CARE OF LBW

BSC NURSING AND GNM NURSING SYLLABUS

1. DEFINITION LOW BIRTH WEIGHT- A baby whose birth weight is less than 2.5kg regardless of gestational age. VERY LOW BIRTH WEIGHT – A baby whose birth weight is less than 1.5 kg. EXTREMELY LOW BIRTH WEIGHT - A baby whose birth weight is less than 1kg.

2. SMALL FOR DATES/SMALL FOR GESTATIONAL AGE INFANTS- An infant whose rate of intrauterine growth was slowed and whose birth weight falls below the 10 th percentile on intrauterine growth curves. INTRAUTERINE GROWTH RETARDATION- Babies who donot grow adequately in utero. PREMATURE/PRETERM INFANT – A baby born before completion of 37 th weeks of gestational age regardless of birth weight . DEFINITION

3. 75% neonatal deaths and 50% infant deaths occur among LBW infants LBW babies are more prone to: Malnutrition . Recurrent infections . Neuro developmental delay . LBW babies have higher mortality and morbidity LBW: Significance

4. TYPES OF LBW Low birth weight infants are of two clinical types:

5. DEFINITION PREMATURE/PRETERM INFANT – A baby born before completion of 37 th weeks of gestational age regardless of birth weight. SMALL FOR DATES/SMALL FOR GESTATIONAL AGE INFANTS- An infant whose rate of intrauterine growth was slowed and whose birth weight falls below the 10 th percentile on intrauterine growth curves.

6. Poor nutritional status of mother. Hypertension, toxemia, anemia.. Multiple pregnancy, post maturity. Chronic malaria, chronic illness. Tobacco, alcohol, drug use. Young mother. Primi / grand multipara . Placental dysfunctions. Incompetent cervix P olyhydromious etc. Causes of SFD / IUGR

7. Low maternal weight, teenage / multiple pregnancy . Previous preterm baby, cervical incompetence . Antepartum hemorrhage, acute systemic disease . Induced premature delivery . Infections, Trauma. Drug abuse, alcohol consumption. Young mother. Primi or grand multipara. Insulin deficiency etc. Majority unknown. Etiology of premature/preterm infant

8. CHARACTERISTICS OF PRETERM

9. SIZE Small in size, usually less than 47 cm, less than 2.5 kg POSTURE Lies in RELAXED attitude and limbs are extended. HEAD Head is relatively large, sutures are widely separated and fontanelles are large. HAIR FINE, FUZZY AND WOOLY. SKIN Thin, pinkish, appears shiny. Covered with abundant lanugo and little VERNIX CASEOSA. EAR Ear cartilage poorly is poorly developed developed and ear may fold easily. BREAST Absent or less than 5 mm wide. SOLE Preterm appears more turgid and may have only one fine wrinkles. The creases are absent. FEMALE G E N E T A L IA The female infants clitoris is prominent and labia majora are poorly developed and gaping. MALE G E N E T A L IA The scrotum is underdeveloped and not pendulous, testes may be in the inguinal canal or in the abdominal cavity. SCARF SIGN Elbow may be easily brought cross chest with little or no resistance. HEEL TO EAR Heels can easily brought to the ear, meeting with no resistance.

10. CHARACTERISTICS OF PRETERM

11. 1. SIZE Small in size, usually less than 47 cm, less than 2.5 kg

12. 2.POSTURE POSTURE : Lies in RELAXED attitude and limbs are extended.

13. 3.HEAD HEAD: Head is relatively large, sutures are widely separated and fontanelles are large.

14. 4.HAIR Hair: fine, fuzzy and wooly .

15. 5.SKIN Thin, pinkish, appears shiny. Covered with abundant lanugo and little VERNIX CASEOSA

16. 6.EAR Ear Cartilage : Ear cartilage poorly is poorly developed and ear may fold easily. P r e term T e rm

17. 7.Breast nodule Pret e rm T erm Breast nodule : Small in size, usually less than 47 cm, less than 2.5 kg Preterm Te r m

18. 8.Sole creases Sole creases : Preterm appears more turgid and may have only one fine wrinkles. The creases are absent. Pre t e r m TERM

19. 9,10.GENETALIA The female infants clitoris is prominent and labia majora are poorly developed and gaping . The scrotum is underdeveloped and not pendulous, testes may be in the inguinal canal or in the abdominal cavity . Pre t er m Ter m

20. 11.SCARF SIGN Elbow may be easily brought cross chest with little or no resistance.

21. 12.HEEL TO EAR Heels can easily brought to the ear, meeting with no resistance.

