The aim of this skin care guideline is to provide evidence-based, contextualized guidelines for the care of full term, healthy neonatal skin. Complications in skin conditions and special populations, such as preterm and critically ill infants are outside the scope of this document.

The content of this document was adapted and used with permission from the AWHONN Neonatal Skincare Evidence-Based Guideline, 3rd edition, (C) 2013 and is referenced in all relevant sections. All sources and recommendations were checked by the working groups, updated and contextualized for the South African context. This was done with permission of AWHONN following a presentation by AWHONN representatives at a consultative meeting in April 2017 where the AWHONN Neonatal Skincare Guidelines, 3rd edition were presented.

This document cannot be resold and is for non-commercial use only.

AWHONN is not responsible for errors or omissions or for any consequences from application of the information in this resource and makes no warranty, expressed or implied, with respect to the contents of the publication.

International KMC day is May 15th. It is high time that neonatal units started to review how they are implementing KMC and in particular ensuring Zero separation for mothers and babies.

Last year an article was published on the Benefits of commencing immediate continuous KMC even in unstable babies.

This research was so impactful that the study was stopped early and many units have already started implementing its recommendations.

Another article has just been published which looks practically how to implement Immediate KMC. It describes experiences and outcomes with mother-newborn care units in India, and provides a basis to change national policies to keep mothers and small and sick newborns together.

While the more immediate benefits of KMC for small and sick newborns are well studied and supported by evidence, there is little evidence surrounding the benefits from KMC beyond infancy. Read this study which aimed to determine what, if any benefits, persisted in children beyond infancy who received KMC as a newborn.  

WHO urges quality care for women and newborns in critical first weeks after childbirth.
The World Health Organization (WHO) has launched its first ever global guidelines to support women and newborns in the postnatal period – the first six weeks after birth. The new guidelines bring together over 60 recommendations that can help shape a positive postnatal experience for women, babies and families. Check out the WHO blog about the release of the guidelines, along with the antenatal and intrapartum care guidelines.

Wealth, place of birth, coverage of care at birth, and, in some cultures, also the newborn’s gender greatly impact the risk of dying and the health outcome of a newborn. The most vulnerable newborns are those in marginalised groups, rural areas, urban slum environments, conflict areas, and humanitarian settings. Too many newborns have only limited or no access to cost-effective, life-saving interventions, and the equity gap is continuously growing. Every day in fragile and humanitarian settings, an estimated 500 women and girls die from complications due to pregnancy and childbirth.
Some concrete examples of what can be done to help newborns survive under these most difficult circumstances:


• Keep babies and parents together: they are the most reliable source of warmth, feeding, and protection in crises.
• Strengthen and scale up essential care for mothers and newborns, focusing on cost-efficient and high-impact interventions, including empowering mothers with information on their individual risk level during pregnancy, thermal care, infection prevention, neonatal resuscitation, early initiation and support for breastfeeding, postnatal checks, delayed cord clamping, vitamin K administration, and eye prophylaxis at birth.
• Educate communities and health workers to identify danger signs before, during, and after pregnancy and monitor these. Develop systems of reliable transportation and communication to facilitate appropriate referral of mothers and newborns when danger signs are detected.
• Share broadly information of essential medicines and commodities (e.g. the field guide “Newborn Health in Humanitarian Settings”) to support safe birth and newborn survival during emergencies. Integrate these medicines into national essential medicines lists and implementing organisations’ supply lists.
• Recognise and guarantee the rights of newborns including birth registration and legal status. Count every newborn in all settings, including humanitarian settings, using birth (and death) registration.
• Integrate family planning during antenatal and postnatal care, encourage early and exclusive breastfeeding, and improve spacing between pregnancies.
With gratitude to: Roadmap to Accelerate Progress for Every Newborn in Humanitarian Settings 2020-2025, ENAP, 2019 and Global estimates for WASH in healthcare facilities, JMP, 2019/2020.

WHY?

