Showing posts with label Neonatology. Show all posts
Showing posts with label Neonatology. Show all posts

10 May 2012

Polyhydramnios



Polyhydramnios, premature delivery
Zae Kim, MD
Bartter_Gitelman_Syndrome.ppt

Renal Failure and Dialysis in Pregnancy
David Shure
Renal_Failure_in_Pregnancy.ppt

Care of the Sick and Prematurely
BornRavi Mangal Patel, MD
Care of the Sick and Prematurely.ppt

Antepartum Surveillance Techniques
Mrs. Mahdia Samaha Kony
Antepartum Surveillance Techniques.ppt

Maternal Risk Factors Fetal Assessment
Pregnancy.ppt

Using Anatomy and Physiology
Diagnosis1.ppt

Pediatric Airway Emergencies
Steven T. Wright, M.D., Seckin Ulualp, M.D.
Pediatric Airway Emergencies.ppt

APGO Objectives for Medical Students Preterm Labor
Preterm_Labor.ppt

Preterm Labor and Birth
Patricia B. Gotsch M.D.
Preterm Labor and Birth.ppt

Reproductive System Pathologies
Reproductive System Pathologies.ppt

Fetal growth restriction
Joseph Breuner, MD
Fetal growth restriction.ppt

Neonatal Hypotonia Clinical Approach To Floppy Baby
Osama Naga, M.D.
naga-neonatal_hypotonia.ppt

Genetics and Prematurity
Joann Bodurtha M.D.,M.P.H.
Bodurtha.Genetics.ppt

Childbirth at Risk: Pre-Labor Complications
Childbirth at Risk: Pre-Labor Complications.ppt

From Birth - Neural tube defects, Hydrocephalus, Hypo-Hyperthyroidism
Peggy Pannell RN, MSN
Hypo-hyperthyroidetc.ppt

Premature Labor and Delivery
Honor M. Wolfe
Wolfe_PTL.ppt

Neonatal Surgical Issues
Sue Ann Smith, MD
http://www.ohsu.edu/xd/health/services/doernbecher/research-education/education/med-education/upload/Neonatal-Surgical-Issues-part1.ppt
Latest 200 scholarly articles

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09 September 2009

Managing Low Birth Weight and Sick Newborns



Managing Low Birth Weight and Sick Newborns

Advances in Maternal and Neonatal Health

Session Objectives
* To define essential elements of the care of sick newborns, including neonatal resuscitation
* To discuss best practices and technologies

Management of Newborn Illness

* Education of mothers to recognize danger signals
* Working with families to develop complication plan for newborns
* Early recognition and appropriate management of newborn illness

Minimum Preparation for ANY Birth
The following should be available and in working order:
* Heat source
* Mucus extractor
* Self-inflating bag of newborn size
* 2 masks (for normal and small newborns)
* 1 clock
* At least one person skilled in newborn resuscitation present at birth

Essential Care for All Newborns
Most newborns breathe as soon as they are born and only need:
* A clean and warm welcome
* Vigilant observation
* Warmth
* To be observed for breathing
* To be given to the mother for warmth and breastfeeding

Immediate Care of the Newborn: Warmth
* Lay newborn on mother’s abdomen or other warm surface
* Immediately dry newborn with clean (warm) cloth or towel
* Remove wet towel and wrap/cover newborn, except for face and upper chest, with a second towel/cloth

* Blood on newborn is not a risk to newborn, but is a risk to caregiver
* Bathe after 24 hours
* In areas with high HIV prevalence, consider bathing earlier to reduce risk of maternal-fetal transmission, and to reduce risk to caregiver and to other newborns

Immediate Care of the Newborn
* Assess breathing
* Keep head in a neutral position
* IMMEDIATELY assess respirations and need for resuscitation

Signs of Good Health at Birth
Objective measures
* Breathing
* Heart rate above 100 beats/minute
Subjective measures
* Vigorous cry
* Pink skin
* Good muscular tone
* Good reactions to stimulus
* Most important measure is whether newborn is breathing
* Assessing all of above delays resuscitation, if it is necessary.

