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Edited by World Health Organization. Published by World Health Organization, Geneva, 2004, £27.00, pp 274. ISBN 9241546220
It is a sobering thought that world wide there are more than four million neonatal deaths per year, the majority occurring in the first week of life with an equal number of stillbirths. Most of these deaths are preventable and the result of a combination of poor maternal health and nutrition and inadequate perinatal care. This manual is the result of a collaboration between the WHO, UNFPA, UNICEF, and the World Bank and represents a renewed effort to address this problem. It forms one of the WHO IMPAC (Integrated Management of Pregnancy and Childbirth) series. Its remit is to complement the Integrated Management of Childhood Illness (IMCI) guidelines and expand these into a comprehensive evidence based perinatal care manual with the emphasis on illnesses in the first week of life. It is targeted at health professionals (doctors, nurses, and midwives) in under-resourced settings where the vast majority of these deaths occur.
The guide has four distinct sections. The first, “Assessment, findings, and management”, is in the IMCI emergency management style. It guides the recognition and diagnosis of sick neonates and the institution of appropriate management of a range of common clinical scenarios such as fast breathing, maternal fever, poor feeding. In section 2 (“Principles of newborn care”) the basics of safe general care from temperature management to immunisation are reviewed. Section 3 describes frequently used procedures including resuscitation, and section 4, the appendices, deals with medical record keeping. Many management pathways will begin in section 1, the scenario/problem, and will be followed through by cross referencing the later sections. There are also additional training packages to accompany the IMPAC guides.
The manual is both detailed and thoughtful: detailed in its cover of most common neonatal illnesses in a clear, well thought through style, and thoughtful in the emphasis afforded to often neglected areas. Emotional support to the family, note taking, and coping with a death are good examples of the way in which the manual looks beyond the immediate clinical realm. It is also gratifying that (in the main) appropriate levels of care are addressed; for example, IPPV is not discussed in the management of respiratory distress but instead suitable, more appropriate, and (for most) equally effective alternatives of delivery such as nasal and ambient oxygen.
The book might sometimes miss the mark in trying to be “all things to all men”. There will inevitably be differences in training and experience between the professionals for whom it is intended, and, for some, the amount of detail and need for cross referencing may be “too much information”. This could confuse and risk that less experienced less educated caregivers revert to the “tried and tested” treatment format. Greater use of short, flow chart style algorithms within the guidelines (as opposed to in a separate manual) would aid interpretation. Some medical workers may find a more pictorial format easier. I assume the manual has been translated into a number of languages but could find no details about which (English being far from universal).
One other (small) criticism is the emphasis placed on facilities for investigation, particularly lab service. This is a “luxury” that is often unavailable, and I think the slant should as far as possible be on management based on clinical features, especially as it assumes by no means guaranteed accuracy and consistency in lab performance.
One final point is that, although the manual comprehensively covers care of the neonate, it does not mention either prevention or recurrence. It is debatable as to whose responsibility this is, but ensuring access to good antenatal care including maternal anti-tetanus vaccination, nutrition, and family planning before the next baby is surely at least partly the remit of the paediatric team.
These points aside, this is a commendable and impressive guide, which comes as close as any I’ve seen to combining the factual information needed in a reference with practical management in the field. One can only hope that it impacts on neonatal morbidity and mortality in the way it deserves to, as these have been static for far too long in the settings for which the book is intended.
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