Case Presentation:

Extremely LBW Neonate

Presenter: Dr. NC OLI

2nd year Resident, Paediatrics, LMCTH

Date: April 21, 2021

Case: B/O Devi Somai, Rampur-5, palpa
• Outborn/S/L/ very preterm (27+6 WOG), ELBW (800 gram),
Female, AGA.
• Vaginal delivery , Vehicle delivery (jeep) on the way to LMCTH
• DOB: 2077-12-30 @1.30 pm
• Clear amniotic fluid

• APGAR score: unknown, cried soon after birth, but minimal cry, pink
after birth, minimal activity.

• Dried and wrapped in clothes on the way

Maternal History:
• Antenatal: 25 yrs, Primigravida, no abortions, conceived after 5 years
of marriage, taken some medications for subfertility (no documents).

• EDD: 078/Asar/26
• ANC checkup regular, folic acid: after few weeks of conception.

• Iron, calcium taken regularly since 2nd trimester, Tetanus vaccine

received. No other drugs during pregnancy.

• Leaking since 3 days prior to presentation, but No PV bleeding.

Maternal…..
• No h/o fever/rash/itching/ foul smelling vaginal discharge/ urinary
symptoms/ perineal lesions/ lymphnodes swelling/ Radiation exposure.

• NO known illness (HTN/ G-HTN/Eclampsia/ DM/Thyroid disorder/Heart ds/

kidney ds….)

• USG : @4th month of pregnancy: said normal, fetal movements regular.

• Non-alcoholic, Non-smoker

• Blood group: A positive, Steroid injection not received prior to delivery.

• Family history: none

• Baby Presented at LMCTH ER at nearly 1 hour of life at 2.45 pm,
attended by pediatrics at 2.50 pm.

• Spontaneous respiration but having moderate-severe respiratory

distress (SCR/ICR/Suprasternal recession, nasal flaring)

• Silverman-Anderson Score: 07

• Acrocyanosis present but No central cyanosis (pink body/lips), No

tachypnea (RR: 40/min), No grunting
• CVS: S1/S2 normal, no murmur, HR: 150 bpm.
• CRT: 3 Sec, brachial pulses/femoral pulses: palpable but low volume

• Cold periphery/ Axillary Temp: 92.5^F (33.6^C): moderate hypothermia.

• SPO2: 90% with Hood box (10 ltr O2), 93-94% with Hand made CPAP at PEEP
5cmH2O.

• AF: not bulged, suture lines not opposed.

• Activity: poor, Tone: poor, Rooting/sucking: absent, Moro: absent, Babinski: positive.
• Chest: b/l equal air entry, b/l clear, Liver/spleen: not enlarged.

• Head to Toe: HC: 22.5cm(3rd percentile), LT: 35cm, No facial dysmorphism, No obvious
anomalies, anus patent, OG tube passed in stomach, NEW BALLARD Score: 09 (28 wks)
 Management: Parents counselling.

• Kept in radiant warmer, Wrapped with cotton and clothes.

• Initially baby on Hood box with 10 ltr o2 switched to Hand made CPAP at ER (PEEP 5
cmH20, 5 litre O2 flow)

• GRBS: 93 mg/dl, shifted immediately to NICU, BP: 45/20(31) mmhg.

• Continued CPAP at same setting as distress decreased (Anderson-silverman score: 04
after half hour)

• Umbilical vein catheter opened and IVF bolus D10: 2ml, NS: 8ml, sepsis package/Blood
grp. sent, IV drip maintenance (IVF D10 @ 95ml/kg/day, GIR: 4 mg/kg/min.

• Cefotaxime/ Amikacin/ Aminophylline/ vitamin K/ Astymin-3 (@ 2gm/kg/day) and

calcium gluconate added in drip.

• Cxray: ?Grade-III HMD , started phototherapy.

• Case managed with provisional diagnosis of Extreme prematurity/ELBW with
Hypothermia with RDS/HMD with suspected EONS.
• Temp: 93.2F @2hrs (on warmer/cotton wrap), 94.8F @4hrs, 97.6F @8HRS.

• Trophic feeding started (1cc 8 hrly: 2 feed ) @6 HOL, but intolerance with billous
aspirate, feed hold. Continued NPO.

• Amino-acid increased to 3 gm/kg/day at 24 HOL.

