INTRODUCTION

Of 8.1 million infant deaths in 1993, almost half (3.9 million, 48%) were neonatal deaths.
While infant mortality has been decreasing steadily all over the world, changes in neonatal
mortality have been much slower. Almost-two thirds (2.8 million) of newborn deaths were
within one week of birth, and deaths of many babies after the first week were also due to
perinatal causes. The major causes of neonatal mortality are listed in Table 1.

Table 1: Causes of neonatal deaths in developing countries (1993)

Number of Proportion of all

Cause of death
newborn deaths newborn deaths (%)

Birth asphyxia 840 000 21.1

Birth injuries 420 000 10.6

Neonatal tetanus 560 000 14.1

Sepsis, meningitis 290 000 7.2

Pneumonia 755 000 19.0

Diarrhoea 60 000 1.5

Prematurity 410 000 10.3

Congenital anomalies 440 000 11.1

Others 205 000 5.1

Total 3 980 000 100.0

In 1993, 42% (1.7 million) of all newborn deaths were due to infections (neonatal tetanus,
sepsis, meningitis, pneumonia, diarrhoea). Two-thirds of those infections were related to the
birth process. Neonatal tetanus causes more than half a million of these deaths (14% of the
total). Increasing coverage of pregnant women with tetanus toxoid can and does reduce
neonatal tetanus deaths but babies may still die of other bacterial infections caused by lack of
hygiene at birth and during the newborn period. Women and infants delivered at home
without a trained birth attendant and without precautions of hygiene are particularly at risk.

In developing countries around 3% of newborns suffer mild to moderate birth asphyxia, and
an estimated 840 000 newborns died of this cause in 1993 (25% of birth-related deaths). An
equal number of survivors suffer brain damage. Although prompt resuscitation after delivery
can prevent many of these deaths and disabilities, it is often not initiated or the procedures
used are inadequate or wrong.

Few data are available on the incidence of hypothermia for home and institutional births and
almost no data exist on how many newborn deaths are due to hypothermia. Existing evidence
show that hypothermia contributes significantly to deaths of low birth weight and pre-term
infants. Taboos that discourage touching the baby before delivery of the placenta or preparing
clothes/wraps before birth contribute to hypothermia.

The proportion of babies who are breast-fed is high in all regions of the world but there are
wide variations in the duration of breast-feeding. Sub-optimal breast-feeding practices are
still the norm in most countries. Failure to give newborn infants colostrum is a common
example of bad practice. Lack of exclusive breast-feeding substantially increases the risk of
poor newborn and childhood outcome.

In many countries where the prevalence of sexually transmitted diseases is high and where
prophylaxis is not widely practised, ophthalmia in newborns is a common cause of blindness.
Blind infants are also at increased risk of dying.

About 19% or almost 24 million of all infants are born with a birth weight less than 2500 g,
which is classed as low birth weight (LBW). LBW is probably the single most important
factor in neonatal mortality, as well as being a significant determinant of post-neonatal
mortality and childhood morbidity. LBW can be caused by many factors, and these
modifiable factors are targeted for intervention by the Safe Motherhood Programme. Major
contributors to the death of LBW infants are prematurity, infections, birth asphyxia,
hypothermia and inadequate feeding.

Around 755 000 newborn infants die of pneumonia. While some of these infections have
their origin in labour and delivery, others are acquired postpartum. Lack of hygiene,
hypothermia and inadequate feeding are important risk factors. Signs of pneumonia in a
newborn are subtle and often remain unrecognized until it is too late.

An unknown proportion of newborn deaths is due to neglect of the female newborn infant.
An unknown number of female newborns are left to die because they are unwanted.

The majority of newborn problems are specific to the perinatal period. They cause not only
deaths but also substantial morbidity and disability. These problems are the result of poor
maternal health, inadequate care during pregnancy, inappropriate management and poor
hygiene during delivery, lack of newborn care and discriminatory care. If a mother dies
during childbirth, her baby will have an even smaller chance of survival. Death among
newborn infants is so frequent that it is accepted as routine by many families and community
members. In some societies a child is named only if she or he survives the critical neonatal
period.

Newborn deaths cannot be substantially reduced without efforts to reduce maternal deaths
and improve maternal health. However, care during pregnancy and delivery must be
accompanied by appropriate care of newborns and measures to reduce newborn deaths due to
postnatal causes such as infections (tetanus, sepsis), hypothermia and asphyxia. Most
postnatal deaths are caused by preventable and/or treatable diseases. Preventive interventions
are simple, inexpensive, available and cost-effective.

