Management of LBW Babies

low birth weight babies and their management

1. Management of Low Birth Weight babies Dr. Keshav C handra

2. Learning objectives To understand the types and causes of LBW To learn how to differentiate Preterm LBW from Term LBW infants To recognize the problems of LBW neonates To learn the principles of management

3. Low birth weight (LBW ) Definiti o n : Birth weight < 2500 g irrespective of their period of gestation Incidence : ~ 30 % of neonates in India

4. Categories of LBW babies LBW – Birth weight < 2.5 KG. VLBW – Birth weight < 1.5 KG. ELBW – Birth weight < 1.0 KG . High incidence of LBW babies in our country is accounted for by a higher number of babies with IUGR(small-for –dates) rather than the preterm babies. .

5. LBW: Significance LBW babies account for about 75% neonatal deaths and 50% infant deaths LBW babies are more prone to: Malnutrition Infections Neurodevelopmental delay LBW babies have higher mortality and morbidities

6. Types of LBW P r eterm < 37 completed weeks of gestation Account for 1/3 rd of LBW Small-for-date (SFD) / intra uterine growth retardation (IUGR) < 10 th centile for gestational age Account for 2/3 rd of LBW neonates 2 types based on the origin

7. Intrauterine growth chart 400 800 160 1200 2000 2400 2800 3600 3200 4000 4400 31 33 35 42 44 45 PRETERM TERM POST-TERM APPROPRIATE FOR DATE SMALL FOR DATE LARGE FOR DATE 90 th percentile 10 th percentile 37 39 Gestation (weeks) Birth weight (grams)

8. Causation: LBW Etiology of prematurity Low maternal weight, teenage / multiple pregnancy Previous preterm baby, cervical incompetence Antepartum hemorrhage, acute systemic disease Induced premature delivery Majority unknown

9. Etiology of SFD / IUGR Poor nutritional status of mother Hypertension, toxemia, anemia Multiple pregnancy, post maturity Chronic malaria, chronic illness Tobacco use Causation: LBW Teaching Aids: NNF LBW- 9

10. LBW (Preterm) : Problems Birth asphyxia Hypothermia Feeding difficulties Infections Hyperbilirubinemia R es pira t ory distress Retinopathy of prematurity Apneic spells I n t ra v en t ri c ular hemorrhage Hypoglycemia Metabolic acidosis

11. Birth asphyxia Meconium aspiration syndrome Hypothermia Hypoglycemia Infections Polycythemia LBW ( SFD /IUGR ) : Problems

12. Management Antenatal management :- Mother is an ideal transport incubator – high risk mother should be referred for confinement to a centre equipped with good quality obstetrical & neonatal care. Arrest of labour – Rest, sedation& tocolytic agents – Isoxsuprine . Assessment lung maturity:- by L/S ratio or phosphatidyl glycerol level in amniotic fluid (before the induction of premature labour ), when it is required in the interest of mother or fetus .

13. Anten a tal stero i d – Less than 34 W ee k s GA - Betamethasone – 12 mg IM 24 Hourly – 2 Doses OR - Dexamethasone – 6 mg IM 12 Hourly – 4 Doses - Opti m al e f fe c t – After 24 hrs of last dose - Therapeutic effect lasts for 7 days.

14. Labour Room Op t imal Care Transfer mother to a well-equipped centre before delivery of an anticipated LBW baby. Skilled person needed for effective resuscitation. Prevention of hypothermia - topmost priority. Delay clamping of cord – Imp r o ves i r on sto r e & d e c r ease incidence & severity of HMD. Promptly dry , cover & warm. Resuscitation with T-piece resuscitator Elective intubation & prophylactic Surfac t ant adm i nistr a t i on – In E L BW (by INSURE method) Early CPAP –if retraction Rescue surfactant –in NICU VIT-K – 0.5 mg IM.

15. LBW: Indications for hospitalization Birth weight less than 1800 gm Gestation less than 34 weeks Neonate who is not able to take feeds from the breast or by katori - spoon (irrespective of birth weight and gestation) A sick neonate (irrespective of the birth weight or gestation ) Teaching Aids: NNF LBW- 15

16. Babies > 1.8 kg. & > 35 Weeks GA If stable – Transfer to mother. Have close supervision in post natal ward.

17. Management in postnatal ward Monitoring:- By specially trained nurses. vital signs with the help of a multichannel vital sign monitor ( HR, RR, SPO 2 , NIBP, ECG & TEMP). Look for the colour , tone, cry, reflexes and activities. Tissue perfusion – suggested by - pink colour - CRT < 2 sec - warm & pink extremities - normal BP - U.O - > 1.5 ml/kg/hour - absence of metabolic acidosis - lack of disparity between Pao 2 & Sao 2.

