PPT_Low Birth Weight & Preterm care -.pptx

PPT_Low Birth Weight & Preterm care -.pptx

1. Care of Low Birth Weight Baby

2. Care of Low Birth Weight Baby

3. Learning Objectives The participant after completing this module should be able to:- Define LBW Classify types of LBW Identify risk factors for Preterm delivery Identify physical features of preterm and assess the gestation using chart Enumerate problems of preterm & SGA. Chart fluid and feed requirements for a sick LBW neonate. Enumerate modes of enteral feeding & for nutritional supplements for LBW babies Follow up of a LBW baby

4. Burden In India Low Birth Weight (LBW) denotes birth weight of less than 2500 gm. In India, 2.6 crore babies are born every year out of which approximately 18 % ( estimated 50 lakh) are LBW and 13% ( estimated 35 lakh )are preterm . (born alive before37 completed weeks of pregnancy) Even after recovering from neonatal complications, some LBW babies may remain more prone to malnutrition, recurrent infections, and neuro development handicaps. LBW, therefore, is a key risk factor of adverse outcome in early life. Mortality of LBW babies is inversely related to gestation and birth weight and directly to the severity of complication . In general, over 90% Low Birth Weight babies who receive appropriate care & adequate attention to feeding and nutrition have no neuro developmental handicaps with improved survival and well being.

5. Definitions Consider 2 parameters in a newborn : Birth weight of the baby (normally babies weigh more than 2500) The Gestation or the maturity of the baby : Term: 37 to 41weeks +6 days Post-term: ≥ 42 completed weeks Preterm is defined as a baby born alive before 37 completed weeks of pregnancy. Note: The baby is 40 weeks on the EDD (Expected Date of Delivery).  TWO TYPES OF LBW   Prematurity : Babies born before 37 completed weeks of gestation. Small for gestational age (SGA): Babies with birth weight below the 10th percentile, for that gestational age and sex. 60% of our LBW neonates fall in this category. Note: At times, a LBW neonate may be both preterm as well as SGA . SGA & IUGR are not interchangeable IUGR describes a fetus that is “falling off” / has diminished growth velocity documented by at least two intrauterine growth assessments and includes neonates with clinical evidence of malnutrition viz. loose skin folds on the face and in the gluteal region, absence of subcutaneous fat and peeling of skin.

6. SUB CATEGORIES

7. RISK FACTORS FOR PRETERM DELIVERY History of a previous premature birth Physical injury or trauma Mother’s age – < 18 years & > 35 years of age Uterine, cervical or placental abnormalities Being underweight or overweight before &/or during pregnancy Substance abuse Multiple Pregnancy Poor nutrition Conceiving through in vitro fertilization Infections Multiple miscarriages or abortions Chronic conditions, such as high blood pressure and diabetes Most of the times there is no identifiable risk factor. Stressful life events, such as the death of a loved one or domestic violence

8. LMP and Antenatal Ultra sonography USG ( esp 1st trimester) facilitate in estimating correctly IDENTIFICATION OF A PRETERM Expanded New Ballard Score (ENBS)

9. Intergrowth 21 ‘Newborn size at birth’ Point A represents a preterm infant. Point B indicates an infant of similar birth weight who is born at term but small for gestational age . The growth curves represent the 10th and 90th percentiles for all of the neonates in the sampling All babies should be classified as soon as they are admitted to SNCU for prognostication and appropriate monitoring. (Adapted from Villar et al : intergrowth 21 growth Charts)

