0 50 100 150 200 250
1960 1970 1980 1990
48 20
2000 2004 2008 2012 2015
Mortality rate per 1000 live births Neonatal mortality
Global mean under-5 mortality rate
Target for MDG 4 (32)
Fig. 73.1 Global progress towards Millennium Development Goal 4 for child survival. (Source: Lawn J.E. Newborn survival in low resource settings – are we delivering? BJOG 2009; 116 (Suppl. 1): 49–59; updated 2014 for data to 2012.)
Key point
Globally, every year there are:
• 135 million births
• 6.6 million deaths at age <5 years
• 3 million neonatal deaths (first 28 days).
0–5 5–15 15–30 30–50 Neonatal mortality per 1000 live births
No data
3
2 1
6 5
4
9
10 8
7 Nine countries with NMR ≥40
Central African Republic (40.9) Mali (41.5)
Pakistan (42.2) Democratic Republic of the Congo (43.5) Lesotho (45.3) Angola (45.4) Guinea-Bissau (45.7) Somalia (45.7) Sierra Leone (49.5)
Ten countries with highest neonatal death numbers 1 India (779,000) 2 Nigeria (267,000) 3 Pakistan (202,400) 4 China (157,400) 5 Democratic Republic of the Congo (118,100) 6 Ethiopia (87,800) 7 Bangladesh (75,900) 8 Indonesia (72,400) 9 Angola (41,200) 10 Kenya (40,000)
Fig. 73.2 Variation between countries in neonatal mortality rate in 2012. (Adapted from Lawn J.E. et al. Every newborn: survival and beyond. Lancet 2014; 384: 189–205.)
Global neonatology 171 Deaths from neonatal tetanus have declined rapidly due to
improved coverage of maternal tetanus toxoid immunization and improved hygiene at birth especially cord care practices. However, slower progress has been made in reducing deaths and disability from other infections, complications of childbirth or preterm birth.
Timing of newborn deaths
The birth of a baby should be a time of celebration, yet all too often it is a time of tragedy. The risk of dying during labor or the first day of life is high. Globally, every year, one million newborns (36% of all neonatal deaths), and 125 000 mothers (nearly half of maternal deaths) die and there are 1.2 million stillbirths during this short time‐period.
Birth and the early neonatal period are also a time of high risk for neurologic injury resulting in long‐term impairment.
Maternal health and obstetric care
Maternal health and obstetric care have a substantial impact on reducing neonatal morbidity and mortality. The following are pri- orities to achieve this:
• Before conception:
– Reduce barriers to family planning – delaying first pregnancy to at least 18 years of age and 3‐year birth intervals are proven health strategies for mother and baby.
– Optimize maternal nutrition – including calories, protein, iodine, folic acid, iron.
– Optimize prevention and treatment of infections – malaria, tetanus and sexually transmitted diseases such as syphilis and HIV (see Chapter 43, Viral infections).
– Optimize management of chronic conditions, e.g. hypertension, diabetes.
• During pregnancy:
– Improve coverage of key interventions, such as mosquito nets and prophylaxis for malaria.
– Improve quality and uptake of antenatal care.
– Improve detection and management of complications of preg- nancy, including maternal infections and hypertensive disorders.
• During labor and delivery:
– Ensure skilled attendants at all births, including essential equipment and logistical support.
– Appropriate use of antenatal steroids for preterm labor.
– Timely management of complications for mother or baby.
Worldwide, 70% of all births are with a skilled birth attendant, but in some countries, such as Ethiopia, Niger, Chad and Sudan, this is not achieved in three‐quarters of births. Improved access to skilled attendants and referral pathways to health facilities equipped to deal with obstetric emergencies is urgently required.
Both participatory women’s groups offering peer counseling and community mobilization (Fig. 73.4) and home‐visit packages by
Sepsis
15%
5%
Preterm 36%
23%
Congenital
10%
Other
8%
Intrapartum
Pneumonia Diarrhea 1%
Tetanus 2%
Fig. 73.3 Cause of neonatal death distribution in 194 countries in 2012.
(Source: Lawn J.E. et al. Every newborn: survival and beyond. Lancet 2014; 384: 189–205.)
Fig. 73.4 Women’s group meeting in Nepal. Participatory women’s groups have been shown to reduce neonatal deaths in rural high‐mortality settings. (Courtesy of Save the Children. Photographer Joanna Morrison.)
Question
In HIV infected mothers, what PMTCT (prevention of mother‐to‐child transmission) interventions should be undertaken in resource‐limited settings?
Without intervention, the risk of perinatal transmission is 20–45%.
It occurs in utero, peripartum and postnatally via breast‐feeding.
In 2013, the WHO recommended universal, lifelong combination antiretroviral therapy for all pregnant women or at least until breast‐feeding has ceased, aiming to suppress maternal HIV viral load and minimize transmission to the infant.
Countries need to either promote breast‐feeding and provide antiretroviral therapy or provide safe nutrition with formula, depending on the degree of increased risk of mortality from gastroenteritis and pneumonia associated with formula.
