Neonatal Nursing and Helping Babies Breathe:

An Effective Intervention to Decrease Global

Neonatal Mortality
George A. Little, William J. Keenan, Susan Niermeyer, Nalini Singhal, and Joy E. Lawn

Helping Babies Breathe (HBB) is an evidence-based medical educational curriculum designed to improve
neonatal resuscitation and be taught in resource-limited circumstances. It has been field-tested for educational
effectiveness and feasibility of wide implementation. We are committed to supporting the expansion of
effective neonatal care, agree that HBB is highly suitable for that purpose, and promote the statement that “the
time 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 that
a program is only as effective as its systematic implementation and that neonatal nursing must serve an
essential role in standard setting, education, and implementation of any bedside change in care of the newly
born infant.

Keywords: Neonatal nursing; Helping Babies Breathe; Global neonatal mortality; Neonatal resuscitation

The neonate has only recently attained its rightful status as a full developing world.2 Authorities agree that in most resource
and equal partner in the spectrum of maternal, newborn and poor areas—those places with inadequate facilities, equipment,
child health (MNCH) care, research, and policy initiatives. The and trained providers—reliable data and information that
United Nations Millennium Development Goals (MDGs) of the distinguishes between stillbirth and neonatal death are not
international development initiative for improving the social generally available and that clinical and research efforts should
and economic conditions of the world's poor adopted 8 goals in be directed at both.3,4 Although the stillbirth population in the
2000 that have a 2015 date for attainment. Significantly, 2 of the resource-limited perinatal population is inadequately studied, it
8 goals are directed at MNCH: MDG 4 for child health including is apparent that a portion of stillbirths occur in late labor and
neonatal survival and MDG 5 for maternal health.1 Neonatal delivery, are related to hypoxia, and may in fact not be stillbirths
deaths (deaths in the first 28 days of life) are a major portion of at all but babies who would respond to resuscitation efforts if
child deaths, are often graphically depicted and monitored with recognized as such and survive if they received clinical
under-5 mortality, and serve as a sentinel indicator of intervention by providers skilled in resuscitation and subse-
reproductive health. Most neonatal deaths occur within hours quent care.5
after birth. Neonatal resuscitation is recognized as an intervention for
which there is evidence of effectiveness.6-8 Of the many babies
who die who would benefit from neonatal resuscitation, there
are 2 large groupings: intrapartum-related deaths, often and
The Global Neonatal Death Problem previously described by the term birth asphyxia, are estimated to
There are about an equal number of neonatal deaths (3.6 occur at an annual rate of approximately 814 000 globally.
million) and stillbirths (3.3 million) in the world each year with There is an obvious relationship between this group of babies
a remarkable 98% occurring in the less-resourced and and the late pregnancy stillbirths discussed in the previous
paragraph. Complications of preterm birth are estimated to be
associated with a million (1,033,000) deaths globally per year.
From the Department of Pediatrics, Dartmouth Medical School, Hanover, NH; In addition to resuscitation at birth, there are other in-
Department of Pediatrics, St Louis University, St Louis, MO; Department of terventions for which there is considered to be reasonable
Pediatrics, University of Colorado Health Sciences Center, Denver, CO; evidence of effectiveness in reducing risk of neonatal death of
Department of Pediatrics, University of Calgary, Calgary, Alberta; and Saving
preterm infants, including thermal support such as skin-to-skin
Newborn Lives/Save the Children, Cape Town, South Africa.
Address correspondence to George A. Little, Department of Pediatrics,
(kangaroo) care, early breastfeeding, and prevention/treatment
Dartmouth Medical School, Hanover, NH. E-mail: george.a.little@ of infection.9
dartmouth.edu. Monitoring of MDG 4 progress has revealed that although
© 2011 Elsevier Inc. All rights reserved. both the under-5 mortality rate and the neonatal mortality rate
1527-3369/1102-0407$36.00/0 are slowly decreasing, an increasing proportion of under-5
doi:10.1053/j.nainr.2011.04.007 deaths occur in the neonatal period or the first 28 days after
 environments ranging from established facilities to the most
impoverished sites of health care systems. Educational and
clinical equipment suitable for those environments has been
developed and includes unique tools such as flip charts and
low-cost manikins that serve as effective nonelectronic
simulators. Field testing of the curriculum has taken place in
several locations with reports appearing in the peer-reviewed
literature.13 The following subsections elaborate and place into
neonatal care context these and other details of the HBB
curriculum and program.

