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Are You Aware? New Global Causes of Child Mortality & Breastfeeding

Are You Aware? New Global Causes of Child Mortality & Breastfeeding.

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New Global Causes of Child Mortality Data Released in Lancet, May 2012. (Reference: Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. (2012) The Lancet, Early Online Publication, 11 May 2012 doi:10.1016/S0140-6736(12)60560-1)

  1. The burden of mortality in children younger than 5 years varied widely across WHO regions in 2010, with the largest number of deaths seen in Africa (3·6 million) and southeast Asia (2·1 million). Breastfeeding has and is playing a crucial role in the survival of the infants.
  2.  In 2010, neonatal mortality was highest in southeast Asia (1·096 million deaths, 52·3% of regional deaths in children younger than 5 years), with 19·2% of deaths (0·402 million, UR 0·262—0·558 million) attributable to preterm birth complications, and 21·8% of deaths (0·457 million, UR 0·359—0·551 million) attributable to pneumonia in the neonatal and postneonatal periods.Of the WHO

NEONATAL MORTALITY – HIGHEST CONTRIBUTOR TO CHILD MORTALITY

The majority of mortality is being contributed by the newly born population. Perinatal mortality has been defined as mortality of either of the mother-infant dyad during the perinatal period, which is defined as the period from 20th week of gestation to seven days after birth. Infants dying in their first week of life then highly speaks of the quality of prenatal care their mothers received. On the other hand, infant deaths occurring between seventh to the 30th day reflects the quality of infant care and may not necessarily a sequela of prenatal care.

A good question to ask is, when do these neonates die? In a data review of the deaths of neonates by day locally, it showed that most infants do not survive more than 48 hours, with a declining incidence towards the end of neonatal period. This first 48 hours of life still coincides with the perinatal period, which then clearly underscores the fact that majority of our mothers are not receiving optimum and adequate prenatal care thus leading to their demise.

 

Deaths of Neonates by Days, Philippines 1998-2003. (MA Silvestre, 2009).

There has been increasing preterm birth in the last few years, and preterm birth complications have contributed significantly to mortality burden among children before their fifth birthday. Locally, pregnancies are terminated prematurely because of urogenital infection (triggering preterm labor), uncontrolled maternal hypertensive disorders, abnormal bleeding (placenta previa, abruptio placenta). Having adequate access to mother-child care providers will significantly improve this saddening statistics. The PhilHealth recently reported that out of the 1400 plus cities and municipalities, only 607 cities and municipalities have mother-child care facilities; LESS than 50%.

PNEUMONIA, SECOND HIGHEST CONTRIBUTOR TO CHILD’S MORTALITY.

The peak incidence of mortality from pneumonia is the first six months of life. Pneumonia is a vaccine-preventable disease. There are currently two conjugated and one polysaccharide pneumococcal vaccines available in the market. Of these, it’s the conjugated vaccines that can protect the infant from pneumococcal death during the first six months of life, as the polysaccharide vaccine can only be administered when the child is at least 2 years of age. Unfortunately, the conjugated pneumococcal vaccine is not available in health centers due to its high cost. Majority of the population that flock to the government vaccination centers, who cannot avail of the said vaccine, are therefore vulnerable to succumb to this disease.

The newly born infant’s immune system is inexperienced, thus any infection immediately at birth may lead to infant’s death. During pregnancy, whatever antibodies the mother has through vaccination or active infection are shared to the fetus through the placenta. (Problem lies when the mother never had infection nor vaccination, there would be nil to share). These antibodies may be the only armamentarium the infant has, however do not confer absolute protection after birth, and wanes by around six months of life. However, mother also continues to provide additional antibodies to the baby after birth during breastfeeding; a process cow milk formula can and will never duplicate.

A person has two manners of acquiring antibodies – active: by producing during vaccination or active infection; and passive: through infusion of already formed antibodies during pregnancy, breastfeeding and infusion of immunoglobulin concentrate. Vaccination is a process whereby a weakened antigen (whether the organism itself of its by-product) is introduced to the individual in an attempt to trigger his immune system to produce antibodies against the offending organism, but the antigen is not strong enough to cause infection or disease by itself. Pneumococcal vaccination should then be accomplished during the infant’s first six months of life to preclude this peak incidence of death from pneumonia during this period.

