby has chest indrawing or grunting on expiration, treat for breathing difficulty x Assess readiness to feed every four hours until the baby’s temperature is within normal range. x If the baby shows signs of readiness to suckle, allow the baby to begin breastfeeding o If the baby cannot breastfeed, give expressed breast milk using an alternative feeding method o If the baby is not able to feed at all, give expressed breast milk by gastric tube once the baby’s temperature reaches 35°C.

3. Provide open and dry cord management

4. Encourage the mother to be with her baby as long as possible

Pregnancy, Childbirth, Postpartum and Newborn Care. A guide for essential practice. World Health organisation, Geneva 2006

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-12 Management of Severe Breathing Difficulty (1)

Give only IV fluid during first 12 hours. Give 10% glucose during the first 3 days, while monitoring blood glucose levels.

Total daily feed and fluid volumes for babies from birth

3N - 9 Effective perinatal care (EPC)

Day of life 1234567+

ml/kg body weight of feeds and/or fluid 60 80 100 120 140 150 160+

Fluid supply must be calculated and assessed every day: x If there is signs of dehydration (sunken eyes, very slow skin pinch, irritability or lethargy) or baby is under a radiant warmer or under phototherapy increase the volume of fluid or feeding by 10% of the needed total daily volume x If excessive hydration (excessive increase of body mass, eyelid swelling or body swelling), decrease the quantity of fluid by half within 24 hours

Assess baby’s urination if too little urine per day (oliguria, diuresis less then 0.5-1ml/kg /hour/day or anuria) increase the volume of fluid or feeding by 10% of the needed total daily volume. Increasing volume of fluid or feeding is not recommended in case of severe asphyxia or brain oedema.

Insert a gastric tube to empty the stomach of air and secretions.

Weigh the baby every day: if the daily body mass lost is more then 5%, increase fluid by 10 ml/kg within 24 hours, to compensate.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003.

Slide 3N -13 Management of Severe Breathing Difficulty (2)

Give oxygen at a high flow rate and observe the baby’s response.

If the baby with severe breathing difficulties is receiving IV fluid it is necessary to continue blood glucose measurements every 12 hours for as long as the baby requires IV fluid. If the blood glucose is less than 45 mg/dl, treat as described in slide 6. If the baby no longer requires or is not receiving IV fluid, measure blood glucose every 12 hours for 24 hours. If the blood glucose remains normal, discontinue measurements.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

3N - 10 Module 3N

Slide 3N-14 Management of Severe Breathing Difficulty (3)

If the baby’s breathing difficulty worsens or the baby has central cyanosis, give oxygen (page C-25) at a high flow rate. If a baby receiving 100% oxygen has a central cyanosis, he should be transferred to a special centre (third level).

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-15 Feeding in Case of Severe Breathing Difficulty (1)

x Start feeding when the breathing difficultly improves

x Use gastric tube at the beginning. Insert the gastric tube via mouth if baby has breathing difficulty x Control correct placement of gastric tube: fill a syringe with 1 or 2 ml of air and connect it to end of the tube; use the stethoscope to listen over the stomach as air is quickly injected into the tube

Each feeding should take 10 to 15 minutes. Calculate volume of milk according to baby’s age and severity of condition If the flow of milk is too fast, slightly pinch the tube below the syringe to slow down the flow

When the feeding is finished, remove, wash, and high-level disinfect or sterilized the syringe, and close the tube with a cap until the next feeding. There is no need to change gastric tube for each feeding. Replace the gastric tube with another clean gastric tube after three days, or earlier if it is pulled out or becomes blocked.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

3N - 11 Effective perinatal care (EPC)

Slide 3N-16 Feeding in Case of Severe Breathing Difficulty (2)

Baby’s breathing (character and rate); skin colour (pale, cyanotic), convulsions, vomiting or regurgitation should be assessed during the feeding

If there is no problem with feeding (no abdominal distension, no vomiting, the baby digests normally more than 70% of feed quantity) continue to increase milk volume and to decrease IV fluid maintaining an adequate daily volume

Encourage the mother to express her milk and then to breastfeed exclusively.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-17 Management of Moderate Breathing Difficulty

Establish and IV line and give only IV fluid during first 12 hours. Give 10% glucose for the first 3 days.

Monitor and record the baby’s respiratory rate, the presence of chest indrawing or grunting on expiration, and episodes of apnoea every three hours until the baby no longer requires oxygen and then for an additional 24 hours.

If the baby’s breathing difficulty does not improve or worsens after two hours, manage for severe breathing difficulty.

If the baby’s condition has improved provide routine care: x “Skin-to-skin” contact (if possible) x Keep baby warm x Provide adequate feeding x Monitor baby’s condition x Help mother to take care of her baby

If the baby’s tongue and lips remain pink without oxygen for at least one day, and the baby has no difficulty breathing and feeding well, and there are no other problems requiring hospitalization, discharge the baby.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

3N - 12 Module 3N

Slide 3N-18 Feeding in Case of Moderate Breathing Difficulty

When the baby begins to show signs of improvement: give expressed breast milk by gastric tube. When, oxygen is no longer needed, allow the baby to breastfeed. Encourage the mother to breastfeed exclusively as soon as the baby is receiving 100% of the daily fluid volume by mouth.

If the baby cannot be breastfed: give expressed breast milk using an alternative feeding method.

Continue to increase the volume of feeds while decreasing the volume of IV fluid to maintain the total daily fluid volume according to the baby’s daily requirement. Feed the baby every three hours, or more frequently if necessary adjusting the volume at each feeding accordingly. Add the total volume of feeds and fluid given each day. Compare this volume with the required daily volume, and adjust the volume that the baby receives accordingly.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-19 Management of Mild Breathing Difficulty

If the baby’s condition is stable monitor the severity of breathing difficulties and response to oxygen therapy every three hours.at a minimum. Monitor: x Respiratory rate x Presence of chest indrawing x Presence of grunting when breathing out x Episodes of apnoea Provide early (if possible) breastfeeding; if impossible, use alternative way of feeding.

If the baby’s tongue and lips remain pink without oxygen for at least one day, the baby has no difficulty breathing and feeding well, and there are no other problems requiring hospitalization, discharge the baby.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

3N - 13 Effective perinatal care (EPC)

Slide 3N-20 Oxygen Therapy is the Basic Treatment for Breathing Difficulty

Ensure that the baby does not receive too little or too much oxygen: x Too little oxygen may cause organ damage and eventual death x Too much oxygen may damage the baby’s lungs and retinas

Give oxygen at a moderate flow rate for mild or moderate breathing difficulty. Give oxygen at a moderate flow rate. If the baby’s breathing difficulty worsens or the baby has central cyanosis, give oxygen at a high flow rate.

.Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-21 Methods of Oxygen Administration (1)

Review carefully the methods of administration and the instructions for use, as well as the advantages and disadvantages.

The flow and concentration of oxygen depends on the severity of breathing difficulty and on the method of oxygen administration.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003 .

Slide 3N-22 Methods of Oxygen Administration (2)

The use of head box (on the left) and nasal catheter (on the right) are shown on the photos.

“Mother and Infant Health Project”, JSI- Ukraine

3N - 14 Module 3N

Slide 3N-23 Methods of Oxygen Administration (3)

Advantages and Disadvantages

Nasal prongs: x The size of nasal prongs should be chosen in compliance with body mass and gestation age – 1 mm for babies with a low birth weight (below 2.5 kg or born before 37 week of gestation) and 2 mm for full-term baby x Insert nasal prongs into baby’s nostrils x Fix prongs with adhesive band x Adjust oxygen flow rate to achieve the desired concentration x Change nasal prongs twice a day. Use mask to give oxygen when you are changing and disinfecting the prongs Nasal catheter x Use the catheter of size 8-F. If it is too big use the catheter of size 6-F x Determine a distance between the edge of nostril and inner margin of eyebrow x Insert catheter carefully into baby’s nostril. If one nostril is occupied already by gastric tube, use this nostril for nasal catheter insertion, if possible x Make sure the catheter is positioned right: it shouldn’t be observed on the back wall of pharynx; If it is, drag it back slowly until becomes invisible x Adjust oxygen flow rate to achieve the desired concentration x Change nasal catheter twice a day. Use mask to give oxygen when you are changing and disinfecting the catheter Head box x Place head box above baby’s head x Ensure that the baby’s head stays within the head box, even if he moves x Adjust oxygen flow rate to achieve the desired concentration. Face mask x Place the mask over the baby’s mouth and nose. x Secure the mask in place suing elastic or a piece of adhesive tape. x Adjust oxygen flow rate to achieve the desired concentration. Incubator x Follow the manufacturer's instruction x Adjust oxygen flow rate to achieve the desired concentration.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

3N - 15 Effective perinatal care (EPC)

Slide 3N- 24 Sources of Oxygen

Ensure that a source of oxygen is available at all times. Oxygen is expensive, so use it only if necessary and terminate as soon as possible.

Three main sources of oxygen are shown on the slide. The oxygen is carried from the source to the baby by means of non- crush, plastic oxygen delivery tube. A face mask, which can give a high concentration of oxygen, should always be available in case of rapid deterioration of the baby’s condition.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-25 Monitor the Baby’s Response to Oxygen (1)

During the oxygen therapy close oxygen response monitoring is necessary.

Use an oximeter according to the manufacturer’s instructions to ensure that the baby receives an adequate concentration of oxygen. If an oximeter is not available, monitor the baby for signs of oxygenation by assessing whether the baby has signs of breathing difficulty or central cyanosis (blue tongue and lips) (note that these observations cannot differentiate between normal and excessive concentrations of oxygen in the blood).

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-26 Monitor the Baby’s Response to Oxygen (2)

Correct oxygen flow rate or method of oxygen administration depends of baby’s response to oxygen. When the baby’s breathing begins to improve (e.g. respiratory rate begins to move towards the normal range, grunting or chest indrawing decreases), decrease the oxygen flow.

When the baby’s respiratory rate is within the normal range and there are no signs of breathing difficulty (e.g.chest indrawing

3N - 16 Module 3N or grunting on expiration), remove oxygen and observe the baby for 15 minutes: if the baby’s tongue and lips remain pink, do not give any more oxygen. Observe for central cyanosis every 15 minutes for the next hour. If central cyanosis reappears at any time, give oxygen again at the last rate given. Continue to observe the baby for 24 hours after oxygen is discontinued.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003.

Slide 3N-27 Criteria to Discharge

See the list of criteria to discharge baby who has experienced breathing difficulty.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003

Slide 3N-28 Home Care Recommendations

It is important to advise the mother to return with the baby immediately if the baby has any problems (e.g. feeding or breathing difficulty, convulsions, abnormal body temperature). Give advice on home care (normal newborn care and breastfeeding, proper position for sleeping, danger signs, when and where to go if danger signs occur, etc.), and make an appointment for a follow-up visit.

Managing Newborn Problems. A guide for doctors, nurses, and midwives. World Health Organisation, Geneva, 2003 Cloherty JP et al. ”Manual of neonatal care” 6th edition, Lippincott, Philadelphia, 2008

3N - 17 Effective perinatal care (EPC)

Slide 3N-29 Conclusion

Breathing difficulty needs to be recognised and treated quickly so it is important that all newborns be carefully monitored in the delivery room and in the post partum unit.

3N - 18 Module 4N

Neonatal Jaundice

Effective Perinatal Care (EPC)

4N - 2 Module 4N

Slide 4N-1

Learning objectives:

At the end of the module participants will: x Be able to perform a newborn examination to identify the early signs of jaundice x Be able to monitor a jaundiced newborn and recognize when the jaundice is severe x Be able to identify “physiological” and “pathological” jaundice x Know the main steps for managing newborns with jaundice x Know that phototherapy is the key treatment for neonatal jaundice x Be able to monitor a baby with jaundice during the treatment x Know the criteria for discharging a jaundiced baby from the hospital x Be able to counsel the mother and family to monitor a baby with jaundice after discharge.

Slide 4N-2 Neonatal Jaundice

Neonatal jaundice is a very common condition; up to 50% of term newborns and 80% of preterm newborns have jaundice. It is very important to carefully observe jaundiced newborns in order to recognise the signs of severe jaundice and to implement treatment quickly if necessary.

Kumar RK. Neonatal jaundice. An update for family . Aust Fam 1999: 28: 679-682

Essential Newborn Care and Breastfeeding: Training Module. WHO Euro, Copenhagen, 2002.

Slide 4N-3 Neonatal Jaundice Is a Result of Hyperbilirubinemia

Neonatal jaundice could be considered part of normal newborn adaptation to life outside of the womb.

Jaundice becomes visible in full-term newborns when the total serum (TSB) level reaches 68-103 μmol/L and it becomes pronounced when TSB levels reach 104-291 μmol/L.

Jaundice in low birth weight (LBW) babies may become visible with a lower serum bilirubin level depending on how much subcutaneous fat the baby has.

4N - 3 Effective Perinatal Care (EPC)

Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Amer J Dis Child. 1969; 118:454-458.

Slide 4N-4 Reasons for Serum Bilirubin Elevation in the Neonatal Period

1. Massive destruction of red cells (erythrocytes). Newborns have a high number of red cells which are destroyed rapidly; newborn’ erythrocytes survive only 80-90 days compared to 120 days in adult. Therefore during the first days of life many erythrocytes are destroyed, which quickly increases the level of free, indirect, non-conjugated bilirubin.

2. Poor bilirubin conjugation: the free indirect (unconjugated) bilirubin is conjugated in the liver with glucuronic acid, and becomes direct or conjugated bilirubin. The newborn’ liver has a reduced capacity to conjugate the bilirubin which leads to impaired elimination of bilirubin.

3. Poor transformation of bilirubin in the intestine and important enterocyst reabsorption: Normally the bilirubin is transformed by appropriate intestinal flora into and urobilin, which are excreted in the stools and in the urine. During the first days the newborn intestine is not fully colonized with the appropriate flora, which limits the possibility of successful transformation of bilirubin into stercobilin and urobilin. Therefore the untransformed bilirubin is reabsorbed by enterocysts and returned to blood circulation.

Unconjugated bilirubin is the main cause of neonatal jaundice. Unconjugated bilirubin has a neurotoxic effect if it reaches high levels of concentration.

Shelly C Springer..eMedicine. Meredith L. Porter, Beth L.Dennis. Hyperbilirubinemia in the Term Newborns. American Family Physician, 2002, Volume 65, Number 4

Slide 4N-5 Non pathological (so-called “Physiological”) Neonatal Jaundice

Jaundice appears after 36 hours and reaches its pick on day 3 or 4 in full term babies and on day 5 or 7 in preterm babies.

In so called “physiological“ jaundice the baby is in good clinical condition; he/she is active, the periods of sleep and activity are clearly distinguishable, he/she has a good sucking reflex, a stable temperature, the liver and spleen are a normal size, the urine is light, and the stools are normal colour.

4N - 4 Module 4N

Meredith L. Porter, Beth L.Dennis. Hyperbilirubinemia in the Term Newborns. American Family Physician, 2002, Volume 65, Number 4

Essential Newborn Care and Breastfeeding: Training Module. WHO Euro, Copenhagen, 2002.

Managing Newborn Problems: A guide for doctors, nurses, and midwives WHO, Geneva, 2003

Kumar RK. Neonatal jaundice. An update for family physicians. Aust Fam Physician 1999: 28: 679-682

Slide 4N-6 Non-physiological Jaundice (1)

Jaundice that begins and progresses during the first 24 hours is always pathologic.

Non physiological jaundice could be a sign of Cholestasis, Glucose-6-phosphate dehydrohenase (G6PD) deficiency, Crigler-Najjar disease, or late .

In any case the rapid elevation of the total serum bilirubin (TSB) > 5 mg/dL/day = 85,5 μmol/L/day is a sign of pathological jaundice which could be due to acute haemolysis, neonatal sepsis, or neonatal .

As an example: In some case the TSB level from the umbilical blood is missing but, the rapid increase of the level of SB >85,5 μmol/L/day can be used as a sign of pathologic jaundice.

Direct or conjugated bilirubin levels >34 μmol/ or •20% of total serum bilirubin can be a sign of: x Cholestasis x Hepatitis x Newborn sepsis

Such newborns require comprehensive examination and appropriate treatment.

Pregnancy, Childbirth, Postpartum and Newborn Care. A guide for essential practice. World Health organisation, Geneva 2006

Essential Newborn Care and Breastfeeding: Training Module. WHO Euro, Copenhagen, 2002.

Meredith L. Porter, Beth L.Dennis. Hyperbilirubinemia in the Term Newborns. American Family Physician, 2002, Volume 65, Number 4

4N - 5 Effective Perinatal Care (EPC)

Slide 4N-7 Non- physiological Jaundice (2)

The baby could have some of the following clinical signs: x floppiness, lethargy x feeding problems x convulsions x poor ability to control body temperature x hepato –splenomegaly x dark urine, discoloured stools x high pitched cry

These newborns require urgent phototherapy, irrespectively of total serum bilirubin level, and complete biological assessment.

Meredith L. Porter, Beth L.Dennis. Hyperbilirubinemia in the Term Newborns. American Family Physician, 2002, Volume 65, Number 4

Managing Newborn Problems: A guide for doctors, nurses, and midwives WHO, Geneva, 2003

Slide 4N-8 Clinical Estimation of Severity of Jaundice

A simple way to estimate the severity of jaundice is to observe where in the body the jaundice appears and on which day of life it appears.

If jaundice appeared anywhere on the 1st day this jaundice is severe. It is also considered a sign of severe jaundice if the arms and legs are yellow on the 2nd of life and if the feet and hands are yellow on the 3rd day [C]

If signs of severe jaundice appear start phototherapy immediately, don’t wait for serum bilirubin results.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

4N - 6 Module 4N

Slide 4N-9 Complications of Neonatal Jaundice

Indirect, unconjugated bilirubin is neurotoxic if reaches high concentrations.

It is crucial to carefully monitor the neuro toxic /dangerous bilirubin level • 350 μmol/L (24 mg/dl) especially in preterm babies and for babies with haemolytic jaundice.

Bilirubin encephalopathy: Acute lesions to central nervous system x Early stages: Lethargy, drowsiness, floppiness and poor sucking reflex

x Later stages: Hyperirritability, muscular hypertonus, high pitched cry, possible fever x Irreversible stage: opisthotonus, convulsions, apnoea, monotonous high pitched cry, deep stupor or coma.

The vast majority of neonatal jaundice cases are physiological, which don’t require any treatment. The skin colour needs be assessed for jaundice every 8-12 hours [C].

