WHO/FRH/MSM/96.13
Distr. General

 

Division of Reproductive Health (Technical Support)
Maternal and Newborn Health / Safe Motherhood

 

Essential Newborn Care

 

Report of a Technical Working Group
(Trieste, 25-29 April 1994)

 


ABSTRACT

This report summarizes the discussions of the Technical Working Group on elements of essential newborn care at home, health centre and hospital. It focuses on interventions for a live-born infant.

The document presents simple and effective interventions that are available and affordable, most of them at almost no cost, at all three levels of care.

Each of the interventions has been, or will be, described in more detail in separate documents.

Despite the simplicity of the interventions, recommendations may vary according to local conditions. Therefore this document should be used as a guide for action after adaptation.

(c) World Health Organization, 1996

This document is issued by the World Health Organization (WHO) for general distribution. All rights are reserved. Subject to due acknowledgement to WHO, this document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, provided that such is not done for or in conjunction with commercial purposes and provided that, if it is intended to translate or reproduce the entire work, or substantial portions thereof, prior application is made to the Maternal and Newborn Health/Safe Motherhood unit, World Health Organization, Geneva, Switzerland.

The views expressed in documents by named authors are solely the responsibility of those authors.


Contents

INTRODUCTION

PROCEEDINGS

Essential interventions

Cleanliness
Thermal protection
Early and exclusive breast-feeding
Initiation of breathing, resuscitation
Eye care
Immunization
Management of newborn illness
Care of the preterm and/or low birth weight newborn

Congenital anomalies

Traditional practices

Examination of the newborn infant

Investigation of a neonatal death

Summary table of essential newborn care

Additional reading

List of participants


INTRODUCTION

Of 8.1 million infant deaths in 1993, almost half (3.9 million, 48%) were neonatal deaths. While infant mortality has been decreasing steadily all over the world, changes in neonatal mortality have been much slower. Almost-two thirds (2.8 million) of newborn deaths were within one week of birth, and deaths of many babies after the first week were also due to perinatal causes. The major causes of neonatal mortality are listed in Table 1.

Table 1: Causes of neonatal deaths in developing countries (1993)

Cause of death

Number of newborn deaths

Proportion of all newborn deaths (%)

Birth asphyxia

840 000

21.1

Birth injuries

420 000

10.6

Neonatal tetanus

560 000

14.1

Sepsis, meningitis

290 000

7.2

Pneumonia

755 000

19.0

Diarrhoea

60 000

1.5

Prematurity

410 000

10.3

Congenital anomalies

440 000

11.1

Others

205 000

5.1

Total

3 980 000

100.0

In 1993, 42% (1.7 million) of all newborn deaths were due to infections (neonatal tetanus, sepsis, meningitis, pneumonia, diarrhoea). Two-thirds of those infections were related to the birth process. Neonatal tetanus causes more than half a million of these deaths (14% of the total). Increasing coverage of pregnant women with tetanus toxoid can and does reduce neonatal tetanus deaths but babies may still die of other bacterial infections caused by lack of hygiene at birth and during the newborn period. Women and infants delivered at home without a trained birth attendant and without precautions of hygiene are particularly at risk.

In developing countries around 3% of newborns suffer mild to moderate birth asphyxia, and an estimated 840 000 newborns died of this cause in 1993 (25% of birth-related deaths). An equal number of survivors suffer brain damage. Although prompt resuscitation after delivery can prevent many of these deaths and disabilities, it is often not initiated or the procedures used are inadequate or wrong.

Few data are available on the incidence of hypothermia for home and institutional births and almost no data exist on how many newborn deaths are due to hypothermia. Existing evidence show that hypothermia contributes significantly to deaths of low birth weight and pre-term infants. Taboos that discourage touching the baby before delivery of the placenta or preparing clothes/wraps before birth contribute to hypothermia.

The proportion of babies who are breast-fed is high in all regions of the world but there are wide variations in the duration of breast-feeding. Sub-optimal breast-feeding practices are still the norm in most countries. Failure to give newborn infants colostrum is a common example of bad practice. Lack of exclusive breast-feeding substantially increases the risk of poor newborn and childhood outcome.

In many countries where the prevalence of sexually transmitted diseases is high and where prophylaxis is not widely practised, ophthalmia in newborns is a common cause of blindness. Blind infants are also at increased risk of dying.

About 19% or almost 24 million of all infants are born with a birth weight less than 2500 g, which is classed as low birth weight (LBW). LBW is probably the single most important factor in neonatal mortality, as well as being a significant determinant of post-neonatal mortality and childhood morbidity. LBW can be caused by many factors, and these modifiable factors are targeted for intervention by the Safe Motherhood Programme. Major contributors to the death of LBW infants are prematurity, infections, birth asphyxia, hypothermia and inadequate feeding.