Birth Asphyxia
* Definition: Failure to initiate and sustain breathing at birth
* Magnitude:
o 3% of 120 million newborns each year in developing countries develop birth asphyxia and require resuscitation
o An estimated 900,000 of these newborns die as a result of asphyxia

Steps in Resuscitation
* Anticipate need for resuscitation at every birth, be prepared with equipment in good condition
* Prevent of heat loss (dry newborn and remove wet clothes)
* Assess breathing
* Resuscitate:
o Open airway
+ Position newborn
+ Clear airway
o Ventilate
o Evaluate

Assess Breathing
Newborn crying?
Provide routine care
* Chest is rising symmetrically
* Frequency >30 breaths/min.
* Not breathing/ gasping
* Breathing < 30 or > 60 breaths/ min.

Immediately start resuscitation
Provide routine care
Open Airway
* Position newborn on its back
* Place head in slightly extend position
* Suction mouth then nostrils

Ventilate
* Select appropriate mask size to cover chin, mouth and nose with a good seal
* Squeeze bag with two fingers or whole hand, look for chest to rise
* If chest not rising:
o Reposition head and mask
o Increase ventilation
o Repeat suctioning

Evaluate
After ventilating for about 1 minute, stop and look for spontaneous breathing
If no breathing, breathing is slow (< 30 breaths/ min.) or is weak with severe indrawing
If newborn starts crying/breathing spontaneously
Continue ventilating until spontaneous cry/ breathing begins

* Stop ventilating
* Do not leave newborn
* Observe breathing
* Put newborn skin-to-skin with mother and cover them both

Harmful and Ineffective Resuscitation Practices
Practices to be avoided include:
* Routine aspiration of the newborn’s mouth and nose as soon as the head is born
* Routine aspiration of the newborn’s stomach at birth
* Stimulation of the newborn by slapping or flicking the soles of her/his feet: only enough stimulation for mildly depressed-delays resuscitation
* Postural drainage and slapping the back: dangerous
* Squeezing the chest to remove secretions from the airway
* Routine giving of sodium bicarbonate to newborns who are not breathing
* Intubation by an unskilled person
* Some traditional practices:
o Putting alcohol in newborn’s nose
o Sprinkling or soaking newborn with cold water
o Stimulating anus
o Slapping newborn

Infection Prevention for Resuscitation
* Handwashing
* Use of gloves
* Careful suctioning if using a mucus extractor operated by mouth
* Careful cleaning and disinfection of equipment and supplies
o Do not reuse bulb—difficult to clean, poses risk of cross infection
* Correct disposal of secretions

Documentation
Details of the re
Post-Resuscitation Tasks: Successful Resuscitation
Post-Resuscitation Tasks: Unsuccessful Resuscitation
Policy Decisions for Resuscitation
Principles of Success
Care of the Low Birth Weight Newborn
Care of the Preterm Newborn
Principles of Management for Low Birth Weight and Preterm Newborns
* Warmth
* Feeding
* Detection and management of complications (e.g., resuscitation, assisted respiration)

As for all newborns:
* Lay newborn on mother’s abdomen or other warm surface
* Dry newborn with clean (warm) cloth or towel
* Remove wet towel and wrap/cover with a second dry towel
* Bathe after temperature is stable

Warmth: Problem with Incubators
* Potential source of infection
* Often temperature controls malfunction
* Often share incubator for more than one newborn

Need alternative method: kangaroo care
Feeding
Early and exclusive breastfeeding
* Breastmilk = best nourishment
* Already warm temperature
* Facilitated by kangaroo care

Definition of Kangaroo Care
* Early, prolonged and continuous skin-to-skin contact between a mother and her newborn
* Could be in hospital or after early discharge

How to Use Kangaroo Care
* Newborn’s position:
o Held upright (or diagonally) and prone against skin of mother, between her breasts
o Head is on its side under mother’s chin, and head, neck and trunk are well extended to avoid obstruction to airways
* Newborn’s clothing:
o Usually naked except for nappy and cap
o May be dressed in light clothing
o Mother covers newborn with her own clothes and added blanket or shawl
* Newborn should be:
o Breastfed on demand
o Supervised closely and temperature monitored regularly
* Mother needs lots of support because kangaroo care:
o Is very tiring for her
o Restricts her freedom
o Requires commitment to continue

Effectiveness of Kangaroo Care
* Randomized controlled trial
* Conducted in three tertiary and teaching hospitals in Ethiopia, Indonesia and Mexico
* Study effectiveness, feasibility, acceptability and cost of kangaroo mother care when compared to conventional methods of care
Benefits of Kangaroo Care
* Is efficient way of keeping newborn warm
* Helps breathing of newborn to be more regular; reduce frequency of apneic spells
* Promotes breastfeeding, growth and extra-uterine adaptation
* Increases the mother’s confidence, ability and involvement in the care of her small newborn
* Seems to be acceptable in different cultures and environments
* Contributes to containment of cost— salaries, running costs (electricity, etc.)

