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What's New? Update on Babies Born Too Small
1. Newborn – What’s New?
Newborn/Preterm/
Small Babies
The Continuum of Care for Preterm and Small Babies: Carolyn Kruger, PCI
Care of Maternal/Newborn Dyad When Preterm Labor and Delivery
Occur: Suzanne Stalls, ACNM
Current Research on Management of Newborn Sepsis: Bina Valsanger,
SNL/SAVE
Integration of Newborn Care with CORE Group Community Polio Platform
in Ethiopia: Alfonso Rosales, World Vision
3. Premature birth is the leading cause of newborn
death and the leading cause of death among
children under 5 worldwide
• 15 million babies are born preterm every year.
• 1.1 million babies die every year due to complications of
prematurity – 75% of these deaths are preventable.
Why Preemies?
• Low birth weight (babies born too small)
is a major contributor to newborn deaths.
Sources: Born Too Soon: The Global Action Report on Preterm Birth (2012); Global, regional, and national
causes of child mortality in 2000–13, with projections to inform post-2015 priorities: an updated systematic
analysis, Lancet (2014).
4. • Expand the uptake of preterm birth
(PTB) and low birth weight (LBW)
interventions in 24 USAID priority
countries in Africa and Asia.
• Shine a spotlight on PTB/LBW within
maternal and newborn health
interventions and approaches.
• Work within global partners, established
health service delivery systems, and
community platforms.
Every Preemie—SCALE
5. • USAID MCSP
• Saving Newborn Lives (SNL)
• USAID Emerging Priorities Initiative
• CORE Group
• Global Maternal/Newborn Technical Working
Groups
• Survive and Thrive Global Development Alliance
• BMGF Grand Challenges Partners
• Country Every Newborn Action Plans
Collaborating with…
6. Preemies: Our Care Agenda
Category Gestational Age Approximate Weight Global Burden
Extremely < 28 weeks < 1500 grams 5.2%
Very 28 - < 32 weeks Approx. 1500 grams 10.4%
Moderate 32 - < 37 weeks 2500 grams 84.3%
The majority of these preemies can
survive with basic essential newborn
care (drying, warming, breastfeeding,
clean cord care and hygiene) PLUS
breathing support, continuous skin-to-
skin contact, infection
prevention/management
7. • Core Package
– Consists of:
• 24 country survey in USAID priority countries in Asia and Africa
• Evidence toolkit
• Advocacy and Awareness Raising module
• Targeted Technical Assistance
– Implemented in selected countries and includes country-specific
TA such as:
• Revision of policy, standards or protocols
• Curricula development
• Health provider training
• Demonstration Countries—up to 4 over LOP
• Focused programming based on stakeholder priorities
• Programming will be designed to advance the scale up of
interventions along the continuum of care from the household
to the facility
• Implementation research designed to answer critical questions
about what works to improve programming for PTB/LBW
Country Support
8. – How do we address the barriers to quality of care
given what we know?:
• In many countries a large proportion
of babies are born at home without
skilled care
• Services for mothers and newborns
are often managed separately
• Services are often inadequate and of
poor quality
• Recognition of preterm and small
babies and appropriate care remains a
significant challenge
– We also know that the majority of moderate
preterm babies can survive with essential newborn
care interventions PLUS respiratory support (where
indicated), continuous skin-to-skin care, support
for feeding and careful growth monitoring
Learning Agenda
9. • Gestational age assessment research (pre-birth and
at birth)
• Post birth assessment of preterm, small babies at
the facility level, immediate care and referral to
advanced or specialized care
• Community/household recognition of preterm and
small babies and ACTION: referral to care
• Barriers to care for vulnerable babies, e.g.