Exclusive breastfeeding on demand and at least 8 to 12 times per day needs to be implemented.

Nevertheless each jaundiced newborn needs to be monitored carefully in order to quickly recognize and treat severe jaundice.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Slide 4N-10 Clinical Examination (1)

Wash your hands before assessing the baby.

Baby is assessed naked in a warm room. The mother is welcome to attend the assessment.

Clinical assessment of the baby including a systematic check of skin colour is the first step in deciding how to manage each case of jaundice. The mother/ family should be informed at every stages of this process. Mothers need training on how to monitor the baby’s skin colour.

It is important to perform the examination on the completely naked baby in a warm place and on a warm surface.

Use good light, preferably day light or day light lamps to properly assess skin colour and jaundice.

4N - 7 Effective Perinatal Care (EPC)

In order to assess the development of the jaundice, it is convenient to use the “modified Kramer Scale”. It shows jaundice begins on the face, and then gradually spreads to extremities, reflecting the degree of TSB elevation.

You can see a rough estimation of the approximate total serum bilirubin levels according to jaundice location.

Knudsen A, Ebbesen F. Cefalocaudal progression of jaundice in newborn admitted to neonatal intensive care units. Biol Neonate 1997;71:357-361).

The visual assessment of approximate bilirubin levels based on body zones is subjective and could be mistaken. Then it is recommended to identify trans cutaneous bilirubin (TCB) levels and/or total serum bilirubin levels if the jaundice appears during the first 3 days in zones different of the “normal zones”(Table “Severe jaundice”, Slide 8) and in Zones 3 to 5 according to the Kramer scale.

The TCB method is a method alternative to the Kramer scale. It identifies the level of intracutaneous/transcutaneous bilirubin; its result could also be inaccurate depending on the intensity of skin pigmentation, haemoglobin level, skin perfusion, phototherapy or room lighting.

Bhutani V, Gourley G, Adler S, Kreamer B, Dalin c, Johnson L. Non-invasive Measurement of Total Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Risk of Severe Hyperbilirubinemia. J Pediatrics (106) 2000, NO 2.)

Kramer LI. Advancement of dermal icterus in the jaundiced newborn. Amer J Dis Child. 1969; 118:454-458).

Slide 4N-11 Clinical Examination (2)

To recognize signs for severe jaundice early it is important to begin observation of a jaundiced newborn as soon as possible: x Assess baby’s appearance and activity. x Assess size of liver and spleen x Assess for bruises and cephalhematoma x Assess colour of stools and urine x Assess suckling reflex and whether breastfeeding is well established Any abnormal signs mean an immediate and complete biological assessment and beginning of phototherapy.

Jaundice and hyperbilirubinemia in the newborn. In: Berhman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 16th ed. Philadelphia: Saunders, 2000:511-28

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

David E. Hertz. Care of the Newborn: A Handbook for Primary Care. Lippincott Williams&Wilkins, 2005. 60-72

4N - 8 Module 4N

Slide 4N-12 Assess Medical History

It is important to understand the family history in each case. Some rare diseases lead to congenital jaundice such as Gilbert, or Crigler-Najjar diseases.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

David E. Hertz. Care of the Newborn: A Handbook for Primary Care. Lippincott Williams&Wilkins, 2005. 60-72

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 4N-13 Assess Jaundice Risk Factors

Newborn blood pathological haemolysis could be caused by mother / infant blood ABO-group or Rh –factor incompatibility; by hereditary haemolytic anaemia; by toxic drug effects (e.g. sulphanilamide); or by .

Historically, trials on the toxic effects of bilirubin on the central neural system were conducted in newborns with haemolytic disease. Mentioned trials showed that for bilirubin levels > 340 μmol/L signs of haemolysis increased the risk and incidence of bilirubin encephalopathy and kernicterus

Gartner LM, Herrarias CT, Sebring RH. Practice patterns in neonatal hyperbilirubinemia. Pediatrics. 1998; 101:25-31.

British Columbia Reproductive Care Program. Jaundice in the Healthy Term Newborn. Newborn Guideline 4. April 2002 (Revised)

4N - 9 Effective Perinatal Care (EPC)

Slide 4N-14 Management of Neonatal Jaundice at Birth and in the Antenatal Period

It is important to identify ABO blood group and Rh-factor for all pregnant women and for newborns if needed. [B]

For a baby born to a mother with an unknown blood group and Rh-factor, it is necessary to use umbilical to identify ABO blood group and Rh-factor [B], and TSB.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Slide 4N-15 Management of Jaundice in Postnatal Period

Adequate breastfeeding at least 8-12 times a day without night break reduces the risk of calorie deficiency and/or baby dehydration, which may increase hyperbilirubinemia. [B]

Per os administration of water or glucose to jaundiced newborns does not prevent the development of hyperbilirubinemia and does not reduce Total Serum Bilirubin level. [B]

Jaundice in the Healthy Term Newborn. British Columbia Reproductive Care Program Newborn Guideline 4. April 2002 (Revised)

If it is impossible to ensure adequate breastfeeding, give expressed breast milk, and if expressed breast milk is not available give infant milk formula . If feeding still does not cover fluids needs, provide IV supplementation.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 4N-16 “Physiological” Jaundice

Babies with “physiological jaundice” do not need any specific treatment but exclusive breastfeeding must be strictly implemented and its importance must be explained to the mother: namely that exclusive breastfeeding will help to quickly solve the jaundice problem.

Routine identification of total serum bilirubin level is not needed.

4N - 10 Module 4N

Nevertheless each jaundiced baby needs to be monitored to be sure that signs of “severity” are recognised quickly.

David E. Hertz. Care of the Newborn: A Handbook for Primary Care. Lippincott Williams&Wilkins, 2005. 60-72

Jaundice and hyperbilirubinemia in the newborn. In: Berhman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 16th ed. Philadelphia: Saunders, 2000:511-28

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Slide 4N-17 Breast Milk Related Jaundice

This jaundice can be diagnosed in 3 to 5% of exclusively breastfed healthy newborn. It is a diagnosis “of exclusion” in the absence of any pathological signs.

Breast milk related jaundice can have 2 bilirubin peaks the first on day 4 or 5 and the second on day 14 or 15.

Breast milk related jaundice could disappear very slowly and still visible for 12 weeks. No treatment is needed and it is recommended to continue breastfeeding.

Meredith L. Porter, Beth L.Dennis. Hyperbilirubinemia in the Term Newborns. American Family Physician, 2002, Volume 65, Number 4

Slide 4N-18 Non-physiological Jaundice

There are different causes of pathological therefore it is important to identify the different fractions of bilirubin (direct/conjugated bilirubin, and indirect bilirubin/free/unconjugated bilirubin) in order to exclude Cholestasis. [D]

A test is also recommended for jaundiced newborns who have a stable hyperbilirubinemia during > 3 weeks. [D]

In case of family anamnesis of glucose 6 phosphate dehydrogenase deficiency associated with poor results of phototherapy, it is necessary to identify the level of glucose 6- phosphate dehydrogenase. [ɋ]

In case of pathological jaundice blood tests for baby’s ABO-group, Rh-factor and Coombs test are recommended. [B]

4N - 11 Effective Perinatal Care (EPC)

TSB level (including direct bilirubin) is the most reliable biological indicator to start treatment.

Newborns with an increased level of direct bilirubin must be assessed (including bacteriological urine tests) for neonatal sepsis. [D]

Newborns with an increased level of direct bilirubin presenting with hepatomegaly need to have an evaluation of ALT and AST levels to identify hepatitis

It is necessary to perform further examinations to identify the cause of the jaundice and to provide specific treatment.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Shelly C Springer.Kernicterus.eMedicine.

Essential Newborn Care and Breastfeeding: Training Module. WHO Euro, Copenhagen, 2002.

Slide 4N-19 Treatment of Neonatal Jaundice

1. Phototherapy

Phototherapy is the most effective method for decreasing bilirubin levels in cases of neonatal jaundice. [A]

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Timely and correct phototherapy decreases the need for exchange blood transfusions to 4% and reduces the risk of neonatal jaundice complications

Brown AK, Kim MH, Wu PYK, Brylaa DA. Efficacy of Phototherapy in Prevention and Management of Neonatal Hyperbilirubinemia. Paediatrics 1985; 75 (Suppl): 393-400).

Phototherapy transforms unconjugated bilirubin in the skin into a water-soluble isomer which is less neuro toxic and which is excreted through the urine.

There are different types of phototherapy: x Classical (with the use of the set of lamps) x Intensive (use of several sources) x Fiber-optic (blankets, sheets)

Classical and intensive phototherapy is more effective than fiber-optic phototherapy. [A] Fiber- optic phototherapy is more effective than no therapy or day-light phototherapy. [A]

Bryla DA, Nelson KB et al. Phototherapy for neonatal hyperbilirubinemia: six-year follow-up of the National Institute of child Health and Human Development clinical trial. Pediatrics 1990;85:455-463

4N - 12 Module 4N

Mills JF, Tudehope D. Fibreoptic phototherapy for neonatal jaundice (Cochrane review). The Cochrane library. Issue 2, 2003

Tan KL. Efficacy of Bidirectional Fiber-optic Phototherapy for Neonatal Hyperbilirubinemia. Pediatrics electronic pages 1997; 99: May, e 13.

2. Exchange blood transfusion There are no randomized trials to comparing the effectiveness of versus phototherapy. Exchange transfusion is needed when phototherapy fails or if bilirubin increases to dangerous levels. [ȼ].

Recommended TSB levels for exchange transfusion are based largely on the goal of keeping TSB levels below those at which kernicterus has been reported. In almost all cases, exchange transfusion is recommended only after phototherapy has failed to keep the TSB level below the exchange transfusion level.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Today there is no evidence supporting the use of any drug for routine treatment of neonatal jaundice.

Phenobarbital was used routinely to treat neonatal jaundice. Phenobarbital stimulates the production of G6PDG which supports the conjugation of free, indirect and neurotoxic bilirubin into direct, conjugated bilirubin but Phenobarbital is also an anticonvulsant which impairs breastfeeding and that will increase neonatal jaundice.

Today there is no evidence to support the routine use of Phenobarbital to treat neonatal jaundice

Slide 4N-20 Graph 1: Management of Term Infants without Haemolytic disease Dependently of SBR

If jaundice appears in first 24 hours or is “severe” - start phototherapy immediately and consider whether to perform an exchange blood transfusion.

In other cases “plot” the results of TSB levels on the graph and make a decision about phototherapy according to the baby’s age.

The main demonstrated value of phototherapy is that it reduces the risk that TSB levels will reach a level at which exchange transfusion is recommended. Approximately 5 to 10 infants with TSB levels between 15 and 20 mg/dL (257–342 ȝmol/L) will receive phototherapy to prevent the TSB in 1 infant from reaching 20 mg/dL (the number needed to treat). Phototherapy has proven to be a generally safe procedure, although rare complications can occur.

Newborn Services Clinical Guideline. Protocol Management of Neonatal jaundice. New Zealand. Reviewed by Peter Nobbs, May 2001

4N - 13 Effective Perinatal Care (EPC)

Royal Prince Alfred Hospital. RPA newborn Care Protocol Book. Jaundice, 2003

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Slide 4N-21 Graph 2: Management of Preterm Infants or Haemolytic Disease Dependently of SBR

There are no randomized trials indicating when to start phototherapy based on the levels of bilirubin. Indications to start phototherapy are based only on medical observations. [C]

The recommendations to use phototherapy and exchange transfusion at lower TSB levels for infants of lower gestation and those who are sick are based on limited observations suggesting that sick infants (particularly those with the risk factors listed in graph) and those of lower gestation are at greater risk for developing kernicterus at lower bilirubin levels than are well infants of more than 38 -37 weeks’ gestation. Nevertheless, other studies have not confirmed all of these associations. There is no doubt, however, that infants at 35 to 37 6/7 weeks’ gestation are at a much greater risk of developing very high TSB levels. Intervention for these infants is based on this risk as well as extrapolations from more premature, lower birth- weight infants who do have a higher risk of bilirubin toxicity. For all newborns, treatment is recommended at lower TSB levels at younger ages because one of the primary goals of treatment is to prevent additional increases in the TSB level.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Jaundice. RPA newborn Care Protocol Book. Royal Prince Alfred Hospital. 2003

Maisels MJ, Watchko JF. Treatment of jaundice in low birth weight infants. Arch. Dis. Child. Fetal Neonatal Ed. 2003; 88; 459-463)

Newborn Services Clinical Guideline. Protocol Management of Neonatal jaundice. New Zealand. Reviewed by Peter Nobbs, May 2001

If jaundice appears in first 24 hours or is severe start phototherapy immediately and consider whether to perform an exchange blood transfusion.

4N - 14 Module 4N

Slide 4N-22 Phototherapy

Phototherapy using an incubator is presented on this slide but phototherapy can also be done in the baby’s cradle, in a warm, draft-free room.

Baby’s eyes needed to be protected with light-proof material.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Some phototherapy lamp’ makers recommend covering baby’s boy genitals; however there is no study confirming the necessity of protecting a baby’s boy genitals with light- proof material.

To get the maximal effect from phototherapy carefully the instructions. Fix the lamp as close as possible to the baby and replace the tube each 2,000 hours.

Slide 4N- 23 Monitoring During Phototherapy

Monitor baby’s temperature and the temperature of the air under the lights every three hours. Maintain baby’s temperature at 36.5 – 37.5°ɋ.

Turn the baby every three hours.

Weigh the baby at least once a day.

During phototherapy the baby’s stools could be liquid and yellow which is normal and do not require any specific treatment.

The baby must be breastfed on demand through the night, no less than 8 times a day. [B]

If the baby receives expressed breast milk or IV solutions increase the volume of liquid by 10% for as long as the baby is under the phototherapy lights.

Measure Serum Bilirubin Level Every 12 Hours.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

4N - 15 Effective Perinatal Care (EPC)

Slide 4N- 24 Finish Phototherapy

There is no standard for discontinuing phototherapy. If phototherapy is used for infants with hemolytic diseases or is initiated early and discontinued before the infant is 3 to 4 days old, a follow-up bilirubin measurement within 24 hours after discharge is recommended. For infants who are readmitted with hyperbilirubinemia and then discharged, significant rebound is rare, but a repeat TSB measurement or clinical follow-up 24 hours after discharge is a clinical option.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Slide 4N-25 Requirements for Exchange Blood Transfusion

Exchange transfusions should be performed only by trained personnel in a neonatal intensive care unit with full monitoring and resuscitation capabilities (evidence quality D: benefits versus harms exceptional).

In almost all cases, exchange transfusion is recommended only after phototherapy has failed to keep the TSB level below the exchange transfusion level.

But in case where there are clinical signs of acute bilirubin encephalopathy (muscular hyper tonus, opisthotonus, fever, high pitched cry) exchange transfusion must be performed regardless of bilirubin level [D].

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Jackson JC. Adverse events associated with exchange transfusion in healthy and ill newborns Paediatrics 1997; 99

Dennery PA, Seidman DS, Stevenson DK. Neonatal hyperbilirubinemia. N Engl J Med 2001; 344: 581-590

Perform phototherapy before and after exchange blood transfusion.

Equipment for exchange blood transfusion: x radiant heater or incubator; thermometer x resuscitation equipment: Ambu bag, masks, source of oxygen; pulseoximeter x naso gastric tube

4N - 16 Module 4N

x set of sterile instruments and materials for vessels catheterization x cardio monitor x controlled blood heating system.

A full term newborn has 80 ml/kg of blood, a pre-term newborn has 90-95 ml/kg of blood .

Calculation of the quantity of blood necessary for exchange transfusion: total baby’s blood quantity X 2. Example: The quantity of blood of a baby of 3 kg is 240 -250 ml. Therefore 480 – 500 ml of blood is necessary to perform an exchange transfusion for this baby. Cloherty JP. Et al, Manual of Neonatal Care, 6th edition, Lippincott, Philadelphia, 2008

Exchange transfusion in case of Rh-incompatibility haemolytic disease - Use baby’ blood group Rh-negative or Rh-negative red cell concentrated Ɉ (I) type diluted in plasma of AB (IV) type.

Exchange transfusion in case of newborn haemolytic disease due to ȺȼɈ-incompatibility - Use red cell concentrate of the same Rh-factor as the baby of Ɉ (I) type diluted in plasma of AB (IV) type.

- In urgent cases, if Rh-factor of the baby is unknown, use Rh-negative red cell concentrated of Ɉ (I) type in plasma of AB (IV) type.

In case of incompatibility both by Rh-factor and ȺȼɈ-group - Use Rh-negative red cell concentrate of Ɉ (I) type diluted in plasma of AB (IV) type.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Jaundice and hyperbilirubinemia in the newborn. In: Berhman RE, Kliegman RM, Jenson HB, eds. Nelson textbook of pediatrics. 16th ed. Philadelphia: Saunders, 2000:511-28

Slide 4N-26 Criteria for Discharge and Follow-up Care at Home

To decide whether a jaundiced baby can be discharged home use the modified Bhutani scale.

If no phototherapy was done but at time of discharge jaundice reaches zone 3 on the Kramer scale but palms and feet are pink, it is necessary to identify TSB level and to ‘plot it ‘on the Bhutani nomogram and make a decision of level of risk zones.

If the baby is discharged at 24 hours, it is necessary to examine the baby at home by 72 hours.

If the baby is discharged between 24 hours and 48 hours after birth it is necessary to examine the baby at home before 96 hours.

In case of discharge between 48 hours and 72 hours after birth it is necessary to examine the baby at home by 120 hours of life [C].

4N - 17 Effective Perinatal Care (EPC)

It is important to train the mother to identify signs of “severe” jaundice: the appearance of yellow coloration on baby’s palms and feet or baby in general is getting worse.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Slide 4N-27 Risk Assessment for Developing Severe Jaundice after Discharge (Bhutani Scale)

This scale was developed to evaluate zones of high, intermediate and low risks zones to develop severe jaundice after discharge. This scale was established babies > 35 weeks of gestation.

Bhutani V., Johnson L., Siviery E. Predictive ability of a predischarge hour- specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. 1999; Paediatrics, 103 (1), 6-14),

The challenge of preventing neonatal bilirubin encephalopathy: a new nursing protocol in the well newborn nursery. Monica A. ɋabra, RNC, NNP, and Jonathan V. Whitfield, MBChB

Bhutany V, Gourley G, Adler S, Kreamer B, Dalin c, Johnson L. Non- invasive Measurement of Total Bilirubin in a Multiracial Predischarge Newborn Population to Assess the Risk of Severe Hyperbilirubinemia. J Paediatrics (106) 2000, NO 2.