Summary

* Skilled attendant
* Equipment available and working
* Begin resuscitation immediately
o Ventilate
o Reassess frequently
o Kangaroo care once successful

References

Managing Low Birth Weight and Sick Newborns.ppt

Read more...

Normal Newborn Care



Normal Newborn Care - Advances in Maternal and Neonatal Health

Normal Newborn Care
Session Objective
* Define essential elements of early newborn care
* Discuss best practices and technologies for promoting newborn health
* Use relevant data and information to develop appropriate essential newborn recommendations

Newborn Deaths
Essential Newborn Care Interventions
* Clean childbirth and cord care
o Prevent newborn infection
* Thermal protection
o Prevent and manage newborn hypo/hyperthermia
* Early and exclusive breastfeeding
o Started within 1 hour after childbirth
* Initiation of breathing and resuscitation
o Early asphyxia identification and management
* Eye care
o Prevent and manage ophthalmia neonatorum
* Immunization
o At birth: bacille Calmette-Guerin (BCG) vaccine, oral poliovirus vaccine (OPV) and hepatitis B virus (HBV) vaccine (WHO)
* Identification and management of sick newborn
* Care of preterm and/or low birth weight newborn

Cleanliness to Prevent Infection
* Principles of cleanliness essential in both home and health facilities childbirths
* Principles of cleanliness at childbirth
o Clean hands
o Clean perineum
o Nothing unclean introduced vaginally
o Clean delivery surface
o Cleanliness in cord clamping and cutting
o Cleanliness for cord care
* Infection prevention/control measures at healthcare facilities

Thermal Protection
* Newborn physiology
o Normal temperature: 36.5–37.5°C
o Hypothermia: < 36.5°C
o Stabilization period: 1st 6–12 hours after birth
+ Large surface area
+ Poor thermal insulation
+ Small body mass to produce and conserve heat
+ Inability to change posture or adjust clothing to respond to thermal stress
* Increase hypothermia
o Newborn left wet while waiting for delivery of placenta
o Early bathing of newborn (within 24 hours)

Hypothermia Prevention
* Deliver in a warm room
* Dry newborn thoroughly and wrap in dry, warm cloth
* Keep out of draft and place on a warm surface
* Give to mother as soon as possible
o Skin-to-skin contact first few hours after childbirth
o Promotes bonding
o Enables early breastfeeding
* Check warmth by feeling newborn’s feet every 15 minutes
* Bathe when temperature is stable (after 24 hours)

Early and Exclusive Breastfeeding
* Early contact between mother and newborn
o Enables breastfeeding
o Rooming-in policies in health facilities prevents nosocomial infection
* Best practices
o No prelacteal feeds or other supplement
o Giving first breastfeed within one hour of birth
o Correct positioning to enable good attachment of the newborn
o Breastfeeding on demand
o Psycho-social support to breastfeeding mother

Breathing Initiation and Resuscitation
* Spontaneous breathing (> 30 breaths/min.) in most newborns
o Gentle stimulation, if at all
* Effectiveness of routine oro-nasal suctioning is unknown
o Biologically plausible advantages – clear airway
o Potentially real disadvantages – cardiac arrhythmia
o Bulb suctioning preferred
* Newborn resuscitation may be needed
o Fetal distress
o Thick meconium staining
o Vaginal breech deliveries
o Preterm

Eye Care To Prevent or Manage Ophthalmia Neonatorum
* Ophthalmia neonatorum
o Conjunctivitis with discharge during first 2 weeks of life
o Appears usually 2–5 days after birth
o Corneal damage if untreated
o Systemic progression if not managed
* Etiology
o N. gonorrhea
+ More severe and rapid development of complications
+ 30–50% mother-newborn transmission rate
o C. trachomatis

Eye Care To Prevent or Manage Ophthalmia Neonatorum (continued)
* Prophylaxis
o Clean eyes immediately
o 1% Silver nitrate solution
+ Not effective for chlamydia
o 2.5% Povidone-iodine solution
o 1% Tetracycline ointment
+ Not effective vs. some N. gonorrhea strains
* Common causes of prophylaxis failure
o Giving prophylaxis after first hour
o Flushing of eyes after silver nitrate application
o Using old prophylactic solutions