10. Problems are prone to develop: Asphyxia Additional resuscitative measures required due to ---large body surface area, immature organ systems, fragile brain capillaries, weak chest muscles coupled with immature lungs and a frail immune system extent of support required increases with degree of prematurity . G entle handling are required to prevent neurologic injury and heat loss, optimize oxygenation, provide respiratory support and prevent infection during resuscitation of these vulnerable neonates. Hypothermia Special attention for maintenance of the ambient temperature of the labour room at 26- 28­ C ensuring warm and gentle resuscitation because of large body surface area and decreased brown fat Feeding difficulty Preterm neonates have immature oropharyngeal coordination and poor reflexes for feeding. Some of the sick preterm babies and those who are extremely preterm need i /v fluids initially. Details given later Respiratory distress Due to physical immaturity of the lungs (deficiency of surfactant) preterm babies often present with respiratory distress soon after birth. They may develop respiratory distress later due to hypothermia, pneumonia, late onset sepsis or metabolic problems like hypoglycemia etc. Avoid complications related to hyperoxia while giving oxygen to these small babies Metabolic   Problems Most common metabolic problem… hypoglycemia can be avoided by careful monitoring of blood glucose at specified intervals and providing appropriate fluids and feeds. Calcium and other electrolytes also need careful monitoring. Problems of the preterm LBW infant due to immaturity of its organ systems

11. Problems Infections Prematurity is one of the most important risk factor for both early and late onset sepsis. Decreasing invasive interventions, maintaining temperature, minimal handling, promoting breastfeeding & KMC and maintaining proper hand hygiene are the best preventive strategies to reduce sepsis . Jaundice Functional immaturity of the liver and other prematurity related factors … increased bilirubin production and poor bilirubin conjugating capability leading to high bilirubin levels . immaturity of the blood brain barrier puts them a t risk of developing neuro-toxicity at lower bilirubin levels than full term babies Frequent monitoring of bilirubin levels and timely initiation of phototherapy prevents neurotoxicity. Brain injury Babies born before 28 weeks are at risk of bleeding in the brain, known as an intra-ventricular haemorrhage due to fragile capillaries. Most haemorrhages are mild and resolve with little short-term impact but some have larger bleeds causing permanent brain injury . Minimise the risk of occurrence of bleeds by slow administration of fluids and drugs avoiding sudden changes in blood pressure and follow a policy of minimal handling . Apnea of prematurity immaturity of the respiratory centre may lead to apneic spells without any evident attributable cause Close monitoring and prompt action by way of stimulation, drugs or assisted ventilation may be required. Watch for

12. Problems Anemia of prematurity Physiological anemia gets exaggerated in preterm babies due to various factors. Monitor the hemoglobin levels and treat the anemia according to standard protocols. Retinopathy of Prematurity (ROP) The immature retina of preterm babies is very susceptible to oxidant damage and risk of development of ROP, a major cause of blindness. To reduce oxidant damage meticulously monitor Oxygen levels during respiratory therapy using pulse oximetry so that at no time saturation be more than 95% Hearing loss Risk for sensorineural hearing loss increases as the gestation and birth weight decreases. Hearing loss can be caused by ototoxic drugs like aminoglycosides and furosemide which are commonly used in preterm. Asphyxia , severe jaundice needing exchange transfusion, prolonged ventilator support (> 5 days), sepsis and meningitis are all important risk factors of sensorineural hearing loss. All preterm babies must undergo hearing screening at specified times. Others Few babies develop other long term complications like cerebral palsy, impaired cognitive skills, behavioural and psychological problems, chronic health issues, etc. It is very important to follow these babies to detect and treat disabilities as early as possible. Watch for (cont .)

13. Provide Respiratory support- CPAP (Continuos Positive Air Pressure) Optimize oxygenation Prevent heat loss - care in a radiant warmer Prevent neurologic injuries Do no harm Preterm care includes Cluster of care, nesting , oiling, cling wrap application Gentle and minimal --- Handling, noise, lighting… DSC AIM OF THE PRETERM CARE Best preventive strategies for infections are: Maintain proper hand hygiene Minimal handling Maintaining temperature Decrease invasive interventions Promote breastfeeding and KMC Phototherapy CPAP

14. 5 core components of Developmentally Supportive Care DSC reduces stress and promotes growth in the preterm neonate by providing a womb like atmosphere. Stimulation of the early developing senses & KMC is the best form of DSC. Provide a supportive Environment to make Preterm birth less stressful event for families, especially mothers are at risk of developing higher levels of anxiety, depression ,anger and stress

