5

CHAPTER 2
THEORITICAL REVIEW

2.1 Review of Theoretical low Birth Weight ( LBW)
2.1.1 Definition
According to the (Atikah 2010) infants of low birth weight (LBW)
babies are born weighing 2,500 grams is less than regardless of
pregnancy. infants of low birth weight (LBW) can be two (2) categories,
infants with very low birth weight (BBLSR) with birth weight 1000 to
1500 grams birth weight and extremely low (BBLASR) with a birth
weight less than 1,000 grams. (Atika 2010)

Generally low birth weight infants (LBW) is associated with gestational
age were not enough months (prematurely) that caused dismaturitas.
which means lair term infants (gestational age 38 weeks), but the smaller
birth weight of pregnancy, which did not reach 2,500 grams. (Atika
2010). All infants with a birth weight equal to or less than 2500 grams
lair called low weight infants (LBW) asrining (2013).

Can be concluded that Low Birth Weight (LBW ) infant who are born
weighing less than or equal to 2500 grams, regardless of the gestational
age, well with masses 38 weeks gestation and infant born with less than
27 weeks gestation.

According to Anik (2013), Classification of newborns based on
gestational age or age of gestation, that is:
2.1.1.1 preterm infant (preterm infants: gestational age of less than 269
days (37 grams)
6

2.1.1.2 terms of infant (term infants: gestational age 259-293 days (37-
41 grams)
2.1.1.3 post-term infant (baby over a month, 254 days of gestation or
more 42 grams /or more)

Based on the this classification, according to (Anik, 2013), low Birth
Weight (LBW) can be grouped into:
2.1.1.4 Premature pure.
are infants with gestation <37 mg or 259 days and the weight in
accordance with the pregnancy or can be called in
accordance preterm neonates during pregnancy.
2.1.1.5 Dismaturitas.
Infants born weighing less than the weight that should for the
gestation, the
baby could mean retardation growth and a small baby for
pregnancy (KMK)

2.1.2 Etiology
The causes of LBW is multifactoral, among other things sorely lacking
maternal nutrition during pregnancy, impaired growth in the womb (
fetal growth is low ), placenta factors, infections, mothers uterine
abnormalities, trauma,(NANDA 2012)
According to (Atika 2010) the factors causing LBW among others are:
2.1.2.1 The Mother Factors:
a. Nutrition during pregnancy is lacking.
b. Age when the pregnancy is less than 20 years old or over
35 years.
c. Pregnancy and birth range is too close.
d. Job is too heavy.
e. Maternal chronic diseases such as hypertension, heart
disease, vascular disorders, active smokers, HIV/AIDS.
7

2.1.2.2 The pregnancy factor:
a. Pregnant with hidromnion, Gemelli pregnancy, antepartum
b. Haemorrhage.
c. Pregnancy complications such as preeclampsia, eclampsia,
premature rupture of membranes.
d. Placenta previa
2.1.2.3 The fetal factors:
a. Congenital defects, infection inside the uterus.
b. Factor is still unknown.
c. Chromosomal abnormalities (trisomy autosomal)
d. Aplasia of the pancreas
2.1.2.4 The environmental factors
a. Residing in the highlands.
b. Exposed to radiation.
c. Exposure to toxic substances.

2.1.3 Pathophysiology
Placenta previa, solucio placenta And premature rupture of membranes
could result in placenta insufficiency so as not to transfer nutrient to the
fetus and can causes premature birth or low birth weight. Volume
maternal malnutrition can lead to decreased blood and lowers blood to
the placenta this causing placenta insufficiency and reduced transfer of
nutrient to the fetus causing the occurrence of LBW. In response to cold
stimulations, the babys body will issue a stimulation norepenefrin
metabolism of fat reserves to produce a calorie of fat which is then
carried by the blood to the tissue.

Cold stress can lead to hypoxia, metabolic acidosis and hypoglycemia.
Increased metabolism in response to cold stress will increase the calorie
and oxygen. When oxygen is available can not meet the needs, reduced
8

oxygen tension (hypoxia) and this will make the situation worse because
lung volume (immature lungs)

Cold stress will be responded by releasing norepenefrin baby causes
pulmonary vasoconstriction. Consequently decrease pulmonary
ventilation effectiveness tat reduced blood oxygen levels. This condition
glucose metabolism and causes anaerobic glycolysis leading to increased
latic acid, the same conditions that produce the fatty acid metabolism
increasing contribution acidosis. Failure eliminate anaerobic metabolism
of glucose metabolism more than aerobic thereby accelerating the
occurrence of hypoglycemia.

