Ten Best practices for managing

Sick & preterm babies for Professionals

‘First Do No Harm’
Dr Ashok Deorari MD FAMS FNNF
Prof & Head, Department of Pediatrics,
President NNF-2020
Chairman Skill Centre
Lead for QI–WHO SEARO
Member WHO Global QED Network
Head , WHO Collaborating Center for Training and Research In
Newborn Care
All India Institute of Medical Sciences, New Delhi

Conflict of interest –None

Outline

• Burden of prematurity & why prematurity is the focus ?

• High impact interventions
• Saving quality lives with best practices
• Multimodal Blended Education for Professionals
• Key messages
 01/09/2017

Preterm birth – ‘Born too soon’

Babies born alive before 37 completed weeks of

pregnancy
1.Late and moderate preterm ( 32 to <37 wks) - 84%
2.Very preterm ( 28 to <32wks) -11%
3.Extreme preterm ( <28wks) - 5%
Preterm births-where are the biggest numbers? 01/09/2017

10 countries
account for 60% of
the world’s preterm
births

1. India
2. China
3. Nigeria
4. Pakistan
5. Indonesia
6. United States
of America
7. Bangladesh
8. Philippines
9. Dem Rep
Congo
10. Brazil

Truly a global problem, affecting all countries

60% are in South Asia and sub-Saharan Africa but with less care
Note: rates by country are available on the accompanying wall chart. Not applicable=non WHO Members State
Source: Blencowe et al National, regional and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications
 Survive ,Thrive & Transform
5 Care for Every small and sick
Newborn -2018

1.Time is to transform care

2.What the number tells us
3.Deliver the care they need and are entitled to
4.Ensure they thrive well
5.Use data for action
6.Act now !
Maternal M1-5
High impact interventions Newborn N1-5
Key packages

partum care

neonate care
900,000
787 500

Small/sick
Intra-
800,000

41%
700,000
580 900
600,000

30
Newborn deaths

500,000
%
400,000

300,000 234400
113 800 189300
200,000 43 400 12%
10%
100,000

-
Preconception Antenatal Care Care During Labor & Immediate Newborn Care Of The Normal Care Of The Small &
Lancet 2014 Nutrition Care Child Birth including Care Newborn Sick Newborn
complications
M1- Potential for lives saved through steroid
injections for women in preterm labor
Single course of ANCS to women in Dexamethasone is low cost (<$1)
preterm labour and available in many settings
• 31% Mortality reduction (RR 0.69, • Low coverage in low and middle
95% CI 0.58 to 0.81) for babies in income settings
settings where ventilation (+/-
surfactant is standard of care
(Cochrane review : CD004454)
• 53% reduction in mortality in 4 studies
in middle income countries (RR 0.47,
95% CI 0.35 to 0.64)
 M2-Best practices in delivery room

Skin to skin contact in the delivery room

• Better breast feeding rates
 32% higher chance that baby would have been
successfully breast fed in the first feed
• Longer duration of breast feeding
24% higher chance to breast feed at 1-4 months
• Higher blood glucose levels in the newborn

Moore ER et al. Early skin‐to‐skin contact for mothers and their healthy newborn infants.
Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD003519.
 M3-Best practices in delivery room

Delayed umbilical cord clamping

• Not earlier than 1 min after birth
(WHO recommendation)
• Decreased need for blood
transfusions by 39%
• Higher blood pressure and blood
volume
• Lower risk of IVH by 41%
• Lowers risk of NEC by 38%

Rabe H et al. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm
birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248
 M4-Best practices: Early initiation of
breastfeeding (1sthour)
Advantages of early initiation of breastfeeding
• Improved success with latch/suckling in first days
• Timely switch from colostrum to milk production
• Improved milk volume at 4 days, 4 weeks, 4 mon

www.who.int/elena/titles/early_breastfeeding/en/
Delayed breastfeeding initiation increases risk of neonatal
Early Initiation of Breast Feeding mortality. Edmond, Zandoh et al. Pediatrics Mar 2006
22% Reduction in NMR
IPA 180319
ashokdeorari@gmail.com
 M5 -Best practices in hospital