Evidence-based, high-quality treatment and care are provided in a timely, people-centred manner by a well-trained, specialised multidisciplinary team. Safe staffing levels improve health outcomes and enhance staff satisfaction.
• Newborn health is closely linked to adequate numbers of qualified nurses and/or midwives working per shift in a newborn unit.
• Multidisciplinary teams provide the necessary skill set to deliver appropriate high-quality inpatient care. Specialists help enhance feeding, neurodevelopmental, and social outcomes of the baby and form part of a broader support system for families during and after hospital stay.
• Avoid harm to newborns who are receiving more advanced clinical care including, for example, appropriate supplemental oxygen. Disabilities can be prevented or mitigated with good-quality, developmentally-supportive care.
• Pain affects brain development with potentially long-term effects: It can lead, e.g., to hypersensitivity to pain at school age as well as older and lower motor and intellectual developmental indices. Healthcare providers should ensure that newborns do not experience discomfort and painful procedures where possible and apply interventions that relieve pain during necessary painful procedures.
• Outcomes for babies can be improved by delivering developmentally supportive care to babies born too soon, small, or sick. This includes, for example, respecting a baby’s sleep, paying attention to correct positioning, minimising noise and light, recognising signs of stress, and pausing interventions when possible.

HOW?

Ensure optimal working conditions including sufficient resources, adequate staff training, and supervisory support as well as support by hospital managers and health policy makers. Promote respect for healthcare providers and their work.
• Provide specific and continued training / continuous professional development and supportive supervision to advance skills and competencies, including safe use of WASH (Water, Sanitation, and Hygiene) and IPC (Infection, Prevention, and Control) facilities.
• Respect and recognise the profession and highly intense working conditions and responsibilities with, e.g., incentives such as increased remuneration, career opportunities, or establishment of a neonatal nursing cadre.
• Establish innovative approaches to motivate and facilitate the work of clinical staff and identify ways to prevent distress and burn-out.
• Ensure each level of care has the necessary staff per shift, equipment, commodities, supplies, and diagnostics so that providers can safely care for babies born too soon, too small, or too sick.
• Identify and procure diagnostics/equipment that are affordable, safe, effective, and appropriate for use in low resource settings.
• Establish clean, functional health centres to support safe delivery and empower women and families to demand and access quality health services from clean and safe healthcare facilities. Highlight the importance of respectful care, particularly for women at risk of disrespect and abuse due to age, socioeconomic status, or marital status. Determine conditions under which disrespect and abuse happen and put in place reporting and redress mechanisms.
With gratitude to: Survive and Thrive: Transforming care for every small and sick newborn, WHO, 2019.

WHY?

Having parents who are actively involved in the care of their newborn and who are in close physical and emotional contact with their baby as early after birth as possible and during hospitalisation can positively impact the short- and long-term outcome of their baby. This includes for example: less need for respiratory support, increased weight gain, improved breastfeeding, shortened hospital stay, less readmission to hospital, or better neurodevelopmental outcome. Active involvement also reduces parental stress, equips parents to take better care of their baby, and has positive effects on the parent-child relationship and family life at home, after hospitalisation.
• Enabling parents to care for their hospitalised baby and strengthening them to fulfil their parental role decreases parental stress and anxiety, improves physical health, and helps to prepare them for taking care of the baby after hospitalisation at home.
• Skin-to-skin contact as early after birth and as continuously as possible has positive and protective effects, including, e.g., the regulation of cardiac and respiratory rates, the prevention of sepsis, hypothermia and hypoglycaemia, and reduced hospital readmission. It has been linked to better reflexes at term and better development at preschool age and beyond. It also supports early initiation and continuation of exclusive breastfeeding.
• Early and exclusive breastfeeding and providing mother’s own milk have a positive impact on the baby’s short- and long-term physiological and neurodevelopmental outcomes.

HOW?