Low birth weight (LBW) are relatively less able to survive because of
the structure of the immature anatomy and physiology and biochemical
function has not worked as older infant. The shortage affect the infants
ability to regulate and maintain body temperature within normal limits,
because the temperature control center in the brain is not yet mature, the
lack of subcutaneous fat and body surface relatively wide will cause the
body to lose heart more. Shivering response in infant less or non-
existent, so baby cannot increase body heart through activity. Beside skin
reflex control is still lacking. (Asrining, 2013)







9

2.1.4 Pathway (NANDA 2012)



















Prematurity Dismature
Maternal factors of age (<20
years) parity, race, infertility,
pregnancy history is not good,
abnormal uterus, etc.
Placental factors: vascular disease,
multiple pregnancy, malformations
tumors.
factor of fetal abnormalities,
chromosomal malformations
TORCH, multiple pregnancy.






Disturbance factor the
exchange of substances
between mother and
infant.





intra-uterine
growth
retardation





wall of lower part
of the uterus is
weak





open uterus
before
pregnancy




infants born
prematurely




body weight
<2500 grams




immature digestive
mechanical function



sucking and
swallowing
reflexes
weak


digestive and
absorption
disorders

lungs function
is not prematur
coordination between
suction and swallowing
reflexes by closing the
epiglottis is not well
developed
Nutrition less
than body
requirement
Ineffective
breathing
pattern
skin thin, transparent
and sub-cutaneous
fat little
asfiksia
Invansive action
OGT/ NGT
Intravenous
risk of impaired
skin integrity
central regulation of body
temperature has not been regularly
ineffective
thermoregulation

immunological system is
not well developed
special care
/ incubator

Acute pain
Risk of
infection
immature central nervous
system
separated from
parents
periventricular
hemorrhage
Change of
family process
developmental
retradation
10

2.1.5 Sign And Symptom
According to Anik ( 2013) low birth weight infant (LBW) highly
variable and that is most evident in infant with gestational age shortened.
As for the traits of characteristics of Low Birth Weight ( LBW) are:
2.1.5.1 General Proportions.
Preterm infants have large heads in proportion to body size.
Head basic the circumference equal to or less than 33 cm.
lanugos air is still a lot. Body length generally equal to less than
40 cm, chest circumference equal to or less tan 30 cm, weight
equal to less tan 2500 grams.
Thorax is relatively small, while the abdomen is relatively large
and small limbs compared to other body members.
2.1.5.2 Activity
Weak muscle tone and the lower the gestational age, the less
thechilds activity.
2.1.5.3 Control Of Temperature
Preterm infant tend to have subnormal. This was caused by poor
heat production and increased heat loss. Heat loss will increase
due to the relatively large body surface and the absence of
subcutaneous fat, as well as the immature state of the heat
regulating center.
2.1.5.4 Respiratory System
Infant respiratory muscles are week and underdeveloped
respiratory center as well as the lack of production of
surfactants to reduce surface tension of the lungs. Nasal
passages are very narrow and injury to the nasal mucosa easily
occur. Ineffective cough reflex which causes fluid inhalation.
2.1.5.5 The Circulatory System
Heart is relatively small at birth, in some preterm infant it works
slow and weak, especially in the blood vessels. Often poor
peripheral circulation and blood vessels too weak wall of first
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on intracranial hemorrhage seen in preterm infant. Systolic
pressure of preterm infants is 45-60 mmHg, while the diastolic
pressure varies from 30-45 mmHg. Pulse varies between 100-
160 / min
2.1.5.6 Digestive System
The lower of gestational age, the more weak sucking and
swallowing reflex, the smallest infants are unable to swallow
effectively. Digestive depends on development of the digestive
tract. Leading to weak intestinal distension and he onset the
digested material retention. The liver is relatively large but
underdeveloped which predisposes to jaundice.
2.1.5.7 Urinary System
Renal function is less efficient because of a declining
glomerular filtration rate that results in a decreased ability to
concentrate urine, and the become slightly. Less easy developed
tubules causing disruption of lower and electrolyte balance.
2.1.5.8 Nervous System
Development of the nervous system is largely dependent on the
degree of maturity. In premature infant more reflex and general
tonic neck reflex and tendon reflex are generally less well.

