Care of low birth

weight babies
 Introduction
Low birth weight baby(less than 2500
gm.) babies have higher morbidity and
mortality. Low birth weight baby result
from either preterm birth (before 37
completed weeks of gestation) or due
to intrauterine growth restriction
(IUGR) or both. IUGR is similar to
malnutrition and may be present in
both term and preterm infants.
Neonates affected by IUGR are usually
malnourished and have loose skin
folds on face and gluteal region.
Although the problem of pre-term
 The normal birth weight of is > 2500 to 3000
gm.
Low birth weight or LBW :
birth weight of less than 2500 gm
regardless to gestational age
Incidence : 15 30 %
Neonatal deaths : 75 % due to LBW
Infant deaths : 50 % caused by LBW
Complication :
Prone to malnutrition
Recurrent infection
Neurodevelopmental handicaps
DEFINITION
Low birth weight(LBW) is defined as
abirth weightof a live born infant of
less than 2,500 g (5 pounds 8
ounces) regardless of gestational age
Subcategories include:-
a. very low birth weight(VLBW)
which is less than 1500 g (3 pounds 5
ounces), and
b. extremely low birth
weight(ELBW) which is less than
1000 g (2 pounds 3 ounces).
Normal Weight at term delivery is
2500 g - 4200 g (5 pounds 8 ounces -
9 pounds 4 ounces).
 Preterm birth
Four different pathways have been
identified that can result in preterm
birth and have considerable evidence:
precocious fetal endocrine activation,
uterine overdistension, decidual
bleeding, and intrauterine
inflammation/infection From a
practical point a number of factors
have been identified that are
associated with preterm birth,
however, an association does not
establish causality.
small for gestational age
Beingsmall for gestational age
can be constitutional, that is,
without an underlying
pathological cause, or it can be
secondary to
intrauterine growth restriction,
which, in turn, can be
secondary to many possible
factors.
What Causes Infant Low Birth
Weight?
problems with the placenta, or
intrauterine growth restriction (IUGR)
complications with the pregnancy
not enough weight gain by the mother
birth defects
Poor maternal nutrition, incomplete
prenatal care, or drug or alcohol abuse
by the mother can also cause LBW.
Physical features
 Face and head
Face appears small for the disproportionately large
head size, sutures are widely separated and
fontanels are large.
Small chin, protruding eyes due to shallow orbits
and absent buccal pad of fat.
Optic nerve is often unmyelinated but presence of
pupillary membrane makes it visualization difficult.
Ear cartilage is deficient or absent with poor recoil.
Hair appears woolly and fuzzy and individual hair
fibers can be seen separately.
Skin and subcutaneous
tissue
Skin is thin, gelatinous, shiny and
excessively pink with abundant lanugo
and very little vernix caseosa.
Edema may be present.
Subcutaneous fat is deficient and
breast nodule is is small or absent.
Deep sole creases are often not
present.
 Genitals
In males, testes are undescended and
scrotum is poorly developed.
In females, labia majora are widely
separated exposing labia minora and
hypertrophied clitoris.
Issues in low birth
baby care
Central nervous system
The immaturity of nervous system is seen by lethargy and
inactivity.
Poor cough reflex, Inco-ordinated sucking and swallowing in
babies weighing less than 1800 gm or born before 35 weeks
of gestation.
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.
They are more resistant to toxic effects of hypoxia as
compared to the term babies.
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.
 Respiratory system

The cuboidal alveolar lining in babies with a

gestational age of less than 26 weeks results in
poor alveolar diffusion of gases and therefore the
infant may not be viable.
They pose resuscitation difficulty at birth, often
followed by hyaline membrane disease, if
associated with deficiency of pulmonary surfactant.
The breathing is mostly diaphragmatic, periodic
and associated with intercostal recession due to
soft ribs.
Pulmonary aspiration and atelectasis are common.
Resuscitation problem
Compromised intrauterine environment with higher
chances of perinatal asphyxia.
Immature lungs that may be more difficult to
ventilate and are also more vulnerable to lung
injury by positive pressure ventilation.
