Newborn – What’s New? Newborn/Preterm/

Small Babies

The Continuum of Care for Preterm and Small Babies: Carolyn Kruger, PCI Care of Maternal/Newborn Dyad When Preterm Labor and Delivery

Occur: Suzanne Stalls, ACNM Current Research on Management of Newborn Sepsis: Bina Valsanger,

SNL/SAVE Integration of Newborn Care with CORE Group Community Polio Platform

in Ethiopia: Alfonso Rosales, World Vision

Every Preemie—SCALE

SCALING, CATALYZING, ADVOCATING, LEARNING, EVIDENCE-DRIVEN

Continuum of Care for Pre-term/Small Babies

Premature birth is the leading cause of newborn

death and the leading cause of death among children under 5 worldwide

• 15 million babies are born preterm every year.

• 1.1 million babies die every year due to complications of prematurity – 75% of these deaths are preventable.

Why Preemies?

• Low birth weight (babies born too small) is a major contributor to newborn deaths.

Sources: Born Too Soon: The Global Action Report on Preterm Birth (2012); Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic analysis, Lancet (2014).

• Expand the uptake of preterm birth

(PTB) and low birth weight (LBW) interventions in 24 USAID priority countries in Africa and Asia.

• Shine a spotlight on PTB/LBW within maternal and newborn health interventions and approaches.

• Work within global partners, established health service delivery systems, and community platforms.

Every Preemie—SCALE

• USAID MCSP • Saving Newborn Lives (SNL) • USAID Emerging Priorities Initiative • CORE Group • Global Maternal/Newborn Technical Working

Groups • Survive and Thrive Global Development Alliance • BMGF Grand Challenges Partners • Country Every Newborn Action Plans

Collaborating with…

Preemies: Our Care Agenda Category Gestational Age Approximate Weight Global Burden

Extremely < 28 weeks < 1500 grams 5.2%

Very 28 - < 32 weeks Approx. 1500 grams 10.4%

Moderate 32 - < 37 weeks 2500 grams 84.3%

The majority of these preemies can survive with basic essential newborn care (drying, warming, breastfeeding,

clean cord care and hygiene) PLUS breathing support, continuous skin-to-

skin contact, infection prevention/management

• Core Package – Consists of:

• 24 country survey in USAID priority countries in Asia and Africa • Evidence toolkit • Advocacy and Awareness Raising module

• Targeted Technical Assistance – Implemented in selected countries and includes country-specific

TA such as: • Revision of policy, standards or protocols • Curricula development • Health provider training

• Demonstration Countries—up to 4 over LOP • Focused programming based on stakeholder priorities • Programming will be designed to advance the scale up of

interventions along the continuum of care from the household to the facility

• Implementation research designed to answer critical questions about what works to improve programming for PTB/LBW

Country Support

– How do we address the barriers to quality of care given what we know?:

• In many countries a large proportion of babies are born at home without skilled care

• Services for mothers and newborns are often managed separately

• Services are often inadequate and of poor quality

• Recognition of preterm and small babies and appropriate care remains a significant challenge

– We also know that the majority of moderate preterm babies can survive with essential newborn care interventions PLUS respiratory support (where indicated), continuous skin-to-skin care, support for feeding and careful growth monitoring

Learning Agenda

• Gestational age assessment research (pre-birth and at birth)

• Post birth assessment of preterm, small babies at the facility level, immediate care and referral to advanced or specialized care

• Community/household recognition of preterm and small babies and ACTION: referral to care

• Barriers to care for vulnerable babies, e.g. acceptance of “small, ugly” babies; community perceptions and action

• Follow up care at the community/household level for preemies and small babies (e.g. home maintenance of KMC: skin to skin care and feeding support at the household level)

Priorities for Learning

How will we learn?

Evidence to Action

Evidence Shared Globally and in USAID Priority

Countries

Demonstration and TTA

Countries Use Evidence and

Information to Prioritize Action

Country Level Learning

Captured and Used to Inform Future Planning

Know-Do Gap Informs New Learning for

PTB/LBW

Focus on Continuum of Care: Best Practice, Gaps, Comparative Value

Pre-pregnancy Pregnancy Labor and

Delivery

Immediate Postnatal

Care

Later Postnatal

Care

Community/Home

Health Center Hospital

• There are multiple points during a women’s reproductive

life when specific services can reduce her risk for preterm birth and improve chances of survival for early and small newborns

• The matrix provides an organized framework for evidence-based interventions and services along the pathway for care of non-pregnant and pregnant women, mothers, and preterm or small babies- from the household/community to the health center and hospital levels

• Used to initiate dialogue and coordination, identify gaps along the pathway to care, and guide prioritization of services.