acceptance of “small, ugly” babies; community
perceptions and action
• Follow up care at the community/household level
for preemies and small babies (e.g. home
maintenance of KMC: skin to skin care and feeding
support at the household level)
Priorities for Learning
10. How will we learn?
Evidence to
Action
Evidence Shared
Globally and in
USAID Priority
Countries
Demonstration
and TTA
Countries Use
Evidence and
Information to
Prioritize Action
Country Level
Learning
Captured and
Used to Inform
Future Planning
Know-Do Gap
Informs New
Learning for
PTB/LBW
11. Focus on Continuum of Care:
Best Practice, Gaps, Comparative Value
Pre-
pregnancy Pregnancy
Labor and
Delivery
Immediate
Postnatal
Care
Later
Postnatal
Care
Community/Home
Health CenterHospital
12. • There are multiple points during a women’s reproductive
life when specific services can reduce her risk for preterm
birth and improve chances of survival for early and small
newborns
• The matrix provides an organized framework for evidence-
based interventions and services along the pathway for
care of non-pregnant and pregnant women, mothers, and
preterm or small babies- from the household/community
to the health center and hospital levels
• Used to initiate dialogue and coordination, identify gaps
along the pathway to care, and guide prioritization of
services.
MATRIX: Continuum of Care for the Prevention of Preterm
Birth, Management of Preterm Labor and Delivery and
Care of the Preterm and Small Newborn
13. PREVENTION OF PRETERM BIRTH AND LOW BIRTH WEIGHT
COMMUNITY/
HOUSEHOLD
• Delayed marriage/childbearing
among adolescents
• Prevention of partner violence
• Family Planning (FP) counseling &
provision
• Optimize pre-pregnancy weight &
use of iron-folate supplements
and/or micronutrient fortification
• Cessation of tobacco use &
reduced exposure to second
hand smoke & household air
pollution
• Cessation of substance abuse
including alcohol
• Prevention of harmful traditional practices
(HTPs)
• Social and cultural norms in place that
promote early care seeking behavior for
pregnancy women
• Early determination of last menstrual period
(LMP) and estimated due date (EDD) at first
antenatal care (ANC) visit
• Counseling on reduced maternal workload
• Identification and management of partner
violence
• Community-based ANC including
identification of complications and referral
and previous history of preterm birth
• Birth preparation including a savings and
transport plan
• Identification of
pregnancy
complications and
referral to care
• Prompt referral
to health facility
if newborn
appears
premature or
small
• See pre-pregnancy
actions at the
community and
household level
HEALTH
CENTER
All of above PLUS
• Diagnosis & management of
infections including HIV
• Routine childhood immunizations
including for adolescents
• Mental health/depression
assessment and referral for
services
All of above PLUS
• Focused ANC including IPT/SP for malaria,
screening/care for maternal infections (TB,
HIV, bacterial vaginosis, UTI, Group B Strep,
chlamydia, gonorrhea, syphilis)
• Maternal immunization (tetanus,
pneumococcal, H. influenzae, influenza),
anemia screening/treatment
• High risk pregnancy screening and referral:
o Chronic diseases (e.g. diabetes)
o ID and Tx of hypertensive disease in
pregnancy
o ID and Tx of antepartum hemorrhage
o ID and Tx of pPROM
o Monitoring multiple pregnancies
o Pregnant adolescents
o Prior preterm birth
• Identification of
pregnancy
complications
• Verify EDD
• If maternal
condition leading
to prematurity is
identified,
transfer to
hospital care
• Confirm
gestational age
at birth
• Nutrition
counseling for
adequate
maternal diet
and successful
breastfeeding
• Postpartum
family planning
counseling and
provision of
services (e.g.
oral
contraceptives,
LAM) and
referral for
permanent or
long-acting
reversible
contraception
(LARC)
All of above PLUS
• Follow-up of women
in the
interconceptional
period who delivered
prematurely to
medically manage
any conditions that
may have
predisposed her to
premature
HOSPITAL Counseling and services for all of
above
All of above PLUS
• Management of women at higher risk of
preterm birth:
o Above conditions plus
• Management of
complications
• Refer to
Management of
All of above plus
• Provision of
permanent or
long-term FP
• Identification and
management of new
onset chronic
diseases (e.g.