What has been noticeable though, according to the article, was the mention of how breastfeeding is playing a crucial role in the survival of these infants.

WHEN TO INITIATE BREASTFEEDING?

Delaying the initiation of breastfeeding is HARMFUL!!! In an observational cohort done at Ghana, observing 10,492 infants who survived beyond their 48th hour from birth, the following were the findings:

  • there is an increased risk of death from infection with increasing delay of initiating breastfeeding;
  • if the breastfeeding was initiated only after 24 hours of life, there is a 2.6-fold risk of death;
  • moreover, if initiation was delayed, the infant was partially breastfed (meaning baby was also given cow milk formula), the risk increases to 5.7-fold. (Reference: Edmond KM, et al. Effect of early infant feeding practices on infection-specific neonatal mortality: In rural Ghana. Am J Clin Nutr.  2007; 86:1126-31.)

In Southern Nepal, frequent home visits were done among 22,838 breastfed newborns, who survived beyond 48 hours. It was noted that

  • in the first hour of life from birth, only 3.4% were breastfed;
  • within 24 hours of life, 56.6% of infants were breastfed;
  • babies who were partially breastfed (72.6%) were at higher mortality risk than exclusively (purely) breastfed infants- the longer the delay of initiating breastfeeding, the higher mortality rate;
  • mortality was higher among late (>24 hours) than early (<24 hours) initiators
  • neonatal death may be avoided if breastfeeding is initiated within first day or 24 hours of life (7.7%), but more when initiated within the first hour of life (19.1%). (Reference: Mullany LC, et al.  Breast-Feeding patterns, time to initiation, and mortality risk among newborns in Southern Nepal. J Nutr, 2008; 138(3):599-603).

WHAT PHILIPPINES HAS DONE AND IS STILL DOING….
During the latter part of 2010, through the efforts and cooperation from Dr. Mianne Silvestre and her colleagues from the Philippine Society of Newborn Medicine, the Department of Health and WHO-Philippines has come up with Unang Yakap, a sequence of essential procedures at the delivery room. This program include:
  1. provision of warmth and drying of the infant, simultaneously stimulating him to breath;
  2. uninterrupted skin-to-skin contact — this procedure allows baby to acquire maternal bacterial flora that will colonize his intestines that will serve to prime his immune system, delays onset of allergic disorder, and positive effect on the duration of breastfeeding (likelihood of prolonged breastfeeding);
  3. delayed cord clamping – helps prevent iron-deficiency anemia; and
  4. initiation of breastfeeding within the first 90 minutes of life.

(Unang Yakap video may be viewed in this link: http://www.youtube.com/watch?v=5hCP7rYHrwA)

The DOH with Bureau of Food and Drugs has also strictly implemented the Milk Code. Among the provisions of milk code are:

  1. exclusive breastfeeding for 0-6 months;
  2. no substitute nor replacement for breastmilk;
  3. appropriate and safe complementary feeding should start from six months onwards in addition to breastfeeding;
  4. breastfeeding is still appropriate for young children up to two years of age and beyond;
  5. infant or milk formula may be hazardous to a child’s health and damage child’s formative development;
  6. advertising, promotions or sponsorships of infant formula, breastmilk substitutes and other related products are prohibited;
  7. other related product such as, but not exclusive of, teats, feeding bottles and other feeding paraphernalia are prohibited in health facilities;
  8. government and all concerned stakeholders must continuously accomplish an information, dissemination campaign/strategy, and do further research on the advantages of breastmilk and the hazards of breastmilk substitutes or replacements; and
  9. milk companies, and their representatives, should not form part of any policy-making body or entity in relation to the advancement of breastfeeding.
          (Reference: http://pcij.org/blog/wp-docs/ao2006-0012.pdf)
Another venue where breastfeeding is being contested by milk companies is the infant’s vision and cognitive development. Breastmilk naturally contains long polyunsaturated fatty acids (LCPUFA) in the form of docosahexanoic acid (DHA) and arachidonic acid (ARA). A breastfed term infant can synthesize his own DHA and ARA relative to the maturity of the enzyme required, in his liver, thus exogenous supplement is not necessary. Breastmilk as well already contain DHA and ARA, on a proper ratio, and works in ways not duplicated by milk formula supplemented with such LCPUFA. Studies have been done, comparing infants fed breastmilk alone vs those infants fed milk formula supplemented with LCPUFAs. After 39 months follow-up of these infants, it was found out that visual, cognitive and language did not differ among the different arms of the study. This then clearly indicates that addition of LCPUFAs to milk formula does not offer additional benefit compared to breastmilk feeding. (Reference: http://pediatrics.aappublications.org/content/112/3/e177.abstract?sid=0457fe1a-2010-4eec-bb16-39087e6b12e3).

