SẢN PHỤ KHOA

1. Essential Newborn
Care
Sarah A. Murphy, MD
Pediatric Critical Care Fellow
MassGeneral Hospital for Children
Boston, MA

2. Presentation Outline: Part One
 Background: the problem of neonatal mortality
 WHO “Essential Interventions” for Mothers
 Tetanus Toxoid Immunization
 Iron and Folate supplementation
 Treatment of infections: especially Malaria, Syphilis
 WHO “Essential Interventions” for Newborns
 Essential care for all newborns
 Cleanliness
 Thermal protection
 Early and exclusive breast-feeding
 Eye Care
 Immunization

3. Presentation Outline: Part Two
 Essential care for sick newborns:
 Care of low birth weight babies
 Management of newborn illnesses
 Neonatal Resuscitation*
 Review Questions

4. Background: Neonatal Mortality
 Neonatal mortality: death < 28 days after birth
 40% of all child deaths (<5 yo) are neonatal!
 Highest rates in sub-Saharan Africa
 Africa: > 1 million neonatal deaths every year
 38% die of infections
 Most are low birthweight (LBW) & many preterm
 Liberia: very high rate – 6.6% die in first month

5. Causes of Neonatal Death
(WHO 2001)
Birth Asphyxia
31%
Complications of
Prematurity
25%
Congenital
Anomalies
11%
Infections
33%

6. Background: Neonatal Mortality
 325,000 deaths from sepsis & pneumonia in Africa .
Simple preventive practices can save most!
 Existing interventions can prevent 35-55%
neonatal deaths worldwide
 These interventions include:
Treating pregnant women
 for example, tetanus toxoid administration
Treating newborns
Bellagio, Lancet Survival Series

7. WHO Essential Interventions
 This presentation will review the principles
behind the “essential interventions” identified
by the WHO as having the greatest potential to
reduce newbown mortality:
Interventions for Mothers
Interventions for Newborns

8. Essential Antenatal Care for Pregnant
Women
Tetanus Toxoid Immunization
Iron and Folate supplementation
Treatment of infections: especially Malaria, Syphilis

9. Tetanus
 Caused by Clostridium tetani
 G+, anaerobic bacterium sensitive to heat & oxygen
 Spores are very resilient and found in soil & animals
 GI tract of horses, sheep, cattle, dogs, cats, chickens, others.
 Spore inoculation occurs through dirty wounds.
 Once inside, spores germinate and produce tetanospasmin
 A very potent neurotoxin
 Tetanospasmin dissminates in lymph and blood to all nerves
 Toxin blocks neurotransmitter release and causes unopposed muscle
contraction and painful muscle spasms

11. Tetanus
 The shortest peripheral nerves are affected first
facial distortion
back and neck stiffness
 Generalizes in a descending fashion
 Seizures may occur
 Autonomic nervous system may also be affected

12. Tetanus cases reported worldwide (1990-2004). Ranging
from strongly prevalent (in dark red) to very few cases (in
light yellow) (gray, no data).

13. Tetanus
 Tetanus kills an estimated 70,000 newborns in Africa
each year
 six percent of all neonatal deaths
 It is very hard to treat neonatal tetanus!!
 Preventing the disease by immunizing mothers is critical!

14. Tetanus
 Tetanus can be prevented through immunization with
tetanus-toxoid (TT) -containing vaccines
 Mothers should receive at least 2 TT vaccines during
pregnancy!!
 This protects the mother and - through a transfer of
tetanus antibodies to the fetus - her baby

15. Iron and Folate Supplementation
 Iron deficiency anemia affects almost half of all women
 Maternal anemia contributes significantly to maternal mortality
and causes an estimated 10,000 deaths per year
 Newborns of mothers with anemia are more likely to have low
birth weight, be born too early, or die shortly after birth
 Also at greater risk for cognitive impairment
 Folate supplements before and around conception can reduce
the occurrence of neural tube defects in newborns

16. Treatment of Maternal Infections
1) Malaria
2) Syphilis

17. Treatment of Maternal Malaria:
 Malarial infection causes 400,000 cases of severe maternal
anemia yearly
 And responsible for 75,000-200,000 infant deaths annually
 Effects on fetus:
 fetal loss
 premature delivery
 intrauterine growth retardation
 low birth-weight infant

18. Treatment of Maternal Malaria
 In high malaria areas, women have some immunity that wanes during
pregnancy
 Malaria infection results in severe maternal anemia and delivery of low birth-
weight infants
 In low malaria transmission areas, women have not developed immunity
 Malaria infection results in severe malaria disease, maternal anemia, premature
delivery, or fetal loss
 Malaria is a major factor in low birth weight babies and amenable to
intervention!

