Early essential newborn care in national tertiary hospitals in Cambodia and Lao People's Democratic Republic: a cross-sectional study

BACKGROUND

Ministries of health in collaboration with the World Health Organization Regional Office for the Western Pacific (WPRO) have been scaling up early essential newborn care (EENC). This study was carried out to understand current EENC practices at hospitals in two priority countries: the Kingdom of Cambodia (Cambodia) and Lao People's Democratic Republic (Lao PDR).

METHODS

EENC is subdivided into 79 checkpoints, referencing the self-monitoring checklist developed by the WPRO. Each checkpoint is rated using a 0 to 2-point scale, and a percentage was calculated for the rate of practice of each checkpoint by dividing the total scores by the maximum possible scores.

RESULTS

In total, 55 and 56 deliveries were observed in Cambodia and Lao PDR, respectively, and 35 and 34 normal deliveries were included in the analysis. The overall rates of the practices within the first 15 minutes after birth were high in both countries. The rates of the practices before birth and 15 minutes after birth were lower than the rates of the practices performed within the first 15 minutes after birth, especially "hand wash before preparation", "preparation for newborn resuscitation", and "monitoring of postpartum mothers and babies". A detailed analysis revealed that the quality of the practices differed between the two countries regarding skin-to-skin contact and breastfeeding support.

CONCLUSIONS

The high rates of the practices within the first 15 minutes after birth suggest that the EENC coaching sessions supported by ministries of health and the WPRO have been effective. Differences in the quality of practices performed at a high rate between the two countries appeared to be related to factors such as the timing of the study, the perception of the staff, and the situation at the health facilities. These differences and identified practices with lower rates should be improved according to the situation in each country or health facility. Therefore, determining the quality of the practices in a country or a health facility is important. To further improve the quality of EENC, interventions tailored to the specific situation are necessary.

Kangaroo mother care alters chromogranin A and perfusion index in preterm babies

BACKGROUND

While providing various benefits, concerns about the potential risks of kangaroo mother care, or skin-to-skin contact (SSC), between mother and her preterm infant hinder its widespread implementation in some resource- rich countries. In neonates, salivary chromogranin A (s-CgA) is elevated upon exposure to stress, whereas the perfusion index (PI) is associated with hemodynamics and peripheral perfusion. Here, we investigated the effects of SSC on s-CgA and the PI in preterm infants.

METHODS

Twelve infants were enrolled in the study. Factors associated with baseline s-CgA were analyzed. Baseline s-CgA and the level after SSC were compared. Secreted IgA in the saliva was compared as the control. The PI before, throughout, and after SSC were compared.

RESULTS

Baseline s-CgA was significantly lower in infants who were supplemented with baby formula milk in addition to breast milk before SSC (n = 2) compared with those fed with their mother's breast milk alone (n = 10, P = 0.03). SSC significantly decreased s-CgA in babies who were fed breast milk only before SSC (n = 10, P = 0.01) but not in those supplemented with formula milk before SSC (n = 2). Secreted IgA in saliva was not affected by SSC. The PI was significantly elevated during SSC (P = .01).

CONCLUSION

Our data indicate that SSC can reduce s-CgA levels when combined with mother's breast milk and increase the PI in preterm infants, thereby providing additional evidence of the benefit of SSC.

What is the impact of mother's bed incline on episodes of decreased oxygen saturation in healthy newborns in skin-to-skin contact after delivery: Study protocol for a randomized controlled trial

BACKGROUND

Early mother-child skin-to-skin contact (SSC) in the first 2 h postpartum is highly beneficial for both mother and child. However, cases have been reported of newborns who have experienced apparently life-threatening events (ALTEs) or sudden death during this procedure. The causes of these events are unknown. Newborn's prone position could influence the onset of these events but there is very little evidence to support any recommendation. We hypothesize that newborns' breathing obstruction episodes increase as mothers lie more horizontally. The main objective of this study is to compare the occurrence of desaturation and bradycardia episodes as a function of mother's bed incline. The study is designed as a randomized, controlled, assessor blind, multicenter, superiority trial with two parallel groups and 1:1 allocation ratio.

METHODS

The study participants will be full-term healthy mother-newborn dyads from ten hospitals in Spain. Participants will be randomly assigned to one of two study arms defined by mother's bed inclination (45° or 15°). The planned sample size is 5866. Centralized permuted blocks randomization and assessor blinding will be implemented. The newborns will be monitored remotely with pulse oximetry, from 10 min to 2 h after delivery. We established SO2 and heart rate (HR) limit alarms, as well as an action protocol in the event of alarm activation. The primary outcome is the number of healthy newborns who undergo episodes of SO2 ≤ 90%. Secondary outcomes are the mean SO2 level, the number of newborns who experience episodes of SO2 ≤ 85%, the time to SSC discontinuation due to abnormal SO2 or HR, and episodes of HR < 111 beats per minute (bpm) or > 180 bpm. Subgroups and pooled analysis will be performed to identify if breast-feeding and mother and child positions favor the occurrence of desaturation or bradycardia episodes.

