Table of Contents

Introduction: ................................................................................................................................................. 3

Definition: ..................................................................................................................................................... 4

Objectives: .................................................................................................................................................... 4

Levels/Types of Neonatal Care ..................................................................................................................... 4

Level I (Well Newborn Nursery) ................................................................................................................ 4

Level II (Special Care Nursery)................................................................................................................... 5

Level III (Neonatal Intensive Care Unit) .................................................................................................... 5

Level IV (Regional NICU) ........................................................................................................................... 6

Description of the services with service schedule: ....................................................................................... 6

Breastfeeding: ........................................................................................................................................... 7

Ensuring warmth: ...................................................................................................................................... 7

Cord care: .................................................................................................................................................. 7

Hygiene Cleanliness: ................................................................................................................................. 8

Benefits of Mom, Child, Family and Society: ................................................................................................ 8

Your baby will have the best caregivers you could ask for ....................................................................... 8

Parents can have time for recovery and self-care .................................................................................... 8

New moms have easy access to maternal services .................................................................................. 8

The baby likely will have an established schedule for eating and sleeping .............................................. 9

Benefits to Infants ..................................................................................................................................... 9

Benefits to Parents.................................................................................................................................... 9

Bangladesh situation ..................................................................................................................................... 9

Management of neonatal illness and complications .................................................................................. 10

Causes of neonatal death ........................................................................................................................... 11

Why has care for newborns fallen between the cracks? ........................................................................ 11

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What can be done? ..................................................................................................................................... 12

Conclusion and Recommendations ............................................................................................................ 13

References: ................................................................................................................................................. 14

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Introduction:
A neonatal or neonate is a child under 28 days of age. During these first 28 days of life, the child
is highest risk of dying. It is thus crucial that appropriate feeding and care are provided during this
period, both to improve the child’s chances of survival and lay to the foundations for a healthy life.
Neonatal care for the babies who born early, with low weight or who have a medical condition that
requires specialized treatment. Essential care of the normal healthy neonates can be best provided
by the mothers under supervision of nursing personnel. About 80% of newborn baby’s require
minimal care. The normal term baby should be kept with their mother rather than separate nursery.
These healthy normal neonates need only warmth, breast feeding, close observation for early
detection of problems and protection from infections and injuries. Mother participates in nursing
care of the baby and develops self confidence in her. Nursing care of healthy new born baby after
birth should be provided as immediate care of neonate and daily routine care.

Worldwide, about eight newborn babies die every minute, yet interventions to reduce early
neonatal mortality and morbidity are still not given high priority in most developing countries. It
is often assumed that neonatal care is too costly for high coverage in poor populations, but in fact
many deaths could be prevented or treated with low technology and improved care. There are four
principles of basic newborn care: an atraumatic and clean delivery, maintenance of body
temperature, initiation of spontaneous respiration and breast feeding shortly after birth. For the

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majority these could be facilitated at the health center by nurse midwives or at home by TBAs or
family members. Low cost special care for many of the 10%-15% who are sick or pre-term or low
birth weight could be provided at district hospitals using appropriate simple technologies.

Definition:
Neonatal means ‘new born’ or ‘neonate’. Neonatal care refers to that care given to the newborn
infant from the time of delivery through about the first month of life. The term "neonate" is used
for the newborn infant during this 28-30 day period.

Objectives:
To ensure every neonatal survives and thrives to reach their full potential, we must focus on
improving care around the time of birth and the first week of life. The high rates of preventable
death and poor health and well-being of newborns and children under the age of five are indicators
of the uneven coverage of life-saving interventions and, more broadly, of inadequate social and
economic development. Poverty, poor nutrition and insufficient access to clean water and
sanitation are all harmful factors, as is insufficient access to quality health services such as essential
care for newborns. Health promotion, disease prevention services (such as vaccinations) and
treatment of common childhood illnesses are essential if children are to thrive as well as survive.