Immature blood vessels in brain are prone to
hemorrhage.
Thin skin and large surface area which contribute to
rapid heat loss.
Increased risk of hypovolemic shock caused by
small blood volume.
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 congenital heart
defect.
In grossly immature infant (less than
32 weeks) EKG shows left ventricular
preponderance.
Gastrointestinal
system
Due to poor or Inco-ordinated sucking, there are
difficulties in self-feeding although their digestive ability
is generally good.
Regurgitation and aspiration is common because of Inco-
ordinated sucking.
Small capacity of stomach, incompetence of cardio-
esophageal junction and poor cough reflex.
Abdominal distension and intestinal obstruction are due
to hypotonia.
Immaturity of glucuronyl transferase system in the liver
leads to hyperbilirubinemia, which may be aggravated
by dehydration, delayed feeding and hypoglycemia.
Relatively low serum albumin, acidosis and hypoxia in
these babies predispose to the development of
kernicterus at lower serum bilirubin levels.
The relative deficiency of vitamin- K dependent
coagulation factors and increased capillary fragility,
especially following hypoxia results in intraventricular or
intracerebral hemorrhage.
 Thermo regulation
Hypothermia is invariable and life
threatening unless environment
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. High surface
area to body weight.
 Infection
The low level of IgG antibodies and
inefficient cellular immunity
predispose them to infection.
Excessive handling, humid and warm
atmosphere, contaminated incubators
and resuscitators expose them to
infecting organisms, thus contribute to
high risk of infection.
 Renal immaturity
The blood urea nitrogen is high due to low
glomerular filtration rate. The renal tubular
ammonia mechanism is poorly developed thus
acidosis occur early. They are vulnerable to develop
late metabolic acidosis especially when fed with
high protein milk formula.
The maximum tubular diluting ability in the new
born is satisfactory but ability to concentrate urea
is very poor.
Preterm baby has to pass 4 to 5 ml of urine to
excrete one milliosmole of solute as compared to
0.7 ml by an adult for the same purpose. Therefore,
the baby cannot conserve water and gets
dehydrated readily. The solute retention and low
 Toxicity of drugs
Poor hepatic detoxification and
reduced renal clearance make a pre-
term baby vulnerable to toxic effects
of drugs unless caution is exercised
during their administration.
Nutritional
handicaps
Low birth weight babies are prone to develop
anemia around 6-8 weeks of age. This is due to
diminished total score of iron due to short
gestation. They may also manifest deficiency of
folic acid and vitamin E.
Vitamin-E deficiency occurs among infant weighing
less than 1.5 kg, particularly those fed on iron
fortified milk formula. These infant are prone to
develop hemolytic anemia, thrombocytopenia and
edema at 6-10 weeks of age.
Vitamin-E is an antioxidant, and its deficiency may
be associated with oxygen toxicity to vulnerable
tissues in the form of retrolental fibroplasia and
broncho pulmonary dysplasia.
Rapid growth following adequate feeding may
cause osteopenia and rickets unless calcium,
phosphorus and vitamin-D are administered.
Biochemical
disturbance
These babies are prone to hypoglycemia,
hypocalcaemia, acidosis and hypoxia.
Low hepatic glycogen stores with rapid
depletion in stress place these infant at
increased risk of hypoglycemia.
Immature glucose homeostatic mechanism in
premature babies can also leads to decreased
inability to utilize glucose and resultant
hyperglycemia, especially during stressful
period like infection.
Early onset of hypocalcemia; presenting within
3 days of life and is usually asymptomatic,
detected on investigation. It is especially seen
in premature babies, infants of diabetic
mothers and those with birth asphyxia. Feed
 Hematological
abnormality
Polycythemia; placental insufficiency with
intrauterine hypoxia leading to stimulation
of erythropoiesis and result in polycythemia,
especially seen in IUGR baby. Polycythemia
produces hyperviscosity with decreased
organ perfusion. Manifestations include
jitteriness, respiratory distress, cardiac
failure, feeding intolerance and
hypocalcemia.