Are You Aware? New Global Causes of Child Mortality & Breastfeeding

 

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Should Preterm Babies Undergo Unang Yakap?

Some question whether preterm babies should undergo the “Unang Yakap” process because they have difficulty in establishing a good respiratory effort…

Let’s dissect the scenario…

  1. The baby’s digestive system is the first portal of infection via ingestion of offending microorganism.
  2. The intestinal epithelia cells should have a tight junction between each to prevent whatever ingested bacteria to cross through the intestinal barrier. (This illustrates the microscopic structure of the intestines. Photo courtesy of http://truenourishment.com)(This picture illustrates the tight junctions between intestinal cells. Photo courtesy of http://antranik.org).
  1. Newly-born babies (term or preterm) have loose gaps between cells. These gaps enable bacteria or allergens to pass through these cells and cause infection or sensitization respectively.
  2. A baby’s gut, whether term or preterm, is sterile (free of any bacteria) while in utero (inside the uterus). They only acquire bacteria into their gut by aspirating the normal vaginal bacterial flora during vaginal birth and/or direct contact to the mother’s skin, e.g. breastfeeding. Thus, babies born by cesarean section are deprived of these maternal vaginal flora. Furthermore, if these CS-delivered babies are not breastfed, they are devoid significantly too of the maternal skin flora.
  3. A baby must ingest some of the maternal bacterial flora to able to activate its immune system to work. In doing so, the bacteria will stimulate the immune system located at the intestinal wall (gut-associated lymphoid tissue, GALT) to secrete immunoglobulin A (secretory IgA, sIgA) that becomes one of the first line of defenses against intestinal pathogens. Also, this will trigger now the loose gap junctions to tighten, thus “closing” the body’s possible route of entry for bacteria and allergen that can incite infection and allergen sensitization.
  4. Uninterrupted skin-to-skin contact, i.e., no cloth between mother and baby, also enables baby to ingest some maternal skin flora that helps him establish his immune system as well.
  5. Maternal vaginal flora confers better protection to the infant compared to that stimulated by the maternal skin flora.
  6. Babies, whether term or preterm, are able to produce the normal number of immune cells. But the function is not yet mature as it was never challenged by infection while the baby was in utero. If term babies’ immune system is immature, all the more for preterm babies. Immune system is a function of maturity and challenges by exposures to offending organisms.

What happens during preterm birth?

  1. Most preterm babies are born via CS route. Baby get’s dried and stimulated to breath. At times, baby might require endotracheal intubation to help him breath regularly. (Photo courtesy of http://www.enotes.com/neonatal-respiratory-care-reference/neonatal-respiratory-care). Some babies might be too distressed to tolerate skin-to-skin contact with the mother thus are transported immediately to the neonatal ICU for further care. In this regard therefore, babies do not have the benefit of acquiring some bacterial flora from the mother, save for some through the cesarean delivery. Babies then are exposed to the bacterial flora of the care providers in the NICU, namely the physicians, nurses, and midwives, which are way too different from that of the mother.
  2. No matter how ideal a NICU set-up is, there may still be harmful microbes cohabiting the unit. Often than not, these microbes are resistant to strong anti-microbes. Given the fact that the preterm baby’s immune system is immature, non-acquisition or minimal acquisition of maternal bacterial flora, babies are susceptible to infection with these harmful microbes. This infection might lead to the demise of the baby even if he was able to survive respiratory distress.