19. Treatment of Malaria
 Provide antimalarial drugs
 Use insecticide-treated bed nets

20. WHO guidelines for the treatment of
Malaria in pregnancy
 Intermittent Preventive Treatment
 All pregnant women in areas of stable malaria transmission should receive at least 2 doses of
IPT after quickening
 The World Health Organization recommends a schedule of 4 antenatal clinic visits, with 3
visits after quickening
 The delivery of IPT with each scheduled visit after quickening will assure that a high
proportion of women receive at least 2 doses
 The most effective drug for IPT is sulfadoxine-pyrimethamine (SP) because of its safety for
use during pregnancy, effectiveness in reproductive-age women, and feasibility for use
 IPT-SP doses should not be given more frequently than monthly.
 Insecticide-Treated Nets
 ITNs should be provided to pregnant women as early in pregnancy as possible.
 Their use should be encouraged for women throughout pregnancy and during the
postpartum period.

21. Placental Infection
Malaria-infected human placenta examined under the microscope. The
intervillous spaces (central area of the picture) are filled with red blood cells, most
of which are infected with Plasmodium falciparum malaria parasites

22. Treatment of Maternal Syphilis
 Provide screening and treatment in areas
where syphilis is endemic
Untreated syphilis can cause malformation, illness,
or death of a fetus or newborn

23. Treatment of Syphilis
 Syphilis is a sexually transmitted disease caused by a spirochete ~
Treponema pallidum
 Syphilis can cause miscarriages, premature birth, still-birth, or
death of newborn babies:
 40% of births to syphilitic mothers are stillborn
 40-70% of the survivors will be infected
 12% of these will subsequently die

24. Syphilis
 Some infants have symptoms at birth, most develop symptoms
later
 Late congenital syphilis occurs in children greater that 2 years of age:
 Hutchinson teeth
 Interstitial keratitis
 Deafness
 Frontal bossing
 Saddle nose
 Swollen knees
 Saber shins
 Short maxillae
 Protruding mandible
 Sores on infected babies are infectious

25. Congenital Syphilis
 Failure to gain weight
 Fever
 Irritability
 No bridge to nose (saddle nose)
 Early rash -- small blisters on the palms and soles
 Later rash -- copper-colored, flat or bumpy rash on the face, palms, soles
 Rash of the mouth, genitalia, and anus
 Severe congenital pneumonia
 Watery discharge from the nose
 Blindness
 Clouding of the cornea
 Decreased hearing or deafness
 Gray, mucous-like patches

27. Treatment of Syphilis
 One dose of penicillin will cure a person who has had
syphilis for less than a year
 More doses are needed to cure someone who has had it
for longer
 A baby born with the disease needs daily penicillin
treatment for 10 days

28. Essential Care for Newborns
 Essential care for all newborns
 Cleanliness
 Thermal protection
 Early and exclusive breast-feeding
 Eye Care
 Immunization
 Essential care for sick newborns
 Care of low birth weight babies
 Management of newborn illnesses
 Neonatal Resuscitation*

29. Routine Supportive Care for All
Newborns after delivery
 Keep baby dry and warm
 Keep baby with mother – room in
 Initiate breast-feeding within 1 hour
 Give Vitamin K
 Keep umbilical cord clean and dry
 Apply eye ointment to prevent infection
 Give oral polio, BCG, and hepatitis B injections

30. Cleanliness
The six “cleans” of the WHO
1. Clean hands of the attendant
2. Clean surface
3. Clean blade
4. Clean cord tie
5. Clean towels to dry the baby and then wrap the
baby
6. Clean cloth to wrap the mother