Promote respectful, culturally appropriate and responsive infant- and family-centred developmental care and support, including the provision of necessary space and facilities. Educate parents so that they gain self-confidence, feel comfortable in fulfilling their parental role, and can bond with their baby.
• Engage parents from the beginning with good communication, education, participation in care giving, and decision-making.
• Keep the baby and parents together (zero separation).
• Facilitate and encourage skin-to-skin contact between baby and parents.
• Provide adequate space in the hospital unit and amenities allowing parents to stay.
• Educate and support parents with breastfeeding.
• Respect the parents’ right to information and consent in all treatments and interventions, invite them to participate in medical rounds.
• Recognize parents as the ultimate caretakers for their baby; listen to their concerns, and provide psychosocial support for their own well-being.
• Ensure mothers of inpatient preterm, small, or sick babies receive routine postnatal care and management of complications, including assessment and management of anxiety, depression, or any other mental health conditions.
• Promote responsive care and early stimulation through a stimulating environment to improve essential neurosensory development for preterm babies whose senses may only be beginning to develop.
• Educate and engage non-birthing partners to understand the needs, risks, and danger signs of pregnancy, childbirth, and the postnatal period. Provide space for non-birthing partners in health facilities.
• Test innovative parent-community / parent-healthcare provider partnership models to expand access to facility-based services and post-discharge follow-up care.
• Develop and implement programmes for financial and social support of families with low social or financial status or living in underserved, marginalised areas during hospitalisation. This should also include follow-up support.
• Develop, validate, and contextualize tools that measure types of support that parents, families, and newborns receive. Give them opportunities to provide feedback and to evaluate their care experience.
• Adapt care to the needs of adolescent mothers – ensure ample time is provided during consultations so that they fully understand the care provided to their babies and what is expected of them. Where possible, hold group counselling sessions with adolescents for peer support and to promote positive behaviour. Assess support available from partners and/or families, encourage their participation, and, if support is not available, explore community options to address this. Ensure linkage to mental health services especially during inpatient care for newborns.
• Create opportunities for sharing/mentoring by other parents to allay anxiety of parents/families.
• Adopt “Water and Sanitation for Health Facility Improvement Tool (WASH FIT): A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities”. Emphasize its use in Low- and Middle-Income Countries (LMIC).
With gratitude to: Survive and Thrive: Transforming care for every small and sick newborn, WHO, 2019.


November 17th 2021

The year 2021 has been unique in many ways as the global COVID-19 pandemic has continued to pose serious challenges to the political, economic, cultural, and social sectors in countries across the globe. It has repeatedly pushed healthcare systems to the brink of functionality – and in some cases even beyond. The pandemic has particularly affected families with a baby born too soon, too small, or too sick since these babies are particularly vulnerable, often need specialised and intensive care, and have to remain in hospital for longer periods of time.
In order to protect both staff and patients from contracting and spreading the virus, many clinics and hospitals were forced to take strict safety precautions and put rigorous hygiene measures in place. Unfortunately, this has also meant that the contact between parents and their baby was often massively restricted. Women had to give birth on their own, without a trusted person by their side to support them. Many NICUs also limited the number of family members who were allowed to enter the unit and the amount of time they were allowed to spend there, effectively keeping parents from seeing their baby for longer periods of time. In some cases, parents were not allowed to look after their baby in the NICU at all. So far, studies have suggested that these safety measures do not prevent the spread of COVID-19 to the extent that they justify separating parents and babies – especially since research has shown the negative long-term effects of familial separation.
This is why the motto of this year’s World Prematurity Day is:
Zero separation
Act now! Keep parents and babies born too soon together.
With this slogan, we advocate that safe, infant- and family-centred developmental care for babies born too soon, too small, or too sick is possible even in times of a global pandemic. On World Prematurity Day, we want to raise our voices for babies born too soon and their families because parents and their babies belong together – always.

  • Babies born too soon refers to babies born before 37 weeks of pregnancy are completed.
  • Preterm birth complications are the leading cause of death for children under 5, causing an estimated 1 million deaths in 2015 globally.
  • An estimated 15 million babies are born preterm every year – more than 1 in 10 babies around the world.
  • Rates of preterm birth are rising in the majority of countries with adequate data. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.
  • (Key facts preterm birth, WHO, 02/2018.)

As research and reports have repeatedly shown, the restrictions put in place to stop the COVID-19 pandemic affect the provision and the quality of neonatal care across the globe. Supported by its international network of partner parent organisations, EFCNI undertook a global study with the aim of exploring parents’ experiences of neonatal care during the pandemic. The study’s focus rested on the impact the restrictions had on key aspects of infant- and family-centred developmental care during the first year of the pandemic.
The full report will be published on 11 November 2021. Its core findings are that restrictions related to COVID-19 severely hindered and at times outright blocked central elements of infant- and family-centred developmental care. While COVID-19 related restrictions are generally necessary to stem transmission, disregarding evidence-based cornerstones of infant- and family-centred developmental care increases the risks of morbidity and mortality for vulnerable newborns across the globe. These risks are, however, so high that they effectively cancel out any gains in safety and security for these babies. Therefore, we call for a policy of zero separation for parents and their babies.