MATRIX: Continuum of Care for the Prevention of Preterm Birth, Management of Preterm Labor and Delivery and

Care of the Preterm and Small Newborn

PREVENTION OF PRETERM BIRTH AND LOW BIRTH WEIGHT COMMUNITY/ HOUSEHOLD

• Delayed marriage/childbearing among adolescents

• Prevention of partner violence • Family Planning (FP) counseling &

provision • Optimize pre-pregnancy weight &

use of iron-folate supplements and/or micronutrient fortification

• Cessation of tobacco use & reduced exposure to second hand smoke & household air pollution

• Cessation of substance abuse including alcohol

• Prevention of harmful traditional practices (HTPs)

• Social and cultural norms in place that promote early care seeking behavior for pregnancy women

• Early determination of last menstrual period (LMP) and estimated due date (EDD) at first antenatal care (ANC) visit

• Counseling on reduced maternal workload • Identification and management of partner

violence • Community-based ANC including

identification of complications and referral and previous history of preterm birth

• Birth preparation including a savings and transport plan

• Identification of pregnancy complications and referral to care

• Prompt referral to health facility if newborn appears premature or small

• See pre-pregnancy actions at the community and household level

HEALTH CENTER

All of above PLUS • Diagnosis & management of

infections including HIV • Routine childhood immunizations

including for adolescents • Mental health/depression

assessment and referral for services

All of above PLUS • Focused ANC including IPT/SP for malaria,

screening/care for maternal infections (TB, HIV, bacterial vaginosis, UTI, Group B Strep, chlamydia, gonorrhea, syphilis)

• Maternal immunization (tetanus, pneumococcal, H. influenzae, influenza), anemia screening/treatment

• High risk pregnancy screening and referral: o Chronic diseases (e.g. diabetes) o ID and Tx of hypertensive disease in

pregnancy o ID and Tx of antepartum hemorrhage o ID and Tx of pPROM o Monitoring multiple pregnancies o Pregnant adolescents o Prior preterm birth

• Identification of pregnancy complications

• Verify EDD • If maternal

condition leading to prematurity is identified, transfer to hospital care

• Confirm gestational age at birth

• Nutrition counseling for adequate maternal diet and successful breastfeeding

• Postpartum family planning counseling and provision of services (e.g. oral contraceptives, LAM) and referral for permanent or long-acting reversible contraception (LARC)

All of above PLUS • Follow-up of women

in the interconceptional period who delivered prematurely to medically manage any conditions that may have predisposed her to premature

HOSPITAL Counseling and services for all of above

All of above PLUS • Management of women at higher risk of

preterm birth: o Above conditions plus o ID and Tx of cervical abnormalities (e.g.

• Management of complications

• Refer to Management of Labor & Delivery,

All of above plus • Provision of

permanent or long-term FP methods (e.g.

• Identification and management of new onset chronic diseases (e.g. diabetes)

CARE

• Pre-conception: youth-delay marriage and pregnancy • Early ANC in first trimester for establishment of EDD,

focused ANC • Family planning counseling and provision • Early care –seeking behaviors for complications • Early identification of high risk pregnancies- screening • Prevention of partner violence and HTP • Birth preparation • Maternal nutrition/micronutrient fortification • Reduced maternal workload • Maternal depression screening

Prevention of Preterm Birth

MANAGEMENT OF PRETERM LABOR & DELIVERY COMMUNITY/ HOUSEHOLD

• Community health education including signs and symptoms of preterm labor and obstetric complications

• Recognition of obstetric complications and signs of preterm labor and immediate referral to hospital for care

• If possible, referral to health facility for obstetric care

• IF UNABLE TO TRANSFER: Skilled birth attendant in the home

• Clean birth practices • Early basic obstetric and newborn care and

referral to health facility for management

• Immediate postpartum care for the mother and referral to health facility for follow up and management of obstetric complications

• Continuation of immediate essential newborn care and referral/transfer to facility for preterm or small newborn

HEALTH CENTER • Establish gestational age • Respectful maternity care • Education and recognition of signs of

preterm labor and obstetric conditions leading to prematurity

• Identify and early Tx of high-risk conditions for preterm birth (pre-eclampsia, pPROM, antepartum hemorrhage, preterm labor

• Immediate referral to hospital for care • Monitor fetal condition • Maternal nutrition and hydration • During transfer to hospital, woman to

remain recumbent if at all possible

• Provision of basic emergency obstetric care for women in preterm labor

• Ongoing monitoring of fetal condition • Transfer to hospital for comprehensive

emergency obstetric care

• Early management of maternal postpartum complications with basic emergency obstetric care

• Transfer to hospital for emergency postpartum care

• See CARE FOR THE PRETERM OR LOW BIRTH WEIGHT NEWBORN

HOSPITAL All of above PLUS • May use tocolytic agents to suppress

labor for time required to administer ACS

• Begin ACS for women 24 to <34 weeks gestational age and at high risk for imminent preterm birth

• Magnesium sulphate for women with gestational age <32 weeks and likely to give birth within 24 hours