If total serum bilirubin and TCB values fall in high risk or in high intermediate risk zones, and baby has risk factors, most likely bilirubin level will exceed the 95-th percentile, which may require some treatment. In this case the discharge from the hospital must be postponed by at least 24 hours or the baby should be referred to a neonatal department.

If total serum bilirubin and TCB values are in low risk zone, the probability of further increase of hyperbilirubinemia is minimal and the baby can be discharged from the hospital.

If total serum bilirubin and TCB values are in intermediate risk zones (these are 2 intermediate risk zones: low and high intermediate risk zones), it is necessary to consider associated risk factors and make the decision regarding discharge from the hospital on an individual basis.

4N - 18 Module 4N

Slide 4N-28 Criteria for Referring Baby to the 3rd Level of Care Facility or for Recurrent Hospitalization

Worsening of baby’s condition could be due to the development of acute bilirubin jaundice and kernicterus, thus this baby need to be re-hospitalised or referred to a higher level.

American Academy of Pediatrics. Clinical practical Guideline. Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. 2004

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 4N-29 Conclusions

Each newborn needs careful observation to identify jaundice early and to recognize signs of severe jaundice. When jaundice, appears 1st day it is severe. Phototherapy is the basic treatment of neonatal jaundice. Exchange blood transfusion, which is dangerous procedure and must be performed by experts if phototherapy is not effective or on strict indication. Discharge of the jaundiced baby from the hospital should be made individually, considering the intensity of jaundice and the result of the treatment.

Each mother/family should be trained to assess baby for jaundice and be able to identify “danger signs”.

4N - 19 Effective Perinatal Care (EPC)

Attachment 1

Case study

It is Maria’s first pregnancy. The pregnancy was normal. Maria’s blood group is Ⱥ (II), Rh- positive.

Her daughter Sofia was born after 40 weeks and 2 days, she was not resuscitated. Sofia was examined by the neonatologist 2 hours after birth. She weighted 3,200 g. Her medical assessment was normal. Sofia was pink, active, she didn’t have bruises nor , her liver and spleen were normal size.

Maria and Sofia went together to “rooming-in” with recommendation to breastfeed on demand.

Sofia was assessed the next morning (26 hours after birth), her face was yellow, she was suckling well and her mother said Sofia breastfed 7 times since birth.

At 8.00 PM (38 hours after birth) the mother informed the nurse that Sofia’s chest was yellow. Neonatologist assessed Sofia under artificial and weak light and, because it was cold in the room the baby was only partially naked with her diaper, socks and shirt still on. Sofia was active and the clinical examination did not change the birth assessment except that baby’ face and chest were yellow. By morning 8 AM, Sofia fed only 4 times because she didn’t requested more. The neonatologist prescribed blood tests and SB levels. The results show erythrocytes: 5, 4 ɯ 1012, haemoglobin: 180 g/L, leucocytes: 8, 5 ɯ 109; TSB Level: 160 μmol/L According to these results the neonatologist prescribed phototherapy: 4 hours phototherapy followed by a 2 hour break, and recommended to continue breastfeeding on demand.

The next day (50 hours after birth) Sofia was assessed again. No change in the clinical status except that jaundice had reached abdomen and arms. The neonatologist recommended to continuing phototherapy, and to start an IV and activated charcoal. Phototherapy was stopped during the infusion and Sofia received activated charcoal per os diluted in water. As soon as the IV was finished, phototherapy restarted, and trans-Cutaneous bilirubin was evaluated to 180 μmol/L The following morning (74 hours after birth) the icteric coloration was in the same zones but less intense. Sofia was active, she breastfed 8 times during the past day, liver and spleen were normal; stools were dark, and urine pale yellow.

Questions for group discussion:

1. How do you evaluate the severity of jaundice? Explain your answer and compare with what happened in Sofia’s case.

2. What are the basic principles of jaundice management? Explain your answer and compare with what was done in Sofia’s case.

3. Which investigations were necessary in Sofia’s case? Explain your answer and compare with what was done in Sofia’s case.

4. Can Sofia be discharged from the hospital? Please explain your answer.

4N - 20 Module 5N

Neonatal Bacterial Infections

Effective Perinatal Care (EPC)

5N - 2 Module 5N

Slide 5N-1 Neonatal Bacterial Infections

Upon completion of the module the participants will know: x That infectious diseases represent the leading cause of neonatal mortality in the world x What the periods and ways of transmission of neonatal infections are x What the main causes of these infections are x How to diagnose neonatal infections taking medical history, assessing for risk factors, and for clinical signs and requesting specific biological tests x That the clinical signs of infection in newborn are usually non specific x That neonatal infections can be localised, focalized or disseminated x How to treat neonatal infections x How to prevent neonatal nosocomial infections.

Slide 5N-2 Causes of 4 million Neonatal Deaths for the Year 2000

Infections are the leading cause of neonatal mortality in the world. While tetanus and diarrhoea occur almost exclusively in least developed regions, sepsis and pneumonia kill newborns everywhere.

This slide presents the data on neonatal mortality in the world from the year 2000.

Joy E Lawn, Simon Cousens, Jelka Zupan. Neonatal Survival 1: 4 million neonatal deaths: When? Where? Why? Lancet, Vol. 365 March 5, 2005

In countries where neonatal mortality level is over 45 per 1,000 live births, nearly 50% of lethal cases are related to severe infections, tetanus, and diarrhoea. In countries with low levels of neonatal mortality, less 15‰, neonatal infection mainly sepsis and pneumonia cause less than 20% of neonatal death, while tetanus and diarrhoea virtually do not exist. The risk of newborn death from infection in a country with a high level of neonatal mortality is 11 times higher than a similar indicator in a country with a low neonatal mortality rate.

The incidence of neonatal sepsis is a good proxy indicator of the importance of neonatal infection in a country or a region.

x Western Europe, North America and Australia: 6 - 9 per 1,000 live births x Asia: 7.1-38 per 1,000 live births x Africa: 6.5-23 per 1,000 live births x South America and the Caribbean countries: 3.5-8.9 per 1,000 live births.

S Vergnano, M Sharland, P Kazembe, C Mwansambo. P T Heath. Neonatal sepsis: an international perspective Archives of Disease in Childhood Fetal and Neonatal Edition 2005;90:F220-F224

5N - 3 Effective Perinatal Care (EPC)

Slide 5N-3 Transmission Routes Of Perinatal Infections

During the pregnancy the foetus can be infected through the or the amniotic fluid.

During labour a newborn can be infected through his/her mother’s blood in case of maternal infection or be infected through the infected amniotic fluid or genital secretions in the birth canal.

After birth the main way of infection is the cross contamination due to the poor implementation of hand washing policy in health facilities and due to inappropriate care for newborn (example: routine application on the umbilicus of inappropriate substance, or routine blood screening for all newborns).

C.Yvenou,Les infections neonatales, Infections neonatales,1999

Slide 5N-4 Frequent Causes of Neonatal Infections

In high-resource countries, the most frequent infection agents of neonatal infections are Group B Streptococcus, E. coli, Enterococcus, and Listeria. The causes of late neonatal infections (>72 hours after birth) are mainly due to Staphylococcus and Fungi.

JA Garcia-Prats, TR Cooper. The critically ill neonate with infection: management considerations in the term and preterm infant. Seminars in pediatric infectious diseases, Saunders Company. 2000.

In low–resource countries late sepsis leading to high mortality is due to Gram-negative bacteria.

S Vergnano, M Sharland, P Kazembe, C Mwansambo. P T Heath. Neonatal sepsis: an international perspective Archives of Disease in Childhood Fetal and Neonatal Edition 2005;90:F220-F224

5N - 4 Module 5N

Slide 5N-5 Why Newborns Have Higher Risk of Infection?

Specific immune response appears possible by the end of the 1st trimester. However, the naive nature of T and B lymphocytes is responsible for a delayed, slow and relatively ineffective primary response. This observation explains the particular susceptibility of neonates, especially premature neonates to bacterial and viral infections.

A. Durandy, Development of specific immunity during prenatal life, 2001.

Slide 5N-6 How to Diagnose Neonatal Infection

The diagnosis of any neonatal infection is the result of a synthesis done after the analysis of the documented medical history, clinical signs and results of biological tests/instrumental investigations.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Essential new born care and Breastfeeding PEPC WHO, 2002

Slide 5N-7 Review the Medical History

It is important to record all the details of the history and development of the infection. The newborn and mother’s medical files have to be reviewed in detail. It may be necessary to directly ask questions to the mother as she is the best observer of her baby.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

5N - 5 Effective Perinatal Care (EPC)

Slide 5N-8 Check the Baby’s Risk Factors for Infection

Some risk of neonatal infection is directly related to the newborn’s medical history such as the term of gestation, neonatal asphyxia or hypothermia.

It is also important to carefully check what has happened with this newborn since the birth: what care he/she received; was he/she with his/her mother; how he/she was fed and how the staff implements the hand washing policy. The risk of nosocomial infection increases in cases of inappropriate care, long hospitalisation, mother and baby separation or a crowded neonatal unit.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 5N-9 Check the Mother’s Risk Factors for Infection

It is crucial to know precisely what the maternal risk factors for infection are. Appropriate prevention strategies are based on this information. To assess the mother’s risk factor it is important to carefully review the mother’s medical file. It is also important to know what care the mother received during the labour (did she receive antibiotics? if yes, when?) and how the staff implements the hand washing policy and follow the hygienic rules.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 5N-10 Assess the Specific Signs of Localized Infections

Some neonatal infections can be limited/ localized to the skin, to the umbilicus or to the eyes.

The identification of specific and obvious clinical signs such as skin pustules or blister, skin or soft tissues are red or swollen, white patches on the tongue or inside the mouth; skin around the umbilicus is red and hardened, umbilicus is swollen, draining pus or foul smelling; , or eye(s) red, swollen or draining pus, leads to timely diagnose and treatment of

5N - 6 Module 5N localized infections which are essential to prevent sepsis.

The majority of localized bacterial infections respond to local treatment, therefore few cases will require to be treated with antibiotics (exception conjunctivitis due to gonococcus).

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 5N-11 Assess the General Signs of Possible Neonatal Infection

There are a variety of clinical signs which commonly occur with neonatal infection but unfortunately these signs are common to many newborn disorders so their presence indicates only that there is a “problem” and that this child needs further evaluation.

Technical basis of revised IMCI young infant algorithm WHO, Geneva, 2006.

Martin Weber and all. Predictors of neonatal sepsis in developing countries. Pediatr Infect Dis J, 2003;22:711–16.

Slide 5N-12 Biological Tests: Blood Tests

Isolation of bacteria from blood, cerebrospinal fluid or urine stands as the most specific way to diagnose sepsis and should always be performed.

Blood Culture Blood cultures drawn by peripheral arterial or venipuncture are the gold standard for diagnosing bacteriemia.

Blood culture may be also drawn from a Central Venous Catheter (CVC) or Peripherally Inserted Central Catheter (PICC) or from Umbilical Arterial Catheter (UAC) if freshly placed.

If the blood for culture is drawn by venipuncture the skin has to be meticulously cleaned with chlorhexidine or iodine-containing liquid, then with 95% alcohol. It is necessary to wait to allow the site to dry before the puncture.

Blood should be cultured for both aerobe and anaerobe organisms.

A false-negative result for a blood culture may occur for the following reasons: x The mother may have received antibiotics just before or during labour x Transient or intermittent bacteriemia x Insufficient amount of sampled blood x “Technical flaws” for sampling, storing, transportation and bacterial processing of blood.

5N - 7 Effective Perinatal Care (EPC)

Garcia-Prats, et al, (2000) showed that in 99% of term neonates with early sepsis without clinical signs, the infectious agent was found within the first 36 hours. Kumar, Y et. al. (2001) showed that if the result was negative during the first 36 hours, 99.8% of neonates have further negative result.

Blood screening tests The inability of any single laboratory test to provide rapid, reliable and early identification of neonates with bacterial sepsis has led efforts to devise a panel of screening tests as a means of increasing predictive accuracy. A sepsis screening involving four tests to discriminate infants with early onset sepsis from non infected neonates has been developed and successfully tested.

The screening tests results which confirm infection are: x Leukocyte count: <5,000/mm3 or >20,000/mm3 x Leukocytes index: Immature( mononuclear ) to total (mature, i.e. polynuclear, plus immature cells ) neutrophil ratio IT>0.2 x Erythrocytes sedimentation rate >15 mm x Latex C-reactive protein (CRP) positive >0.8 mg/dL (quantitative method).

For newborns during first 24 hours of life the normal Leukocyte count is in ranges 5,000/mm3 – 30,000/mm3, from the second day of life the leukocyte level is decreasing.

This screening test is considered positive when two or more of the above laboratory abnormalities are present.

C-reactive protein (CRP) level CRP is one of most specific “late” markers of a bacterial infection. The level of CRP should be repeated after 12-24 hours. An isolated result is difficult to interpret.

A series of negative CRP results allow practitioners to exclude neonatal infection with a high percentage of reliability and to stop antibiotic therapy.

William E. Benitz, Michael Y. Han, Ashima Madan, Pramela Ramachandra. Serial Serum C-Reactive Protein Levels in the Diagnosis of Neonatal Infection. PEDIATRICS Vol. 102 No. 4 October 1998, p. e41

It is important to repeat the screening tests 12-24 hours after the first ones to follow the evolution of infection. If after a few days the newborn’s status improves and/or if the newborn responds positively to the treatment, laboratory investigations can be done every 3-5 days.

Average normal blood values in Newborns: x Haemoglobin (Hb): 150-220 g/L x Haematocrit (Ht): 45-65 % x White blood cells (leukocytes): 8- 25 x 109 x Platelets: 120- 400 x 103.

Note: Quantitative values of blood count can be influenced by the newborn’s age and blood sampling techniques (venous/arterial/capillary).

5N - 8 Module 5N

Slide 5N-13 Biological Tests: Urine Tests, Germ Cultures and Lumbar Puncture

Urine needs to be analyzed and cultured in case of suspicion of infection, moreover if any urinary tract malformation is found.

The Merck Manuals online medical library. Bacterial Urinary Tract infections, November 2005.

Body surface cultures should be done as well as a Gram stain examination for germ identification and sensitivity However, Gram stained smears of the mucous membranes, skin, tracheal mucous, stomach content or stool do not allow staff to differentiate between infection and colonization. Therefore, positive results alone do not prove infection.

Lumbar puncture is used to confirm the diagnosis of meningitis. The clinical signs of meningitis are often non specific, nevertheless some clinical signs such as convulsions and bulging fontanelle can orient the diagnosis to meningitis.

Term newborns without clinical manifestation of sepsis but having only maternal risk factors, do not need a lumbar puncture.

Sometimes lumbar puncture can be difficult to perform in a neonate, and there is some risk of hypoxia. Poor clinical conditions (e.g., respiratory distress, shock, thrombocytopenia) make lumbar puncture risky.

See technique of Lumbar Puncture in Attachment 1.

Pong A, Bradley JS. Bacterial meningitis and the newborn infant. Infect Dis Clin North Am. 1999 Sep;13(3):711-33, viii.

Candice E. Johnson, Judy K. Whitwell, Kalpana Pethe, Kapil Saxena, and Dennis M. Super. Term Newborns Who Are at Risk for Sepsis: Are Lumbar Punctures Necessary? PEDIATRICS Vol. 99 No. 4 April 1997, p. e10.

Slide 5N-14 X-Ray Examinations

The need for X-Ray examinations should be considered against the risk of radiation in a newborn baby.

Chest radiographs are requested if pneumonia is suspected.

Abdominal radiographs are requested if enterocolitis is suspected.

The bone radiographs are used in case of suspicion of osteoarthritis, osteomyelitis and congenital syphilis.

5N - 9 Effective Perinatal Care (EPC) Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On- Call Problems, Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

Slide 5N-15 Clinical Types of Neonatal Infections

Neonatal infections can be “organized” according to their localization. It can be localized infection, systemic/focalized infection or disseminate infection in case of sepsis.

Any localized or systemic/focalized neonatal infection can be severe and can disseminate and then become a neonatal sepsis. Timely diagnosis and appropriate management of localized or focalized infections may prevent neonatal sepsis and its consequences.

A localized infection is an infection limited to a specific part of the newborn’s body (umbilicus, skin, eyes). In each case of localized infection it is extremely important to carefully assess the newborn for unspecific signs of infection in order to recognize timely possible dissemination of this infection Usually localized infection can be treated locally.

Some “More specific” clinical signs of systemic/focalized infections:

Meningitis: Enterocolitis: x Convulsions x Vomiting often bile stained x Opisthotonos x Abdominal distension and x Bulging fontanelle x Blood in the stool

Osteomyelitis: Pneumonia x Painful joints, joints swelling x Breathing difficulties x Reduced limb movement x Pain if parts are moved

Urinary tract infection: x Urinary tract malformation

C.Yvenou,Les infections neonatales, Infections neonatales,1999

5N - 10 Module 5N

Slide 5N-16 Diagnosis of Localized Skin and Umbilical Bacterial Infections

Assess the newborn completely, naked (keep he/she warm) and look on the skin for: x Vesicles (small, clear fluid-filled blisters <10 mm in diameter) x Bullae (clear fluid-filled blisters >10 mm in diameter) x Pustules are elevated lesions that contain pus x Papules (elevated lesions usually <10 mm in diameter that can be felt or palpated) x Crusts (scabs) consisting of dried serum, blood, or pus x Red and swollen skin (baby cry when swelling is touched) x Blistering rash.

Note where the lesion are localized (in the axillae, around the umbilicus and groin, on the palms and soles).

In case of congenital syphilis vesicobullous rash can be observed specially on the palms and soles.

It is important to differentiate skin infection from “thrush in the napkin area” (bright red patches often scaly in appearance or with small white centers).

Assess the umbilical region and look for: x Umbilicus red and swollen x Umbilicus is draining pus x Skin around umbilicus is red and hardened x Foul smelling. x Abdominal distention

In each case of localized infection assess for general signs of infection.

Always obtain a Gram stain smear of the secretion/discharge to check for white cells and bacteria (to identify the specific organism). A sample of secretion/discharge should also be submitted for culture and sensitivity testing.

The Merck Manuals online medical library. Skin Infections, November 2005

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

5N - 11 Effective Perinatal Care (EPC)

Slide 5N-17 Management of Skin and Umbilical Infection

Skin infections in babies are extremely contagious. Observe strict infection prevention practices at all times to prevent spreading one baby’s infection to other babies in the nursery. Dispose all the items in direct contact with the umbilicus or draining pus (e.g. gauze) in a plastic bag or leak proof covered waste container.

