THE LOW BIRTH WEIGHT INFANT

Julniar M Tasli Herman Bermawi

OBJECTIVE
1. Student must be able to understand the definition

and classification of low birth weight infant. 2. Student must be able to recognize risk factors which predispose of low birth weight infant. 3. Student must be able to diagnose low birth weight infant. 4. Student must be able to manage low birth weight infant.

NEWBORN INFANT CLASSIFED ACCORDING TO :

1. Birthweight # < 2500 g : Low birthweight (LBW) # < 1500 g : Very low birthweight (VLBW) # < 1000 g : Extremely low birthweight (ELBW) Gestational age # < 37 weeks : Preterm # 37 42 weeks : Term # 42 weeks : Post term Size for gestasional age # Weight beween 90th & 10th centile for gestation : AGA # Weight < 10th centile for gestation : SGA # Weight > 90th centile for gestation : LGA

2.

3.

Ballards Score

Ballards Score

FIGURE 3-2. Classification of newborns (both sexes) by intrauterine growth and gestational age. (Reproduced, with permission, from Battaglia FC, Lubchenco LO: A practical lassification for newborn infants by weight and gestational age. J Pediatr1967;71:159; and Lubchenco LO et al: Intrauterine growth in length and head circumference as estimated from live births at gestational ages from 26 to 42 weeks. Pediatrics 1966;37:403. Courtesy of Ross Laboratories, Columbus, Ohio 43216.)

THE LOW BIRTH WEIGHT INFANT Definition : A low birth infant baby is one who weight less than 2500 grams at birth The low birth infant divided into two clinical types : 1. The preterm infant ( prematurity ) 2. The small for gestational age infant ( small for dates, light for dates )

1.

Premature or preterm : # A baby born before the 37th week of pregnancy. # May not be ready to live outside the uterus and may have difficulty initiating breathing, sucking, figting infection and stay warm. Small for gestational age( SGA ) : # A baby who did not grow well enough in the uterus during fregnancy. # The baby usually full-term and often to breath and suck well.

2.

FACTORS ASSOSIATED WITH LOW BIRTH WEIGHT 1. Fregnancy in women who : # Age less than 20 years # Have birth that are less than 3 year apart or have many fregnancy ( five or more ) 2. Women who : # Had a LBW baby before # Are under weight and have poor nutrition. # Have health problem ( hypertension, anemia )

FACTOR ASSOSIATED WITH LOW BIRTH WEIGHT

3. Women who have pregnancy problem such as : # Severe anemia # Pre-eclampsia or hypertension # Infection during pregnancy ( Urinary tract infection, HIV/AID, malaria ) # Multiple gestation Babies who have : # Congenital or genetic abnormalities # An infection while in uterus ( TORCHs infection )

4.

THE PRETERM INFANT ( PREMATURITY )

WHO defines a preterm birth : < 37 completed weeks gestation (< 259 days).
Incidence of preterm deliveries : ? 33% small for gestational age, have different problems from the appropriate for gestational age preterm infant.

The paediatrician have an objective test for determine : # Gestational age : New Ballard examination # Size for gestational age : Lubchenco chart

CLINICAL CHARACTERISTIC
1. Skin : Maybe reddenes. The skin may thin so blood vesel are easiliy see. Lanugo : There is a lot of this fine hair all over the babys body Limbs : The limb are thin and may be poorly flexed or floopy due to muscle tone Head size : The head appears large in proportion to the body. Fontanella are smooth and flat Genital : Male, the testes may not be descended and scrtum may be small. Female, The clitoris and labia minora may be large Sole of feet : Creased are located only in the anterior t hird of the sole, not all over, as in term newborn

2.
3. 4. 5.

6.

SPECIFIC PROBLEMS
1. Birth asphyxia 2. Thermal instability 3. Lack of primitive survival reflexes, suck, swallow, and gag with high incidence of milk aspiration. 4. Jaundice 5. Pulmonary disease : apnoe, hyaline membrane disease, transient tachypnoea of newborn, pneumothorax, pneumonia, Wilson-Mikity syndrome and bronchopulmonary dysplasia. 6. Metabolic disturbances: hypoglycaemia, hypocalcaemia, hypomagnesaemia, hyponatraemia, hypernaetremia.