According to Anik (2013) the signs and symptoms of general of low
birth weight LBW) are:
a. Weight less than 2,500 grams
b. Body length less than or equal to 45 cm.
c. Chest circumference of less than or equal to 30 cm.
d. Head circumference less than 33 cm. gestational age less than 37
weeks
e. Vernik caseating little / no.
f. Fatty tissue under the skin a little.
g. Soft skull bones easy move.
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h. Weak cry.
i. Thin skin, red and transparent.
j. Hypotonic muscle tone.
k. The location of the ear decreases.
l. Enlargement of one or two kidneys.
m. Small head size.
n. Feeding problems (swallowing reflex and suck less).
o. Anemia
p. Hyper billirubinemia.
q. Thermoregulation.

2.1.6 Examination Support
2.1.6.1 Diagnostic examination according to Anik (2013) For Low
Birth Weight (LBW) are :
a. white blood cell count: 18.000/mm
3
, neutrophils increased to
23,000 24.000/mm
3
, first day after birth (decreased when
sepsis).
b. Hematocrit (Ht): 43% - 61% (an increase of up to 65% or
more indicates polycythemia, decreased levels indicate
anemia or hemorrhagic prenatal).
2.1.6.2 Examination level of bilirubin:
a. Normal bilirubin levels in preterm infants is 10 mg / dl, with
6 mg / dl on the first day of life, 8 mg / dl 1-2, and 12 mg / dl
in 3-5 days.
b. Hiperbilirubin occurs because the maturation of liver
function.
2.1.6.3 Examination glucose levels :
a. Destrosix: The first drops of glucose for 4 -6 hours after birth
an average of 40-50 mg / dl increased by 60-70 mg / dl on the
third day.
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b. monitoring of electrolytes (k Na.. CI): usually within normal
limits.
c. blood gas monitoring as needed.
d. shake test.

2.1.7 Medical Management
2.1.7.1 According to Anik (2013) general management of infants born at
low birth weight (LBW) which need to be prepared and in
anticipation of the treatment are :
a. Baby's body temperature regulation:
Regulation of body temperature in the show to reach a neutral
temperature environment in accordance with the protocol
with less regulation means the baby's body temperature by
using an incubator babies placed in incubators with
temperature:
infants <kg is 35
0
c
infants from 2 to 2.49 kg is 34
0
c
and incubator temperature can be scaled 1c per week for
infants over 2 kg. If no incubator, heating can be done by
wrapping the baby and put the bottles warm surroundings.

b. Oxygen therapy and help ventilation

c. Maintain the balance of fluids and electrolytes to replace the
WL (insensible water loss) and maintain the good hydration
and electrolyte concentrations of glucose and normal plasma.

d. Giving of adequate nutrition:
nutrition of preterm infants with low birth weight may require
careful feeding, and some even requiring intake LBW with
sonde or parenteral nutrition. way of providing nutrition in
14

infants with low birth weight is the amount of fluid
administration first 1-5 ml / hour. the amount of fluid that is
given at 60 ml / kg / day. When giving of drink to note in
order to avoid penemonia aspiration is to put the baby on the
right side to petrified gastric emptying, or in a half-sitting
position on his lap.
Or by elevating the head and shoulder 30
0
in a crib. At the
time of drinking it should be considered whether the baby's
skin color to blue and the presence of respiratory problems or
stomach bloat. To prevent bloated stomach, the baby was
given a sip, slowly and carefully. The addition of milk should
not be more than 30 ml - 5 ml each time feedings. After
drinking in the seat the baby or put on the shoulder for 10-15
minutes to remove the air in the stomach
e. Hyperbilirubinemia management:
Hyperbilirubinemia usually can be treated effectively with
careful monitoring bilirubin levels and implementation of
light therapy.

f. Prevention and treatment of infection:
prevention of infection in low birth weight can be done is to
separate the infants who become infected with HIV-
uninfected infants. And wash your hands before and after
holding the baby as well as other measures such as, clean the
baby bedding, baby room cleaning, bathing the baby,
umbilical cord hygiene and wear clean / sterile for the
officers. And for visitors only be seen from the glass.

use of antibiotics for the treatment of infections appropriate
doses. and when there is a strong suspicion of infection
15

indicated the baby broad spectrum antibiotics can be given.
As well as for the consideration of antibiotics and anti
staphilokokus should that have experienced a large number of
procedures or who have been in care for a long time in the
hospital
g. Monitoring of a PDA (patent ductus arteriosus):
initial management of PDA in LBW usually conservative,
adequate oxygen, fluid restriction and diuretia.

