Varsha sharma

M.Sc Nursing, second year

 Introduction
Low birth weight baby(less than 2500 gm.)
babies have higher morbidity and mortality. Low
birth weight baby result from either preterm
birth (before 37 completed weeks of gestation)
or due to intrauterine growth restriction (IUGR)
or both. IUGR is similar to malnutrition and may
be present in both term and preterm infants.
Neonates affected by IUGR are usually
malnourished and have loose skin folds on face
and gluteal region. Although the problem of
pre-term babies and IUGR babies are
completely different.
 The normal birth weight of is > 2500 to 3000 gm.
Low birth weight or LBW :
birth weight of less than 2500 gm regardless to gestational
age
Incidence : 15 30 %
Neonatal deaths : 75 % due to LBW
Infant deaths : 50 % caused by LBW
Complication :
Prone to malnutrition
Recurrent infection
Neurodevelopmental handicaps
Low birth weight (LBW) is defined as a birth
weight of a live born infant of less than 2,500 g
(5 pounds 8 ounces) regardless of gestational
age Subcategories include :-
a. very low birth weight (VLBW) which is less
than 1500 g (3 pounds 5 ounces), and
b. extremely low birth weight (ELBW) which is
less than 1000 g (2 pounds 3 ounces).
Normal Weight at term delivery is 2500 g -
4200 g (5 pounds 8 ounces - 9 pounds 4
ounces).
Four different pathways have been identified
that can result in preterm birth and have
considerable evidence:
precocious fetal endocrine activation, uterine
overdistension, decidual bleeding, and
intrauterine inflammation/infection From a
practical point a number of factors have been
identified that are associated with preterm
birth, however, an association does not
establish causality.
Being small for gestational age can be
constitutional, that is, without an
underlying pathological cause, or it
can be secondary to intrauterine
growth restriction, which, in turn, can
be secondary to many possible
factors.
What Causes Infant Low Birth Weight?
problems with the placenta, or intrauterine
growth restriction (IUGR)
complications with the pregnancy
not enough weight gain by the mother
birth defects
Poor maternal nutrition, incomplete prenatal
care, or drug or alcohol abuse by the mother
can also cause LBW.
Face appears small for the disproportionately large head size,
sutures are widely separated and fontanels are large.
Small chin, protruding eyes due to shallow orbits and absent
buccal pad of fat.
Optic nerve is often unmyelinated but presence of pupillary
membrane makes it visualization difficult.
Ear cartilage is deficient or absent with poor recoil.
Hair appears woolly and fuzzy and individual hair fibers can be
seen separately.
Skin is thin, gelatinous, shiny and excessively
pink with abundant lanugo and very little vernix
caseosa.
Edema may be present.
Subcutaneous fat is deficient and breast nodule
is is small or absent.
Deep sole creases are often not present.
In males, testes are undescended and scrotum
is poorly developed.
In females, labia majora are widely separated
exposing labia minora and hypertrophied
clitoris.
The immaturity of nervous system is seen by lethargy and inactivity.
Poor cough reflex, Inco-ordinated sucking and swallowing in babies weighing
less than 1800 gm or born before 35 weeks of gestation.
Resuscitation difficulties at birth and recurrent apneic attacks are common.
Retrolental fibroplasia due to oxygen toxicity is limited to babies with a
gestation of less than 35 weeks.
They are more resistant to toxic effects of hypoxia as compared to the term
babies.
The blood brain barrier, which is possibly a function of available serum
proteins, is inefficient in preterm babies; thus brain damage may occur at
lower serum bilirubin levels.
The cuboidal alveolar lining in babies with a gestational age of
less than 26 weeks results in poor alveolar diffusion of gases and
therefore the infant may not be viable.
They pose resuscitation difficulty at birth, often followed by
hyaline membrane disease, if associated with deficiency of
pulmonary surfactant.
The breathing is mostly diaphragmatic, periodic and associated
with intercostal recession due to soft ribs.
Pulmonary aspiration and atelectasis are common.
Compromised intrauterine environment with higher chances of
perinatal asphyxia.
