Janette L.

Ortega,RMT,RN

Essential newborn care (ENC)

is a comprehensive strategy designed to improve the health of newborns through interventions before conception, during pregnancy, at and soon after birth, and in the postnatal period.

ENC comprises: (a) Basic preventive newborn care such as care before and during pregnancy, clean delivery practices, temperature maintenance, eye and cord care, and early and exclusive breastfeeding on demand day and night; (b) Early detection of problems or danger signs (with priority for sepsis and birth asphyxia) and appropriate referral and care seeking. (c) Treatment of key problems such as sepsis and birth asphyxia.

82,000 Filipino children die annually, most could have been prevented

Source: CHERG estimates of under-five deaths, 2000-03

The Philippines is one of the 42 countries that account for 90% of global under-five mortality

Majority of newborns die due to stressful events or conditions during labor, delivery and the immediate postpartum period

What Immediate Newborn Care Practices will save lives?

Four Core Steps of Essential Newborn Care

Immediate and thorough drying of the newborn Immediate and thorough drying for 30 seconds to one minute warms the newborn and stimulates breathing.

Early skin-to-skin contact between mother and newborn Early skin-to-skin contact between mother and newborn and delayed washing for at least six hours prevents hypothermia, infection and hypoglycemia.

Four Core Steps of Essential Newborn Care

Properly-timed cord clamping and cutting Properly-timed cord clamping and cutting prevents anemia and protects against brain hemorrhage in premature newborns. Properly timed cord-clamping means waiting for the cord pulsations to stop (between 1 to 3 minutes).

Non-separation of newborn and mother for early breastfeeding Continous non-separation of newborn and mother for early breastfeeding protects infants from dying from infection. The first feed provides colostrum, a substance equivalent to the babies first immunization in its protective properties.

Time Band: At perineal bulging Prepare for the Delivery

Check temperature of the delivery room 25 - 28 o C Free of air drafts Notify appropriate staff Arrange needed supplies in linear fashion Check resuscitation equipment Wash hands with clean water and soap Double glove just before delivery

Time Band: Within 1st 30 secs Immediate Thorough Drying

Call out the time of birth Dry the newborn thoroughly for at least 30seconds Wipe the eyes, face, head, front and back, arms and legs

Remove the wet cloth

Time Band: Within 1st 30 secs Immediate and Thorough Drying

Do a quick check of breathing while drying Notes: During the 1st secs: Do not ventilate unless the baby is floppy/limp and not breathing Do not suction unless the mouth/nose are blocked with secretions or other material

Time Band 0 - 3 mins: Immediate, Thorough Drying

Notes: Do Do Do No No No

not wipe off vernix not bathe the newborn not do footprinting slapping hanging upside - down squeezing of chest

Time Band: After 30 secs of drying Early Skin-to-Skin Contact b/w Mother & Newborn
If newborn is breathing or crying: Position the newborn prone on the mothers abdomen or chest Cover the newborns back with a dry blanket Cover the newborns head with a bonnet Notes: Avoid any manipulation, e.g. routine suctioning that may cause trauma or infection Place identification band on ankle (not wrist) Skin to skin contact is doable even for cesarean section newborns

Time Band: 1 - 3 mins Properly - timed cord clamping and cutting

Remove the first set of gloves After the umbilical pulsations have stopped, clamp the cord using a sterile plastic clamp or tie at 2 cm from the umbilical base Clamp again at 5 cm from the base Cut the cord close to the plastic clamp

 Notes: Do not milk the cord towards the baby After the 1st clamp, you may strip the cord of blood before applying the 2nd clamp Cut the cord close to the plastic clamp so that there is no need for a 2nd trim Do not apply any substance onto the cord

Time Band: 1 - 3 mins Properly timed cord clamping & cutting

Time Band: Within 90 mins Nonseparation of Newborn from Mother for Early Breastfeeding
Leave the newborn in skin-to-skin contact Observe for feeding cues, including tonguing, licking, and rooting Point these out to the mother and encourage her to nudge the newborn towards the breast Counsel on positioning Newborns neck is not flexed nor twisted Newborn is facing the breast Newborns body is close to mothersbody Newborns whole body is supported

Time Band: Within 90 mins Nonseparation of Newborn from Mother for Early Breastfeeding
Counsel on attachment and suckling Mouth wide open Lower lip turned outwards Babys chin touching breast Suckling is slow, deep with some pauses Notes: Minimize handling by health workers Do not give sugar water, formula or other prelacteals Do not give bottles or pacifiers - Do not throw away colostrum