Levels/Types of Neonatal Care

The American Academy of Pediatrics categorizes hospitals into four levels based on the care a
facility can provide to newborns. These levels of care correspond to the therapies and services
provided. Facilities offering neonatal intensive care must meet health care standards through
federal/state licensing or certification.
The four categories are:

 Level I: Well newborn nursery

 Level II: Special care nursery
 Level III: Neonatal intensive care unit (NICU)
 Level IV: Regional neonatal intensive-care unit (regional NICU)

Level I (Well Newborn Nursery)

Level I units are typically referred to as the well-baby nursery. These facilities have the capability
to provide neonatal resuscitation at every delivery; evaluate and provide postnatal care to healthy
newborn infants; stabilize and provide care for infants born at 35 to 37 weeks gestation who remain
physiologically stable; and stabilize newborn infants who are ill and those born less than 35 weeks'
gestation until transfer to a facility that can provide the appropriate level of neonatal care. Required
provider types for well newborn nurseries include pediatricians, family physicians, nurse
practitioners and other advanced practice registered nurses.
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Level II (Special Care Nursery)
Level II units are also known as special care nurseries and have all of the capabilities of a Level I
nursery. These facilities are required to have pediatric hospitalists, neonatologists and neonatal
nurse practitioners, in addition to Level I health care providers.
Level II units are able to:

 Provide care for infants born at 32 weeks gestation or older and weighing more than or
equal to 1,500 grams who have physiologic immaturity or who are moderately ill with
problems that are expected to resolve rapidly and are not anticipated to need subspecialty
services on an urgent basis
 Provide care for infants who are feeding and growing stronger or recovering after intensive
care
 Provide mechanical ventilation for a brief duration or continuous positive airway pressure
 Stabilize infants born before 32 weeks gestation and weighing less than 1,500 grams until
transfer to a neonatal intensive care facility

Level III (Neonatal Intensive Care Unit)

Level III units are required to have the same care providers required for Level II facilities (pediatric
hospitalists, neonatologists and neonatal nurse practitioners) and Level I facilities (pediatricians,
family physicians, nurse practitioners and other advanced practice registered nurses).
In addition, Level III units must provide, either on site or at a closely related institution by
prearranged consultative agreement, the following providers: pediatric surgeons, pediatric medical
subspecialists, pediatric anesthesiologists and pediatric ophthalmologists.
Level III neonatal intensive-care units are able to:

 Provide sustained life support

 Provide comprehensive care for infants born at all gestational ages and birth weights with
critical illness
 Offer prompt access to a full range of pediatric medical subspecialists, pediatric surgical
specialists, pediatric anesthesiologists and pediatric ophthalmologists
 Provide a full range of respiratory support that may include conventional and/or high-
frequency ventilation and inhaled nitric oxide
 Perform advanced imaging, with interpretation on an urgent basis, including computed
tomography, MRI and echocardiography

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Level IV (Regional NICU)
The highest level of neonatal care provided occurs at regional NICUs, or Level IV neonatal
intensive care units. These units are required to have pediatric surgical subspecialists on staff in
addition to the care providers required for Level III units.
Regional NICUs have all of the capabilities of Level I, II and III units. In addition to providing the
highest level of care, Level IV NICUs:

 Are located within an institution that has the capability to provide surgical repair of
complex congenital or acquired conditions
 Maintain a full range of pediatric medical subspecialists, pediatric surgical
subspecialists and pediatric anesthesiologists at the site
 Facilitate transport and provide outreach education
 Provide ECMO (Extracorporeal Membrane Oxygenation)

Description of the services with service schedule:

Everyday care refers to the care needed by all newborn babies after the first few hours of birth till
the time of their discharge from the health facility. These needs are the same even for babies born
at home - it is the duty of the health care provider to ensure that each baby receives appropriate
care irrespective of the place of delivery. The key areas of everyday care include

 Breastfeeding
 Warmth
 Cord care
 Hygiene

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Breastfeeding:

All health workers must be knowledgeable as well as skilled enough to support mothers to
breastfeed their babies. They should know the key points of correct positioning and attachment of
the baby to the breast. In addition to teaching about Teaching Aids: Essential Newborn Care 3
positioning and attachment, health workers must also be able to give mothers the correct
information about infant feeding. Mothers should be informed that in the first few days after birth,
only small amount of thick yellow milk (colostrum) is secreted (if she needs to express at this time,
only a teaspoonful can be expressed). They should be reassured that even this much amount is
sufficient for a normal baby in the first 2 days and that the amount of milk secreted will gradually
increase. The importance of giving colostrum should also be emphasized and any doubts or false
beliefs should be clarified. It is important to practice rooming or bedding in to ensure successful
breastfeeding; the mother and baby should not be separated. The mother should be advised to
breastfeed on demand, day and night as long as the baby wants. She should be asked if there is any
difficulty in breastfeeding her infant; if yes, she must be instructed to get help from any skilled
health provider. Health providers should assess the feeding, especially positioning and attachment,
in any mother with difficulty in breastfeeding. They should help and counsel her; demonstrate
good positioning and attachment and allay her anxiety. The baby should not be discharged if proper
breastfeeding is not established.