Almost two-thirds of births in developing countries occur at home and only half are attended
by a trained birth attendant (Table 2). Strategies to reduce newborn deaths should therefore
also target traditional birth attendants (TBAs), families and communities as well as health
workers within the formal health care system.
Table 2: Births by region, place and attendance at birth (1993)

By trained Neonatal deaths

Region Births (in thousands) At home
person (in thousands)

Number % % % Number %

World 142 000 100% 56% 60% 4 150

Developed (1) 17 000 12% 5% 99% 170 4%

Developing 125 000 88% 63% 55% 3 980 96%

Africa 28 000 20% 66% 42%

Asia 85 000 60% 67% 56%

Latin America 12 000 8% 34% 76%

(1) In developed countries it is assumed that neonatal mortality is 10/1000 live-births

In 1994, WHO convened a Technical Working Group to define essential newborn care at
three levels of care (at home/in the family, at the health centre and at the first referral level, a
district hospital). The aims of the meeting were:

 to review and update best practices and technologies for prevention of neonatal
mortality, morbidity and disabilities through protective actions;
 to discuss various ways to integrate these practices and technologies into essential
neonatal care;
 to review and adapt the health information systems for recording, reporting and
registering births, deaths and causes of deaths;
 to outline an appropriate system for gathering information from communities and
maternity facilities; and
 to discuss the indicators of newborn health.

This document presents the summary of the meeting and the recommendations designed to
assist health planners and programme managers in developing countries to improve newborn
health at the health centre and district hospital and to plan IEC activities at the community
level. They will have to be adapted to country-specific guidelines.

The World Health Organization welcomes comments and feedback from users of this document and
will use such comments in the preparation of the new edition of this and other documents. Please
send comments to the Maternal and Newborn Health/Safe Motherhood unit, World Health
Organization, 1211 Geneva 27, Switzerland.

PROCEEDINGS
Essential interventions

There are striking variations from place to place in the patterns of care and
interventions that newborn infants receive. In many cases there is a lack of
knowledge of what is needed for optimal newborn care. Modern hospital practices
and traditional ones neglect the basic needs of newborns: warmth, cleanliness,
breast milk, safety and vigilance.

Most newborn deaths can be avoided by both preventive measures (such as clean
delivery) and by effective management of complications (such as resuscitation,
management of infections). Other interventions also have important preventive
effects (thermal protection, breast-feeding, eye care to reduce blindness).

Interventions that improve maternal health will have a major impact on the health of
newborns. The knowledge should be translated into practices of health workers who
deliver babies at home, at health centres and in hospitals.

The essential newborn care interventions are:

1. Cleanliness: clean delivery and clean cord care for the prevention of
newborn infections (tetanus and sepsis)

Clean delivery and clean cord care can be ensured everywhere: in health
facilities by policies and practices for prevention, detection and control of
nosocomial infections; in home deliveries by strengthening standards of
cleanliness by using disposable delivery kits. A complementary strategy to
reduce neonatal tetanus is immunizing pregnant women with tetanus toxoid.

2. Thermal protection: prevention and/or management of neonatal

hypothermia and hyperthermia

Simple measures such as a warm room for delivery, immediate drying of the
baby and skin-to-skin contact with the mother can prevent loss of body
warmth. Birth attendants and families need instruction on how to rewarm
babies that become hypothermic.

3. Early and exclusive breast-feeding

Breast-feeding should be started within an hour of birth. Feeding should be

as frequent as the baby demands, without prelacteal feeds or other fluids and
food. Knowledge about the importance of breast-feeding should be
disseminated among families and communities as well as health workers and
managers.

4. Initiation of breathing, resuscitation

Birth asphyxia should be recognized promptly and management should

follow the basic principles of resuscitation: aspiration of mouth and nostrils,
 end ventilation with positive pressure.

5. Eye care: prevention and management of ophthalmia neonatorum

Eye prophylaxis involves cleaning the eyes immediately after birth and
applying either silver nitrate drops or tetracycline ointment within the first
hour of birth. There must be early diagnosis and management of ophthalmia.

6. Immunization

1. At birth BCG, OPV-0 and Hepatitis B vaccines are recommended by WHO.

2. Management of newborn illness

Major newborn illnesses should be recognized early both at home and at the
health centre so that the baby can be referred to hospital for management.

3. Care of the preterm and/or low birth weight newborn

Additional warmth, cleanliness, and nutrition, early recognition and management of

diseases.

The above interventions are effective in reducing deaths and diseases in any
newborn. They can be divided into basic care and special care.

Basic care means interventions for all infants to meet their physiological needs:
prevention of infections due to uncleanliness at birth and later; preservation of
warmth and prevention of hypothermia; appropriate nutrition by early, exclusive
and frequent breast-feeding; initiation of breathing by resuscitation when needed.
Basic newborn care assures survival of those that are born well-equipped to survive
(term, well-grown newborns without malformations) and give good start for preterm
and small newborns.

Special care is required for a small group of newborns because of diseases acquired
before, during or after birth and/or because they were born too soon and/or too
small.

Management of sick newborns includes early recognition and management of

newborn diseases, management of hypothermia and selected other conditions
specific for the early newborn period. Preterm and/or low birth weight infants need
more attention and care. Early detection of problems requires vigilance and skills
for observing and assessing/examining newborns.

