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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.
Preterm birth is the most common direct cause of newborn mortality. Preterm birth and being
small for gestational age (SGA), which are the reasons for low-birth-weight (LBW), are also
important indirect causes of neonatal deaths. LBW contributes to 60% to 80% of all neonatal
deaths. The global prevalence of LBW is 15.5%, which amounts to about 20 million LBW infants
born each year, 96.5% of them in developing countries.
DEFINITION:-
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 very low birth
weight (VLBW) which is less than 1500 g (3 pounds 5 ounces), and 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
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. For example, babies with congenital anomalies or chromosomal
abnormalities are often associated with LBW. Problems with the placentacan prevent it from
providing adequate oxygen and nutrients to the fetus. Infections during pregnancy that affect the
fetus, such as rubella, cytomegalovirus, toxoplasmosis, and syphilis, may also affect the baby's
weight.
The functional immaturity of various systems result in different clinical problems and their
knowledge is essential for the satisfactory management of these babies.
2. Respiratory system :-
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.
Resuscitation problem:-
a.Compromised intrauterine environment with higher chances of perinatal asphyxia.
b. Immature lungs that may be more difficult to ventilate and are also more vulnerable to
lung injury by positive pressure ventilation.
c.Immature blood vessels in brain are prone to hemorrhage.
d. Thin skin and large surface area which contribute to rapid heat loss.
e.Increased risk of hypovolemic shock caused by small blood volume.
3. Cardiovascular system :-
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.
4. Gastrointestinal system:-
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.
5. Thermo regulation:-
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.
6. Infection:-
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.
7. Renal immaturity:-
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.
8. Toxicity of drugs:-
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.
9. Nutritional handicaps:-
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.
10. Biochemical disturbance:-
These babies are prone to hypoglycemia, hypocalcaemia, acidosis and hypoxia.
Low hepatic glycogen stores with rapid depletion in stress place these i nfant 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.
MANAGEMENT
a) Arrest of premature labour:-
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 suphate is more effective but have very high risk of fetal respiratory distress.
b) Induction of premature labour:-
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.
c) Labour room:-
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.
d) Nursery :-
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:-
a) Skin and incubator temperature hourly for four hour and then every four hourly.
b) Respiratory rate should be observed hourly for 24 hrs and then four hourly.
c) Child should be observed for apneic attacks or preferably nursed on apneic monitor.
d) Colour, general activity, regurgitation, distension of abdomen and consistency of stool
should be noted at all the time after each feeding.
e) Jaundice should be checked twice a day during first week.
e) Position of the baby:-
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.
f)Temperature regulation:-
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.
g) Feeding :-
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.
h) Respiratory problem :-
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.
Management of resuscitation problem:
a. Gentle resuscitation using small bags for positive pressure ventilation, use of CPAP.
b. Use extra care to hypothermia.
i) Phototherapy:-
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.
j) Weight record:-
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.
k) Nutritional supplement :-
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.
Child-parent contact:-
Hypothermia
Abdominal distension
• Heat source
• Mucus extractor
• 1 clock
– Most low birth weight newborns in developing countries are term or near term (Small
for gestation age)
OXYGEN DANGER :-
– retinopathy of prematurity
– NEC
– periventricular leukomalacia
• Warmth
• Feeding
1. Warmth
As for all newborns:
• Lay newborn on mother’s 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
Definition of Kangaroo Mother Care:-
Early, prolonged and continuous skin-to-skin contact between a mother and her newborn
Could be in hospital or after early discharge.
Methods of feeding:-
Direct and exclusive breast feeding is the main aim for LBW babies. However because of various
limitation, not all low birth weight baby will be able to have breast feeding at least in the initial
few days of life. These infants have to be fed by spoon, paladai or intragastric tube. Those babies
who cannot accept oral feedings they would require intravenous fluids.
Low birth weight babies are categorizing in two groups, sick and healthy, before deciding the
initial method of feeding.
a.Sick infants-
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.
It is important to understand that enteral feeding is important even for sick neonates. Oral feeds
should not be delayed in them without any valid reason. Even infants with respiratory distress and
assisted ventilation can be started on enteral feeds once the acute phase is over and infants color,
saturation and perfusion have improved.
b. Healthy low birth infant-
Enteral feeding should be initiated immediately after birth in healthy LBW infants with appropriate
feeding method determine by their oral feeding skills and gestation.
It is true and unfortunate that many low birth weight babies come after the discharge with the
complaint of diarrhea, sepsis and cold. It is essential that proper appraisal of available physical
facilities, resources and environmental conditions be made by a pre-discharge home visit by a
health visitor or a public health nurse before the baby get discharge. Periodic home visit should be
done after the discharge of baby.
a) Environmental control:-
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.
b) 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.
All danger sign should be explained to parents in details like:
i. History of difficulty in feeding.
ii. Movement only when stimulated.
iii. Temperature below 35.5 degree Celsius -37.5 degree Celsius.
iv. Respiratory rate over 60 breaths per minute.
v. Severe chest indrawing.
vi. History of convulsion.
Follow up within 3-7 days of discharge to ensure the baby has been adapted well to home
environment.
Prognosis:-
Prognosis for survival is directly related to the birth weight of the child and quality of neonatal
care. Over three fourth of neonatal death occur among low birth weight babies. Therefore in
countries with high incidence of low birth babies, neonatal mortality is likely to occur. 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
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. Low birth weight babies have lot off complication like
neurological, respiratory, renal system, temperature regulation, infection . then we also discussed
criteria for discharge and management of low birth weight babies issues.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
Conclusion
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.
Refrences
Books:
1) Marlow and Redding. Text book of paediatric nursing. Sixth edition. Elsevier
publication.2010. Page no-990-1100.
2) Wongs and Werry. Text book of pediatric nursing. Third edition, Elsevier
publication.2005. page no-1145-1167
3) Bagga and Paul. Ghai essential pediatrics. Eighth edition. CBS publishers and distributors
pvt. Limited. 2013. Page no-155-162.
4) Singh meharban, care of the new born, fifth edition, sagar publication,1996,page no-112-
120.
Net:
1) http://www.intelihealth.com/IH/ihtIH/EMIHC000/20722/8632/187947.
2) http://www.chadd.org.