Efficacy of Prophylaxis for Conjunctivitis in China
* Objective: To assess etiology of newborn conjunctivitis and evaluate the efficacy of regimens in China
* Design: November 1989 to October 1991 rotated regimens monthly: tetracycline, erythromycin, silver nitrate
* 302 (6.7%) infants developed conjunctivitis, most S. aureus (26.2%) and chlamydia (22.5%)
* Silver nitrate, tetracycline: fewer cases than no prophylaxis (p < 0.05), erythromycin: not significant

Prophylaxis for Conjunctivitis: Objective and Design
* Objective: To compare efficacy in prevention of nongonococcal conjunctivitis
* Design: Randomized control trial to compare erythromycin, silver nitrate, no prophylaxis
o Examined with test for leukocyte esterase and chlamydia trachomatis antibody probe 30–48 hours postpartum, 13–15 days later, and telephone contact up to 60 days of life
* Main outcome measured: conjunctivitis within 60 days of life and nasolacrimal duct patency

Prophylaxis for Conjunctivitis: Results and Conclusion

* Results: 630 infants
* 109 with conjunctivitis
o Silver nitrate vs. no prophylaxis: Hazard ratio 0.61 (0.39-0.97)
+ Chemical conjunctivitis with silver nitrate resolves within 48 hours
o Erythromycin vs. no prophylaxis: Hazard ratio 0.69 (not significant)
* Conclusion: Parental choice of prophylaxis, including no prophylaxis, is reasonable IF antenatal care and STD screening

Povidone-Iodine for Conjunctivitis: Objective and Design

* Objective: To determine incidence and type of conjunctivitis after povidone-iodine in Kenya
* Design: Rotate regimen weekly: erythromycin, silver nitrate, povidone iodine
* Results:
o Conjunctivitis:
+ Chlamydia in 50.5%
+ S. aureus in 39.7%
o More infections in silver nitrate than povidone-iodine, OR 1.76, p < 0.001
o More infections in erythromycin OR 1.38, p=0.001

Povidone-Iodine for Conjunctivitis: Conclusion
Povidone-iodine:
o Is good prophylaxis
o Has wider antibacterial spectrum
o Causes greater reduction in colony-forming units and number of bacterial species
o Is active against viruses
o Is inexpensive

Immunization
* BCG vaccinations in all population at high risk of tuberculosis infection
* Single dose of OPV at birth or in the two weeks after birth
* HBV vaccination as soon as possible where perinatal infections are common

Summary
The essential components of normal newborn care include:

* Clean delivery and cord care
* Thermal protection
* Early and exclusive breastfeeding
* Monitoring
* Eye care
* Immunization
References

Normal Newborn Care.ppt

Read more...

Infant Lung Disease and Associated Complications



Infant Lung Disease and Associated Complications
By:Mary P. Martinasek, BS, RRT
Director of Clinical Education
Hillsborough Community College

Respiratory Distress Syndrome
* RDS , formerly called Hyaline Membrane disease (HMD)
* Primary cause of respiratory disorders
* 70% preterm deaths, 30% neonatal deaths
* Etiology - deficiency in surfactant
o Premature pulmonary system

Risk Factors associated with RDS
* Less than 35 weeks gestation
* Maternal diabetes
* Hx of RDS in sibling
* White male
* PFC (Persistent Fetal Circulation)
* Prenatal maternal complication
* Abnormal placental conditions
* Umbilical cord disorders

Pathophysiology of RDS
Decreased surfactant
Surface Tension
Compliance
Stiffer Lungs
Wide spread atelectasis
Worsening V/Q
FRC
WOB
PaO2& __ PaCO2
Respiratory Acidosis
Capillary damage
Alveolar Necrosis
Clinical Signs of RDS
* Respiratory Rate > 60 bpm
* Grunting
* Retracting
* Nasal flaring
* Cyanosis
* Hypothermia
* CXR = underaeration, opaque, ground glass appearance

Treatment of RDS
* Maternal steroids
* Artificial surfactant therapy
* Adequate hydration
* Thermoregulation
* Goal = support the patient’s respiratory system while minimizing complications

Complication of RDS
* ICH occurs in 40% of < 1500 grams
* Barotrauma = pulmonary air leaks
* Infection
* PDA

