Essential Newborn (including Chlorhexidine for umbilical cord care)
Essential Newborn Care
Most newborn deaths can be prevented by mothers and CHWs (Community Health Workers) carrying out the following healthy practises:
- cleaning airway and stimulating crying
- drying the baby with a clean, dry cloth, covering the head, without wiping the vernix caseosa, and refraining from bathing the baby for 24 hours
- immediate warming by placing baby in skin-to-skin contact with mother (use KMC for LBW baby)
- cleaning umbilical cord and wiping eyes with a clean cloth
- immediate and exclusive breast-feeding
- recognition and care-seeking for special care (see"danger signs" below)
Having been nourished by the pregnant woman for nine months in the womb the most important need of a newborn for the first 24–48 hours is protection. Unlike adults, who can readily adjust to changes in temperature, newborns become hot or cold more quickly and can easily die from rapid changes in temperature. A newborn does not have a mature system to fight infections so it is essential to breast-feed exclusively which provides colostrum combined with warming (skin-to skin contact and the act of loving care).
- Essential Newborn Care(ENC) is care that every newborn baby needs regardless of where it is born or its size. ENC should be apllied immediately after the baby is born and continued for at least the first 7 days after birth. Many ENC interventions are simple and can be provided by a Skilled Birth Attendant(SBA) or a trained Community Health Worker(CHW) or Traditional Birth Attendant(TBA) or by a family member supporting the mother in a health facility or at home.
- Keep baby warm: Care givers and mothers make sure the newborn baby is immediately dried after birth, placed on teh abdomen(skin to skin), covered with a clean towel/cloth and a hat on the head. They make sure the baby is NOT bathed for the first 24 hours.
- Help baby breathe: Care givers and mothers assist the newborn baby to take its first breath by immediately rubbing its back and feet to stimulate it to cry and by clearing the mouth if it having any difficulty in breathing
- Keep baby clean: Care givers and mothers wash their hands before touching the newborn baby, they cut the umbilical cord with a clean blade, they keep the cord area clean and dry, they do not put anything on the cord stump(exception in some country/district contexts-care giver or mother applies chlorhexidine antiseptic(gel or liquie) as soon possible after cutting the cord and then daily for 7 days)
- Help baby feed: Care givers and mothers assist the newborn baby to breastfeed within 1 hour after birth and make sure the baby recieves the first milk(colostrum) and only breast milk and no other fluids for the first 6 months
- Help the small baby surivive: Care givers and mothers give extra special care to the small baby by practicing ENC plus kangaroo mother care(KMC) which means placing it naked skin to skin on the mother's chest and continuing this day and night
- Help protect from HIV: Care givers and mothers ensure the newborn of a HIV positive mother is brought to the facility for early infant diagnosis(EID) testing at one month
If the baby is born at home, the mother should take the baby to the health facility for first immunisations (bCG, polio and Hepatitis b if available) and vitamin K administration during the first few days after birth. The baby must also be taken to a health facility if any of the following danger signs are present:
- breathing problems or gasping
- difficulty feeding or sucking
- cold to touch
- fits or convulsions
- yellowish skin or eyes (juandice)
- red, swollen eyelids and pus (yellowish discharge) in eyes
- swelling/redness of skin, pus or foul odour around the umbilical cord
HIV-exposed infants should be tested for HIV using a virological assay (measures the presence of virus rather than antibodies) at first post-natal visit or by 4–6 weeks. In most instances these tests must be sent to central labs, and results will not be received for 3–4 weeks. To avoid needless deaths, all HIV-exposed infants should be provided with ART and cotrimoxozole immediately, until infected is ruled out, and enrolled on life-long treatment if infection is diagnosed.
Chlohexidine for umbilical cord
Recent community-based randomized trial studies in rural Bangladesh, Nepal, and Pakistan have shown that applying 7.1% chlorhexidine digluconate (delievering 4% chlorhexidine) to the umbilical cord prevents infection and saves newborn lives. The results confirm that 20% to 38% reduction of neonatal mortality and prevention of up to three-quarters of serious umbilical infections.
Both liquid and gel forms of 7.1% chlorhexidine are acceptable to families, and families are able to use the product as recommended. In contexts with high homebirth and poor sanitation or delivery in health facilities with poor access to adequate water and sanitation, the application of chlorhexidine to the umbilical cord as soon as possible after birth is recommended. World Vision is well placed to support the Ministry of Health and development partners in the roll out and scale up of this intervention. (Adapted from www.healthynewbornnetwork.org/topic/chlorhexidine-umbilical-cord-care)
Forseeable Challenges: Delay in MoH (Ministry of Health) policy changes, procurement and distribution system of supplies; effective CHW (Community Health Worker) home visiting program to deliver and monitor intervention
When do most newborn babies die?
Nearly 3 million newborn babies die every year, mostly in developing countries and where many births happen at home. Most of these newborn babies die on their first day of life or in the first week. These babies do not need to die and most of these deaths are preventable if every newborn baby received ‘Essential Newborn Care’ (ENC).