In resource-poor countries, exclusive breast‐feeding in combination with antiretroviral therapy for the newborn (for a minimum of 6 weeks) is recommended for first the 6 months.
Thereafter, complementary foods, continuing to breast‐feeding until 12 months of age.
Formula‐fed infants should also receive antiretroviral therapy for 6 weeks, to prevent transmission from exposure during delivery.
community health workers, during pregnancy and after birth, have been shown to provide an opportunity to empower women to have better outcomes for themselves and for their newborns.
Newborn care in low‐resource settings – what works?
It is estimated that over 1 million lives could be saved each year even with simple care that can be provided outside hospitals and does not require intensive care or high‐tech machines.
Care around the time of birth
Newborn survival would be improved if:
• Skilled birth attendants were not only present at birth but able to provide care not only for the mother but also for the newborn, including basic resuscitation with a bag and mask and recognition of infants needing additional care.
• Essential newborn care was provided (Table 73.1):
– Infection control – hand‐washing of the birth attendant, clean delivery surface, clean cutting and tying of cord and ongoing cord care (with application of chlorhexidine) to prevent neonatal infections, including tetanus.
– Adequate thermal care – including drying the baby at birth, keeping warm with skin‐to‐skin contact, having a warm environ- ment, covering the baby, including the head, and delaying bathing.
– Early and exclusive breast‐feeding – starting within 1 hour of birth and avoiding any formula milk. Exclusive breast‐feeding plays a crucial role in prevention of infection and should be strongly encouraged in all countries (Fig. 73.5). Breast milk is especially important for low‐birthweight infants.
– Early detection of problems and appropriate care‐seeking.
Education of mothers and communities on ‘danger signs’, but care‐seeking may be impeded by cost, distance or, in some cul- tures, by strong pressure on mothers and newborn babies not to go outside their home for the first 4–6 weeks. In addition, the hospital or health facility must be able to provide quality care
for sick babies. When this is not available, home‐based treatment may be an alternative. Several studies in South Asia have shown that treatment of infections with antibiotics by injection can be provided at home by community health workers, with reduction of 30% or more in neonatal deaths.
Hospital‐based care
Hospitals should be able to provide safe, quality care for sick or small newborns, a key priority for improving newborn survival and health. This includes:
• Health‐care professionals specifically trained in providing newborn care.
• Neonatal resuscitation available.
• Up‐to‐date, evidence based guidelines for common conditions.
• Measures for infection control practiced, e.g. hand hygiene and sterile procedures, equipment cleaned.
• Thermal regulation – warm delivery room, skin‐to‐skin policy, clothing and hats for babies. Other warming devices such as radiant heaters, incubators or warming mattresses are used appropriately and maintained.
• Feeding support for mothers of preterm babies and supplemental feeding – help for mothers to express milk, cup feeding, gavage (nasogastric) tube feeding if needed.
• Intravenous (IV) fluids, closely monitored.
• Antibiotic treatment for babies at increased risk or signs of infection.
• Management of jaundice.
(a) (b)
Fig. 73.5 Examples of the promotion of breast‐feeding: (a) Nepal;
(b) Oman. (Courtesy of Dr Saleh Al‐Khusaiby.)
Key point
• Breastmilk offers major health benefits to infants compared to formula milk.
• The promotion and marketing of infant formula milk is restricted by the International Code of Marketing of Breast Milk Substitutes (WHO, UNICEF).
Fig. 73.6 Kangaroo mother care for a preterm newborn. (Photo courtesy of Save the Children, South Africa.)
Global neonatology 173
• Kangaroo mother care – provided continuously by mothers for stable preterm babies (Fig. 73.6). This is a cost‐effective interven- tion which improves thermal care, breast‐feeding and bonding and reduces infection and neonatal mortality in low‐ and middle‐
income countries. Allows limited staff resources to be focused on the sickest babies. Often limited by lack of space.
• Respiratory support – oxygen, aminophylline or caffeine for apnea, bubble CPAP (continuous positive airway pressure) or other forms of non-invasive respiratory support. Artificial ventilation may be appropriate in some settings with well‐functioning neonatal
units able to provide basic respiratory support, but requires a high level of resources.
• Supportive care, e.g. control of seizures in hypoxic–ischemic encephalopathy.
• Monitoring, including oxygen monitoring with pulse oximetry – blindness from retinopathy of prematurity has been reported in many middle‐income countries affecting relatively mature infants from use of excessively high concentrations of oxygen without appropriate monitoring.
Further reading and resources
• The Lancet Every Newborn series 2014.
• Health Newborn Network Topic Resources: http://www.
healthynewbornnetwork.org/topics Question
What role can doctors and neonatologists in developed countries play in improving global newborn health?
They can help by:
• Advocacy – promoting newborn care in resource‐poor countries.
• Assisting with training courses for health professionals in resource-poor countries e.g. Helping Babies Breathe (neonatal resuscitation), ETAT+ (Emergency Triage, Assessment and Treatment plus Admission).
• Participating in one of the many collaborative programs or partnerships. These need to be appropriate for local conditions, but still retain scientific rigor and be evidence based. Programs must also be aligned to local and national strategy.