Around 755 000 newborn infants die of pneumonia. While some of these infections have their origin in labour and delivery, others are acquired postpartum. Lack of hygiene, hypothermia and inadequate feeding are important risk factors. Signs of pneumonia in a newborn are subtle and often remain unrecognized until it is too late.

An unknown proportion of newborn deaths is due to neglect of the female newborn infant. An unknown number of female newborns are left to die because they are unwanted.

The majority of newborn problems are specific to the perinatal period. They cause not only deaths but also substantial morbidity and disability. These problems are the result of poor maternal health, inadequate care during pregnancy, inappropriate management and poor hygiene during delivery, lack of newborn care and discriminatory care. If a mother dies during childbirth, her baby will have an even smaller chance of survival. Death among newborn infants is so frequent that it is accepted as routine by many families and community members. In some societies a child is named only if she or he survives the critical neonatal period.

Newborn deaths cannot be substantially reduced without efforts to reduce maternal deaths and improve maternal health. However, care during pregnancy and delivery must be accompanied by appropriate care of newborns and measures to reduce newborn deaths due to postnatal causes such as infections (tetanus, sepsis), hypothermia and asphyxia. Most postnatal deaths are caused by preventable and/or treatable diseases. Preventive interventions are simple, inexpensive, available and cost-effective.

Almost two-thirds of births in developing countries occur at home and only half are attended by a trained birth attendant (Table 2). Strategies to reduce newborn deaths should therefore also target traditional birth attendants (TBAs), families and communities as well as health workers within the formal health care system.

Table 2: Births by region, place and attendance at birth (1993)

Region

Births (in thousands)

At home

By trained person

Neonatal deaths
(in thousands)

 

Number

%

%

%

Number

%

World

142 000

100%

56%

60%

4 150

 

Developed (1)

17 000

12%

5%

99%

170

4%

Developing

125 000

88%

63%

55%

3 980

96%

Africa

28 000

20%

66%

42%

   

Asia

85 000

60%

67%

56%

   

Latin America

12 000

8%

34%

76%

   

(1) In developed countries it is assumed that neonatal mortality is 10/1000 live-births

In 1994, WHO convened a Technical Working Group to define essential newborn care at three levels of care (at home/in the family, at the health centre and at the first referral level, a district hospital). The aims of the meeting were:

This document presents the summary of the meeting and the recommendations designed to assist health planners and programme managers in developing countries to improve newborn health at the health centre and district hospital and to plan IEC activities at the community level. They will have to be adapted to country-specific guidelines.

The World Health Organization welcomes comments and feedback from users of this document and will use such comments in the preparation of the new edition of this and other documents. Please send comments to the Maternal and Newborn Health/Safe Motherhood unit, World Health Organization, 1211 Geneva 27, Switzerland.


PROCEEDINGS

Essential interventions

There are striking variations from place to place in the patterns of care and interventions that newborn infants receive. In many cases there is a lack of knowledge of what is needed for optimal newborn care. Modern hospital practices and traditional ones neglect the basic needs of newborns: warmth, cleanliness, breast milk, safety and vigilance.

Most newborn deaths can be avoided by both preventive measures (such as clean delivery) and by effective management of complications (such as resuscitation, management of infections). Other interventions also have important preventive effects (thermal protection, breast-feeding, eye care to reduce blindness).

Interventions that improve maternal health will have a major impact on the health of newborns. The knowledge should be translated into practices of health workers who deliver babies at home, at health centres and in hospitals.

The essential newborn care interventions are:

  1. Cleanliness: clean delivery and clean cord care for the prevention of newborn infections (tetanus and sepsis)

    Clean delivery and clean cord care can be ensured everywhere: in health facilities by policies and practices for prevention, detection and control of nosocomial infections; in home deliveries by strengthening standards of cleanliness by using disposable delivery kits. A complementary strategy to reduce neonatal tetanus is immunizing pregnant women with tetanus toxoid.

  2. Thermal protection: prevention and/or management of neonatal hypothermia and hyperthermia

    Simple measures such as a warm room for delivery, immediate drying of the baby and skin-to-skin contact with the mother can prevent loss of body warmth. Birth attendants and families need instruction on how to rewarm babies that become hypothermic.

  3. Early and exclusive breast-feeding

    Breast-feeding should be started within an hour of birth. Feeding should be as frequent as the baby demands, without prelacteal feeds or other fluids and food. Knowledge about the importance of breast-feeding should be disseminated among families and communities as well as health workers and managers.

  4. Initiation of breathing, resuscitation

    Birth asphyxia should be recognized promptly and management should follow the basic principles of resuscitation: aspiration of mouth and nostrils, end ventilation with positive pressure.

  5. Eye care: prevention and management of ophthalmia neonatorum

    Eye prophylaxis involves cleaning the eyes immediately after birth and applying either silver nitrate drops or tetracycline ointment within the first hour of birth. There must be early diagnosis and management of ophthalmia.

  6. Immunization

    At birth BCG, OPV-0 and Hepatitis B vaccines are recommended by WHO.

