Updates in neonatology by mohana (2018)

S.K. Mohanasundari PhD scholar
Faculty, college of Nursing
AIIMS, Jodhpur
11/6/2018 1

SPEAK OUT THE COLOR NOT
THE WORD’S
11/6/2018 2

OBJECTIVES
At the end of the seminar the
delegates are able to
1. explain the current status of newborn mortality and
new born health facility in India
2. explain current status of neonatal intensive care
services in India
3. explain the neonatal golden hour
4. Explain about neonatal golden minutes-key updates
in neonatal resuscitation
5. discuss current status, challenges, and the way
forward in neonatal research in India.

TERMINOLOGY
1. Early neonatal period (ENP)
2. Late neonatal period (LNP)
3. Post naonatal period (PNP)
Infant period
Peri-natal period
FP ENP LNP PNP
22 wks of GA Birth 7 days 28 days 1 yr
Neonatal period
11/6/2018 5

INTRODUCTION:
NEONATOLOGY:
Neo, "new", natal, "pertaining to birth or origin’’.
It is a hospital-
based specialty, and is usually practiced in Neonatal In
tensive Care Unit (NICUs)
Neonatology is a subspecialty of Pediatrics that
consists of the medical care of newborn infants,
especially the ill or premature newborn (up to 28 days
after birth)
11/6/2018 6

36.6
34.3
30.6
26
22.1
19 18
0
5
10
15
20
25
30
35
40
1990 1995 2000 2005 2010 2015 2017
World -NMR
Neonatal Mortality Rate: trends and
projections
(Sources form WHO & UNICEF -2018)
11/6/2018 8

UNICEF published its first-ever report
on the NMR 20th February 2018
11/6/2018 9

Ranked 12th position in NMR - 2018
11/6/2018 10

Ranked 12th position in NMR - 2018
India NMR
25.4/1000 live
birth
11/6/2018 11

The major reason of having such high
mortality rate is due to
• lack of availability and accessibility to proper
healthcare, well-trained health workers, clean
water, proper nutrition and education about the
dos and don’ts of childcare.
• There is also a desperate need to create awareness
about sex selection, where the girl child is
unwanted.
11/6/2018 12

Neonatal mortality: causes (Globally)
11/6/2018 13

Neonatal mortality: causes (INDIA)
11/6/2018 14

NMR=10/1000
State wise disparity in NMR -2018
11/6/2018 15

NMR=44/1000
11/6/2018 16

57% of total
NMR
11/6/2018 17

25.4 /1000
18/1000
12/1000
0 5 10 15 20 25 30
India NMR
2018
Global NMR
2018
Global taget
by 2030
SDG’S global target on NMR by 2030
is
11/6/2018 18

India is far from attaining SDG target of
NMR (12/1000 LB by 2030) due to--
11/6/2018 19

India is far from attaining SDG target of
NMR (12/1000 LB by 2030) due to--
11/6/2018 20

976
964 962
945
927
914
900
860
880
900
920
940
960
980
1000
1961 1971 1981 1991 2001 2011 2015
11/6/2018 21
Falling number of girls aged 0-6
years/1000 boys in India since 1961

UNICEF -2018 report identified one
positive aspect about under five mortality
rate in India
11/6/2018 22

UNICEF global campaign on
“Every Child Alive”
1. Firstly, recruiting and training sufficient doctors and
nurses with expertise in maternal and newborn care.
2. Secondly, guaranteeing clean, functional health
facilities equipped with water, soap and electricity,
within the reach of every mother and baby, a major
area of concern for India.
3. Thirdly, making it a priority to provide every mother
and baby with the life-saving drugs and equipment
needed for a healthy start in life;
4. and lastly empowering adolescent girls, mothers and
families to demand and receive quality health care.
11/6/2018 23

INDIA HEADWAYS TO NMR
Milestones in Child Survival Programmes in India
1. Child Survival and Safe Programme (CSSM)
Motherhood (1992)
2. RCH I (1997)
3. RCH II (2005)
4. National Rural Health Mission (2005)
5. RMNCH+A Strategy (2013)
6. National Health Mission (Rural and urban)
(2013)
7. India Newborn Action Plan (INAP) (2014)
11/6/2018 24