Should preterm babies undergo “unang yakap?”

Ideally, they should! And they’re the population who would benefit the most from this intervention. Even a brief skin-to-skin contact with the mother will already provide significant help for them, not only from infection but later in establishment of successful breastfeeding. Until they show sign/s of respiratory distress, they should be exposed to the mother.

 
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Posted by on April 22, 2012 in neonates, Pregnancy

 

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The Science of Unang Yakap

(Please click the video clip link above to understand the succeeding discussion. Thank you)

People might be wondering what is this “UNANG YAKAP” program by the DOH. The Unang Yakap is a special program being implemented in the delivery or operating room during child birth. It refers to the Essential Intrapartum Newborn Care — sequential procedures that needs to be carried out for the optimal welfare of the newly born baby. It has four components, namely

  1. provision of warmth, drying and stimulating the baby;
  2. uninterrupted skin-to-skin contact (between the mother and the baby);
  3. delayed or properly-timed cord clamping; and
  4. initiation of breastfeeding.

Immediately upon the birth of the baby, the obstetrician/nurse/midwife wipes the baby dry. This will remove the amniotic fluid that can be a cause heat loss via evaporation. The baby is also stimulated to breath or cry during the process of drying especially if baby hasn’t cried yet. This is done while umbilical cord still isn’t cut.

After which, baby is now placed prone onto the mother’s bare abdomen/between the breasts/chest. Baby is also still naked during this time. The beanie is place on the baby’s head to prevent heat loss. The uninterrupted skin-to-skin contact simply means that there’s no physical barrier between the mother’s and baby’s skins. A blanket is then placed over the baby to keep him/her warm. This step during the delivery procedure has been shown by studies to bring about several benefits:

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(Photo courtesy: http://givingbirthwithconfidence.com)

  1. helps baby to regulate his/her temperature normally;
  2. allows baby to swallow normal bacteria from the mother’s skin that will colonize his/her intestines and aid baby fight against infection. These bacteria also stimulates intestinal cells and delays onset of allergic disorders;
  3. helps correct abnormality of blood gas analysis; and
  4. helps baby maintain normal blood sugar.

The third step is now the clamping and cutting of the umbilical cord without milking it. This delay in clamping allows additional blood to transfuse from the placenta to the baby and thus an extra iron depot for the baby. It has been shown that babies who are exclusively breastfed (no receipt of milk formula) will usually have drop in blood iron levels by six months, a condition known as iron-deficiency anemia. A slight delay in cord clamping (1-3 minutes after baby is born) decreases this incidence and save the baby from iron supplementation at the said age.

The last step is the initiation of breastfeeding. This step usually is appreciated at about 20 to 30 minutes from birth, maybe earlier for more term babies. Studies have underscored the benefits of early breastfeeding. In studies done in Uganda and Ghana, babies who were exclusively breastfed were protected from pneumonia and diarrhea by about 19-fold and 11-fold, respectively, compared to those who were given milk formula. Furthermore, those who were breastfed immediately had better protection vs those who were breastfed only several hours after birth. This is because breast milk contains protective antibodies (derived from the mother’s armory of antibodies she produced during her exposures to her own infections and vaccines) that the baby can not produce yet until exposure to infection.

This sequence of events may not be done entirely if during assessment the baby needs additional help to breath. The sequence may also be a little modified from hospital to hospital depending on the hospital’s policy.

(Acknowledgement: My mentors Drs Mianne Silvestre and Blas Mantaring III for pioneering on this endeavor)

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Addendum:

Bathing of babies is done after at least 6 hours from birth so baby can maximize assimilating the maternal bacterial flora into his system.

 
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Posted by on April 22, 2012 in neonates, Pregnancy

 

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