18. Monitoring –contd.. fluids, electrolytes , blood sugar & ABGs . tolerance of feeds – vomiting, gastric residuals, abdominal girth. look for RDS, Apnoea , Sepsis, PDA , NEC, IVH . weight gain velocity – 10-15 gm/kg/day frequency of monitoring depends on gestational age & clinical status.

19. Provide in – utero milieu in NICU Aim is to c reate u t erus like b a by – f r iendly eco l ogy in nursery. Create a s oft, comfortable, nestled & cushioned bed. A v oid exc e ss i ve li g ht, sounds, ha n dling & painful procedures. Provide warmth Ensure asepsis Prevent evaporative skin losses by effectively covering the baby. Effective and Safe oxygenation. Provide partial parenteral nutrition & trophic feeds with EBM. P r ovide tactile & kin e st h etic stimulation like skin to skin contact, interaction , music, caressing & cuddling .

20. Maintainance of Temperature LBW babies should be nursed in a thermoneutral environment with a servo sensor to maintain skin temp of 36.5 C. ELBW baby should be covered with a cellophane sheet to prevent convective and evaporative heat loss from skin. Stable LBW baby should be covered with perspex shield or effectively clothed with a frock, cap, socks and mittens.

21. 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 Skin-to-skin contact Warm room, fire or heater Prevent heat losses Baby warmly wrapped Conduction Radiation Convection Evaporation

22. Well covered newborn LBW: Keeping warm at home

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

24. KMC Mother should be encouraged to provide partial KMC to prevent hypothermia, to promote bonding and breast feeding.

25. Starting KMC based on Birth weight <1200g 1200 to 1800g >1800g May take days to weeks before KMC can be initiated May take a few days before KMC can be initiated KMC can be initiated immediately after birth

26. 21 Kangaroo Ca r e

27. Oxygen therapy Oxygen should be administered only when indicated, given at lowest ambient concentration preferably blended with air. oxygen concentration adjusted so as to keep the saturation level the same as that used during NICU care for all babies <32 weeks (suggested target of 90% to 95%).

28. Fluid and Electrolyte The fluid requirement of LBW babies is higher due to greater insensible fluid losses because of larger surface area, faster breathing rate and more use of radiant heaters. Fluid : - B abies wt >1000gm – 10% dextrose IV. ELBW(< 1000 gm) – 5% dextrose IV. @80-100 ml/kg/day from day 1. -From Day 2 onward fluid containing electrolyte should be given. - Daily increment 15 ml/kg till day 7 - Add extra 20-30 ml/kg for infants under radiant warmer

29. Fluid requirement of neonates( ml /kg/day ) Day of life Birth Weight > 1500 gm < 1500 gm <1000 gm 1 60 80 100 2 75 95 115 3 90 110 130 4 105 125 145 5 120 140 160 6 135 15 5 175 7 150 1 70 190

30. Deciding the initial feeding method Two factors Hemodynamically stable or not? Feeding ability

31. Deciding the initial feeding method Is (s)he stable? Fast breathing (RR>60/min) Severe chest in-drawing Apnea Requirement for oxygen Convulsions Fever (>37.5 C) or low temperature (<35.5 C) Abnormal state of consciousness Abdominal distension If unstable, start intravenous (IV) fluids Presence of any one of these signs = UNSTABLE

32. Deciding the initial feeding method Feeding ability Gestational age Maturation of feeding skills Initial feeding method < 28 weeks No proper sucking efforts No gut motility Intravenous fluids 28-31 weeks Sucking bursts develop No coordination between suck/swallow and breathing OG tube feeding with occasional spoon/ paladai feeding 32-34 weeks Slightly mature sucking pattern Coordination begins Feeding by spoon/ paladai /cup >34 weeks Mature sucking pattern More coordination between breathing and swallowing Breastfeeding

33. Manage as per guidelines for sick neonates* Give oral feeds by cup/spoon/ paladai Is the baby able to breastfeed effectively? Is the baby able to accept feeds by alternative methods? When offered the breast, the baby roots, attaches well and suckles effectively Able to suckle long enough to satisfy needs Is the baby clinically stable? No Yes Yes Y e s No Is birth weight more than 1250 g? Y e s No Start intra-gastric tube feeds Start intravenous fluids Initiate breast feeding No Action Assessment * Assess daily for clinical stability ; once stable, assess for initial feeding method When offered cup or spoon feeds, the baby opens the mouth, takes milk and swallows without coughing/ spluttering Able to take an adequate quantity to satisfy needs

