2. Introduction Care at birth When a newborn baby should be examined ? Danger signs Examining the newborn at birth High risk neonates Prevention of hypothermia Prevention of infection Immunisation Normal phenomena after birth Resuscitation of newborn not breathing soon after birth Care of LBW babies Care of sick newborn babies Special situation Training Health Programmes Key messages References.
3. INTRODUCTIONWORLD: NMR: 4 millions/yr 50% in 1st 24 hrs 2/3rd in South-East Asia , AfricaINDIA: 61.3% of infant deaths -in neonatal period. 50% of these deaths-in 1st wk of life. NFHS-3(05-06): 2/3rd of IMR & ½ of U5MR Major causes: birth asphyxia hypothermia infections Essential Newborn Care(ENC).
4. CARE AT BIRTH Delivery room- 5 Cleans PROVISION OF WARMTH: *dry, pre-warmed & clean cloth *200W bulb *dry immediately *do not remove vernix *close contact with mother
5. CORD CARE: *4 ‘C’s *left dry *no antiseptics/dressings EYE CARE: *clean cotton swabs *medial to lateral side *no prophylactic eye applications RECORDING BIRTH WEIGHT: *N: 2.5-3 kg
6. INITIATING BREASTFEEDING: *within 1 hr of birth(within 4hr-C.S.) *advantage for mother baby *no pre-lacteal feeds.
7. WHEN A NEWBORN BABY SHOULDBE EXAMINED ? AFTER BIRTH: + at around 1 hr +before discharge from hospital +if there is a maternal concern about the baby’s condition +if a danger sign is observed during monitoring AFTER LEAVING THE HOSPITAL: +during the 1st wk of life at a routine visit + follow-up + sick newborn visit
8. DANGER SIGNS Not suckling (after 6 hours of age) Fast breathing (> 60 breaths/min) Grunting Eyes swollen and draining pus Yellow skin on face and < 24 hours old > 10 skin pustules
9. EXAMINING THE NEWBORN ATBIRTH IDENTIFICATION OF MALFORMATIONS: hydrocephalus meningomyelocele large omphalocele absent anal openings BREATHING PATTERN: N: 30-40/min irregular periodic at least 1 min quiet,not feeding
10. Respiration is not normal if- RR >60/min intercostal/subcostal retractions assoociated apnoea(+ cyanosis/HR <100 bpm) HR: N: 100-160 bpm ASSESSING PERFUSION: capillary refill time: N- 3s COLOUR: N: pink pale yellow blue
11. APGAR SCORING
12. TEST 0 Points 1 Points 2 PointsAppearance(skin Blue-grey,pale all Pink body & blue Normal over entirecolor) over extremities body,completely pinkPulse(HR) Absent <100 bpm >100 bpmGrimace(Reflex No response Facial grimace Sneeze,cough,pullirritability) s awayActivity(m.tone) Absent Arms & legs Active movement extended with flexed arms & legsRespiration(Breathi Absent Slow,irregular Good,cryingng) N: 7-10, 4-6: mod. Depressed, 0-3: severely depressed. ‘ONLY INDICATES IMMEDIATE HEALTH CONDITION OF BABY’
13. Posture1.Term newborn baby: loosely clenched fists flexed arms, hips, and knees2.Small babies ( 2.5 kg at birth or born before 37 weeks gestation) limbs may be extended3.Babies born in the breech position may have fully flexed hips and knees, feet and mouth, and legs may even reach near the mouth.
14. HIGH RISK NEONATES birth wt. < 1800 g and/or <35 wk GA SFD(<3rd centile) & LFD(>97th centile) Peri-natal asphyxia-APGAR score 3 at 5 min and/ or HIE Mechanical ventilation for >24 hrs Metabolic problems-symptomatic hypoglycemia & hypo- calcemia Seizures Infections- meningitis and/or culture + sepsis Shock requiring inotropic / vasopressor agents Infants born to HIV + mothers Sr. B >20 mg% or requirement of exchange transfusion Major malformations
15. PREVENTION OF HYPOTHERMIA < 36 C 1st signs: less active, doesnot BF well, has a weak cry, has resp. distress STEPS OF WARM CHAIN:1. Warm delivery room2. Warm resuscitation3. Immediate drying4. Skin to skin contact5. BF6. Bathing postponed7. Appropriate clothing8. Mother & baby together9. Professional alertness10. Warm transportation
16. TEMPERATURE RECORDING: axilla/ per rectally at least 3 min N: 36.5- 37.5 C MANAGING HYPOTHERMIA: immediate Tt 200W bulb/45cm or KMC or radiant warmer refer if:
17. PREVENTION OF INFECTION Minimize Neonatal tetanus 5 ‘C’s Cord: dry , clean Exclusive BF Persons with infective disease must not handle the baby till infection is under control.
