International Helping Babies Breathe course teaches newborn resuscitation

By David Brown
Washington Post Staff Writer
Sunday, June 20, 2010

It's been called the most dangerous minute of the most dangerous day of a person's life. For 829,000 babies each year, it's the beginning of the end.

In the first minute after birth, an infant must inhale, pop open millions of microscopic air sacs and take the first of numberless breaths that will sustain life for decades. For the majority of newborns, this happens naturally. Some, however, require help and in too many places around the world, they're not getting it.

The Helping Babies Breathe campaign, an international effort to prevent "birth asphyxia" was rolled out in Washington last week with the goal of teaching midwives and traditional birth attendants in poor countries how to gently nudge newborns into the world of respiration.

The tools include a dry towel, a suction bulb and a hand-operated bag-and-mask resuscitator. A big part of the campaign is expected to be a newborn mannequin, made by a Norwegian medical device company and soon to be distributed by the thousands to village clinics.

But the most important part is convincing practitioners -- many of whom went no further than elementary school and don't undergo regular retraining -- that there is something they can do in the blood-chilling moment when a delivery goes awry.

A key concept in the Helping Babies Breathe campaign is that simple actions can save a dusky and limp baby, but they must be done quickly.

"We use the idea of the 'golden minute,' " said Susan Niermeyer, a neonatologist at the University of Colorado School of Medicine, who helped write the curriculum. "It conveys a sense of urgency. It pushes the idea that prompt action predisposes to a positive result."

Little equipment (and no electricity) is required for newborn resuscitation. More than 80 percent of newborns will breathe spontaneously immediately after birth. About 10 percent will need the stimulation of being dried off and having their nose and mouth gently suctioned. Five percent will need "positive pressure ventilation," either by mask or mouth. Less than one percent need the full CPR procedure.

About 7.7 million children will die this year before age 5, according to an estimate published this month in the Lancet, a medical journal. Birth asphyxia will account for nine percent of the deaths; it accounts for one-quarter of deaths in the first month of life. It kills more children than malaria, and nearly five times more than AIDS.

Experts say better instruction in newborn resuscitation could reduce deaths from birth asphyxia by about 30 percent and deaths attributed to premature birth by up to 10 percent. They say 500,000 lives a year might be saved.

Helping Babies Breathe is an initiative of the American Academy of Pediatrics, the U.S. Agency for International Development, the National Institute of Child Health and Human Development, and Save the Children. The curriculum is being offered immediately to health ministries in about 10 countries in Africa, Asia and Latin America where USAID has maternal and newborn health programs. Save the Children is implementing it in 18 countries. The curriculum may eventually be used in most of the 68 countries where 90 percent of mother or newborn deaths occur (and where 46 percent of births lack a medically trained attendant).

Trainers use flip-chart books with little text and emphasize practicing the maneuvers. The training kit for six students includes a washable, brown plastic mannequin filled with about two quarts of water, which gives it the weight and floppiness of a non-breathing newborn. The person running the simulation has three squeeze bulbs connected by tubes to the mannequin. One produces a cry and another a pulse in the umbilical cord. The third makes the chest rise (as does air blown into the mouth).

Previous newborn mannequins cost about $400, said Joy Lawn, a physician at Save the Children. Laerdal Medical, a device-maker in Stavanger, Norway, developed the new mannequin and is providing it at cost (about $50). The company is also selling bag-and-mask sets at cost (about $13) and has made a clear, boilable suction syringe to replace opaque bulb syringes that are reused without sterilization in many places.

Pilot projects have been run in Bangladesh, India, Pakistan, Kenya and Tanzania. About a hundred people from around the world became "master trainers" in the resuscitation techniques last week at the 37th Annual International Conference on Global Health in Washington. They will teach the curriculum in their home countries.

"Where are the maximum gains? It is in the less-trained attendants," Shivaprasad S. Goudar, a physician who piloted the Helping Babies Breathe curriculum in the southern India state of Karnataka, told a gathering at the Global Health Council. "But there is a group ready to learn, ready to soak up the skills."

Whether it will make a difference to newborns is another question.

The neonatal mortality rate went down only a small amount in the Karnataka pilot study. In an unrelated clinical trial reported in the New England Journal of Medicine last winter, rural birth attendants in six countries who had been taught resuscitation techniques also saw no significant decline in newborn deaths. However, there were fewer stillbirths, which the researchers believe might be attributable to the successful resuscitation of babies who once would have been considered born dead.

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