Author's details
Reviewer's details
Rules Thumb in Neonatology
Background
Neonatology in sub-Saharan Africa focuses on managing the care of newborns, particularly preterm infants and those with birth complications. The region faces significant challenges in neonatal care, such as limited healthcare infrastructure, high rates of infection, malnutrition, and insufficient access to skilled healthcare providers, especially in remote areas. Despite these obstacles, following certain rules of thumb and guidelines can help improve neonatal survival and outcomes.
Rules of thumb
1. Antenatal Care (ANC)
Antenatal care is essential for improving maternal and foetal outcomes. However, in sub-Saharan Africa, many women receive limited ANC due to healthcare access challenges. It is very important for women to have their children delivered by skilled birth attendants.
Rules of Thumb
Early and Regular Visits:
Encourage pregnant women to attend at least four ANC visits, starting as early as possible (within the first trimester especially after the first missed period). Screen for alcohol consumption, smoking and substance use with history taking to enhance prevention of neonates being affected.
Nutrition and Supplements:
Counsel women on proper nutrition and ensure they receive folic acid, iron and calcium supplements.
Guidelines
WHO ANC Guidelines:
Recommend at least eight ANC visits, although in low-resource settings, four is considered a minimum. The guidelines emphasize early detection of pregnancy complications, HIV testing, and malaria prophylaxis.
2. Immediate Newborn Care
The first few minutes after birth are critical for ensuring a newborn's survival and long-term health.
Rules of Thumb
Immediate Skin-to-Skin Contact:
Place the newborn on the mother’s chest immediately after birth. This promotes bonding, stabilizes the baby’s temperature, and supports breastfeeding initiation.
Delayed Cord Clamping:
Unless there is a medical emergency, delay cord clamping by 1-3 minutes. This allows for better placental transfusion, reducing the risk of anaemia.
Apgar Score Monitoring:
Assess the newborn’s Apgar score at 1 and 5 minutes to evaluate heart rate, respiration, muscle tone, reflexes, and skin colour.
Guidelines
WHO Essential Newborn Care (ENC) Guidelines:
Recommend immediate skin-to-skin contact, delayed cord clamping, and early breastfeeding. ENC protocols also include temperature management and infection prevention strategies.
3. Breastfeeding and Nutrition
Proper nutrition from birth is crucial for neonatal development and survival.
Rules of Thumb
Early Initiation of Breastfeeding:
Initiate breastfeeding within the first hour of birth to ensure the newborn receives colostrum, which provides essential antibodies and nutrients.
Exclusive Breastfeeding for 6 Months:
Promote exclusive breastfeeding for the first 6 months of life to reduce the risk of infections and support optimal growth.
Support for Low-Birth-Weight Babies:
For infants with low birth weight (LBW), provide additional breastfeeding support and consider supplementary feeding with expressed breast milk if needed.
WHO Breastfeeding Guidelines:
Recommend early and exclusive breastfeeding for the first 6 months, with continued breastfeeding for up to 2 years or beyond. These guidelines also include recommendations for supporting mothers with breastfeeding in challenging settings, such as those with HIV.
4. Thermoregulation
Hypothermia is a common and dangerous condition for newborns, particularly preterm and low birth weight infants.
Rules of Thumb
Keep the Newborn Warm:
Delivery baby onto the mother's chest and skin-to-skin contact. Afterwards, immediately dry the newborn after birth and wrap them in warm, dry cloths. Use hats and blankets to prevent heat loss, especially in colder environments or at night.
Use Kangaroo Mother Care (KMC):
For preterm or low birth weight infants, KMC, which involves continuous skin-to-skin contact between the mother and baby, is highly effective for maintaining warmth and promoting bonding.
Avoid Hypothermia:
Keep the delivery room warm (around 25°C) and avoid placing newborns on cold surfaces or exposing them to drafts.
Guidelines
WHO Thermal Protection Guidelines:
Recommend drying and covering newborns immediately after birth, avoiding exposure to cold, and using KMC for preterm and LBW infants to maintain body temperature.
.
5. Neonatal Resuscitation
A significant number of neonatal deaths in sub-Saharan Africa occur due to birth asphyxia, which is preventable with timely and appropriate interventions.
Rules of Thumb
Basic Neonatal Resuscitation:
All birth attendants should be trained in basic neonatal resuscitation. For non-breathing newborns, use the "Helping Babies Breathe" protocol: clear the airway, stimulate breathing, and provide positive pressure ventilation using a bag and mask if necessary.