Historical Background
Fig 1. Data from 2 sources. United Nations and the
Institute for Health Metrics and Evaluation demon- HBB is a direct independent branch of the neonatal
strating that progress in reduction of the under-5 resuscitation tree of knowledge. It grows from appreciation of
the unique physiology of the transition from fetal to neonatal
mortality rate slowed after rapid reduction between existence and knowledge of the pathophysiology that can occur.
1970 and 1990 and that the annual neonatal The international recommendations that form the scientific basis
mortality rate has decreased more slowly with a of HBB originate from the International Liaison Committee on
resultant increased portion of neonatal deaths. Note Resuscitation, an ongoing international effort for evidence
the challenge remaining to reach the MDG 4 goal. review and derivation of recommendations for resuscitation at
Reprinted with permission. 10 any age including neonatal.14 HBB focuses on resource-poor
environments and interventions that are effective for most
neonatal resuscitation challenges, whereas recognizing that
situation-specific limitations may mean that some difficult and
birth.10 Fig 1 depicts data updated to September 2010 and calls resource-demanding problems such as the needs of extremely
attention to the reality that approximately 4 of 10 under-5 low birth weight babies may not be possible to treat under the
childhood deaths are neonatal (most of which occur on the first circumstances at the time. The principle that every infant
day) with that proportion increasing. Furthermore, the early deserves at least initial evaluation, effort, and judgment applies.
neonatal mortality rate (first week of life) in low-income The Neonatal Resuscitation Program (NRP) of the American
countries has shown little improvement, whereas the neonatal Academy of Pediatrics and the American Heart Association has
mortality rate has improved in high-income countries. Each of been a prominent leader of neonatal resuscitation develop-
the major causes of neonatal mortality—prematurity, infection, ment and is now in its third decade. The NRP, along with
and asphyxia― leave many survivors with lifelong disabilities other neonatal resuscitation programs, has been taught in
or morbidities. Community mobilization and expanded more than 100 countries. Experience teaching and dissemi-
effective services for women and their newly born babies will nating neonatal resuscitation around the world helped expand
be necessary for any further progress.11 the growing understanding of the special needs of resource-
poor environments.
Helping Babies Breathe
Helping Babies Breathe (HBB) is a hands-on educational
curriculum created specifically for birth attendants in resource- Educational Design
limited settings. The HBB's heritage includes evidence derived
Development of a standardized and flexible HBB education
from resuscitation research and previous resuscitation pro-
program was undertaken to facilitate use in widely varied
grams. The first page of the HBB Learner Workbook12 stresses 2
environments. The evaluation-decision-action cycle repeats
basic teachings:
throughout and is presented in symbols and words. Adaptabil-
• All infants need to be kept clean, warm, and encouraged to ity to cultural and linguistic influences has always been a
breastfeed; primary consideration.
• An infant who does not breathe needs extra help within The Action Plan seen in Fig 2 is a core integrative illustration
the first minute after birth. within HBB and provides educational content and design
information. Several specifics within HBB are worthy of note.
These basic HBB principles are applied within an interna- Pictorial representation has been carefully developed to be
tionally harmonized, evidence-based, and carefully constructed universally recognizable. Color is seen in zones that signify the
educational program that includes recommendations for level of help needed: green, routine care; yellow, initial steps of
teaching techniques and site arrangements. The curriculum is help to breathe; and red, continued ventilation and possible
developed to be taught and applied in a wide range of need for advanced care. These colors, along with illustrations,

NEWBORN & INFANT NURSING REVIEWS, JUNE 2011 83

Fig 2. The HBB Action Plan. 12 Note color zones guiding care paths, pictorial illustrations, and Golden Minute
notation 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 with
permission from the American Academy of Pediatrics.