Anemia ; accelerated destruction of fetal
RBCs, low reticulocyte count and inadequate
response of the bone marrow to
erythropoietin cause anemia of prematurity.
 LBW: Indications for
hospitalization
Birth weight <1800 g
Gestation <34 wks
Unable to feed*
Sick neonate Irrespective of birth
weight and gestation
 Danger signals (Early
detection and
Lethargy, refusal to feed
referral)
Hypothermia
Tachypnea, grunt, gasping, apnea
Seizures, vacant stare
Abdominal distension
Bleeding, icterus over palms/soles
Minimum Preparation for any
Birth:-
The following should be available and
in working order:
Heat source
Mucus extractor
Self-inflating bag of newborn size
2 masks (for normal and small newborns)
1 clock
At least one person skilled in newborn
resuscitation present at birth
Care of the Low Birth Weight
Newborn:-
Birth weight = Gestation duration +
intrauterine growth
Most low birth weight newborns in
developing countries are term or near
term (Small for gestation age)
Increased risk of hypothermia and poor
growth
 Delivery management
LBW is prone to be asphyxiated
Management at birth accordingly
to Guidelines of Resuscitation
(AHA/AAP)
Consider :
Early intubation
Early CPAP
Prevent hypothermia
Prevent hyperoxia
MANAGEMENT
 Arrest of premature
labour
Efforts should always be made to
arrest the progress of true labour.
Apart from bed rest and sedation, a
variety of tocolytic agents are
recommended but none is entirely
safe and effective.
Magnesium sulphate is more effective
but have very high risk of fetal
respiratory distress.
Induction of premature
When induction oflabour
labour is contemplated before
term, either in the interest of mother or the fetus
should be ascertained by examination of amniotic
fluid for phosphatidyl glycerol or L/S.
As far as possible, delivery should be postponed till
fetal pulmonary maturity is assured.
When delivery can be safely delayed for 36 to 48
hrs, administration of betamethasone or
dexamethasone to mother in a dose of 12 mg
intramuscularly in three doses in an interval of 12
hours is associated with significant reduction in the
incidence of hyaline membrane disease. The
prophylactic therapy benefit is seen more effective
in female infant than male.
 Labour room
When a preterm baby is delivered than
the delivery room should be attended
by a senior doctor, fully prepared for
resuscitate the baby.
The delayed clamping of cord helps in
improving the iron stores of the bay. It
may also reduce the incidence and
severity of future hyaline membrane
disease.
Vitamin-K 0.5 mg should be given
intramuscularly. The baby should be
 Nursery
A pre warmed incubator should be available at all
times to receive any baby with hypothermia or with
birth weight of less than 1.8 kg. the following
observation should be recorded by nurses:-
Skin and incubator temperature hourly for four hour
and then every four hourly.
Respiratory rate should be observed hourly for 24
hrs and then four hourly.
Child should be observed for apneic attacks or
preferably nursed on apneic monitor.
Colour, general activity, regurgitation, distension of
abdomen and consistency of stool should be noted
at all the time after each feeding.
Jaundice should be checked twice a day during first
 Position of the baby
Prone position improves ventilation,
increase dynamic lung compliance and
enhance arterial oxygenation.
It also make child comfortable.
It relieves abdominal discomfort by
passage of flatus and reduces risk of
aspiration.
Temperature regulation
During first 24-48 hours of life is very
critical for giving care to a child to
prevent hypothermia.
Kangaroo mother care.
Special attention to maintenance of
warm chain.
 Feeding
Intravenous feeding is recommended for babies
weighing less than 1200 gm and those with severe
birth asphyxia, respiratory distress syndrome,
apneic attacks and acute problem like diarrhea.
Fortified expressed breast milk is ideal for feeding
the preterm babies.
Mother room should be adjacent to nursery as it
improves the child mother emotional bond and
promote lactation and feeding with human milk.
Strict adherence to asepsis and hand hygiene.
Decreasing exposure to adults with communicable
diseases particularly respiratory.