Immature lungs that may be more difficult to ventilate and are
also more vulnerable to lung injury by positive pressure
ventilation.
Immature blood vessels in brain are prone to hemorrhage.
Thin skin and large surface area which contribute to rapid heat
loss.
Increased risk of hypovolemic shock caused by small blood
volume.
The closure of ductus arteriosus is delayed
among preterm infants. About one third infants
with gestational age of 34 weeks or less
manifest clinical evidences of patent ductus
arteriosus with or without congenital heart
defect.
In grossly immature infant (less than 32 weeks)
EKG shows left ventricular preponderance.
Due to poor or Inco-ordinated sucking, there are difficulties in self-
feeding although their digestive ability is generally good.
Regurgitation and aspiration is common because of Inco-ordinated
sucking.
Small capacity of stomach, incompetence of cardio-esophageal
junction and poor cough reflex.
Abdominal distension and intestinal obstruction are due to hypotonia.
Immaturity of glucuronyl transferase system in the liver leads to
hyperbilirubinemia, which may be aggravated by dehydration, delayed
feeding and hypoglycemia. Relatively low serum albumin, acidosis and
hypoxia in these babies predispose to the development of kernicterus
at lower serum bilirubin levels.
The relative deficiency of vitamin- K dependent coagulation factors
and increased capillary fragility, especially following hypoxia results in
intraventricular or intracerebral hemorrhage.
The poor hepatic glycogen stores, delayed feeding, birth asphyxia and
respiratory distress syndrome contribute to the development of
hypoglycemia.
Hypothermia is invariable and life threatening
unless environment temperature is monitored.
Excessive heat loss is due to relatively large
surface area and poor generation of heat due to
paucity of brown fat in a baby who is equipped
with an inefficient thermostat. High surface
area to body weight.
The low level of IgG antibodies and inefficient
cellular immunity predispose them to infection.
Excessive handling, humid and warm
atmosphere, contaminated incubators and
resuscitators expose them to infecting
organisms, thus contribute to high risk of
infection.
The blood urea nitrogen is high due to low glomerular filtration
rate. The renal tubular ammonia mechanism is poorly
developed thus acidosis occur early. They are vulnerable to
develop late metabolic acidosis especially when fed with high
protein milk formula.
The maximum tubular diluting ability in the new born is
satisfactory but ability to concentrate urea is very poor.
Preterm baby has to pass 4 to 5 ml of urine to excrete one
milliosmole of solute as compared to 0.7 ml by an adult for the
same purpose. Therefore, the baby cannot conserve water and
gets dehydrated readily. The solute retention and low serum
proteins explain occurrence of edema in some preterm infants.
Poor hepatic detoxification and reduced renal
clearance make a pre-term baby vulnerable to
toxic effects of drugs unless caution is exercised
during their administration.
Low birth weight babies are prone to develop anemia around 6-
8 weeks of age. This is due to diminished total score of iron due
to short gestation. They may also manifest deficiency of folic
acid and vitamin E.
Vitamin-E deficiency occurs among infant weighing less than 1.5
kg, particularly those fed on iron fortified milk formula. These
infant are prone to develop hemolytic anemia,
thrombocytopenia and edema at 6-10 weeks of age.
Vitamin-E is an antioxidant, and its deficiency may be associated
with oxygen toxicity to vulnerable tissues in the form of
retrolental fibroplasia and broncho pulmonary dysplasia.
Rapid growth following adequate feeding may cause osteopenia
and rickets unless calcium, phosphorus and vitamin-D are
administered.
These babies are prone to hypoglycemia, hypocalcaemia,
acidosis and hypoxia.
Low hepatic glycogen stores with rapid depletion in stress
place these infant at increased risk of hypoglycemia.
Immature glucose homeostatic mechanism in premature
babies can also leads to decreased inability to utilize
glucose and resultant hyperglycemia, especially during
stressful period like infection.
Early onset of hypocalcemia; presenting within 3 days of
life and is usually asymptomatic, detected on investigation.