DISCUSSION

A simple intervention such as modifying mother's bed angle of inclination while in SSC with her child during the first 2 h postpartum could favor newborn's hemodynamic and respiratory stabilization and thus contribute to reducing the onset of ALTEs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02585492 . Registered on 22nd October 2015.

PROTOCOL VERSION

2 (30th June 2015).

Neonatal Safety of Elective Family-Centered Caesarean Sections: A Cohort Study

BACKGROUND

Although little data are available concerning safety for newborns, family-centered caesarean sections (FCS) are increasingly implemented. With FCS mothers can see the delivery of their baby, followed by direct skin-to-skin contact. We evaluated the safety for newborns born with FCS in the Leiden University Medical Center (LUMC), where FCS was implemented in June 2014 for singleton pregnancies with a gestational age (GA) ≥38 weeks and without increased risks for respiratory morbidity.

METHODS

The incidence of respiratory pathology, unplanned admission, and hypothermia in infants born after FCS in LUMC were retrospectively reviewed and compared with a historical cohort of standard elective cesarean sections (CS).

RESULTS

From June 2014 to November 2015, 92 FCS were performed and compared to 71 standard CS in 2013. Incidence of respiratory morbidity, hypothermia, temperatures at arrival at the department, GA, and birth weight were comparable (ns). Unplanned admission occurred more often after FCS when compared to standard CS (21 vs 7%; p = 0.03), probably due to peripheral oxygen saturation (SpO₂) monitoring. There was no increase in respiratory pathology (8 vs 6%, ns). One-third of the babies were separated from their mother during or after FCS.

CONCLUSION

Unplanned neonatal admissions after elective CS increased after implementing FCS, without an increase in respiratory morbidity or hypothermia. SpO₂ monitoring might have a contribution. Separation from the mother occurred often.

Sudden unexplained early neonatal death or collapse: a national surveillance study

BACKGROUND

The incidence of sudden unexpected early neonatal death (SUEND) or acute life-threatening events (ALTEs) is reported as 0.05/1,000 to 0.38/1,000 live births. There is currently no national system in Australia for reporting and investigating such cases.

METHODS

A 3-y prospective, national surveillance study, run in collaboration with the Australian Pediatric Surveillance Unit (APSU). Data were provided by pediatricians reporting to APSU; and independently ascertained by the Coroner in two states (NSW and QLD) and the Newborn Early Transport Network in NSW. A detailed deidentified questionnaire was created.

RESULTS

In NSW and QLD, the incidence was 0.1 and 0.08/1,000 live births, respectively. Forty-eight definitive cases were identified. Common causes included accidental asphyxia, cardiac disease, persistent pulmonary hypertension of the newborn, and sudden infant death syndrome. Twenty-six babies collapsed on day 1 and 19 were found on the carer's chest.

CONCLUSION

The incidence in NSW and QLD is higher than previously published. The first postnatal day is a vulnerable period for newborns, who require close observation particularly during skin-to-skin contact. Development and implementation of guidelines for safe sleeping in hospital are needed. Collaboration between obstetricians, midwives, and pediatricians is essential to ensure safety of the newborn.

Immediate or early skin-to-skin contact after a Caesarean section: a review of the literature

The World Health Organization and the United Nations International Children's Emergency Fund recommends that mothers and newborns have skin-to-skin contact immediately after a vaginal birth, and as soon as the mother is alert and responsive after a Caesarean section. Skin-to-skin contact can be defined as placing a naked infant onto the bare chest of the mother. Caesarean birth is known to reduce initiation of breastfeeding, increase the length of time before the first breastfeed, reduce the incidence of exclusive breastfeeding, significantly delay the onset of lactation and increase the likelihood of supplementation. The aim of this review is to evaluate evidence on the facilitation of immediate (within minutes) or early (within 1 h) skin-to-skin contact following Caesarean section for healthy mothers and their healthy term newborns, and identify facilitators, barriers and associated maternal and newborn outcomes. A range of electronic databases were searched for papers reporting research findings published in English between January 2003 and October 2013. Seven papers met the criteria. This review has provided some evidence that with appropriate collaboration skin-to-skin contact during Caesarean surgery can be implemented. Further evidence was provided, albeit limited, that immediate or early skin-to-skin contact after a Caesarean section may increase breastfeeding initiation, decrease time to the first breastfeed, reduce formula supplementation in hospital, increase bonding and maternal satisfaction, maintain the temperature of newborns and reduce newborn stress.