 Respiratory problem
Continuous monitoring should be done
with cardiac monitor and apneic
monitor.
Oxygen is given to prevent hypoxic
brain injury.
Possible safe guard should be taken to
prevent oxygen toxicity.
Phototherapy
Due to immaturity of blood brain
barrier, hypoproteinemia and perinatal
distress factor, bilirubin brain damage
may occur at relatively lower serum
bilirubin levels.
Early phototherapy is advised to keep
serum bilirubin level within safe limits
and obviate the need for exchange
blood transfusion.
 Weight record
The weight should be recorded on alternate days
but for sick baby it should be recorded daily.
Mostly pre term babies lose weight during first 3-4
days of life and loss is up to 10-15percent of birth
weight. The weight remains same for the next 4 -5
days and then start gaining 1 to 1.5 percent of
body weight per day.
They regain birth weight by second week of life.
Excessive weight loss, delay in regaining the birth
weight or slow weight gain suggest that either the
baby is not being fed adequately or he is unwell
and need early attention.
Excessive weight gain of 100 gm or more per day
may occur in babies with cardiac failure.
Nutritional supplement
Hemoglobin and reticulocyte count should be checked once
weekly. Multivitamin drops with folic acid supplementation
should be stared at two weeks of age. Early
supplementation of iron is not recommended because it
may increase the requirements of vitamin-E. Early loading
of iron in infants make them prone to infection by depletion
of unsaturated lactoferrin, which is credited to possess
useful antibacterial properties.
Free radical lipid peroxidation in cell membranes is
catalyzed by iron and polyunsaturated fatty acids (PUFA)
thus increase requirement of vitamin-E in very low birth
weight babies. The requirements of vitamin-E are,
therefore, related to linoleic acid content formula. It is
recommended that vitamin-E to linoleic ac id ratio should
be greater than 1 iu/gm of linoleic acid. Vitamin E is
powerful antioxidant and prevents hemolytic anemia and
edema of prematurity.
Transfer from incubator
to cot
A baby who is able to feed properly is
responsibly active with a stable body
temperature, irrespective of his body
weight, qualifies transfer to cot. The
baby should be observed for another
12 hours after putting the incubator
off to see whether he can maintain his
body temperature.
The infant should be stay in incubator
for as short a period as possible
because incubators are a potent
 Child-parent contact
Parents must be fully informed about
progress of baby.
Mother should be encouraged to come
in nursery and touch her baby.
Mother should be involved in the care
of baby to promote infant mother
bonding.
During her visit to nursery routine care
of the baby, art of feeding , need for
warmth, importance of hand washing
 Principles of
Management for
Low Birth Weight
and Preterm
Newborns
Warmth
Feeding
Detection and management of
complications (e.g., resuscitation,
assisted respiration)
 Warmth
As for all newborns:
Lay newborn on mothers abdomen or
other warm surface
Dry newborn with clean (warm) cloth
or towel
Remove wet towel and wrap/cover
with a second dry towel
Bathe after temperature is stable
Kangaroo Mother Care
Early, prolonged and continuous skin-
to-skin contact between a mother and
her newborn Could be in hospital or
after early discharge.
How to Use Kangaroo
Mother Care
 Newborns position:
Held upright (or diagonally) and prone
against skin of mother, between her
breasts
Head is on its side under mothers chin,
and head, neck and trunk are well
extended to avoid obstruction to airways
 Newborns clothing:
Usually naked except for nappy and cap
May be dressed in light clothing
Mother covers newborn with her own
clothes and added blanket or shawl
Newborn should be:
Breastfed on demand
Supervised closely and temperature
monitored regularly
Mother needs lots of support
because kangaroo care:
Is very tiring for her
Restricts her freedom
Requires commitment to continue
Benefits of Kangaroo
Mother Care
Is efficient way of keeping newborn warm
Helps breathing of newborn to be more regular;
reduce frequency of apneic spells
Promotes breastfeeding, growth and extra-
uterine adaptation
Increases the mothers confidence, ability and
involvement in the care of her small newborn
Seems to be acceptable in different cultures
and environments
Contributes to containment of cost salaries,
running costs (electricity, etc.) Increases the
mothers confidence, ability and involvement in
the care of her small newborn
Seems to be acceptable in different cultures
and environments
Contributes to containment of cost salaries,
Feeding of low birth
weight babies
Majority of these infants are born at term, a
significant proportions are born premature with
inadequate feeding skills.