If the newborn does not have general signs of infection treat the skin or the umbilicus lesions locally. Usually skin and umbilical infections respond to topical treatment with antiseptic and gentian violet solution. The mother needs to be trained to treat her baby whenever it is possible as she will be often responsible to continue the treatment at home and because the treatment done by the mother reduce the risk of cross contamination to other babies.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Pregnancy, Childbirth, Postpartum and newborn Care: A guide for essential practice. WHO, Geneva, 2006

Slide 5N-18 Diagnosis of Eyes Infection

The eye infection is the most common neonatal infection. The major causes of neonatal eyes infection are chemical inflammation, bacterial infection, and viral infection. Bacterial eye infection can be transmitted during the birth due to infected secretion in the birth canal. If eye infection developed while the baby is hospitalized, suspect a nosocomial infection.

Check if the baby’s eye(s) is red, swollen, or draining pus.

Always obtain a Gram stain smear of the secretion/discharge to check for white cells and bacteria (to identify the specific organism) A sample of secretion/discharge should also be submitted for culture and sensitivity testing. A viral culture is requested only if viral infection is suspected (aspect of skin lesions or maternal history).

Chlamydia ophthalmia usually occurs 5 to 14 days after birth. Both eyes are involved. Watery discharge from eyes first then changing to pus, small to moderate amount of pus,

Gonorrheal ophthalmia appears 2 to 5 days after birth or earlier if premature rupture of membranes. Both eyes are involved with large amount of pus. If not treated, corneal ulcerations and blindness may occur.

5N - 12 Module 5N

Conjunctivitis caused by other bacteria has a variable onset, ranging from 4 days to several weeks.

The Merck Manuals online medical library. Eyes Infections, November 2005

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On-Call Problems,Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

Slide 5N-19 Management of Eyes Infection

Conjunctivitis usually responds to local care and antibiotic eye ointments (1% Tetracycline).

In case of Chlamydia it is recommended to treat with Erythromycin ethylsuccinate 12.5 mg/kg by mouth every 6 h for 14 days and continue the local treatment four times daily until the eyes are not longer red, swollen, sticky, or draining pus. The efficacy of this treatment is only 80%, so a 2nd antibiotic course may be needed.

In case of gonorrhea it is recommended to give a single dose of Cefriaxone: 50 mg/kg IM. There is no need for antibiotic eyes ointment.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Pregnancy, Childbirth, Postpartum and newborn Care: A guide for essential practice. WHO, Geneva, 2006

Slide 5N-20 Meningitis

Neonatal meningitis is infection of the meninges and central nervous system in the first month of life .The incidence is ~1 in 2,500 live births. The mortality rate is 20-50 % and there is a high incidence (>50%) of neurodevelopment sequela in survivors. In the preterm infant, inflammatory mediators associated with neonatal sepsis may contribute to brain injury and poor neurodevelopmental outcomes.

The clinical presentation is usually nonspecific. Meningitis must be excluded in any infant being evaluated for sepsis or infection. A full or bulging fontanelle is often a late finding in meningitis.

Neonatal meningitis occurs more often (by 10 times) in low-birth-weight (LBW) neonates, with a male predominance.

5N - 13 Effective Perinatal Care (EPC)

Definitive diagnosis is made by cerebrospinal fluid (CSF) examination obtain by lumbar puncture (LP), which should be performed in any neonate suspected of having sepsis or meningitis. Send a sample of the CSF to the laboratory for cell count, Gram stain, culture, and sensitivity.

A Gram stained smear is helpful in making a more rapid definitive diagnosis and identifying the initial classification of the germ.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

Slide 5N-21 Meningitis: Liquor Analysis

The diagnosis of meningitis is confirmed if: x White cells in the CSF is 20/mm3 or more if the baby is less than 7 days old, or 10/mm3 if the baby is 7 days older or more OR x Culture or Gram stain of the CSF sample is positive.

Normal CSF values are age-related.

Average cerebrospinal fluid values in a full term newborn: x Leucocytes < 30 per mL x Neutrophiles < 60% x Glucose > 60% of glycemy level x Protein < 70 mg/dL (1.7 g/L).

Considering the high permeability of the blood-brain barrier in preterm neonates, as well as the high immaturity of their immune system, it is recommended to do a lumbar puncture as a standard investigation for newborn <1,500 g with a suspicion of sepsis.

Pong A, Bradley JS. Bacterial meningitis and the newborn infant. Infect Dis Clin North Am 1999;13:711-33.

Candice E. Johnson, Judy K. Whitwell, Kalpana Pethe, Kapil Saxena, and Dennis M. Super. Term Newborns Who Are at Risk for Sepsis: Are Lumbar Punctures Necessary? PEDIATRICS Vol. 99 No. 4 April 1997

5N - 14 Module 5N

Slide 5N-22 Management of Meningitis

Perform a complete biological assessment. Establish an IV line and give Ampicillin and Gentamycin IV according to the baby’s age and weight. Note that the dose of Ampicillin given for meningitis is double the dose given for sepsis.

- Assess the baby’s condition after 48 hours of treatment with antibiotics: x If the baby’s condition is improving continue the treatment with antibiotics for 14 days or for 7 days after signs of improvement are first noted, whichever is longer.

x If the baby condition is not improving or is getting worse, repeat the LP: - If organism is seen on Gram stain of the CSF, change antibiotics according to the organism identified, and treat for 14 days or for seven days after signs of improvement are first noted, whichever is longer.

- If the organism cannot be identified in CSF, discontinue Ampicillin. Give Cefotaxime IV, in addition to Gentamycin, for 14 days or for 7 days after signs of improvement are first noted, whichever is longer.

If the LP is delayed (baby has shock or severe breathing difficulty) in a newborn with general signs of infection the treatment has to be given as if the meningitis was present.

Measure every 3 days. If hemoglobin is less than 10 g/dl give a blood transfusion.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 5N-23 Necrotizing Enterocolitis

Necrotizing enterocolitis is an acquired disorder representing an end expression of serious intestinal injury due to the combination of different factor (vascular, mucosal and metabolic) to a relatively immature gut.

75% of cases of necrotizing enterocolitis (NEC) occur in preterm, with an incidence of 6-10% in infants weighting <1.5 kg. Incidence of NEC in very low weight baby increases in case of prolonged rupture of membranes or asphyxia at birth. The risk factors for NEC development are , very low birth weight, improper feeding timing, inappropriate feeding volume and rapid advancement of enteral feeding.

5N - 15 Effective Perinatal Care (EPC)

The clinical signs may vary from abdominal distension (the most frequent sign noted in 70% of the cases), ileus, and increased volume of gastric aspirate or bilious aspirate, to frank signs of shock, bloody stools, peritonitis, and perforation. In other case clinical signs are not specific such as labile temperature or apnea.

NEC is a tentative diagnosis in any infant presenting feeding intolerance, abdominal dilatation and clear bloody stools or change in stool character.

Shelley C Springer and David J Annibale Necrotizing Enterocolitis, eMedicine, 2007

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On- Call Problems, Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Manual of Neonatal Care Sixth edition by John P. Cloherty,2008.

Slide 5N-24 Necrotizing Enterocolitis: X Rays

The radiographic signs are different according to the evolution of the disease Findings include ileus, with dilated loops with focal areas of pneumatosis intestinalis. Intrahepatic portal venous gas may be present. In late stages findings commonly show absent bowel gas and often evidence of intraperitoneal free air. Pneumoperitoneum indicates bowel perforation.

Enterocolitis is confirmed if intramural gas (pneumatosis intestinalis) and intrahepatic portal venous gas (in the absence of an umbilical catheter) are observed.

Manual of Neonatal Care Sixth edition by John P. Cloherty,2008.

Slide 5N-25 Management of Necrotizing Enterocolitis

Laboratory tests: x Laboratory tests should be performed and repeated every 8-12 hours x : the white cell are frequently elevated with a thrombocytopenia platelets < 50,000/μL x Blood culture should be done for aerobes, anaerobes and fungi x Stool screening for occult blood of enterally fed preterm infants may help diagnose NEC early.

5N - 16 Module 5N

Although no single infectious etiology is known to cause necrotizing enterocolitis (NEC), clinical consensus finds that antibiotic treatment is appropriate. Broad-spectrum parenteral therapy is initiated at the onset of symptoms after obtaining blood, spinal fluid, and urine for culture. Antibacterial coverage for gram-positive and gram-negative organisms is essential, with the addition of anaerobic coverage for infants older than 1 week who show radiologic or clinical disease progression. Antifungal therapy should be considered for premature infants with a history of recent or prolonged antibacterial therapy or for babies who continue to deteriorate clinically or hematologically despite adequate antibacterial coverage.

Various antibiotic regimens can be used; one frequently used regimen includes vancomycin, cefotaxime, and clindamycin or metronidazole. This combination provides broad gram-positive coverage (including staphylococcal species), excellent gram-negative coverage (with the exception of pseudomonads), and anaerobic coverage.

Treatment is primarily supportive and includes nasogastric suction, parenteral fluids, antibiotics and, often, : x Feedings must be stopped immediately if NEC is suspected x Insert a nasogastric tube to ensure a free drainage x Establish IV line and give only IV fluids at maintenance volume according to the baby’s age for the first five days. x Start the treatment for NEC with Ampicillin and Gentamicin IV. x Measure haemoglobin daily until bleeding stops, if it is less than 8 g/dl, give a blood transfusion x If an abdominal mass becomes palpable, it is likely that the baby has bowel perforation or intestinal obstruction from an abscess. Transfer the baby urgently to a tertiary level hospital or specialized surgical centre, if possible.

The dosage of Metronidazole needs to be adapted by postnatal age and weight:

Age < 1,200 g 1,200 – 2,000 g >2,000 g Weight <8 days after birth 7.5 mg/kg IV 7.5 mg/kg IV every 24h 7.5 mg/kg IV every 12h •8 days after birth every 48 hours 7.5 mg/kg IV every 12h 15 mg/kg IV every 12h

The dosage of Clindamycin (Cleocin) needs to be adapted by postnatal age and weight:

Age Weight ”7 days after birth and <2,000 g 5 mg/kg IV every 12h >7 days after birth and > 2,000 g 5 mg/kg IV every 6h

Shelley C Springer and David J Annibale Necrotizing Enterocolitis, eMedicine, 2007

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On- Call Problems, Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

The Merck Manuals online medical library. Necrotizing Enterocolitis, November 2005

5N - 17 Effective Perinatal Care (EPC)

Slide 5N-26 Pneumonia

Pneumonia is defined as an inflammation of one or both lungs, usually caused by infection from a bacteria or virus. The most frequent germs in neonatal pneumonia are gram-positive cocci (e.g. groups A and B streptococci, Staphylococcus aureus), gram-negative bacilli (e.g. Escherichia coli, Klebsiella, Proteus) and Chlamydia.

The contamination can be antenatal through mother blood, it is a congenital pneumonia. Newborns can also be contaminated during birth through maternal blood or infected birth channel. If the contamination occurs after birth, nosocomial contamination can be suspected.

The signs of pneumonia may be appears within the first hours after birth or later on. Pneumonia isolated with only breathing difficulties or part of a generalized sepsis syndrome where breathing difficulties are associated with other severe signs of infection such as shock. The diagnosis of pneumonia is done clinically and confirmed by radiography .The different blood and screening tests are necessary to confirm and follow the evolution of infection.

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On- Call Problems, Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

Slide 5N-27 Pneumonia: X Rays

X-Rays show localized interstitial or alveolar infiltrates usually asymmetric. Pneumatoceles (air-filled lung cysts) can occur with staphylococcal pneumonia. Pleural effusions or empyema may occur with any bacterial pneumonia.

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

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Slide 5N-28 Management of Pneumonia

The management of neonatal pneumonia associates IV antibiotherapy and oxygen administration. x Give Ampicillin + Gentamicin IV x In case of Chlamydia treat with Erythromycin 50mg/kg/24h per os for 10-14 days x Give only IV fluids within first 12 hours x Give oxygen to all children with pneumonia using mask or nasal prongs, or nasal catheter. Check every 3 hours to be sure that nasals prongs or nasal catheter are not blocked with mucus and that they are in correct place x Monitor the baby response to oxygen using an oximeter if available. If oximeter is not available monitor the baby response to oxygen by assessing whether the baby has signs of breathing difficulty or central cyanosis (blue tongue and lips ).

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 5N-29 Osteomyelitis/Osteo- Artritis

Neonatal osteomyelitis is rare, mainly found in preterm baby. Multiple heelstick blood punctures and arterial catheterization have been recognized as possible risks of neonatal osteomyelitis. The most frequent germ is the staphylococcus.

Two ways of contamination: 1. Hematogenous osteomyelitis if bacteriemia 2. Direct or contiguous inoculation causes by direct contact of the tissue and bacteria during trauma or surgery.

Randall W King, David Johnson. Osteomyelitis. eMedicime from WebMD. July 13, 2006.

The clinical signs of osteomyelitis are not obvious; only pseudo paralysis of a limb is frequently observed.

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. McGraw-Hill, 2004.

5N - 19 Effective Perinatal Care (EPC)

Slide 5N-30 Management of Osteomyelitis

Biological tests in case of osteomyelitis are usually non specific: x The leucocytes count may be elevated, but it is frequently normal x A leftward shift is common with increased polymorph nuclear leukocyte counts x The C-reactive protein level usually is elevated x The erythrocyte sedimentation rate is usually elevated (90%) x Culture or aspiration of the infected site is normal in 25% of cases x Blood culture results are positive in only 50% of patients with haematogenous osteomyelitis.

Treatment x Immobilize the limb x Start the antibiotic treatment IV, give a combination of penicillinase-resistant synthetic penicillin + a 3rd/4th generation cephalosporin x The treatment has to continue for at least 4-6 weeks. After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending on the type and location of the infection, on an outpatient basis. x Surgery is necessary only in case of under periostis abscess x Neonatal Osteomyelitis/Osteo-Artritis require referring to a specialized orthopedic centre.

Randall W King, David Johnson. Osteomyelitis. eMedicime from WebMD. July 13, 2006.

Tricia Lacy Gomella et al. Neonatology: Management, Procedures, On- Call Problems, Diseases, and Drugs. McGraw-Hill, 2004. 724 p.

Slide 5N-31 Disseminated Infection: Sepsis

The mortality rate in neonatal sepsis may be as high as 50% for infants who are not treated. The incidence of bacterial sepsis and meningitis, especially for gram- negative enteric bacilli, is higher in males than in females.

Premature infants have an increased incidence of sepsis. The incidence of sepsis is significantly higher in infants with very low birth weight (<1,000 g), at 26 per 1,000 live births, than in infants with a birth weight of 1,000-2,000 g, at 8-9 per 1,000 live births. The risk for death or meningitis from sepsis is higher in infants with low birth weight than in full-term neonates. The clinical signs of neonatal sepsis are non-specific and are associated with characteristics of the causative organism and the body's response to the invasion. These non-specific clinical signs of early sepsis syndrome are also associated with other neonatal diseases, such as respiratory distress syndrome (RDS), metabolic disorders, intracranial haemorrhage, and a

5N - 20 Module 5N traumatic delivery. Given the non-specific nature of these signs, providing treatment for suspected neonatal sepsis while excluding other disease processes is prudent.

The clinical signs of sepsis are not specific and can be summarized by the rule of 3 P: x “Poor breathing” x “Poor feeding” x “Poor looking”.

The diagnosis is clinical and is supported by comprehensive laboratory investigations.

S Vergnano, M Sharland, P Kazembe, C Mwansambo. PT Heath Neonatal sepsis: an international perspective Archives of Disease in Childhood Fetal and Neonatal Edition 2005;90:F220-FF224

Slide 5N-32 Classification of Neonatal Sepsis

Neonatal sepsis may be categorized as early or late onset. 65% of newborns with early-onset infection present within 24 hours, 5% present at 24-48 hours, and a smaller percentage of patients present between 48 hours and 6 days of life.

Onset is most rapid in premature neonates. Early-onset sepsis syndrome is associated with acquisition of microorganisms from the mother. Transplacental infection or an ascending infection from the cervix by passage through a colonized birth canal at delivery. The microorganisms most commonly associated with early-onset infection include group B Streptococcus (GBS), Escherichia coli, Haemophilus influenzae, and Listeria monocytogenes.

Late-onset sepsis syndrome occurs at 7-90 days of life and is acquired from the caregiving environment. Organisms that have been implicated in causing late-onset sepsis syndrome include coagulase-negative staphylococci, Staphylococcus aureus, E coli, Klebsiella, Pseudomonas, Enterobacter, Candida, GBS, Serratia, Acinetobacter, and anaerobes. .Vectors for such colonization may include vascular or urinary catheters, other indwelling lines, or contact from caregivers with bacterial colonization.

Pneumonia is more common in early-onset sepsis, whereas meningitis and bacteremia are more common in late-onset sepsis. Premature and ill infants have an increased susceptibility to sepsis and subtle nonspecific initial presentations; therefore, they require much vigilance so that sepsis can be identified and treated effectively.

Ann L Anderson-Berry Neonatal Sepsis University of Nebraska School of Updated August 18,2006

Barbara J. Stoll et al., Late-Onset Sepsis in Very Low Birth Weight Neonates: The Experience of the NICHD Neonatal Research Network. PEDIATRICS Vol. 110 No. 2 August 2002, pp. 285-291.

5N - 21 Effective Perinatal Care (EPC)

Slide 5N-33 Risk Factors of Early Neonatal Sepsis

The most common risk factors associated with early-onset neonatal sepsis include maternal Streptococcus B colonization (especially if untreated during labor), premature rupture of membranes (PROM), preterm rupture of membranes, prolonged rupture of membranes, prematurity, maternal , and . Risk factors implicated in neonatal sepsis reflect the stress and illness of the fetus at delivery, as well as the hazardous uterine environment surrounding the fetus before delivery.

Late onset sepsis is associated with the following risk factors: prematurity, central venous catheterization (duration of >10 days), nasal cannula continuous positive airway pressure use, H2 blocker/proton pump inhibitor use, and gastrointestinal tract pathology.

Risk factors have different prognostic value. The risk factors associated with Group B Streptococcal infection (GBS), have been thoroughly investigated. Intrapartum maternal positive results of Group B Streptococcus screening increases the risk of neonatal sepsis by 204 times; gestation age < 28 weeks increases the risk of neonatal sepsis by 21.7 times. An awareness of the many risk factors associated with neonatal sepsis prepares the clinician for early identification and effective treatment, thereby reducing mortality and morbidity.