It is especially seen in premature babies, infants of diabetic
mothers and those with birth asphyxia. Feed with higher
phosphate load such as cow milk and some formula result
in hyperphosphotemia with subsequent hypocalcemia.
Polycythemia; placental insufficiency with intrauterine
hypoxia leading to stimulation of erythropoiesis and
result in polycythemia, especially seen in IUGR baby.
Polycythemia produces hyperviscosity with decreased
organ perfusion. Manifestations include jitteriness,
respiratory distress, cardiac failure, feeding intolerance
and hypocalcemia.
Anemia ; accelerated destruction of fetal RBCs, low
reticulocyte count and inadequate response of the
bone marrow to erythropoietin cause anemia of
prematurity. Low iron stores, higher incidence of sepsis
and frequent blood sampling in low birth weight babies
may lead to sever anemia.
Birth weight <1800 g
Gestation <34 wks
Unable to feed*
Sick neonate Irrespective of birth weight and
gestation
Lethargy, refusal to feed
Hypothermia
Tachypnea, grunt, gasping, apnea
Seizures, vacant stare
Abdominal distension
Bleeding, icterus over palms/soles
Minimum Preparation for any Birth:-
The following should be available and in
working order:
Heat source
Mucus extractor
Self-inflating bag of newborn size
2 masks (for normal and small newborns)
1 clock
At least one person skilled in newborn resuscitation
present at birth
Care of the Low Birth Weight Newborn:-
Birth weight = Gestation duration + intrauterine
growth
Most low birth weight newborns in developing
countries are term or near term (Small for gestation
age)
Increased risk of hypothermia and poor growth
 Delivery management
LBW is prone to be asphyxiated
Management at birth accordingly to
Guidelines of Resuscitation (AHA/AAP)
Consider :
Early intubation
Early CPAP
Prevent hypothermia
Prevent hyperoxia
Efforts should always be made to arrest the
progress of true labour. Apart from bed rest and
sedation, a variety of tocolytic agents are
recommended but none is entirely safe and
effective.
Magnesium sulphate is more effective but have
very high risk of fetal respiratory distress.
When induction of labour is contemplated before term, either in
the interest of mother or the fetus should be ascertained by
examination of amniotic fluid for phosphatidyl glycerol or L/S.
As far as possible, delivery should be postponed till fetal
pulmonary maturity is assured.
When delivery can be safely delayed for 36 to 48 hrs,
administration of betamethasone or dexamethasone to mother
in a dose of 12 mg intramuscularly in three doses in an interval
of 12 hours is associated with significant reduction in the
incidence of hyaline membrane disease. The prophylactic
therapy benefit is seen more effective in female infant than
male.
When a preterm baby is delivered than the
delivery room should be attended by a senior
doctor, fully prepared for resuscitate the baby.
The delayed clamping of cord helps in improving
the iron stores of the bay. It may also reduce the
incidence and severity of future hyaline
membrane disease.
Vitamin-K 0.5 mg should be given
intramuscularly. The baby should be kept warm
and transferred to nursery as soon as breathing
is established.
A pre warmed incubator should be available at all times to
receive any baby with hypothermia or with birth weight of less
than 1.8 kg. the following observation should be recorded by
nurses:-
Skin and incubator temperature hourly for four hour and then
every four hourly.
Respiratory rate should be observed hourly for 24 hrs and then
four hourly.
Child should be observed for apneic attacks or preferably nursed
on apneic monitor.
Colour, general activity, regurgitation, distension of abdomen
and consistency of stool should be noted at all the time after
each feeding.
Jaundice should be checked twice a day during first week.
Prone position improves ventilation, increase
dynamic lung compliance and enhance arterial
oxygenation.
It also make child comfortable.
It relieves abdominal discomfort by passage of
flatus and reduces risk of aspiration.
During first 24-48 hours of life is very critical for
giving care to a child to prevent hypothermia.
Kangaroo mother care.
Special attention to maintenance of warm
chain.
Intravenous feeding is recommended for babies weighing less
than 1200 gm and those with severe birth asphyxia, respiratory
distress syndrome, apneic attacks and acute problem like
diarrhea.