2.1.8 Prognosis
According to Anik (2013) the prognosis of infants born low birth weight
(LBW) depending on the severity of prenatal problems, eg gestation (the
younger the more severe the lower the gestational age infants, the higher
the death rate) than that of the other factors that influence birth weight
low as, social, economic, parental education and care during pregnancy
and post-natal care and others.
2.1.9 Complication
According to Anik (2013) complications that can arise in low birth
weight (LBW) is as follows:
2.1.9.1 Idiopathic respiratory distress syndrome.
Idiopathic respiratory distress syndrome occurred in 10% of
preterm infants with progressive pulmonary consolidation looks
terliat due to lack of surfactant that lowers the surface tension in
the alveoli and prevent. Collapse at the time of or shortly after
birth
2.1.9.2 Takepnea in newborns.
Takepnea in newborns is the most edematous lung preterm
infants at term or within a few hours after birth, causing
tachypnea.

16

2.1.9.3 Fibroplasias retrolentral.
Fibroplasias retrolentral is the high oxygen concentration in the
area of the artery that causes the growth of the fiber or fibrous
tissue at the back of the lens and retinal detachment causing
blindness.
2.1.9.4 Attacks Apnea
Apnea is an attack caused the inability of the respiratory center
or functional relationship with hypoglycemia or intracranial
hemorrhage.
2.1.9.5 Necrotizing enterocolitis (NEC).
Necrotizing enterocolitis (NEC) the occurrence of abdominal
bloating baby vomits out blood from the rectum, and loose
stools, shock and suffered intestinal perforation. This is where
the symptoms occur in infants with a history of asphyxia or
occurs after exchange transfusion.
2.1.9.6 Hypothermia.
Hypothermia is a decrease in body temperature is below
normal.
2.1.9.7 Hypoglycemia
Hypoglycemia is shortages or decrease blood sugar levels.
2.1.9.8 Breath distress syndrome.
Breath distress syndrome is the lack of surfactant in the alveoli
of the lungs due to lack work optimally make surfactant.
2.1.9.9 Hyperbilirubinemia.
Hiperbilirubinemia are increased levels of bilirubin in the blood
is worth more than the normal levels.

2.1.1 Assessment
Assessment was done by a nurse can to obtain objective data and
subjective data from mother by Anik (2013) are:

17

2.2.1.1 Previous health history
a. Whether the mother had experienced chronic illness,
hypertension, diabetic toxemia,
b. Mother had experienced a menstruation, pervious
c. pregnancy and history about psychosocial like mother
nutrition (malnutrition, caffeine consumption, drug use,
smoking,alcohol consumption, etc).
2.2.1.2 Mother history.
a. Maternal age below 16 years or above 35 years.
b. low socioeconomic backgrounds
c. lack of nutrition during pregnancy
d. Genetic consultation ever undertaken

2.2.1.3 History of pregnancy
a. Have had multiple pregnancies
b. Pregnancy distance is too close
c. Hard abortion history
d. No treatment before pregnancy
2.2.1.4 Physical Assessment
a. Circulation
1) Pulse apical my quickly and regularly or irregularly
within the normal range (120-160 seconds per
minute).
2) Heart murmur that can be heart to determine ductus
arteriosus (PDA).
b. Breathing
1) May be shallow, irregular and intermittent
diaphragmatic breathing or periodic (40-60 times /
minute)
2) Breathing nostrils, supraexsternal or subternal

18

retractions, also the degree of cyanosis which max
exist.