34. Gavage feeding

35. Paladai feeding

36. Progression of oral feeds Based on two factors Stable or not? Maturation of feeding ability

37. Baby on IV fluids Assess for stability If stable Introduce small amounts of intra-gastric tube feeds Baby on i ntra- Gastric tube feeds Monitor daily for signs of feeding readiness Offer small amounts of oral feeds by spoon/ paladai M ake him suckle at breast Put him on breast more frequently Baby on breastfeeding Continue breastfeeding Baby on oral feeds byspoon/ paladai Progressing from initial feeding method Put on breast Continue till the baby is on full spoon feeds

38. Choice of milk Breast milk Perfectly adapted to the infants’ needs Consistent evidence: Reduces infections and NEC Improves neurodevelopmental outcomes Long term effects on BP, lipid profile and pro-insulin levels

39. Choice of milk The best milk for a LBW infant is his/her own mother’s milk In case mother’s milk is not available, then the choices in order of preference are: Expressed donor milk (only where milk banking available) Infant formula (standard/pre-term formula) Animal milk: e.g. cow’s milk.

40. BW >1500 g Iron: from 2-3 months Multivitamin: from 2 weeks of life (for vitamin D) BW <1500 g Calcium & phosphorus Vitamin D & E; other vitamins Iron Zinc Nutritional supplements

41. Recommended supplements for infants >1500g Nutrient Route Dose When Iron Enteral 2 mg elemental iron/kg/day (maximum 15 mg/day) From 4 wk of life till of age of 2 yr Vitamin D Enteral 400-800 IU/day From 2 wk of age till age of 2 yr. Nutritional supplements

42. Supplements for breast milk fed infants <1500g Nutrient Route Dose When to start? When to stop? Calcium Enteral 140-160 mg/kg/day once infant is on 100 ml/kg/day of EBM Until 40 weeks post-menstrual age Phosphorus Enteral 70-80 mg/kg/day - do - Until 40 weeks post-menstrual age Zinc and vitamin A, B 6 , etc Enteral 1 ml/day - do - Vitamin D Enteral 400 IU/day - do - - do - Iron Enteral 2 mg/kg/day Started at 4 weeks of life Till 2 yr of age Nutritional supplements

43. Ask: how many times the infant feeds in 24 hours? Observe: the infant’s attachment and suckling if the infant seems to tire or if the mother takes the infant off the breast before completing a feed look for sore nipple / breast engorgement Feeding less than 8 times in 24 hours Poor attachment and ineffective suckling The baby tires or the mother takes him off the breast before completion of feeds Mother having sore nipple or breast engorgement Features that indicate inadequate breastfeeding Assessing feeding adequacy

44. Ask: how many times the infant feeds in 24 hours? the volume of each feed given by spoon/cup/ paladai Observe: is he spluttering/spitting the milk is he tiring or takes too long to take the required amount If each feed volume is less than that indicated Feeding the baby less frequently than recommended If there is excessive spilling during feeds Takes too long to finish the required amount Features that indicate inadequate spoon feeding Assessing feeding adequacy

45. Growth monitoring of LBW infants Weight pattern Loses 1 to 2% weight every day initially Cumulative weight loss 10 % in term LBW & 15% in preterm LBW in 1 st 7 day of life Regains birth weight by 10-14 days Therafter wt gain should be atleast 15- 20 gm/kg/day till a et of 2-2.5 kg is reached. After this a gain of 20-30 gm/day is considered appropriate.

46. Discharge of LBW infants Criteria for discharging a LBW infant :- - reach 34 wk of gestation and are above 1600 gm - show consistent wt gain for at least 3 consecutive days - hemodynamically stable - on full enteral feed(breast feed/ paladai /spoon) - not on any mediction (except vitamins and iron) - parents confident enough to take care of baby at home

47. Growth monitoring Growth charts Until 40 weeks: Dancis, Ehrenkranz After 40 weeks: WHO charts

48. Growth monitoring for PT neonates Modified Dancis chart

49. Key messages LBW infants - at risk of high mortality and significant morbidities Two major types of LBW - Preterm and IUGR/SGA Morbidities different in both types Choice of feeding method - based on the feeding ability of the infant Breast milk – milk of choice, irrespective of the feeding method