CARE
14. • Pre-conception: youth-delay marriage and pregnancy
• Early ANC in first trimester for establishment of EDD,
focused ANC
• Family planning counseling and provision
• Early care –seeking behaviors for complications
• Early identification of high risk pregnancies- screening
• Prevention of partner violence and HTP
• Birth preparation
• Maternal nutrition/micronutrient fortification
• Reduced maternal workload
• Maternal depression screening
Prevention of Preterm Birth
15. MANAGEMENT OF PRETERM LABOR & DELIVERY
COMMUNITY/
HOUSEHOLD
• Community health education including
signs and symptoms of preterm labor
and obstetric complications
• Recognition of obstetric complications
and signs of preterm labor and
immediate referral to hospital for care
• If possible, referral to health facility for obstetric
care
• IF UNABLE TO TRANSFER: Skilled birth attendant
in the home
• Clean birth practices
• Early basic obstetric and newborn care and
referral to health facility for management
• Immediate postpartum care for the mother
and referral to health facility for follow up and
management of obstetric complications
• Continuation of immediate essential newborn
care and referral/transfer to facility for
preterm or small newborn
HEALTH CENTER • Establish gestational age
• Respectful maternity care
• Education and recognition of signs of
preterm labor and obstetric conditions
leading to prematurity
• Identify and early Tx of high-risk
conditions for preterm birth (pre-
eclampsia, pPROM, antepartum
hemorrhage, preterm labor
• Immediate referral to hospital for care
• Monitor fetal condition
• Maternal nutrition and hydration
• During transfer to hospital, woman to
remain recumbent if at all possible
• Provision of basic emergency obstetric care for
women in preterm labor
• Ongoing monitoring of fetal condition
• Transfer to hospital for comprehensive
emergency obstetric care
• Early management of maternal postpartum
complications with basic emergency obstetric
care
• Transfer to hospital for emergency
postpartum care
• See CARE FOR THE PRETERM OR LOW BIRTH
WEIGHT NEWBORN
HOSPITAL All of above PLUS
• May use tocolytic agents to suppress
labor for time required to administer
ACS
• Begin ACS for women 24 to <34 weeks
gestational age and at high risk for
imminent preterm birth
• Magnesium sulphate for women with
gestational age <32 weeks and likely to
give birth within 24 hours
• Managing and treating the high-risk
complications leading to prematurity
• Comprehensive emergency obstetric care
• Ongoing monitoring of fetal condition
• Management of postpartum care for the
mother
• See CARE FOR THE PRETERM OR LOW BIRTH
WEIGHT NEWBORN
PREGNANCY LABOR & DELIVERY
IMMEDIATE
POSTPARTUM/POSTNATAL CARE
16. • Establish gestational age
• Respectful maternity care
• Education and recognition of signs of preterm labor and
obstetric conditions leading to prematurity
• Identification and early treatment of high-risk conditions
leading to prematurity
• Basic emergency obstetric care
• Monitor maternal and fetal conditions
• Referral to special care centers for very small/preterm babies
• Infection prevention
•
Management of Preterm Birth
17. CARE OF THE PRETERM OR LOW BIRTH WEIGHT NEWBORN
COMMUNITY/
HOUSEHOLD
• Be prepared for preterm birth
and newborn requiring special
care
• Clean birth practices
• Recognition of preterm or small newborn
• Essential care for small babies (infant stimulation to
breathe, drying, warming, continuous skin-to-skin
contact and immediate/exclusive breastfeeding or
alternative method to feed breastmilk)
• Chlorhexidine for cord care at home births in settings
with newborn mortality over 30 per 1000, or to
replace application of harmful substances (single
application for babies <28 weeks)
• Prompt referral to health facility for care of preterm
or small newborn
• Household sanitation including hand washing and other
hygiene practices
• High frequency follow up care for preterm and small
babies at home post-facility discharge: careful growth
monitoring; support to mother for exclusive