• Managing and treating the high-risk complications leading to prematurity

• Comprehensive emergency obstetric care • Ongoing monitoring of fetal condition

• Management of postpartum care for the mother

• See CARE FOR THE PRETERM OR LOW BIRTH WEIGHT NEWBORN

PREGNANCY LABOR & DELIVERY IMMEDIATE POSTPARTUM/POSTNATAL CARE

• Establish gestational age • Respectful maternity care • Education and recognition of signs of preterm labor and

obstetric conditions leading to prematurity • Identification and early treatment of high-risk conditions

leading to prematurity • Basic emergency obstetric care • Monitor maternal and fetal conditions • Referral to special care centers for very small/preterm babies • Infection prevention

•

Management of Preterm Birth

CARE OF THE PRETERM OR LOW BIRTH WEIGHT NEWBORN COMMUNITY/ HOUSEHOLD

• Be prepared for preterm birth and newborn requiring special care

• Clean birth practices • Recognition of preterm or small newborn • Essential care for small babies (infant stimulation to

breathe, drying, warming, continuous skin-to-skin contact and immediate/exclusive breastfeeding or alternative method to feed breastmilk)

• Chlorhexidine for cord care at home births in settings with newborn mortality over 30 per 1000, or to replace application of harmful substances (single application for babies <28 weeks)

• Prompt referral to health facility for care of preterm or small newborn

• Household sanitation including hand washing and other hygiene practices

• High frequency follow up care for preterm and small babies at home post-facility discharge: careful growth monitoring; support to mother for exclusive breastfeeding till 6 mo; support for continuous skin-to-skin contact; identification of newborn problems

• Identification and prompt referral to health facility for new onset of newborn problems

HEALTH CENTER • Be prepared for preterm birth and newborn requiring special care

• Confirm GA at birth • Eye care, vitamin K and clean dry cord care • Essential care for small babies including newborn

resuscitation • For newborns who present with danger signs

(abnormal temp, respirations, feeding difficulties, lethargic or with seizures) give antibiotics and immediately refer to advanced care

• For newborns <32 weeks and/or <2000 gms immediate transfer to advanced care

• Continuous skin to skin contact is recommended for the routine care of neonates weighing <2000g at birth as soon as they are clinically stable

• Ongoing essential care for preterm and small babies • Infection prevention • Linkages to community providers for home-based small

baby checks including feeding and growth monitoring; and childhood Immunizations post-facility discharge

• Monitor for developmental milestones • Monitor for new onset of newborn problems and

manage or refer according to country guidelines • Neonates weighing ≤2000g at birth should be provided

with as close to continuous skin to skin contact as possible

HOSPITAL • Be prepared for preterm birth and newborn requiring special care

All of above PLUS • Essential care for small babies: continuous skin to skin

contact + supplemental feeding + monitored oxygen use during stabilization + strict hygiene

• During ventilation of preterm babies born ≤32 weeks gestation, it is recommended to start oxygen therapy with 30% oxygen or air (if blended oxygen is not available), rather than with 100% oxygen

• Transfer extreme newborns (<28 weeks) and/or small newborns (<1200 gms) to advanced care (where available)

All of above PLUS • Management and treatment of preterm and small infant

with complications (inadequate feeding, respiratory conditions, infections, severe jaundice)

• CPAP with oxygen titration using blender and pulse oximeter for RDS, surfactant for RDS with intubation/ventilation

• Monitored oxygen use to minimal required • Support for transfer to local care and follow up after

discharge

TERTIARY or REFERRAL HOSPITAL

• Be prepared for preterm birth and newborn requiring special care

All of above care PLUS • Neonatal intensive care for extreme preterm

newborn (<28 weeks) and/or small newborns (<1200

All of above care PLUS • Continued advanced care for extreme premature infants

<28 weeks

LABOR & DELIVERY IMMEDIATE POSTNATAL CARE LATER POSTNATAL CARE

•Recognition of preterm or small newborn •Essential care for small babies (infant stimulation to

breathe/HBB, drying, warming, continuous skin-to-skin contact and immediate/exclusive breastfeeding or alternative method to feed breast milk)

•Chlorhexidine for cord care at home births • Eye care, vitamin K and clean dry cord care •For newborns who present with danger signs (abnormal

temp, respirations, feeding difficulties, lethargic or with seizures) give antibiotics and immediately refer to advanced care

•Lactation and feeding support •Post-facility discharge counseling and follow-up in the

community; growth monitoring • Infection prevention

Care or Preterm and LBW Baby

• Building the enabling environment for improved maternal and newborn health along the continuum of care is a shared responsibility among families, communities, civil society organizations, religious groups, professional organizations, the private sector and governments

• Integration of preterm prevention, management and care for the mother and newborn can be integrated into RMNCH existing programs

• There are evidenced-based interventions and services that

are simple, low-cost and life-saving that are not new- but just good quality of care

Discussion

Questions/Discussion

Every Preemie—SCALE Team Program Director: Judith Robb-McCord Program Officer: Chelsea Dunning Sr. Operations Officer: Rebecca Freeman Technical Team: Carolyn Kruger (PCI) Jim Litch (GAPPS) Suzanne Stalls (ACNM)