Fortified expressed breast milk is ideal for feeding the preterm
babies.
Mother room should be adjacent to nursery as it improves the
child mother emotional bond and promote lactation and feeding
with human milk.
Strict adherence to asepsis and hand hygiene. Decreasing
exposure to adults with communicable diseases particularly
respiratory.
Continuous monitoring should be done with
cardiac monitor and apneic monitor.
Oxygen is given to prevent hypoxic brain injury.
Possible safe guard should be taken to prevent
oxygen toxicity.
Due to immaturity of blood brain barrier,
hypoproteinemia and perinatal distress factor,
bilirubin brain damage may occur at relatively
lower serum bilirubin levels.
Early phototherapy is advised to keep serum
bilirubin level within safe limits and obviate the
need for exchange blood transfusion.
The weight should be recorded on alternate days but for sick
baby it should be recorded daily.
Mostly pre term babies lose weight during first 3-4 days of life
and loss is up to 10-15percent of birth weight. The weight
remains same for the next 4 -5 days and then start gaining 1 to
1.5 percent of body weight per day.
They regain birth weight by second week of life. Excessive
weight loss, delay in regaining the birth weight or slow weight
gain suggest that either the baby is not being fed adequately or
he is unwell and need early attention.
Excessive weight gain of 100 gm or more per day may occur in
babies with cardiac failure.
Hemoglobin and reticulocyte count should be checked once weekly.
Multivitamin drops with folic acid supplementation should be stared at
two weeks of age. Early supplementation of iron is not recommended
because it may increase the requirements of vitamin-E. Early loading of
iron in infants make them prone to infection by depletion of unsaturated
lactoferrin, which is credited to possess useful antibacterial properties.
Free radical lipid peroxidation in cell membranes is catalyzed by iron and
polyunsaturated fatty acids (PUFA) thus increase requirement of vitamin-
E in very low birth weight babies. The requirements of vitamin-E are,
therefore, related to linoleic acid content formula. It is recommended
that vitamin-E to linoleic ac id ratio should be greater than 1 iu/gm of
linoleic acid. Vitamin E is powerful antioxidant and prevents hemolytic
anemia and edema of prematurity.
Supplementation of calcium and phosphorus are essential to prevent
osteopenia of prematurity.
A baby who is able to feed properly is
responsibly active with a stable body
temperature, irrespective of his body weight,
qualifies transfer to cot. The baby should be
observed for another 12 hours after putting the
incubator off to see whether he can maintain
his body temperature.
The infant should be stay in incubator for as
short a period as possible because incubators
are a potent source of iatrogenic infection.
Parents must be fully informed about progress
of baby.
Mother should be encouraged to come in
nursery and touch her baby.
Mother should be involved in the care of baby
to promote infant mother bonding.
During her visit to nursery routine care of the
baby, art of feeding , need for warmth,
importance of hand washing and prevention of
infection should be explained to her.
Warmth
Feeding
Detection and management of complications
(e.g., resuscitation, assisted respiration)
As for all newborns:
Lay newborn on mothers abdomen or other
warm surface
Dry newborn with clean (warm) cloth or towel
Remove wet towel and wrap/cover with a
second dry towel
Bathe after temperature is stable
Early, prolonged and continuous skin-to-skin
contact between a mother and her newborn
Could be in hospital or after early discharge.
Held upright (or diagonally) and prone against skin
of mother, between her breasts
Head is on its side under mothers chin, and head,
neck and trunk are well extended to avoid
obstruction to airways
Usually naked except for nappy and cap
May be dressed in light clothing
Mother covers newborn with her own clothes and
added blanket or shawl
Newborn should be:
Breastfed on demand
Supervised closely and temperature monitored
regularly
Mother needs lots of support because
kangaroo care:
Is very tiring for her
Restricts her freedom
Requires commitment to continue
Is efficient way of keeping newborn warm
Helps breathing of newborn to be more regular; reduce
frequency of apneic spells
Promotes breastfeeding, growth and extra-uterine
adaptation
Increases the mothers confidence, ability and involvement
in the care of her small newborn
Seems to be acceptable in different cultures and
environments
Contributes to containment of cost salaries, running
costs (electricity, etc.) Increases the mothers confidence,
ability and involvement in the care of her small newborn
Seems to be acceptable in different cultures and
environments
Contributes to containment of cost salaries, running
costs (electricity, etc.)