Two cases of apparent suffocation of newborns during side-lying breastfeeding

The side-lying position is one of several options offered to women in the postpartum period to assist with early establishment of breastfeeding. Many new mothers are exhausted and experiencing significant pain following birth. While the side-lying position for breastfeeding can allow women to get needed rest, it can increase their risk of falling asleep while in this position and potentially smothering their babies. We report two cases of apparent suffocation in newborns on the maternity ward when women unintentionally fell asleep while breastfeeding in the side-lying position. Interventions that may help to prevent such events are suggested.

Effect of early skin-to-skin contact on breast-feeding

We examined the effect of early skin-to-skin contact (SSC) on breast-feeding at 1 month after delivery, in Japanese women. We reviewed the obstetric records of healthy nulliparous women with vaginal singleton delivery at 37-41 weeks' gestation, at the Japanese Red Cross Katsushika Maternity Hospital and between 1 February and 30 November 2011, there was a total of 403 women who planned to breast-feed their babies at birth. Of these, 272 women (67.5%) initiated early SSC in the delivery room and 131 women (32.5%) did not initiate early SSC. There were no significant differences in the obstetric characteristics and birth outcomes between the two groups of women with and without initiating early SSC. However, the rate of exclusive breast-feeding at 1 month after delivery in the group of women following early SSC (59.6%, 162/272) was significantly higher than that in the group of women without early SSC (45.8%, 60/131; crude OR 1.74, 95% CI 1.1-2.7, p = 0.009). The current results may support the benefit of early SSC in Japanese women after vaginal delivery.

Deaths and near deaths of healthy newborn infants while bed sharing on maternity wards

OBJECTIVE

Our aim was to evaluate programs promoting bed sharing on maternity wards and determining ways to reduce these risks.

STUDY DESIGN

Members of the National Association of Medical Examiners were contacted requesting information on deaths of healthy infants while bed sharing on maternity wards.

RESULT

Fifteen deaths and three near deaths are reported. One or more factors that increase the risk of bed sharing were present in all cases. Accidental suffocation was deemed the most likely cause of these incidents.

CONCLUSION

Cases of infant deaths and near deaths while bed sharing on maternity wards are under reported. The 'Baby Friendly' (BF) initiative in maternity hospitals to promote breastfeeding is endorsed by the American Academy of Pediatrics and the US Center for Disease Control and Prevention. The BF initiative encourages prolonged skin-to-skin contact and bed sharing. Education of mothers and more efficient monitoring should significantly reduce the risk of maternity ward bed sharing.

[Severe apparent life-threatening event during "skin-to-skin": treatment with hypothermia]

'Skin-to-skin' in healthy newborn infants is currently routine practice in Spanish maternity wards. This practice has shown benefits in increasing the duration of breast-feeding and maternal bonding behaviour with no significant adverse events. Early sudden deaths and severe apparent life-threatening events (ALTE) during the first 24 hours of life are infrequent, but well recognised. Risk factors during 'skin to skin' have been established. These events can lead to high neonatal morbidity and mortality. Hypothermia is now the standard of care for moderate to severe hypoxic-ischaemic encephalopathy and has shown to reduce mortality and neurological morbidity in children with hypoxic-ischaemic brain injury. Although there are no clinical trials that evaluate hypothermia after a severe ALTE, neonates who suffer it should be considered for this treatment. We present a case of a healthy newborn who had an ALTE during skin-to-skin with his mother and was treated with hypothermia.

Sudden unexpected postnatal collapse of newborn infants: a review of cases, definitions, risks, and preventive measures

This study aimed to review available published reports concerning sudden unexpected postnatal collapse (SUPC) of apparently healthy infants within the first days of postnatal life, establish a structured presentation and delineate recommendations for preventive measures. All published reports of SUPC cases were retrospectively analyzed, and three not previously published SUPC cases at Karolinska University Hospital were detailed to exemplify the varying presentations and outcomes of SUPC. We found 398 published cases of SUPC occurring during first postnatal week. Estimated incidence of the SUPC of a presumably healthy infant after birth differs widely, ranging from 2.6 cases to 133 cases/100,000. However, definition, inclusion, and exclusion criteria vary substantially between reports. Our summary indicates that reported SUPC occurs more frequently than expected from recent surveys. About half of the infants die, and of the remaining survivors, half have neurological sequela. Of the 233 cases of sudden unexpected death described, no etiology was found in 153 cases. When a defined time for the SUPC event is described, approximately one third of reported events occur during the first 2 h, between 2 and 24 h and between 1 and 7 days after birth, respectively. Adequate education of caregivers and appropriate surveillance during the first days of newborns should enable us to save hundreds of lives.

