Born too soon: care for the preterm baby

Abstract

As part of a supplement entitled “Born Too Soon”, this paper focuses on care of the preterm newborn. An estimated 15 million babies are born preterm, and the survival gap between those born in high and low income countries is widening, with one million deaths a year due to direct complications of preterm birth, and around one million more where preterm birth is a risk factor, especially amongst those who are also growth restricted. Most premature babies (>80%) are between 32 and 37 weeks of gestation, and many die needlessly for lack of simple care. We outline a series of packages of care that build on essential care for every newborn comprising support for immediate and exclusive breastfeeding, thermal care, and hygienic cord and skin care. For babies who do not breathe at birth, rapid neonatal resuscitation is crucial. Extra care for small babies, including Kangaroo Mother Care, and feeding support, can halve mortality in babies weighing <2000 g. Case management of newborns with signs of infection, safe oxygen management and supportive care for those with respiratory complications, and care for those with significant jaundice are all critical, and are especially dependent on competent nursing care. Neonatal intensive care units in high income settings are de-intensifying care, for example increasing use of continuous positive airway pressure (CPAP) and this makes comprehensive preterm care more transferable. For health systems in low and middle income settings with increasing facility births, district hospitals are the key frontier for improving obstetric and neonatal care, and some large scale programmes now include specific newborn care strategies. However there are still around 50 million births outside facilities, hence home visits for mothers and newborns, as well as women’s groups are crucial for reaching these families, often the poorest. A fundamental challenge is improving programmatic tracking data for coverage and quality, and measuring disability-free survival. The power of parent’s voices has been important in high-income countries in bringing attention to preterm newborns, but is still missing from the most affected countries.

Figure 1

135 million newborns and 15 million premature babies-health system needs and human capital outcomes around the year 2010. Source: Born Too Soon report, chapter 5 [113]. Analysis using data from Blencowe et al., 2012 [1]; Cousens et al., 2011 [114]; Liu et al., 2012 [8].

Figure 2

Increasing survival gap for preterm babies around the world: Regional variation in preterm birth as direct cause of neonatal deaths showing change between 2000 to 2010. Source: Born Too Soon, Chapter 5 [113]. Data from Child Health Epidemiology Reference Group and World Health Organization estimates of neonatal causes of death (Liu et al. 2012) [8].

Figure 3

Preterm babies face specific risks. Source: Born Too Soon, Chapter 5 [113].

Figure 4

Missed opportunities to reach preterm babies with essential interventions, median for Countdown to 2015 priority countries. Source: Born Too Soon, Chapter 5 [113]. Data sources: Adapted (Kinney et al., 2010) [115] using data from UNICEF Global Databases (UNICEF, 2012) [116] based on Demographic Health Surveys, Multiple Indicator Cluster Surveys and other national surveys, neonatal resuscitation from LiST [117].

Figure 5

Kangaroo Mother Care -what works to accelerate progress towards scale? Source: Born Too Soon, Chapter 5 [113].

Figure 6

The right people for reducing deaths and disability in preterm babies. Source: Born Too Soon, Chapter 5 [113].

Figure 7

The history of neonatal care in the United Kingdom and the United States shows that dramatic declines in neonatal mortality are possible even before neonatal intensive care is scaled up. Source: Born Too Soon, Chapter 5 [113]. Acroynms used: ANCS = antenatal corticosteroids, CPAP = continuous positive airways pressure, NICU = neonatal intensive care, IPPV = intermittent positive pressure ventilation, VLBW = very low birth weight. Data sources: (Smith et al., 1983; NIH, 1985; Baker, 2000; Wegman, 2001; Philip, 2005; Jamison et al., 2006; Lissauer and Fanaroff, 2006; CDC, 2012; Office for National Statistics, 2012) [118-126] with thanks to Boston Consulting Group for help with the layout.

Figure 8

Parents' pain and parents' power. Source: Born Too Soon, Chapter 5.