Monitor for Respiratory Distress:
For any newborn with poor breathing, initiate resuscitation within the first minute ("Golden Minute"). Failure to do so can lead to long-term complications or death.
Guidelines
WHO Neonatal Resuscitation Guidelines:
Recommend that resuscitation should start within 60 seconds of birth for any baby not breathing or crying. The guidelines stress proper training for healthcare workers in resuscitation techniques.
6. Infection Prevention
Newborns in sub-Saharan Africa are at high risk of infections, including sepsis, pneumonia, and tetanus.
Rules of Thumb
Clean Delivery Practices:
Ensure clean delivery techniques, including sterilized instruments and gloves, to prevent neonatal sepsis. Use chlorhexidine for umbilical cord care to reduce infections.
Antibiotic Prophylaxis:
Administer prophylactic antibiotics when there is a high risk of infection (e.g., prolonged rupture of membranes or maternal infection).
Immunization:
Administer the BCG vaccine at birth to protect against tuberculosis and provide the first dose of the hepatitis B vaccine as per the national immunization schedule.
Guidelines
WHO Guidelines on Infection Prevention:
Recommend clean delivery practices, cord care using chlorhexidine, and antibiotic use in high-risk settings. Immunization with BCG and hepatitis B at birth is also advised.
7. Management of Neonatal Sepsis
Neonatal sepsis is a leading cause of mortality in sub-Saharan Africa and requires prompt identification and treatment.
Rules of Thumb
Early Detection of Sepsis:
Look for signs of sepsis, including poor feeding, lethargy, respiratory distress, and temperature instability. Suspect sepsis if the baby has any risk factors, such as maternal infection or premature rupture of membranes.
Antibiotic Therapy:
Start broad-spectrum antibiotics (ampicillin and gentamicin) immediately upon suspicion of sepsis, without waiting for confirmation through laboratory results, especially in resource-limited settings.
Supportive Care:
Ensure adequate hydration, temperature regulation, and oxygen support for newborns with sepsis.
Guidelines
WHO Sepsis Management Guidelines:
Recommend prompt antibiotic treatment with first-line antibiotics (ampicillin and gentamicin) and supportive care for suspected sepsis. Monitoring and follow-up are crucial, especially in low-resource settings.
8. Low Birth Weight and Preterm Infants
Preterm birth and low birth weight (LBW) are major contributors to neonatal morbidity and mortality in sub-Saharan Africa.
Rules of Thumb
Kangaroo Mother Care (KMC):
For stable preterm or LBW infants, KMC should be practiced to promote warmth, breastfeeding, and bonding. KMC has been shown to significantly improve outcomes for preterm babies.
Nutrition Support:
Provide breast milk as the primary nutrition source for preterm and LBW babies. Where necessary, express breast milk or provide fortified milk to ensure adequate growth.
Monitor for Complications:
Preterm infants are at high risk for complications, including respiratory distress syndrome (RDS), infections, and feeding difficulties. Monitor for these and provide appropriate interventions, such as oxygen therapy, respiratory support or feeding support.
Guidelines
WHO Guidelines on Preterm and Low Birth Weight Care:
Recommend KMC, breastfeeding, and specific care protocols for managing common complications in preterm infants, including respiratory support and infection prevention.
9. Neonatal Jaundice
Neonatal jaundice, if untreated, can lead to severe complications, including kernicterus and brain damage.
Rules of Thumb
Early Recognition:
Monitor all newborns for jaundice, especially within the first 72 hours. Yellowing of the skin and eyes is a common sign.
Phototherapy:
For moderate jaundice, phototherapy is the treatment of choice. Ensure that the newborn receives sufficient light exposure and monitor bilirubin levels regularly.
Avoid Kernicterus:
For severe jaundice, where bilirubin levels are dangerously high, consider exchange transfusion to prevent kernicterus.
Guidelines
WHO Neonatal Jaundice Guidelines:
Recommend regular screening for jaundice and the use of phototherapy for treatment. In cases of severe hyperbilirubinemia, exchange transfusion is advised.
10. Neonatal HIV Management
In sub-Saharan Africa, the risk of mother-to-child transmission of HIV remains a significant challenge.
Rules of Thumb
Prevention of vertical transmission:
ANC, voluntary testing on mothers, early commencement of ART in HIV-positive mothers
Early Testing and ART:
Ensure that infants born to HIV-positive mothers receive early infant diagnosis (EID) through PCR testing within the first six weeks. Initiate antiretroviral therapy (ART) in all HIV-positive infants.
