Neonatal Nursing And Helping Babies Breathe: An Effective .

Neonatal Nursing and Helping Babies Breathe:An Effective Intervention to Decrease GlobalNeonatal MortalityGeorge A. Little, William J. Keenan, Susan Niermeyer, Nalini Singhal, and Joy E. LawnHelping Babies Breathe (HBB) is an evidence-based medical educational curriculum designed to improveneonatal resuscitation and be taught in resource-limited circumstances. It has been field-tested for educationaleffectiveness and feasibility of wide implementation. We are committed to supporting the expansion ofeffective neonatal care, agree that HBB is highly suitable for that purpose, and promote the statement that “thetime to act on behalf of every newborn infant is now” (Little G, Niermeyer S, Singhal N, Lawn J, Keenan W,Neonatal Resuscitation: A Global Challenge, Pediatrics, 2010;126(5):e1259-e1260). We also note thata program is only as effective as its systematic implementation and that neonatal nursing must serve anessential role in standard setting, education, and implementation of any bedside change in care of the newlyborn infant.Keywords: Neonatal nursing; Helping Babies Breathe; Global neonatal mortality; Neonatal resuscitationThe neonate has only recently attained its rightful status as a fulland equal partner in the spectrum of maternal, newborn andchild health (MNCH) care, research, and policy initiatives. TheUnited Nations Millennium Development Goals (MDGs) of theinternational development initiative for improving the socialand economic conditions of the world's poor adopted 8 goals in2000 that have a 2015 date for attainment. Significantly, 2 of the8 goals are directed at MNCH: MDG 4 for child health includingneonatal survival and MDG 5 for maternal health.1 Neonataldeaths (deaths in the first 28 days of life) are a major portion ofchild deaths, are often graphically depicted and monitored withunder-5 mortality, and serve as a sentinel indicator ofreproductive health. Most neonatal deaths occur within hoursafter birth.The Global Neonatal Death ProblemThere are about an equal number of neonatal deaths (3.6million) and stillbirths (3.3 million) in the world each year witha remarkable 98% occurring in the less-resourced andFrom the Department of Pediatrics, Dartmouth Medical School, Hanover, NH;Department of Pediatrics, St Louis University, St Louis, MO; Department ofPediatrics, University of Colorado Health Sciences Center, Denver, CO;Department of Pediatrics, University of Calgary, Calgary, Alberta; and SavingNewborn Lives/Save the Children, Cape Town, South Africa.Address correspondence to George A. Little, Department of Pediatrics,Dartmouth Medical School, Hanover, NH. E-mail: george.a.little@dartmouth.edu. 2011 Elsevier Inc. All rights reserved.1527-3369/1102-0407 36.00/0doi:10.1053/j.nainr.2011.04.007developing world.2 Authorities agree that in most resourcepoor areas—those places with inadequate facilities, equipment,and trained providers—reliable data and information thatdistinguishes between stillbirth and neonatal death are notgenerally available and that clinical and research efforts shouldbe directed at both.3,4 Although the stillbirth population in theresource-limited perinatal population is inadequately studied, itis apparent that a portion of stillbirths occur in late labor anddelivery, are related to hypoxia, and may in fact not be stillbirthsat all but babies who would respond to resuscitation efforts ifrecognized as such and survive if they received clinicalintervention by providers skilled in resuscitation and subsequent care.5Neonatal resuscitation is recognized as an intervention forwhich there is evidence of effectiveness.6-8 Of the many babieswho die who would benefit from neonatal resuscitation, thereare 2 large groupings: intrapartum-related deaths, often andpreviously described by the term birth asphyxia, are estimated tooccur at an annual rate of approximately 814 000 globally.There is an obvious relationship between this group of babiesand the late pregnancy stillbirths discussed in the previousparagraph. Complications of preterm birth are estimated to beassociated with a million (1,033,000) deaths globally per year.In addition to resuscitation at birth, there are other interventions for which there is considered to be reasonableevidence of effectiveness in reducing risk of neonatal death ofpreterm infants, including thermal support such as skin-to-skin(kangaroo) care, early breastfeeding, and prevention/treatmentof infection.9Monitoring of MDG 4 progress has revealed that althoughboth the under-5 mortality rate and the neonatal mortality rateare slowly decreasing, an increasing proportion of under-5deaths occur in the neonatal period or the first 28 days after