15. NEONATAL SENSORY SYSTEMS Early stimulation promotes growth and development KMC - BEST DEVELOPMENTALLY SUPPORTIVE CARE … stimulates all the senses

16. PRE TERM BABY BED Preparing a nest like oval boundary around the infant, which promotes in utero feeling and promotes protected sleep NESTING CLING WRAP APPLICATION

17. PROBLEMS IN LBW BABIES The basic underlying problem amongst them is in-utero under nutrition and hypoxia. They are more prone to: Fetal distress, meconium passage in utero and perinatal asphyxia. Polycythemia Hypothermia Hypoglycemia Congenital malformations.

18. Place of Delivery: In hospital with established newborn care facilities. The in-utero transfer of a LBW fetus is far more desirable, convenient and safe than transport after birth.   Place of Management for LBW : weighing >1800 grams (>34 weeks): w ith the mother in post natal care area along with extra assistance and monitoring . weighing less than 1800 grams (<34 weeks) : SNCU(Special Newborn Care Units), till they can be shifted to the mother side. MANAGEMENT OF LBW BABIES Any baby who is unable to feed from the breast or katori spoon or is sick should be immediately admitted to the SNCU/NBSU.

19. BABY WITH THE MOTHER Counselling and training of Mother By the health care provider, doctor or Birth companion or counsellor wherever available on a regular basis. Mother during her stay to be trained on: Kangaroo Mother care (KMC) assessment of temperature by touch technique Breastfeeding and expression of milk LBW feeding (content and technique) Recognition/reporting of danger signs and Inputs into all her queries related to care of a LBW baby. Note: Many of these babies do not need IV fluids, antibiotics and o xygen

20. Temperature Management (Keeping LBW Babies Warm) At home Baby should be nursed next to the mother The room should be kept warm. The baby should be clothed well (2-3 layers of clothes). Feet should be covered with socks, hands with mittens and head with a cap. A blanket should be used to cover the baby. The mother should be trained to monitor the baby for cold stress by hand touch. The baby in cold stress should be given additional warmth immediately. BABY WITH THE MOTHER (cont.)

21. Nutrition and fluids Enteral feeds should be initiated as early as clinically appropriate in all stable LBW babies. Consider the following while planning the feeding of the LBW baby: Type of feeding : Mother’s milk (hind milk), The multi component fortified breast milk should be only reserved for the preterm <32 weeks gestation or <1500 grams, who fail to gain weight despite full volumes of breastfeeding . Quantity of feeds : In a stable, growing LBW baby daily intake of feeds should be gradually built up to 150 ml/kg and increased thereafter if needed (generally up to 180mL-200ml/Kg in babies <32 wks / < 1500 grams). The quantity delivered should be monitored and charted. Frequency of feeding : every 2 hours starting as soon as possible after birth. Mother’s milk is the best feeding option for the LBW infants Modality of feeding that is appropriate for the baby. neonates less than 30 wks (or 1200 grams need to be tube fed to avoid aspiration as do not have suck-swallow coordination. ) those less than 1800 but more than 1200 grams can to be fed by katori spoon/ paladai babies > 1800gms can be breastfed One should also consider the presence or absence of sickness and individual feeding efforts of the baby to decide how a LBW neonate should be provided fluids and nutrition.

22. Guidelines for the modes of providing fluids and feeding Birth Weight (gm) <1200 1200-1800 >1800 Gestation (wks) <28 28-31 and 31-34 >34 Initial Intravenous fluids. Try gavage feeds, If not sick Gavage Breastfeeding. If unsatisfactory, give katori -spoon feeds After 1-3 days Gavage Katori-spoon Breastfeeding Later (1-3 wks) Katori-spoon Breastfeeding Breastfeeding After some more time (4-6 wks) Breastfeeding Breastfeeding Breastfeeding The facilitator may conduct a drill on mode of feeding considering different examples

