Pediatrics II

ESSENTIAL NEWBORN CARE

In December 2000, 189 Heads of States or

Governments
jointly
endorsed
the
Millennium Declaration which committed
signatories to achieving 8 millennium
development goals by the year 2015. Of
the 8 goals, Goals 4 and 5 relate to
reduction of child mortality by two-thirds
and improvement of maternal health.

Dr. Wangdali

From 1988-1998, there was a steep decline

in the <5 year old mortality rate due to the
various
programs
geared
towards
improving child health.
From 1998-2008, there was a smaller
decrease despite the maintenance of these
programs.
Neonatal mortality rate has remained
unchanged despite the advances in
technology (ventilators), drug therapy
(surfactant, broad-spectrum antibiotics),
and increase in the number of specialists
caring for the newborn (neonatologists and
pediatricians).
If we are to decrease the child mortality
rate, we need to address the causes of
neonatal mortality.

MAJOR CAUSES OF UNDER FIVE

DEATHS

Kat and JV

Doctor of Medicine - II

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Is the risk of dying less in the higher

economic brackets in the country?
The average neonatal mortality in the
country is 15/1000 live births.
In the lowest socio-economic quintile,
it is 20/1000 live births, while in the
least poor it is 10/1000 live births.
This shows that being in the highest
wealth quintile does not give one a
significant advantage because the
neonatal mortality rate is not far from
the national average.
the neonatal mortality rate in a first
world country like Japan is only
2.4/1000 live births.
3 out of 4 newborns die in the first
week of life, specifically the first 2
days of life.
Existing
perinatal
conditions
predispose the newborn to an
increased risk of dying immediately
after delivery.

Globally, approximately 10 million

children die each year.
This is the Lancet Child Survival Series
which
looked
at
preventive
interventions to save childrens lives.

Kat and JV

Doctor of Medicine - II

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 With 23 interventions we can prevent

6 million of the 10 million global under
five deaths.
Notice that the only 2-digit figure in
the table is breastfeeding at 13%, yet
not enough emphasis is placed on
breastfeeding
as
a
life-saving
intervention.
Compare this with the giving of
antibiotics for PROM as interns, we
were assigned journal reports or given
demerits for failing to order this in
the mothers chart, yet it contributes
to only an estimated 1% reduction in
childhood mortality.
Good nutrition through breastfeeding,
appropriate complementary feeding,
supplementation OR fortification can
already prevent 2.5 million deaths.

being treated as an infection control

problem. The first thing the team
leader asked was: How much
colostrum did the cases receive?
Answer: Not a drop.

In Baguio General Hospital, babies

were routinely removed from their
mothers at birth, placed in a
nursery, and given infant formula.
The graph at the bottom shows the
high incidence of sepsis among
these babies.

A few years ago, a sepsis outbreak in

an NCR hospital became front-page
news despite the fact that all large
hospitals
nationwide
have
experienced being in the same
situation. At the end of the outbreak,
a total of 32 term babies who were
born healthy succumbed to sepsis.
The father of one of these babies
wrote to the WHO in Geneva saying
that he saved money so that his wife
could deliver in a hospital, only to
have the baby die from infection.
WHO referred the case to the Office of
the WHO Representative to the
country and an investigating team
was formed. When the team arrived
at the hospital, the outbreak was
Kat and JV

Dra. Clavano instituted a new

regimen that allowed mothers and
babies to room together, and
encouraged women to breastfeed
on demand. The results were
dramatic: the incidence of oral
thrush, diarrhea, clinical sepsis,
and death were drastically reduced
Doctor of Medicine - II

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during the intensification of the

breastfeeding program.
This contributed to the formation
of the Baby Friendly Hospital
Initiative.
In the Philippines, Dra. Clavano
continued to advocate against the
use of infant formulas, work that
contributed to the 1986 Philippine
National Milk Code, and the 1992
Rooming-In and Breastfeeding Act.

A similar study done in Ghana with

half the number of babies also
shows the same dose-response
relationship between initiation of
breastfeeding and risk of infectionrelated death. This dose response
curve is very strong evidence for
the
protective
property
of
breastfeeding.

This study was done in Nepal

involving 23,000 breastfed babies.
It looked at the risk of infectionrelated death correlated with the
time of initiation of breastfeeding
(in hours).
If breastfeeding is started within
an hour after birth, the risk of
infection-related death is 1.
If
breastfeeding is started after 1
hour but within the 1st 24 hours,
the risk doubles to 2.
If
breastfeeding is started after 3
days, there is a four-fold increase
in the risk of infection-related
death.

Kat and JV

This is a randomized controlled

trial that studied the type of
feeding received by low birth
weight babies against the risk of
serious illness.
The result of the study was
significant in that it showed that
the less breastmilk the baby
receives, the higher the risk of
serious illness.

Doctor of Medicine - II

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 In a baseline study of consecutive

deliveries in 51 of the largest
hospitals in 9 regions in the
Philippines, the incidences of
neonatal sepsis, neonatal and
maternal
mortalities
were
obtained. In that hospital study,
the neonatal sepsis rate was 6%.
There is no available data for
sepsis rates in babies delivered at
home.
Newborn mortality was 16.8/1000
live births in home deliveries vs
16/1000 live births in hospitals.
Does this mean that hospital
deliveries
do
not
have
an
advantage over home deliveries?
Even
more
glaring
are
the
statistics for maternal mortality:
162/100,000 deliveries if homebased vs. 234/100,000 hospital
deliveries.
These figures only goes to show
that we need to institute measures
that will allow mothers and
newborns to benefit from safe and
quality care.

Giving
antenatal
steroids
to
mothers who are in preterm labor
has several beneficial outcomes in
the neonate.
Foremost among these is the
overall reduction in neonatal death
with an RR of 0.69.
There is also a reduction in the
incidences of respiratory distress
syndrome and cerebroventricular
hemorrhage.
Contrary to the notion that steroids
will suppress the immune system,
there is also a reduction in sepsis
in the first 48 hours of the
newborns life.
It likewise does not increase the
risk of death, chorioamnionitis or
peurperal sepsis in the mother.

What Immediate Newborn Care

Practices Save Lives?
Implementation of the ENC protocol has
the potential to avert approximately 70
percent of newborn deaths that are due
to preventable causes.

Kat and JV

Betametasone is the preferred

steroid because it is associated with
less periventricular leukomalacia, a
disorder of the white matter of the
brain. However it is much more
expensive and is not always readily
available.
Doctor of Medicine - II

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 Dexamethasone is more available and

is easily obtained; it should always be
in the E-cart of your facility for
immediate access when a mother
comes in preterm labor.
If a quick delivery is expected and
dexa can be given only once, can we
double the dose and give 12 mg q12
hours? Studies have shown that there

Kat and JV

is no additional benefit to using higher

or more frequent doses.
If a mother with asthma has been
taking oral steroids for 1 week, can
we defer the dexa? We should still
give it because the absorption of
other forms of steroids is unreliable.

Doctor of Medicine - II

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