Describe essential newborn care and the problem of low birth weight.

The Newborn and Low Birth Weight

• The definitions must be precise — low birth weight (LBW) is a birth weight of less than 2500 g, irrespective of gestation; very low birth weight is under 1500 g; and extremely low birth weight under 1000 g
• Preterm is birth before 37 completed weeks; and small for gestational age (SGA) is a weight below the 10th centile for gestation
• The distinction between preterm and SGA is clinically important and is examined — a preterm baby is small because it is born early, and is otherwise appropriately grown; an SGA baby has undergone intrauterine growth restriction
• They differ in their problems — the preterm baby faces respiratory distress from surfactant deficiency, apnoea, intraventricular haemorrhage, jaundice, feeding difficulty and infection; while the SGA baby faces hypoglycaemia, hypothermia, polycythaemia, meconium aspiration and perinatal asphyxia
• IN INDIA the majority of low birth weight is due to intrauterine growth restriction rather than prematurity, which is the opposite of the pattern in developed countries
• That difference matters for policy — it means Indian low birth weight is largely a problem of maternal nutrition and health before and during pregnancy, and is therefore preventable by improving the mother rather than by neonatal intensive care
• The causes of low birth weight — maternal undernutrition and low pre-pregnancy weight and height; anaemia; short stature; young maternal age and adolescent pregnancy; short birth interval and high parity; hard physical work during pregnancy; tobacco in any form, and passive smoking; infection, including malaria and urinary infection; pre-eclampsia; multiple pregnancy; and poverty and illiteracy
• The consequences extend far beyond infancy — higher neonatal and infant mortality; higher risk of infection, hypothermia and hypoglycaemia; impaired growth and cognitive development; and, through the BARKER hypothesis, a higher adult risk of diabetes, hypertension and coronary disease
• Low birth weight is therefore both a consequence of one generation’s undernutrition and a cause of the next generation’s chronic disease, which is why breaking the cycle requires acting on the adolescent girl and the pregnant woman

Essential Newborn Care and Neonatal Mortality

• The causes of neonatal death in India, which differ from those in older infants — prematurity and its complications; birth asphyxia and birth trauma; infection — sepsis, pneumonia, tetanus and diarrhoea; and congenital anomalies
• Early neonatal deaths (first 7 days) predominate, and are related chiefly to pregnancy and delivery; late neonatal deaths relate more to infection and the environment
• Essential newborn care consists of a small number of simple actions that together prevent most deaths:
• 1. Cleanliness — the six cleans: clean hands, clean surface, clean blade, clean cord tie, clean cord stump (nothing applied), and clean towel
• Nothing should be applied to the cord, since traditional applications of ash, cow dung or oil cause neonatal tetanus; where infection risk is high, chlorhexidine may be applied instead
• 2. Thermal protection — dry the baby immediately and remove the wet cloth; place skin-to-skin with the mother; cover the head; delay the first bath by at least 24 hours; and keep the room warm
• The newborn loses heat rapidly through a large surface area, thin skin and little subcutaneous fat, and cannot shiver — and hypothermia causes hypoglycaemia, acidosis and death, so this simple measure saves many lives
• The warm chain is the term for maintaining this from delivery through transport to the ward
• 3. Initiation of breastfeeding within one hour, with colostrum and nothing else
• 4. Resuscitation where needed — the golden minute, meaning that ventilation should be established within the first minute of life in a baby who does not breathe
• The essential skill is bag-and-mask ventilation, which is what saves the baby; chest compressions and drugs are rarely needed and are of far less importance
• 5. Eye care, vitamin K and immunisation — BCG, oral polio zero dose and hepatitis B birth dose
• 6. Recognition of danger signs and prompt referral
• The newborn danger signs should be memorised, since they are what a mother and a health worker act on — not feeding well or refusing to feed; convulsions; fast breathing (60 per minute or more) or severe chest indrawing; lethargy, or movement only when stimulated; fever or low body temperature; and jaundice of palms and soles, or on the first day
• Kangaroo mother care (KMC) deserves detailed treatment, since it is cheap, effective and specifically suited to India
• It consists of three components — early, continuous and prolonged skin-to-skin contact between the baby and the mother’s chest; exclusive breastfeeding; and early discharge with follow-up
• Its proven benefits — reduced mortality in low birth weight babies; better temperature regulation; reduced infection; improved breastfeeding and weight gain; shorter hospital stay; and better bonding
• Its importance for India is that it requires NO equipment, NO electricity and NO incubator, and therefore works precisely where neonatal intensive care is unavailable
• The INDIAN programmes for newborn care — home-based newborn care (HBNC), in which the ASHA makes a defined schedule of home visits in the first 42 days (more visits for a low birth weight baby), weighing, checking for danger signs, supporting breastfeeding and referring
• Newborn care corners in every delivery room; newborn stabilisation units at CHC; and special newborn care units (SNCU) at district level
• Navjaat SHISHU suraksha karyakram, which trains delivery-room staff in resuscitation and essential newborn care; and facility-based newborn care guidelines
• The INDIA newborn action plan targets a single-digit neonatal mortality rate and the elimination of preventable stillbirths
• The principle that should conclude the answer — most newborn deaths are prevented not by technology but by warmth, cleanliness, early breastfeeding and prompt recognition of danger, all of which can be delivered in a village
• Dry the baby and keep it skin-to-skin, since a newborn cannot shiver and loses heat through a large thin surface
• Delay the first bath by a day, which is a free intervention that prevents a great deal of hypothermia
• Hypothermia leads to hypoglycaemia and death, which is why thermal care saves more babies than equipment
• Indian low birth weight is growth restriction rather than prematurity, which is the opposite of the Western pattern
• That makes it a maternal nutrition problem, preventable before birth rather than treatable in intensive care
• Apply nothing to the cord, since ash, dung and oil cause neonatal tetanus, though chlorhexidine may be used
• The six cleans prevent sepsis and tetanus — hands, surface, blade, tie, stump and towel
• Bag and mask ventilation is what saves the baby; compressions and drugs matter far less and are rarely needed
• Establish ventilation in the golden minute, which is the target for a baby who does not breathe at birth
• Kangaroo care needs no equipment or electricity, and therefore works precisely where intensive care does not
• Kangaroo care reduces mortality in low birth weight babies, which is a proven outcome rather than a plausible one
• Preterm and small for gestational age differ; one is born early and the other is growth-restricted
• Preterm babies face respiratory distress while growth-restricted ones face hypoglycaemia and hypothermia
• Low birth weight raises adult diabetes risk, linking one generation undernutrition to the next chronic disease
• Act on the adolescent girl to break the cycle, since her nutrition determines her future baby weight
• Learn the newborn danger signs, since they are what a mother and a health worker actually act upon
• Jaundice on the first day is a danger sign, as is jaundice reaching the palms and soles
• The ASHA visits on a fixed schedule in the first forty-two days, with extra visits for a low birth weight baby
• Early neonatal deaths relate to delivery and late ones to infection and the environment
• Hard physical work in pregnancy contributes to low birth weight, and is a modifiable social factor
• Give BCG, polio zero and hepatitis B at birth, which is the immunisation component of essential newborn care
• The warm chain runs from delivery to ward, and is broken most often during transport