Beyond Newborn Resuscitation: Essential Care for Every Baby and Small Babies

Helping Babies Breathe (HBB) was developed in 2010 in response to a need for a newborn resuscitation teaching program that would be effective, widely accepted, and feasible in the context of low-resource settings.¹  The program provided a simplified, pictorial algorithm and low-cost training materials in addition to a novel educational strategy using small-group, interactive teaching with a focus on hands-on skills performance. This strategy empowered providers because they were given a voice in these more personal, interactive sessions and novel access to skills acquisition through repeated practice with paired feedback. In-country champions advocated for continued use and expansion of HBB, including delivery of the program to broader cadres of providers. Translation into regional languages further facilitated local ownership and supported implementation efforts. Within the first 2 years after its availability, HBB was used to train >80 000 providers, with national-level strategic planning and commitment of funds in 51 of 64 Millennium Developmental Goal 4 countries. During this time, >82 000 bag and mask devices, 93 000 suction bulbs, and 23 000 neonatal simulators were distributed, and 10 countries developed national plans for HBB training and service delivery. By 2013, the first studies identifying reduced rates of stillbirth and decreased early newborn mortality after implementation of HBB were published.^2,3 

As early efforts to expand access to newborn resuscitation training were underway, a recurring message from educators and providers in the field was identified. Providers trained in resuscitation were left with questions regarding the next steps in caring for an infant. In addition, newborn metrics implied that reduction in neonatal mortality would need to be accelerated to meet the international goals established for reduction in “under-5” mortality rates.^4,5  Educational programming needed to be expanded to include content addressing additional causes of neonatal mortality beyond intrapartum-related events (or asphyxia). Inclusion of content on the care of small or premature infants, as well as the prevention, identification, and management of infection, would support efforts to reduce neonatal mortality attributed the other main causes of newborn mortality: preterm birth and infection.⁶ 

Although an evidence-based curriculum to teach essential newborn care (ENC) exists, the World Health Organization’s (WHO’s) ENC training program is intended to be taught over the course of 4 to 7 days and relies on access to advanced technology with teaching.⁷  This resource-intensive approach limits the adoption of ENC, and studies reveal low rates of knowledge acquisition and subsequent delivery of essential care practices in low-resource settings.^8–11  The Essential Care for Every Baby (ECEB) and Essential Care for Small Babies (ECSB) programs were developed in the wake of HBB’s success (Fig 1) with the goal of achieving greater dissemination of educational programming and improved provision of ENC. The successful educational strategies developed with HBB were merged with the content of the WHO’s ENC program to create complementary and comprehensive training platforms, now collectively referred to as the Helping Babies Survive programs.

The earliest work on what eventually became the ECEB program was initiated in 2011 and performed in the absence of funding or a sponsoring organization. A group of HBB-experienced North American pediatricians with neonatal expertise used the WHO ENC content to create training materials in the HBB format. Both the 2010 ENC course and the WHO’s pregnancy, childbirth, postpartum, and newborn care recommendations were reviewed, and key content was compiled.^7,12  Clinical topics of ECEB include provision of preventive care, assessment and classification of an infant, breastfeeding and nutritional support, thermal support and skin-to-skin care, infection prevention, sepsis identification, and antibiotic administration. Content on the small and sick infant was originally considered but ultimately omitted with concerns that the program would become too cumbersome. In addition, the care of these patients is not available in many facilities in low-resource settings. Content on referral was instead included, with plans to create supplemental modules to cover the small and sick infant separately for providers involved in that level of care.

Although ECEB uses a train-the-trainer teaching strategy identical to that used with HBB, including a portable facilitator flip chart to be used by a master trainer, the companion provider guide has been modified from the workbook used with HBB. The ECEB provider guide includes added content addressing quality improvement, communication, and knowledge and skills retention. The guide incorporates questions regarding facility practices in an effort to identify gaps in the delivery of care and to explore solutions (Table 1). These questions are framed with an introduction identifying the basic steps of quality improvement, a focus that was expanded on for Helping Babies Survive programming with the development of ECEB. Beyond recognizing the need for quality improvement, experience with HBB highlighted the need for inclusion of additional education on communication and family counseling, key actions in the provision of basic newborn care. Finally, in early studies, researchers identified concerns for knowledge and skills retention after training and for ineffective translation of training principles into clinical care.¹³  The ECEB provider guide thus emphasizes strategies to ensure maintenance of skills. These include guidelines for paired learning after training and a suggested schedule with a documentation form for completion of refresher training.