They are prone to have significant illnesses in
the first few weeks of life, the underlying
condition often precludes enteral feeding.
Preterm infants have higher fluid requirements
in the first few days of life due to excessive
insensible water loss.
Since intrauterine accretion occurs mainly in
the later part of the third trimester, preterm
infants have low body stores of various
nutrients at birth which necessitates
supplementation in the postnatal period.
 Early and exclusive
breastfeeding
Breastmilk = best nourishment
Already warm temperature
Facilitated by kangaroo care
If Breast milk is not availble, consider
milk formula : Preterm formula ---
until 2000 gm then change to After
Discharged Formula
START ANTIBIOTIC
ADMINISTRATION EVEN WITHOUTH
67
ANY SYMPTOMS
68
69
 Methods of feeding
The appropriate methods of feeding
actually depend upon following
factors:-
Whether the infant is sick or not.
Feeding ability of infant.
Level of sickness
 Sick infants
This group constitutes infants with
respiratory distress requiring assisted
ventilation, shock seizures, necrotizing
enterocolitis, hydrops. These infants
should be started on IV fluids. Enteral
feedings should be initiated as soon as
they are hemodynamically stable with
the choice of feeding method based on
the infants gestation and clinical
condition.
Healthy low birth infant-
Enteral feeding should be initiated
immediately after birth in healthy LBW
infants with appropriate feeding
method determine by their oral
feeding skills and gestation.
75
76
LBW: Supplements
Common problems and
its management
ESPIRATORY DISTRESS PROBLEM
Usually due to Hyaline Membrane
Disease ( HMD )
Assess : Antenatal steroids ???

CPAP : BUBBLE CPAP

Surfactant
 INFECTION :
ANTIBIOTICS
SUPPORTING TREATMENT :
NUTRITION
OXYGENATION
WARMTH
IMMUNOTHERAPY ; IF IT IS NEEDED
HYPERBILIRUBINEMIA
Accordingly to Level of Serum Total
Bilirubin

photo therapy
Feeding : Breast milk
Fluid therapy
Antibiotics according to
condition of infection
 APNEIC SPELL : APNEA

OF PREMATURITY
Very often : < 1500 grams
Complication : Hypoxemia
Oxygenation and breathing
stimulation : Aminophylline or
Theophylline
Mechanical Ventilator
 HYPOGLYCAEMIA
Awarness of symptoms , sometime
asymptomatic
Blood Glucose level
Hypoglycemia : < 45 mg/dL
Dextrose infusion
Glucose Infusion Rate ( G I R )
 INTRAVENTRICULAR

HEMORRHAGE
Due to weakness of blood brain
barrier and hypoxemia
Decreasing of consicousness , deficit
neurologics, seizure
USG or CT scan
Consult to Pediatric Neurology
Division and Neurosurgery
 METABOLIC ACIDOSIS
Due to hypothermia, hypoxemia and
infection
Confirmed by clinically and
laboratory
Should be corrected by considering
anion gap
Administration of bicarbonate :
awarness of false route
Home care
 Environmental control
The infant should be well covered; like woolen cap,
socks and mitten should be worn.
Infant should lie next to mother as it is useful as
biological controlled heat source.
In winter, room should be warmed with room
heater. The cot of the mother and infant should be
located away from walls to reduce radiation heat
loss.
Mother should be trained to assess baby
temperature and advised to ensure that extremities
are warm and pink.
The visitors handing should be restricted to bare
minimum. The hand should be wash before
touching to baby and before feeding.
Feeding :-
Breast feeding should be encouraged.
