A Practical Approach to

Preventing Child Deaths:

What the Pediatrician Can Do

Maria Asuncion Silvestre, MD, FPSNbM, FAAP

Consultant, Essential Intrapartum & Newborn Care, WHO
Associate Professor of Pediatrics and Neonatology
UP College of Medicine
 Disclosure Statement
•  I declare no conflict of interest with any
proprietary entity producing health care
goods or services consumed by, or used
on, patients.

•  I declare no financial relationships with the

manufacturer(s) of any commercial
product(s) and or provider(s) of
commercial services discussed in CME
activities.
 Outline
•  Problem of child mortality focusing on
neonatal mortality
•  Preventive interventions to address the
above
•  Practices that are easy to apply that
save lives
•  Preparing mothers and their families
for above
 <5 year old and
Neonatal Mortality
# of deaths per 1000 live births

Under Five MR

Neonatal MR

998: 40%
•  1988-1998: 40%
•  1998-2008:  20%
•  Neonatal mortality hasn’t improved
DHS 88, 93, 98, 03, 08
 Causes of U-5 Deaths,
Pertussis Measles Malaria 2008
Meningitis
1% 0% 1% 3%
HIV
0%
Injury
4%
NCD
9%

Other
Neonatal
Infections
45%
12%

Pneumonia
18%

Diarrhea
7%

Source: WHO/ Child Health Epidemiology Reference Group (CHERG) 2010

 Causes of Neonatal Deaths,
2008
Prematurity 41%

Infection 16%

Asphyxia 15%

Other 14%

Congenital anomalies 14%

Tetanus 2%

Diarrhea 0%

Source: WHO/ Child Health Epidemiology Reference Group (CHERG) 2010

 When do newborns die?
35
# of deaths per 1000 live births

30

25

20
3 out of 4 newborn deaths
occur in the 1st week of life
15

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Day of Life
NDHS 2003, special tabulations
The Lancet Child Survival Series.
Lancet 2003; 362: 65–71
Preventive Interventions % Child
Mortality
Reduction
Antibiotics for PROM 1%

Measles vaccine 1%
Antimalarial intermittent
preventive treatment in <1%
pregnancy
 The Lancet Child Survival Series.
Lancet 2003; 362: 65–71

% Child Mortality
Preventive Interventions Reduction

Water sanitation, hygiene 3%

Antenatal Steroids 3%
Newborn temperature management 2%
Vitamin A 2%
Maternal Tetanus Toxoid 2%
Nevirapine & replacement feeding 2%
 The Lancet Child Survival Series.
Lancet 2003; 362: 65–71

% Child Mortality
Preventive Interventions Reduction

EXCLUSIVE BREASTFEEDING 13%

Insecticide-treated materials 7%
COMPLEMENTARY FEEDING 6%
Zinc 4%
Clean delivery 4%
Hib Vaccine 4%
 Breastfeeding initiation
and infection-related death
Nepal 2008 N = 22,838 breastfed babies
12
11
10
9
8
Relative Risk

7
6
5
4
3
2
1
0
<1 1-24 24-48 48-72 >72
Hours after Birth
Mullany LC, et al. JNutr, 2008; 138(3):599-603.
 Formative research:
51 hospital study, 2008
 Essential
Newborn Care
Protocol was
developed to
address these
issues
 What Immediate
Newborn Care
Practices Save Lives?
 Antenatal Steroids
Betamethasone 12 mg IM q 24 hrs x 2 doses OR
Dexamethasone 6 mg IM q 12 x 4 doses
•  Overall reduction in neonatal death
– RR 0.69 (95% CI 0.58 - 0.81)

•  Reduction in RDS
– RR 0.66, (95% CI 0.59 to 0.73)

Roberts D, Dalziel SR. Cochrane Database of Systematic Reviews 2006, Issue 3.