environments ranging from established facilities to the mostimpoverished sites of health care systems. Educational andclinical equipment suitable for those environments has beendeveloped and includes unique tools such as flip charts andlow-cost manikins that serve as effective nonelectronicsimulators. Field testing of the curriculum has taken place inseveral locations with reports appearing in the peer-reviewedliterature.13 The following subsections elaborate and place intoneonatal care context these and other details of the HBBcurriculum and program.Fig 1. Data from 2 sources. United Nations and theInstitute for Health Metrics and Evaluation demonstrating that progress in reduction of the under-5mortality rate slowed after rapid reduction between1970 and 1990 and that the annual neonatalmortality rate has decreased more slowly with aresultant increased portion of neonatal deaths. Notethe challenge remaining to reach the MDG 4 goal.Reprinted with permission. 10birth.10 Fig 1 depicts data updated to September 2010 and callsattention to the reality that approximately 4 of 10 under-5childhood deaths are neonatal (most of which occur on the firstday) with that proportion increasing. Furthermore, the earlyneonatal mortality rate (first week of life) in low-incomecountries has shown little improvement, whereas the neonatalmortality rate has improved in high-income countries. Each ofthe major causes of neonatal mortality—prematurity, infection,and asphyxia― leave many survivors with lifelong disabilitiesor morbidities. Community mobilization and expandedeffective services for women and their newly born babies willbe necessary for any further progress.11Historical BackgroundHBB is a direct independent branch of the neonatalresuscitation tree of knowledge. It grows from appreciation ofthe unique physiology of the transition from fetal to neonatalexistence and knowledge of the pathophysiology that can occur.The international recommendations that form the scientific basisof HBB originate from the International Liaison Committee onResuscitation, an ongoing international effort for evidencereview and derivation of recommendations for resuscitation atany age including neonatal.14 HBB focuses on resource-poorenvironments and interventions that are effective for mostneonatal resuscitation challenges, whereas recognizing thatsituation-specific limitations may mean that some difficult andresource-demanding problems such as the needs of extremelylow birth weight babies may not be possible to treat under thecircumstances at the time. The principle that every infantdeserves at least initial evaluation, effort, and judgment applies.The Neonatal Resuscitation Program (NRP) of the AmericanAcademy of Pediatrics and the American Heart Association hasbeen a prominent leader of neonatal resuscitation development and is now in its third decade. The NRP, along withother neonatal resuscitation programs, has been taught inmore than 100 countries. Experience teaching and disseminating neonatal resuscitation around the world helped expandthe growing understanding of the special needs of resourcepoor environments.Helping Babies BreatheHelping Babies Breathe (HBB) is a hands-on educationalcurriculum created specifically for birth attendants in resourcelimited settings. The HBB's heritage includes evidence derivedfrom resuscitation research and previous resuscitation programs. The first page of the HBB Learner Workbook12 stresses 2basic teachings: All infants need to be kept clean, warm, and encouraged tobreastfeed; An infant who does not breathe needs extra help withinthe first minute after birth.These basic HBB principles are applied within an internationally harmonized, evidence-based, and carefully constructededucational program that includes recommendations forteaching techniques and site arrangements. The curriculum isdeveloped to be taught and applied in a wide range ofNEWBORNEducational DesignDevelopment of a standardized and flexible HBB educationprogram was undertaken to facilitate use in widely variedenvironments. The evaluation-decision-action cycle repeatsthroughout and is presented in symbols and words. Adaptability to cultural and linguistic influences has always been aprimary consideration.The Action Plan seen in Fig 2 is a core integrative illustrationwithin HBB and provides educational content and designinformation. Several specifics within HBB are worthy of note.Pictorial representation has been carefully developed to beuniversally recognizable. Color is seen in zones that signify thelevel of help needed: green, routine care; yellow, initial steps ofhelp to breathe; and red, continued ventilation and possibleneed for advanced care. These colors, along with illustrations,& INFANT NURSING REVIEWS, JUNE 201183

Fig 2. The HBB Action Plan. 12 Note color zones guiding care paths, pictorial illustrations, and Golden Minutenotation in the upper right corner indicating that bag/mask ventilation should be provided within a minute.Reprinted from the American Academy of Pediatrics. Helping Babies Breathe, Learner Workbook; 2010 withpermission from the American Academy of Pediatrics.84VOLUME 11, NUMBER 2, www.nainr.com

Fig 3. Page 37 from HBB Learner's Workbook. 12 Note use of cases to further illustrate clinical pathwaysdepicted in the Action Plan seen in Fig 2. Note coordinated colors and questions. Reprinted from theAmerican Academy of Pediatrics. Helping Babies Breathe, Learner Workbook; 2010, p37 with permissionfrom the American Academy of Pediatrics.appear in the Learner Workbook and Flip Chart in acoordinated fashion.The Golden Minute adds the concept of time to the ActionPlan and is a key part of the education curriculum content.The action plan design places this concept within the yellowcolor specific zone and in a specific dominant area toemphasize that the infant is the priority in the minute afterNEWBORNbirth. The core life-saving skill of HBB, bag-mask ventilation,is taught and illustrated to be applied by 1 minute after birth.Fig 3 shows a page of the 46-page Learner Workbook,which complements the core Action Plan with comparativeinformation of 6 cases. Note the use of color and the graycolored box at the lower left with questions to help guidethe learner.& INFANT NURSING REVIEWS, JUNE 201185