  7. Management of newborn illness

    Major newborn illnesses should be recognized early both at home and at the health centre so that the baby can be referred to hospital for management.

  8. Care of the preterm and/or low birth weight newborn

Additional warmth, cleanliness, and nutrition, early recognition and management of diseases.

The above interventions are effective in reducing deaths and diseases in any newborn. They can be divided into basic care and special care.

Basic care means interventions for all infants to meet their physiological needs: prevention of infections due to uncleanliness at birth and later; preservation of warmth and prevention of hypothermia; appropriate nutrition by early, exclusive and frequent breast-feeding; initiation of breathing by resuscitation when needed. Basic newborn care assures survival of those that are born well-equipped to survive (term, well-grown newborns without malformations) and give good start for preterm and small newborns.

Special care is required for a small group of newborns because of diseases acquired before, during or after birth and/or because they were born too soon and/or too small.

Management of sick newborns includes early recognition and management of newborn diseases, management of hypothermia and selected other conditions specific for the early newborn period. Preterm and/or low birth weight infants need more attention and care. Early detection of problems requires vigilance and skills for observing and assessing/examining newborns.

Each neonatal death should be investigated, not only for bio-medical causes but other circumstances that led to the death. The findings should be used to improve practices.

Congenital anomalies are more common at birth than at any other time of life. Many are lethal and not susceptible to interventions. Others require sophisticated corrective surgery, not available in most places. Only few are amenable to public health interventions.

Recommendations for these good practices for newborn care at three levels - home, health centre and referral hospital - are based on available scientific evidence or, in the absence of such evidence, on best clinical judgement. Details will be available in separate guidelines for each of the interventions. However, global guidelines for good practices need to be adapted to local conditions and traditional practices before they can become the operational standards for newborn care in a country. Such changes will have to be incorporated into training materials for health care providers. At the end of the process, each health facility should have written policies on newborn care and staff trained in the skills necessary to implement them.

Recommendations for care at the peripheral level and for home delivery are based on the assumption that a single trained birth attendant is available for a non-complicated delivery. If complications develop, they must make it clear how to divide priorities between mother and baby.

Two-thirds of babies in developing countries are born at home and the others are discharged from health facilities soon after birth. All birth attendants should be familiar with the basic principles of preventive newborn care and should be able to recognize danger signs. Health facilities must be the first to adopt good clinical practices since they set examples of good practice for communities. Nevertheless, education of the birth attendants who deliver babies and look after them at home is very important. Health workers need guidance on how to change family behaviour regarding both newborn care at home and care-seeking.

 

Cleanliness, clean delivery and cord care for the prevention of newborn infections (tetanus and sepsis)

Clean delivery and cord care means observing principles of cleanliness throughout labour and delivery and after birth until the separation of the cord stump. Principles of cleanliness at birth are:

The hands of the birth attendant must be washed with water and soap, as well as the perineum of the woman. The surface on which the baby is delivered must be clean. Instruments, gauze and ties for cutting the cord should be sterile. Nothing should be applied either to the cutting surface or to the stump. The stump should be left uncovered to dry and to mummify.

Principles of cleanliness are as essential in health facilities as they are at home. In addition to hygiene during delivery - clean hands, clean environment, sterilized/disinfected equipment and supplies - these principles include special measures for newborns to prevent hospital infections - rooming-in, prevention of overcrowding, provision of clean water and washing of hands by health personnel. Institutional policies need to define methods for prevention, detection and control of nosocomial infections.

There is an abundance of traditional practices for cutting the umbilical cord. Many of them are harmful. Those that observe the principles of cleanliness can be preserved but others must be changed. For home deliveries, the use of simple disposable delivery kits will help in achieving as clean a delivery as possible. The kit should contain, as a minimum, a nail cleaning stick, a small piece of soap for clean hands and clean perineum, a plastic sheet of about 1 x 1 m to provide a clean surface, and a sterile razor blade, ties and gauze for the clean cutting and care of the umbilical cord. All the materials should be packed in a sealed plastic bag with instructions on how to wash hands thoroughly before delivery and again before handling the baby's umbilical cord, and how to use other items in the package. The best means of producing, distributing and promoting the kits to pregnant women should be determined locally. One option is the local assembly of disposable delivery kits by women's groups.

The cord stump remains the major means of entry for infections after birth. Principles of clean cord stump care (keep it dry and clean and do not apply anything) apply at home as well as in the health facility. The stump will dry and mummify if exposed to the air without any dressing, binding or bandages. It will remain clean if it is protected with clean clothes and is kept from urine and soiling. No antiseptics are needed for cleaning. If soiled, the cord can be washed with clean water and dried with clean cotton or gauze. Local practices of putting various substances on the cord stump - whether in health facilities or homes - should be carefully examined. They should be discouraged if found harmful and substituted with acceptable ones.