The year 2020 has been unique in many ways, leading us into a new decade posing serious challenges such as the SARS-CoV-2 pandemic or rising conflict and humanitarian crises, placing women, newborns, children, and adolescents at particular risks. Yet this is also the start of a new decade with new opportunities for babies to survive and develop to their best potential. Maternal and newborn health is still off track from political agendas in too many countries. The lives of millions of mothers and newborns could be saved by expanding care for women and adolescents during pregnancy, before, during and after birth. Promoting healthy behaviours and practices at household and community levels, investing in quality care, supporting parents physically and emotionally, providing respectful care throughout pregnancy and birth and ensuring basic and specialised in patient-care for newborns and the provision of focused follow-up, are essential. With greater investment, the right political commitment and the will to transform and improve maternal and newborn care, making maternal and newborn health a priority, we can improve the lives of mothers and babies globally and impact the future of our societies. Cost-effective solutions exist to prevent preterm birth, manage preterm birth complications, and helping newborns to survive and thrive. Everywhere.

  • Babies born too soon refers to babies born before 37 weeks of pregnancy are completed.
  • Preterm birth complications are the leading cause of death for children under 5, causing an estimated 1 million deaths in 2015 globally.
  • An estimated 15 million babies are born preterm every year – more than 1 in 10 babies around the world.
  • Rates of preterm birth are rising in the majority of countries with adequate data. Across 184 countries, the rate of preterm birth ranges from 5% to 18% of babies born.
    (World Health Organization, key facts preterm birth (02/2018)
Skin-to-skin contact as early after birth and continuously as possible has positive and protective effects, including e.g. regulation of cardiac and respiratory rates, prevention of sepsis, hypothermia and hypoglycaemia, reduced hospital readmission. It has been linked to better reflexes at term and better development at preschool age and beyond. It also supports early initiation and continuation of exclusive breastfeeding.

Supporting Families:

Parents who are actively involved in the care of their newborn and are in close physical and emotional contact with their baby as early after birth as possible and during hospitalisation can have great benefits on the short- and long-term outcome of their baby, including for example: less need for respiratory support, increased weight gain, improved breastfeeding, shortened hospital stay, less readmission to hospital, or better neurodevelopmental outcome. Active involvement reduces parental stress, equips parents in better taking care of their baby and has positive effects on the parent-child relationship and family life at home, after hospitalisation.

Head of High Care Neonatal Unit at Charlotte Maxeke Noma-Afrika Selekane, Known as super nurse Selekane has been in charge of the unit for more than 10 years. Photo Thulani Mbele. 01/05/2019

Supporting healthcare professionals:

Evidence based, high-quality treatment and care provided in a timely, people centred manner, by a well-trained, specialised multidisciplinary team and safe staffing levels improve health outcomes and enhance staff satisfaction.

  • Newborn health is closely linked to adequate numbers of qualified nurses and/or midwives working per shift in a newborn unit.
  • Multidisciplinary teams provide the necessary skill set to deliver appropriate high-quality inpatient care.
  • Specialists help enhance feeding, neurodevelopmental and social outcomes of the baby and form part of a broader support system for families during and after hospital stay.

Strengthening health systems:

Ensure optimal working conditions including sufficient resources, adequate staff training and supervisory support, as well as support by hospital managers and health policy makers and promote respect for healthcare providers and their work.

  • Provide specific and continued training / continuous professional development and supportive supervision to advance skills and competencies, including safe use of WASH (Water, Sanitation and Hygiene) and IPC (Infection, prevention and control) facilities.
  • Respect and recognise the profession and highly intense working conditions and responsibilities with e.g. incentives such as increased remuneration, career opportunities or establishment of a neonatal nursing cadre.
  • Establish innovative approaches to motivate and facilitate the work of clinical staff and identify ways to prevent distress and burn-out.
  • Ensure each level of care has the necessary staff per shift, equipment, commodities, supplies and diagnostics so that providers can safely care for babies born too soon, too small or sick.