Each neonatal death should be investigated, not only for bio-medical causes but
other circumstances that led to the death. The findings should be used to improve
practices.

Congenital anomalies are more common at birth than at any other time of life. Many
are lethal and not susceptible to interventions. Others require sophisticated
corrective surgery, not available in most places. Only few are amenable to public
health interventions.

Recommendations for these good practices for newborn care at three levels - home,
health centre and referral hospital - are based on available scientific evidence or, in
the absence of such evidence, on best clinical judgement. Details will be available in
separate guidelines for each of the interventions. However, global guidelines for
good practices need to be adapted to local conditions and traditional practices before
they can become the operational standards for newborn care in a country. Such
changes will have to be incorporated into training materials for health care
providers. At the end of the process, each health facility should have written
policies on newborn care and staff trained in the skills necessary to implement them.

Recommendations for care at the peripheral level and for home delivery are based
on the assumption that a single trained birth attendant is available for a non-
complicated delivery. If complications develop, they must make it clear how to
divide priorities between mother and baby.

Two-thirds of babies in developing countries are born at home and the others are
discharged from health facilities soon after birth. All birth attendants should be
familiar with the basic principles of preventive newborn care and should be able to
recognize danger signs. Health facilities must be the first to adopt good clinical
practices since they set examples of good practice for communities. Nevertheless,
education of the birth attendants who deliver babies and look after them at home is
very important. Health workers need guidance on how to change family behaviour
regarding both newborn care at home and care-seeking.

Cleanliness, clean delivery and cord care for the prevention of newborn infections
(tetanus and sepsis)

Clean delivery and cord care means observing principles of cleanliness throughout
labour and delivery and after birth until the separation of the cord stump. Principles
of cleanliness at birth are:

 clean hands
 clean perineum
 nothing unclean to be introduced into the vagina
 clean delivery surface
 cleanliness in cutting the umbilical cord
 cleanliness for cord care of the newborn baby

The hands of the birth attendant must be washed with water and soap, as well as the
perineum of the woman. The surface on which the baby is delivered must be clean.
Instruments, gauze and ties for cutting the cord should be sterile. Nothing should be
applied either to the cutting surface or to the stump. The stump should be left
uncovered to dry and to mummify.

Principles of cleanliness are as essential in health facilities as they are at home. In

addition to hygiene during delivery - clean hands, clean environment,
sterilized/disinfected equipment and supplies - these principles include special
measures for newborns to prevent hospital infections - rooming-in, prevention of
overcrowding, provision of clean water and washing of hands by health personnel.
Institutional policies need to define methods for prevention, detection and control of
nosocomial infections.

There is an abundance of traditional practices for cutting the umbilical cord. Many
of them are harmful. Those that observe the principles of cleanliness can be
preserved but others must be changed. For home deliveries, the use of simple
disposable delivery kits will help in achieving as clean a delivery as possible. The
kit should contain, as a minimum, a nail cleaning stick, a small piece of soap for
clean hands and clean perineum, a plastic sheet of about 1 x 1 m to provide a clean
surface, and a sterile razor blade, ties and gauze for the clean cutting and care of the
umbilical cord. All the materials should be packed in a sealed plastic bag with
instructions on how to wash hands thoroughly before delivery and again before
handling the baby's umbilical cord, and how to use other items in the package. The
best means of producing, distributing and promoting the kits to pregnant women
should be determined locally. One option is the local assembly of disposable
delivery kits by women's groups.

The cord stump remains the major means of entry for infections after birth.
Principles of clean cord stump care (keep it dry and clean and do not apply
anything) apply at home as well as in the health facility. The stump will dry and
mummify if exposed to the air without any dressing, binding or bandages. It will
remain clean if it is protected with clean clothes and is kept from urine and soiling.
No antiseptics are needed for cleaning. If soiled, the cord can be washed with clean
water and dried with clean cotton or gauze. Local practices of putting various
substances on the cord stump - whether in health facilities or homes - should be
carefully examined. They should be discouraged if found harmful and substituted
with acceptable ones.

If the umbilical stump is draining pus, the skin around it is becoming red and it has
a foul smell, these are signs of an umbilical infection that requires treatment with
antibiotics. If the baby stops suckling well, is sleepy, does not wake up or is having
difficulty breathing, this may be a sign of serious infection. The baby must be
referred immediately to the hospital for proper treatment.

Infections acquired after birth need special attention. They can be prevented by
clean practices, clean delivery and cord care, early and exclusive breast-feeding,
rooming-in, thermal protection by early skin-to-skin contact, and eye care.
Maintaining the mother-infant contact that was established immediately after birth
favours colonization of the infant's skin and gastrointestinal tract with the mother's
microorganisms, which tend to be non-pathogenic and against which the mother has
antibodies in her breast milk. The infant is thus simultaneously exposed to and
protected against the organisms for which active immunity will be developed only
later in life. There are a number of ways to organize rooming-in to allow a mother
free and easy access to her infant, whether the infant shares the mother's bed or is in
another bed in the same room. In health facilities where mothers and babies are
separated, babies are often kept in nurseries where they share equipment and
supplies. Here they may be exposed to microorganisms of the hospital staff which
are more pathogenic, are often resistant to many antimicrobial drugs and for which
breast milk contains no specific antibodies. Keeping babies with mothers, and
having mothers taking care of them, eliminates the danger of cross-infections.