William E. Benitz, Jeffrey B. Gould, Maurice L. Druzin. Risk Factors for Early-onset Group B Streptococcal Sepsis: Estimation of Odds Ratios by Critical Literature Review. PEDIATRICS Vol. 103 No. 6 June 1999, p. e77.

Slide 5N-34 Neonatal Sepsis – Diagnosis

When diagnosed late, neonatal sepsis is responsible for a high mortality, but it is often difficult to do an early diagnosis because the clinical signs are non- specific. Therefore, physicians frequently treat newborns with antibiotics due to their concern to miss a life-threatening infection.

To do an early diagnosis it is necessary to carefully consider the risk factors together with the clinical signs. Newborns with general non specific signs of infection, those born to mothers with premature rupture of membranes (PROM), preterm rupture of membranes, prolonged rupture of membranes, maternal urinary tract infection, chorioamnionitis or fever during delivery, and those born preterm or with asphyxia at birth, should be completely screened for infection. The diagnosis of sepsis is confirmed by the isolation of a pathogen agent in the culture.

5N - 22 Module 5N

Claudio Chiesa, Alessandra Panero, John F. Osborn, Antonella F. Simonetti and Lucia Pacifico. Diagnosis of Neonatal Sepsis: A Clinical and Laboratory Challenge. . 2004;50:279-287.

William E. Benitz, Jeffrey B. Gould, Maurice L. Druzin. Risk Factors for Early-onset Group B Streptococcal Sepsis: Estimation of Odds Ratios by Critical Literature Review. PEDIATRICS Vol. 103 No. 6 June 1999, p. e77.

Slide 5N-35 Management of Sepsis (1)

Perform a complete biological assessment. Establish an IV line and give Ampicillin + Gentamicin in association treat positive and negative germs. The choice of antibiotics should be re-evaluated as soon as the germ and its sensibility are identified The dosage of antibiotics depends on weight and age of a newborn (please see Attachment 2). Assess the baby’s condition every 6 hours for improvement.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 5N-36 Management of Neonatal Sepsis (2)

The results of the antibiotic treatment are evaluated after 3 days. If the condition of the newborn improves and the blood culture is negative, discontinue ampicillin and gentamicin after five days of treatment. If the condition of the newborn improves and the blood culture is positive or is not possible, continue ampicillin and gentamicin to complete 10 days of treatment. If after 3 days using the first line antibiotic the newborn’s condition did not improved or became worse, it is recommended to change the antibiotic according to the organism and its sensitivity.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

5N - 23 Effective Perinatal Care (EPC)

Slide 5N-37 When Should Antibiotic Treatment for Neonatal Sepsis be Started?

In case of clinically obvious case of neonatal sepsis, no investigation is required to start the treatment. Early treatment is crucial because neonatal sepsis is a life-threatening emergency and any delay may cause death. Supportive care and antibiotics are two equally important components of the treatment. General supportive measures include respiratory and hemodynamic management.

S Vergnano, M Sharland, P Kazembe, C Mwansambo. PT Heath Neonatal sepsis: an international perspective Archives of Disease in Childhood Fetal and Neonatal Edition 2005;90:F220-FF224

Slide 5N-38 Antibiotics Use in Neonatal Sepsis It is recommended to start to treat neonatal sepsis with Ampicillin + Gentamicin, evaluate after 3 days to decide what needs to be done according to the clinical condition and to the organism sensitivity. If bacterial culture and sensitivity test are not possible, it is recommended to replace the initial antibiotics by the second line antibiotic or a combination of antibiotics is given an empiric basis and to continue the treatment for 10 day or 7 days after signs of improvement are first noted, whichever is longer.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. WHO, Geneva, 2003

Slide 5N-39 Suspected Sepsis

American Academy of Pediatrics recommends a prophylactic treatment with broad-spectrum antibiotics (Ampicillin + Gentamicin IV) if: - The baby is preterm ” 34 weeks - The mother has risks factors. The treatment will be stopped after 3 days if the baby’s condition is good and if less than 2 screening tests are abnormal. If the baby’s condition is not good or if more than 2 screening tests are abnormal, the treatment is to be continued for a total of 10 days.

5N - 24 Module 5N

Prevention of perinatal Group B Streptococcus Disease. Revised guideline from CDC. August 16, 2002

Slide 5N-40 Principles of Management after Antibiotic for Neonatal Infections

Monitor baby’s condition while is treatment with antibiotics to make decision timely for changing or discontinuing of treatment with antibiotics.

Observe the baby for 24 hours after discontinuing antibiotics. If the signs of infection reapers repeat a complete medical examination, all biological test and treat with antibiotic for late sepsis.

Managing newborn Problems: A guide for doctors, nurses, and midwives. World Health organization, Geneva. 2003

Slide 5N-41 Supportive Care for the Sick Newborn

Ensure a regular complete assessment: examine the baby under a radiant heater or in an incubator and encourage the mother to be present during the examination. Explain your findings to the mother in simple terms.

x Keep the baby warm. Do not allow the baby to become too cold or overheated x Provide supportive ventilation or oxygenation if there are breathing difficulties x Prevent or treat hypoglycemia or any metabolic imbalances by proper feeding and/or the IV administration of fluids x Prevent infections, wash your hands before touching the baby, restrict invasive interventions and involve the mother in the care of her baby x Isolate infected babies.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. World Health Organization, Geneva, 2006

5N - 25 Effective Perinatal Care (EPC)

Slide 5N-42 Monitoring of Sick Newborn

Monitor the indicators mentioned every hour in a 4 hour period, then every two hours for the next 24 hours, then every 3 hours until the baby no longer requires oxygen. Then for an additional 24 hour and continue as the newborn’s condition requires. If baby’s condition worsens monitor the baby more often.

x Look for central cyanosis or pallor and remember that central cyanosis is a very late clinical sign x Check for convulsions or lethargy and remember that between convulsions or lethargy the baby may appear normal x Check for baby’s response to feeding: Is the baby digesting his/her food? Is the baby vomiting? In this case aspirate gastric content x Check to see if the baby has more difficulty breathing after feeding x Check for urine and stool output (quantity) and assess presence of mucus or blood in the stool.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 5N-43 General Principles of Fluid Management

Give IV fluids to ensure that the baby receives the necessary fluids, minimum calories and electrolytes. Use an infusion set with a micro dropper if possible (1ml=60 micro drops). Determine the required volume of fluid according to the baby’s age and weight.

Give only 10% glucose for the first three days of life. On the fourth day if urine output is good, add to 10% glucose 3 mmol/kg body weight of sodium and 2 mmol/kg body weight of potassium. It is necessary to regularly assess the quantity of urine and the body weight when the IV is on.

Measure blood glucose every six hours: x if the blood glucose is less than 45 mg/dl (2.6 mmol/l), treat for low blood glucose x if the blood glucose is more than 105 mg/dl (6 mmol/l) (hyperglycaemia) on two consecutive readings o Change to a 5% glucose solution, if possible; o Measure blood glucose again in 3 hours.

Assess quantity of urine daily: if the baby’s urinates less than 6 times per day, or if the quantity of urine is less then 1 ml/kg/hour, do not increase the infusion volume the next day.

When the quantity of urine increases, increase the volume of IV fluids according to the tables.

5N - 26 Module 5N

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 5N-44 General Principles of Feeding

A newborn after resuscitation often has feeding problems.

Poor suckling reflex, vomiting, poor digestion or necrotizing enterocolitis are the most common manifestations of this problem. The sucking reflex, or the coordination of sucking swallowing, and breathing may be impaired because of central nervous system damage. In these cases, intravenous fluid administration should be given until the baby improves.

Once the baby’s condition improves begin the enteral feeding. Give expressed milk using an alternative feeding method. If the baby tolerates it and there are no problems, continue to increase the volume of expressed milk while decreasing the volume of IV fluid to maintain the total daily volume according to the baby’s daily requirement. Feed the baby every three hours or more frequently if necessary.

Discontinue the IV fluid when the baby receives more than two-thirds of the daily fluid volume by mouth and the abdomen is not distended and there is no vomiting.

Help the mother to express breast milk and feed her baby. Encourage the mother to breastfeed exclusively as soon as the baby is receiving 100% of daily fluid volume by mouth.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 5N-45 Criteria for Discharge from Hospital

Examine the baby and confirm that the baby meets the requirements for discharge:

x Baby is breathing without difficulty. x If the baby has other problems, these can be managed on an outpatient basis. x Baby’s body temperature is stable (36.5-37.5°C) x Baby is breastfeeding well or mother is confident using an alternative feeding method x Baby is gaining weight.

Advise the mother to return immediately with the baby if the baby has any problems (e.g. feeding or breathing difficulties, convulsions, abnormal body temperature, etc.). Advise the mother on home care:

5N - 27 Effective Perinatal Care (EPC)

x How to keep the baby warm x Breastfeeding on demand and exclusively x Providing dry cord care x Providing standard hygienic care x The back sleeping position x Observing the baby and immediately returning to hospital if any danger signs occur x Ensure the baby has regular medical surveillance and care.

Give the mother a sufficient supply of drugs to complete any treatment at home, or give prescriptions for the drugs.

Complete the baby’s clinical record with full information.

Plan at least one follow-up visit after discharge to: x Assess the baby for the any specific problem identified before discharge and which required additional observation. Make sure that the problem is solved or under control x Assess the general condition of the newborn x Weigh the infant and assess growth x Counsel the mother and/or help her to solve any problems that she might have x Assess breastfeeding or alternative feeding methods and counsel the mother to breastfeed exclusively x Remind to the parents of the danger signs and essential newborn care. x Promote the family’s continued use of the primary health care facility. x Give immunization (C-51) if they are due, or refer the baby and mother to the relevant service.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

Slide 5N-46 Neonatal Nosocomial Infections (NNI)

Neonatal Nosocomial Infection is an important problem as late sepsis which is mainly due to nosocomial contamination represents 45% of neonatal deaths after the 2nd weeks of age.

Since it is well known that the newborn baby will easily acquire infections, rigorous hygiene routines should be practiced in maternity wards and neonatal units. The most dangerous source of infections is the hands of the staff. Consequently hand washing is the most important method for combating infections. Hands must be washed before clean and after dirty activities.

Essential Newborn care and Breastfeeding WHO Euro 2002

The effective implementation of hand washing policy is a quite challenging task as hand washing places must be organized, staff trained, and the process carefully and regularly controlled. The Merck Manual of Diagnosis and Therapy, Section 19. 1999

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Slide 5N-47 Strategy to Prevent Nosocomial Infections in Maternity (1) Improvement of the organization of neonatal care is important to decrease nosocomial infection Separation of the infant from the mother in order to avoid infection is never to be recommended. Only one infant should be put in each bed or incubator (if needed) in order to avoid cross contamination. A rooming-in system, keeping the mother and child together, is to be preferred to care of mother and child in separate rooms.

Essential Newborn care and Breastfeeding WHO Euro 2002

Slide 5N-48 Strategy to Prevent Nosocomial Infections in Maternity (2)

x Avoid invasive methods if possible: do not use suction on the babies unless necessary; if you have to use suction, do it carefully and for short periods x Do not use endotracheal tubes unless necessary; use bag and mask x Do not use intravenous or intra- arterial catheters unless necessary x If possible avoid putting more than one baby in each incubator. In such conditions it is better to use the mother as a source of heat. In incubators, the humidifying system implies a risk of contamination of the baby. It must be cleaned properly and the water replaced regularly x Tools and instruments used in care such as forceps, tubes and masks, must be cleaned carefully and sterilized with boiling water for 20 minutes before use.

Essential Newborn care and Breastfeeding WHO Euro 2002

5N - 29 Effective Perinatal Care (EPC)

Attachment 1 PERFORMING A LUMBAR PUNCTURE

Lumbar puncture is used to confirm the diagnosis when the baby has signs suggestive of meningitis. Do not perform a lumbar puncture if the baby has spina bifida/meningomyelocoele.

SUPPLIES x Clean examination gloves x High-level disinfected or sterile gloves x Sterile drapes x Swabs or cotton-wool balls soaked in antiseptic solution x Spinal needle or intravenous needle (22- to 24-gauge) x Appropriate collection tubes x Dry cotton-wool ball x Adhesive bandage.

PROCEDURE x Be prepared to resuscitate the baby using a bag and mask if necessary x Gather necessary supplies x Place the baby under a radiant warmer if possible, and undress the baby only when ready to perform the procedure x Follow principles of infection prevention and aseptic technique x Position the baby: – Have an assistant hold the baby in a sitting position: - Position the baby so that the baby’s legs are straight and the back is arched (Fig. 1) - Ensure that the baby’s neck is partially extended and not flexed towards the chest, which could obstruct the baby’s airway.

Figure 1 Sitting position for lumbar puncture

– Alternatively, place the baby on her/his side facing the assistant (most right-handed health care providers find it easiest if the baby is on her/his left side; Fig. 2):

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- Position the baby so that the baby’s back is closest to the side of the table from which the lumbar puncture will be performed - Have the assistant place one hand behind the baby’s head and neck, and place the other hand behind the baby’s thighs to hold the spine in a flexed position - Ensure that the baby’s neck is partially extended and not flexed towards the chest, which could obstruct the baby’s airway.

Figure 2 Lying position for lumbar puncture x Wash hands and put on clean examination gloves x Prepare the skin over the area of the lumbar spine and then the remainder of the back by washing in an outward spiral motion with a swab or cotton-wool ball soaked in antiseptic solution. Repeat two more times, using a new swab or cotton-wool ball each time, and allow to dry x Identify the site of the puncture between the third and fourth lumbar processes (i.e. on a line joining the iliac crests; Fig. 3)

Figure 3 Site of lumbar puncture x Remove examination gloves and put on high-level disinfected or sterile gloves x Place sterile drapes over the baby’s body so that only the puncture site is exposed x Insert the needle in the midline of the vertebrae, angled towards the baby’s umbilicus x Slowly advance the needle to a depth of about 1 cm (or less if the baby is small [less than 2.5 kg at birth or born before 37 weeks gestation]). A slight “pop” may be felt as the needle enters the subarachnoid space x If using a spinal needle, remove the stylet x If bone is encountered, the needle cannot be redirected. Pull the needle back to just beneath the skin and reinsert the needle, directing it slightly upward while aiming for the baby’s umbilicus. x Collect the cerebrospinal fluid (CSF): - Collect about 0.5 to 1 ml (about 6 to 10 drops) of CSF in each collection tube

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- If CSF does not come out, rotate the needle slightly

- If CSF still does not come out, remove the needle and reinsert it between the fourth and fifth lumbar processes - If blood is seen in the CSF, the needle probably went through the spinal canal and caused bleeding. If the CSF does not clear, collect enough CSF for culture and sensitivity only. x After the CSF is collected, remove the needle x Have an assistant apply gentle pressure to the puncture site with a cotton wool all until bleeding or leakage of fluid stops x Apply an adhesive bandage to the site.

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

5N - 32 Module 5N

Attachment 2

ANTIBIOTICS

CHOICE AND ADMINISTRATION OF ANTIBIOTICS

Antibiotic choice begins empirically with the selection of the drug(s) that is most likely to be effective against the organism causing the baby’s illness. If bacterial culture and sensitivity are possible, the results of these investigations guide further treatment, particularly if the baby is not responding to the empirically chosen antibiotic(s).

If bacterial culture and sensitivity are not possible and the baby is not responding to the initial antibiotic(s), a second-line antibiotic or combination of antibiotics is given on an empiric basis. Table C-7 lists the first- line antibiotic(s) for the infections described in this guide and the second-line antibiotic(s) to use if the baby shows no improvement (by the third day, unless directed otherwise by a chapter in the section Assessment, Findings, and Management) and if culture and sensitivity have not been performed. Review Table C-8 for information on diluting antibiotics, and see Table C-9 for antibiotic doses according to the baby’s age.

Note that the information provided in this chapter applies only to antibiotics given to the baby. For information regarding dosage of antibiotics for the mother and/or her partner (e.g. for a sexually transmitted infection), see the appropriate chapter in the section Assessment, Findings, and Management.

ROUTE OF ADMINISTRATION

• For sepsis, meningitis, tetanus, and congenital syphilis, give antibiotics intravenously (IV):

- Give the antibiotics, especially gentamicin and cefotaxime, slowly over a period of at least three minutes;

- Monitor the baby while giving IV fluids to ensure that fluid overload does not occur;

- If an IV line cannot be established immediately, give antibiotics intramuscularly (IM) until an IV line is in place;

- When the baby is recovering and an IV line is no longer needed for another purpose, give the antibiotics IM to complete the course of treatment.

• For most other infections, give the antibiotics IM. If an IV line is needed for another purpose, however, give the antibiotics IV.