The stepwise approach to clinical assessment designed with ECEB is similar to HBB, although the time frame is notably different (minutes with HBB versus 24 hours with ECEB). Placement of the essential steps of newborn care in red, yellow, and green zones on an action plan resembling HBB was an early vision but was not without challenge. Although the algorithm for resuscitation fell comfortably into this format, the road map for the care of an infant in the first day of life is more complex (Fig 2). A key concept in ECEB is the continued evaluation of a newborn for signs of infection based on the WHO’s danger signs. These need to be identified efficiently with timely intervention to avoid clinical decompensation and possible death from sepsis. In this respect, the action plan is less a stepwise algorithm compared with the HBB action plan because movement from a normal (green) or problem (yellow) infant to one with danger signs (red) could occur at any time. However, the complementary graphics of HBB’s and ECEB’s action plans facilitate the transition of resuscitative to basic newborn care. Inherent in the placement of the action plans of HBB and ECEB side by side in facilities is added attention to the essential steps of newborn care immediately after resuscitation, including assessment of all infants, provision of preventive care, assurance of early initiation of breastfeeding, maintenance of thermal support, and close surveillance for signs of infection. Although these actions are less urgent than providing bag-mask ventilation to an apneic infant, they have direct impacts on newborn survival.^14–20  Moreover, these are the steps that are at risk for omission when providers are busy or overextended.

ECEB expands on the role-playing model used in HBB to include practice of communicating with the mother and family. By including training on counseling, ECEB addresses care provided by health care workers as well as mothers (or other family members). As an example, providers are asked to demonstrate counseling mothers regarding breastfeeding and manual breast milk expression, positioning an infant for skin-to-skin care, and assessment of their infant for danger signs. Although counseling of mothers for breastfeeding is not routinely performed by providers in some cultures, the need to support women to achieve successful breastfeeding is universal because early and exclusive breastfeeding has a direct impact on infant survival.¹⁴  Surveys of primiparous and multiparous women have revealed significant gaps in knowledge of optimal breastfeeding behaviors, even in developing countries with high rates of breastfeeding.²¹  To assist in counseling on breastfeeding, a purpose-design breast model, MamaBreast (Laerdal Global Health, Stavanger, Norway) was developed for use with ECEB (Fig 3A). This breast model and locally produced versions can complement training in proper breastfeeding positioning and attachment as well as manual breast milk expression. Use of a simulated breast model in clinical settings may assist in overcoming barriers to breastfeeding counseling, including those that may be cultural and/or gender based. Studies evaluating the efficacy of the Laerdal breast simulator are in progress and may provide insight into optimal use.²² 

Expanding provider education to address the process of counseling families inspired the development of a novel tool to complement ECEB training and clinical care. A pictorial parent’s guide can be used to remind providers of the content that should be discussed at discharge and to facilitate the transition of care to home (Fig 4). This guide has been evaluated by providers as well as parents of newborns and was enthusiastically embraced because it reinforced key messages, including exclusive breastfeeding, maintenance of appropriate hygiene, and recognition of danger signs, in a colorful graphic format.²³  The parent’s guide has been translated into several languages and is used both with ECEB training and clinically.

Although ECEB was developed by North American specialists, a structured Delphi review was performed by international experts familiar with the HBB program. An additional formal review by the WHO occurred in Geneva, with representation of leaders in newborn health from all 6 geographic regions.