Thermal protection: prevention and/or management of neonatal hypothermia and

hyperthermia

The normal body temperature of the newborn infant is 36.5 - 37.5 oC. Hypothermia
occurs when the body temperature drops below 36.5 oC. The newborn infant is most
sensitive to hypothermia during the stabilization period in the first 6 - 12 hours after
birth, although hypothermia may occur at any time if the environmental temperature
is low and thermal protection inadequate. The newborn has a relatively large surface
area, poor thermal insulation, a small body mass to produce and conserve heat, little
ability to conserve heat by changing posture and no ability to adjust its own clothing
in response to thermal stress. Hypothermia can easily occur if a newborn infant is
left wet and unprotected from cold while waiting for the placenta to be delivered.
Hypothermia can occur after birth even at moderate environmental temperatures
when babies are not well protected or because of practices such as bathing the
newborn. As the body temperature decreases, the baby becomes less active,
lethargic, hypotonic, sucks poorly and the cry becomes weaker. Respiration
becomes shallow and slow and the heart-beat decreases. Sclerema - hardening of
skin with redness - develops mainly on the back and the limbs. The face can also
become bright red. As the condition progresses it causes profound changes in body
metabolism resulting in impaired cardiac function, haemorrhage (especially
pulmonary), jaundice and death.

The principles for preventing hypothermia in newborn infants require delivery of

the baby in a warm room, drying it thoroughly after birth, wrapping it in a dry warm
cloth while keeping it out of draughts on a warm surface and giving it to the mother
as soon as possible. The baby's mother is the best source of warmth. Early skin-to-
skin contact for the first few hours after birth is more than just a measure for
preventing hypothermia; it provides warmth, enables early breast-feeding and
prevents hypoglycaemia.

If separated from its mother, a newborn baby needs to be well protected from cold
and/or heat. Swaddling is not a good way to keep babies warm. If the cloths are
wrapped tightly round the baby, there is little air trapped between the body and the
cloth and the cloth itself does not provide sufficient insulation. A better way of
protecting babies is to use clothes or wrap the baby in loose layers of light but warm
material.

The temperature of a newborn infant should be checked regularly. Families need to

know how to recognize hypothermia by touching the feet and body of the baby.
They need to know how to rewarm the baby by skin-to-skin contact with the mother
or father - the simplest and most effective method. Other simple and safe measures
of rewarming at home include wrapping a baby in layers of warm clothes and
changing them frequently, and using measures such as warm water bottles. Families
also need to know that if the baby does not get better it must be taken to the health
centre or hospital to prevent further complications. An unexplained fall in body
temperature may accompany severe infection.

In health facilities, the baby's temperature should be checked regularly, especially in

the period immediately after birth. If the temperature is found to be low, the infant
must be rewarmed and health evaluated. A newborn infant with hypothermia should
also trigger a review of the institution's practices for thermal protection.

The newborn infant may be bathed when the temperature is stable and the baby is
doing well. This is usually done for cosmetic purposes (to remove the vernix).
Vernix has lubricating and anti-infection properties and does not need to be
removed.

Infants with severe hypothermia need rapid rewarming. They must be referred to the
hospital where they can receive support treatment in addition to effective
rewarming. During transport, skin-to-skin is the best way to rewarm.

Hyperthermia is defined as body temperature above 37.5oC. Newborn infants

develop hyperthermia if exposed to an environment that is too warm (sun, proximity
to a heater, etc). The baby is initially irritated, breathes fast, with increased heart
rate, hot and dry skin and the face appears flushed. It gradually becomes apathetic,
lethargic and pale. When the body temperature goes above 41oC, stupor, coma and
convulsions develop. The infant should be moved from the heat, undressed and the
body should be cooled. Dehydration is a serious complication of hyperthermia and
usually needs hospitalization.

The infant's condition should be reevaluated when the causes of hypothermia or

hyperthermia are determined and removed. Signs of hypothermia, hyperthermia and
infection are similar. If any of the danger signs persist after normalization of its
temperature, the infant must be referred to the hospital.

Early and exclusive breast-feeding

Breast milk provides optimal nutrition and promotes the child's growth and
development; it is associated with improved growth during the first months of life.
By breast-feeding, a mother begins the immunization process at birth and protects
her child against a variety of viral and bacterial pathogens before the acquisition of
active immunity through vaccination. Breast milk has unique anti-infective
properties. Frequent and exclusive breast-feeding can be an appropriate method of
fertility regulation for many women, particularly when other family planning
methods are not readily available or desired.
Early contact (immediately after birth) between the mother and the baby has a
beneficial effect on breast-feeding. Early suckling provides the baby with colostrum
that offers protection from infection, gives important nutrients, and has a beneficial
effect on maternal uterine contractions. The baby's skin and gastrointestinal tract are
colonized with the mother's microorganisms, against which she has antibodies in her
breast milk.

