Ethical and social issues in the care of the newborn

Ethical and social issues are based upon a system of moral values that serve the best interests of the society in a humane and compassionate manner. The ethical decisions should be based upon the well-enunciated principles of beneficence, non-maleficence, parental autonomy, correct medical facts and justice. In view of our economic constraints, we should follow the philosophy of utilatarian ethics based on the concept of “value for money” and focus our resources and efforts for the care of salvageable babies. Nevertheless, we should try to ensure equitable development of health care of neonates at all levels, and NICU facilities should be developed in the country in a phased manner. In order to ensure justice and cost-effectiveness, the narrow principles of “best interest” of the child should be replaced by the concept of global beneficence to the family, society and the state. Neonatologists are often faced with a large number of ethical issues and dilemmas in the care of critically sick newborn babies and they should be resolved jointly by taking nurses, sub-speciality colleagues and family members into confidence. The technology should not be allowed to further dehumanize medicine and we must establish rapport and provide emotional support to the family members by showing our concern, sympathy and compassion in the care of their critically sick and extremely preterm babies. It is desirable that all the medical and nursing schools in the country should initiate regular education programs in the field of behavioural sciences, communication techniques and medical ethics for the benefit of graduate and postgraduate medical and nursing students.     

Infant mortality: a practical approach to the analysis of the leading causes of death and risk factors

The analysis of infant mortality data provides an opportunity for developing preventive strategies to improve this indicator of a population's health. All infant deaths in North Carolina during a 5-year period (1980 through 1984) were analyzed using the International Classification of Diseases, 9th revision (ICD-9), and a system for linked birth and death records that allows the analysis of birth certificate information on deaths. Causes of death were aggregated based on common etiology such as prematurity or obstetric-related conditions rather than the more traditional organ system taxonomy of the ICD-9 codes. Analyses were carried out separately for very low birth weight (less than or equal to 1500 g), moderately low birth weight (1501 through 2500 g), and normal birth weight (greater than 2500 g) babies. Maternal characteristics identified from the birth certificate were also compared with the different causes of death. Prematurity-related conditions accounted for 37.5% of all deaths, ranking far above the 17.4% for congenital anomalies and 12.9% for sudden infant death syndrome. For normal birth weight babies, sudden infant death syndrome ranked first, followed by congenital anomalies and nonperinatal infections. For the moderately low birth weight babies, congenital anomalies ranked first, with sudden infant death syndrome second and prematurity-related conditions third. For the very low birth weight babies, prematurity-related conditions accounted for nearly 70% of the deaths, with obstetric conditions and congenital anomalies ranking second and third, respectively. Maternal risk factors identified an overrepresentation of nonwhite, unmarried, and young teenage mothers and mothers with less than adequate prenatal care.(ABSTRACT TRUNCATED AT 250 WORDS)     

Training program for pain assessment in the newborn

Aim

Pain management is correlated with pain assessment in the newborn infant. The aim of this study was to assess the impact of a 2-week training program composed of short (20 min), repeated training sessions conducted in the unit.

Care of the well newborn

The birth of an infant is one of the most memorable experiences a family shares. Pediatric health care professionals are privileged to participate in this experience and recognize it as a time to promote the health of the newborn and family. Ideally, a well-designed care system would be replete with comprehensive supports during the prenatal period, birth, and transition to home. Opportunities exist to improve the care we deliver with universal screening of all pregnant women; coordinated assessments of family health, including mental health; and access to coordinated supports and services for mother and infant. If 90% of US families could comply with medical recommendations to breastfeed exclusively for 6 months, it is estimated the United States would save billions of dollars per year and prevent more than 900 deaths, nearly all of which would be in infants. All infants, whether breastfed or formula fed, should receive 400 IU supplemental vitamin D. Influenza and TdaP vaccination of postpartum mothers and other caregivers helps cocoon the vulnerable infant from influenza and pertussis until he or she can be fully vaccinated. When children reach the highest weight or length allowed by the manufacturer of their infant-only seat, they should continue to ride rear-facing in a convertible seat. It is best for children to ride rear-facing as long as possible to the highest weight and height allowed by the manufacturer of their convertible seat.     