31. Cleanliness
 Hygiene during delivery:
 Clean hands, perineum, delivery surface
 Sterilized equipment
 Clean cutting of umbilical cord
 Clean hands with soap and water, under the nails
 Sterile razor blade for cutting cord
 Sterile ties or gauze to tie cord off
 Umbilical cord care
 Umbilical stump is main source of entry for infections
 Cord should be kept clean and dry, no dressings should be applied if stump is able
to be kept clean without them
 Infant’s clothes and blanket should be kept clean
 If cord becomes dirty, it should be washed and then dried with clean cotton or
gauze

32. Cleanliness
 Prevention of hospital infections:
 Rooming-in with mother:
 Allows micro-organisms from mother to be given to infant
 These tend to be non-pathogenic
 Mother can give antibodies to these organisms to the baby through
breast-milk
 Reduces risk of cross-infection when babies are not being roomed
together
 No over-crowding
 Clean water
 Importance of hospital staff hand-washing!!!

33. Thermal Protection
Normal temperature of a newborn is between 36.5
and 37.5 degrees Celsius

34. Thermal Protection
 Hypothermia can be a sign of infection!!!
 Hypothermia is temperature less than 36.5 degrees C
 Large surface area
 Poor insulation
 Small body mass to produce heat
 Signs of hypothermia
 cool hands and feet
 less active or lethargic
 Hypotonic
 poor suck
 weak cry
 shallow breathing
 redness of face and skin

35. Thermal Protection
 Preventing hypothermia:
 deliver infant in warm room
 dry thoroughly after birth, including drying the head,
 wrap in warm dry cloth
 give to mother as soon as possible for skin to skin contact
 no washing in the 1st 6 hours after birth
 Treatment:
 skin to skin contact
 warm water bottles
 loosely wrapped warm blanket

36. Mechanisms of Heat Loss in Babies

37. Thermal Protection
 Hyperthermia is a temperature > 37.5 degrees C
 Signs:
 Irritable
 Rapid respirations
 Rapid heart rate
 Hot and dry skin
 Lethargic
 Convulsions
 Hyperthermia is often accompanied by dehydration and re-
hydration should be considered if infant is showing any signs

38. Thermal Protection
 Prevention:
 Hyperthermia in an infant is environmental
 Do not expose infant to high temperatures, sunlight, heaters,
etc!!
 Treatment:
 Active cooling

39. Early and Exclusive Breast-feeding
 Early and exclusive breastfeeding is one of
the least expensive and most cost-effective
interventions for saving children’s lives!!!!

40. Early and Exclusive Breastfeeding
 Exclusive breastfeeding for six months and continued
breastfeeding for the first year could avert 13 percent of the
more than 10 million deaths among children
 Benefits:
 including improved cognitive development
 reduced risk of infections
 better overall chances of survival

41. Early and Exclusive Breastfeeding
 Formula feeding raises risk of illness by depriving infants of
infection-fighting components of human milk
 Bottle feeding carries risks of possible contamination of water
and formula
 In areas with a high level of infectious disease and unsafe water,
an infant who is not breastfed during the first 2 months of life is
up to 23 times more likely to die from diarrhea

42. 1. Initiation of breastfeeding within one hour of birth
colostrum
continuous skin-to-skin contact
2. Exclusive breastfeeding for six months
3. Assess for good attachment and positioning
4. Prompt treatment of breast conditions
5. Frequent breastfeeds, day and night
(8-12 times per 24 hours)
6. Continuation of breastfeeding when mother or newborn is ill
7. Extra support for feeding more vulnerable newborns
low birthweight or premature babies
HIV-infected women
sick or severely malnourished babies

43. Early and Exclusive Breast-feeding
 Breast-feeding and HIV:
 Exclusive breastfeeding recommended for all mothers in
HIV-endemic areas, including HIV-positive mothers where
 alternatives are not acceptable, feasible, affordable, sustainable, and
safe
 This applies to much of sub-Saharan Africa and South Asia, among
other places.
 Exclusive breastfeeding is associated with two to four times lower
rates of mother to child transmission of HIV compared to non-
exclusive breastfeeding