3) There is a gizzard sounds on auscultations,
indicating syndrome respiratory distress.
c. Hematology
1) low birth weight (LBW) has predisposing factors in
hematologic problems
2) low birth weight (LBW) has an easy fragile
capillaries, low plasma prothrombin formation of red
blood cells is slow, and hemolysis.
d. Gastrointestinal
1) The digestive tract is not functioning LBW as in term
infants
2) Lack of coordination of sucking and swallowing until
the age of 24-35 weeks.
3) Spinkter incompetent cardiac
4) Slow gastric emptying time.
5) Less able to absorb fats and protein digest
6) Decrease or not the coordination of motility in the
digestive system.
e. Genitourinary
1) On low birth weight (LBW) can not excrete the
metabolism on the urine and maintain fluid balance,
acid-base and electrolyte.
2) LBW baby female who is a prominent clitoris, labia
majora undeveloped.
3) Baby male who is a prominent yet LBW scrotum with
small rugae. testicles have not dropped in the scrotum.


19


f. Neurological
1) Reflexes and movement on neurological tests appear
not resistant, the return movement of partially
developed.
2) Swallow, suck and cough very weak or ineffective.
3) No neurological signs or decline.
4) Eyes may be closed if it has not reached the gestational
age 25-26 weeks.
5) Unstable body temperature or hypothermia occur.
6) Shaking, seizures and eye swirling usually temporary
but may also indicate a neurological disorder.
g. Temperature
1) Lack of subcutaneous fat, causing a decrease in body
temperature and hypothermia occurs.
2) Absence of reflex control of skin capillary blood
vessels.
3) Inadequate immature muscle activity and body
temperature regulation center in the brain.
h. Skins
1) On LBW have any signs of skin looks shiny and dry.
2) Skin looks red, pink, yellowish. cyanosis or mixture.
3) Looked little vernik caseating.
4) Lanugo hair looked around or in the whole body.
5) Body looked thin, transparent skin looks, smooth and
shiny.
6) looked short nails, yet passes fingertips, sparse hair
and\ even no.
7) Looked pteki or ecchymosis on the skin

20


i. Activity and rest
1) In infants of low birth weight (LBW) maybe 2-3 hours
of sleep a day the first few days, an average of 20
hours and cries still audible entry, inactivity, tremors.
2.2.1.5 Assessment response of parents
a. Response
1) Response of parents who have babies born with low birth
weight (LBW) the premature normally be sad, anxious
and afraid of losing her baby.
2) Problems in the family
Ineffective family coping because the baby's condition is
critical so that takes care of the old and the lack of
parental knowledge about how to care for LBW infants
in hospital after discharge from the hospital or the
ministry of health facilities

2.1.2 Nursing Diagnosis
Nursing diagnosis in low birth weight (LBW) by Nanda (2013) are:
2.11.1.1. Risk of imbalance in body temperature related to the failure of
maintaining body temperature, decreased subcutaneous fat
tissue
2.11.1.2. Ineffective of infant feeding patterns related to prematurity
2.11.1.3. Imbalance nutrition less than body requirements related to
inability to receive nutrients, gastrointestinal peristalsis
immaturity
2.11.1.4. Ineffective breathing pattern related to the immaturity of
neuromuscular respiratory and decreased of lungs
expansion
2.11.1.5. Risk of infection related to immunological defenses
inadequate
21

2.12 Planning
Nursing action plan based on the nursing diagnoses according to
(Nanda, 2013) are as follows:
1.11.1. Risk of imbalance in body temperature related to the failure of
maintaining body temperature, decreased subcutaneous fat
tissue
Intervention:
a. Put the baby in the incubator or wearing warm enough
clothes and head cover
Rational : To keep the body temperature to remai stable
b. Monitor Axillary temperature
Rational : To observe regular body temperature
c. Monitor for signs of hyperthermia
Rational: To avoid dehydration in infants because of
excessive hot temperatures
d. Monitor serum glucose
Rational: To find out the baby's condition during a
Eugilekimia
e. Monitor for signs of cyanosis
Rational : To prevent cyanosis

2.11.1.2. Ineffective of infant feeding patterns related to prematurity
Intervention :
a. Monitor the baby's ability to suck
Rational: To knowing readiness baby for brast feeding
b. Monitor the infant's ability to reach out breast nipple
Rational: Knowing the baby to suckle reflex interest
c. Instruct the mother to eat nutritious foods during
breastfeeding
d. Rational: To improve the nutrition and protein levels in
breast milk are in need of a baby during the growth process
22


d. Advise mothers for not limited breastfeed time Rational: To
help effectiveness in the process of breastfeeding infant
e. Monitor the increase in charging breast milk
Rational: To know the availability of water breast milk
time