Ensuring warmth:
The essential steps in preventing heat loss and maintaining the normal temperature in a newborn
baby are discussed in detail in the module on ‘Thermal protection in neonates’. All mothers should
be explained about the importance of keeping their babies warm. They should be instructed to
dress / wrap the baby in a dry clean cloth and to cover the head and feet with cap and socks
respectively. They should be taught to assess the baby’s temperature by touching the feet every
four hours; if the feet are found to be cold, the baby should be kept in skin-to-skin contact position
and be covered with a blanket. Mother should reassess the baby’s temperature after one hour; if
the feet are still cold, she should inform the health provider. The principles of maintaining normal
temperature apply even after the baby is discharged from the hospital. Mother should ensure that
the room is kept warm; the baby is dressed or wrapped properly (i.e. one more layer than older
children/adults); his head and feet are covered and he is sleeping with her in the Teaching Aids:
Essential Newborn Care 4 same bed in the night.

Cord care:

It is important to teach the mothers that the umbilical stump should be left dry and that they
SHOULD NOT APPLY ANYTHING on the stump. It should be loosely covered with clean
clothes and should not be covered by the nappy (diaper). If the stump gets soiled, it should be
washed with soap and water and dried by using a clean cloth. Health care providers should look

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for any possible sign(s) of infection of the umbilical stump such as pus discharge from the stump
and redness around the cord. Mother should be explained about these signs and advised to report
if they are present.

Hygiene Cleanliness:

It requires mothers, families, and health professionals to avoid harmful traditional practices and
follow appropriate guidelines. The baby need not be bathed daily; (s) he should be washed only if
necessary. However, the face, neck, and underarms should be wiped daily. The gluteal region
should be wiped whenever it gets soiled. If the baby is being bathed, make sure that the room is
warm; only lukewarm water is used to bathe; and the baby is thoroughly dried and covered with
warm clothes immediately after bath. It is important to take additional precautions in case of small
babies. Mothers should be strongly discouraged against applying anything in their babies’ eyes or
ears both during their stay in the health facility and after their discharge.

Benefits of Mom, Child, Family and Society:

Your baby will have the best caregivers you could ask for
Compassionate, knowledgeable doctors, advanced practice providers, and nurses care for
babies in the NICU. These providers are there 24/7, and are available when you have questions
about your baby’s condition or care. Additionally, support staff such as dietitians and physical
therapists are involved in optimizing the baby’s care.
Parents can have time for recovery and self-
care
It’s important for parents of newborns,
especially in the NICU, to take care of
themselves as well as the baby. We know you
want to bond with your newborn as much as
you can, but you need to take time to rest and
recover, too.
New moms have easy access to maternal
services
New mothers have easy access to a variety of
services as well. For example, lactation
consultants are nearby and always willing to assist new mothers with breastfeeding tips and

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extra supplies. Because of support like this, my breastfeeding experience went smoother than
after the birth of my first child, who was born vaginally and at full term.
The baby likely will have an established schedule for eating and sleeping
This is just one pleasant result of the structured care newborns get in the NICU. Because of
his set schedule, it was easier for my family to get used to having a newborn at home this time
around.
Having a baby who needs NICU care can be a difficult and stressful time for new parents.
But, I want to let you know there are a few hidden advantages that make the separation easier
to tolerate.