23. Techniques or Methods of Feeding Non-Nutritive Sucking T rophic Feeds (Minimal Enteral Nutrition) Gavage feeds Katori (cup )-spoon feeds Breast feeding

24. Techniques or Methods of Feeding Non-Nutritive Sucking (NNS) Pre terms develop the sucking behaviour (co-ordinated sucking, swallowing and breathing) over time to be able to feed on breast. This transition may be facilitated by encouraging Non-Nutritive sucking (NNS) in these small babies. The NNS sucking is initiated by allowing the baby to suck on an empty breast (after expression). The NNS may be started right from the time the baby is on gavage feeds. NNS may encourage the development of sucking behaviour, improve digestion of the feed, blood oxygenation and has shown to reduce hospital stay . Minimal Enteral Nutrition (MEN) Minimal enteral nutrition or trophic feeds are small volumes of expressed breast milk (typically 12 to 24 ml/kg/day every 1 - 3 hours) delivered intra gastric and started early in sick babies. These feeds enhance the gut growth, hormonal secretion, motility in a LBW neonate. The clinical benefits of MEN are; less feed intolerance, reduction in the days required for attaining full feeds, improved weight gain, fewer days on parentral nutrition and decreased hospital stay. The augmentation of feeds after MEN may be done as per guidelines in the IV Fluids chapter.

25. For gavage feeding; place 5-6 French size polyethylene orogastric feeding catheter irrespective of weight of the baby. (Details on insertion of feeding catheter will be taught at the skill station). At the time of feeding, the outer end of the tube is attached to a 10 ml syringe (without plunger) and milk is allowed to trickle by gravity. Place the baby in the left lateral position for 15 to 20 minutes to avoid regurgitation but no need to burp The orogastric tube may be left in situ for 2 or 3 days or more. While pulling out a feeding tube, keep it pinched and pulled out gently to avoid trickling of gastric mucus into the trachea. The position of the tube should always be checked if in doubt by small aspiration of gastric content or by injecting one ml of air and hearing for a gurgling sound with a stethoscope placed over the stomach . Gavage feeds Routine pre-feed gastric aspirates are not recommended More prone to regurgitation and aspiration, hence DO take precautions during feeding. Measure the abdominal girth (just above the umbilical stump) before every feed If the abdominal girth increases by more than 2 cm from the baseline, evaluate for the cause of ileus and suspend feeds till the abdominal distension improves.

26. Katori (cup )-spoon feeds Feeding with a washed, cleaned and boiled spoon/ ‘ paladai and katori / cup ) is safe in LBW babies and serves as a bridge between gavage feeding and direct breast feeding. It is based on the premise that neonates with a gestation of 30-32 weeks or more are in a position to swallow the feeds satisfactorily even though they may not be good at sucking or coordinated sucking and swallowing. Take the required amount of expressed breast milk in the katori. Place the baby in a semi-upright posture with a napkin around the neck to mop up the spillage. Fill the spoon with milk, a little short of the brim, place it at the lips of the baby in the corner of mouth and let the milk flow into the baby’s mouth slowly avoiding spilling. The baby will actively swallow the milk. Repeat the process till the required amount has been fed. If the baby does not actively accept and swallow the feed, try gentle stimulation. If he is still sluggish, do not insist on this method. It is better to switch back to gavage feeds till the baby is ready . Assisted Breast Feeding Breast feeding is essentially the same as for the normal weight babies. LBW babies may be slow in sucking and take longer to feed.