Motherhood (1992)
2. RCH I (1997)
3. RCH II (2005)
(2013)
11/6/2018 25

Motherhood (1992)
2. RCH I (1997)
3. RCH II (2005)
(2013)
11/6/2018 26

INTERVENTIONS UNDER NATIONAL HEALTH
MISSION FOCUSING ON NEWBORNS
1. Janani Suraksha Yojana (JSY) (2005)
2. Integrated Management of Neonatal and
Childhood Illnesses (IMNCI) at the community
level and F-IMNCI at health facilities (2007)
3. Navjat Shishu Suraksha Karyakram (NSSK) (2009)
4. Janani Shishu Suraksha Karyakram (JSSK) (2011)
5. Facility Based Newborn Care (FBNC) (2011)
6. Home Based Newborn Care (HBNC) (2011)
7. Rashtriya Bal Swasthya Karyakram (RBSK) (2013)
11/6/2018 27

11/6/2018 28

11/6/2018 29

Childhood Illnesses (IMNCI) at the community level
and F-IMNCI at health facilities (2007)
11/6/2018 30

11/6/2018 31

3. Navjat Shishu Suraksha Karyakram (NSSK)
(2009)
7. Rashtriya Bal Swasthya Karyakram (RBSK) (2013)11/6/2018 32

11/6/2018 33

Childhood Illnesses (IMNCI) at the community level
and F-IMNCI at health facilities (2007)
11/6/2018 34

INDIA NEWBORN ACTION PLAN (INAP)
Goal: 1 Reduce NMR to single digit by 2030
11/6/2018 36
Projected level of NMR in India from 2012 to 2035

Goal-2: Reduce SBR to single digit by 2030
11/6/2018 37
INDIA NEWBORN ACTION PLAN (INAP)
Projected level of SBR in India from 2012 to 2035

SNAPSHOT OF INDIA NEWBORN ACTION PLAN (INAP)
• Builds on existing commitments under the National Health Mission
and 'Call to Action' for Child Survival and Development
• Aligns with the Global Every Newborn Action Plan (ENAP); defines
commitments based on specific contextual needs of the country
• Aims at attaining Single Digit Neonatal Mortality Rate by 2030, five
years ahead of the global plan
• Emphasizes strengthened surveillance mechanism for tracking
stillbirths
• Focuses on ending preventable newborn deaths, improving quality of
care and care beyond survival
• Prioritizes those babies that are born too soon, too small, or sick—as
they account for majority of all newborn deaths
• Aspires towards ensuring equitable progress for girls and boys, rural
and urban, rich and poor, and between districts and states
• Serves as a framework for states/districts to develop their own action11/6/2018 38

INAP IS GUIDED BY THE PRINCIPLES OF
11/6/2018 39
Principles of
INAP
1. Equity
2. Gender
3. Quality of
care
4. Convergence
5. Accountability
6. Partnership

INAP INCLUDES SIX PILLARS OF INTERVENTION
PACKAGES
11/6/2018 40
6. Care beyond
newborn survival
5. Care of small & sick
newborn
4. Care of healthy newborn
3. Immediate newborn care
2. Care during labour &
child birth
1. Preconception
& antenatal care

Family and Community Outreach/Sub Centre Health Facility
Reproductive Health & Family
Planning
- Adolescent reproductive
health
- Delaying age of marriage &
first
pregnancy
- Birth spacing
2. Nutrition related
interventions
- Balanced energy protein
supplementation
- Peri-conceptional folic acid
- Maternal calcium
supplementation
- Multiple micronutrient
supplementation (Iron, Folic
Acid & Iodine)
- Nutrition Counselling
Antenatal screening for
Anemia and Hypertensive
disorders of pregnancy
(PIH, Preeclampsia, Eclampsia)
6. Antenatal screening for
Malaria
7. Prevention and management
of mild to moderate anemia
8. Maternal tetanus
immunization
9. Adolescent friendly
health services (nutrition
and reproductive health
counselling)
10. Interval IUCD insertion
Antenatal screening &
management of Severe anemia,
Hypertensive disorders of
pregnancy (PIH, Preeclampsia,
Eclampsia), Gestational
Diabetes,
Syphilis
12. Antenatal screening &
management of
Hypothyroidism,
Hepatitis B, HIV, Malaria
13. Adolescent friendly health
clinics
(as per RKSK guidelines)
14. Post-partum family planning
services including PPIUCD
insertion
15. Prevention of Rh disease
using
11/6/2018 41
1. Preconception
& antenatal care