44. Eye Care: application of topical
antibiotic
 Tetracycline eye ointment
 Prevents infection of tissues surrounding the eyes
caused by bacteria from the birth canal
 The most significant of these bacteria are gonorrhea and
chlamydia
 Also helps prevent infection with other bacteria
 Untreated, gonorrhea and chlamydia can cause permanent
visual impairment and also spread to other parts of the body
such as the lungs causing pneumonia

45. Immunization
 Each year, over four million African children die before their
fifth birthday, many from vaccine-preventable diseases
 Immunizations will be covered in later lecture
 But, notably, there are a number of vaccines given to babies just
after birth to be aware of:
• BCG vaccination to reduce the risk of tuberculosis
• Hepatitis B vaccination to prevent hepatitis B infection
• OPV to prevent polio infection

46. Supportive Care for All Newborns after
delivery: KEY POINTS!!!
 Keep baby dry and warm
 Keep baby with mother – room in
 Initiate breast-feeding within 1 hour
 Give Vitamin K
 Keep umbilical cord clean and dry
 Apply eye ointment to prevent infection
 Give oral polio, BCG, and hepatitis B injections

47. Management of Sick Infant

48. Management of Sick Infant: Outline
 Care for ALL sick infants
 Recognizing danger signs
 Treating serious bacterial infection
 Treating convulsions
 Treating low birth weight baby
 Review of key points

49. Management of Newborn Illness
 Neonates and young infants present with non-
specific symptoms which may indicate a serious
illness or serious bacterial illness
 It is imperative to monitor for and recognize
these danger signs to initiate treatment early
 Treatment is aimed at stabilizing child and
preventing deterioration

50. General principles of management of all
sick infants:
Keep infant dry and warm
 Wrap infant
 Cap
 Kangaroo infant with mother if possible
Follow temperature closely

51. General principles of management of
sick infants:
Encourage frequent breast-feeding if infant is alert
 If baby is lethargic or having frequent convulsions, avoid
oral feeding

52. General principles of management of
sick infants:
 If giving IV fluids, follow the TOTAL amount of fluids given
to infant
 This includes oral and IV fluid
 WHO recommends:
 60cc/kg/day on Day 1
 90cc/kg/day on Day 2
 120cc/kg/day on Day 3
 150cc/kg/day thereafter
 Note: Infant may need more fluids if kept under radiant warmer
 Note: Following infant’s weight is good measure of over or under-
hydration

53. General principles of management of
sick infants:
Oxygen should be given by nasal prongs at initial
flow rate of 0.5L/min
If able to follow pulse oximeter, goal is oxygen
saturation greater than 90%

54. Recognizing Danger Signs
Danger signs in a newborn:
• Convulsions
• Drowsy or unconscious
• Not feeding well
• Fast breathing (more than 60 breaths per minute)
• Slow breathing (less than 20 breaths per minute or not
breathing)
• Grunting or severe chest in-drawing
• Fever (above 38°C)

55. Recognizing Danger Signs
 Danger signs in a newborn:
• Hypothermia (below 35.5°C),
• Very small baby (less than 1500 grams or born more than two
months early)
• Bleeding
• Severe jaundice
• Severe abdominal distension
• Bulging fontanelle
• Signs of local infection (ex: swollen joints, skin pustules or
redness)
• Central cyanosis

56. Emergency Treatment of Danger Signs
Give oxygen by nasal prongs or catheter to
any ill-appearing infant
 Especially if having respiratory symptoms
Provide bag and mask ventilation if breathing
is too slow or labored
 With oxygen if available, or room air

57. Emergency Treatment of Danger Signs
Give penicillin/ampicillin and gentamicin as
soon as possible to any infant presenting with
signs of illness

58. Emergency Treatment of Danger Signs
If convulsing, give Phenobarbital (IM 15mg/kg)
If patient is drowsy, unconscious, or convulsing:
 Check blood sugar if possible, give IV glucose if blood
sugar is low
 If unable to check blood sugar, give IV glucose
 If unable to give IV glucose, give either expressed breast-
milk or glucose through a nasogastric tube