Cause-specific neonatal mortality in a neonatal care unit in Northern Tanzania: a registry based cohort study

ABSTRACT: BACKGROUND: The current decline in under-five mortality shows an increase in share of neonatal deaths. In order to address neonatal mortality and possibly identify areas of prevention and intervention, we studied causes of admission and cause-specific neonatal mortality in a neonatal care unit at Kilimanjaro Christian Medical Centre (KCMC) in Tanzania. METHODS: A total of 5033 inborn neonates admitted to a neonatal care unit (NCU) from 2000 to 2010 registered at the KCMC Medical Birth Registry and neonatal registry were studied. Clinical diagnosis, gestational age, birth weight, Apgar score and date at admission and discharge were registered. Cause-specific of neonatal deaths were classified by modified Wigglesworth classification. Statistical analysis was performed in SPSS 18.0. RESULTS: Leading causes of admission were birth asphyxia (26.8%), prematurity (18.4%), risk of infection (16.9%), neonatal infection (15.4%), and birth weight above 4000 g (10.7%). Overall mortality was 10.7% (536 deaths). Leading single causes of death were birth asphyxia (n = 245, 45.7%), prematurity (n = 188, 35.1%), congenital malformations (n = 49, 9.1%), and infections (n = 46, 8.6%). Babies with birth weight below 2500 g constituted 29% of all admissions and 52.1% of all deaths. Except for congenital malformations, case fatality declined with increasing birth weight. Birth asphyxia was the most frequent cause of death in normal birth weight babies (n = 179/246, 73.1%) and prematurity in low birth weight babies (n = 178/188, 94.7%). The majority of deaths (n = 304, 56.7%) occurred within 24 hours, and 490 (91.4%) within the first week. CONCLUSIONS: Birth asphyxia in normal birth weight babies and prematurity in low birth weight babies each accounted for one third of all deaths in this population. The high number of deaths attributable to birth asphyxia in normal birth weight babies suggests further studies to identify causal mechanisms. Strategies directed towards making obstetric and newborn care timely available with proper antenatal, maternal and newborn care support with regular training on resuscitation skills would improve child survival.     

Is “Transient Tachypnoea of the Newborn” Always a Benign Disease? Report of 6 Babies Requiring Mechanical Ventilation

Tudehope, D. I., and Symth, Margaret H. (1979). Aust. Paediatr. J., 15, 160–165. Is “transient tachypnoea of the newborn” always a benign disease? Report of 6 babies requiring mechanical ventilation. A retrospective study in an intensive care nursery revealed that transient tachypnoea of the newborn (TTN) was the commonest cause of respiratory distress. This condition was frequently associated with marginal prematurity, hypoproteinaemia, birth asphyxia, Caesarean section, breech presentation and male babies. The signs associated with TTN abated by 48 hours in 74% of the babies; the remainder had a prolonged, often complicated course. Six of the nine babies with signs persisting more than 46 hours required mechanical ventilation; three because of hypoxaemia and three with severe respiratory acidosis. Babies with the clinical signs and radiographic features consistent with TTN may develop severe ventilation-perfusion imbalance, fatigue and pulmonary hypertension with right to left shunting of blood across the ductus arteriosus.     

Anthropometric surrogates to identify low birth weight Nepalese newborns: a hospital-based study

Background  

In Nepal, more than 90% of the deliveries take place at home where birth weight is often not recorded. In developing countries, low birth weight (LBW, <2500 grams) accounts for 60–80% of neonatal deaths. Early identification and referral of LBW babies for extra essential newborn care is vital in preventing neonatal deaths. Studies carried out in different populations have suggested that the use of newborn anthropometric surrogates of birth weight may be a simple and reliable method to identify LBW babies in a home setting. However, a reliable anthropometric surrogate to identify LBW babies and its cut-off point is not known for Nepalese newborns.     

Regionalized perinatal care in developing countries.

Neonatal-perinatal ill health and mortality are overwhelmingly a burden of the developing world. As many as 90% of births, 98% of fetal deaths and 98% of neonatal deaths occur in less developed countries. Regionalized perinatal services were introduced in developed countries when most neonatal mortality was confined to very-low-birthweight babies who required intensive perinatal care to survive. A large proportion of newborn morbidity and mortality in developing countries, however, continues to occur among full-term and moderate-sized low-birthweight neonates who can be managed well in the community and at small hospitals. The model of regionalized perinatal care as practiced in developed countries is, at present, neither affordable nor relevant to the needs of many developing countries. It is possible to achieve considerably lower neonatal mortality rates in resource-poor settings by implementing home-based newborn care delivered by community health workers, and by promoting institutional perinatal care at simple facilities provided by trained midwives.     