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TABLE C-7 Antibiotics used to treat infections described in this guide

Infection First-Line Antibiotic(s) Second-Line Antibiotics Sepsis or meningitis Ampicillin and gentamicin Cefotaxime and gentamicin Sepsis with infection of the Cloxacillin and gentamicin Cefotaxime and umbilicus or skin gentamicin Congenital syphilis with central Benzylpenicillin nervous system (CNS) involvement Congenital syphilis without CNS Procaine benzylpenicillin or involvement benzathine benzylpenicillin Tetanus Benzylpenicillin Skin infection with 10 or more Cloxacillin Cloxacillin and pustules or blisters or covering gentamicin more than half the body but without sepsis Skin infection with fewer than 10 Cloxacillin pustules or blisters or covering less than half the body but without sepsis Cellulitis Cloxacillin Cloxacillin and gentamicin Conjunctivitis due to gonorrhoea Ceftriaxone Conjunctivitis due to chlamydia Erythromycin Mother with uterine infection or Ampicillin and gentamicin fever, or rupture of membranes for more than 18 hours before birth; asymptomatic baby Mother not treated for syphilis; Procaine benzylpenicillin or asymptomatic baby benzathine benzylpenicillin

TABLE C-8 Antibiotic dilutions

Antibiotic Dilution

Ampicillin Add 5 ml sterile water to 500-mg vial = 100 mg/ml Benzathine Add 5 ml sterile water to 1.8-g (2.4-million unit) benzylpenicillin vial = 360 mg/ml (480 000 units/ml) Benzylpenicillin Add 5 ml sterile water to 600-mg (1-million unit) vial = 120 mg/ml (200 000 units/ml) Cefotaxime Add 5 ml sterile water to 500-mg vial = 100 mg/ml Ceftriaxone Add 2.5 ml sterile water to 250-mg vial = 100 mg/ml Cloxacillin for injection Add 5 ml sterile water to 500-mg vial = 100 mg/ml Cloxacillin for oral Add 5 ml boiled water to 125-mg bottle = 25 mg/ml administration Erythromycin for oral Add 5 ml boiled water to 125-mg bottle = 25 mg/ml administration Gentamicin Use 10 mg/ml, 2-ml vial = 10 mg/ml Procaine benzylpenicillin Add 5 ml sterile water to 1-g (1-million unit) vial = 200 mg/ml (200 000 units/ml)

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TABLE C-9 Antibiotic doses Antibiotic Dose in mg Dose in ml

Day 1 to 7 Day 8+ Day 1 to 7 Day 8+

Ampicillin for meningitis ONLY 100 mg/kg every 100 mg/kg 1.0 ml/kg 1.0 ml/kg 12 hours every 8 hours every 12 every 8 hours hours Ampicillin for sepsis 50 mg/kg every 50 mg/kg 0.5 ml/kg 0.5 ml/kg 12 hours every 8 hours every 12 every 8 hours hours Benzathine benzylpenicillin for 75 mg/kg (100 75 mg/kg 0.2 ml/kg in 0.2 ml/kg in a asymptomatic baby of mother 000 units/kg) in a (100 000 a single single dose not treated for syphilis single dose units/kg) in a dose single dose Benzathine benzylpenicillin for 75 mg/kg (100 75 mg/kg 0.2 ml/kg 0.2 ml/kg congenital syphilis without CNS 000 units/kg) (100 000 once daily once daily involvement once daily units/kg) once daily Benzylpenicillin for congenital 30 mg/kg (50 30 mg/kg (50 0.25 ml/kg 0.25 ml/kg syphilis without CNS 000 units/kg) 000 units/kg) once daily once daily involvement once daily once daily Benzylpenicillin for congenital 30 mg/kg (50 30 mg/kg (50 0.25 ml/kg 0.25 ml/kg syphilis with CNS involvement 000 units/kg) 000 units/kg) every 12 every 12 every 12 hours every 12 hours hours hours Benzylpenicillin for tetanus 60 mg/kg (100 60 mg/kg 0.5 ml/kg 0.5 ml/kg 000 units/kg) (100 000 every 12 every 12 every 12 hours units/kg) hours hours every 12 hours Cefotaxime for meningitis ONLY 50 mg/kg every 50 mg/kg 0.5 ml/kg 0.5 ml/kg 8 hours every 6 hours every 8 every 6 hours hours Cefotaxime for sepsis 50 mg/kg every 50 mg/kg 0.5 ml/kg 0.5 ml/kg 12 hours every 8 hours every 12 every 8 hours hours Ceftriaxone 50 mg/kg in a 50 mg/kg in a 0.5 ml/kg in 0.5 ml/kg in a single dose single dose a single single dose dose Less than 2 kg: Less than 2 kg: 50 mg/kg every 50 mg/kg 2 ml/kg 2 ml/kg 8 hours every 8 hours every 8 every 8 hours hours Cloxacillin (oral administration) 2 kg or more: 2 kg or more: 50 mg/kg every 50 mg/kg 2 ml/kg 2 ml/kg 8 hours every 8 hours every 8 every 8 hours hours Less than 2 kg: Less than 2 kg: 50 mg/kg every 50 mg/kg 0.5 ml/kg 0.5 ml/kg 8 hours every 8 hours every 8 every 8 hours hours Cloxacillin (injection) 2 kg or more: 2 kg or more: 50 mg/kg every 50 mg/kg 0.5 ml/kg 0.5 ml/kg 8 hours every 8 hours every 8 every 8 hours hours

5N - 35 Effective Perinatal Care (EPC)

Erythromycin 12.5 mg/kg every 12.5 mg/kg 0.5 ml/kg 0.5 ml/kg 6 hours every 6 hours every 6 every 6 hours hours Less than 2 kg: Less than 2 kg: 4 mg/kg once 7.5 mg/kg 0.4 ml/kg 0.75 ml/kg daily once daily once daily once daily OR 3.5 OR 0.35 mg/kg every ml/kg every 12 hours 12 hours Gentamicin 2 kg or more: 2 kg or more: 5 mg/kg once 7.5 mg/kg 0.5 ml/kg 0.75 ml/kg daily once daily once daily once daily OR 3.5 OR 0.35 mg/kg every ml/kg every 12 hours 12 hours Procaine benzylpenicillin for 100 mg/kg (100 100 mg/kg 0.5 ml/kg 0.5 ml/kg congenital syphilis without CNS 000 units/kg) (100 000 once daily once daily involvement once daily units/kg) once daily Procaine benzylpenicillin for 100 mg/kg (100 100 mg/kg 0.5 ml/kg in 0.5 ml/kg in a asymptomatic baby of mother 000 units/kg) in a (100 000 a single single dose not treated for syphilis single dose units/kg) in a dose single dose

Managing Newborn Problems: A guide for doctors, nurses, and midwives. World Health Organization, Geneva. 2003

5N - 36 Module 6N

Care of a Newborn with Birth Defects/Congenital Malformations or Birth Trauma Effective Perinatal Care (EPC)

6N - 2 Module 6N

Slide 6N-1 Care of a Newborn with Birth Defects/Congenital Malformations or Birth Trauma

At the end of this module, the participants will:

x Know how to Assess, Classify and Treat newborns with birth defects/ congenital malformations or birth trauma x Understand how to take care of a newborn with congenital birth defects /congenital malformations or birth trauma x Learn effective and safe skills to care for newborns with birth defects /malformations or birth trauma.

Slide 6N-2 Causes of Neonatal Deaths Worldwide (2000)

Congenital malformations or birth defects are responsible for 7% of neonatal deaths in the world.

In developed countries, many of congenital malformation could be diagnosed during the antenatal period. Nevertheless, in these countries the neonatal mortality due to congenital malformations is high, as compared with lower neonatal mortality caused by infection and asphyxia.

Joy E lawn, Simon Cousens, Jelka Zupan, for the Lancet Neonatal Survival Streeting Team. 4 million neonatal deaths: When? Where? Why? The Lancet, March 2005, 9-18.

Slide 6N-3 Birth Defects/Congenital Malformations

A birth defect or congenital malformation is an abnormality of structure, function or metabolism (body chemistry) present at birth that results in a physical or mental disability, or is fatal. Several thousand different birth defects have been identified. Birth defects are the leading cause of death in the first year of life.

March of Dimes Perinatal Data Center. Maternal, Infant, and Child Health in the United States, 2001.

6N - 3 Effective Perinatal Care (EPC)

Both genetic and environmental factors can cause birth defects. However, the causes of about 60 to 70 percent of birth defects are currently unknown.

Malformations often come in clusters; if you find one malformation, check for others.

Frequency of minor and severe congenital malformations comprise 3-4% of all births.

Robinson A. and Linden MG. Clinical Genetic Handbook, Boston, Blackwell Scientific Publications, 1993.

Care for newborns with minor birth defects can be provided in any maternity and the baby doesn’t need to be separated from his/her mother. These newborns need to be kept warm, breast-fed and receive care from their mother.

Newborns with severe abnormalities need to be transferred to a third-level medical facility for special care and treatment.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

Slide 6N-4 Assessing and Classifying Newborns with Birth Defects or Birth Traumas

Immediately after birth, as the baby is dried, conduct an immediate assessment to see if there is a need for immediate care such as neonatal resuscitation.

If the newborn is breathing well, has heartbeat rate over 100 per minute and become rapidly pink, he/she do not need any resuscitation measure.

This rapid assessment allows recognising important malformation which need immediate treatment such as, Spina bifida or Gastroschisis.

The majority of threatening life malformations need to be treated in a third-level medical facility, in this case the newborn with a severe birth defect must be prepared for transportation.

Essential Newborn Care and Breastfeeding: Training Module. WHO Euro, Copenhagen, 2002.

6N - 4 Module 6N

Slide 6N-5 Examples of Minor Birth Defects

Newborns with minor birth defects should stay with their mother in the facility and if necessary, eventually and timely referred to a specialised institution/department.

These newborns require essential care: to be kept warm, to be breastfed, to receive dry cord care management and to be immunised. They can be discharged from hospital on a standard basis.

The mother needs to be reassured and trained to observe the newborn and to provide appropriate care if any.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

Slide 6N-6 Minor Birth Defect: Cleft Palate

Cleft palate is a frequent congenital malformation. The malformation may be limited to the lip or could involve the hard and soft palate. The malformation can be unilateral or bilateral.

The major problem for newborns with cleft palate during the first months of life is feeding.

If the malformation is minor, the newborn can breastfeed. If the malformation is more complex alternative feeding methods are recommended, such as spoon or syringe to feed with expressed breast milk; in some cases an obturator should be applied.

Newborns with cleft palate are at risk for milk aspiration and may not gain weight well.

The date for surgical correction depends on the type of malformation: 3-6 months for cleft lip and 9-12 months for cleft palate. . Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

Essential Newborn Care and Breastfeeding: Training Module. WHO Euro, Copenhagen, 2002.

6N - 5 Effective Perinatal Care (EPC)

Slide 6N-7 Cleft Lip with Cleft Palate

Photograph of a newborn with cleft lip involving also the palate.

“Mother and Infant Health Project”, JSI, Ukraine.2004

Slide 6N-8 Minor Birth Defect: Club Foot (Talipes Equinovarus)

Provide emotional support and reassurance to the mother.

Refer to a specialized department within one month, if necessary, to treat the club foot.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003

David E. Hertz. Care of the Newborn: A Handbook for Primary Care. Lippincott Williams & Wilkins, 2005, p 234.

Slide 6N-9 Major Birth Defect: Congenital Diaphragmatic Hernia (CDH) (1)

Congenital diaphragmatic hernia is a severe abnormality defined by: x Lung hypoplasia (most severe on the affected side) x Structural and functional lung immaturity x Reduction of pulmonary arteriolar cross x Muscular hyperplasia of remaining pulmonary arterioles.

In almost 20 % of cases CDH is associated with other major anomalies.

After birth the following clinical signs could be observed: x Chest movements are not well coordinated with baby's breathing rhythm x Breath sounds are absent on the affected side 6N - 6 Module 6N

x Bowel sounds are heard in the chest x Concave abdomen that feels less full when touched.

March of Dimes Perinatal Data Center. Maternal, Infant, and Child Health in the United States, 2001.

Langham MR Jr et al. Congenital diaphragmatic hernia. Epidemiology and outcome. Clin Perinatol. 1996 Dec, 23(4), 671-88.

Slide 6N-10 Congenital Diaphragmatic Hernia (CDH) (2)

During the antenatal period: x If ultrasonography confirms the diagnosis, refer the pregnant woman to the 3rd level health facility

Delivery Strategy: In a full term pregnancy spontaneous vaginal delivery is recommended. . Principles of postnatal care: x If unexpected delivery occurs in a low level of care facility, resuscitation must be undertaken and supervised by the most experienced clinician available x Never ventilate with bag and mask, intubate immediately x Establish venous access x Insert a large gastric tube to decompress the stomach and small bowel x Transfer to specialized surgery department x Provide emotional support and reassurance to the mother.

Krisa Van Meurs, Billie Lou Short. Congenital Diaphragmatic Hernia: The Neonatologist's Perspective. Paediatrics in Review. 1999, 20, 79-87.

Slide 6N-11 Major Birth Defect: Oesophageal Atresia

Oesophageal atresia is a severe malformation requiring urgent treatment. Ultrasonography supports antenatal diagnostic. Polyhydramnios is associated in 60% of cases or difficulty detecting the foetal stomach.

If the diagnosis is suggested during the antenatal period the pregnant woman needs to be referred to a special multidisciplinary fetal diagnostic/management team.

At birth if clinical signs are observed such as excessive salivation, breathing difficulties, cough or apnoea, a trial should be made to gently insert a suction catheter or feeding tube (size 8-10F

6N - 7 Effective Perinatal Care (EPC) is adequate) into the stomach before the first feeding, then inject 2 or 3 cm3 of air while listening to the stomach with a stethoscope. If the tube is in the stomach, the sound of air will be heard.

The diagnosis of oesophageal atresia is confirmed if it is impossible to insert the tube into the stomach. Most often only half of the tube can be inserted; when air is pushed in it comes back into the mouth.

A smaller, softer tube may curl up in the upper oesophageal pouch and give a false negative result.

Establish an IV line, and give only IV fluids at maintenance volume according to the baby’s age Insure that the baby is in supine position with the head up (approximately 30 to 60 degrees). Insure free drainage.

The baby should be transported to a level III surgical neonatal unit as soon as possible. Provide emotional support and reassurance to the mother.

Dwayne C. Clark. Oesophageal Atresia and Tracheoesophageal Fistula. American family Physician, February 15, 1999, Vol. 59, ʋ 4.

Slide 6N-12 Major Birth Defect: Imperforate Anus

Imperforate anus is a severe congenital malformation, which may be complicated by intestinal obstruction and requires surgical correction. Imperforate anus is identified during the first complete newborn examination within 2 hours after birth.

In case of imperforate anus, the abdomen can swell; there is an absence of meconium discharge, and vomiting. Some newborns have imperforate anus with fistula, the meconium is discharged in uncommon places: through vagina, perineum, or with urine.

Do not let the baby receive anything by mouth: establish an IV line and give only IV fluids at maintenance volume according to the baby’s age.

Insert a gastric tube and ensure free drainage. Transfer the baby to a tertiary level hospital or to a specialised ward.

Provide emotional support and reassurance to the mother.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

6N - 8 Module 6N

Slide 6N-13 Imperforate Anus

Photograph of a newborn with imperforate anus.

Slide 6N-14 X-ray of a Baby with Imperforate Anus

This x-ray (invertogram) shows there is no air in the rectal canal.

Slide 6N-15 Major Birth Defects: Gastroschisis and Omphalocoele: x Is a defect of the anterior abdominal wall just lateral to the umbilicus which is associated with an evisceration of the gastro intestinal tract x The surface of the bowel is usually oedematous and matted and it is not covered by a membrane x Associated anomalies are reported in up to 15% of cases (mainly gastrointestinal) x Preterm delivery and growth restriction are frequent x Necrotising enterocolitis and malabsorption may occur x Survival rates are about 90%.

Omphalocoele (Exomphalos): x Is a malformation of the abdominal ring of the umbilicus x Covered by a thin membrane of amnion and peritoneum

6N - 9 Effective Perinatal Care (EPC)

x Herniation of abdominal content is variable , the liver could accompany the intestine if there is a large sac, intestine are present if it is a small sac x Associated anomalies are very frequent in 45 – 67% of cases x Survival rates are mainly dependent on the presence of associated anomalies x Necrotising enterocolitis and malabsorption are associated complications.

David E. Hertz. Care of the Newborn: A Handbook for Primary Care. Lippincott Williams & Wilkins, 2005, p. 234.

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003.

Slide 6N-16 Gastroschisis and Omphalocoele

In addition to essential care before referral to a specialised surgical ward: x Provide emotional support and reassurance to the mother x Do not let the baby receive anything by mouth x Establish an IV line , and give only IV fluids at maintenance volume according to the baby’s age x Transfer the baby to a tertiary level hospital or specialised surgical ward x Monitor temperature frequently. Patients with a ruptured exomphalos sac or gastroschisis may have major problems with temperature control due to evaporative heat loss.

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003.

Slide 6N-17 Omphalocoele

Please pay attention that the provider holding the cord clamp in this photo is not wearing gloves thus not practicing universal precautions.

6N - 10 Module 6N

Slide 6N-18 Birth Traumas/Birth Injuries

Birth injuries are mechanical injuries avoidable or inevitable.

Predisposing factors include macrosomia, prematurity, cephalopelvic disproportion, dystocia, prolonged labour and breech presentation as well as instrumental deliveries ( vacuum, forceps) (ENC, 2002, page 108)

Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert, issue 30: Preventing infant death and injury during delivery. July 21, 2004.

Essential Newborn Care and Breastfeeding: Training Module. WHO Euro, Copenhagen, 2002.

Slide 6N-19 Cephalohaematoma

One of the most frequent birth injuries is the cephalohematoma – subperiosteal haemorrhage.

A cephalohaematoma occurs when friction during the birth causes blood vessels to rupture between the periosteum and the skull. The blood accumulates under the periosteum. Unless there is a history of prolonged head engagement, a cephalohematoma is not usually present at birth. Its develops slowly during the first 24 hours of life. A cephalohaematoma is a palpable mass more often in the parietal region; it can be unilateral or bilateral and is limited by the suture lines.

Cephalohaematoma does not need any treatment such as ice, or puncture

The cephalohaematoma will disappear spontaneously and completely by 3 months of age. Be alert for hyperbilirubinemia (late onset) and if there has been significant blood loss, look for, mild anaemia.

Essential Newborn Care and Breastfeeding. Training Module. WHO Euro, 2002

Parker, Leslie A. Advances in Neonatal Care: Part 1: Early recognition and treatment of birth trauma, injuries of the head and face [foundations in newborn care]. December 2005, Volume 6(5), p 288-297.

6N - 11 Effective Perinatal Care (EPC)

Slide 6N-20 Subaponeutrotic (Subgaleal) Haemorrhage

A subgaleal haemorrhage is a potentially severe haemorrhage into a large potential space between the skull periosteum and the scalp galea aponeurosis. The epicranial aponeurosis is a fibrous tissue covering the entire cranial arch. It is a large space (large enough to carry an infant's entire blood volume). Extensive blood loss is possible, and mortality rate is high (22%).

Subgaleal haemorrhage can occur spontaneously but it is more often associated with vacuum or forceps assisted deliveries.

The initial signs of subgaleal haemorrhage are not specific such as generalized scalp oedema and ecchymosis. Important periorbital and periauricular oedema could appear as the haemorrhage progresses. Other signs such as an irritable cry and or cry of pain can be observed, especially when the head is touched.

Most references state there is no definitive treatment . The subgaleal haemorrhage will disappear spontaneously.

In rare cases bleeding may be serious and a blood transfusion may be necessary thus these infants need to be carefully monitored so that clinical signs of anaemic shock can be recognised in time.

Essential Newborn Care and Breastfeeding. Training Module. WHO Euro, Copenhagen, 2002.

Slide 6N-21 Fractured Clavicle

Fractured clavicle is the most common bone trauma in newborns.