59. Emergency Treatment of Danger Signs
Give vitamin K injection to all sick newborns
if they have not already received it

60. Serious Bacterial Illness
 Serious bacterial infection should be suspected if
an infant presents with any DANGER SIGN
Risks for serious bacterial infection include:
 maternal fever
 rupture of membranes for more than 24 hours
 foul-smelling amniotic fluid

61. Serious Bacterial Illness
 Also look for signs of a local infection:
swollen joints
many severe skin pustules
bulging fontanelle
redness around umbilicus
pus from umbilicus

62. Serious Bacterial Illness
 Treatment of suspected serious bacterial illness:
 Admit to Hospital
 Send blood cultures if possible
 Ampicillin/Penicillin and Gentamicin for 10 days
 If no improvement in 2-3 days consider changing antibiotics
 If extensive skin infection consider giving Cloxacillin if
available instead of Penicillin for staph aureus coverage

63. Convulsions
 Treatment:
Initial dose of Phenobarbital is 15mg/kg IM
If convulsions continue, give 10mg/kg IM in repeat
doses up to maximum of 40mg/kg
Monitor for apnea or slowed breathing and assist
breathing if needed
Check for low blood sugar
Continue daily Phenobarbital at 5mg/kg if needed

64. Low Birth Weight Baby
 Most newborn deaths are among low
birthweight babies
 Low birth weight is baby weighing less than
2500 grams
 Simple care of these small babies, close
monitoring and early treatment of problems
could save many newborn lives

65. Low Birth Weight Baby
 Birthweight of 2.25-2.5kg
 These infants normally do well with routine newborn care
 Monitor carefully
 Ensure proper warmth and infection control

66. Low Birth Weight Baby
 Birthweight 1.75 to 2.25kg
Initiate Kangaroo Care for warmth
Start feeding within 1 hr
If infant is able to nurse, allow normal, frequent
breast-feeding
If infant cannot breast-feed, give expressed breast-
milk by cup and spoon
Monitor carefully for signs of infection

67. Low Birth Weight Baby
 Birthweight less than 1.75 kg
 These infants need to be admitted to special care nursery for
extra care
 Give oxygen by nasal prongs or nasal catheter if there are any
signs of difficulty breathing, fast breathing rate or cyanosis
 Maintain temperature of 36-37 deg C
 Kangaroo Care
 Humidicrib if available
 Hot water bottle wrapped in a towel if no heating source

68. Low Birth Weight Baby
 Birthweight less than 1.75 kg
 If possible, give IV fluids
 Give 2-4ml of expressed breastmilk every 2 hours by
nasogastric tube IF:
 baby looks well
 no abdominal distension
 bowel sounds present
 baby has passed meconium,
 If baby is tolerating these feeds, increase volume slowly

69. Low Birth Weight Baby
 Birthweight less than 1.75 kg
Monitor for signs of infection and begin antibiotic
therapy if any sign prsent
If infant has apnea, treat:
 caffeine citrate 20mg/kg PO or IV x 1, then daily 5mg/kg
 OR aminophylline 10mg/kg x 1, then 2.5 - 4 mg/kg q 12
hours

70. Low Birth Weight Baby
 Kangaroo Care:
 The baby is undressed except for cap, nappy, and socks
 Placed upright between the mother’s breasts, with head turned to one side
 Then tied to the mother’s chest with a cloth and covered with the mother’s
clothes
 If the mother is not available, the father or any adult can provide skin-to-skin care
 Provides warmth, breastfeeding, protection from infection, stimulation, and
love
 Effective way to care for a small baby weighing between 1,000 and 2,000
grams who has no major illness

71. Low Birth Weight Baby
 Kangaroo Care:
This care is continued until the infant no longer
accepts it, usually when the weight exceeds 2,000
grams
Research has shown that for preterm babies, KMC is
at least as effective as an incubator
Shorter average stay in hospital compared to
conventional care, have fewer infections, and gain
weight more quickly

72. Neonatal Resuscitation Prototcols
 See next lecture in the series