Essential "nutrition-related" Essential "nutrition-related" delivery care practices for delivery care practices for short- and long-term infant short- and long-term infant and maternal health and and maternal health and

nutritionnutritionAMTSL and the newborn – an immediate

postpartum care package: new directions and collaborative efforts

POPPHI PPH Working Group, March 20, 2008

Camila M Chaparro, PhDCamila M Chaparro, PhD

Pan American Health OrganizationPan American Health Organization

What are the practices?What are the practices?

• Delayed umbilical cord clamping• Immediate mother to newborn skin-

to-skin contact• Early initiation of exclusive

breastfeeding

Why are they important?Why are they important?

• Delayed cord clamping:– Evidence that a minimum delay of 2

minutes:• Improves infant hematological and iron status

through 6 months of age in full-term infants

– Preterm infants: delay of 30-45 seconds shows immediate benefits: prevention of late-onset sepsis, intraventricular hemorrhage; decreased blood transfusions, increased hematocrit

Infant iron statusInfant iron status

• Iron deficiency is the most common nutritional deficiency worldwide, the most common cause of anemia

• Up to 50% of infants in developing countries are estimated to become anemic by age 1

• IDA in young children associated with impaired cognitive, motor and behavioral development

• Some effects may be irreversible even after treatment, and many years later negative effects still evident

Prevalence of anemia:6-9 Prevalence of anemia:6-9 momo

0

10

20

30

40

50

60

70

80

90

100

Leso

tho 

2004

Congo

(Bra

zzav

ille) 2

005

Gha

na 20

03

Ethiop

ia 2

005

Rwanda 

2005

Zimba

bwe 

2005/0

6

Seneg

al 2005

Guin

ea 2

005

Tanzania

 200

4

Camer

oon 

2004

Mad

agas

car 2

003/

2004

Niger 2

006

Mala

wi 200

4

Uganda

 200

6

Burkin

a Fas

o 200

3

Rep

ublic

of M

oldov

a 20

05

Jord

an 2

002

Egypt

 200

5

Armen

ia 2

005

Nepal 2

006

Cambo

dia 200

5

Hondur

as 2

005

Bolivi

a 200

3

Haiti 2

005

Hb

< 1

1 g

/dL

(%

)

Sub-saharan AfricaN. Africa/W.

Africa/Europe

S/SEAsia

LAC

Iron deficiency during Iron deficiency during infancy: Preventive infancy: Preventive

interventions?interventions?• Particularly in developing countries

there may be few feasible and affordable interventions to prevent iron deficiency in infants

• One intervention to improve infant iron status is delayed umbilical cord clamping (DC)

(Chaparro CM et al, Lancet 2006)

DC significantly increased infant DC significantly increased infant body storage iron at 6 months of body storage iron at 6 months of

ageage11

EC

DC

20

29

38

47

56

65

Body storageiron (mg)

30.7

57.6

p = 0.0003

1 Adjusting for maternal ferritin and employment

27 mg Fe= 1.25 mo Ferequirements

DC increases body iron more DC increases body iron more in infants born to ID mothersin infants born to ID mothers11

Iron-replete mothers Iron deficient mothers

EC

DC

35

38

41

44

47

50

InfantBody Iron (mg/kg)

46.7

42.1

47.548.6

p = 0.008 for interaction term

ID = ferritin < 12µg/L

DC increases body iron more in DC increases body iron more in infants with birth weight ≤ infants with birth weight ≤

3000 g3000 g

Birth weight > 3000 g

Birth weight 2500 to 3000 g

EC

DC

35

38

41

44

47

50

Infantbody iron (mg/kg)

45.2

41.2

47.7 48.3

p = 0.04 for interaction term

Why are they important?Why are they important?

• Skin-to-skin contact:– Improves time to effective

breastfeeding, as well as more "successful" breastfeeding on the first latch• breastcrawl.org

– Positively associated with breastfeeding status at 1-4 months postpartum and a longer breastfeeding duration

Why are they important?Why are they important?

• Early initiation of exclusive breastfeeding– Reduces neonatal and infant morbidity and

mortality • Initiation of breastfeeding within the first hour

could reduce 22% of all-cause mortality (Edmond et al Pediatrics, 2006)

• Single most effective intervention for preventing under-5 mortality (13%) (Lancet, 2005)

– Nutritionally ideal food– Long-term health benefits for mother and

infant

Are they being done?Are they being done?

• Delayed cord clamping– POPPHI data: % of deliveries where cord

clamped ≤ 1 min• Ethiopia: 93%• Tanzania: 75%• El Salvador: 71%• Guatemala: 90%• Honduras: 88%• Nicaragua: 94%• Indonesia: 96%• Indonesia (domiciliary deliveries): 86%

Are they being done?Are they being done?

• Skin-to-skin contact– ?

• Early initiation of exclusive breastfeeding– DHS data

Percent of respondents reporting breastfeeding their infant within the first hour after birth (5 years prior to the survey)

0102030405060708090

%

Source: Macro International Inc, 2008. MEASURE DHS STATcompiler. http://www.measuredhs.com, March 3 2008.

Why not?Why not?• Lack of research on benefits/risks• Barriers to "evidence-based" clinical

practice: habit, convenience, little access to medical literature, outdated guidelines/curricula/clinical norms

• Other barriers: cultural• Lack of integrated nature of guidelines for

maternal and newborn care (perceived incompatibility between maternal and newborn care practices)

Philip AGS, Saigal S. NeoReviews 2004;5:142-154.

• Presents the evidence base for the three practices

• Recommendations for each practice

• Suggested steps to ensure integration within the context of other programs

• Addresses "common concerns/FAQs" with delayed cord clamping

• Briefly presents the evidence supporting the three practices plus AMTSL

• Presents a suggested sequence of steps for integration of the practices

What can be done?What can be done?

• Simple, safe, effective and no-cost practices to improve infant nutrition, with potential long-term implications for health and development

• Greater awareness of revised AMTSL guidelines (WHO/FIGO/ICM) recommending delayed cord clamping

• Coordination between obstetric and pediatric programs to bridge the divide between "maternal" and "newborn" care

What can be done?What can be done?

• Re-emphasis on importance of delivery care practices/hospital routines for infant nutrition and health

• Renewed emphasis on BFHI certification, and importance of re-certification