Question
Why is neonatal mortality in resource‐poor countries not declining rapidly?
Many reasons, including:
• Improving maternal care – maternal nutrition, health and educa- tion, and care antenatally, during labor and delivery, all of which markedly affect the newborn – is complex and takes time.
• Essential newborn care following birth – often not provided;
indeed, in some countries, newborn care practices following hone births are harmful, e.g. delay in initiating breast‐feeding, early bathing which results in hypothermia, cutting the cord with dirty implements (Table 73.1).
• Early recognition of illness in newborn infants – often difficult and illness progresses rapidly – urgent transfer from home or health center for effective hospital care requires a responsive, integrated health system.
• Inadequate hospital care for sick or preterm infants – health professionals insufficient in number and not trained in neona- tology, equipment not available or not maintained, poor facilities that are often hot and cramped.
• Insufficient focus on and investment in newborn‐specific nursing skills.
• Neonatal care is wrongly considered too ‘high‐tech’ and diffi- cult to provide.
• Many doctors, including some pediatricians, lack interest and experience in newborn care.
• Lack of data on newborn health outcomes; contributes to lower visibility and investment and political will for improvement.
Table 73.1 Summary of survey of newborn care in rural Nepal before 2002, when the neonatal mortality was 50/1000 live births. By addressing these and other issues, neonatal mortality declined to 24/1000 in 2012.
90% Gave birth at home
6% Skilled attendant at delivery
11% Alone at delivery
33% Cord cut with household sickle
64% Wrapped baby only at 30 minutes of age
92% Bathed in first hour (high risk of hypothermia)
99% Breast‐fed
Adapted from Osrin D. et al. Cross sectional, community based study of care of newborn infants in Nepal. BMJ 2002; 325: 1063.
Neonatology at a Glance, Third Edition. Edited by Tom Lissauer, Avroy A. Fanaroff, Lawrence Miall and Jonathan Fanaroff.
© 2016 John Wiley & Sons, Ltd. Published 2016 by John Wiley & Sons, Ltd.
The need for neonatal transport is increasing with centralization of specialist services. Infants must be moved to the right place, by the right team, by the right mode of transport.
Infrastructure
• Specialized trained teams.
• Dedicated equipment (Fig. 74.1).
• A ‘transport hotline’ – providing efficient referral process, advice and bed locator (if available).
• Contracts and protocols for transport – ambulance, helicopter, fixed‐wing airplane.
• Insurance liabilities to cover adverse events.
• Outreach training for less specialized units.
Why transfer?
• Uplift in care level, e.g. extreme prematurity, unstable term infants.
• For subspecialty care – cardiology, surgery, etc.
• Transport back to referral hospital after specialist care.
Equipment
• Transport incubator or lightweight Baby Pod.
• Airways – mask, oro- and nasopharyngeal tracheal tubes.
• Respiratory support – ventilator, CPAP, air, oxygen, nitric oxide.
• Full ICU monitoring.
• IV access – cannulae, syringes, infusion pumps.
• Hand‐held blood testing – glucose, electrolytes, hemoglobin, blood gases.
• Power source – available in ambulance, aircraft or hospital.
Battery for transfers between power supply.
Equipment is heavy – needs handling skills and special equip- ment to assist.
Documentation
• Use standardized clinical assessment and treatment records.
• Necessary for debriefing, audit, legal records.
The ACCEPT principle is a comprehensive system to ensure that all aspects of the transfer process are managed optimally:
A – Assessment
• Determine the appropriate destination for the identified specialist care needs.
C – Taking Control of the situation and Communication with all teams involved
These include transport team, receiving unit and subspecialists.
Ideally done through central coordinating center using call con- ferencing facilities.
Initial communication:
• Record all clinical details necessary to plan the retrieval.
• Give appropriate advice for stabilization and ongoing care:
– ensure that vital signs, laboratory tests and blood gases are up‐to‐date and appropriate
– request respiratory support, vascular access, infection treatment, specialist care for cardiac or surgery to be initiated if necessary.
• Ask referring hospital to prepare:
– full documentation of pregnancy, birth and postnatal course;
radiographs; laboratory results; vitamin K status – names of baby and parents and contact details – maternal blood for cross‐match.
• Record exact location of patient, city, hospital, ward.
• Estimate arrival time and inform referring hospital.
• Provide ongoing contact number for clinical advice from specialist if needed.
E – Evaluation of the infant to be moved.
On arrival of transport team:
• Ensure detailed handover of patient’s condition.
• Review current treatment and management.
Before transport, the infant should have:
• normal temperature (except during therapeutic hypothermia)
• secure airway and breathing
• IV access – two lines preferably if critically ill
• gavage (naso‐/orogastric) tube
• optimized blood pressure, circulation, urine output – consider arterial access
• optimized blood results – glucose, electrolytes, complete blood count (CBC), blood gases, etc.
• immediate treatment given, e.g. antibiotics, transfusion, prosta- glandin (Prostin), anticonvulsants as appropriate.
• further specialized treatment started if required, e.g. active or passive cooling.