Majority of these infants are born at term, a significant
proportions are born premature with inadequate feeding
skills.
They are prone to have significant illnesses in the first few
weeks of life, the underlying condition often precludes
enteral feeding.
Preterm infants have higher fluid requirements in the first
few days of life due to excessive insensible water loss.
Since intrauterine accretion occurs mainly in the later part
of the third trimester, preterm infants have low body stores
of various nutrients at birth which necessitates
supplementation in the postnatal period.
Because of the gut immaturity, they are more likely to
experience feed intolerance necessitating adequate
monitoring and treatment.
 Early and exclusive breastfeeding
Breastmilk = best nourishment
Already warm temperature
Facilitated by kangaroo care
If Breast milk is not availble, consider milk
formula : Preterm formula --- until 2000 gm
then change to After Discharged Formula
START ANTIBIOTIC ADMINISTRATION EVEN
WITHOUTH ANY SYMPTOMS
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The appropriate methods of feeding actually
depend upon following factors:-
Whether the infant is sick or not.
Feeding ability of infant.
This group constitutes infants with respiratory
distress requiring assisted ventilation, shock
seizures, necrotizing enterocolitis, hydrops.
These infants should be started on IV fluids.
Enteral feedings should be initiated as soon as
they are hemodynamically stable with the
choice of feeding method based on the infants
gestation and clinical condition.
Enteral feeding should be initiated immediately
after birth in healthy LBW infants with
appropriate feeding method determine by their
oral feeding skills and gestation.
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76
LBW: Supplements
RESPIRATORY DISTRESS PROBLEM

Usually due to Hyaline Membrane

Disease ( HMD )
Assess : Antenatal steroids ???

CPAP : BUBBLE CPAP

Surfactant
 INFECTION :
ANTIBIOTICS
SUPPORTING TREATMENT :
NUTRITION
OXYGENATION
WARMTH
IMMUNOTHERAPY ; IF IT IS NEEDED
 HYPERBILIRUBINEMIA
Accordingly to Level of Serum Total Bilirubin

photo therapy
Feeding : Breast milk
Fluid therapy
Antibiotics according to
condition of infection
 APNEIC SPELL : APNEA OF
PREMATURITY
Very often : < 1500 grams
Complication : Hypoxemia
Oxygenation and breathing stimulation :
Aminophylline or Theophylline
Mechanical Ventilator
 HYPOGLYCAEMIA
Awarness of symptoms , sometime
asymptomatic
Blood Glucose level
Hypoglycemia : < 45 mg/dL
Dextrose infusion
Glucose Infusion Rate ( G I R )
 INTRAVENTRICULAR
HEMORRHAGE
Due to weakness of blood brain barrier and
hypoxemia
Decreasing of consicousness , deficit
neurologics, seizure
USG or CT scan
Consult to Pediatric Neurology Division and
Neurosurgery
 METABOLIC ACIDOSIS
Due to hypothermia, hypoxemia and
infection
Confirmed by clinically and laboratory
Should be corrected by considering anion
gap
Administration of bicarbonate : awarness of
false route
The infant should be well covered; like woolen cap, socks and
mitten should be worn.
Infant should lie next to mother as it is useful as biological
controlled heat source.
In winter, room should be warmed with room heater. The cot of
the mother and infant should be located away from walls to
reduce radiation heat loss.
Mother should be trained to assess baby temperature and
advised to ensure that extremities are warm and pink.
The visitors handing should be restricted to bare minimum. The
hand should be wash before touching to baby and before
feeding.
The linen should be clean and sun dried.
Feeding :-
Breast feeding should be encouraged.