11/6/2018 42
1. Skilled birth
attendance
2. Clean birth practices
3. Identification of
complications and
timely referral
4. Pre-referral dose by ANM
- Antenatal corticosteroids in
preterm labour
- antibiotics for premature
5. Emergency obstetric care
- Basic and Comprehensive
6. Management of preterm
labour
- Antenatal corticosteroids
in preterm labour
- Antibiotics for
2. Care during
labour & child
birth

11/6/2018 43
1. Delayed cord clamping
2. Interventions to prevent
hypothermia
• Immediate drying
• Head covering
• Skin-to-skin care
• Delayed bathing
3. Early initiation and exclusive
breastfeeding
4. Hygiene to prevent infection
5. Vitamin K at birth
6. Neonatal Resuscitation
Advanced neonatal
resuscitation
3. Immediate
newborn care

11/6/2018 44
1. Home visits till six weeks by
trained ASHA
• Counseling
• Prevention of hypothermia,
cord care
• Early identification of danger
signs
• Prompt and appropriate
referral
2. Exclusive breastfeeding
3. Clean postnatal practices
4. Immunization
• BCG
• OPV
• Hepatitis B
All the interventions
(except
home visits)
4. Care of
healthy newborn

11/6/2018 45
1. Thermal care and
feeding support (for
home deliveries)
2. Integrated management
using IMNCI and use of oral
antibiotics
3. Injectable Gentamicin by
ANMs for sepsis
• Pre referral
• Completion of antibiotic
course in case referral is
refused / not possible “OR”
as advised by treating
physician
4. Kangaroo mother care at
facility
5. Full supportive care at
block and district level
• NBSU at block level
• SNCU at district level
6. Intensive care services
(NICU) at regional level for
• Assisted ventilation
• Surfactant use
5. Care of small &
sick newborn

11/6/2018 46
1. Screening for birth
defects,
failure to thrive and
developmental delays
2. Follow up visits of
- SNCU discharged babies
till 1 year of age
- small and low birth
weight babies till 2 years
of age
3. As before 4. Newborn screening
5. Management of birth
defects
- Diagnosis
- Treatment, including
surgery
6. Follow-up of high-risk
infants (discharged from
SNCUs,
and small newborns) for
- Developmental delay
- Appropriate
management
6. Care beyond
newborn survival

EVOLUTION OF NICU SERVICES
• In 1898 Dr. Joseph DeLee  first premature infant
incubator station in Chicago,
• in 1922. The first American textbook
on prematurity
•In 1931 Dr A Robert Bauer  first incubator to
combine heat, and oxygen, as well as humidity .
•The 1950s  advent of mechanical ventilation of
the newborn.
•In 1952 Dr. Virginia Apgar described the Apgar
score scoring system as a means of evaluating a
newborn's condition.
• In 1965 that the first American newborn intensive
care unit (NICU) was opened in New Haven11/6/2018 48

EVOLUTION OF NICU SERVICES
•In the 1980spulmonary surfactant replacement therapy
further improved survival of extremely premature infants and
decreased chronic lung disease one of the complications
of mechanical ventilation, among less severely premature
infants.
• In 2006 newborns as small as 450 grams and as early as 22
weeks gestation have a chance of survival.
• In modern NICUs, infants weighing more than 1000 grams
and born after 27 weeks gestation have an approximately
90% chance of survival and the majority have normal
neurological development
11/6/2018 49

BRIEF UPDATE OF THE MOST IMPORTANT
RECENT CHANGES IN NEONATAL MEDICINE.
• Surfactant treatment-> Prophylaxis and rescue
treatment
• Inhaled nitric oxide
• Prophylaxis against group B streptococcal
infection
• Extra corporeal membrane oxygenation
• High frequency oscillation ventilation
11/6/2018 50