Prophylaxis for HIV-Exposed Infants:
Administer antiretroviral prophylaxis (e.g., nevirapine) to all HIV-exposed newborns from birth to reduce the risk of transmission.
Breastfeeding and ART:
Encourage breastfeeding in HIV-positive mothers who are on effective ART, as it significantly reduces transmission risk while ensuring the baby receives essential nutrition.
Guidelines
WHO Guidelines for the Prevention of Mother-to-Child Transmission (PMTCT):
Recommend early infant diagnosis, ART initiation in HIV-positive infants, and prophylaxis for HIV-exposed newborns. These guidelines also emphasize breastfeeding in the context of effective maternal ART.
11. Neonatal Tetanus
Neonatal tetanus often arises from unhygienic delivery practices and the use of non-sterile instruments during delivery or postnatal cord care.
Rules of Thumb
Treat Suspected Tetanus Promptly:
If neonatal tetanus is suspected (symptoms such as rigidity, muscle spasms, and difficulty feeding), initiate immediate treatment, including antitoxins, antibiotics (usually penicillin or metronidazole), and supportive care to manage spasms.
Sterilize Delivery Equipment:
Ensure that any instruments used in cutting the umbilical cord are properly sterilized. Train birth attendants in clean birth practices to prevent infections.
Guidelines
WHO Neonatal Tetanus Elimination Guidelines:
Focus on immunizing pregnant women with tetanus toxoid vaccines, ensuring clean delivery and cord care practices, and training healthcare workers in neonatal tetanus management. WHO promotes community outreach to educate about proper birth and cord care practices in rural areas.
12. Neonatal Respiratory Distress Syndrome (RDS)
RDS is a common problem in preterm infants due to underdeveloped lungs and insufficient surfactant production.
Rules of Thumb
Monitor Preterm Babies Closely:
Preterm infants are at high risk for RDS. Monitor their breathing closely in the hours and days after birth for signs of respiratory distress, including rapid breathing, grunting, and retractions.
Provide Oxygen Therapy:
Administer supplemental oxygen if needed. For severe cases, continuous positive airway pressure (CPAP) or mechanical ventilation may be necessary.
Surfactant Replacement Therapy:
Where available, administer surfactant therapy to preterm infants with RDS to improve lung function and oxygenation.
Guidelines
WHO Guidelines for Preterm Infants with RDS:
Recommend early initiation of CPAP for preterm infants with breathing difficulties. Surfactant therapy should be used where available, and oxygen therapy must be carefully monitored to avoid complications such as retinopathy of prematurity.
13. Neonatal Hypoglycaemia
Newborns, particularly those born prematurely or with low birth weight, are at risk of developing hypoglycaemia, which can lead to neurological damage if untreated.
Rules of Thumb
Early Feeding:
Ensure early initiation of breastfeeding or feeding to prevent hypoglycaemia, especially in high-risk newborns (preterm, small for gestational age, or born to diabetic mothers).
Monitor Blood Glucose:
For newborns at high risk of hypoglycaemia, monitor blood glucose levels regularly in the first 24-48 hours after birth.
Monitor Blood Glucose:
Immediate Intervention: If hypoglycaemia is detected (blood glucose < 2.6 mmol/L), provide immediate feeding or glucose supplementation to stabilize the newborn.
Guidelines
WHO Hypoglycaemia Guidelines:
Recommend regular glucose monitoring for at-risk neonates and prompt feeding or intravenous glucose for treatment. Prevention through early feeding is emphasized, especially in resource-limited settings.
14. Neonatal Anaemia
Anaemia is common in neonates, especially in areas with high rates of malaria, maternal anaemia, or haemorrhage during birth.
Rules of Thumb
Check haemoglobin Levels:
Monitor haemoglobin levels in newborns who are at risk of anaemia (preterm infants, those with maternal anaemia, those delivered operatively or those born after a complicated delivery).
Treat with Iron Supplementation:
For mild anaemia, provide iron supplementation to prevent further complications. In severe cases, consider blood transfusions if available.
Prevent Iron Deficiency:
Ensure that breastfeeding mothers receive adequate iron in their diets or supplements to prevent neonatal iron deficiency anaemia.
Guidelines
WHO Guidelines on Iron Deficiency Anaemia:
Recommend early identification and treatment of neonatal anaemia with iron supplementation or blood transfusions in severe cases. These guidelines also emphasize maternal health and nutrition as key factors in preventing neonatal anaemia.
15. Neonatal Malaria
In malaria-endemic areas of sub-Saharan Africa, neonates can contract malaria in utero or shortly after birth.
