Sri Lanka has recently been commended by the World Health Organisation (WHO ) for its low neonatal mortality rate, which is far ahead of the South East Asian region and on par with high income developed countries. This decline didn’t happen overnight. It took a great deal of effort on the part of the Health Ministry to put in place many interventions that helped bring about a sharp decline in neonatal births.
Today, we have a new emerging health crisis that could put the neonatal’s life at risk – namely the Covid-19 virus spreading throughout this country.
Senior Lecturer and Head, Department of Paediatrics, University of Colombo and Consultant Neonatologist, University Unit, De Soysa Hospital for Women, Colombo Dr Nishani Lucas fields some questions on this subject as well as how best a newborn can get the optimal benefits from feeding right from the day it is born.
Following are excerpts from her interview with the Sunday Observer
Q: World health authorities have recently focussed attention on addressing an important health issue that has been sidelined: namely, the premature death of newborn babies. As there is some confusion on who is a newborn tell us up to what period of its life is an infant categorised as a ‘newborn’ or ‘neonatal?’ One week? One month?
A: A newborn is a baby who has been just born. A neonate is a baby within the first 28 days of life.
Q: Who are those most at risk? According to a recent report of the World Health Organisation, globally 2.5 million children died in the first month of life in 2018. The report further states, while the world has made substantial progress in child survival since 1990, and globally, the number of neonatal deaths declined from 5.0 million in 1990 to 2.5 million in 2018, the decline in neonatal mortality from 1990 to 2018 has been slower than that of post-neonatal under-5 mortality. Most of these deaths occur in middle level and low level income countries, with countries in Asia being at highest risk. What is the position of the Lankan neonatal care in this context? Are still births also included in the list?
A: Sri Lanka has a neonatal mortality rate (NMR) of 6.5 per 1,000 live births in 2018 which is far ahead of South East Asia (42 per 1,000 births) and on par with high income developed countries. We too had a rapid decline from 1945 to 2000 from 80 to < 10/1000 NMR and a slower decline thereafter. To answer your second question, a neonatal death is the death of a baby who is born alive, which occurs during the first 28 days of life.
Q: What is a still birth? Are still births also included in neonatal deaths?
A: A still birth is a baby who is born dead or is found dead while within the mother’s uterus, after 28 weeks of gestation. In answer to the 2nd question, No, still births are not included in neonatal deaths.
Q: Q. What are the most common causes for these neonatal deaths?
A: Congenital abnormalities (54.5%) is the commonest cause, followed by prematurity (27%), birth asphyxia (10.1%) and sepsis (8.3%) (FHB, 2016 data)
Q: What are the danger signs of a sick neonate?
A: Poor activity, lethargy, not wanting to feed, irritability, excessive crying which is difficult to console, fever, skin turning cold, skin turning blue, bile stained vomiting (yellow/green vomit), blood stained vomiting, bleeding, redness, swelling, purulent discharge, bleeding from the umbilicus, breathing difficulty, breathing fast, chest in-drawing, shallow breathing and abnormal movements are danger signs.
Q: What should the family do when they detect these symptoms?
A: The family should take the neonate and rush to the nearest hospital that provides neonatal care, as discussed and planned at the time of discharge. All families with neonates should have a plan for transport and which hospital to go in the event of an emergency to avoid unnecessary delays that can be detrimental.
Q: Reducing the number of neonatal deaths- how did the Health Ministry go about this task?
A: Mortality was high in the past due to hypoxia and infection. This was overcome by training staff on neonatal resuscitation and improved infection control. Once the NMR drops to single digits, main cause of death would be due to congenital abnormalities and prematurity. Inclusion of neonatology as a specialized branch of paediatric training, ensuring availability of surfactant, parenteral nutrition, non-invasive respiratory support, development of standards and guidelines, screening programs by the Ministry of Health, are some of the steps taken to overcome these challenges.
Q: We now draw your attention to an emerging health crisis – Covid-19, now rapidly spreading throughout the world including Sri Lanka. As there are conflicting views whether this virus could pose a serious threat to the newborn, give us your comments.
A: There are only a few reported cases of Covid-19 in neonates from China, Israel, Spain and London all of whom had mild disease.