Surfactant treatment
11/6/2018 51

Inhaled nitric oxide
11/6/2018 52

Prophylaxis against group B
streptococcal infection
11/6/2018 53

High frequency oscillation ventilation
11/6/2018 55

REASON FOR ADVANCED FACILITIES IN NICU
SERVICES
11/6/2018 56
Reason for
advanced
facilities.
1. Consumer
demand
2. Educated
parents
3. The ability
to pay for
high-end care
4.Availability of
insurance
5. Liberalisation of
economy
6. Better funding
from the
government

LEVELS OF NICU CARE IN INDIA:
11/6/2018 57
Level-I I
• Basic resuscitation and healthy newborn care,
Level-2
• Preterm care >32 weeks GA (subdivided into IIA and IIB
based on brief ventilation of <24 h and CPAP support)
Level-3
• Extreme preterm care.(subdivided into III A and III B)

LEVELS OF NICU CARE IN INDIA:
1. Private sector hospitals: level II A or B; some are even level
IIIA. The neonates who require extensive support, prolonged
ventilation and surgical/cardiac procedures are referred to
tertiary-level centres (level IIIA or B) in larger hospitals;
transport facilities are provided by the referral centre.
2. Public sector hospital care and SNCUs
Under the NRHM, a network of facility-based newborn care
has been established at different levels.
•Primary care providers are newborn stabilisation units
(NBSU).
•Secondary care is provided in SNCUs
11/6/2018 58

MANPOWER ISSUES IN NICU:
11/6/2018 59

11/6/2018 60

11/6/2018 61

•A specialised training programme for doctors under the
Doctorate of Medicine /Diplomat of the National Board in
Neonatology is being conducted by many centres, producing
>40 specialists annually.
• Similarly, shorter fellowship programmes of 12 months
produce >80 neonatal specialists annually.
•Apart from training, retaining doctors and nurses is a big
challenge.
•These issues could be overcome by securing or centralizing
the permanent jobs, compulsory medical service following
training, improving the future prospects and enrolling into
fellowship programmes.11/6/2018 62

EQUIPMENTS ISSUES IN NICU:
•Equipment shortage, high cost of capital expenditure,
maintenance issues, costly repairs, delayed arrival of newer
technology, and so on were major setbacks in the
development of NICUs in the past.
• However, the situation has significantly changed in the last
decade with liberalization, easy imports and indigenization.
Indigenous equipment have led to cost reduction in NICUs in
the country.
• Alternate low-cost devices like thermal care devices are
being used in resource constrained areas.
11/6/2018 63

COSTS AND FUNDING FOR NICU CARE
Private sector hospitals
•Costs here are either self-funded by the family or through
insurance and are exorbitant, but the emergence of insurance
has given a great boost to families.
•In 2003, a study on costing of NICU care in India found the
average total NICU cost to be US $3800, US$2000 and US$950
for ELBW, VLBW and LBW infants, respectively.
• The current cost is probably 3–4 times more; the estimated
cost of a sick neonate on cardiopulmonary support is
US$385–600 per day.
11/6/2018 64

COSTS AND FUNDING FOR NICU CARE
Public sector hospitals
•Under the umbrella of the National Rural Health Mission, the
Government of India launched the Janani Shishu Suraksha
Karyakram ( JSSK) in 2011, which unquestionably signals a
huge leap forward in the quest to make ‘Health for All’ a
reality and assures ‘nil out of pocket expenses’ in all
government institutions.
•The scheme provides free and cashless services to pregnant
women accessing public health institutions including the
delivery and the caesarean section charges and also
treatment of the sick newborns till 30 days of life.
11/6/2018 65

THE NEONATAL GOLDEN HOUR:
•The concept of “Golden Hour” has been introduced
recently in field of neonatology, highlighting the
importance of neonatal care in the first 60 minutes of
postnatal life .
•The prime objective of golden hour is to use
evidence based interventions and treatment for better
neonatal outcome, importantly for extremely low
gestational age neonates (ELGAN).
11/6/2018 67

Various components of “Golden 60 minutes” project for
term and preterm newborn:
S. no Components
1 Antenatal counseling and team briefing
2 Delayed cord clamping
3 Prevention of hypothermia/temperature
maintenance
4 Support to respiratory system
5 Support to cardiovascular system
6 Early nutritional care
7 Prevention of hypothermia
11/6/2018 68