Criteria for
discharge
Screening test are performed before discharge or
on follow up e.g. those for ROP detection in
infants<32 weeks and auditory brainstem evoked
response (ABER).
Nutrition supplements including multivitamins, iron,
calcium and vitamin-D are started.
Immunization with BCG, hepatitis B and OPV is
given.
Weight gain should be consistently demonstrated
before discharge and plotted on growth chart,
which can be used on follow up to determine if
growth is adequate.
Baby should be feeding well, if on alternate feeding
technique like paladai feeding, the mother should
be confident regarding its detail.
Absence of danger signs and completion of
treatment like IV antibiotics. If baby is being
 All danger sign should be
explained to parents
History of difficulty in feeding.
in
Movement details
only whenlike:
stimulated.
Temperature below 35.5 degree
Celsius -37.5 degree Celsius.
Respiratory rate over 60 breaths per
minute.
Severe chest indrawing.
History of convulsion.
 General nursing
management in low
birth weight baby
care
 Maintenance of body
Thermal stability, maintenance of normal
temperature
core temperature within narrow limits,
results when a balance exists between
production and conservation of heat and
dissipation. So provision of neutral
temperature.
Thermal sensor should always be placed on
a part of the body that is exposed to the
circulating incubator air and not where the
skin temperature may be influenced by
cooler substance. Child should be put in
incubator. If incubator not available radiant
warmer should be available.
Proper checking of vital
signs:-
Child should be well observed for
apneic episode or any type of periodic
breathing.
 Prevention of infection
Handwashing and injury:-
and complete sterilization or
disinfection of equipment and supplies are
two important points to be remember to
prevent the risk of nosocomial infection.
Hand washing should also be done in
between handling different infants.
Proper infusion pump should be used so that
exact amount of fluid in minutes is given to
infant.
Nurse must look infilterated fluids around
insertion site like palmar area when the
insertion cannula is at the back of hand.
Before giving any medication nurse
should be clear about the action of the
drug and should be prepared for any
emergency condition like if vitamin-K
is to be given than nurse should be
prepare with its analogus, novobiocin
and oxygen.the computation,
prepration and administration of
parentral fluids or medication should
be done with serious responsibilities of
the nurse.
 Use of equipment
Nurse should have proper knowledge
and skill regarding monitoring devices,
ventilation, oxygen therapy and
infusion pumps.
She should be well skilled in parentral
and enteral feeding procedure.
If any malfunctioning or hazard is not
treated by nurse she should
immediately report and proper action
should be taken.
 Supporting and
educating parents
Parents should be encouraged to
confront the problem reliastically
instead of trying to pretend that it
does not exceed.
Parents need to know that their infant
will develop normally both physically
and mentally.
Parents should be encouraged to
report any concern they have to
primary nurse who know about their
infant.
Early infant stimulation programme
should be started which is beneficial to
parents and their children. By this
parents have the opportunity to learn
about infant development and about
methods of physical and psychological
stimulation as well as interacting with
the parents of same concern.
Parents needs encouragement in
learning to handle a small, delicate
neonate when they visit in
nursery.help the parents to feel secure
in their ability to care for the
 Prognosis
Prognosis for survival is directly
related to the birth weight of the child
and quality of neonatal care.
The prognosis for mental development
is good if there is no incident birth
hypoxia, apneic attacks, respiratory
distress and hypoglycemia.
Neurological prognosis is adversely
affected by degree of immaturity,
intrauterine growth retardation,
intraventricular hemorrhage and
severity of respiratory failure
 SUMMARY
Premature birth and low birth weight (LBW)
still a health problem with high Morbidity
and mortality
The survival at high risk of LBW for long
term neurocognitive deficits
Two types of LBW : premature and IUGR
Problems accordingly to the type
Management consist of : warmth, feeding,
management of complication
Breast feeding is prioritized, in case of
breastmilk is not available, consider milk
formula
 Conclusion
Low birth weight babies have high
survival rate if they are managed well
at the initial stage of their problem
and get cured. If there is no incidence
of hypoxia and apneic episode then
these infants are neurologically also
normal.