Important factors in establishing and maintaining breast-feeding after birth are:

giving the first feed within one hour of birth, correct position that enables good
attachment of the baby, frequent feeds, no prelactal feeds or other supplements, and
psychosocial support for breast-feeding mothers.

Babies have a wide range of behaviours following spontaneous delivery and are not
all ready to feed at the same time. A skilled person can help to facilitate the process
by ensuring correct positioning and attachment. A healthy baby has no need for
large volumes of fluid any earlier than they become available physiologically from
the mother's breast. There is no evidence to support the practice of providing
supplementary feeds of water, glucose or formula. Traditional prelactal feeds should
be strongly discouraged although harmless rituals may be allowed so long as they
do not delay breast-feeding. Every birth attendant should also know the importance
of unrestricted feeding and the ways to support breast-feeding mothers. Mothers
should be instructed about the need for an adequate diet to sustain lactation. They
should be helped and encouraged if they have difficulties breast-feeding.

Rooming-in has many advantages over separating babies from mothers. In health
facilities its advantage, in addition to breast-feeding, is to prevent nosocomial
infections.

Many publications are available which describe the importance of breast-feeding

and the best ways to support it.

Initiation of breathing, resucitation

The operational definition of birth asphyxia is a delay in initiating breathing at birth.

To a certain extent, birth asphyxia can be prevented by referring women to health

facilities when complications that may cause birth asphyxia (such as prolonged
labour or preterm delivery) are expected. However, when a newborn is not
breathing after birth, urgent and skilled resuscitation is needed immediately.

If a newborn infant does not cry after initial stimulation by drying, it must be
assessed for breathing. If the infant is not breathing or the breathing is poor, it needs
active resuscitation. Newborn infants may have difficulty in initiating breathing due
to prologued and/or obstructed labour, prematurity, infection, and many unknown
causes. Often it is impossible to anticipated that the newborn infant will have
trouble in initiating breathing. Therefore, the equipment and skills for resuscitation
are needed for every birth.

The aim of resuscitation is to initiate breathing by expanding the lungs, filling them
with air to allow an exchange of gases and to permit changes in circulation.
Aspiration of the upper airways is recommended as the first step in resuscitation but
it is not sufficient to initiate breathing. Obstruction of the upper airway is
uncommon and therefore not a primary reason for a newborn not breathing.
However, thick meconium may obstruct airways and it should be removed from the
upper airways before initiating ventilation.

The great majority of infants with asphyxia can be successfully managed by

appropriate ventilation without drugs, volume expanders or other interventions.
Applying the basic principles of resuscitation to all infants at all levels of care will
substantially improve newborn health and decrease deaths. Timely and correct
resuscitation will not only revive them but will enable them to develop normally.
Most will need no further special care after resuscitation.

Every birth attendant should know the basic principles of resuscitation, have basic
skills in neonatal resuscitation and have access to appropriate resuscitation
equipment. Whenever possible, a person skilled in resuscitation, and who can
devote full attention to the infant, should attend deliveries when complications are
anticipated. Resuscitation equipment should not only be available in every delivery
room, but its presence and proper working order should be verified before every
delivery.

Proper ventilation of the infant is the most important aspect of resuscitation.

Positive pressure ventilation with a self-inflating bag and a mask using additional
oxygen is a usual method for management of birth asphyxia. When additional
oxygen is not available, infants should be resuscitated using air. If no equipment is
available, mouth-to-mouth ventilation can be effective for initiating breathing in
newborns with mild and moderate asphyxia. In experienced hands, ventilation by
endotracheal tube is likely to be more effective than ventilation by face-mask.
However, personnel who do not frequently intubate newborn infants should initiate
resuscitation using a face-mask and should consider intubation only if the heart rate
does not increase promptly with properly performed bag and mask ventilation.

The most common serious error in neonatal resuscitation is the failure to recognize
and correct hypoventilation, a problem which is preventable with sufficient staff
training and experience.

Resuscitation of the newborn is also possible at home. The same principles apply.
The birth attendant should be trained in recognizing a problem and managing it.
When teaching mouth-to-mouth ventilation, special attention should be given to
providing the right volume and pressure, to the importance of urgency in initiating
ventilation and some sense of its duration for situations where no clock is available.

Eye care: prevention and management of ophthalmia neonatorum

Ophthalmia neonatorum is defined as any conjunctivitis with discharge occurring

during the first two weeks of life. It typically appears 2-5 days after birth, although
it may appear as early as the first day or as late as the 13th. Most often both eyelids
become swollen and red with purulent discharge. Corneal damage with ulceration,
perforation, synechiae and pan-opthalmitis develop if there is no treatment or if
there is delay in treatment. Many infants will also progress into systemic disease.