7. Patent ductus arteriosus : congestive heart failure. 8. Intracranial haemorrhage, especially intraventricular haemorrhage and subarachnoid haemorrhage. 9. Susceptibility to infection 10. Gastrointestinal intolerance and necrotizing enterocolitis 11. Opthalmic problems : retrolental fibroplasia, myopia, strabismus 12. Surgical lesions : undescended testes, inguinal and umbilical hernia 13. Haematological problems : haemorrhagic disease of prematurity, disseminated intravascular coagulation, iron deficiency anaemia 14. Renal immaturity : inability to concentrate urine, and inability to excrete an acid load with low renal bicarbonate threshold results in late (feeding) metabolic asidosis .

SUPORTIVE CARE
Resuscitation The Obstetrician and Paediatrician should ideally function as a perinatal team during premature labor appropriate assessment of perinatal asphyxia and resuscitation can be performed. Monitoring Heart rate and respiratory rate, blood pressure and temperature must be monitored continuously

Monitoring Total intake-output of fluids should be recorded every 24 hours in critically ill infants. Head circumference is measured twice weekly and plotted on a percentile graph. Daily weights are measured and recorded. Thermoregulation Body temperature must be maintained in the normal range (36,5-37,0C per axilla) by nursing infant in incubator.

Feeding Infants < 34 weeks gestation should be fed via an orogastric/naso-gastic tube. Prematures with small gastric volumes require frequent feeding (every 2 hours) and should be started on 2ml/kg/feed and increased in increment of 1-2ml/kg/every feed, as tolerated. Gastric aspirate must be checked before the next feed. The preterm infant should ideally be fed his own mothers expressed breast milk.

Parenteral fluids Sick babies and infants < 1500 g may need parenteral feeding Parenteral fluid requirements can only be determined by close observation of urine-output, urine osmolality, body weight and electrolytes. In general, fluid volumes for healthy preterm infants given enterally are: 60ml/kg-day 1; 80ml/kg-day 2; 100ml/kg-day 3; 120ml/kg-day 4; 140ml/kg-day 5; 160ml/kg-day 6; 180ml/kg-day 7.

Electrolytes Preterm infants receiving parenteral fluids should receives maintenance electrolytes after they have passed urine. Normally they require: sodium 2,5-3,0 mmol/kg/day; potassium 2,0-2,5 mmol/kg/day; calcium 45mg/kg/day. Vitamins A single intramuscuar dose 0,5 1,0 mg IM Vit.K1 at birth Preterm babies being fed with breast milk or vitamin fortified formulae will all need additional vitamin C (by day 3) and vitamin D.

Respiratory Distress Syndrome (RDS) RDS should be managed with humidified oxygen given in a controlled fashion via a head box, nasl CPAP or mechanical ventilation. Babies of birthweight < 2000g with RDS should be managed in an intensive care nursery.

Jaundice Extremely common in the preterm infant and must be followed with frequent bilirubin estimations. The treatment sheet provides guidelines for management of hyperbilirubinaemia.

Anemia The venous haematocrit should be maintained at > 40% in all sick babies. All preterm infants < 2500 g or 34 weeks gestation should receive supplemental iron in a dose of 30 mg daily from the age of three weeks.

THE SMALL FOR GESTASIONAL AGE INFANT

INSIDEN
Varies between countries, usually : 3-7% of all infants are SGA 20% of stillborn infants are SGA 25% of SGA Infants are Type I 75% of SGA infants are type II

ETIOLOGY
The causes SGA infants can be classified as extrinsic and intrinsic in origin 1. Extrinsic Extrinsic mechanisms operate during the latter half of pregnancy and may be associated with placental insufficiency. Fetal growth is affected because of inadequate supply line of nutriens and/or oxygen.

a. Maternal Factors # Maternal hypertension e.g. essential, pregnancy induced, renal. # Vascular disease, e.g. DM, cardiac, renal, sickle cell and collagen disease # Smoking, narcotic abuse

b. Placental and uterine factors

# # # # # Abnormal placentation Placental infarct, fibrosis, haemangioma Premature placental separation Single umbilical artery Uterine crowding e.g. multiple pregnancy, uterine abnormalities

2. Intrinsic The intrinsic group implies that there is something wrong with the fetus at the time of conception or during the first semester. a. Constitutional e.g. parental stature, racial, ethnic b. Chromosomal anomaly e.g. Trisomy 13, 18, 21, Turners Syndrome c. Fetal infections e.g. TORCH d. Maternal drugs e.g. chronic alcoholism, cytotoxic, heroin addiction e. Primordial dwarf, e.g. achondroplasia, Russel Silver Dwarf

CLINICAL FINDING
IUGR can be suspected by: poor maternal weight gain, suboptimal uterine growth, low or falling oestriol levels, reduced growth of biparietal diameter on serial USG Physical apperanceof babies in the intrinsic groupwill be characteristic of the spesific aetiology e.g. Toxoplasma, rubella, achondroplasia

 The growth failure in the extrinsic group is greatest for weight, then length and head circumference is least affected. There is little subcutaneous fat, the skin may be loose and thin, muscle mass is decreased, especially buttock and thighs, and the infant often exhibit wide eye, anxious faces.