If the umbilical stump is draining pus, the skin around it is becoming red and it has a foul smell, these are signs of an umbilical infection that requires treatment with antibiotics. If the baby stops suckling well, is sleepy, does not wake up or is having difficulty breathing, this may be a sign of serious infection. The baby must be referred immediately to the hospital for proper treatment.

Infections acquired after birth need special attention. They can be prevented by clean practices, clean delivery and cord care, early and exclusive breast-feeding, rooming-in, thermal protection by early skin-to-skin contact, and eye care. Maintaining the mother-infant contact that was established immediately after birth favours colonization of the infant's skin and gastrointestinal tract with the mother's microorganisms, which tend to be non-pathogenic and against which the mother has antibodies in her breast milk. The infant is thus simultaneously exposed to and protected against the organisms for which active immunity will be developed only later in life. There are a number of ways to organize rooming-in to allow a mother free and easy access to her infant, whether the infant shares the mother's bed or is in another bed in the same room. In health facilities where mothers and babies are separated, babies are often kept in nurseries where they share equipment and supplies. Here they may be exposed to microorganisms of the hospital staff which are more pathogenic, are often resistant to many antimicrobial drugs and for which breast milk contains no specific antibodies. Keeping babies with mothers, and having mothers taking care of them, eliminates the danger of cross-infections.

 

Thermal protection: prevention and/or management of neonatal hypothermia and hyperthermia

The normal body temperature of the newborn infant is 36.5 - 37.5 oC. Hypothermia occurs when the body temperature drops below 36.5 oC. The newborn infant is most sensitive to hypothermia during the stabilization period in the first 6 - 12 hours after birth, although hypothermia may occur at any time if the environmental temperature is low and thermal protection inadequate. The newborn has a relatively large surface area, poor thermal insulation, a small body mass to produce and conserve heat, little ability to conserve heat by changing posture and no ability to adjust its own clothing in response to thermal stress. Hypothermia can easily occur if a newborn infant is left wet and unprotected from cold while waiting for the placenta to be delivered. Hypothermia can occur after birth even at moderate environmental temperatures when babies are not well protected or because of practices such as bathing the newborn. As the body temperature decreases, the baby becomes less active, lethargic, hypotonic, sucks poorly and the cry becomes weaker. Respiration becomes shallow and slow and the heart-beat decreases. Sclerema - hardening of skin with redness - develops mainly on the back and the limbs. The face can also become bright red. As the condition progresses it causes profound changes in body metabolism resulting in impaired cardiac function, haemorrhage (especially pulmonary), jaundice and death.

The principles for preventing hypothermia in newborn infants require delivery of the baby in a warm room, drying it thoroughly after birth, wrapping it in a dry warm cloth while keeping it out of draughts on a warm surface and giving it to the mother as soon as possible. The baby's mother is the best source of warmth. Early skin-to-skin contact for the first few hours after birth is more than just a measure for preventing hypothermia; it provides warmth, enables early breast-feeding and prevents hypoglycaemia.

If separated from its mother, a newborn baby needs to be well protected from cold and/or heat. Swaddling is not a good way to keep babies warm. If the cloths are wrapped tightly round the baby, there is little air trapped between the body and the cloth and the cloth itself does not provide sufficient insulation. A better way of protecting babies is to use clothes or wrap the baby in loose layers of light but warm material.

The temperature of a newborn infant should be checked regularly. Families need to know how to recognize hypothermia by touching the feet and body of the baby. They need to know how to rewarm the baby by skin-to-skin contact with the mother or father - the simplest and most effective method. Other simple and safe measures of rewarming at home include wrapping a baby in layers of warm clothes and changing them frequently, and using measures such as warm water bottles. Families also need to know that if the baby does not get better it must be taken to the health centre or hospital to prevent further complications. An unexplained fall in body temperature may accompany severe infection.

In health facilities, the baby's temperature should be checked regularly, especially in the period immediately after birth. If the temperature is found to be low, the infant must be rewarmed and health evaluated. A newborn infant with hypothermia should also trigger a review of the institution's practices for thermal protection.

The newborn infant may be bathed when the temperature is stable and the baby is doing well. This is usually done for cosmetic purposes (to remove the vernix). Vernix has lubricating and anti-infection properties and does not need to be removed.

Infants with severe hypothermia need rapid rewarming. They must be referred to the hospital where they can receive support treatment in addition to effective rewarming. During transport, skin-to-skin is the best way to rewarm.

Hyperthermia is defined as body temperature above 37.5oC. Newborn infants develop hyperthermia if exposed to an environment that is too warm (sun, proximity to a heater, etc). The baby is initially irritated, breathes fast, with increased heart rate, hot and dry skin and the face appears flushed. It gradually becomes apathetic, lethargic and pale. When the body temperature goes above 41oC, stupor, coma and convulsions develop. The infant should be moved from the heat, undressed and the body should be cooled. Dehydration is a serious complication of hyperthermia and usually needs hospitalization.