22. CHARACTERISTICS OF SFD/IUGR

23. Intrauterine growth chart 4 4 4000 LARGE FOR DATE 90 th percentile 3600 3200 2800 APPROPRIATE FOR DATE 2400 2000 1600 SMALL FOR DATE 10 th percentile 1 2 8 4 31 33 35 37 39 Gestation (weeks) 42 44 45 P O S T - T E R M TERM PRETERM Birth weight (grams)

24. SFD / IUGR 3.2 Kg - S FD 2.1 Kg - IUGR

25. LBW (Preterm) : Problems Birth asphyxia . Hypothermia . Feeding difficulties . Infections . Hyperbilirubinemia . R espir a t ory distress . Retinopathy of prematurity . Apneic spells . Seizures. Hypoglycemia . Metabolic acidosis . Nutritional deficiencies. Bradychardia .

26. LBW (SFD) : Problems Birth asphyxia. Intrauterine hypoxia. Meconium aspiration syndrome. Hypothermia. Hypoglycemia . Infections. Polycythemia . Congenital malformation.

27. LBW: Issues in delivery Transfer mother to a well-equipped centre before delivery Skilled person needed for effective resuscitation. Prevention of hypothermia - topmost priority.

28. LBW: Indications for hospitalization Birth weight <1800 g Gestation <34 wks Unable to feed* Sick neonate * * Irrespective of birth weight and gestation*

29. PRINCIPLES OF MANAGEMENT OF LBW INFANTS Care at birth. Appropriate place of care. Thermal protection. Nutrition. Motoring and early detection of complications. Appropriate management of specific complications especially infection.

30. CARE AT BIRTH Select a suitable place for delivery which has optimum facilities for handling LBW baby. In case of premature labor is indicated, administered Betamethasone (12 mgIM, 2 doses at the interval of 18 hours) or 100 mg hydrocortisone to mother as they help in improving the lung maturity. Avoid sedatives to mother. Delayed cord clamping to help improves iron stores of baby and prevent anemia. Efficient resuscitation.

31. Vit K 0.5 mg. Prevent hypothermia. APPROPRIATE PLACE OF CARE If birth weight > 1800 gm- Home care, if baby is well. If birth weight 1500-1800 gm- Secondary level new born unit (Level II) If birth weight < 1500 gm – Tertiary level new born care (Level III)

32. LBW: Keeping warm at home Birth weight (Kg) Room temperature ( C) 1.0 – 1.5 34 – 35 1.5 – 2.0 32 – 34 2.0 – 2.5 30 – 32 > 2.5 28 - 30 Warm room, fire or heater Skin-to-skin contact Convection E vapo r a t ion Conduction Radiation Prevent heat losses Baby warmly wrapped

33. LBW: Keeping warm at home Well covered newborn

34. LBW: Keeping warm in hospital Radiant warmer Skin-to skin method Warm room, fire or electric heater Warmly wrapped Heated water-filled mattress Air-heated Incubator

35. LBW: Keeping warm in hospital Overhead Radiant warmer

36. LBW: Fluids and feeding (Nutrition) Start initial intravenous fluids. Expressed breast milk with NG tube or Katori and spoon. Direct breast feeding, if possible for baby too suck and swallow.

37. LBW: Feeding Gavage feeding

38. LBW: Feeding Katori-spoon feeding

39. GUIDELINES FOR FLUID REQUIREMENTS First day 60-80 ml/kg/day . Daily increment 15 ml/kg till day 7 . Add extra 20-30 ml/kg for infants under radiant warmer and 15 ml/kg for those receiving phototherapy .

40. FLUID REQUIREMENTS (ML/KG) Day of life Birth Weight >1500 g 1000 – 1500g 1 60 80 2 75 95 3 90 110 4 105 125 5 120 140 6 135 155 7 onwards 150 170

41. LBW: Supplements Vitamins : IM Vit K at birth Vit A* 1000 I.U. per day Vit D* 400 I.U. per day Iron : Oral 2 mg/kg per day from 8 weeks of age *From 2 weeks of age

42. EARLY DETECTION Weight and other clinical signs. Monitoring HR, temp, O2 etc … Monitoring Hemoglobin , blood sugar, serum billurubin etc..

43. DISCHARGE AND FOLLOW UP Before discharge, the baby is evaluated for any complication of maturity. Nutrition supplements including multivitamins, iron, calcium, vit D. Baby should be immunized. Teach parents for feeding. Teach parents regarding prevention of hypothermia, infections, proper feeding, personel hygiene etc….

44. DANGER SIGNS Refusal to feed. Lethargy . Hypothermia Tachypnea, grunt, gasping, apnea Seizures, vacant stare. Abdominal distension. Bleeding, icterus over palms/soles.

45. TRANSPORTATION OF LBW BABY Adequate warmth. Life support. With mother. Referral note.

46. P R O G N O S IS Mortality Inversely related to birth weight and gestation Directly related to severity of complications Long term Depends on birth weight, gestation and severity of complications