Benefits to Infants
1. Physiologic stability (temperature and blood pressure regulation, heart rate and
respiratory stability)
2. Brain, cognitive and motor development
3. Improved immune system function
4. Weight gain
5. Better, deep sleep
6. Greater bonding with decrease in stress and crying
7. Decreased length of stay, pain and stress from environment (pre-term infants in the NICU)
Benefits to Parents
1. Attachment and bonding
2. Sensitivity and responsiveness to infant
3. Confidence in providing care and transitioning to home
4. Breast milk production, greater success in breastfeeding and decreased risk of postpartum
depression

Bangladesh situation
Bangladesh has made considerable progress in recent decades in improving the health of its people.
The Bangladesh total fertility rate at around 3.4 during the 1993-94 declined to 2.7 in 2007.
However, with the population size of more than 140 million people, more than 3 million babies
are born each year. Maternal Mortality Ratio (MMR) is high and was estimated to be 320 per
100,000 live births in 2001, although there had been 44% reduction compared to 1990
(570/100,000 live births). Most of maternal deaths occur at home. Neonatal mortality rate (NMR)
was estimated to be as high as 37 per 1000 live births in 2007.

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The high prevalence of anaemia in pregnant women with its consequence of high rate of Low Birth
Weight indicates high risks of complications from pregnancy, childbirth and after birth. The high
rate of early marriage and adolescent pregnancy increases the rate of complications and the risk of
maternal and neonatal death. Poor knowledge, poverty and poor quality of care delay receiving
appropriate services, resulting in increase of unmet need of services.
There are major gaps in human resources which affect the efficiency of the delivery of maternal
and neonatal health services. There are major concerns about the skills of service providers,
particularly midwifery skills. The lack of adequate skilled human resources for provision of
Emergency Obstetric Care (EmOC) has been identified as a major gap in dealing with
complications.
Programme management and research capacity of programme managers is still limited and need
to be strengthened to effectively manage the national programme.

Management of neonatal illness and complications

The most common causes of neonatal deaths are preterm birth complications, newborn
infections and birth asphyxia. They account for over 80% of all global neonatal deaths. A
newborn baby who is born preterm or has a potentially life-threatening problem is in an
emergency situation requiring immediate diagnosis and management. Delay in identification of
the problem or in providing the correct management may be fatal.
Preterm and/or low birth weight infants need special care, including additional attention to
breastfeeding and breast-milk feeding and to keeping them warm at home and in health

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facilities. Those with preterm birth complications, including respiratory problems, need
appropriate treatment in hospitals.
Appropriate care during labour and childbirth combined with neonatal resuscitation, when
needed, can substantially reduce mortality due to birth asphyxia. Newborns with severe
asphyxia need post-
resuscitation care in hospitals.

Early identification of
newborn infections with
prompt and appropriate
antibiotic treatment will
substantially reduce mortality
due to newborn sepsis and
pneumonia. Newborns with
serious infections need
intramuscular or intravenous
antibiotics and supportive care in hospitals. Where hospital referral is not possible,
intramuscular antibiotics delivered by skilled health-care providers will save lives.
Other common newborn problems are jaundice, eye infections and diarrhoea, which may be
managed at health facilities or hospitals depending on their severity.
The Integrated Management of Childhood Illness (IMCI) training materials and Essential
Newborn Care Course aim to improve skills of health-care staff for managing newborn illness
at first level health facilities. The Pocketbook for Hospital Care for Children and Managing
Newborn Problems aim to improve case management of severe newborn illness in hospitals.

Causes of neonatal death

The three major causes of neonatal deaths worldwide are infections (36%, which includes
sepsis/pneumonia, tetanus and diarrhoea), pre-term (28%), and birth asphyxia (23%). There is
some variation between countries depending on their care configurations.

Why has care for newborns fallen between the cracks?

 Lack of continuum of care from maternal to child: a lack of continuity between maternal and
child health programmes has meant that care of the newborn has fallen through the cracks.
More than half the neonatal deaths occur after a home birth and without any health care.
 In many countries there is no record of neonatal deaths: until recently, there has been little
effort to tackle the specific health problems of newborn babies. Most of their deaths are
unrecorded.
 Neonatal mortality and gender: reduced care-seeking for girl babies compared with boy
babies has been reported, especially in South Asia.

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What can be done?
1. Effective care can reduce almost 3 of the 4 million deaths of babies under-one month: the
package of essential care includes antenatal care for the mother, obstetric care and birth
attendant's ability to resuscitate newborns at birth. Most of the infection-related deaths
could be avoided by treating maternal infections during pregnancy, ensuring a clean birth,
care of the umbilical cord and immediate, exclusive breast-feeding. For infections,
antibiotics is life-saving and needs to be available locally. Low birth weight babies need to
maintain body temperature through skin-to-skin contact with the mother. Several of the
above interventions would also help save the lives of mothers and prevent stillbirths.