The infant's condition should be reevaluated when the causes of hypothermia or hyperthermia are determined and removed. Signs of hypothermia, hyperthermia and infection are similar. If any of the danger signs persist after normalization of its temperature, the infant must be referred to the hospital.

 

Early and exclusive breast-feeding

Breast milk provides optimal nutrition and promotes the child's growth and development; it is associated with improved growth during the first months of life. By breast-feeding, a mother begins the immunization process at birth and protects her child against a variety of viral and bacterial pathogens before the acquisition of active immunity through vaccination. Breast milk has unique anti-infective properties. Frequent and exclusive breast-feeding can be an appropriate method of fertility regulation for many women, particularly when other family planning methods are not readily available or desired.

Early contact (immediately after birth) between the mother and the baby has a beneficial effect on breast-feeding. Early suckling provides the baby with colostrum that offers protection from infection, gives important nutrients, and has a beneficial effect on maternal uterine contractions. The baby's skin and gastrointestinal tract are colonized with the mother's microorganisms, against which she has antibodies in her breast milk.

Important factors in establishing and maintaining breast-feeding after birth are: giving the first feed within one hour of birth, correct position that enables good attachment of the baby, frequent feeds, no prelactal feeds or other supplements, and psychosocial support for breast-feeding mothers.

Babies have a wide range of behaviours following spontaneous delivery and are not all ready to feed at the same time. A skilled person can help to facilitate the process by ensuring correct positioning and attachment. A healthy baby has no need for large volumes of fluid any earlier than they become available physiologically from the mother's breast. There is no evidence to support the practice of providing supplementary feeds of water, glucose or formula. Traditional prelactal feeds should be strongly discouraged although harmless rituals may be allowed so long as they do not delay breast-feeding. Every birth attendant should also know the importance of unrestricted feeding and the ways to support breast-feeding mothers. Mothers should be instructed about the need for an adequate diet to sustain lactation. They should be helped and encouraged if they have difficulties breast-feeding.

Rooming-in has many advantages over separating babies from mothers. In health facilities its advantage, in addition to breast-feeding, is to prevent nosocomial infections.

Many publications are available which describe the importance of breast-feeding and the best ways to support it.

 

Initiation of breathing, resucitation

The operational definition of birth asphyxia is a delay in initiating breathing at birth.

To a certain extent, birth asphyxia can be prevented by referring women to health facilities when complications that may cause birth asphyxia (such as prolonged labour or preterm delivery) are expected. However, when a newborn is not breathing after birth, urgent and skilled resuscitation is needed immediately.

If a newborn infant does not cry after initial stimulation by drying, it must be assessed for breathing. If the infant is not breathing or the breathing is poor, it needs active resuscitation. Newborn infants may have difficulty in initiating breathing due to prologued and/or obstructed labour, prematurity, infection, and many unknown causes. Often it is impossible to anticipated that the newborn infant will have trouble in initiating breathing. Therefore, the equipment and skills for resuscitation are needed for every birth.

The aim of resuscitation is to initiate breathing by expanding the lungs, filling them with air to allow an exchange of gases and to permit changes in circulation. Aspiration of the upper airways is recommended as the first step in resuscitation but it is not sufficient to initiate breathing. Obstruction of the upper airway is uncommon and therefore not a primary reason for a newborn not breathing. However, thick meconium may obstruct airways and it should be removed from the upper airways before initiating ventilation.

The great majority of infants with asphyxia can be successfully managed by appropriate ventilation without drugs, volume expanders or other interventions. Applying the basic principles of resuscitation to all infants at all levels of care will substantially improve newborn health and decrease deaths. Timely and correct resuscitation will not only revive them but will enable them to develop normally. Most will need no further special care after resuscitation.

Every birth attendant should know the basic principles of resuscitation, have basic skills in neonatal resuscitation and have access to appropriate resuscitation equipment. Whenever possible, a person skilled in resuscitation, and who can devote full attention to the infant, should attend deliveries when complications are anticipated. Resuscitation equipment should not only be available in every delivery room, but its presence and proper working order should be verified before every delivery.

Proper ventilation of the infant is the most important aspect of resuscitation. Positive pressure ventilation with a self-inflating bag and a mask using additional oxygen is a usual method for management of birth asphyxia. When additional oxygen is not available, infants should be resuscitated using air. If no equipment is available, mouth-to-mouth ventilation can be effective for initiating breathing in newborns with mild and moderate asphyxia. In experienced hands, ventilation by endotracheal tube is likely to be more effective than ventilation by face-mask. However, personnel who do not frequently intubate newborn infants should initiate resuscitation using a face-mask and should consider intubation only if the heart rate does not increase promptly with properly performed bag and mask ventilation.

The most common serious error in neonatal resuscitation is the failure to recognize and correct hypoventilation, a problem which is preventable with sufficient staff training and experience.