Thukral et al²³  published the earliest experience with ECEB after evaluation of the program in India and Kenya in 2013. Twelve facilitators in India (only a few of whom were experienced in HBB) were trained as facilitators and subsequently trained a total of 62 learners; 11 facilitators in Kenya (9 of whom were HBB experienced) trained 64 learners. Facilitators and learners reported increased confidence in providing essential care on the basis of comparison of pre- and post-training surveys. ECEB training also improved knowledge about newborn care, evidenced by performance on a 28-item multiple-choice questionnaire (MCQ) (India: pre-training 19.5, post-training 24.8; Kenya: pre-training 20.8, post-training 25.0; P < .001). Effective skills acquisition was evidenced by high rates of satisfactory scores (90%–94% of participants) on objective structured clinical evaluations with training.

However, confidence and knowledge do not reliably equate with improvements in clinical care. The ability of ECEB implementation to improve the quality of care provided to newborns was evaluated in Nicaragua by Perez et al²⁴  In this study, the authors identified higher rates of cord care, early skin-to-skin care, and early initiation of breastfeeding after a combination of HBB and ECEB training with supportive supervision. Similarly, ECEB was evaluated along with HBB training in Somalia.²⁵  In this study, the authors found that the proportion of newborns who received ≥2 of 3 ENC practices (skin-to-skin contact shortly after birth, early breastfeeding, and dry cord care) improved from 19.9% (95% confidence interval: 4.9–39.7) to 94.7% (95% confidence interval: 87.7–100.0).

Successful efforts to expand and sustain ECEB programming are directly influenced by the support of local ministries, health organizations, and clinical leaders.²²  Numerous steps have been identified to best ensure that this is achieved. The first is supporting local ownership, facilitated by train-the-trainer strategies, development of local champions, translation of materials, and use of regionally appropriate illustrations (to match dress, physical features, etc). At present, ECEB has been translated into 8 languages; an additional 11 translations are in progress (Table 2). The content being presented in these trainings should match local guidelines. Notable differences have been identified in many regions (eg, variable practices of cord and eye care), highlighting the need for ECEB to be adaptable. Specific pages can be omitted or revised locally to address inconsistencies with regional guidelines. The American Academy of Pediatrics (AAP) editorial team has offered support in this process, although some countries have proceeded with local adaptation on their own.

Finally, an important message identified during beta testing was that successful implementation of newborn care practices was dependent on critical elements of the health care system. Participants expressed concerns that practices recommended in ECEB would not align with procurement of supplies or existing policies, arguing for integrated training sessions that included administrative staff, physicians, and nurses to most successfully affect change.

Paralleling the experience with HBB, added content was requested after early use of ECEB. Because prematurity represents the leading cause of neonatal mortality,⁷  a module to address the care of these infants was deemed a priority. ECSB was intentionally titled “small baby” rather than premature because gestational dating in low-resource settings remains a challenge.²⁶  However, the management of premature and small infants is comparable, including provision of thermal and nutritional support and recognition and prevention of infection. Of concern was the cohort of growth-restricted infants who might inaccurately be omitted from this algorithm of care if classified by gestational age only. “Small baby” was chosen because the term was more inclusive and captured both the premature and more mature, but small, infant.

An early and continuing challenge in addressing the request for a small infant program was defining whether this training should stand alone or supplement ECEB. The decision was made to create a stand-alone program (that assumed some level of preliminary knowledge) because it might be applicable to a different cohort of providers. To create a program that included all relevant content for the small infant, key elements of ECEB were repeated in the ECSB algorithm but modified as needed for the small infant. This overlap creates challenges with implementation. A review of ECEB content is logical when ECSB is taught remotely from ECEB training. However, conducting contiguous ECEB and ECSB trainings has required some finesse to address the repeated content. The concept of merging the two has been explored by the ECEB and ECSB editorial teams at length. Numerous attempts at creating a combined algorithm have highlighted the strengths and weaknesses of this approach, with concerns that the small infant content can be lost and/or an action plan can become too complicated.

