Neonatal Care: Past, Present and Future Professor Dr Mohammod - - PowerPoint PPT Presentation

Neonatal Care: Past, Present and Future

Professor Dr Mohammod Shahidullah Department of Neonatology, BSMMU President, Bangladesh Paediatric association (BPA) President, Federation of Asia Ocenia Perinatal Society (FAOPS) Chairman, National Technical Working Committee , (NTWC) , Bangladesh

Presentation Outline

• Introduction
• Basics of Neonatal care & its organization
• Evolution of neonatal care in Bangladesh
• Neonatal care in the past
• Neonatal care at present
• Visionary for future neonatal care

Standard facility care for sick newborn had been a priority area at all times

Introduction

What Evidence says…….

• Scale-up of full supportive

care of sick k newborn at facility for r pre re-term rm newborn rn, , sepsis, jaundice etc. have the potential effect of re reducing neonatal mortality in high burd rden countries.

Lancet ‘Every Newborn Series 3’: Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Page 12-13

Basics of newborn care at facility

Infection control

Fluid & nutrition

Respiratory support

Thermal Care

Organization of neonatal care

Neonatal Care

Allocated Space

Supplies

Infrastructure

Equipments

Human resources

Investigations Laboratory & In house

• Till eighties preventive and public health

programmes got due importance

• Budget allocation for developing & maintaining

neonatal care unit was insufficient

• Establishing standard neonatal care unit was in

fact economic burden for the national health care system

What was the reality

How neonatal care started its journey?

• Enthusiasm among paediatricians initiated care

for newborn in this country

• Neonatal care at facility thereafter evolved a lot

through a long journey over last 4 decades

• Last 4 decades can be divided into two era:
• past and present
• Current concern is
• the era to come in future.

Neonatal Care:The Past

Evolution of the Care

• Medicine
• Pediatrics
• Neonatology

The Past…..

• The past began in early eighties
• Ended in the last century
• The span was a period of twenty years
• Only one or two tertiary care hospitals

started this type of newborn care

Neonatal Unit: Brief History

Year Place Key Person 1978 Dhaka Shishu Hospital Prof Khaleda Banu 1981 IPGM&R Prof M R Khan 1982 Dhaka Medical College Prof Maleka Khatoon 1986 Sir Salimullah Medical College Prof M A Rob

Dhaka Medical College

IPGM&R

Dhaka Shishu Hospital

The Past : Quality of care

• Quality of care was very primitive and not organized
• Few beds allocated for sick newborns inside the

paediatric ward

• No trained nursing staff
• Thermal care was not optimal nor meticulous to keep in

neutral thermal zone (NTZ)

• Few closed incubator in some tertiary care hospital

Neonatal Care along with general Paediatric Care

Incubator

Quality of care….

• Enteral nutrition was offered by NG tube
• Venous access was difficult
• IV infusion given with butterfly needle in

eighties

• Use of I/V canula and microburette started in

nineties

• Lack of availability of micro infusion pump was a

challenge to provide infusion for preterm babies

• Parenteral nutritient was only glucose

Microburette & Butterfly Needle

Quality of care ……..

• Intravenous access for medication was
• nly possible in few tertiary care hospital
• For district hospitals and below

intramuscular medications were used

• Capillary blood glucose ( CBG) estimation

was established in nineties

• Blood sample collection was a difficult task

& investigations were seldom done

Quality of care…….

• Respiratory care was only with

supplemental oxygen from cylinders

• No central supply of respiratory gases
• No monitoring device for status of
• xygenation & no scope for doing

arterial blood gas (ABG)

Oxygen Cylinder as a source of Oxygen therapy

Neonatal Care: at Present

Neonatal care at present……

• The present era began from the beginning
• f the new millennium
• There has been significant progress as due

emphasis has been given on neonatal health

• Neonatal care has been organized at all

level of health care facilities

• Infrastructure has already been developed
• Equipment/supplies have been provided

Neonatal care at present……

• Trained human resources are being

developed

• Professional bodies (BNF, BPA, PSB )

have come forward for developing neonatal health care

• Developing partners are coming forward

with all support

• Generation of competent neonatologists are
• n the way

Neonatal care at present……

• Private sector has also taken the

lead in establishing neonatal units based on Western standards of equipments and personnel

Neonatal care set up : current Bangladesh Perspective

• BSMMU
• BIRDEM
• Dhaka Shishu Hospital
• Medical Colleges
• Corporate Hospitals
• District & Upazila hospitals

NICU,BSMMU

Yellow Block

NICU, BSMMU

Main Entrance

Upgrading District Hospitals with SCANU

Geographical Coverage for SCANU

Existing SCANU (41) Planned SCANU (9)

Existing SCANU UNICEF-30 SDF-10 JICA-1 Planned SCANU UNICEF- 6 Mamoni-3

• 550 medical officers and around

1200 nurses were trained in the Emergency Triage and Treatment for sick newborns (ETAT) at BSMMU and other training centers during 2011-15

• More than 100 SSNs have been

provided long term (30 days) training on SCANU SOP at BSMMU

• A visual learning tool on SOP was

developed by UNICEF with technical support from BSMMU and professionals

Strengthen Service Delivery Capacity Development of Human Resource

31

Quality of care

• Incubators and radiant warmers are being used in all

level of care meticulously by trained staffs

• Intravenous access is no longer difficult
• Accurate administration of IV fluids with the use of

syringe/infusion pump is a turning point for caring extremely preterm infants

• Minimal enteral nutrition (MEN) with expressed breast

milk and addition of amino acid as parenteral nutrient are being employed for nutritional care