Resuscitation of the newborn is also possible at home. The same principles apply. The birth attendant should be trained in recognizing a problem and managing it. When teaching mouth-to-mouth ventilation, special attention should be given to providing the right volume and pressure, to the importance of urgency in initiating ventilation and some sense of its duration for situations where no clock is available.

 

Eye care: prevention and management of ophthalmia neonatorum

Ophthalmia neonatorum is defined as any conjunctivitis with discharge occurring during the first two weeks of life. It typically appears 2-5 days after birth, although it may appear as early as the first day or as late as the 13th. Most often both eyelids become swollen and red with purulent discharge. Corneal damage with ulceration, perforation, synechiae and pan-opthalmitis develop if there is no treatment or if there is delay in treatment. Many infants will also progress into systemic disease.

Infection by Neisseria gonorrhoea and Chlamydia trachomatis are the two main causes of ophthalmia but cannot be accurately distinguished on clinical grounds alone. Complications are more severe and appear more rapidly in gonococcal ophthalmia. The transmission rate for gonorrhoea from an infected mother to her newborn is 30-50%. In the absence of systematic diagnosis and treatment of maternal genital infections before delivery, most cases of conjunctivitis of the newborn can be prevented by disinfection of the infant conjunctivae immediately after birth.

Infection can be prevented by cleaning the eyes immediately after birth and applying either 1% silver nitrate solution, 1% tetracycline or 0.5% erythromycin ointment to the eyes within one hour of delivery. Nonetheless, newborns given silver nitrate or tetracycline ointment still run the risk of infection (7% and 3% respectively) if the mother was infected. Purulent discharge that starts within the first two weeks of life must be recognized as a sign of ophthalmia and the newborns treated or referred for parenteral application of antibiotics.

The most common reasons for failure of ocular prophylaxis are giving it too late (after the first hour), flushing the eyes after administration of silver nitrate to prevent chemical conjunctivitis, and giving drops that are too concentrated through evaporation. The latter can be prevented by dispensing silver nitrate in small containers, avoiding prologued storage or using single-dose preparations.

Silver nitrate is not effective in preventing Chlamydia conjunctivitis. Some strains of Neisseria gonorrhoea are resistant to tetracyclines. The decision about what to use should be based on a local epidemiological evaluation. Conjunctivitis can be caused by other microbes (Staphylococcus aureus is the most common) but the clinical signs are usually milder.

Since there is a lack of evidence of the extent to which the traditional practice of applying mother's milk to the eyes of the newborn is effective in preventing ophthalmia, this practice cannot be recommended in place of silver nitrate drops or tetracycline ointment.

 

Immunization

BCG should be given as soon after birth as possible in all populations at high risk of tuberculosis infection.

A single dose of OPV at birth or in the two weeks after birth is recommended to increase early protection.

Hepatitis B vaccine should be integrated into national immunization programmes in all countries by 1997. Where perinatal infections are common it is important to administer the first dose as soon as possible after birth.

 

Management of newborn illness

Many newborn problems can be prevented by the interventions described above. However, when a disease occurs, many deaths can be avoided if the signs are recognized early and the newborn managed effectively.

Since most infants are either born at home or are discharged from the health facility early, families should be able to recognize signs of newborn illnesses and bring the newborn infant to the attention of a health worker.

Many signs of the normal transition period mimic those of early disease. Differentiation of signs of mild illness from normal transitional variation is difficult. Therefore disease is often in an advanced stage when the newborn is brought to the attention of the health workers. Danger signs in the newborn period are also non-specific; they can be a manifestation of almost any newborn disease. The most common presentation of illness in an infant who has been doing well after birth is that it stops feeding well, it is cold to the touch or - in rare cases - it has fever. Breathing may be fast and difficult with grunting and intercostal retractions; the infant may be irritable but may become lethargic and not wake for feeds. The infant may vomit, have diarrhoea and a distended abdomen. If pus is draining from red swollen eyes or from the umbilicus, classification of the problem is easier. Jaundice on the first day and convulsions are always a sign of a serious illness.

The health worker should have the knowledge and skills to assess the newborn infant, to classify the infants into those that need referral, those that need treatment at the health centre, those that can be treated at home and those who are probably healthy. Breast-feeding assessment, with advice if necessary, should always be a part of newborn care, as should immunization when indicated.

A series of documents describing the danger signs, assessment of the newborn, and classification and treatment of problems at the three levels of care is in preparation.

 

Care of the preterm and/or low birth weight newborn

Most of the low birth weight infants in developing countries are born at, or near, term. They have reached maturity and have the full potential for survival. However, because of their reduced weight and a lack of fat as the source of energy and insulation, they are at an increased risk of hypothermia and poor growth. Good thermal protection and breast milk are the two most important elements of their care. The best source of warmth is the mother's body and the best food is breast milk. Having a baby in skin-to-skin contact with the mother provides the necessary warmth and permits frequent breast-feeding. If possible, a low birth weight infant should not be separated from the mother solely on the basis of birth weight. If the baby does not have difficulty breathing and can be breast-fed, it should stay with the mother. If the small baby becomes hypothermic after birth, their chances for survival are reduced even with good hospital care. Adequate warmth can substantially reduce mortality in small babies.