27. Stable preterm and VLBW Infants: initiate feeding as early as within 2 hours of birth and 2hrly feeds subsequently Entire fluid requirement for the day can be given as enteral feeds starting from D1 of life ETEF (Early total enteral feeding) saves the infant from invasive interventions related to IVF like skin breach, pain, suboptimal weight gain, sepsis and parenteral nutrition associated metabolic syndromes . ETEF is not associated with increased feed intolerance or NEC, reduces antibiotic usage, duration of hospital stay and cost of therapy while promoting optimal growth Initiation and progression of assisted enteral feeds S ick preterm and ELBW infants: B abies with significant respiratory distress/ other signs of sickness/weighing <1 kg at birth:, initiate minimal enteral feeding @ 15–20 mL/kg/day as soon as baby is hemodynamically stable. If the feeds are tolerated (abdomen is soft and not distended with no increase in abdominal girth), consider increasing feeds @ 20-30 mL /kg/day. Further increments of 30-50ml/kg/day can be considered depending on the baby’s clinical condition. Such increments in enteral feeding have shown no increase in NEC, late onset sepsis or neurodevelopmental disability.

28. Judging Adequacy of Nutrition Weight pattern of the baby. Preterm LBW baby : loses up to 1 to 2 percent weight every day amounting to 10 percent cumulative weight loss during the first week of life. Birth weight is regained by the14th day . SGA-LBW babies : who are otherwise healthy should not have any appreciable weight loss at all and they should start gaining weight early . Weigh all LBW babies at 2 weeks (to check regaining of the birth weight). Once birth weight is regained, the LBW baby should gain 15 to 20gm/kg/day daily. Hospitalized LBW babies should be weighed every day on the same weighing machine . Optimal weight gain: Daily weight gain of 15-20 gms /kg/day Suboptimal weight gain: A gain of less than 10 grams/kg/day for three consecutive days.

29. Delayed initiation and slow augmentation of enteral feeds remains the most important cause of delay in regaining birth weight and subsequent adequate weight gain Check the following if weight gain is suboptimal Insufficient intake 2. Increased requirement Care of Low Birth Weight Baby (cont.)

30. Causes for Suboptimal weight gain 1. Insufficient intake Breastfed infants: Improper technique – (positioning/attachment) Infrequent breastfeeding (less than 8–10 times in 24 hours including nighttime feeding) Incomplete emptying of breast (prematurely terminating feed at breast- depriving baby of hindmilk) Infants on assisted feeding (spoon/ paladai ) Inadequate amount (error with calculation/measurement or missed feeds) Improper technique of feeding (e.g. excess spillage) Inadequate supplementation/fortification 2. Increased requirement Conditions - hypothermia/cold stress, feed intolerance, anemia, hyponatremia & late onset metabolic acidosis Disease states – Late onset sepsis, bronchopulmonary dysplasia, Osteopenia of prematurity, persistent PDA & GER Medications – corticosteroids

31. Management of suboptimal weight gain: Breastfeeding counseling of mothers and families including importance of MOM along with correct technique, frequency and nighttime feeding . Counseling regarding correct frequency and technique of assisted feeding (spoon/ paladai ) feeds . Provide practical support for breastfeeding and assisted feeding if required . Look for signs of fatigue during assisted/breastfeeding and modify mode of feeding Ensure appropriate and timely supplementation/fortification of breast milk . Prevent and manage underlying condition and disease states.

32. Vitamin K1 (Phytoandione, 0.5ml=1 mg of VitK 1 ) All LBW <1000 grams should receive 0.5 mg IM of Vitamin K 1 at birth and others 1 mg IM. Vitamin D All LBW infants who are exclusively breastfed should receive 400 IU daily of vitamin D, once they are receiving 100ml/kg/day of feeds. The supplementation should continue until one year of age. The larger doses (800-1000IU) may benefit the smaller babies (<1500 grams). Most available vitamin D drops contain 400 IU/ml. Iron Initiate Iron supplementation with 2-3 mg/Kg/day at 2 weeks of age and continue till one year of age. All very low birth weight babies (< 1500 grams) should receive the following supplements once they are on 100ml/kg/day of feeds and should be continued till 40 weeks post menstrual age (PMA). Multivitamin drops with Zinc : 1ml /day. Calcium and Phosphorous Calcium at 120-140mg/Kg/day and phosphorous at 60-90mg/ Kg/day (use preparations containing calcium and phosphorous in a 2: 1 ratio) Nutritional Supplements needed by LBW Babies:

33.   Temperature Management: overhead radiant warmer /incubator used to keep the baby warm. Regular monitoring of axillary temperature at least once every 6-8 hours. Fluid requirement On the first day the fluid requirements range from 60 to 80 ml/kg. The daily increment in all the groups is around 15 ml per kg till 150 ml/kg is reached. Adequacy of therapy is indicated by weight pattern in the expected range.   BABY IN SNCU

34. Following points should be considered prior to discharge: Weight gain consistently demonstrated for 3 consecutive days. Record weight , head circumference and the length at the time of discharge. Mother should be confident in feeding the neonate (Breast feeding / any alternate feeding method like paladai or spoon). Start required nutritional supplements and administer BCG, Hep B and OPV. The methods of temperature regulation like the KMC and any other skills should be well known to the mother and adequately practiced in the hospital under medical supervision. All danger signs (as below) should be explained in detail to the parents with information regarding whom and where to contact mentioned on the discharge slip Discharge Planning of LBW Babies

35. Follow-up   All preterm babies discharged from SNCU must be followed up for: G rowth monitoring Feeding Immunization S ystemic examination early detection of disability by a team of specialists. Effective referral system for sickness or higher care.

36. Discharge Planning of LBW Babies Once the mother and the family are confident and the health worker has assessed the knowledge and practice personally, the LBW baby can be discharged and managed at home . Screening for ROP : Babies <32 wks/<1500 grams at 32wks of PMA or 4wks of postnatal age, whichever is later. < 28wks : screen at 3wks of postnatal age to detect APROP????. Hearing evaluation : at 34 weeks of corrected gestational age or at discharge. USG Brain to detect Intracranial hemorrhage

37.   Vaccinations in LBW Babies LBW baby is not sick : the vaccinations schedule is the same for as the normal babies. A sick LBW baby : should receive these vaccines only on recovery at discharge.   Growth monitoring in LBW Babies All LBW infants should be checked for during their SNCU stay: weight (daily), head circumference (weekly) and length (weekly or fort-nightly) Serial growth monitoring allows early identification of growth faltering. Intergrowth charts (Annexure 16) can be used for preterm babies. WHO Growth charts (2006) should be used from corrected age of 40 weeks into childhood (Annexures 18&19).   . Discharge Planning of LBW Babies (cont .)

38. Preterm Labour Management Antenatal steroids (ANS) to mother : Government of India recommends Injection Dexamethasone 6 mg IM every 12 hrs (4 doses) to mothers at risk of imminent preterm birth (24-34 weeks and have optimal benefit when the delivery occurs 24 hrs after completion of therapy. However, even a single dose is beneficial . Institutional deliveries attended by trained staff, availability of functional equipment and essential drugs Safe transport & Functional and effective referral system Antibiotics for Preterm Pre-labour Rupture of Membranes (PPROM ) may help to prolong pregnancy giving time for ANS to act thus reducing number of short term morbidities. Amoxyclav to the mother should be avoided to prevent risk of NEC . Antenatal Magnesium Sulphate administration to mothers with imminent preterm birth (≤ 31+6 weeks) labour for fetal neuroprotection; should be considered ( I-A) a 4g IV loading dose, over 30 minutes, followed by a 1g/ hr maintenance infusion until birth or 24 hours, whichever first . Other determinants, Female education & empowerment, Improved maternal nutrition , better access to family planning, There is no role of giving steroids to the baby after birth to prevent the complications of prematurity

39. Essential care of the LBW neonates - a highly rewarding experience EXERCISE Mention the fluid requirement of a 1500 gm baby on D6 of life ? How will you initiate feeding in a 1400 gm 32 weeks gestation baby on D3 of life ? A 1350 gms baby is on enteral feeds @100ml/kg/day . What supplements will you advise; in what quantity and till what time will you continue the supplements ? A 1200 gms baby who has been admitted in the SNCU for the last 12 days is being discharged today. Mention the advice you will give the mother regarding care and feeding of this baby at home