 Antenatal Steroids
•  Reduction in IVH
– RR 0.54 (95% CI 0.43 to 0.69)

•  Reduction in sepsis in the 1st 48 hours of

life
– RR 0.56 (95% CI0.38 to 0.85)
Does not increase risk of death,
chorioamnionitis or
puerperal sepsis in the mother
Roberts D, Dalziel SR. Cochrane Database of Systematic Reviews 2006, Issue 3.
 At least 4 antenatal visits
Iron and folate supplementation
Antenatal Tetanus Toxoid Vaccine
Prepare a BIRTH PLAN including UnangYakap

Identify mothers in PRETERM LABOR at point of entry

Upon Administer 1st dose of Antenatal Steroids
arrival at
Facility History, Physical Exam and Vital Signs
Obtain Birth Plan, Determine Companion of choice
Use Partograp;
Allow Position of Choice
No routine enema, shaving
During
Labor Allow mother to have oral fluids IV fluid and NPO only when
and light snacks indicated;

Check room temperature Arrange all instruments in a

Prior to and air drafts linear fashion
Delivery
Discuss care in the 1st hours Check resuscitation equipment

Perineal Perform Proper HANDWASHING and

Bulging Don 2 pairs of sterile gloves; NO routine episotomy,
NO fundal pressure
Time Mother Baby
Support the perineum with Call out time of birth and sex
Delivery controlled delivery of the head

Dry, check breathing

First 30
secs 4
Put in skin-to-skin contact
Give Oxytocin IM Core
Feel for cord pulsation ,
1 minute
After excluding a 2nd baby Steps
Clamp, cut cord
to 3 Return baby to prone position
Do controlled traction of cord
minutes
with counter-traction
Massage the uterus gently

Examine the placenta

Support 1st FULL BREASTFEED. Monitor as a DYAD q15 mins

15-90 Continue uterine massage; Do PE, weigh, do eye care,

minutes Monitor every 15 minutes inject Vit K, Hep B, BCG

Transport to room TOGETHER

> 6 hours Breastfeeding Support Optional: Bathing

Your 5 Moments for Hand Hygiene
 Estimates of global numbers of babies
undergoing resuscitation at birth

Adapted fr S.N. Wall et al. Neonatal resuscitation in low-resource settings: What, who, and how to overcome
challenges to scale up? International Journal of Gynecology and Obstetrics 107 (2009) S47–S64
 Providing Warmth:
Check the Environment

•  Check temperature of the

delivery room *
–  Ideal temp: 25 – 28°C
•  Check for air drafts
•  Turn air conditioner off
before the delivery
*non-mercury thermometer
 Apnea Rates at Birth
•  Pre-EINC: 5.4% of 481 births in 51 hospital
observational study
•  EINC Cohort (QMMC)
–  With 4 Core Steps in place: 3.0%

Sobel, Silvestre, Mantaring, Oliveros, ActaPaediatrica 2011

 Unnecessary Suctioning
•  Of the 455 who were already breathing
- 94.9% suctioned once
- 84.0% suctioned more than once

•  Likelihood of UNNECESSARY suctioning

-  With training in Neonatal Resuscitation:
-  2.5 times
-  With training in Pediatric Resuscitation:
-  2.2 times
Sobel, Silvestre, Mantaring, Oliveros, ActaPaediatrica 2011
 Neonatal resuscitation: Suctioning

•  RECOMMENDATION 3
•  Suction of the mouth and nose should
not be done for babies born through clear
amniotic fluid who start breathing on
their own after birth.

WHO. Dept. of Maternal, Newborn, Child and Adolescent Health.

Guidelines on Basic Newborn Resuscitation. Forthcoming.
Revised Cord Clamping/Cutting

Clamp cord using a •  Clamp again Cut the cord

sterile plastic clamp or at 5 cm from close to the
tie at 2 cm from the the base plastic clamp
umbilical base
 Dry Cord Care
•  DRY cord care is recommended.
–  Do not apply any substance onto the cord
–  Faster sloughing
–  Equivalent to cord care with alcohol
•  Do not use a binder or “bigkis”
•  Observe for the oozing of blood. If blood
oozes, place a second tie between the
skin and the clamp
 Non-separation of the
Newborn from the Mother
for Early Initiation of
Breastfeeding
 Early and Appropriate
Breastfeeding Initiation
•  Help the mother and baby into a comfortable position
•  Observe the newborn for feeding cues
•  Once with feeding cues, ask the mother to
encourage her newborn to move toward the breast
 Non-separation of Newborn from
Mother for Early Breastfeeding
•  Weighing, bathing, eye care, examinations,
injections should be done after the first full
breastfeed is completed
•  Postpone bathing until at least 6 hours
 Non-Separation
•  Mother moved onto
a stretcher with her
baby and
transported to
Recovery Room,
mother-baby ward or
private room
•  Breastfeeding
support is continued
 Changes in OB practices