Birth weight is governed by two major processes: duration of gestation and intrauterine growth. The more premature the newborn, the more problems it will have. Preterm babies have a wide range of difficulties - with feeding, respiratory problems due to immaturity of lungs, severe jaundice due to immaturity of the liver, and intracranial haemorrhage due to immaturity of the brain. Hospital care, skilled personnel, special equipment for thermal protection, intravenous feeding and artificial ventilation are all needed for survival and to prevent disabilities. Hospital infections are the major threat during these treatments. Countries need to decide on what resources can be made available for the care of very preterm newborn infants.


Congenital anomalies

Congenital anomalies, major and minor, occur in 3-4% of births. Some can be recognized at birth, many become obvious later in childhood, and some are never identified. Many deaths due to birth defects in the perinatal period result from lethal malformations and malformations where survival is not possible without complicated surgical intervention. Many birth defects leave infants disabled. Anomalies such as club foot and cleft lip/palate can be corrected to allow normal development.

There are a few birth defects that are more common in developing than in developed countries. Among these are neural tube defects and congenital hypothyroidism. Both can be prevented to a certain extent by giving the mother folic acid and iodine respectively, before conception and during early pregnancy when the fetal organ systems are developing.


Traditional practices

Traditional practices cannot be ignored when trying to achieve better neonatal care in developing countries because most deliveries occur at home and health services may not be available. Even babies delivered in hospital may be affected by traditional practices after discharge. These practices have a major impact on neonatal morbidity and mortality patterns. Traditional and cultural practices must be identified and the extent of their impact on newborn health evaluated before global standard guidelines are adapted to the local situation. Practices related to antenatal and intra-natal events, resuscitation, thermal control, feeding and infections for example, should be classified as follows:

  1. good practices worth promoting
  2. harmful practices that should be discontinued
  3. harmless practices which may be ignored for the time being
  4. practices that need further research before a decision can be taken as to their beneficial or harmful effects.

Some modern practices are also harmful. Bottle-feeding, pacifiers, and separation of the mother from her baby should be discouraged.

Once beneficial and harmful practices are identified, suitable communication strategies should be developed for individual and community education. They should be monitored as a part of essential newborn care. A special effort should be made to study home remedies for simple problems and to promote those that are effective.


Examination of the newborn infant

Rapid assessment of the baby is needed as soon as it is born. Designation of sex, inspection for vital signs and major anomalies are the first observations to be made. Definitive examination should be done after the transitional stabilization period in a well-lit room and in the presence of the parents. The examination should take into account maternal pregnancy history, labour and delivery. It should also include an assessment of gestational age and weight since this helps to establish the level of risk for immediate neonatal morbidity and mortality. Before leaving the mother and baby, the birth attendant should evaluate the newborn's respiration pattern (effort and rate), state of alertness, colour, posture, spontaneous activity, and breast-feeding. Parents should be given instructions for normal newborn care and information about danger signs that indicate that the newborn infant is not doing well. It may include immunization according to national policy and instructions for further immunization.


Investigation of a neonatal death

A neonatal death investigation consists of an interview with care providers and a review of medical records, laboratory results, prescriptions and other data, to determine the biomedical causes of death and ascertain non-clinical factors contributing to death. When birth and death occur at home, a postmortem interview of the family should aim at determining the medical as well as non-medical causes of newborn death. This is called verbal autopsy. It is also useful for deaths that occur in health facilities where information concerning newborn deaths is poorly recorded or suspect.

The description of all the events surrounding each newborn death is important, since it serves as a basis for the development of more comprehensive strategies for prevention. The circumstances, other than biomedical, in which the newborn dies may help in identifying departures from accepted standards of care, including the failure of services to provide adequate care.

The following table summarizes strategies for essential newborn care at different levels of the health care.

Table 3: Summary table of essential newborn care
( landscape printing version)

Strategy At birth Conceptual discharge (*)

Check for:

Home messages for normal care: Home message about danger signs:

Seek help if:

Assessment, classification and management at health centre:
Cleanliness, clean delivery and cord care Clean delivery:

Clean hands, perineum, surface, cutting, ties

Nothing applied to the cord stump

Umbilical stump: clean, dry, tie tight, no bleeding

Nothing applied to the cord stump

Keep the stump dry, clean (using pieces of sterile dry gauze), do not apply anything to the cord stump Umbilicus red or draining pus, redness extends to skin If umbilicus red or draining pus, redness extends to skin:
give the first dose of antibiotics and refer to the hospital
Thermal protection Warm place of birth