The earliest work on the ECSB program was initiated in 2013, again in the absence of funding but with the administrative support of the AAP. Although nursing was not represented in previous editorial groups, ECSB’s inclusion of the nursing perspective and expertise strengthened the development of training materials. ENC and pregnancy, childbirth, postpartum, and newborn care were again reviewed along with materials specific to the premature infant, including the WHO’s kangaroo mother care (KMC) guide²⁷  and guidelines on optimal feeding of low birth weight infants in low- and middle-income countries.²⁸ 

The topics in ECSB parallel those covered in ECEB, including provision of essential care, classification of infants, nutrition and thermal support, and prevention, identification, and early management of infection. With ECSB, these topics are focused on the unique needs of the small infant, who is more vulnerable to temperature instability, poor feeding, growth failure, and infection. In addition, because the care of the small infant in many settings includes task shifting, communication with a mother or family was built on to include teaching of care practices and skills themselves. As an example, providers practice teaching a mother prolonged skin-to-skin care, infant monitoring, and nasogastric feeding. Inclusion of content on a sick small infant was again considered, but ultimately the program was limited to the well small infant and recognition of danger signs, highlighting that the interpretation of danger signs (eg, poor feeding) is influenced by small or premature status alone. A separate module was envisioned for the care of the (appropriately sized or small) sick infant, in which basic interventions, including intravenous fluids, oxygen therapy, phototherapy, and glucose infusion, might be covered.

Furthering efforts to include quality improvement, ECSB added a skills practice on the quality improvement process. The steps of forming an improvement team, deciding on a process to improve, implementing a change, and measuring the effect are included in the exercise. Monitoring and evaluation are highlighted, with the addition of specific examples of process indicators and outcomes, with each step of ECSB in the provider guide (Table 3). ECSB further envisioned pairing clinical experience with skills training, suggesting that breastfeeding, manual expression of breast milk, and use of cup feeding could be taught and then observed in the clinical setting.

ECSB again uses the familiar tricolored action plan (Fig 2). However, because small infants are considered higher risk in the newborn period, the original classification options included yellow and red but not green. In ECSB, small infants who fall into the yellow category are considered well small infants but remain at risk for need for thermal or nutritional support. In contrast, infants in the yellow section of ECEB are considered to have a problem. Although this discrepancy complicates use of the 2 action plans together, most small infants move into a green zone before discharge from the hospital, which was maintained for ECSB.

Early iterations of the ECSB action plan and facilitator flip chart included 2 pages for use of alternative thermal support (incubators or warmers). However, inclusion of these interventions on the action plan raised concerns for a message that technology was both necessary and superior to simpler approaches. To more appropriately emphasize skin-to-skin care and KMC, alternative thermal support was removed from the action plan and flip chart, and the content on incubators and warmers was added as appendices to the program. Notably, both incubators and warmers continue to be used in low-resource settings but are not without risk of complications with unsafe use.²⁹ 

To complement the content of ECSB, a purpose-designed premature infant simulator was developed (Fig 3B). When filled with water, Preemie Natalie weighs ∼1.6 kg, modeling an infant of ∼32 weeks’ gestation. The manikin can be used to teach positioning for breastfeeding (because small infants require more support), positioning for skin-to-skin care, and securement in KMC wraps. Inclusion of a reservoir to mimic the stomach and patent nares allows the simulator to be used for practice of nasogastric tube placement. After appropriate placement, injection of air into the reservoir elicits sounds that are audible when auscultating the manikin (because air is pushed into the water-filled reservoir).

Consistent with the process used with ECEB, a structured Delphi review was performed for the ECSB program, with an additional review by WHO content experts.