• CPAP continued with PEEP 5 cmH2O as distress improved within 6 hrs upto 65 HOL.
• Caffeine was not available.

• Surfactant (SURVANTA) available at 24 HOL but Respiratory distress was improved

on CPAP and not inserted at that time.
• Baby having stable vital signs, minimal distress, without Apnea/ hypoglycemia/
seizure, with normal urine output normal perfusion upto 65 HOL.

• But deteriorated after 65 HOL with increased respiratory distress, CPAP

increased to PEEP 6 cmH20 and SURVANTA (@4ml/kg in 4 divided doses)
inserted @ 72 HOL by INSURE technique (Intubation-Surfactant-Extubation).

• Cxray: Rt upper lobe consolidation/collapse.

• Baby not deteriorated further till 92 HOL but developed recurrent apnea (3
times: desaturation, bradycardia). Inj durataz/amikacin/metronidazole

• GRBS was normal, UVC blocked, poor perfusion, given 10ml NS bolus and 3 ml
D10 via i.v canula. Perfusion: normal after bolus.
• Intubated and kept in mechanical ventilator.
• Ventilator: FIO2=99%, PIP=20, PEEP=7, I:E=1:2, Rate: 45 (stable vitals)

• After 2 hours of intubation, Baby developed sudden bradycardia (HR:70

bpm), desaturation (54%), cyanosis under Mechanical ventilator.

• CPR and adrenaline inj. (3 times: for bradycardia/desaturation within one

hour duration). Adr (1:10,000): @ 0.1ml/kg.

• Inj dopamine/dobutamine infusion @10 mcg/kg/min started after bolus for

poor perfusion. Cxray: B/l lung fields clear.

• Baby declared expired @ 99 HOL : (5.15 pm on 2078-01-03)

Investigations:
• WBC: 20000 , N43% , PLT: 200000, CRP: 5 mg/l
• PBS: N32% at admission
• Blood grp: A positive
• Blood c/s: sterile

• WBC: 31000, N77%, PLT: 180000 at 4th day

Mishaps?
• ? Surfactant delay
• ? Surfactant complications
• ? Hypovolemia/Shock
• ? Sepsis/Septic shock
• ? Pneumothorax
• ? Ventilator failure/ Poor Oxygen supply/ ET tube dislodge
• ? Intracranial hemorrhage
ELBW Baby/ Very Preterm

<1000 gram / <28 WOG

ELBW:
• facility with a high-risk obstetrical service and neonatal intensive care
unit (NICU).

• physiologically immature, extremely sensitive to small changes in

respiratory management, blood pressure, fluid administration,
nutrition etc.

• Prenatal administration of glucocorticoids to the mother

• The first several days after birth, and in particular the first 24 to 48
hours, are the most critical for survival.
Elements of Care of the Extremely Low Birth Weight (ELBW) Infant
Ventilation strategy
Prenatal consultation
Parental education Low tidal volume, short inspiratory
Determining parental wishes when time
viability is questionable Avoid hyperoxia and hypocapnia
caregiver-parent teamwork Early surfactant therapy as indicated

Delivery room care

Warm Fluids
Resuscitation
humidified incubators
Respiratory support
Prevention of heat and water loss Judicious use of fluid bolus therapy
Early surfactant therapy Careful monitoring of fluid and
electrolyte status
umbilical venous catheters
Nutrition
• parenteral nutrition
• Early initiation of trophic
feeding with EBM
• adequate calories/protein/fat
for healing and growth
Cardiovascular support
• Maintenance of blood pressure
• Use of dopamine support
• Corticosteroids for unresponsive
hypotension
PDA
Avoidance of excess fluid
Treat hemodynamically significant
PDA
Consider surgical ligation
Infection control
hand hygiene, use of spirit
Limiting blood drawing, skin
punctures
Protocol for CVL insertion and care,
minimize dwell time
Complications:
• Hypothermia, Hypoglycemia, Polycythemia, Apnea, RDS,
Feed intolerance, Neonatal sepsis
• patent ductus arteriosus
• pulmonary hemorrhage
• necrotizing enterocolitis, GI bleed
• intracranial hemorrhage
• chronic lung disease,
• cerebral palsy, cognitive delay, deafness, and blindness(Retinopathy)
hydrocephalus, seizure disorder, and microcephaly
• death.
RDS: HMD
RDS: Pathophysiology
• Surfactant deficiency
• End-Expiratory Alveolar Atelectasis AND V/Q mismatch
• Hypo-perfusion of lungs
• Epithelial Necrosis
• Transudation of Plasma
• Formation of Hyaline Membrane
• Reduced Compliance
• Hypoventilation
• ↑pCO2 ↓p02
• ↓ PH
• PPHN
 Risk of RDS:
Increased Risk Decreased Risk