2. Empowering families
and communities to
close the gap of
postnatal care: healthy
home practices and
empowering families
to recognize problems
and access care will
quickly save many
lives. In high mortality
settings with low
access to care, some
interventions may need
to be provided closer to
home.
3. The gap for care of mothers and babies in the first few days of life is important even where
women do deliver in facilities. New approaches are required to reach a large majority of
these families.
4. Political commitment and social visibility. Communities and decision makers need to be
informed that neonatal deaths are a huge portion of child deaths, and need therefore to
receive adequate attention. Improved registration and increasing the availability and use of
relevant information in programmes and to decision makers is essential if health care for
newborn babies and their mothers is to be given adequate attention. Stillbirths should also
be counted.

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Conclusion and Recommendations
1. Regionalized systems of perinatal care are recommended to ensure that each newborn infant is
cared for in a facility most appropriate for his or her health care needs and to facilitate the
achievement of optimal health outcomes.
 Because VLBW and/or very preterm infants are at increased risk of predischarge mortality
when born outside of a level III center, they should be delivered at a level III facility unless
this is precluded by the mother’s medical condition or geographic constraints.
2. The functional capabilities of facilities that provide inpatient care for newborn infants should
be classified uniformly on the basis of geographic and population parameters in collaboration
with state health departments, as follows:
 Level I: a hospital nursery organized with the personnel and equipment to perform neonatal
resuscitation, evaluate and provide postnatal care of healthy newborn infants, provide care for
infants born at 35 to 37 weeks’ gestation who remain physiologically stable, and stabilize ill
newborn infants or infants born at less than 35 weeks’ gestational age until transfer to a facility
that can provide the appropriate level of neonatal care.
 Level II: a hospital special care nursery organized with the personnel and equipment to provide
care to infants born at 32 weeks’ gestation or more and weighing 1500 g or more at birth who
have physiologic immaturity, such as apnea of prematurity, inability to maintain body
temperature, or inability to take oral feedings; who are moderately ill with problems that are
expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent
basis; or who are convalescing from a higher level of intensive care. A level II center has the
capability to provide continuous positive airway pressure and may provide mechanical
ventilation for brief durations (less than 24 hours).
 Level III: a hospital NICU organized with personnel and equipment to provide continuous life support
and comprehensive care for extremely high-risk newborn infants and those with critical illness. This
includes infants born weighing <1500 g or at <32 weeks’ gestation. Level III units have the capability
to provide critical medical and surgical care. Level III units routinely provide ongoing assisted
ventilation; have ready access to a full range of pediatric medical subspecialists; have advanced imaging
with interpretation on an urgent basis, including CT, MRI, and echocardiography; have access to
pediatric ophthalmologic services with an organized program for the monitoring, treatment, and follow-
up of retinopathy of prematurity; and have pediatric surgical specialists and pediatric anesthesiologists
on site or at a closely related institution to perform major surgery. Level III units can facilitate transfer
to higher-level facilities or children’s hospitals, as well as back-transport recovering infants to lower-
level facilities, as clinically indicated.
 Level IV units have the capabilities of a level III NICU and are located within institutions that can
provide on-site surgical repair of serious congenital or acquired malformations. Level IV units can
facilitate transport systems and provide outreach education within their catchment area.
 The functional capabilities of facilities that provide inpatient care for newborn infants should be
classified uniformly and with clear definitions that include requirements for equipment, personnel,
facilities, ancillary services, training, and the organization of services (including transport) for the
capabilities of each level of care.
 Population-based data on patient outcomes, including mortality, morbidity, and long-term outcomes,
should be obtained to provide level-specific standards for patients requiring various categories of
specialized care, including surgery.

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References:
1. http://www.searo.who.int/bangladesh/areas/maternal_and_neonatal/en/
2. https://utswmed.org/medblog/nicu-unexpected-advantages/
3. https://pediatrics.aappublications.org/content/130/3/587
4. https://www.who.int/maternal_child_adolescent/newborns/management_illness_complications/en
/
5. https://www.who.int/pmnch/media/press_materials/fs/fs_newborndealth_illness/en/

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