84 VOLUME 11, NUMBER 2, www.nainr.com

Fig 3. Page 37 from HBB Learner's Workbook. 12 Note use of cases to further illustrate clinical pathways
depicted in the Action Plan seen in Fig 2. Note coordinated colors and questions. Reprinted from the
American Academy of Pediatrics. Helping Babies Breathe, Learner Workbook; 2010, p37 with permission
from the American Academy of Pediatrics.

appear in the Learner Workbook and Flip Chart in a birth. The core life-saving skill of HBB, bag-mask ventilation,
coordinated fashion. is taught and illustrated to be applied by 1 minute after birth.
The Golden Minute adds the concept of time to the Action Fig 3 shows a page of the 46-page Learner Workbook,
Plan and is a key part of the education curriculum content. which complements the core Action Plan with comparative
The action plan design places this concept within the yellow information of 6 cases. Note the use of color and the gray-
color specific zone and in a specific dominant area to colored box at the lower left with questions to help guide
emphasize that the infant is the priority in the minute after the learner.

NEWBORN & INFANT NURSING REVIEWS, JUNE 2011 85

Training neonatal care commitment such as Essential Newborn Care
and the educational methodology was developed to be
Train-the-trainer is the basic model used and advanced by applied across systems and organizations of any size. The
HBB. The curriculum is designed for learners or trainees to intent is to create educational and clinical excellence, and
participate in pairs or dyads with the 2 persons alternating as there are indications that HBB is in fact such a center or focus
trainers (teachers) and trainee (learners), thereby changing roles of excellence.
during learning. Specific exercises are provided. Evaluation is Dissemination and implementation of HBB is being
integrated into the training experience with the learner expected guided and coordinated through a dynamic Global
to demonstrate knowledge, judgment, and skills such as bag/ Development Alliance with multiple partners that include
mask ventilation performance. Objective Structured Clinical the American Academy of Pediatrics, the US Agency for
Evaluations and multiple choice questions are used to complete International Development, Save the Children, the US
the evaluation process. National Institute of Child Health and Development, and
Laerdal Medical.16 The Global Development Alliance links
with ministries of health, nongovernmental organizations,
Educational and Clinical Equipment professional groups, and many others. The HBB programs
The HBB tools to facilitate training are available, and have been initiated in a first tier of 26 countries with plans
although not essential to the use of the curriculum, they have expanding nearly every day.
been developed in parallel and are available as a package (see The potential of improving neonatal survival is building and
helpingbabiesbreathe.org). In addition to the Learner Work- near the tipping point. As mentioned in the introduction, new
book, a flip chart for use by each learner pair is recommended. programs such as HBB integrated within Essential Newborn
A low-cost neonatal mannikin simulator is available that can be Care are only as successful as their systematic dissemination and
filled with air or water and is useful for scenarios. Clinical implementation. Neonatal nursing plays an essential role in
equipment in the form of a bag and mask and a newly designed policy leadership, education, bedside decision making, and
suction device is available. Translation of education material “hands on” practice. The discipline is facing an opportunity
into multiple languages is encouraged and underway. We through HBB to be a change agent to significantly impact global
anticipate a dynamic inventive process. Development of other neonatal mortality and morbidity.
educational and teaching equipment as HBB is implemented is Neonatal nursing is a key discipline within MNCH care and
anticipated with appropriate field assessment reports in peer- is undervalued and recognized as woefully understaffed in
reviewed informational exchange. many places. The same descriptors can be applied to the
medical profession members who are available to improve the
care of the newly born. With increasing awareness of the needs
Field Testing of the neonate globally, the need for skilled pediatric personnel
has assumed increasing prominence. This clearly apparent
Before the June 2010 formal rollout of the HBB, field testing
deficiency provides a strong rationale for concluding that
of the educational curriculum and program dissemination was
nursing and medicine can and should deliberately collaborate to
undertaken. These efforts provided important data and
address professional growth and development and strengthen a
information that was used before the rollout in modification
child and infant focus.
of the curriculum and assessment. Ongoing field testing with
Collaboration of nursing and medicine has been, and
publication of results is encouraged as future editions of HBB
continues to be, dynamic and productive in the ongoing
are anticipated.
evolution of the NRP. The NRP is the established standard of
resuscitation in the United States and is directly or indirectly
Discussion reflected in the programs of many countries. A 5-year cycle
for production of new NRP editions that now spread across 3
A “major gap” exists in the effort to decrease neonatal deaths decades has involved collaborative multidisciplinary effort.
by providing care to the infant intrapartum and early Nursing, in addition to being very involved in the production
postnatally. Nurses and physicians with skills to care for of the NRP manual and teaching material, has always been a
children and, especially, neonates at birth are in very short major leader and provider of NRP teaching and management
supply in areas with high neonatal mortality. A recent at the regional and local level. This collaboration serves as
publication points to a survey in sub-Saharan Africa that a model for HBB as it explores implementation models
found that 15% of maternity hospitals had appropriate staff and and opportunities.
equipment to perform neonatal resuscitation for a population International nursing and medical organizations have an
where it is reasonable to expect that 30% of neonatal deaths can opportunity to draw closer together for reasons of their
be averted. Attention is drawn to the need for new initiatives, individual strength and their mutual ability and effectiveness
with HBB mentioned specifically.15 to serve children. The International Pediatric Association17
HBB is the product of rigorous effort to create a tested and the Council on International Neonatal Nurses,18 for
effective intervention to improve neonatal survival. The example, should explore ways to cooperate and improve
curriculum is designed to be part of a comprehensive perinatal outcomes. Council on International Neonatal Nurses,