Airleak Identification
Clinical Scenario
BPD
Pathophysiology of BPD
CXR in BPD
* Stage I
o First 3 days of life
o Ground glass appearance on x-ray
* Stage II
o 3 - 10 days
o Opaque, obscure cardiac markings
* Stage III
o 10 - 20 days
o Cyst formations
* Stage IV
o 28 days
o Increased lung density, larger cysts
Treatment of BPD
* Avoidance of factors that lead to development
* Adequate ventilatory humidification
* CPT and bronchodilators
* Fluid management
* Nutrition

Persistent Pulmonary Hypertension
Treatment of PPHN
* Nitric Oxide (NO)
* Hyperventilation
* Tolazoline
* Dopamine
* ECMO (extracorporeal membrane oxygenation
* High frequency ventilation
Reverse Jeopardy
* What color tank is NO?
* What color tank is NO2?

Transient Tachypnea of the Newborn
* TTN
* Aka RDS II
* Term infants delivered via cesarean section
* Signs of RDS
* CXR - streaky infiltrates
* R/O pneumonia
* Treatment

TTN x-ray
Meconium Aspiration Syndrome
* Term and Postterm infan
Diagnosis and Treatment
* Aspiration of meconium
* Classic sign of RDS
* Irregular densities on CXR
* Treatment
o Suction meconium
o Peep
o Low peak pressures
o Antibiotics
o amnioinfusion

MAS x-ray
Asphyxia
* Major complication is hypoxic-ischemic encephalopathy
o Periventricular leukomalacia
* Tubular necrosis of kidneys and GI effects
* Liver damage
* Lung damage
PVL
Wilson- Mikity Syndrome
* AKA - Pulmonary dysmaturity
* BPD lung changes in unventilated infant
* Signs
o Hyperpnea, cyanosis, retractions, hypercarbia, respiratory acidosis
* Treatment
o Supportive
o Ventilated to treat apnea
o O2 to treat hypoxemia
Air leak syndrome
PIE x-ray
Apnea
Central or Nonobstructive Apnea
* Apnea of prematurity
* Chemoreceptor sensitivity
* Arousal response
* Stimulation of airway reflexes
* Dysfunction of the respiratory centers
* Dysfunction of the ventilatory muscles
* Dysfunction of the peripheral nervous system
* Treatment = caffeine or theophylline
Obstructive apnea
* Anatomic abnormalities
* Pierre Robin Syndrome (micronathia)
* choanal atresia, laryngeal webs, vocal cord paralysis, enlarged tonsils and adenoids
* Treatment = pharmacologic agents, surgery

What is choanal atresia and what is the classic sign?
Pierre Robin Syndrome
What is this x-ray terminology for this condition?
Retinopathy of Prematurity
Pathophysiology
Treatment of ROP
Intracranial/Intraventricular
Hemorrhage
* ICH and IVH
* Majority of hemorrhages in neonate are periventricular/ Intraventricular (IVH)
* Preterm and Infants <1500 grams high risk
* Germinal matrix most common

IVH
Signs of germinal matrix bleeding
IVH Classifications
Complications/ Treatment of IVH

Infant Lung Disease and Associated Complications.ppt

Read more...

Neonatal Resuscitation



Neonatal Resuscitation
By:Mary P. Martinasek, BS, RRT
Director of Clinical Education
Hillsborough Community College

Asphyxia
* Hypoxia + Hypercapnia + Acidosis
* May lead to irreversible brain damage
* The necessity to resuscitate is related to the degree of asphyxia

Causes of fetal asphyxia
* Maternal hypoxia
* Insufficient placental blood flow
* Blockage of umbilical blood flow
* Fetal disorders

Primary vs. Secondary Apnea
* Primary
o Initial asphyxia
o Signs
+ Initial period of rapid breathing
+ Respiratory movements cease
+ Heart rate and bp drop
+ Neuromuscular tone diminishes

Secondary Apnea
* If no resuscitation and apnea continues
* Signs
o Deep gasping respirations
o Heart rate continues to decrease
o Blood pressure begins to fall
o Infant flaccid

* Primary
o Stimulation and oxygen will usually induce respirations

* Secondary
o Infant unresponsive to stimulation – must be resuscitated

Effects of asphyxia on the lungs
* Ineffective respirations cannot open alveoli
* Pulmonary Hypertension
* Pulmonary vasoconstriction
o Hypoxia, hypercarbia, acidosis

Persistent Fetal Circulation
known as PPHN

* Leads to further asphyxia
* Blood shunted
* CO2 remains high despite ventilation
o Indocin
o Ligation of PDA