Right-to-left shunting in the ductus arteriosus is induced readily by intense crying and rapid postural change in neonates with meconium-stained amniotic fluid

OBJECTIVE

To investigate postnatal changes in the direction of blood flow through the ductus arteriosus in neonates with meconium-stained amniotic fluid, we measured preductal and postductal oxygen saturation in normal neonates, neonates with meconium-stained amniotic fluid, and a neonate with persistent pulmonary hypertension of the newborn.

DESIGN

Prospective, observational case series report.

SETTING

A single, tertiary neonatal intensive care unit.

PATIENTS

Twelve normal neonates, seven neonates with meconium-stained amniotic fluid, and a neonate with persistent pulmonary hypertension of the newborn.

INTERVENTIONS

SpO2 is simultaneously monitored in the right upper and lower limbs after birth.

MEASUREMENTS AND MAIN RESULTS

Compared with normal neonates, three neonates with meconium-stained amniotic fluid required longer than +2 SD of the mean time for the postductal SpO2 to reach 90% and/or 95%. In a neonate with meconium-stained amniotic fluid, intense crying triggered frequent decreases to <70% in the postductal SpO2 from 25 mins after birth, while the preductal SpO2 remained at 95% or above. When the other newborn with meconium-stained amniotic fluid was held in the father's arms after 98 mins, the postductal SpO2 decreased rapidly to <80%, while the preductal SpO2 remained at 95%. Thus, 5% or greater difference between the preductal and postductal SpO2 was observed from 25 mins after birth until 120 mins in all neonates with meconium-stained amniotic fluid, whereas the difference disappeared after 25 mins in 12 normal neonates. In a neonate with persistent pulmonary hypertension of the newborn who required vigorous resuscitation, 5% or greater difference between the preductal and postductal SpO2 levels was observed until 6 hrs after birth.

CONCLUSIONS

Right-to-left shunting in the ductus arteriosus may be induced readily by intense crying and rapid postural change in infants with meconium-stained amniotic fluid. It is important to monitor SpO2 at both pre- and postductal regions until 120 mins after birth in neonates with meconium-stained amniotic fluid and to subject these infants to minimal manipulations.

Apparent life-threatening events in presumably healthy newborns during early skin-to-skin contact

The death or near death of a presumably healthy newborn in the delivery room is uncommon. We report here 6 cases of apparent life-threatening events (ALTEs) in the delivery room during the first 2 hours of life. In each case, the incident occurred in a healthy infant who was in a prone position on his or her mother's abdomen during early skin-to-skin contact. In most cases, the mother was primiparous, and in all cases the mother and infant were not observed during the initiation of skin-to-skin contact and breastfeeding. There are many benefits of early skin-to-skin contact and breastfeeding in the delivery room. However, in view of the risk of a rare but significant ALTE, we suggest that surveillance of newborns is needed. Although many ALTEs are apparently caused by obstruction, we suggest that a standardized investigational workup be performed after an ALTE.

Sudden deaths and severe apparent life-threatening events in term infants within 24 hours of birth

OBJECTIVE AND DESIGN

To determine the incidence of and possible risk factors for unexpected sudden infant deaths (SID) and severe apparent life-threatening events (S-ALTE) that occurred within 24 hours of birth. This was a monthly epidemiologic survey.

PATIENTS AND METHODS

Throughout 2009, every pediatric department in Germany was asked to report such cases of unexplained SID or S-ALTE in term infants after a good postnatal adaptation (10-minute Apgar score ≥ 8) to the Surveillance Unit for Rare Pediatric Conditions in Germany. The latter has a capture rate of > 95%. S-ALTE was defined as acute cyanosis/pallor and unconsciousness, requiring bagging, intubation and/or cardiac compressions. Hospitals that reported a case were asked to return an anonymized questionnaire and discharge letter as well as the autopsy protocol in SID cases.

RESULTS

Of 43 cases reported, 17 fulfilled entry criteria, yielding an incidence of 2.6 in 100 000 live births. There were 7 deaths (ie, 1.1/100 000); 6 of the 10 S-ALTE infants were neurologically abnormal at discharge. Twelve infants were found lying on their mother's chest or abdomen, or very close to and facing her. Nine events occurred in the first 2 hours after birth; 7, were only noticed by a health professional despite the mother being present and awake.

CONCLUSIONS

SID or S-ALTE may occur in the first 24 hours after birth, particularly within the first 2 hours. Events seem often related to a potentially asphyxiating position. Parents may be too fatigued or otherwise not able to assess their infant's condition correctly. Closer observation during these earliest hours seems warranted.