Various components of “Golden 60 minutes” project for
term and preterm newborn:
S. no Components
8 Initiation of breast feeding
9 Infection prevention
10 Starting of therapeutic hypothermia for
birth asphyxia
11 Laboratory investigation
12 Monitoring/record
13 Communication with family
11/6/2018 69

Figure showing golden hour interventions to be done at the time of preterm and term newborn birth
11/6/2018 70

THE NEONATAL GOLDEN MINUTE
The first 60 second of a newborn's life can be the
most critical and considered as Golden minute. .
11/6/2018 72

:
KEY UPDATES IN NEONATAL RESUSCITATION:
Indications for neonatal resuscitation: AHA
Guidelines
•Preterm
•Poor muscle tone
•Poor breathing or crying
Indications for neonatal resuscitation: NNF
Guidelines
•Poor or no breathing or crying
11/6/2018 74

1. Order of the assessment
2. The sequence of actions during Golden minute
a) The Initial steps
b) Reevaluation
c) Beginning of Ventilation and oxygen
3. Time of cord clamping
4. Temperature
a) In fully equipped hospital
b) In resource-limited settings.
5. Intervention for Newborn born with meconium-
stained amniotic fluid:
11/6/2018 76

6. Assessment of accurate heart rate: A 3-lead ECG is
recommended
7. Oxygenation
8. laryngeal mask
9. Chest compression
10. Epinephrine during CPR and volume
administration
11. Induced therapeutic hypothermia
13. Withholding or withdrawing resuscitation
14. NR task training interval
11/6/2018 77

WHERE DOES INDIA STAND IN THIS NEW
SCENARIO?
•Neonatal research has accelerated in India in the last
decade but the current status cannot be considered
satisfactory.
•Its contribution in major indexed Indian journals is
approximately 9–12%.
•The majority of studies are unicentric and hence the
main drawback of acceptance internationally.
•Few multicentric trials, have provided valuable
information. There is a need for robust neonatal
network for collaboration and to initiate multicentric
trials.
11/6/2018 79

TYPES OF STUDIES IN NEONATOLOGY
11/6/2018 80

MAJOR TOPICS FOR RESEARCH IN NEONATOLOGY:
11/6/2018 81
0
0.05
0.1
0.15
0.2
0.25
0.3
28.8%
12.2%
6.8%
5.9% 6.6%
3%
0

AUTHOR AFFILIATION FOR NEONATAL STUDIES
11/6/2018 82
Govt
academic
insitutions
66.3%
Non Govt
academic
insitutions
24.5%
others
9.2%

SETTINGS OF THE STUDIES
11/6/2018 83
Facility
based
setting
86.8%
Community
based
setting
11%
Multisite
setting
3.2%

FUNDING FOR THE STUDY
11/6/2018 84
0
10
20
30
40
50
60
70
80
Self funding External
funding
Major indian
research
funding bodies
73%
22.6%
4.4%

•The number of publications (n=2,020) in the last 10 years retrieved
on the search does look impressive, but a simple comparison with
China shows us how much India lags behind - a total of 3,827
articles were identified by the same search strategy on replacing
“India” with “China”.
•Interestingly, only 8 % (337/4164) of the articles identified for
China were case reports.
• In contrast, more than a quarter of all articles from India were
case reports (764/2784; 27.4 %). There are a total of 242 medical
colleges offering M.D.
NUMBER OF PUBLICATIONS
11/6/2018 85

•Out of 13 colleges and 5 institutions who ofer DM
neonatology and DNB neonatology, undertaken over
10.000 research studies in pediatrics in last 10 years as
a part of PG disseration, a significant proportion of
which is likely to be in neonatology.
•However, only a small fraction of it gets translated to
publications. It is also to be noted that only a few
institutions contribute to major proportion of
published research in the field. It is therefore
imperative to identify means to harness the research
capacity of other institutions.
•The study designs seem to be tilted in favor of studies
at lower hierarchy of evidence.11/6/2018 86