Rules of Thumb
Monitor for Symptoms:
Neonates in malaria-endemic areas should be closely monitored for symptoms of malaria, such as fever, irritability, and anaemia.
Treat Promptly:
In areas where malaria is endemic, newborns suspected of having malaria should be treated immediately with age-appropriate antimalarial medications.
Prevent Malaria:
Mothers should receive intermittent preventive treatment in pregnancy (IPTp) with antimalarials, and insecticide-treated nets (ITNs) should be used to protect both the mother and newborn from mosquito bites.
.
Guidelines
WHO Guidelines on Malaria in Neonates:
Emphasize the importance of maternal malaria prevention through IPTp and ITNs. Newborns should be treated immediately upon suspicion of malaria, with age-appropriate dosages of antimalarial drugs.
Conclusion
Neonatal care in sub-Saharan Africa is challenging due to limited healthcare resources, high rates of infectious diseases, and a lack of specialized neonatal care units. However, following established rules of thumb—such as early breastfeeding, infection prevention, Kangaroo Mother Care, and neonatal resuscitation—and adhering to guidelines from organizations like the WHO can significantly improve neonatal outcomes.
A comprehensive approach that includes preventive measures (maternal immunization, infection control), early detection (monitoring for jaundice, hypoglycaemia, and sepsis), and immediate intervention (resuscitation, thermal regulation, oxygen therapy) is essential for reducing neonatal mortality and improving the health of newborns across sub-Saharan Africa.
Further readings
- World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 28 November 2016. https://www.who.int/publications/i/item/9789241549912 . Accessed 22 September 2024.
- WHO recommendations for care of the preterm or low-birth-weight infant. 15 November 2022. https://www.who.int/publications/i/item/9789240058262 Accessed 12th September 2024
- WHO. Regional Office for Africa. Essential Newborn Care Guidelines 2014. Accessed 12th September 2024
- WHO Guidelines for malaria. https://www.who.int/publications/i/item/guidelines-for-malaria. 16 October 2023. Accessed 12th September 2024
- Anbalagan S, Falkowitz DM, Mendez MD. Neonatal Abstinence Syndrome. [Updated 2024 Apr 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK551498/
- Thermal protection of the newborn: a practical guide 26 March 1997 https://www.who.int/publications/i/item/WHO_RHT_MSM_97.2 Accessed 12th September 2024
- Resuscitation of the newborn. https://platform.who.int/docs/default-source/mca-documents/policy-documents/operational-guidance/IND-CH-14-04-OPERATIONAL-GUIDANCE-2009-eng-Manual.pdf Accessed 12th September 2024
- WHO Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level 1 November 2016 https://www.who.int/publications/i/item/9789241549929 Accessed 12th September 2024
- Guidelines on the Clinical Management of Sepsis. 30 January 2024. https://www.who.int/news/item/30-01-2024-guidelines-on-the-clinical-management-of-sepsis Accessed 12th September 2024
- Sampurna MTA, Pratama DC, Visuddho V, Oktaviana N, Putra AJE, Zakiyah R, Ahmad JM, Etika R, Handayani KD, Utomo MT, Angelica D, Ayuningtyas W, Hendrarto TW, Rohsiswatmo R, Wandita S, Kaban RK, Liem KD. A review of existing neonatal hyperbilirubinemia guidelines in Indonesia. F1000Res. 2023 Nov 13;11:1534. doi: 10.12688/f1000research.110550.2. PMID: 38025296; PMCID: PMC10682606.
- Louw JG, Broodryk M, White L, Acker D, Viljoen DL, Olivier L. A multi-year, multi-site study of the prevalence of fetal alcohol syndrome in South Africa. Alcohol Clin Exp Res (Hoboken). 2024 May;48(5):867-879. doi: 10.1111/acer.15306. Epub 2024 Mar 28. PMID: 38548386.
- Mother-to-child transmission of HIV https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/prevention/mother-to-child-transmission-of-hiv. Accessed 12th September 2024
- Maternal and Neonatal Tetanus Elimination. https://www.who.int/initiatives/maternal-and-neonatal-tetanus-elimination-(mnte) Accessed 12th September 2024
- WHO Recommendation on Interventions to Improve Preterm Birth Outcomes. August 2015. https://iris.who.int/bitstream/handle/10665/183055/WH?sequence=1#:~:text=Recommendation%209.3%3A%20In%20intubated%20preterm,intubation%2C%20ventilator%20care%2C%20blood%20gas Accessed 12th September 2024