SGA and IUGR are not synonymous SGA refers to the size of the infant at birth and not fetal growth IUGR suggests diminished intrauterine growth velocity IUGR indicates the presence of a pathologic process in-utero that inhibits fetal growth

SGA VS IUGR
A child who is born SGA is not always IUGR Infants born after a short period of IUGR are not always SGA SGA: IUGR Constitutionally small infant

Types of SGA infat

a. Symmetric: Weight, head circumference and length all < 2SD b. Asymmetric: Weight below 2 SD, but head circumference and length preserved

Classification

Symmetrical
Baby's head and body are proportionately small
May occur when the fetus experiences a problem during early development

Asymmetrical
Baby's head and length are preserved
Occur when the fetus experiences a problem later in pregnancy

In a normal infant, the brain weighs about three times more than the liver. In asymmetrical IUGR, the brain can weigh five or six times more than the liver.

Types of SGA / IUGR

Symmetric IUGR Type I
Early onset growth restriction Uniform growth restriction Long-term growth failure Associated with decreased cell number Associated with less catch-up growth in the first year of life

Asymmetric IUGR Type II

Late onset growth restriction Head Sparing Potentially reversible Associated with decreased cell size Infants demonstrate more catch-up growth than symmetric IUGR in first year of life

DIAGNOSIS
Decreased subcutaneous fat with soft tissue, desquamated skin, meconium stained Widened cranial sutures with large fontanelles Thin umbilical cord Skin and sole creases more mature than GA alert-looking and jittery Congenital malformations Stigmata of congenital infections

SPECIFIC PROBLEMS
1. Intrauterine : sudden fetal death, fetal distress during labor 2. At birth: birth asphyxia, MAS often complicated by pneumotorax

3. Neonatal period # Congenital malformations: There is 20 x increased incidence of congenital malformation in SGA babies compared with their birthweight peers # Infections: There is 7 x increased incidence of infections. The intrauterine infections may be the cause of the growth retardation, but SGA babies are also more likely to acquire a nursery infections

# Hypocalcaemia: the increased incidence of hypocalcaemia relates to the birth asphyxia & not to SGA infant # Hypoglycaemia : due to poor body reserves of brown fat & glycogen. # Polycythaemia :especially when there has been prolonged intrauterine hypoxia resulting in elevated levels of erythropoertin

# Thermal instability: maintenance of body temperature is a problem to the SGA infant but less so than for preterm infant. This probably related to the large surface area to body weight ratio. # Respiratory Distress: may due to MAS, Polycythaemia, massive pulmonary haemorrage or pneumonia but not usually due to RDS

4. Infancy and childhood Growth and development : in the neonatal period, the infant loses little weight & begins to gain weight rapidly after birth. However, this growth spurts is often not maintained & permanent deficit in somatic growth may persist into childhood.

MANAGEMENT If IUGR suspected: monitoring of fetal & uteroplacental function will be necessary with test such as 24 hr urinary oestriol, serial biparietal diameters, stress & non stress challenge test & L/S ratio of amniotic fluid prior to early delivery

A careful decision: best methode of & time of delivery will need to be made.

 The baby should be transferred to special care nursery for careful observation for signs of RDS, hypoglycaemia, & temperature instability. The SGA infants should commence feeds at 2 hr of age, if possible & initially feeding should be every 2 hr with dextrostix estimated of blood glucose before each feed.

The first feed should be D10% & then followed by full strength formula.

 The infant should receive 60 ml/kg on day 1 & increased to 200 ml/kg by day 7.If the infant develops hypoglycaemia (dextrostix < 2,2 mmol/l or < 40 mg/dl) dispite early feeding D10% is given by uninterrupted intravenous infusion, in the additional to the oral feed. A cappilary haematrocit at 4 to 6 hr of age should always be performed if > 70%, venous haematrocrit is indicated. If venous Ht > 70 or if the baby has symptoms polycytemia dilutional exchange transfusion with FFP is indicated

TERIMAKASIH