THE LOW

BIRTH WEIGHT INFANT

Julniar M Tasli
Herman Bermawi
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.

OBJECTIVE
NEWBORN INFANT CLASSIFED
ACCORDING TO :
1. Birthweight
# < 2500 g : Low birthweight (LBW)
# < 1500 g : Very low birthweight (VLBW)
# < 1000 g : Extremely low birthweight (ELBW)
2. Gestational age
# < 37 weeks : Preterm
# 37 42 weeks : Term
# 42 weeks : Post term
3. Size for gestasional age
# Weight beween 90
th
& 10
th
centile for gestation : AGA
# Weight < 10
th
centile for gestation : SGA
# Weight > 90
th
centile for gestation : LGA
b 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 37
th
week of
pregnancy.
# May not be ready to live outside the uterus
and may have difficulty initiating breathing,
sucking, figting infection and stay warm.

2. 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.
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

4. Babies who have :
# Congenital or genetic abnormalities
# An infection while in uterus ( TORCHs
infection )


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.
2. Lanugo : There is a lot of this fine hair all over the
babys body
3. Limbs : The limb are thin and may be poorly flexed or
floopy due to muscle tone
4. Head size : The head appears large in proportion to the
body. Fontanella are smooth and flat
5. Genital : Male, the testes may not be descended and
scrtum may be small. Female, The clitoris and labia
minora may be large
6. Sole of feet : Creased are located only in the anterior t
hird of the sole, not all over, as in term newborn

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 oro-
gastric/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 Asymmetrical
Baby's head and length
are preserved

Occur when the fetus
experiences a problem
later in pregnancy
Baby's head and body are
proportionately small

May occur when the fetus
experiences a problem
during early development
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.
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
Types of SGA / IUGR
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