86 VOLUME 11, NUMBER 2, www.nainr.com

International Pediatric Association, and other organizations 8. Wall SN, Lee ACC, Niermeyer S, et al. Neonatal
involved in MNCH should critically evaluate HBB and resuscitation in low-resource settings: what, who and how
consider being actively involved in efforts that use HBB to to overcome challenges to scale up? Int J Gyn Obs.
decrease neonatal mortality and meet MDG 4 targets. 2009;107:S47-S64.
9. Darmstadt GL. Global perinatal health: accelerating pro-
gress through innovations, interactions and interconnec-
References tions. Semin Perinatol. 2010;34:367-370.
10. Lawn JE, Kerber K, Enweronu-Laryea C, et al. 3.6 million
1. United Nations. Millennium development goals: goal 4: neonatal deaths—what is progressing and what is not?
reduce child mortality. http://www.un.org/millennium- Semin Perinatol. 2010;34:371-386.
goals/childhealth.shtml. [Accessed: February 2, 2011]. 11. Bahl R, Qazi S, Darmstadt GL, Martines J. Why is continuum
2. Carlo WA, Goundar SS, Jehan I, et al. Newborn-care of care from hoe to health facilities essential to improve
training and perinatal mortality in developing countries. perinatal survival. Semin Perinatol. 2010:477-485.
N Engl J Med. 2010;363:614-623. 12. Niermeyer S, Keenan WJ, Little GA, Singhal N, editors.
3. Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet's Helping Babies Breathe, Learner Workbook. Elk Grove, IL:
Stillbirths Series Steering Committee. Stillbirths: Where? American Academy of Pediatrics; 2010.
When? Why? How to make the data count? Lancet. 13. Singhal N, Lockyer J, Fidler H. Report to the American
2011;377:1448-1463. Academy of Pediatrics Global Implementation Task Force:
4. Spector JM, Daga S. Preventing those so-called stillbirths. Evaluation of Helping Babies Breathe Educational Program.
Bull World Health Organ. 2008;86:315-316. Elk Grove Village, OH: American Academy of Pediatrics;
5. Nelson K, Simonsen SE, Henry E, Wilder S, Rose NC. The 2010.
apparently stillborn infant: risk factors, incidence and 14. www.ilcor.org/. [Accessed February 2, 2011]
neonatal outcomes. Am J Perinatol. 2011;28:75-82. 15. Darmstadt GL. Global perinatal health: accelerating pro-
6. Little G, Niermeyer S, Singhal N, Lawn J, Keenan W. gress through innovations, interactions, and interconnec-
Neonatal resuscitation: a global challenge. Pediatrics. tions. Semin Perinatol. 2010;34:367-370.
2010;126:e1259-e1260. 16. www.helpingbabiesbreathe.org/docs. [Accessed February
7. The Executive Summary of the Lancet Neonatal Survival 22, 2011].
Series. www.who.int/child_adolescent_health/documents/lan- 17. www.ipa-world.org/. [Accessed February 22, 2011].
cet_neonatal_survival/en/. [Accessed February 23, 2011]. 18. www.coinnurses.org/. [Accessed February 22, 2011].

NEWBORN & INFANT NURSING REVIEWS, JUNE 2011 87