2.11.1.3 Imbalance nutrition less than body requirements related to
inability to receive nutrients, gastrointestinal peristalsis
immaturity
Intervention :
a. Help baby on to meet the needs of breastfeeding
Rational : to meet the nutritional needs of income
Monitor signs TPN intolerance, especially protein and
glucose
Rational : To observe the signs of intolerance TPN
b. Follow the procedure to increase the volume
concentration of the formula
Rational : Preventing intolerance in infants
c. Increase knowledge of the importance of breast feeding
mothers to infants
Rational: Improving nutrition knowledge of mothers about
the importance of breast milk for babies
d. Monitor the baby's weight
Rational: to knowing the effectiveness of the intake of
nutrient absorption in infants

2.2.4.4 Ineffective breathing pattern related to the immaturity of
neuromuscular respiratory and decreased of lungs expansion
Intervention :
a. Prevent hyperextension of the neck position.
23

Rational : The position of hyperextension can reduce the
diameter of the trachea.
b. Observation of deviation, or signs of respiratory distress.
Rational : To prevent or detect the presence of cyanosis,
apnea
c. Give the side lying position
Rational : Prevent aspiration in infants with excessive
secretions or after eating
d. Observation of respiratory distress, such as retraction,
Tachypnoea, apnea, cyanosis when low O
2

Rational : To prevent the occurrence of distressbreathing
e. Keep the ambient temperature remains neutral
Rational : To keep the O
2
income evenly and prevent
hypothermia

2.2.4.5 Risk of infection related to immunological defenses inadequate
Intervention :
a. Advise all health care workers to wash hands, wear a mask
and gown before nursing action
Rational : Minimize the possibility of exposure to
microorganisms that cause infections in infants
b. Use a clean / sterile when performing actions
Rational :Minimize transmission of microorganisms through
to encourage the mother to wear a gown before entering the
infant
c. Encourage the mother to wear a gown before entering the
infant spatial
Rational : minimize exposure to microorganisms from
outside

24

d. Suggest mothers to wash their hands before contact with
baby
Rational : Prevent transmission of microorganisms via the
hands of mother
e. Teach mothers to breast wiping with water before feeding
baby
Rational : To be clean and healthy breasts and minimal
presence of microorganisms which can cause the baby
illness
f. Limiting the time of visit
Rational : Maximizing time care and rest on baby

2.13 Evaluation
Evaluations on low birth weight (LBW) by (Nanda, 2013) are:
1.11.1. Risk of imbalance in body temperature related to the failure of
maintaining body temperature, decreased subcutaneous fat
tissue
Evaluation result:
Normal body temperature
Body temperature of 36
0
37
0
c
adequate hydration
Gidak seemed to shiver
DBN blood sugar
Acid-base balance DBN
bilirubin DBN
2.2.4.2 Ineffective of infant feeding patterns related to prematurity
Evaluation result:
Clients can breastfeed effectively
showed techniques to overcome breastfeeding problems
Seen satisfied baby after feeding
Mother showed positive self-esteem with breastfeeding
25


2.2.4.3 Imbalance nutrition less than body requirements related to
inability to receive nutrients, gastrointestinal peristalsis
immaturity
Evaluation result:
An increase in body weight in accordance with the objectives
Ideal weight according to height
Being able to identify nutritional needs
There are no signs of malnutrition
Showed an increase in tasting and swallowing function
No weight loss
2.2.4.4 Ineffective breathing pattern related to the immaturity of
neuromuscular respiratory and decreased of lungs expansion
Evaluation result:
Demonstrate effective cough and breath sounds loc no
cyanosis and dyspenu capable of removing sputum and able to
breathe easily and do not seem pursed lips .
Showed a patent airway , breath rhythm , respiratory
frekuwensi within the normal range , there was no abnormal
breath sounds
Vital signs within normal range ( blood pressure , pulse
respiration
2.2.4.5 Risk of infection related to immunological defenses inadequate
Evaluation result:
Describing the process of transmission of the disease , factors
that influence the transmission and its management Clients are
free from signs and symptoms of infection Demonstrated ability
to prevent infection Number leokosit within normal limits
Showed healthy behavior