Occurs frequently during shoulder dystocia or in breech presentation.

The fracture is easy to diagnose by clavicle palpation which finds typical crepitation, and displacement of fragments. The infant may have restricted active movements on the affected side, with absent Moro reflex but normal biceps reflex. This fracture can be accompanied by limited arm mobility. In some cases the fracture is discovered a few days after birth.

No special treatment; however, if arm movements are painful, the arm could be fixed with a bandage on the newborn’s chest.

Sometimes the fracture is found later after a bone callus is discovered.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

6N - 12 Module 6N

Kaplan B, Rabinerson D, Avrech OM, Carmi N, Steinberg DM, Merlob P. Fracture of the clavicle in the newborn following normal labor and delivery. Int J Gynaecol Obstet. 1998 Oct, 63(1), 15-20.

Slide 6N-22 Fractured Humerus

Clinical signs are variable - the baby could seem normal, or could have pain, or may seem paralyzed.

The diagnosis is confirmed by radiography.

The treatment is immobilisation of the arm.

It is important to check the fingers twice daily: x If the fingers become blue or swollen - remove the bandage and rewrap it more loosely. x If the bandage is rewrapped – observe the fingers for blueness or swelling for an additional three days.

This fracture usually heals very well.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

Slide 6N-23 Fractured Femur

Clinical signs are variable - legs are not moving symmetrically; leg swelling, leg in abnormal position, baby cries when leg is touched.

Fractured femur requires leg immobilization.

It is important to check the toes twice daily: x If the toes become blue or swollen - remove the bandage and rewrap it more loosely. x If the bandage is rewrapped – observe the toes for blueness or swelling for an additional three days.

Train the mother to care for the baby.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

6N - 13 Effective Perinatal Care (EPC)

Slide 6N-24 Splinting Fractured Humerus and Fractured Femur

Pictures of splinting fractured humerus and fractured femur.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

Slide 6N-25 /Arm Palsy

Approximately 45% of brachial nerve injuries are associated with shoulder dystocia.

They are two categories of arm palsy: 1. Erb's palsy (also called Erb-Duchenne paralysis).The arm is in adduction with an extended forearm, internally rotated and pronated. It is the classical "porter's tip" or "waiter's tip" appearance. Bicepital and Moro reflexes are absent on the arm. The sensory function is usually preserved. 2. Klumpke's palsy.The distal part of the arm is paralyzed, hand sensitivity and mobility are affected, palmar grab reflex is absent.

If mobility and sensitivity are not restored within 3 months, newborns need to be referred for specialised treatment.

Selected of Abnormal Arm Posture in a Newborn

Condition Description Klumpke's paralysis/palsy Hand paralysis with possible ptosis (drooping upper eyelid), and myosis (constricted pupil), anhidrosis (decreased perspiration) (Horner syndrome).

Fractured clavicle Crepitation and bone callus ; occasional bruising; possibly restricted active movements with absent Moro reflex on affected side; biceps reflex present

Erb's palsy Restricted active movements and absent Moro and biceps reflexes on affected side; "porter's tip" or "waiter's tip" appearance of upper extremity

Fractured humerus Restricted active movements and absent Moro reflex on affected side, biceps reflex present; crepitus may be felt.

6N - 14 Module 6N

Nik Hemady, Colleen Noble. Newborn with Abnormal Arm Posture. American Family Physician, June 1, 2006, Vol. 73, No. 11.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

Slide 6N-26 Brachial Plexus Injury/Arm Palsy

Photograph of a brachial plexus injury on the right side.

The injured arm lies limply by the baby’s side. The arm is in adduction with an extended forearm internally rotated and pronated.

“Mother and Infant Health Project”, JSI, Ukraine.2004

Slide 6N-27 Facial Palsy

Facial nerve palsy is caused by the compression of the facial nerve during the delivery or due to traumatic forceps delivery. Facial palsy usually becomes visible on the first or second day after birth. On the paralyzed side, the naso- labial fold is evened–out, the corner of the mouth droops and when crying, the mouth is drawn to the normal side. The baby is unable to wrinkle forehead or close eye on affected side

Apply ointment to this eye, 4 times daily and as long as this eye does not close. Teach the mother how to do it.

Newborns with facial palsy can have difficulty attaching to the breast.

Most facial nerve palsies resolve spontaneously within days, although full recovery may require weeks to months.

Referral to a specialised department may be necessary if there is no improvement within 10 days.

Managing Newborn Problems: A guide for doctors nurses and midwives. WHO, Geneva, 2003.

Mamta Fulora, Shelley Kreiter. The Newborn Examination: Part I. Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems. American Family Physician, 2002, 65, 61-8.

6N - 15 Effective Perinatal Care (EPC)

Slide 6N-28 Conclusions

It is important to recognise the malformation that needs urgent referral.

The family of a baby with a birth defect or one recovering from a birth trauma need to be reassured and counselled.

6N - 16 Module 7N

Low-Birth Weight Baby/ Small Baby Care and Feeding Effective Perinatal Care (EPC)

7N - 2 Module 7N

Slide 7N-1. Low-Birth Weight Baby/Small Baby Care and Feeding

Learning Objectives At the end of this module, participants will know: • The definitions for Small Baby, Very Small Baby, Low Birth Weight LBW and Very Low-Birth Weight Baby (VLBW) • The special needs of the small baby/LBW • How to keep the small baby /LBW warm • What additional care is required for the small baby/LBW • Feeding methods for the Small Baby /LBW • The Kangaroo Mother Care Method and its advantages • The criteria for discharging the small baby /LBW from maternity • How to counsel the mother of a small baby/ LBW to care for her baby at home.

Slide 7N-2. Definitions

In the presentation the term “small baby” is used to describe a preterm or Small for Gestational Age because in many case the exact gestational age is not precisely known. Precise gestational age can be defined after birth using the Ballard scale. If the gestational age is known, use it, when possible to guide diagnosis and management decisions. The smaller or more preterm the baby is, the more likely they are to have problems. The “extremely small baby “has a birth weight less than 1,000g.The “very small baby, less than 1,500 g. Both are more vulnerable than bigger newborns and often need to be referred to a special unit for specific care. As it is recommended for all newborns, it is especially important that small or very small babies will be referred together with their mothers to a specialized department. Ideally, this referral to a specialised department should be done “in utero “before the birth. If perinatal care is regionalised, severely preterm deliveries have to be referred to a specialised maternity where the preterm or very small baby will get appropriate care.

There are two categories of small baby/LBW: x Preterm baby with a birth weight between 1,500 g to 2,500 g x Full-term babies, Small for the Gestational Age (SGA) born with a weight less than 2,500g grams. These babies are more mature than preterm babies.

Small babies face many problems: a high risk of infection, feeding problems, breathing difficulties, abnormal body temperature, necrotizing enterocolitis, intra ventricular bleeding, important and prolonged jaundice, anaemia and low blood glucose. Typically, small babies face several problems at once or consecutively.

Essential Newborn Care Course Training Manual (Draft) WHO, Geneva. 2006.

7N - 3 Effective Perinatal Care (EPC)

Slide 7N-3. Small Baby/LBW in the European Region (WHO data 2003)

Why is this problem important? EU countries use the WHO life birth definition: x Live-birth: complete expulsion or extraction from the mother of a product of conception irrespective of the duration of the pregnancy which after separation breaths or shows any other evidence of life. x : complete expulsion or extraction from the mother of a product of conception of at least 22 weeks gestation or 500 g which after separation does not show any signs of life.

Basic Newborn Resuscitation a practical guide ,WHO, Geneva 1997

In EU countries, all newborns born with at least one sign of life are declared “alive” no matter their gestational age and/or birth weight.

NIS countries often still follow another definition of life: children born weighing less than 1,000g are recorded as a late abortion if they died before 7 days of life.

In the countries of the WHO’s European region, small babies are responsible for more than 30% of early neonatal deaths. In order to provide appropriate care to these babies a country should invest considerable funds to teach and implement effective perinatal care. Funding efforts should go to equip special units to care for very small babies <1000g.

Health For All, Database, 2006

Essential Antenatal, Perinatal and Postpartum Care. WHO Euro, 2002

Worldwide the percentage of small babies born in developed countries went up to 7% and more than18% in the developing countries. In developed countries this number is increasing due of the growing number of extremely low birth babies <1,000 g who survive due to improvements in perinatal medicine, including artificial reproductive technologies.

With restricted antenatal and perinatal care in developing countries, the official statistical population data is problematic. Birth registration often contains incomplete or untrue information: sometimes there is no exact information on the child’s gestational age, especially when birth is outside of the maternity.

In developing countries, the births of LBW are often connected to intrauterine growth retardation. The mother’s malnutrition, anaemia and chronic infections during pregnancy are the main factors for intrauterine growth retardation. At the same time in developed countries, the care for LBW makes up an important part of the health care budget and the advanced technological of LBW care influences the improved outcomes. However, it has not influenced the level of neonatal mortality and morbidity in the countries with a limited obstetric base.

7N - 4 Module 7N

Slide 7N-4. Gestational Chart

It is 2 categories for small babies: - A baby born before 37 weeks of gestation with a birth weight less than 2500g - A baby born after 37 weeks of gestation with a birth weight less than 2500g.

The normal duration of a pregnancy is 40 weeks ± 2 weeks. A birth is declared preterm if it occurs before complete 37 weeks gestation or before 259 days from the first day of the last menstruation.

This graph classifies newborns according to their birth weight and to their gestational age. Using this graph you can see the correlation between body weight and gestational age at 26 weeks gestation. The area between the two black lines represents the parameters of normal foetal development. The area under the lower line represents insufficient foetal growth and the area over the upper line represents an “over” development of the baby.

Children under the lower line are classified as “Small for Gestation Age” (SGA). This classification refers to intrauterine growth retardation which could have many causes. Children over the upper line area are classified as “Large for Gestational Age”, such as baby born to diabetic mother. The red dot represents a child born at 34 weeks weighting 2,100g. This baby is classified as “Low- Birth Weight, preterm baby” his/her weight corresponds to his/her gestational age. The green dot represents a child, born at 38 weeks weighting 1,600g. This child is classified as a full-term child “Small for Gestation Age” because his/her weight doesn’t’ correspond to his/her gestational age.

Slide 7N-5. Main Causes of Small Baby Births

Women who smoke during pregnancy give birth to children with a lower weight than those who do not smoke. The probability that smoking women give birth at 32 weeks gestation is 2 times higher compared to non-smoking women. Meta-analysis results of randomized control trials shows that anti-smoking programs during pregnancy help to reduce pre-term deliveries.

Bull J, Mulvihill C, Quigley R. Prevention of low birth weight: assessing the effectiveness of smoking cessation and nutritional interventions: evidence briefing. 2003

Lumley J, Oliver S, Waters E. Smoking cessation programs implemented during pregnancy. Cochrane review. Evidence-Based Nursing 1999; 2:42.

Mother’s higher arterial pressure reduces blood supply to the placenta that in turn reduces supply of nutrients to the foetus and the result is intrauterine growth retardation.

7N - 5 Effective Perinatal Care (EPC)

Edwin Chandraharan, Sabaratnam Arulkumaran. Recent advances in management of preterm labor. J Obstet Gynecol India Vol. 55, No. 2: March/April 2005 Pg 118- 124

Slide 7N-6. Challenges for Caring for the Small Baby

Small babies have a greater risk for illness than those weighing over 2,500g. Some of them are not “sick” but because they are small, they need special care and attention from family and health workers. Small babies stay longer in the maternity and are often referred to specialized care.

Essential Newborn Care Course Training Manual (Draft). WHO, Geneva. 2006

Slide 7N-7. Special Characteristics of the Small Baby

Small babies are often immature and have a limited storage of fat and glycogens thus are more subjected to hypothermia, hypoglycaemia and anaemia.

Jaundice is more severe in the small baby due to the biological immaturity of the liver to conjugate bilirubin.

An immature immune system leads to an increased risk of infections.

An immature thermoregulation system leads to difficulties in maintaining body temperature.

Essential new born care and Breastfeeding PEPC WHO 2002

Slide 7N-8. Preparation for the Birth of a Small Baby

If the birth of a small baby is expected the labour and birth room needs to be specially prepared and heated. Trained health care personnel with resuscitation equipment need to be in the birth room.

The birth room should be warm, ideally 28°ɋ. Warm clothes, diapers, a cap, socks and warm blankets must be ready. A warm incubator should also be prepared if available.

7N - 6 Module 7N

The best way to prevent small baby hypothermia is to ensure immediate skin-to-skin contact with the mother if the baby doesn’t need resuscitation.

If resuscitation is needed, it is recommended to do it under a good radiant heater or in a warm incubator.

Thermal Protection of the Newborn: a practical guide. WHO, Geneva, 1997

European Resuscitation Council Guidelines for Resuscitation. Section 6: Paediatric life support, Resuscitation of babies at birth, 2005:S115-S133

Slide 7N-9. Care for the Small Baby at Birth (1)

1. Implement Universal Precautions: x Always use appropriate hand washing techniques x Use clean clothes (it’s better to use baby clothes from the child’s home ) x Reduce the number of invasive procedures (e.g. examination) x Do all the procedures at once using sterile instruments.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Guideline for hand Hygiene in Health-Care Settings. CDC, MMWR, October 25, 2002/Vol.51/No. RR-16 2. Prevent hypothermia immediately after birth and the first days of life x Small babies often become hypothermic. At birth the normal temperature of a newborn is 36.5 °C - 37.5 °C x Dry baby with warm towels and remove wet towels x Immediately place the baby on the mother’s chest skin to skin x Cover baby’s head and feet; then cover baby and mother with warm blanket x Conduct an immediate assessment of the baby on the mother’s chest x Monitor carefully during the first two hours after birth: every 15 minutes for the first hour and every 30 minutes for the second hour. x To assess the baby, the staff does not need to interrupt skin-to-skin contact. o The breathing rate can be counted by watching the baby’s back, grunting is easy to listen for and the colour should be checked on the face. o The feet should be checked for warmth. This correlates with the baby’s warmth. If the baby’s feet are cold, take the baby’s temperature at that time. o Axillary temperature can be taken while the baby is in skin-to-skin contact with the mother. x Routinely measure the baby’s temperature every 30 minutes for the first two hours after birth with a digital or low reading thermometer

While rooming-in with mother x A small baby needs warm clothes and the head must be covered x Provide extra blankets to mother and baby x Do not use tight swaddling. It makes the baby cold x When a mother provides kangaroo mother care, measure the temperature every 6 hours for 3 days; if stable then measure twice a day.

Thermal Protection of the Newborn: a practical guide. WHO, Geneva, 1997

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

7N - 7 Effective Perinatal Care (EPC)

Slide 7N-10. Care for the Small Baby at Birth (2)

3. Prevent Hypoglycaemia. Hypoglycaemia occurs often among small babies; 15% of preterm babies and 70% of SGA babies develop hypoglycaemia. Mainly because they have a limited storage of glycogen, in addition these babies frequently become hypothermic mobilizing all their glucose stores to maintain their body temperature.

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

A small baby needs to be fed within the first 2 hours of life. If breastfeeding is not possible expressed colostrum/breast milk needs to be given by cup-feeding or gavage feeding. If no feeding method is possible give 10% of glucose solution intravenously based on the baby’s body weight and age.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003

Slide 7N-11 Care for the Small Baby at Birth (3)

Carefully monitor his/her breathing condition in the birth room, and watch for breathing difficulty. Avoid unnecessary procedures. If the baby is not “sick”, do everything possible to keep mother and small baby together.

Strictly reduce biological tests and medical examinations to the strict minimum necessary.

The mother needs to be reassured. Explain the situation with words she can understand. Her baby is small but he/she will develop normally. Stress the importance of early breastfeeding, and reassure her that she has the capacity to breastfeed her small baby.

It is important not to leave the mother and her small baby alone in the birth room. A trained medical caregiver (midwife, neonatologist, paediatric nurse) must stay with them in the birth room.

Small babies often have a difficult adaptation period in the first hours of life. These difficulties can appear quickly and must be managed as soon as possible by trained medical worker.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

7N - 8 Module 7N

Slide 7N-12. Postpartum Care for a Small baby(1)

Mothers should be taught to take the baby’s temperature 3 times a day or how to recognise hypothermia by touching baby’s feet. If the baby’s feet feel cold, check the axillary temperature immediately.

During the stay in the maternity/specialized care department the mothers should be taught to warm their babies with skin-to-skin contact and to maintain this contact as long as possible.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N-13 Characteristics of the Thermoregulation the Small Baby

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

Slide 7N-14. Postpartum Care for a Small Baby (2)

x Rooming-in is extremely important for all newborn, and even more so for the small baby x Rooming-in needs to be implemented if the baby is not in an acute situation x Rooming-in prevents nosocomial infection, supports breastfeeding and bonding x The mother should be counselled in caring for and communicating with her baby x A mother’s care helps the small baby to recover more quickly.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

7N - 9 Effective Perinatal Care (EPC)

Slide 7N-15. Postpartum Care for a Small Baby (3)

Encourage the mother to feed her baby on demand every 2-3 hours. Reassure her that she can breastfeed her small baby and she has enough milk.

Explain that a small baby may tire easily and suck weakly at first, suckle for shorter periods before resting, fall asleep during feeding, have long pauses after suckling and feed longer, and not always wake up for feeds. If necessary, the mother will have to wake a sleepy baby every 2-3 hours for feeding. Changing the baby before the feeding may help the baby be more alert. Long and frequent skin-to-skin contact can enhance breastfeeding.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N-16. Postpartum Care for a Small Baby (4)

Examine the baby daily in the presence of the mother in a warm room. Do not put the baby on a cold surface, and use a heated/warm surface. It’s preferable to assess jaundice in daylight. Look for jaundice on the abdomen the first day then on palms and soles. Ask the mother if she has any questions and/or concerns. It’s important to make the mother confident. The mother should feel the health care personnel is listening to her and respect her concerns and opinions. The mother is the most important care provider for any baby and especially for the small baby.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Slide 7N-17. Postpartum Care for a Small Baby” (5)

If the mother takes care (rooming-in) of her baby herself, the risk of cross- contamination will be reduced. The mother should be taught how to wash her hands. Maternity personnel should designate places for hand-washing (warm water, single-use towels and soap), watch how the mother washes her hands, and offer support. The staff must also implement a strict hand washing policy.

7N - 10 Module 7N

The baby’s cord stump must be kept dry. No bandages, alcohol or antiseptics. Show the mother how to wash the cord stump with soap and water if wet or spoiled with urine or stool. Biological tests should be strictly limited (e.g. blood test) to only what is necessary since they are painful, expensive and increase the risk of anaemia and infection. Do not bath the small baby, wash as needed.