Family centred care

• Involving mothers in the care ( RCT-India )
 Incidence of nosocomial episodes of sepsis was
not different between two groups
• Better continuity of care at home
 Pre discharge breast feeding higher 81% vs 68% ( p<0.005)

Family-Centered Care to Complement Care of Sick Newborn : A Randomized Controlled Trial

Ankit Verma, Maria Arti et al Ind Ped Vol 54, June15, 2017
 N1-Dividends of Resuscitation
Training
• SFNRT (Standardised formal neonatal resuscitation training) compared to basic newborn resuscitation, in
developing countries, results in a reduction of early neonatal and 28-day mortality (CD009106)

• Reduction in early neonatal mortality by 21% in traditional birth attendants (Moderate quality evidence )

Impact of education and training on neonatal resuscitation practices in

14 teaching hospitals in India .Deorari et al Annals of Trop Ped 2001,21:29-33
N2- Resuscitation :safe oxygen use

• Oxygen use with newborns: Retinopathy of

prematurity (ROP) and lung injury
• Begin positive-pressure ventilation in
preterms with 30% FiO2
• Use blenders to provide Fio2 b/w 21%-100%
• Adjust oxygen concentration after 30 seconds
in steps of 10% to reach target Spo2
https://www.everypreemie.org/donoharmbriefs
N3-Use of expressed breast milk

• Decreased incidence of sepsis, mortality

• Deceased incidence and severity of necrotizing
enterocolitis
• Improved feed tolerance, advancement of feeds
• Decreased retinopathy of prematurity
• Decreased bronchopulmonary disease
• Cost effective
https://www.everypreemie.org/donoharmbriefs
 N4- Implementation of
best practice kangaroo
mother (and father) care
Advantages of Kangaroo Care
Improved survival of LBW in resource-limited settings
Support of breastfeeding/ breast milk feeding
• improved growth
• infection prevention
• thermal stability
• shorter facility stay
https://www.healthynewbornnetwork.org/hnn-content/uploads
/ PA-KMC-Joint-Statement_final_2017.pdf

15
Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants.
Cochrane Database of Systematic Reviews 2016, Issue 8.
 IPA 180319 ashokdeorari@gmail.com

16

N5- Continuum of Care..

In Community is a must
Digital Learning REAC HING THE
EVERY NEWBO RN
INNOVATION (embraced NATIO NAL 2020
M ILESTO NES
low fidelity models to teach CO UNTRY PRO G RESS, PLANS AND M OVING FO RWARD

point of care management)

M AY 2017
Standard treatment
protocols for
management of
Sick Newborn-WHO SEARO
• Small group learning
• Wall charts
• Neonatalie /Preemie
/Breast model
• Case based learning
• Debriefing
Healthcare provider performance review
Effectiveness of strategies to
improve health-care provider
practices in low-income and
middle-income countries:
a systematic review

Lancet Glob Health 2018; 6: e1163–75 October 2018

 Improvement Science plus
Accreditation (QA )structure
‘4 step’ simplified approach

Identifying
Analyzing and Developing and
problem Sustaining
measuring quality testing changes
Forming Team improvement
of care PDSA
& Aim Statement

www.aiimsqi.org
A Quality Improvement Initiative: Improving Exclusive Breastfeeding Rates of Preterm Neonates
The Indian Journal of Pediatrics April 2017,Volume 84, Issue 4, pp 322–325
Educational package: Learner and
Facilitator guide part 1 and part 2
E Learning platform
www.pretermcare-eliminatingrop.com
Focus on self learning followed by skill learning and
simulation at partner /your own institution
E learning platform-Focus on self learning followed
by skill learning and simulation at partner institution
www.pretermcare-eliminatingrop.com

ADVANTAGES
• Auto generation of
certificate
• Self directed, mentor
monitored online learning
• Synchronous and
asynchronous interaction
Ten modules-Make in India for India !
Using latest technology ,high class mobile
reflective contents
Webinars-65 Short Videos-130
 Hard work of over 45
neonatologists,
nursing professionals and
supporting faculty