LBW

Content of Low Birth Weight Baby.

1. NURSING CARE OF LOW BIRTH WEIGHT BABY CHILD HEALTH NURSING

2. Definition: Low birth weight has been defined by the WHO as weight at birth of less than 2,500 grams (5.5 pounds). This is based on epidemiological observations that infants weighing less than 2,500 g are approximately 20 times more likely to die than heavier babies.

3. Definition: Birth weight <2500 gm Incidence :30% of neonates in India

4. Types of LBW: Preterm Small-for-date (SFD) / intra uterine growth retardation (IUGR) < 37 completed weeks of gestation  < 10th Percentile for gestational age Account for 1/3rd of LBW Account for 2/3 rd of LBW neonates

5. Overview: More common in developing than developed countries. The goal of reducing LBW incidence by at least one third between 2000 and 2010 is one of the major goals in ‘A World Fit for Children’,. Forms an important contribution to the Millennium Development Goal (MDG) for reducing child mortality.

6. Overview: More than 20 million infants worldwide, representing 15.5% of all births, are born LBW, 95.6 % in developing countries. LBW is closely associated with: foetal and neonatal mortality and morbidity, inhibited growth and cognitive development, and chronic diseases later in life.

7. Risk factors for LBW: Mother's Malnutrition Heavy work load High blood pressure Infection and diseases Unregulated fertility.

8. Causes and consequences of LBW ) Preterm babies: There are babies born too early before 37 weeks of gestation, their intrauterine growth may be normal, that is their, weigh, length and development may be within normal tomtits for the duration of gestation. Given good neonatal care, these babies can catch up growth and by 2 to 3 years of age will be of normal size and performance.

9. Approximately 2 thirds of all babies of LBW in developed countries are estimated to be preterm the causation of preterm babies is multifactoral. There include multiple births, hard physical works hypertensive disorders of pregnancy. But it is often preventable by such measures as good prenatal screening and care.

10. Small for dates (SFD): These babies are result of intrauterine fetal growth. The factors associated with intra uterine growth retardation are multiple and interrelated to mother, placenta or to foetus.

11. Factors affecting birth weight: The maternal factors: Include malnutrition. Anaemia. Heavy physical work-during pregnancy. Hypertension. Malaria. Toxaemia. Smoking.

12. The maternal factors: : Low economic status. Short maternal stature. Young age. High parity. Dose birth spacing. Low education status.

13. Factors related to placenta: Placental insufficiency. Placental abnormalities.

14. The foetal causes: Foetal abnormality. Intra uterine infections. Chromosomal abnormalities. Multiple gestation.

15. SFD babies has a high risk of dying not only during the neonatal period but during their infancy, thus significantly raising the rate of infant and prenatal mortality. Most of them become victims of protein energy mal nutrition and infection.

16. Importance: LBW is one of the most serious challenges in maternal and child health indevelped and developing countries.

17. Its public health significance may be ascribed, to numerous factors: Its high incidence. Its association with mental retardation. A high risk of prenatal and infant mortality and morbidity.

18. Its public health significance may be ascribed, to numerous factors: LBW is the single most important factor determining the survival chances of the child (the infant mortality rate is about 20 times greater for all breast fed babies. .

19. Its public health significance may be ascribed, to numerous factors: Many of them become victims of protein – energy – malnutrition and infection. There is a strong and significant positive status and the length of pregnancy and birth weight

20. Prevention: The rates of LBW could not be reduced to more than 10 percent in all parts of the world. There is no universal solution, interventions have to be case specific.

21. In recent years good attention has been given to ways and means of preventing LBW through good prenatal care and interventions programmes rather than treatment of low birth weigh babies born later.

22. Direct intervention measures : (mothers ) Increasing food intake Controlling infection Early detection and treatment of medical disorders

23. Prevention: Indirect intervention: Family planning Improved sanitation Improving health and nutrition of young girls Improvement of socio-economic conditions Government support (maternity leave)

24. Identification: Preterm LBW Breast nodule Preterm Term

25. Identification: Preterm LBW Sole creases

26. Identification: Preterm LBW Male genitalia Preterm Term Term

27. Identification: Preterm LBW Female genitalia Preterm Term

28. Identification: Preterm LBW Ear Cartilage Preterm Term

29. LBW: Identification of types SFD / IUGR Intrauterine growth chart Physical characteristics  Emaciated look  Loose folds of skin  Lack of subcutaneous tissue  Head bigger than chest by >3cm

30. Central nervous system : The immaturity of central nervous system is expressed as inactivity and lethargy, poor cough reflex. 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.

31. On the other hand, they are more resistant to toxic effects of hypoxia as compared to the term babies. They are extremely vulnerable to develop intraventricular , periventricular haemorrhage due to relative deficiency of vitamin-K dependent coagulation factors and increased capillary fragility. 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.

32. Respiratory system They pose resuscitation difficulties at birth, often followed by hyaline membrane disease, if associated with deficiency of pulmonary surfactant. Pulmonary aspiration and atelectasis are common. They are vulnerable to develop chronic pulmonary insufficiency due to bronchopulmonary dysplasia.

33. 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 congestive heart failure.

34. Gastrointestinal system Regurgitation and aspiration are common because of in coordinated sucking and swallowing reflex, small capacity of stomach, incompetence of cardioesophageal junction and poor cough reflex. Gastro,esophagal reflux and is consequences are common. Abdominal distension and functional intestinal obstruction are due to hypotonia.

35. Enterocolitis occurs when other predisposing factors are present. Immaturity of glucuronyl transferase system in the liver leads to hyperbilirubinemia, which may be aggravated by dehydration, delayed feeding and hypoglycemia.