breastfeeding till 6 mo; support for continuous skin-to-
skin contact; identification of newborn problems
• Identification and prompt referral to health facility for
new onset of newborn problems
HEALTH CENTER • Be prepared for preterm birth
and newborn requiring special
care
• Confirm GA at birth
• Eye care, vitamin K and clean dry cord care
• Essential care for small babies including newborn
resuscitation
• For newborns who present with danger signs
(abnormal temp, respirations, feeding difficulties,
lethargic or with seizures) give antibiotics and
immediately refer to advanced care
• For newborns <32 weeks and/or <2000 gms
immediate transfer to advanced care
• Continuous skin to skin contact is recommended for
the routine care of neonates weighing <2000g at birth
as soon as they are clinically stable
• Ongoing essential care for preterm and small babies
• Infection prevention
• Linkages to community providers for home-based small
baby checks including feeding and growth monitoring;
and childhood Immunizations post-facility discharge
• Monitor for developmental milestones
• Monitor for new onset of newborn problems and
manage or refer according to country guidelines
• Neonates weighing ≤2000g at birth should be provided
with as close to continuous skin to skin contact as
possible
HOSPITAL • Be prepared for preterm birth
and newborn requiring special
care
All of above PLUS
• Essential care for small babies: continuous skin to skin
contact + supplemental feeding + monitored oxygen
use during stabilization + strict hygiene
• During ventilation of preterm babies born ≤32 weeks
gestation, it is recommended to start oxygen therapy
with 30% oxygen or air (if blended oxygen is not
available), rather than with 100% oxygen
• Transfer extreme newborns (<28 weeks) and/or small
newborns (<1200 gms) to advanced care (where
available)
All of above PLUS
• Management and treatment of preterm and small infant
with complications (inadequate feeding, respiratory
conditions, infections, severe jaundice)
• CPAP with oxygen titration using blender and pulse
oximeter for RDS, surfactant for RDS with
intubation/ventilation
• Monitored oxygen use to minimal required
• Support for transfer to local care and follow up after
discharge
TERTIARY or
REFERRAL HOSPITAL
• Be prepared for preterm birth
and newborn requiring special
All of above care PLUS
• Neonatal intensive care for extreme preterm
All of above care PLUS
• Continued advanced care for extreme premature infants
LABOR & DELIVERY
IMMEDIATE
POSTNATAL CARE
LATER POSTNATAL CARE
18. •Recognition of preterm or small newborn
•Essential care for small babies (infant stimulation to
breathe/HBB, drying, warming, continuous skin-to-skin
contact and immediate/exclusive breastfeeding or alternative
method to feed breast milk)
•Chlorhexidine for cord care at home births
• Eye care, vitamin K and clean dry cord care
•For newborns who present with danger signs (abnormal
temp, respirations, feeding difficulties, lethargic or with
seizures) give antibiotics and immediately refer to advanced
care
•Lactation and feeding support
•Post-facility discharge counseling and follow-up in the
community; growth monitoring
•Infection prevention
Care or Preterm and LBW Baby
19. • Building the enabling environment for improved maternal
and newborn health along the continuum of care is a
shared responsibility among families, communities, civil
society organizations, religious groups, professional
organizations, the private sector and governments
• Integration of preterm prevention, management and care
for the mother and newborn can be integrated into
RMNCH existing programs
• There are evidenced-based interventions and services that
are simple, low-cost and life-saving that are not new- but
just good quality of care
Discussion
20. Questions/Discussion
Every Preemie—SCALE Team
Program Director: Judith Robb-McCord
Program Officer: Chelsea Dunning
Sr. Operations Officer: Rebecca Freeman
Technical Team:
Carolyn Kruger (PCI)
Jim Litch (GAPPS)
Suzanne Stalls (ACNM)