Screening test are performed before discharge or on follow up
e.g. those for ROP detection in infants<32 weeks and auditory
brainstem evoked response (ABER).
Nutrition supplements including multivitamins, iron, calcium
and vitamin-D are started.
Immunization with BCG, hepatitis B and OPV is given.
Weight gain should be consistently demonstrated before
discharge and plotted on growth chart, which can be used on
follow up to determine if growth is adequate.
Baby should be feeding well, if on alternate feeding technique
like paladai feeding, the mother should be confident regarding
its detail.
Absence of danger signs and completion of treatment like IV
antibiotics. If baby is being discharged on oral medication then
parents should be well educated regarding how to administer.
Method of temperature regulation, either KMC practice or other
method should be well known to parents.
History of difficulty in feeding.
Movement only when stimulated.
Temperature below 35.5 degree Celsius -37.5
degree Celsius.
Respiratory rate over 60 breaths per minute.
Severe chest indrawing.
History of convulsion.
Thermal stability, maintenance of normal core
temperature within narrow limits, results when a
balance exists between production and conservation of
heat and dissipation. So provision of neutral
temperature.
Thermal sensor should always be placed on a part of
the body that is exposed to the circulating incubator
air and not where the skin temperature may be
influenced by cooler substance. Child should be put in
incubator. If incubator not available radiant warmer
should be available.
Mother should be educated about kangaroo mother
care.
Child should be well observed for apneic
episode or any type of periodic breathing.
Handwashing and complete sterilization or disinfection
of equipment and supplies are two important points to
be remember to prevent the risk of nosocomial
infection.
Hand washing should also be done in between
handling different infants.
Proper infusion pump should be used so that exact
amount of fluid in minutes is given to infant.
Nurse must look infilterated fluids around insertion site
like palmar area when the insertion cannula is at the
back of hand.
Before giving any medication nurse should be
clear about the action of the drug and should
be prepared for any emergency condition like if
vitamin-K is to be given than nurse should be
prepare with its analogus, novobiocin and
oxygen.the computation, prepration and
administration of parentral fluids or medication
should be done with serious responsibilities of
the nurse.
Nurse should have proper knowledge and skill
regarding monitoring devices, ventilation,
oxygen therapy and infusion pumps.
She should be well skilled in parentral and
enteral feeding procedure.
If any malfunctioning or hazard is not treated by
nurse she should immediately report and
proper action should be taken.
Parents should be encouraged to confront the
problem reliastically instead of trying to pretend
that it does not exceed.
Parents need to know that their infant will
develop normally both physically and mentally.
Parents should be encouraged to report any
concern they have to primary nurse who know
about their infant.
Parents should be informed about the sources
available in community.
Early infant stimulation programme should be
started which is beneficial to parents and their
children. By this parents have the opportunity
to learn about infant development and about
methods of physical and psychological
stimulation as well as interacting with the
parents of same concern.
Parents needs encouragement in learning to
handle a small, delicate neonate when they visit
in nursery.help the parents to feel secure in
their ability to care for the premature infant is
probably the most important factor in forming
good parent child relationship.
Prognosis for survival is directly related to the
birth weight of the child and quality of neonatal
care.
The prognosis for mental development is good if
there is no incident birth hypoxia, apneic
attacks, respiratory distress and hypoglycemia.
Neurological prognosis is adversely affected by
degree of immaturity, intrauterine growth
retardation, intraventricular hemorrhage and
severity of respiratory failure demanding
assisted ventilation.
 SUMMARY
Premature birth and low birth weight (LBW)
still a health problem with high Morbidity
and mortality
The survival at high risk of LBW for long
term neurocognitive deficits
Two types of LBW : premature and IUGR
Problems accordingly to the type
Management consist of : warmth, feeding,
management of complication
Breast feeding is prioritized, in case of
breastmilk is not available, consider milk
formula
Low birth weight babies have high survival rate
if they are managed well at the initial stage of
their problem and get cured. If there is no
incidence of hypoxia and apneic episode then
these infants are neurologically also normal.