36. Relatively low serum albumin, acidosis and hypoxia in these babies predispose to bilirubin levels. The poor hepatic glycogen stores, delayed feeding, birth asphyxia and respiratory distress syndrome contribute to the development of hypoglycemia.

37. Thermo regulation Hypothermia is invariable and life threatening unless environmental 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.

38. Infections Infections are an important cause of neonatal mortality in low birth weight babies. The low levels of IgG antibodies and inefficient cellular immunity predispose them to infections . Excess handling, humid and warm atmosphere, contaminated incubators and resuscitators expose them to infecting organisms, thus contributing to high incidence of infections.

39. Renal immaturity The blood urea nitrogen is high due to low glomerular filtration rate. The renal tubular amonia mechanism is poorly developed thus acidosis occurs early. They are vulnerable to develop late metabolic acidosis especially when fed with a high protein milk formula.

40. Toxicity of drugs Poor hepatic detoxification and reduced renal clearance make a preterm baby vulnerable to toxic effects of drugs unless caution is exercised during their administration.

41. Nutritional handicaps Low birth weight babies are prone to develop anaemia around 6 to 8 weeks of age. This is due to diminished total stores of iron due to short gestation and also deficiency of folic acid. Vitamin E deficiency occurs among infants weighing less than 1,500g, particularly those fed on iron fortified milk formula. These infants are prone to develop haemolytic anaemia, thrombocytopenia, and oedema at 6 to 10 weeks of age.

42. Biochemical disturbances These babies are prone to develop hypoglycemia, hypocalcemia, hypoproteinemia, acidosis and hypoxia.

43. Treatment: From the point of view of treatment. LBW babies can be divided into 2 groups. Those under 2 kg. Those between 2 – 2.5 kg. The first group require first class modern neonatal care which is hardly available

44. globally in an intensive care unit their weight reaches the weight of the second group. The second group may need an intensive care unit for a day or two.

45. The intensive care comprises of: Incubatory care, that adjust temp, humility oxegen supply (low levels of oxygen in the blood steam can produce cerebral palsy. If it is excessive leads to retrolenta fit roplasia).

46. Feeding: Nasal catheter. Prevention of infection: Infection can cause death in the first few hours (respiratory infection so prevention of infection is there fore one of the most important functions of an intensive care unit.

47. The leading causes of death in low birth weight babies: Atelectasia. Malformation. Pulmonary haemorrhage. Intracranial bleeding. Pneumonia and other infections. The development of perinatal intensive care units has been associated with a decline in neonatal mortality.

48. Feeding of infants: Breast feeding: Ideal Protect from infection and malnutrition Reduces infant mortality

49. Advantages: Safe, clean ,cheap, and available in correct temp. Meets nutritional requirement of infant in first months of life Antimicrobial factors Easily digested ,has biochemical advantages. Promotes bonding Protects against obesity Sucking is good for development of jaws & teeth Prevents malnutrition Child spacing

50. Artificial feeding: Dried milk,cow`s milk Indications: Failure of breast milk Prolonged illness Death of mother

51. Comparison between breast milk and cow's milk Cow's milk Breast milk constituent ↑ ↓ proteins = = fats ↓ ↑ carbohydrates ↑ ↓ Minerals ↓ ↑ vitamins

52. Weaning: Gradual process starts around 4-5 months Supplementary foods If not done properly ,diarrhoea and growth failure Solid foods introduced at age of one year Nutrition education Promoting home-made weaning foods.

53. Nursing care of low birth weight baby: The objectives of management are to: Support respiratory effort Provide neural thermal environment Provide fluid and nutrition Prevent infection Provide sensory stimulation Keep mother infant attachments

54. Support respiratory effort: Position-neck slightly extended, use shoulder roll. Continuous monitoring of SPO 2 If apnea occurs, give tactile stimulation by flicking on soles Administer O 2 by hood method. Prevent complication of retrolental fibroplasia.

55. LBW: Keeping warm in hospital Overhead Radiant warmer

56. Maintaining Temperature Temperature of nursery should be maintained 30+/- 2 C Temperature probe should be attached to skin of baby. Monitoring of temperature for hyperthermia and hypothermia.

57. LBW: keeping warm at home well covered newborn

58. LBW: Fluids and feeding Weight <1200 g; Gestation <30 wks* Start initial intravenous fluids Introduce gavage feeds once stable Shift to katori -spoon feeds over next few days. Later on breast feeds

59. LBW: Fluids and feeding Weight 1200-1800 g; Gestation 30-34 wks* Start initial gavage feeds  Katori -spoon feeding after 1-3 days Shift to breast feeds as soon as baby is able to suck

60. LBW: Fluids and feeding Weight >1800 g; Gestation > 34 wks* Breast feeding  Katori -spoon feeding, if sucking not satisfactory on breast Shift to breast feeds as soon as possible

61. LBW: Feeding schedule Begin at 60 to 80ml/kg/day Increase by 15ml/kg/day Maximum of 180-200ml/kg/day First feed at 2 hrs of age then every 2 hourly

62. LBW: Feeding Gavage feeding

63. LBW: Feeding Paladi / Katori -spoon feeding

64. Guidelines for the modes of providing fluids and feeding Age Categories of neonates   Birth weight (gm) Gestation (wks) Condition <1200 < 30 weeks 1200-1800 30-34 weeks >1800 > 34 weeks Initial Intravenous fluids Try gavage feeds, if not sick Gavage Breast feeding. If unsatisfactory, give katori-spoon feeds After 1-3 days Gavage Katori -spoon Breast Later (1-3 wks) Katori-spoon Breast Breast After some more time (4-6 wks) Breast Breast Breast

65. Prevention of infection:

66. Danger signals (Early detection and referral) Lethargy, refusal to feed Hypothermia Tachypnea, grunt, gasping, apnea Seizures, vacant stare Abdominal distension Bleeding, icterus over palms/soles