An implementation algorithm to improve skin‐to‐skin practice in the first hour after birth

Evidence supporting the practice of skin‐to‐skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby. The 2009 revision of Step 4 of the WHO/UNICEF “Ten Steps to Successful Breastfeeding” elaborated on the practice of skin‐to‐skin contact between the mother and her newly born baby indicating that the practice should be “immediate” and “without separation” unless documented medically justifiable reasons for delayed contact or interruption exist. While in immediate, continuous, uninterrupted skin‐to‐skin contact with mother in the first hour after birth, babies progress through 9 instinctive, complex, distinct, and observable stages including self‐attachment and suckling. However, the most recent Cochrane review of early skin‐to‐skin contact cites inconsistencies in the practice; the authors found “inadequate evidence with respect to details … such as timing of initiation and dose.” This paper introduces a novel algorithm to analyse the practice of skin to skin in the first hour using two data sets and suggests opportunities for practice improvement. The algorithm considers the mother's Robson criteria, skin‐to‐skin experience, and Widström's 9 Stages. Using data from vaginal births in Japan and caesarean births in Australia, the algorithm utilizes data in a new way to highlight challenges to best practice. The use of a tool to analyse the implementation of skin‐to‐skin care in the first hour after birth illuminates the successes, barriers, and opportunities for improvement to achieving the standard of care for babies. Future application should involve more diverse facilities and Robson's classifications.     

Criterios de alta hospitalaria del recién nacido a término sano tras el parto

Criteria for newborn hospital discharge have to include physiological stability and family competence to provide newborn care at home. In this document, the Committee of Standards of the Spanish Society of Neonatology reviews the minimum criteria to be met before hospital discharge of a term newborn infant. We include a review of hospital discharge criteria for the late preterm infants, as these infants are often not hospitalised and remain with their mother after birth. A shortened hospital stay (less than 48 h after delivery) for healthy term newborns can be considered, but it is not appropriate for every mother and newborn. Newborn infants discharged before 48 h of age, should be examined within 3-4 days of life.     

Strategy for child survival.

The rates of infant and under-five mortality are too high in India. Almost half of these child deaths could, however, be avoided with greater primary health care. Evidence from other countries demonstrates the potential of primary health care programs to slash infant mortality by 50-60% over a 1-5 year period. Such programs should consider: prenatal care; delivery by trained birth attendant; care of newborn infants; primary care for diarrhea, acute respiratory infections, and other common diseases; immunizations; prophylaxis against anemia and vitamin and iodine deficiency; growth monitoring and nutritional guidance of staff; and stronger secondary and tertiary care. While components of this program may be in place, inadequate staff training and essential medicines and equipment combine with poor infrastructure, communication, and supervision to produce inadequate service coverage. This paper proposes the employment of female multipurpose workers to provide both primary health care and family planning services to rural communities. Each worker would be responsible for services in 5-6 villages of 5000 inhabitants within a 5-km radius of her headquarters. Elements of the program are discussed in the bulk of the paper.     

Neonatologische Versorgung – Fallzahlregelung

Germany’s infant mortality rate is high compared with Scandinavian countries, for instance, despite relatively high expenditure on health care. Since the infant mortality rate is influenced mainly by the neonatal mortality rate, which in turn is strongly determined by premature infant mortality, the national discussion has been focusing on the improvement of very low birthweight (VLBW) infant care in Germany. In 2005, the Joint Federal Committee (Gemeinsamer Bundesausschuss), the legislative organ of self-governance in the German statutory health care system, after drawing up a list of structural requirements, agreed upon a minimum number of 14 VLBW babies below 1250 g birthweight or between 1250 and 1500 g birthweight, as well as publishing outcome quality. The pros and cons of such regulations to reduce infant mortality and improve the care of VLBW are discussed.     

Outcome for newborn babies declined admission to a regional neonatal intensive care unit.

Between July 1979 and June 1980 the regional neonatal intensive care unit (NICU) at St Mary''s Hospital, Manchester, received 170 requests from maternity units for the transfer of ill newborn babies. Most of the babies were suffering from respiratory failure. The initial request was declined in 65 babies because of overcrowding or lack of facilities at the NICU (n = 59), or because transfer was not justified on medical grounds (n = 6). Forty-two of the 65 babies were compelled to remain in the maternity unit because they could not be accommodated at hospitals with facilities for ventilating newborn babies. The neonatal survival rate of babies with respiratory failure who were transferred to the NICU was 66% whereas the survival rate of similar babies who were declined transfer was 30%. Our findings support the efficacy of intensive care for ill babies with respiratory failure and suggest that such facilities need to be more widely developed.     

An innovative curriculum for primary care neonatology

This article describes the design of an innovative curriculum for pediatric residency newborn nursery rotation. In 1989, the Accreditation Committee for Graduate Medical Education added the requirement of newborn care to pediatric residency training; in 1996, the Accreditation Committee for Graduate Medical Education expanded that requirement. Specifically, certification required 4 weeks of newborn care, separate from any neonatal intensive care experience, and with at least 2 weeks in a newborn nursery. In response, we designed a structured newborn nursery curriculum for our pediatric residency training program. Three areas of focus were identified, from which the content and the strategies for teaching were derived. The areas of focus were (1). primary care, (2). confluence of levels of care that arise in newborn care, and (3). limitations and advantages of the structure and the environment of the rotation. The curriculum was implemented on a pediatric level 1 (PL-1) rotation entitled "primary care neonatology."     