Decrease in routine IVF, Increase in dexamethasone

JRMMC use, GSCH
 Jose Reyes Memorial
Medical Center (JRMMC)
16

14

12

10
Per cent

Neonatal Mortality
8 Neonatal Sepsis
6 NICU Admission Rate
Preterm Rate
4

0
Jan-15 Feb-15 Mar-15 Apr-15 May-15
 Eastern Visayas Regional
Medical Center (EVRMC)
20
18
16
14
Per cent

12 Neonatal Mortality
10 Neonatal Sepsis
8 NICU Admission Rate
6 Preterm Rate
4
2
0
Feb-15 Mar-15 Apr-15 May-15 Jun-15
 The Birth Plan
•  Contains information on:
•  the woman’s condition during pregnancy
•  preferences for her place of delivery and
choice of birth attendant
•  available resources for her childbirth and
newborn baby
•  preparations needed should an emergency
situation arise during pregnancy, childbirth
and postpartum.
 Tondo Medical Center’s
BIRTH and EMERGENCY PLAN
 E.O. 51 and its rIRR
DO NOT REQUEST or ACCEPT
from Milk Companies or their representatives:
•  Gifts of any sort
•  Samples or products covered under the Milk
Code
•  Posters, other promotional materials or direct
promotions of products covered under the
code within your Health Facility, Community,
Barangays, Events, etc.
•  Sponsorships without permission from FDA
•  Endorsements of products covered by the Milk
Code
 Summary
•  Deaths in the newborn period =
1 in 2 child deaths
•  Birth plans for mothers/fathers
•  4 Core Steps of Immediate Newborn Care
•  Compliance with MBFHI and the Milk
Code
•  “It takes a Village”
 Every Newborn Has Needs
•  To breathe normally

•  To be warm

•  To be protected

•  To be fed
41
 “The secret of success
is to do the common things
uncommonly well.”
- John D. Rockefeller
 Hospital
Reform
Agenda
Network of
Centers of
Excellence
The EINC Campaign
LUZON (8):
QMMC ,Quirino
PGH,
Memorial
Fabella,
Social
Curriculum
Changes
Marketing Medical
Jose Reyes, East
Campaign
Ave,Center
Tondo Medical,
San Lorenzo Ruiz,
Project Jose Rodriguez
Sites St. Lukes
VISAYAS (1):
MINDANAO (2): Medical
EVRMC
GSCH (General Center
(Tacloban)
Santos)
CRMC (Cotabato
City)
 Spontaneous Scale-Up
NCR:
Private Institutions

Local Government Units (LGU)

General Santos City The Medical City
Cotabato City St. Luke’s - Global City
Quezon City Perpetual Help Las Pinas
Parañaque City VRP Medical Center
Pagsanjan Cardinal Santos Med Center
Medical Center Muntinlupa
Provincial Health Offices (PHO) Jesus Delgado Memorial
Bulacan Rizal World Citi Medical Center
Aurora Sorsogon UST Hospital
Capiz Chinese General Hospital
Cavite Asian Hospital & Medical Center
Centers for Health Development (CHD) Parañaque Doctors’ Hospital
Region IV-A (CALABARZON) Manila Doctors Hospital
Region XI (Davao) Las PinasDoctors Hospital
Region VIII (Eastern Visayas)
Provincial Sites:
Government Hospitals Tagaytay Medical Center
Bataan General Hospital New Sinai MDI Hospital
Pasay City General Hospital Our Lady of the Pillar Med Ctr
Zamboanga City Medical Center Lorma Medical Center