Preparation for Resuscitation

* Anticipation of high risk delivery
* Proper equipment
* Trained personnel

Purpose of Resuscitation

* Reverse asphyxia before irreparable damage has occurred

ABC’s of Resuscitation

* A – Establish an open airway
o Position infant
o Suction mouth then nose
* B – initiate breathing
o Use tactile stimulation
o Use PPV if necessary

Resuscitation

* C – Maintain circulation
o Stimulate and maintain circulation
+ Chest compressions
+ drugs

Initial steps
* Dry the infant
* Warm the infant
* Position the infant
* Suction the infant
* Stimulate the infant

Next step
* Evaluate respirations
o If none or gasping , provide PPV with 100% O2 for 15-30 seconds
o If spontaneous respirations then evaluate HR
* After 15-30 seconds of PPV or evaluation of spontaneous respirations then:
* EVALUATE HEART RATE
* If HR is above 100 then reevaluate respirations and color
* If HR is less than 60 continue/start PPV and start compressions

Reassess
* After 30 seconds reassess
* HR greater than 60 stop compressions
* HR greater than 100 and breathing stop PPV
* Evaluate infant’s color
o Peripheral vs. central cyanosis
o What is acrocyanosis?

Thermoregulation
* Maintain a neutral thermal environment
* Possible causes of heat loss
o Radiant
o Evaporative
o Convective
o Conductive

Neonatal Resuscitation.ppt

Read more...

Global trends of neonatal, infant and child mortality



Global trends of neonatal, infant and child mortality: implications for child survival
By:Dr KANUPRIYA CHATURVEDI & Dr S.K CHATURVEDI

When are child deaths occurring?

What are under-fives dying of?
(excluding neonatal causes of death)

* Pneumonia
* Diarrhoea
* Malaria
* Measles
* HIV/AIDS

Malnutrition contributes to more than half of all under-five deaths
What are neonates dying of?
* Preterm births
* Severe infection
* Asphyxia
* Congenital anomalies
* Tetanus

INDIA’S SHARE OF GLOBAL BURDEN
SOLUTIONS EXIST

* A mix of community and facility-based interventions
* A mix of integrated child health approaches
* Integrated management of neonatal and child hood illnesses is proven tool

Goals of IMNCI
* Standardized case management of sick newborns and children
* Focus on the most common causes of mortality
* Nutrition assessment and counselling for all sick infants and children
* Home care for newborns to
o promote exclusive breastfeeding
o prevent hypothermia
o improve illness recognition & timely care seeking

Essential components of IMNCI
* Improve health and nutrition workers’ skills
* Improve health systems
* Improve family and community practices
Home visits for young infants: Schedule
Colour Coded Case Management Strategy
Other innovations in case
Innovations in therapy
* Single daily dose gentamycin
* How to treat at home when hospital admission is not feasible
* Counselling the mother to give oral drugs at home
* Clear recommendations for follow up
* Negotiated feeding counselling
What does IMNCI not provide at all or fully
* Antenatal care
* Skilled birth attendance
* Birth asphyxia management
* Improved health system management
* What can be rapidly added to IMNCI
* Inpatient care modules for first level referral hospitals
IMNCI Experience--Milestones
* Early 2002, GOI constituted an Adaptation Group
* In joint GOI-UNICEF review meeting in April 2002 GOI requested to experiment IMNCI in BDCS districts
* July 2002, First national 2 days planning meeting
* December 2002, pre-tested 8-days physician course material
* Early 2003 - adaptation of H&N workers module
* May 2003 – First field testing in Osmanabad followed by one in Shivpuri & content & methodology frozen
* Implementation started in Andoor PHC, Osmanabad in June 03 followed by Valsad district
* Follow-up training of supervisors in April 04 in Osmanabad
* Field trial for case registers initiated in late 2004
* Physicians courses from 2005 included community visit, facilitation technique and briefing on Health workers’ course
* First Facilitation technique course in Orissa in June 2005

Training Flow
Training: Strengths -- Contents Doable
Training Limitations: Contents
Key messages

* Maternal and newborn care and support is essential to achieve a substantial reduction in neonatal mortality
* Improving child survival requires coordinated action between maternal and child health, and other programme areas (e.g. EPI, NUT, RBM, HIV)
* IMCI is an effective delivery strategy for multiple child survival interventions (India has already incorporated newborn care)
* For substantive impact, strong community component must accompany the health system strengthening

Global trends of neonatal, infant and child mortality.ppt

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