|Management of the Sick Newborn: Report of a Technical Working Group (WHO - OMS, 1996, 20 p.)|
The meeting was opened by Dr T. Türmen, Director of WHOs Division of Family Health; Dr G.J. Ebrahim was the chairman. The meeting dealt with the tasks and procedures for assessment, classification and treatment of major newborn diseases by health workers in the community, at the health centre and at the referral hospital during the first week of life.
Not all newborn disease and conditions were discussed at the meeting. More emphasis was placed on the early neonatal period (first week of life) since that is when most neonatal deaths occur. The management of illness in older newborns is dealt with in other WHO documents.
Diseases were selected on the basis of the following criteria:
· diseases that contribute most to mortality and/or morbidity/disability;
· diseases for which treatment is available in most circumstances within the health care system (health centre, referral hospital).
The global burden of newborn illness was described at the meeting. In 1993, 4 million babies in developing countries died within one month of their birth. Some 42% of these deaths were due to infections (neonatal tetanus 14%, sepsis and meningitis 7%, pneumonia 19%, diarrhoea 1.5%). Other causes of neonatal deaths were birth asphyxia (21%), birth injuries (11%), prematurity and low birth weight (10%), and congenital abnormalities (11%). Newborn deaths are declining at a slower rate than post-neonatal deaths. More deaths occur during the first week of life than at any other time in childhood. This pattern has been observed even in countries with good neonatal care.
Two-thirds of babies in developing countries are born at home, and only a small proportion of these births take place with the assistance of a trained birth attendant. Most babies born in institutions are discharged within 24 hours of birth. Therefore most diseases manifest themselves when the newborn is at home and must therefore be recognized at home. Family members, especially mothers, need to be able to recognize signs of newborn diseases promptly in order to make the decision to seek care.5
In the newborn period, particularly during the first week of life, most diseases present with similar unspecific signs. It is difficult to determine the exact cause of disease because of the overlap of these signs. In any case, normal conditions vary widely. In addition, health workers have limited time and limited laboratory support for diagnosing and managing newborn diseases. Therefore the Technical Working Group tried to identify those signs that are most predictive of severe disease and attempted to simplify decision-making about treatment. Diseases were categorized according to similarity of signs and response to similar (initial) treatment.
Discussions of the Technical Working Group were based on the assumption that no special diagnostic facilities for newborns (micromethod for haematology, biochemistry, microbiology) would be available either at the health centre or at the hospital level.
Strong emphasis was placed on urgency in managing newborn diseases. The group stressed that urgency must be reinforced at all levels and that:
· mothers and families must understand that a good outcome depends on rapid recognition and management;
· health workers must give higher priority to newborn care.
For each condition, the meeting discussed:
· identification at home by mother/family and at the health facility of danger signs that are most predictive of the condition;
· assessment (ask/observe/examine) at the health centre;
· classification into disease categories at the health centre (further refinement into treatment groups for hospital care was not completed);
· treatment at the health centre, referral to hospital and treatment at hospital (antibiotics, other specific treatment, supportive treatment);
· advice to the mother about home care, breast-feeding, danger signs and follow-up (e.g. when to bring the baby back to the health centre).
Most of the time of the Technical Working Group was spent on discussion of assessment, classification and treatment at the health centre level. The tables produced by the group will be the technical basis for the development of guidelines and/or training materials for health workers at the health centre.
Inpatient care was found to be a more complex issue. Some general principles of inpatient newborn care were discussed and appropriate treatment was agreed for most disease groups. The assessment and classification process at hospital level was not defined.
Although rare, congenital abnormalities are more common in the first week than at any other period of life. Some are treatable, but only if good surgical services are available. The group did not discuss these problems in depth but noted the need to review congenital abnormalities and identify those that are treatable with limited resources to prevent deaths and disabilities.
The Technical Working Group gave guidance to the secretariat for further development of materials on these topics. It also identified several areas for research and development.
Common English expressions were used to describe signs of illness. These are also used in this document. However, the importance of using local expressions in adapted guidelines and training materials was emphasized. For definitions of terms, see the Glossary on page 18.