Q: If the mother is a Covid positive patient what is the percentage of transmission risk from mother to child?
A: We do not have enough data to give an exact percentage as there are only a few cases on Covid positive neonates reported so far (4 from China, 1 from Israel, 1 from Spain and I from London etc). There has been no documented vertical transmission from mother to child so far. Placenta, amniotic fluid and breast milk were found to be negative for the virus in Covid 19 positive mothers. Transmission is suspected to be horizontal in neonates i.e by direct contact, droplets etc.
Q: Newborns of HIV-infected mothers are also at risk. What are the solutions?
A: A mother who is on regular treatment, often has an undetectable viral load minimizing the risk of disease transmission. These mothers can opt to deliver their baby vaginally as well as breastfeed their babies as per WHO/UNICEF guidelines. Baby is started with antiviral treatment soon after birth, which is continued until the duration of breastfeeding. Studies have shown that the benefits conferred by breastfeeding outweigh the risk when the viral load is low.
Q: What are the essential procedures carried out when a mother has just given birth?
A: Health personnel skilled in attending to emergencies with the mother and neonate are present at all deliveries. The categories of personnel attending the delivery vary according to the risk to the mother and or the baby. Baby will be delivered on to the mother’s abdomen, wiped dry while checking as to whether the baby is in good condition, (good colour, good cry, good tone and heart rate >100/min) and then placed skin to skin on the mothers chest and supported to breastfeed within the first hour of life.
Q: Sri Lanka has been commended as having one of the best breastfeeding coverages in the world . However, there are still some mothers who only breast feed during their stay in hospital, and switch to the bottle and artificial milk as they have no support at home. Others breast feed for only the 4 months they are given maternity leave and don’t complete the 6 months that UNICEF has recommended. What is the significance of breast milk for newborn babies in terms of reducing malnutrition risks?
A: Breastfeeding reduces the risk of respiratory (72%), diarrhoeal (64%), ear (50%) and many more infections during early childhood, It reduces the risk of asthma (9%). It contributes to early programming and ensures a healthier adulthood by reducing the risk of obesity(26%), diabetes, heart disease, hypercholesterolaemia, hypertension and immune mediated disease like multiple sclerosis, ulcerative colitis etc. The first thousand days of life, i.e. from the time of conception until 2 years of age, determines the outcome of a neonate. Therefore, improving the quality of maternal and newborn care from pregnancy onwards will improve the neonatal outcome.
Q: What are the nutritional needs of a newborn?
A: The newborn needs energy, carbohydrate, protein, lipid, mineral and vitamins in the appropriate amounts according to the period of gestation. Breast milk provides all these nutrients in the appropriate amounts from birth to 6 months of age. Preterm/growth restricted babies < 1500g, < 32 weeks gestation are given parenteral nutrition, which comprises intravenous amino acids, lipids, dextrose, minerals and oral vitamin supplements in addition to breast milk. Breast milk is given directly when possible, but is expressed and given via cup/tube for small/sick babies.
Q: To return to the Covid-19 crisis, tell us what precautionary methods have been taken in our hospitals to protect both mother and child from its deadly impact? Are there separate wards for pregnant women? What happens if she is tested positive once admitted to the ward? What happens to the baby thereafter? Is it separated from the mother?
A: All pregnant mothers suspected to have Covid 19 are admitted to a separate ward until they are tested. If tested positive they will be transferred to the designated hospital, if negative they will be sent to a normal ward. If the mother delivers while awaiting test results, baby will also be tested for Covid 19. Baby is kept with the mother to enable skin to skin care and breastfeeding, as the benefits outweigh the risks of the baby getting a mild illness. Baby may be protected by the Covid-19 antibodies transmitted through the breast milk, from getting the disease from others after going home. This is in accordance to the WHO guidelines.
Q: How do you prevent a baby getting the infection especially if the mother is breastfeeding?
A: Mother is advised to wear a mask during breastfeeding and to use contact precautions such as washing hands every time she touches the baby.
Q: Your message to all mothers on ensuring optimal care for the newborn amid this difficult period?
A: Enjoy your baby; Ensure you have given the best quality nutrition through exclusive and continued breastfeeding and best quality stimulation by spending quality time reading books, singing songs, listening to music and keeping away from screen time.