It’s important for relatives to visit the mother and help her. There is good evidence that relatives who are allowed to freely visit the mother and baby in hospital do not increase the risk of infection.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Guideline for hand Hygiene in Health-Care Settings. CDC, MMWR, October 25, 2002/Vol.51/No. RR-16

Slide 7N-18. How to Treat Newborn Hypothermia (1)

It is important that all maternity staff know how to rewarm a hypothermic newborn.

The following are methods for warming a baby and/or preventing him/her to become hypothermic: A. Skin-to-skin contact B. Warm water filled mattresses C. Radiant heaters/warmers D. Incubator.

A. Skin-to-skin contact

Besides the advantages of using this system globally and for long periods of time in the care of newborns when used to care for LBW babies (see Kangaroo care, below), skin-to-skin contact can also be used for shorter periods of time, as a method of thermal protection or for rewarming hypothermic infants.

The infant is kept naked, except for a nappy (diaper) or lightly dressed and held in contact with the skin of the mother, between the mother’s breasts. The mother covers the infant with her own clothes and an added blanket if she wishes. If the mother is wearing clothes, a belt around her waist can help to keep the infant in a good position. This position allows the mother to know immediately when the infant moves and to quickly attend to his/her needs. . This method is appropriate for infants who are breathing regularly, exhibit no signs of cyanosis or severe neurological deficits.

The father or another member of the family should also be encouraged to participate. Infant, mother and father all seem to benefit psychologically when this procedure is used, strengthening the bond among all three.

This method helps mothers to initiate breastfeeding within a half hour after birth. A mother should have access to guidance from trained personnel, for example a health worker or lactation counselor, on the proper positioning of her baby and other breastfeeding management techniques.

7N - 11 Effective Perinatal Care (EPC)

B. Warm water filled mattresses

The heated water-filled mattress is a relatively new method of keeping babies warm. The mattress is placed in the cot/bed and filled with 5 liters of water. An electric heating plate fits into a compartment in the bottom of the mattress and warms the water to 36.5–37°C (97.7–98.6°F). The infant is kept clothed and covered with a blanket in the cot.

Unlike other heating devices dependant on electricity, the mattress can be used for several hours without power after being heated to the optimum temperature. The temperature of water falls very slowly. This device has been tested extensively and functions well as an alternative to incubators, when it not necessary to observe the baby naked.

C. Radiant heaters/warmers

Radiant warmers are overhead heating elements that provide a warm environment by radiant heat transfer and at the same time allow direct observation of and free access to the infant. For short term use, when needed only for a few hours, a 400W radiant warmer placed 50 cm above the baby will be sufficient. Spot lights or bulbs are dangerous because they may burn or may fall on the infant, causing injury. Care using radiant heat care requires expensive equipment and very skilled personnel and is suitable only for sophisticated care centers.

D. Air-heated incubators

Air heated incubators are now widely used to provide a clean, warm environment and control of temperature and humidity and an oxygen supply. Humidity is achieved with a water reservoir. They allow adequate observation of the naked infant and isolation when needed. Newer models are furnished with double walls to maximize their ability to maintain a stable environmental temperature. Two main types of air-heated incubator are available. o One depends on convection for the internal distribution of warmed air, the air currents are produced naturally by the heater in the incubator without the use of a fan. o The other circulates warm air by a fan with a small heating element within the incubator.

Incubators with manual regulation of temperature are safer (automatic devices can be impaired) and more cost-effective.

Because of the need for trained staff, maintenance and back-up support, incubators should only be used in hospitals where such skills are available.

Essential Newborn Care and Breastfeeding , PEPC, WHO/Euro, 2002

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Thermal Protection of the Newborn: a practical guide. WHO, Geneva, 1997

William McGuire, Ginny Henderson and Peter W Fowlie. Feeding the preterm infant. BMJ 2004;329;1227-1230

7N - 12 Module 7N

Slide 7N-19. How to Treat Newborn Hypothermia (2)

Assess readiness to feed every four hours until the baby’s temperature is within the normal range.

If the baby shows signs of readiness to suckle, allow the baby to begin breastfeeding.

If the baby cannot be breastfed, give expressed breast milk using an alternative feeding method.

If the baby is not able to feed at all, give expressed breast milk by gastric tube once the baby’s temperature reaches 35 °C.

Essential Newborn Care and Breastfeeding. PEPC, WHO/Euro, 2002

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003

Slide 7N-20. Feeding Challenges for the Small Baby

A small baby needs many calories to growth but small babies due to their small size have a small gastric capacity, and often an immature suckling reflex and digestive tract.

The solution is frequent small feedings with breast milk, which requires commitment and patience.

The gastric capacity is estimated to be ± 20 ml/kg.

Neutral temperature is the ideal temperature so the body does not to use additional calories to maintain normal temperature.

For a small baby the neutral temperature is 26ºC - 30ºC, depending on her/his weight and gestational age.

A good prerequisite for per os feeding is the child’s capability to coordinate suckling, swallowing and breathing.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Alain Dabadie.Alimentation de l ‘enfant.1999

7N - 13 Effective Perinatal Care (EPC)

Slide 7N-21 Feeding: Quantity and Frequency (1)

Frequent small feedings are recommended.

Monitor weight and quantity of milk in cases of alternative feeding methods.

Signs that the baby is receiving an adequate amount of milk: x The baby is satisfied with the feed x The weight is loss is less than 10% in the first week of life x The baby gains at least 160 g in the following weeks and a minimum of 300 g in the first month x The baby urinates more that 6 times a day after the first day x After the 3rd day of life, the baby’s stool becomes a yellow colour.

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N-22. Feeding: Quantity and Frequency (2)

Assess the quantity of milk the child takes daily. Since the volume of feedings can differ, teach the mother to calculate on a daily basis the amount of milk the baby receives. If the child does not get the adequate amount of milk or is not gaining weight it is necessary to increase the duration and frequency of feedings. The mother is the most patient and concerned person to feed her small baby.

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

7N - 14 Module 7N

Slide 7N-23. How to Feed a Small Baby. Use of Breast Milk Versus Breast Milk Substitute

The nutritional management of preterm infants may have a major impact on their growth and development. Various feeding strategies are available, including the use of expressed mother’s milk, human donor human milk, fortified breast milk, adapted milk formulas and total .

The risk of necrotising enterocolitis is 5- 10% in very low birth weight infants. The mortality rate is consistently as greater than 20%.

The risk of necrotising enterocolitis in the group fed with formula is higher than in group fed with breast milk.

McGuire W, Anthony MY. Donor human milk versus formula for preventing necrotizing enterocolitis in preterm infants: systematic review. Arch Dis Child Fetal Neonatal Ed. 2003;88:11-14.

Essential Newborn Care Course Training Manual (Draft). WHO, Geneva. 2006.

Breast milk is the best for the small baby, preterm milk is richer than term milk. Special formulas for preterm babies do not increase the growth of small baby therefore, they need to be used only if no breast milk is available. If possible never use cow’s milk for feeding the small baby, however if infant formula is not available boil cow’s milk, dilute with boiled water and add sugar (for 100 ml of cow’s milk add 20 ml of boiled water and 10 g of sugar).

Pishva N., Hemmati F. Comparison of Protein, Fat, Sodium and Calcium in the Milk of Mothers of Preterm and Full term Infants. Shiraz E-Medical Journal Vol. 5, No. 4, October 2004

Essential Newborn Care Course Training Manual (Draft). WHO, Geneva. 2006.

Slide 7N-24. Small Baby Feeding Methods

The feeding method for a small baby depends on the maturation of the suckling reflex in relation to gestational age.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

7N - 15 Effective Perinatal Care (EPC)

Slide 7N-25. Breastfeeding a Small Baby (1)

The birth weight of a baby is not always the best criteria to decide if a baby is able to suckle. It is better to use gestational age when deciding which feeding method should be implemented. Breastfeeding a small baby is long and difficult, and the mother needs to be encouraged and told that this will improve over the time and that her milk is the best “treatment “for her small baby The signs of readiness need to be assessed to determine the optimum time for breastfeeding

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

Slide 7N-26. Breastfeeding the Small Baby (2)

Breastfeeding the small baby requires patience and dedication and every support needs to be provided to the mother to help her be successful.

Health care personnel understand it’s not an easy task to breastfeed a small baby but too often due to their busy schedule, they propose alternative methods that are quicker and easier.

The mother has the patience and she is fully attentive to improving the health of her baby. Hospital personnel should support and encourage her in this.

x Make the mother confident in breastfeeding her baby and assure her she has enough milk. x Explain to the mother that her milk is the best food for her baby. x Explain to her that in over the time breastfeeding will become easier x Encourage skin-to-skin contact as this will make breastfeeding easier as well.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Managing Newborn Problems: A guide3 for doctors, nurses and midwives. WHO, Geneva, 2003

7N - 16 Module 7N

Slide 7N-27. Teach the Mother Colostrum/Milk Expression Techniques

Teach the mother how to correctly express breast milk but don’t do it for her. o Use clean containers for milk expression: cup, bowl or jar with a wide mouth o Wash the cup in soap and water and it in the sun to dry. (She can do this the day before) o Pour boiling water into the cup and leave it for a few minutes. The sun and boiling water will kill most of the germs. o When ready to express milk, pour the water out of the cup. (See Appendix A: How to express milk by hand) o Expressed breast milk must be kept in a sterilized, closed container in the coolest place available. It can be kept for 24 hours at 18-20°C in a shady place; for about 72 hours in a refridgerator at a temperature of 4 -5 °C and for about four months in a freezer at a temperature of - 18-20qC. When the milk is defrosted it must not be frozen again.

If the baby doesn’t gain enough weight (at least 15 g/kg daily over three days) tell the mother to express her milk into two different cups in order to collect the richest caloric milk: the hind milk. o Explain to the mother that she should start feeding the baby with the second cup because that contains more calories because its fat content is higher. Then she can give milk from the first cup.

It is also possible to express breast milk directly into the baby’s mouth.

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003

William McGuire, Ginny Henderson and Peter W Fowlie. Feeding the preterm infant. BMJ 2004;329;1227-1230

Slide 7N-28. Alternative Feeding Methods

If the baby is too small or too sick to suckle, alternative feeding methods with expressed breast milk need to be proposed. Cup/ spoon feeding for baby over 30 -32 weeks of gestational age, and gastric gavage for those who are or too sick or those less than 30-32 weeks.

Advantages of cup-feeding in comparison with spoon-feeding: it is easer to feed the baby with a spoon but every time the child empties the spoon he stops suckling.

Spoon-feeding can be replaced with pipette-feeding.

7N - 17 Effective Perinatal Care (EPC)

Essential Newborn Care Course Training Manual (Draft). WHO, Geneva. 2006.

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

Slide 7N-29. Cup Feeding Technique

Train the mother to feed her baby with a cup; Do not feed the baby yourself. The mother should: x Measure the quantity of milk in the cup x Hold the baby in semi-upright is sitting on her lap x Hold the cup to the baby’s lips - rest cup lightly on the lower lip - touch edge of the cup to outer part of upper lip - tip cup so than milk just reaches the baby’s mouth - do not pour the milk into the baby’s mouth x Baby becomes alert, opens his/her mouth and eyes and starts to feed x The baby will suckle the milk, spilling some x Small babies will start to take milk into their mouth using their tongue x Baby swallows the milk. x Baby finishes feeding when mouth closes or when he/she is not interested in taking more

If the baby does not take the calculated amount: - feed for a longer time or feed more often - teach the mother to measure the baby’s intake over 24 hours, not just at each feeding.

Baby is cup feeding well if the required amount of milk is swallowed, if there is little spilling and weight gain is maintained..

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

William McGuire, Ginny Henderson and Peter W Fowlie. Feeding the preterm infant. BMJ 2004;329;1227-1230

Slide 7N- 30. Gavage-Feeding Technique (1)

A gastric tube is inserted through one nostril or through the mouth.

If the child is breathing well insert the thinnest tube through one nostril.

Insert the tube through the mouth if the baby has some breathing difficulties.

Use sterile single-use, plastic tube according to the baby’s weight: • Use tube 5-F or 6-F is the child’s weight is less then 2 kg

7N - 18 Module 7N

• Use tube 8-F if the child’s weight is 2 kg and more

If while inserting the tube, you feel an obstacle, don’t push, instead take the tube out. Try again with a thinner tube and/or in the other nostril.

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N-31 Gavage-Feeding Technique (2)

Gavage feeding needs to be done slowly over 15 minutes. Encourage the mother to have contact with the baby during gavage feeding. Either skin to skin, or holding the baby, or by speaking to and /or and touching him/her . Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Premji S, Chessell L. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams (Cochrane Review), May 2002.The Cochrane library, Issue 1,2004

Slide 7N-32. When to Interrupt Feeding

The signs listed show the baby is not digesting well and the recommendation is to stop feeding until the baby recovers.

Essential Newborn Care and Breastfeeding. WHO EURO, 2002

7N - 19 Effective Perinatal Care (EPC)

Slide 7N-33. Vitamins and Micronutrients for a Small Baby

Breastfed children do not need additional supplementation with Vitamin A.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N-34. Kangaroo Mother Care Method (KMC)

Photos illustrate the KMC method for a small baby

Essential Newborn Care Course Training Manual (Draft). WHO, Geneva. 2006.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N-35. Advantages of the Kangaroo Mother Care Method (1)

KMC is a method of care that provides skin to skin contact with the mother .on a permanent basis.

Many studies have proven the effectiveness of the KMC method for LBW care.

It is a powerful, easy-to-use method that promotes the health and well-being of all newborns, but is especially helpful for preterm babies

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

7N - 20 Module 7N

Slide 7N-36. Advantages of the Kangaroo Mother Care Method (2)

Convince hospital personnal of the benefits of KMC, then train them so they will be confident in counselling the mother to use this form of care.

Slide 7N-37. When the KMC Method Could Be Implemented?

The staff and the mother need to be willing to use this method of newborn care.

The baby needs to be in stable condition with no breathing difficulty. Body temperature should also be stable.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N- 38 How Can the KMC Method Be Implemented?

This method can be used both for LBW and full-term babies but it was initially develop to take care of small babies.

Kangaroo Mother Care (KMC) can be implemented in various facilities and at different levels of care. The implementation of the KMC needs to be facilitated by supportive health authorities at all levels.

KMC does not require additional staff; existing staff should be trained in all aspects of KMC. KMC does not require special facilities but simple arrangements should be implemented.

The ward for KMC should have an open-door policy for family. x Two or four-bed to a room with comfortable beds and chairs for mothers

7N - 21 Effective Perinatal Care (EPC) x Rooms should be kept warm (25-28 °C) x Strict hand washing policy: water, soap, towels should be implemented x Using of home/appropriate clothes for mother and baby(clothes allowing direct skin to skin contact) x Other equipment and supplies o A thermometer suitable for measuring low temperatures < 35°C; o Scales o Basic resuscitation equipment and oxygen where possible; x Record sheets to note daily observations and information about feeding and weight.

Health care personnel must provide practical support and counselling to the mother using the KMC method.

Medical surveillance should be minimal but the baby needs to be completely exanimed at least 3 times a week.

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N-39 Criteria for Discharging a Small Baby

It is very important for a small baby to be discharged from the maternity as soon as possible. Mother and baby will benefit from the family support, and early discharge decreases the risk of nosocomial infection. It should be done when the baby’s health is stabilized: developed suckling reflex, stable temperature and weight gain for 3 consecutive days. The weight is not an absolute criteria for discharge and must not to be a reason to keep a healthy small baby longer in the unit. It is important to take into account the social conditions of the family.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Slide 7N- 40. Home Care Recom- mendations

The baby should be kept in warm but not over warm. The child feels comfortable when his/her body temperature is within the norm. If the body temperature is higher than 37.5 °C he/she has a fever.

Stress prevention of Sudden Infant Death Syndrome which is higher in preterm infants.

Very preterm infants in intensive care nurseries are frequently cared for in the

7N - 22 Module 7N prone position; and the infants and their caregivers become habituated to using this position. Mothers are likely to follow the advice given by physicians and other health care professionals, and advice is more likely to be conveyed during a long hospitalization.

Health care professionals responsible for organizing the hospital discharge of infants from neonatal intensive care units should become more vigilant about endorsing and modelling SIDS risk-reduction recommendations significantly before the infant’s anticipated discharge.

The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. Policy statement AAP. November 2005.

All this information should be carefully explained to the mother before the discharge from the unit and hand-outs be given to her to take home. The staff needs to allocate enough time for this during discharge counselling. It will help the mother to remember if she is given this information in a written document.

Make sure that the mother/relatives understand the information you are giving them. The recommendation is to use checking /open-ended questions, ones that can not be answered by “yes” or “no” such as “ What position does your baby need to sleep in? ’Not this “ Do you know with position your baby should sleep”.

This is another good way to ask a question “Tell me what the normal temperature is for your baby “? Not this “Do you know what is the normal temperature for your baby “?

You do not want to ask question that the mother can just answer yes or no.

Be very precise about the date of the follow up visits.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Kangaroo Mother Care: A practical guide. WHO, Geneva. 2003

Advising mother/family to return to hospital. She should come back immediately, if her baby has: Feeding difficulties (feeds less than 5 times in 24 hours; not feeding at all) or becomes ill.

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. WHO, Geneva, 2006

Slide 7N- 41. Conclusions

The care of small babies over >1,500gin the majority of cases, does not need expensive medical equipment Simple care such as breastfeeding, rooming in and Kangaroo Mother Care (KMC)could very significantly improve the health of a small baby

7N - 23 Effective Perinatal Care (EPC)

HOW TO EXPRESS BREAST MILK BY HAND

x Obtain a clean (washed, boiled, or rinsed with boiling water, and air dried) cup or container to collect and store the milk;

x Wash her hands thoroughly;

x Sit or stand comfortably and hold the container underneath her breast;

x Express the milk; o Support the breast with four fingers and place the thumb above the areola; o Squeeze the areola between the thumb and fingers while pressing backwards against the chest; o Express each breast for at least four minutes, alternating breasts until the flow of milk stops (both breasts are completely expressed).

x If the milk does not flow well: o Ensure that the mother is using the correct technique; o Have the mother apply warm compresses to her breasts; o Have someone massage the mother’s back and neck.

Managing Newborn Problems: A guide for doctors, nurses and midwives. WHO, Geneva, 2003; C-15-16.

7N - 24