•However, the distribution seems a little skewed with
the number of studies on hyperbilirubinemia exceeding
those on birth asphyxia, a major cause of neonatal
mortality (6.8 % vs. 5.9 %).
•Similarly, the number of studies on retinopathy of
prematurity far exceeded the number on respiratory
distress syndrome or even thermal care of preterm
neonates.
•Most studies were facility based, primarily investigator
driven with little external funding, and had small
sample size. The data on impact factor and citation
profile – possibly surrogate markers of quality and
utility of a research article - suggests that most studies
from India do not rank high on these two parameters.11/6/2018 87

CHALLENGES IN NEONATAL RESEARCH:
1. Faculty crunch in medical colleges
2. In adequate technical expertise in research
methods
3. Lack of funding
4. Limited access to literature
5. System issues
6. Non Existence of Research Administration
Unit/Cell
7. Research staff related issues
8. Poor IT and Statistical Support
9. Lack of national research priorities
10.Revised regulations for clinical trials
11/6/2018 88

Conclusion
11/6/2018 89
CONCLUSION
1. Last 10 years the newborn mortality has shown significant reduction
globally, but INDIA is still on the way to achieve SDG’s goal .
2. India is launching more health programs which focus on newborn
care to control NMR, also those programs are giving significant
expected outcome.
3. Recent advances in NICU services brought significant reduction in
NMR.
4. The components of golden hour in newborn care helps in reducing
NMR significantly, frequent revising of NR by The AHA and NNF
further contributing to effective newborn care.
5. The research in neonatology seems to be increasing from last 10
years. And it definitely will aid for evidecne based care in
neonatology and help India achieve NMR to single digit by 2030.

REFERENCES:
1. India newborn action plan. http://nrhm.gov.in/images/pdf/programmes/inap-
final.pdf
2. Sundaram V, Chirla D, Panigrahy N, et al. Current status of NICUs in India: a
nationwide survey and the way forward. Indian J Pediatr 2014;81:1198–204.
3. Narayan S, Aggarwal R, Upadhyay A, et al. Survival and morbidity in extremely low
birth weight (ELBW) infants. Indian Pediatr 2003;40:130–5.
4. WHO, UNICEF. Home visits for the newborn child: a strategy to improve survival –
WHO/UNICEF Joint Statement. Geneva, Switzerland: WHO; 2009.
5. Gogia S, Sachdev HS. Home visits by community health workers to prevent neonatal
deaths in developing countries: a systematic review. WHO. 2010; 88(9): 658–666.
6. Perlman JM, et all neonatal resuscitation: 2015 Circulation.2015;132(suppl 1):S204–
S241.
7. Shuchita Gupta & Suman Chaurasia & M. Jeeva Sankar & Ashok K. Deorari & Vinod
K. Paul & Ramesh Agarwal. Neonatal Research in India: Current Status, Challenges,
and the Way Forward Indian J Pediatr (November 2014) 81(11):1212–1220.
8. Deepak sharma. Golden hour of neonatal life: Need of the hour. Matern Health
Neonatol Perinatol. 2017 Sep 19. 3: 16.
11/6/2018 90

REFERENCES:
10. Reynolds RD, Pilcher J, Ring A, Johnson R, McKinley P. The Golden Hour: care of the
LBW infant during the first hour of life one unit’s experience. Neonatal Netw NN. 2009
Aug;28(4):211-219; quiz 255-258
11. Morley CJ (1997) Systematic review of prophylactic versus rescue surfactant. Arch
Dis Child 77:F70–FF4.
12. Soll RF. Update Software. Prophylactic administration of natural surfactant
(Cochrane review). 4 edn. Oxford: 1998..
13. Soll RF. Update Software. Prophylactic synthetic surfactant in preterm infants
(Cochrane Review). 4 Edn. Oxford: 1998..
14. Jobe AH, Mitchell BR, Gunkel JH (1993) Beneficial effects of the combined use of
prenatal corticosteroids and postnatal surfactant on preterm infants. Am J Obstet
Gynecol 168:508–513.
15. Soll RF (1996) Appropriate surfactant usage in 1996. Eur J Pediatrics 155:S8–S13.
16. Findlay RD, Taeusch HW, Walther FJ (1996) Surfactant replacement therapy for
meconium aspiration syndrome. Pediatrics97:48–52.
17. Soll RF, Morley CJ.Update Software. 4 Edn.Prophylactic surfactant versus treatment
with surfactant (Cochrane Review).Oxford: 1998..
11/6/2018 91

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