Beta testing of ECSB was performed in Nepal and Uganda, including 12 HBB-experienced facilitators from Nepal, India, and Bangladesh, who subsequently trained a total of 24 providers. In Uganda, 11 HBB-experienced providers from Uganda, Ethiopia, and Kenya trained a total of 18 providers. Pre-post surveys revealed improved confidence with care of the small infant (Fig 5A). The top 5 areas of improvement for the experienced facilitators and less experienced providers were similar (Fig 5B).³⁰  Pre-post knowledge checks by using MCQs revealed improved performance of both facilitators and providers (Fig 6). Similarly, performance on objective structured clinical evaluations revealed skills acquisition, with average provider scores of 11.0 ± 1 (out of 12 total) and 18.2 ± 2.5 (out of 22) for 2 scenarios unique to small infant care. The impact of ECSB training on care practices for small infants, as well as on clinical outcomes, remains unknown. Notably, many low-resource settings have expertise with cup feeding of premature infants.³¹  The role that nasogastric feeding plays in these environments remains unclear, and evaluative studies to assess the added survival benefits would be helpful.

Although ECEB and ECSB have potentially improved access to and the quality of education on newborn care, limitations of these programs exist. Translation of knowledge and skills gained with these trainings into changes in clinical care remains poorly defined, with the exception of publications by Perez et al²⁴  and Amsalu et al.²⁵  In addition, the impact of these programs on newborn outcomes, including neonatal morbidity and mortality, remains unknown.

Short hospitalizations may limit the ability of providers to improve outcomes. With early discharge from health care settings, the opportunity to identify and intervene in the care of an infant who is becoming sick remains a challenge. Early symptoms of infection may be subtle, with more obvious signs representing a late stage at which antibiotics may be less effective at improving survival. Arguably, several of the WHO danger signs themselves represent delayed presentation of disease, including, but not limited to, the presence of convulsions, yellow soles (severe jaundice), and not feeding. Clinical signs indicative of a serious medical condition, most notably apnea, are also not among the WHO danger signs.

Although ECEB and ECSB highlight communication and use parent guides to assist in counseling, this practice presents a challenge in many clinical settings.²⁵  Exhausted postpartum mothers may not be accessible for counseling, and cultural barriers to meeting with new mothers may exist. Time constraints may further limit a provider’s ability to cover the intended content. Studies confirm that women often do not receive postnatal counseling,^25,32  a worrisome observation because maternal knowledge of neonatal danger signs (from studies in both inpatient and outpatient settings) is poor.^33–38  Adding to the complexity of relying on parents to screen infants for danger signs (after discharge) are the challenges of geographic distance and complicated travel in low-resource settings. Mobile health tools have the potential to facilitate identification of infants with danger signs^39–42 ; however, these are not always available, and access to needed care often remains a challenge.

Although training in both ECEB and ECSB facilitates knowledge and skills acquisition, the retention of these skills and the ability to translate them into improved clinical practice remains unknown. Evaluation of skills retention with HBB has revealed the critical contribution of ongoing skills practice with refresher or low-dose, high-frequency training.^43,44  Complementing training with clinical experience and peer learning may further solidify teaching principles. In addition to integrating clinical exposures, ECEB and ECSB could include multimedia to reinforce teaching principles. As an example, the Global Health Media Project (https://globalhealthmedia.org/) has developed a series of videos that complement the content of both programs and has recently released an application to ease access to the teaching content. Viewing of these educational videos has been shown to improve maternal confidence and knowledge of neonatal topics.⁴⁵  With online access, these videos could be used to complement training of providers as well as counseling of families. Several applications have also been developed to present the content of these programs in digital format.⁴⁶  As access to advanced technology progresses globally, novel strategies to integrate multimedia into newborn training will be key.

HBB provided a strategy and template for low-cost, interactive, skills-based education, which was subsequently applied to the development of supplemental programs addressing the two additional main causes of neonatal mortality. These novel training programs have brought additional attention to newborn health and the goal of delivering quality newborn care to every newborn. As the global health community approaches new challenges in the decade to come, it is critical that the newborn remains present on the global health agenda. Access to low-cost, evidence-based interventions that improve the quality of both newborn care and neonatal outcomes is greatly in need, now more than ever.

AAP

American Academy of Pediatrics

ECEB

Essential Care for Every Baby

ECSB

Essential Care for Small Babies

ENC

essential newborn care

HBB

Helping Babies Breathe

KMC

kangaroo mother care

MCQ

multiple-choice questionnaire

WHO

World Health Organization