Infection by Neisseria gonorrhoea and Chlamydia trachomatis are the two main
causes of ophthalmia but cannot be accurately distinguished on clinical grounds
alone. Complications are more severe and appear more rapidly in gonococcal
ophthalmia. The transmission rate for gonorrhoea from an infected mother to her
newborn is 30-50%. In the absence of systematic diagnosis and treatment of
maternal genital infections before delivery, most cases of conjunctivitis of the
newborn can be prevented by disinfection of the infant conjunctivae immediately
after birth.

Infection can be prevented by cleaning the eyes immediately after birth and
applying either 1% silver nitrate solution, 1% tetracycline or 0.5% erythromycin
ointment to the eyes within one hour of delivery. Nonetheless, newborns given
silver nitrate or tetracycline ointment still run the risk of infection (7% and 3%
respectively) if the mother was infected. Purulent discharge that starts within the
first two weeks of life must be recognized as a sign of ophthalmia and the newborns
treated or referred for parenteral application of antibiotics.

The most common reasons for failure of ocular prophylaxis are giving it too late
(after the first hour), flushing the eyes after administration of silver nitrate to
prevent chemical conjunctivitis, and giving drops that are too concentrated through
evaporation. The latter can be prevented by dispensing silver nitrate in small
containers, avoiding prologued storage or using single-dose preparations.

Silver nitrate is not effective in preventing Chlamydia conjunctivitis. Some strains

of Neisseria gonorrhoea are resistant to tetracyclines. The decision about what to
use should be based on a local epidemiological evaluation. Conjunctivitis can be
caused by other microbes (Staphylococcus aureus is the most common) but the
clinical signs are usually milder.

Since there is a lack of evidence of the extent to which the traditional practice of
applying mother's milk to the eyes of the newborn is effective in preventing
ophthalmia, this practice cannot be recommended in place of silver nitrate drops or
tetracycline ointment.

Immunization

BCG should be given as soon after birth as possible in all populations at high risk of
tuberculosis infection.

A single dose of OPV at birth or in the two weeks after birth is recommended to
increase early protection.

Hepatitis B vaccine should be integrated into national immunization programmes in

all countries by 1997. Where perinatal infections are common it is important to
administer the first dose as soon as possible after birth.

Management of newborn illness

Many newborn problems can be prevented by the interventions described above.

However, when a disease occurs, many deaths can be avoided if the signs are
recognized early and the newborn managed effectively.

Since most infants are either born at home or are discharged from the health facility
early, families should be able to recognize signs of newborn illnesses and bring the
newborn infant to the attention of a health worker.

Many signs of the normal transition period mimic those of early disease.
Differentiation of signs of mild illness from normal transitional variation is difficult.
Therefore disease is often in an advanced stage when the newborn is brought to the
attention of the health workers. Danger signs in the newborn period are also non-
specific; they can be a manifestation of almost any newborn disease. The most
common presentation of illness in an infant who has been doing well after birth is
that it stops feeding well, it is cold to the touch or - in rare cases - it has fever.
Breathing may be fast and difficult with grunting and intercostal retractions; the
infant may be irritable but may become lethargic and not wake for feeds. The infant
may vomit, have diarrhoea and a distended abdomen. If pus is draining from red
swollen eyes or from the umbilicus, classification of the problem is easier. Jaundice
on the first day and convulsions are always a sign of a serious illness.

The health worker should have the knowledge and skills to assess the newborn
infant, to classify the infants into those that need referral, those that need treatment
at the health centre, those that can be treated at home and those who are probably
healthy. Breast-feeding assessment, with advice if necessary, should always be a
part of newborn care, as should immunization when indicated.

A series of documents describing the danger signs, assessment of the newborn, and
classification and treatment of problems at the three levels of care is in preparation.

Care of the preterm and/or low birth weight newborn

Most of the low birth weight infants in developing countries are born at, or near,
term. They have reached maturity and have the full potential for survival. However,
because of their reduced weight and a lack of fat as the source of energy and
insulation, they are at an increased risk of hypothermia and poor growth. Good
thermal protection and breast milk are the two most important elements of their
care. The best source of warmth is the mother's body and the best food is breast
milk. Having a baby in skin-to-skin contact with the mother provides the necessary
warmth and permits frequent breast-feeding. If possible, a low birth weight infant
should not be separated from the mother solely on the basis of birth weight. If the
baby does not have difficulty breathing and can be breast-fed, it should stay with the
mother. If the small baby becomes hypothermic after birth, their chances for
survival are reduced even with good hospital care. Adequate warmth can
substantially reduce mortality in small babies.