Radiant Warmer Portable Warmer

Infusion Pump & Syringe Pump

Paradigm shift

• Convulsion

Per Rectal Diazepam PHB

• Perinatal Asphyxia
• Oradexon ,NHCo3, 10%Calcium gluconate,

25%glucose 10% glucose , Adrenalin,Phenobarbitone,NS

Quality of Care ……

• A significant improvement in respiratory care

has been observed in the last decade

• Use of surfactant in many tertiary and

corporate hospitals has brought a dramatic change in respiratory morbidities in preterm babies

• Respiratory support with CPAP, IMV/SIMV

are available in many centres

Mechanical Ventilator

CPAP

Cardiac Monitor Cardiac monitor

Surfactant Therapy

Quality of Care ……

Monitoring of respiratory status using pulse

• xymeters and arterial blood gas (ABG) are

wide practised Electronic monitoring of cardiorespiratory status Newer phototherapy strategies include LED phototherapy, bili-blankets jin addition to conventional phototherapy

Phototherapy Unit

Quality of Care ……

There are ample scope for doing different laboratory tests In-house facilities for bed side X rays, Echo, USG are increasingly available Neonatal surgery are increasingly being done more with better outcome now a days

Bed Side Echocardiogram

In House ABG analyser

Quality of Care …..

Neonatal screening programmes like ROP, Hearing Screening, Thyroid screening, Developmental screening are the promising activities practised in some tertiary care centres to prevent future disabilities

ROP screening

Neonatal Care: at Future

Neonatology Future in Bangladesh

Therapeutic Hypothermia (TH)

• Neonatal encephalopathy(NE)

from Perinatal asphyxia, occurs in 2.0–6.0 / 1000 live births

• Intellectual delay and cerebral

palsy are often severe.

• TH is the gold standard in NE
• Two types of TH

Selective head cooling Total body cooling

Limitations:

• High cost of equipment
• Meticulous care
• Trained care giver (doctor, nurses)

Therapeutic hypothermia……

Total Perenteral Nutrition

• Nutrition for preterm in NICU
• Any infant unable to tolerate

adequate enteral feeding for more than 2-3 days PN support.

• PN and/or enteral nutrition

should begin within 24 hours after birth.

TPN

• Who are the candidates?

 All preterm less than 32 weeks  Late preterm and term babies unlikely to reach full oral feeds within 5 days  Any surgical condition involving GIT

• Advantages:

Better weight gain Better metabolic homeostasis Less risk of Osteopenia of prematurity

TPN

• Advantages:

Easy to manage acid base disorder Easy to optimize nutrition despite severely ill condition which enhances growth and development in extremely premature babies

• Limitation:

Requires trained manpower (preferably dietician/nutritionist) High cost

iNO therapy

 PPHN is a common condition in modern neonatology, complicated by MAS, RDS, Lung hypoplasia, Pneumonia  iNO is the mainstay of treatment  Current evidence shows  iNO improves oxygenation  decrease death or need for extracorporeal membrane

• xygenation in infants ≥35 weeks’

gestational age at birth.  <35 weeks’ gestational age is not yet established

iNO Therapy

• Advantages

Life saving medication in PPHN

• Limitations:

High cost Baby has to be ventilated Bed side echocardigram has to be available for diagnosing and following up of PPHN

ECMO

• ECMO is proven treatment for life-threatening respiratory

and/or cardiac failure in neonates.

• Overall survival rates are approximately 80% in infants with a

predicted survival of 20%.

• Common indications:

Fulminant Respiratory failure following MAS, Pneumonia, RDS, Pulmonary embolism after failing to conventional management

• Main principle:

Circulatory system to bypass lungs for oxygenation

• Limitations:

highly trained personnel and high cost of the equipments

ECMO

Complicated neonatal cardiac surgery

Complete repair in neonatal period

• Transposition of great arteries
• Coarctation of aorta
• Total anomalous venous return
• Truncus Arteriosus

• From past, we have come a long way to

the present practice of newborn care.

• From present, we need to envisage the

newer approach for optimal care of all types of critically ill newborn for not

• nly preventing death but an intact

survival.

Where we were & where we now

Future of Newborn Care: Community

• Promotional Activities by

Community Health workers:

– Promote healthy maternal newborn health behavior to ensure BNEP (Birth Preparedness; Newborn Care Preparedness and Emergency Preparedness) of the family and proper hygiene and nutrition – Promotion of proper care seeking for ANC, Delivery, Newborn Illness and Maternal Illness

• Home visit during pregnancy:

– Registration, – Distribution of commodities (IFA, Calcium, Misoprostol, CHX), – Linking with facilities for routine and emergency care

• Postnatal Home Visit

– Ensure ENC and breastfeeding support – Identification and referral of sick newborn – Follow-up of cases

Future of Newborn Care: Lower Level Facilities

• Basic Care:

– Quality ANC with proper counselling on newborn care – Identification of high risk pregnancy and refer with counselling – NVD and pre-referral management of delivery complications – Ensure ENC including application of CHX

• Management of Sick

Newborn and Newborn with Complications:

– Resuscitation – Pre-referral management of sick newborn and referral support – Management of clinical severe infection if referral failure – Management of isolated fast- breathing and local infections.