Dry the baby with warm cloth

Provide warm environment by skin-to-skin or wrapping in warm clothes

Delay bathing

Warm to touch

If cold, rewarm by skin-to-skin

Protect from cold/heat by wrapping/clothing, bedding according to climate

If cold to touch, rewarm (skin- to-skin, clothing, bedding)

If too warm, undress

Cold to touch in spite of rewarming

Hot to touch in spite of undressing

Suckling poorly, crying weakly

Measure body temperature

If no danger signs and mild hypothermia, rewarm; otherwise refer

Breast-feeding Early and exclusive breast-feeding within first hour of birth

No prelactal feeds or other fluids, no pacifiers

Good suckling

If suckling poor, assure correct positioning and attachment

Frequent early breast-feeding day and night

No other food but breast milk

Suckling becomes poor

Baby does not wake-up for feeding

Observe suckling; check mouth for thrush; if yes and no other signs treat thrush with gentian violet and reassess next day
Eye care Clean eyes immediately after birth

Apply eye drops or ointment

  Do not apply anything Eyes becomes swollen, sticky or draining pus Red swollen eyes and pus draining from eyes

Clean eyes, give parenteral antibiotic or refer to the hospital

Initiation of breathing If no cry at birth check for breathing, if no breathing initiate resuscitation:

- aspiration of mouth and nose, ventilation:

- ventilation (by bag and mask at health facility, mouth to mouth at home)

Good cry, no difficulty breathing

If difficulty breathing, refer

  Difficulty breathing Count breathing rate, look for retractions

Look and listen for grunting,if present, refer

Immunization   Immunize according to policy A visit for next immunization    
Low birth weight

Preterm

Measures above, plus

Weigh baby or use a surrogate to estimate weight

Determine gestational age

If baby weak and not suckling well, express breast milk into baby's mouth

Check:

Breathing

Warmth

Suckling

Frequent breast-feeding

If a small baby is not suckling well, feed with expressed breast milk by cup and spoon

Thermal protection

Cleanliness

Difficulty breathing

Poor suckling

Not pink

If any of:

difficulty breathing, not able to feed, lethargy, jaundice on palms and feet, refer to hospital

Other       Pustules

Jaundice on palms and feet

Abnormal movements

Convulsions

Lethargy

Refer to hospital
Congenital anomalies   Advice on possible treatment Normal care As for other newborn infants  
Investigation of deaths Registration of birth

Reporting of death

      Reporting of death

Investigation of death

(*) Conceptual discharge means the time when the birth attendant leaves the mother and the baby or hands the responsibility over to a different care provider, often 2 to 24 hours after birth


Additional reading

Detailed information on essential newborn care is available in the following WHO publications:

Care of the mother and newborn at the health centre: a practical guide. WHO/FHE/MSM/94.2

 

Clean delivery

Guidelines for introducing simple delivery kits at the community level. MCH/87.4

Clean delivery: a set of guidelines for strengthening clean delivery techniques and practices. WHO/MSM 1995

 

Thermal protection

Thermal control of the newborn: A practical guide. WHO/FHE/MSM 93.2

 

Eye care

Conjunctivitis of the newborn. WHO 1986

 

Breast-feeding

Protecting, promoting and supporting breast-feeding. The special role of maternity services. A joint WHO/UNICEF statement. WHO 1989

Breast-feeding. Technical basis and recommendation for action (WHO/NUT/MCH/93.1).

Breast-feeding counselling. A training course (WHO/CDR 93.4).

Breast-feeding Management and Promotion in a Baby-Friendly Hospital. UNICEF/WHO 1993

Indicators for assessing health facility practices that affect breast-feeding (WHO/CDR 93.2).


Essential Newborn Care
Technical Working Group

Trieste, Italy, 25-29 April, 1994

List of participants

 

Dr S. Arsan, Neonatology, University of Ankara, Turkey

Dr A.W. Brann, Emory University School of Medicine, Atlanta, United States of America

Dr J.L. Diaz Rosello, Latin American Center of Perinatology and Human Development (CLAP), Montevideo, Uruguay

Dr A.C. Gatmaitan, College of Medicine, University of the Philippines, Quezon City, MetroManila, Philippines

Dr B. McCarthy, Centers for Disease Control and Prevention, Atlanta, United States of America

Mrs H.H. Owusu, Association of Ghana Midwives, Accra, Ghana

Dr P. Rolfe, Dept of Biomedical Engineering & Medical Physics, University of Keele, Stoke-on-Trent, United Kingdom

Dr S.N. Vani, B.J. Medical College and Civil Hospital Ahmedabab, Gujarat, India

Dr G. Tamburlini, Instituto per l'Infanzia "Burlo Garofolo", Trieste, Italy

 

SECRETARIAT

WHO, Geneva, Switzerland

Dr T. Türmen, FHE

Dr R. Guidotti, CHD

Dr J. Zupan, CHD

 

WHO Collaborating Centre, Trieste, Italy

Dr R. Davanzo

Dr U. de Vonderweid

Dr J. Gonçalves

Dr F. Uxa