Birth weight is governed by two major processes: duration of gestation and

intrauterine growth. The more premature the newborn, the more problems it will
have. Preterm babies have a wide range of difficulties - with feeding, respiratory
problems due to immaturity of lungs, severe jaundice due to immaturity of the liver,
and intracranial haemorrhage due to immaturity of the brain. Hospital care, skilled
personnel, special equipment for thermal protection, intravenous feeding and
artificial ventilation are all needed for survival and to prevent disabilities. Hospital
infections are the major threat during these treatments. Countries need to decide on
what resources can be made available for the care of very preterm newborn infants.

Congenital anomalies

Congenital anomalies, major and minor, occur in 3-4% of births. Some can be recognized at
birth, many become obvious later in childhood, and some are never identified. Many deaths
due to birth defects in the perinatal period result from lethal malformations and
malformations where survival is not possible without complicated surgical intervention.
Many birth defects leave infants disabled. Anomalies such as club foot and cleft lip/palate
can be corrected to allow normal development.

There are a few birth defects that are more common in developing than in developed
countries. Among these are neural tube defects and congenital hypothyroidism. Both can be
prevented to a certain extent by giving the mother folic acid and iodine respectively, before
conception and during early pregnancy when the fetal organ systems are developing.

Traditional practices

Traditional practices cannot be ignored when trying to achieve better neonatal care in
developing countries because most deliveries occur at home and health services may not be
available. Even babies delivered in hospital may be affected by traditional practices after
discharge. These practices have a major impact on neonatal morbidity and mortality patterns.
Traditional and cultural practices must be identified and the extent of their impact on
newborn health evaluated before global standard guidelines are adapted to the local situation.
Practices related to antenatal and intra-natal events, resuscitation, thermal control, feeding
and infections for example, should be classified as follows:

1. good practices worth promoting

2. harmful practices that should be discontinued
3. harmless practices which may be ignored for the time being
 4. practices that need further research before a decision can be taken as to their
beneficial or harmful effects.

Some modern practices are also harmful. Bottle-feeding, pacifiers, and separation of the
mother from her baby should be discouraged.

Once beneficial and harmful practices are identified, suitable communication strategies
should be developed for individual and community education. They should be monitored as a
part of essential newborn care. A special effort should be made to study home remedies for
simple problems and to promote those that are effective.

Examination of the newborn infant

Rapid assessment of the baby is needed as soon as it is born. Designation of sex, inspection
for vital signs and major anomalies are the first observations to be made. Definitive
examination should be done after the transitional stabilization period in a well-lit room and in
the presence of the parents. The examination should take into account maternal pregnancy
history, labour and delivery. It should also include an assessment of gestational age and
weight since this helps to establish the level of risk for immediate neonatal morbidity and
mortality. Before leaving the mother and baby, the birth attendant should evaluate the
newborn's respiration pattern (effort and rate), state of alertness, colour, posture, spontaneous
activity, and breast-feeding. Parents should be given instructions for normal newborn care
and information about danger signs that indicate that the newborn infant is not doing well. It
may include immunization according to national policy and instructions for further
immunization.

Investigation of a neonatal death

A neonatal death investigation consists of an interview with care providers and a review of
medical records, laboratory results, prescriptions and other data, to determine the biomedical
causes of death and ascertain non-clinical factors contributing to death. When birth and death
occur at home, a postmortem interview of the family should aim at determining the medical
as well as non-medical causes of newborn death. This is called verbal autopsy. It is also
useful for deaths that occur in health facilities where information concerning newborn deaths
is poorly recorded or suspect.

The description of all the events surrounding each newborn death is important, since it serves
as a basis for the development of more comprehensive strategies for prevention. The
circumstances, other than biomedical, in which the newborn dies may help in identifying
departures from accepted standards of care, including the failure of services to provide
adequate care.

The following table summarizes strategies for essential newborn care at different levels of the
health care.
Table 3: Summary table of essential newborn care
( landscape printing version)

Strategy At birth Conceptual Home messages Home Assessment

discharge ( for normal message ,
*) care: about classificatio
Check for: danger n and
signs: manageme
Seek help nt at health
if: centre:

Cleanliness, Clean Umbilical Keep the stump Umbilicus If umbilicus

clean delivery: stump: dry, clean (using red or red or
delivery and clean, dry, pieces of sterile draining draining
cord care Clean tie tight, no dry gauze), do pus, pus, redness
hands, bleeding not apply redness extends to
perineum, Nothing anything to the extends to skin:
surface, applied to cord stump skin give the first
cutting, ties the cord dose of
stump antibiotics
Nothing and refer to
applied to the hospital
the cord
stump

Thermal Warm place Warm to Protect from Cold to Measure

protection of birth touch cold/heat by touch in body
If cold, wrapping/clothin spite of temperature
Dry the rewarm by g, bedding rewarming If no danger
baby with skin-to-skin according to signs and
warm cloth climate Hot to mild
touch in hypothermia
Provide If cold to touch, spite of , rewarm;
warm rewarm (skin- undressing otherwise
environmen to-skin, clothing, refer
t by skin- bedding) Suckling
to-skin or poorly,
wrapping in If too warm, crying
warm undress weakly
clothes