Time Band: Within 90 mins Nonseparation of Newborn from Mother for Early Breastfeeding
Weighing, bathing, eye care, examinations, injections (hepatitis B, BCG) should be done after the first full breastfeed is completed

Postpone washing until at least 6 hours

Non-Immediate Interventions within 6 hours

after birth and should never be made to compete with the time-bound interventions

1. Give Vitamin K prophylaxis 2. Inject Hepatitis B and BCG vaccinations 3. Examine the newborn. Check for birth injuries, malformations or defects 4. Cord care

UNNECESSARY PROCEDURES

1. Routine suctioning
No benefit if the amniotic fluid is clear and especially with newborns who cry or breathe immediately after birth Moreover, a dirty bulb can become a source of infection Has been associated with cardiac arrhythmia Indicated only if the mouth/nose is blocked with secretions or other materials

2. Early bathing/washing
Hypothermia which can lead to infection, coagulation defects, acidosis, delayed fetal to newborn circulatory adjustment, hyaline membrane disease, brain hemorrhage Infection the vernix is a protective barrier to bacteria such as E. coli and Group B Strep; so is maternal bacterial colonization No crawling reflex

3. Foot printing Proven to be an inadequate technique for newborn identification purposes Better identification techniques such as DNA genotyping and human leukocyte antigen tests

4. Giving sugar water, formula or other prelacteals and the use of bottles or pacifiers Delayed initiation to breastfeeding has been linked to a 2.6 fold increase in the chances of newborn deaths due to infection If the sugar water, formula or prelacteals are introduced using a bottle, the newborn may develop a learned preference for the bottle leading to nipple confusion and inefficient suckling which can further lead to failure in breastfeeding

 A pacifier contributes to nipple confusion if these are used before the newborn is offered the mothers breast This undermines the chances of successful breastfeeding by contributing to a vicious cycle of poor attachment, sore nipples and lactational insufficiency
5. Application of alcohol, medicine and other substances on the cord stump and bandaging the cord stump or abdome

DISCHARGE INSTRUCTIONS

1. Advise the mother to return or go to the hospital immediately if:

Jaundice of the soles or any of the following areas present* Difficulty of feeding Convulsions Movement only when stimulated Fast or slow or difficult breathing (e.g. severe chest in-drawing) Temperature >37.5 C or <35.5 C
*From Lancet 2008, new IMCI algorithm for Young Infant II study

2. Advise the mother to bring her newborn to the health facility for routine check-up at the following prescribed schedule:
Postnatal visit 1: at 48-72 hours of life Postnatal visit 2: at 7 days of life Immunization visit 1: at 6 weeks of life

3. Advise additional follow-up visits appropriate to problems in the following:

Two days if with breastfeeding difficulty, Low Birth Weight in the first week of life, red umbilicus, skin infection, eye infection, thrush or other problems Seven days if Low Birth Weight discharged more than a week of age and not gaining weight adequately

DISCHARGE INSTRUCTIONS

4. Advise for Newborn Screening

Newborn Screening (NBS) - is a simple procedure to find out if your baby has a congenital metabolic disorder that may lead to mental retardation and even death if left untreated. -ideally done on the 48th hour or at least 24 hours from birth. Some disorders are not detected if the test is done earlier than 24 hours. The baby must be screened again after 2 weeks for more accurate results.

The goal of newborn screening is to give all newborns a chance to live a normal life. It provides the opportunity for early treatment of diseases that are diagnosed before symptoms appear. Included in the panel of disorders under the Philippine Newborn Screening Program are: Congenital Hypothyroidism (CH), Congenital Adrenal Hyperplasia (CAH), Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency, Galactosemia (Gal) and Phenylketonuria (PKU).

Newborn screening is a simple procedure.Using the heel prick method, a few drops of blood are taken from the baby's heel and blotted on a special absorbent filter card. The blood is dried for 4 hours and sent to the Newborn Screening Laboratory (NBS Lab).

5. Advise Newborn Hearing Screening. - Republic Act #9709:

It is an act establishing universal hearing screening program for the prevention, early diagnosis and intervention of hearing loss.

- When the baby is born, he/she is

subjected to an OtoAcoustic Emmission test (OAE). This is done by placing a probe in the babys ear that emits a sound that stimulates the hair cells inside the ear. It is a simple and painless procedure that can be done among infants. Ideally, testing should be done 2 days after birth to reduce the chance of failing the test due to dirt in the ear canal. If they do not pass the initial OAE screening, they undergo an Auditory Brainstem Response (ABR) test.