Prävention des Plötzlichen Kindstodes

Cot death is a generic term for sudden, unexpected and unexplained death in infancy. It has numerous causes. More than 10,000 such deaths could be prevented in Germany over the past 20 years by changing infant sleeping conditions (“back position in a sleeping bag”). The body of knowledge which has been gathered and confirmed in epidemiological studies needs to be transferred to all future generations of parents in order to prevent a repetition of the disaster which occurred after the introduction of the “well-meant fashion” of the prone sleeping position.     

Strategies for lowering perinatal mortality

In India neonatal mortality is responsible for 60%-65% of infant mortality and perinatal mortality is equally high: 60-70/1000 births. Low birth weight babies are at a 3-4 times higher risk of dying than normal weight babies. 2/3rds of all 1st-week deaths have been found preventable. In addition to its medical component health is composed of social, psychological, behavioral, and economic factors. Health status is associated with the literacy of the mother and her social status. Pregnancies starting around 15-16 years of age adversely impact maternal health and life. Between the ages of 15 and 35 women are either pregnant or nursing. Extremely young or old maternal age, anemia, toxemia, hemorrhage, sepsis, and cephalopelvic disproportion result in maternal and neonatal deaths. The Indian health infrastructure has about 1000.000 subcenters and 16.000 primary health centers. At these centers a trained medical worker is entrusted with providing care for a population of 5000.     

Parental Information and Behaviors and Provider Practices Related to Tummy Time and Back to Sleep

IntroductionThis exploratory study aimed to discern parental understanding and behaviors, provider practices, and available online information related to infant positioning including “Back to Sleep” and “Tummy Time” (TT) during early infancy.MethodThe study employed three methods of exploration: surveys of 119 mothers of newborns, a focus group of nine health care providers, and an analysis of popular parental Web sites.ResultsNinety percent of the mothers reported receiving information about positioning the infant while asleep. However, only 55% mothers postpartum and 26% at 2 months after birth received information regarding infant positioning during awake time. Providers reported barriers such as lack of time and confusing guidelines to TT education. Parenting Web sites were inconsistent regarding TT initiation and duration information.DiscussionStudy outcomes suggest that, with the implementation of “Back to Sleep” guidelines, there has been a need for parental education about positioning infants during sleep and awake times.     

Birth weight gestational age correlates of neonatal mortality

Two hundred and fifty five neonatal deaths out of 6,222 live born babies born at All-India Institute of Medical Sciences hospital during a period of 4 years were analysed for their birth weight and gestational age. The neonatal mortality data by birth weight and gestational age parameters is presented in a variety of ways to indicate their usefulness in everyday practice. The overall neonatal mortality rate was 4.1 per cent. Preterm and low birth weight babies accounted for 66.6 per cent and 75.2 per cent of total deaths respectively. Although neonatal mortality rate is reduced with higher birth weight and longer gestational age, the gestational maturity influences the survival of infants irrespective of other factors. The significance and utility of the data when expressed in large and small weightgestational age groupings and their routine use in evaluating an individual pregnancy outcome or assessing an individual newborn infant is discussed.     

Recent trends in hospital use by children in England

BACKGROUND—Routine hospital statistics for England appear to overestimate use of children''s wards and include numbers of well newborn babies staying with their mothers after delivery ("well babies").AIM—To review trends in use of children''s wards excluding data on newborn babies.METHODS—We reviewed routine, published, and age stratified data requested from the Department of Health to identify separately "well babies" and babies receiving neonatal specialist care from admissions (surgical and paediatric) to children''s wards.RESULTS—Routine reports for paediatric activity contain large numbers of "well babies", (almost half the total) as well as babies receiving specialist neonatal care. After excluding these, paediatric admissions represent 9.9% of the child population aged under 5years each year (an additional 2.5% are admitted for surgical care). Between 1989 and 1997 paediatric admissions rose by 19% and surgical admissions fell by 25% with a plateau reached in overall child admissions. There are now fewer beds in which children stay for a shorter time and there is more day case surgery. Neonatal specialist care work has risen despite a fall in births.CONCLUSION—Categories should be established for reporting paediatric episodes on children''s wards separately from those on neonatal units, with better identification of "well babies". When monitoring use of children''s inpatient facilities or planning new units, care must be taken to separate paediatric data on neonatal units from work on children''s wards. Children''s surgical episodes should also be taken into account.