Delay
bathing

Breast- Early and Good Frequent early Suckling Observe

feeding exclusive suckling breast-feeding becomes suckling;
breast- If suckling day and night poor check
feeding poor, assure No other food Baby does mouth for
 within first correct but breast milk not wake- thrush; if
hour of positioning up for yes and no
birth and feeding other signs
No attachment treat thrush
prelactal with gentian
feeds or violet and
other fluids, reassess
no pacifiers next day

Eye care Clean eyes Do not apply Eyes Red swollen

immediatel anything becomes eyes and
y after birth swollen, pus draining
Apply eye sticky or from eyes
drops or draining Clean eyes,
ointment pus give
parenteral
antibiotic or
refer to the
hospital

Initiation of If no cry at Good cry, Difficulty Count

breathing birth check no difficulty breathing breathing
for breathing rate, look
breathing, If difficulty for
if no breathing, retractions
breathing refer Look and
initiate listen for
resuscitatio grunting,if
n: present,
refer
- aspiration
of mouth
and nose,
ventilation:

- ventilation
(by bag and
mask at
health
facility,
mouth to
mouth at
home)

Immunizatio Immunize A visit for next

n according to immunization
policy
Low birth Measures Check: Frequent breast- Difficulty If any of:
weight above, plus feeding breathing difficulty
Preterm Breathing breathing,
Weigh baby If a small baby Poor not able to
or use a Warmth is not suckling suckling feed,
surrogate to well, feed with lethargy,
estimate Suckling expressed breast Not pink jaundice on
weight milk by cup and palms and
spoon feet, refer to
Determine hospital
gestational Thermal
age protection

If baby Cleanliness
weak and
not
suckling
well,
express
breast milk
into baby's
mouth

Other Pustules Refer to

hospital
Jaundice
on palms
and feet

Abnormal
movement
s

Convulsio
ns

Lethargy

Congenital Advice on Normal care As for

anomalies possible other
treatment newborn
infants

Investigatio Registratio Reporting of

n of deaths n of birth death
Reporting Investigatio
of death n of death
(*) Conceptual discharge means the time when the birth attendant leaves the mother and the
baby or hands the responsibility over to a different care provider, often 2 to 24 hours after
birth

13.5 Genetics education in schools

In the long run, genetics education for the public can best be achieved through education in schools. It is also
worth noting that because of the young age structure of most populations of the Eastern Mediterranean Region,
education (and other) efforts focused on schools can have a relatively greater and more rapid impact than in
most more industrialized societies. The scientific community in universities must take greater responsibility in
the reform of school curricula, and in working with schoolteachers to revise school science texts and formulate
an ideal science curriculum for each stage that addresses concepts and principles and not just the delivery of
factual knowledge. Scientists in universities can also make themselves available as consultants to education.

Experiences from industrialized countries should be sought and reviewed in the light of regional circumstances.
Teacher/scientist partnerships developed in intensive summer programmes have been very successful. In
Kansas, United States of America, a programme of 60 contact hours (including lectures on basic human
genetics, genetic disorders, genetic counselling, ethical issues and new technology) has been aimed at leading
high schoolteachers in human genetics, who in turn can train others. The teaching was enriched by laboratory
sessions, with visits to chromosome and recombinant DNA laboratories, computer-assisted instruction and use
of videotapes [296].

It is important for some genetics information to reach every pupil. It is therefore important to define the fewest,
simplest pieces of information that should be included in biology teaching in schools, and the most appropriate
stage for teaching them. Some agreement is developing that the recessive mode of inheritance is the single most
important message to introduce, because it shows that anyone may be a carrier without having an affected
individual in the family (i.e. genetics involves us all), and it prepares students for later offers of screening.

Special high school educational programmes in human genetics have been introduced in North America. In the
United States of America, a module for teaching the Human Genome Project has been incorporated into the
general high schools biology programme [297], and in the United Kingdom the revised national curriculum
requires some teaching on genetics technology for all students. In Canada, a two-decade experience in
introducing genetics science to high school students has proved highly successful. It involved teaching, followed
two weeks later by the offer of voluntary genetics screening for carrier status for Tay-Sachs disease, -
thalassaemia and cystic fibrosis for 60 000 students. The programme "converts public abstractions about
heredity into private facts about genotypes, and converts general statements about prevalence and variation into
specific statements about personal identity and risks". It increased the students' knowledge about genetic
diseases in general and about specific diseases in particular, and revealed favourable attitudes of students
towards the educational and screening experiences [298].

Despite the fact that similar programmes are difficult to implement in some countries because of limited
resources, combining educational goals with community genetics services may prove very valuable in countries
of the Eastern Mediterranean Region. For example, carrier screening for common genetic disorders offered to
high school students could be a form of premarital screening, meet the ethical need for the early offer of testing,
and constitute an important step towards prevention of hereditary disorders.

When adequate services are available, there is every reason to provide information to the public whenever and
wherever possible, and particularly in schools.