Many lives would be saved if all newborns were provided with ENC and this is best done in a quality health facility by a trained SBA.
What do newborn babies die from?
The most common cause of newborn death is because of being born too early or too small. Small babies have more difficulty to keep warm, are weak to suck at the breast and have a much higher chance of getting an infection. Breathing complications are the second most common problem where the baby cannot take its first breath or has trouble breathing. This is more common in small babies. Breathing problems need to be recognized very quickly and the baby can be helped to clear the mouth and to take a breath.
Infections in the lungs, brain or the whole body are the third most common cause of deaths and can occur as a result of unclean practices at the time of birth such as cutting the umbilical cord with something dirty. Most of these deaths can be prevented by providing mothers with quality ANC and for all births to be in a health facility with a SBA who will perform ENC.
Why do all newborn babies need essential newborn care(ENC)?
The baby was protected from infection in the mother’s womb and kept warm and fed by the placenta. After the birth these protections are gone and it takes a newborn baby some time to adapt but especially so in the first 24 – 48 hours after birth. The air temperature is much cooler than in the womb, they must get nourishment from the breast rather than the placenta and they are not protected from outside infections by the womb. It takes most newborn babies 1 week to 4 weeks to become strong and adapt to being outside the womb and for small babies this will take even longer.
What are the main essential newborn care practices?
Keep baby warm: Care givers and mothers make sure the newborn baby is immediately dried after birth, placed on the abdomen (skin to skin), covered with a clean towel/cloth and a hat on the head. They make sure the baby is NOT bathed for the first 24 hours.
Help baby breathe: Care givers and mothers assist the newborn baby to take its first breath by immediately rubbing its back and feet to stimulate it to cry and by clearing the mouth if it is having any difficulty in breathing.
Keep baby clean: Care givers and mothers wash their hands before touching the newborn baby, they cut the umbilical cord with a clean blade, they keep the cord area clean and dry, they do not put anything on the cord stump (exception in some country /district contexts – care giver or mother applies chlorhexidine antiseptic (gel or liquid) as soon possible after cutting the cord and then daily for 7 days).
Help baby feed: Care givers and mothers assist the newborn baby to breastfeed within 1 hour after birth and make sure the baby receives the first milk (colostrum) and only breast milk and no other fluids for the first 6 months.
Help the small baby survive: Care givers and mothers give extra special care to the small baby by practicing ENC plus kangaroo mother care (KMC) which means placing it naked skin to skin on the mother’s chest and continuing this day and night.
Help protect from HIV: Care givers and mothers ensure the newborn of a HIV positive mother is brought to the facility for early infant diagnosis (EID) testing at one month.
If the birth is at home, can a family member do ENC?
Yes; either the family member who is assisting at the birth or support a trained CHW or TBA who is present. They can apply the ENC actions and this will help the newborn survive the first minutes and the first day of life.
It is better to go to the health facility for the birth but sometimes births happen very fast, or on the way, so all family members and CHWs/TBAs should know what to do. It is important to have a birth kit ready with cloths and a hat for the baby, a clean cord cutting blade, clean cord ties and soap and water. If using chlorhexidine antiseptic is advised in your context then this should also be in the birth kit and applied as soon as possible after the cord is cut.
In some circumstances women are left to birth alone however this is not acceptable as the mother needs help during her labour and birth and she cannot apply ENC easily. She needs someone to help her do ENC and to take care of the newborn baby.
What are some harmful practices that may cause newborn babies to become sick or die?
If the newborn baby is not immediately dried after birth then the wet fluid left on the body and head will cause the baby to get very cold very quickly. Sometimes in home births families wait until the placenta arrives before drying and caring for the baby but this could take a long time and by then the baby will be very cold.
Other practices which are very harmful are cutting the cord with a piece of bamboo or unclean blade that has been used by others. This can lead to an infection of the lungs or brain or the whole body. Bathing the baby soon after birth can make the baby very cold. Throwing away the colostrum and not feeding it to the newborn is very bad as this is full of natural protection and sugar to help the baby adapt to being outside the womb. Giving the baby fluids other than breast milk (colostrum) such as juice, sugar water, honey or tea makes the baby less likely to suck at the breast and may cause it to become sick with diarrhea.
What are the newborn danger signs?
All members of the community need to be aware that newborn babies can get sick and die very quickly. Mothers and fathers and other family members, TBAs and CHWs and leaders of the community should all know these signs and help parents to take the newborn to the facility as soon as possible if they see the newborn with:
- Difficulty breathing or chest indrawing
- Fever or very cold
- Fits or convulsions
- Difficulty breastfeeding or sucking (especially if feeding well before or if a small baby)
- Redness/swelling or pus in the umbilical cord or skin around it
- Red swelling or pus in the eyes o Pustules and rash on the skin or yellow skin