19. NORMAL PHENOMENA AFTER BIRTH MECONIUM PASSAGE: dark, greenish-black, sticky N: within 24 hrs URINE PASSAGE: N: soon after birth/ by next 24 – 48 hrs after 2nd day, 6 – 7 times/day TRANSITIONAL STOOLS: greenish yellow ed frequency loose (& sometimes watery) N: highly variable; after first 2wk,upto 15-20 times/day or once in 5-6days
20. VOMITTING: mucous gastritis swallow air during feeding pathological if: MONGOLIAN SPOT: bluish-black patches of pigmentation sacral & buttock; also trunk & extremities disappear by 6 months of age ERYTHEMA TOXICUM: an erythematous rash on 2nd/3rd day begins from face & spreads to trunk &extremities over next 24 hrs disappears spontaneously in 2-3 days
21. VAGINAL DISCHARGE/BLEEDING: thin white mucoid secretions Tt: clean it with clean water & keep the place dry upto 25%: menstrual like withdrawl bleeding after 3-5 days of life &for 2-4 days MASTITIS: breast engorgement on 3rd /4th day may last for 2-4 days avoid local massage, fomentation or manual expression of discharging milk
22. PHYSIOLOGICAL JAUNDICE: clinical jaundice after 24 hrs of birth > 15 mg% ng by 7-10 days of lifeIf not, Pathological: immediate referral & Tt >20 mg% - risk of brain damage
23. CAPUT SUCCAEDANEUM: a boggy s/c swelling over scalp soon after birth benign CEPHALHEMATOMA: sub-periosteal hemorrhage does not cross sutural lines can be asso. With anaemia/jaundice
24. RESUSCITATION OF NEWBORN NOTBREATHING SOON AFTER BIRTH Equipment needed: self-inflating bag & mask 02 mucus sucker syringe/needle(no.24) adrenaline(1:1,000) SUCTION: most cry soon after birth but if not started to breathe by the time it is dried start IMMEDIATE RESUSCITATION:
25. 200W bulb/radint warmer extend the neck mucus sucker- 1st mouth , then nose do not use gauge/clothIf still does not cry: flick the soles with fingers 2 or 3 times do not slap the baby/hang upside downIf does not start breathing or is gasping: start ASSISTED VENTILATION with a bag & mask
26. USE OF DRUGS: Adrenaline- when HR <60/min in spite of CC & assisted ventilation 0.1 mg/kg (1:10,000) intracardiac /IVHOW LONG SHOULD RESUSCITATIVE EFFORTS BE CONTINUED ? discontinued if a baby did not establish spontaneous breathing efforts after 30 min after birth In fresh still born babies(1 min APGAR-O) IF NO SIGNS OF LIFE at 10 min
27. CARE OF LBW BABIES India (2000-07): 28% Preterm SFD PREVENTION OF HYPOTHERMIA: rooming-in KMC adequate cloth & dry room free from cold air 100-200W bulb/18 inch from baby temp. recorded at least 3-4 hrly
28. EXCLUSIVE BF: no pre-lacteal feeds early BF 2hrly/more frequently if suck poorly-manual expression/spoon after 7 days of life, gain in BW:15-20 gms/day PREVENTION OF INFECTION: ed risk people with diarrhoea , skin infections & skin infections must stay away if the mother has diarrhoea/respiratory inf.- only breast milk must be wrapped in clean , dry linen & clothing & not placed on dusty/dirty surfaces immunisation-same schedule
29. DISCHARGING A LBW BABY: when it is- feeding well gaining wt. no sickness REFERRING A LBW BABY: >1800g –home mt. 1500-1800g : PHC <1500g : referred to a health facility where specialist care is available
30. CARE OF SICK NEWBORN(IMNCI) MILD ILLNESS: umbilical discharge HOME management conjunctivitis pyoderma SEVERE ILLNESS: Inpatient care at diarrhoea PRIMARY fast breathing/chest compression HEALTH CARE FACILITY feeding poorly ed activity fever
31. PROVIDE WARMTH: 200W bulb/radiant warmer O2: Indications- central cyanosis RR > 60/min severe chest-indrawing nasal canula ( no.8) inserted 2cm into nostril O2 must be humidified & water-warm in absence of O2 monitors, O2 level determined by the level at which cyanosis disappears. ANTIBIOTICS: Inj Amp(50mg/kg BD)+ Inj Gentamicin(2.5mg/kg BD) at least 5 days If no response after 48 hrs: Refer
32. FLUIDS & FEEDING: 1st 2 days – 10D day 3 onwards – 1/6 saline in 10D DAILY FLUID REQUIREMRNTS DURING 1ST WK OF LIFE (50 ML/KG/DAY) : BIRTH DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 WT. & ONWA RDS < 1500g 80 95 110 120 130 140 150 >1500g 60 75 90 105 120 135 150 ORAL FEEDING: started as soon as baby can suck if difficulty in sucking- expressed milk using a NG tube 20ml/kg/feed, 6times /day
33. VERY SEVERE ILLNESS: Iinability to feed persistent hypothermia abdominal distention REFER to health facility which has cyanosis specialist care available apnoea convulsions bleeding severe jaundice grunting/ stridor 1st dose antibiotic a referral slip a vehicle mother with newborn KMC & adequate clothing
34. SPECIAL SITUATIONS IF MOTHER HAS AIDS / TB : immediate skin-to-skin contact BF
35. TRAINING NAVJAAT SISHU SURAKSHYA KARYAKRAM: 1 day basic newborn care & resuscitation 2009(MOHFW, IAP,deptt. of padiatrics , AIIMS)
36. HEALTH PROGRAMMES RCH-II IMNCI JSY VHND MAMATA SCHEME UIP
37. KEY MESSAGES Hand should be washed each time before handling the baby Exclusive BF No pre-lacteal feeds Baby should be kept warm check if body & feet are warm If DANGER SIGNS are present, health care providers should be immediately conacted: not able to take feeds ed drowsiness difficulty breathing/ 60/min
38. yellow staining of palm & soles convulsions Mother is advised to bring the child at 6 wks for immunisation Mother is instructed to keep the immunisation card carefully & encouraged to weigh the child at a near by health centre No pacifier .
39. REFERENCES RCH module for MO(PHC). GHAI essential paediatrics,7th edition PARK’S textbook of preventive & social medicine. 21st edition www.who.int