Prematurity Chronic intra-uterine stress

Male gender Prolonged rupture of membranes
Cesarean section Maternal hypertension
Infant of diabetic mother IUGR/SGA
Perinatal asphyxia Antenatal glucocorticoids
Caucasian race Maternal use of narcotics/cocaine
Chorioamnionitis Tocolytic agents
Non-Immune hydrops fetalis Hemolytic disease of the newborn
RDS: Cxray grading
RDS: Diagnosis/grading
RDS: Diagnosis: clinical
• Amniotic Fluid Lecithin/Sphingomyelin Ratio
– ≥2 suggests lung maturity.
– ≤1.5 associated with HMD

• Phosphatidyl Glycerol estimation

– More specific than L/S ratio
– Absence is invariably associated with HMD

• Gastric Aspirate Shake Test

– Unreliable if gastric aspirate is contaminated with blood
or meconium
– Serial tests can be done to assess maturity of lungs during
course of disease
Respiratory support:
1. CPAP
2. Surfactant therapy
3. Ventilator
4. Caffeine (prevent apnea/BPD); Aminophylline
Indications for starting CPAP:
• Downes’ or Silverman score of >4 at birth

• FiO2 requirement of >0.4 to maintain an acceptable

saturation on pulse oximeter.

• CPAP is said to have failed when the FiO2 requirement is

>0.6 or the pressure required to maintain oxygenation
exceeds 7-8 cm of H2O.
 Surfactant:
• Infasurf 3mL/kg
Survanta 4 mL/kg
 infants with RDS who are ventilated with a MAP of at least 7 cm H2O and
requiring FiO2 of 0.3 or higher in the first 2 hours after birth.

 Preferably within the first hour.

 with increased use of CPAP as initial therapy, the timing of surfactant therapy
may be delayed.

 surfactant should be considered in preterm infants with signs of RDS in the

immediate perinatal period after a failed trial of CPAP or in infants for whom
CPAP is contraindicated, i.e., apnea, air leak.
RDS: Mechanical ventilator setting
• Synchronized Intermittent Mandatory Ventilation (SIMV)
• Rate: 30-40/minute
• PIP:
• <1500 grams: 16-28 cm H2O.
• >1500 grams: 20-30 cm H2O.

• PEEP: 5-6 cm , to maintain FRC.

• FiO2: 0.4 to 1.0, depending on the clinical situation.
• Inspiratory time: 0.3-0.5 sec.

@IOWA neonatal handbook, University of IOWA stead family children hospital.

 Recent Advances:

• No association between outcome (no neurologic, neurosensory, or

cognitive deficits) and birth weight. several other known risk factors are
related to poor outcome: ICH, CLD, and social risk.

• Mild to moderate cognitive delays were associated with chronic lung

disease: bronchopulmonary dysplasia (oxygen >60 days) 

@Outcome of Extremely Low Birth Weight Infants (500 to 999 Grams) Over a 12-Year Period: by Robert E.
and Co., Journal of AAP
• Early enteral feeding should be promoted soon after birth to enhance
gastrointestinal maturation, growth and functional development.

• Early initiation of nutrition support in ELBW infants produces a rapid

regain of initial weight loss, improves weight gain, and enhances
earlier achievement of full enteral feedings.
• Early surfactant administration (at FiO2 <0.45) was superior to late (FiO2 >0.45)
administration. 

• Surfactant: Upto Two times.

• Better to start with CPAP support in the delivery room if possible and administer
surfactant with INSURE technique only to infants with signs of RDS.

• studies do not find a benefit of prophylactic surfactant with INSURE over CPAP.

• Minimally invasive surfactant therapy (MIST)

@Surfactant for Respiratory Distress Syndrome: New Ideas on a Familiar Drug with Innovative
Applications, H.J. Niemarkt,a M.C. Hütten,b and Boris W. Kramerb,*
Thank you
References:
• Cloherty and stark^s manual of neonatal care
• Articles
• IOWA handbook
• Internet source