Management of Low Birth Weight Babies

Management of Low Birth Weight Babies

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

Teaching Aids: ENC NH- 2

Low Birth Weight (LBW)

Definition: Birth weight <2500 g

Incidence : ~30% of neonates in India


LBW: Significance

• LBW babies account for about 75% neonatal deaths and 50% infant deaths

• LBW babies are more prone to:• Malnutrition • Recurrent infections• Neurodevelopmental delay

LBW babies have higher mortality and morbidities


Types of LBW

Preterm

• <37 completed weeks of gestation

• Account for 1/3rd of LBW

Small-for-date (SFD) /

Intra Uterine Growth Restriction (IUGR)

• <10th centile for gestational age

• Account for 2/3rd of LBW neonates

Two types based on the etiology


LBW: Causation

Etiology of Prematurity

• Low maternal weight, teenage / multiple pregnancy

• Previous preterm baby, cervical incompetence

• Antepartum hemorrhage, acute systemic disease

• Induced premature delivery• Majority unknown


Etiology of SFD / IUGR

• Poor nutritional status of mother• Hypertension, toxemia, anemia• Multiple pregnancy, post maturity• Chronic malaria, chronic illness• Tobacco use

LBW: Causation


LBW: Identification of types

Prematurity

• Date of LMP• Physical features

• Breast nodule• Genitalia• Sole creases• Ear cartilage / recoil


Preterm vs Term LBW

Breast nodule

Preterm Term


Male genitalia

Identification: Preterm LBW

Preterm TermPreterm Term


Female genitalia


Preterm Term



Sole creasesPreterm Term


Ear Cartilage


Preterm Term


SFD / IUGR• Intrauterine growth chart• Physical characteristics

• Emaciated look• Loose folds of skin • Lack of subcutaneous tissue• Head bigger than chest by >3cm

LBW: Identification of SFD/IUGR


Intra uterine Growth chart

0

500

1000

1500

2000

2500

3000

3500

4000

4500

25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42

Gestation (weeks)

Bir

th w

eig

ht

(gm

)

10th centile 90th centile

AFD

SFD

LFD

Classification of neonates


2.1 Kg - IUGR 3.2 Kg - AFD

SFD / IUGR vs Term appropriate for date ( AFD)


LBW (Preterm) : Problems

• Birth asphyxia

• Hypothermia

• Feeding difficulties

• Infections

• Hyperbilirubinemia

• Respiratory distress

• Apneic spells

• Intraventricular hemorrhage

• Hypoglycemia

• Metabolic acidosis


• Birth asphyxia• Meconium aspiration syndrome• Hypothermia• Hypoglycemia• Infections• Polycythemia

LBW (SFD) : Problems


LBW: Issues at birth

• Transfer mother to a well-equipped centre before delivery

• Skilled person needed for effective resuscitation

• Prevention of hypothermia - topmost priority


LBW: Need for referral/admission

• Birth weight <1800 g• Gestation <34 wks• Unable to feed*• Sick neonate*

* Irrespective of birth weight and gestation


Keeping warm at home

Birth weight (Kg) Room temperature (0C)

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


Well covered newborn

Keeping warm at home


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

Deciding the initial feeding method

Two factors

1.Hemodynamically stable or not? 2.Feeding ability


Is (s)he stable?• Fast breathing (RR>60/min)• Severe chest in-drawing• Apnea• Requirement for oxygen• Convulsions• Fever (>37.50C) or low temperature (<35.50C)• Abnormal state of consciousness • Abdominal distension

If unstable, start intravenous (IV) fluids

If unstable, start intravenous (IV) fluids

Presence of any one of these signs = UNSTABLE



Feeding ability

Gestational age

Maturation of feeding skills

Initial feeding method

< 28 weeks No proper sucking effortsNo gut motility

Intravenous fluids

28-31 weeks Sucking bursts developNo coordination between suck/swallow and breathing

OG tube feeding with occasional spoon/paladai feeding

32-34 weeks Slightly mature sucking patternCoordination begins

Feeding by spoon/paladai/cup

>34 weeks Mature sucking patternMore coordination between breathing and swallowing

Breastfeeding



Manage as per guidelines for sick neonates*

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

Yes

No

Is birth weight more than 1250 g?

Yes

No

Start intra-gastric tube feeds

Start intravenous fluids

Initiate breast feeding

No

ActionAssessment

* Assess daily for clinical stability ; once stable, assess for initial feeding methodTeaching Aids: ENC NH- 27

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

Gavage feeding


Katori-spoon feeding


Based on two factors

• Stable or not? • Maturation of feeding ability

Progression of oral feeds


Baby on IV fluids

Assess for stabilityIf stable

Introduce small amounts of intra-gastric tube feeds Baby on intra-

Gastric tube feeds

Monitor daily for signs of feeding readiness

• Offer small amounts of oral feeds by spoon/paladai

Make him suckle at breast

Put him on breast more frequently Baby on

breastfeeding

Continue breastfeeding

Baby on oral feeds byspoon/paladai

• Put on breast

Continue till the baby is on full spoon feeds

Teaching Aids: ENC

Choice of milk

Breast milk

• Perfectly adapted to the infants’ needs

• Consistent evidence:

o Reduces infections and NEC

o Improves neurodevelopmental outcomes

o Long term effects on BP, lipid profile and pro-

insulin levels


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

Choice of milk


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


Recommended supplements for infants >1500g

Nutrient

Route Dose When

Iron Enteral 2 mg elemental iron/kg/day (maximum 15 mg/day)

From 2-23 months of age

Vitamin D

Enteral 200-400 IU/day Until 1 year of age



Supplements for breast milk fed infants <1500g

Nutrient Route Dose When to start? When to stop?

Phosphorus

Enteral

100 mg/kg From time of tolerating full enteral feeds

Until 40 weeks post-menstrual age

Calcium Enteral

200 mg/kg/day

- do - - do -

Vitamin D Enteral

400 IU/day - do - - do -

Iron Enteral

2 mg/kg/day From 2months of age

Until 23 months of age



Day of life Fluid requirements (mL/kg/day)

> 1500 g < 1500 g

Day 1 60 80

Day 2 80 95

Day 3 100 110

Day 4 120 120

Day 5 140 130

Day 6 150 140

Day 7 onwards 160+ 150* * If the infant is on intravenous fluids, do not increase beyond 140 -150 ml/kg/day

Feed volumes


Ask: how many times the infant

feeds in 24 hours?

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


Ask: how many times the

infant feeds in 24 hours? the volume of each feed

given by spoon/cup/paladai

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




Weight pattern*• Loses 1 to 2% weight every day initially• Cumulative weight loss 10%; more in

preterm• Regains birth weight by 10-14 days• Then gains weight up to 1 to 1.5% of birth

weight daily

Excessive loss or inadequate weight

• Cold stress, anemia, poor intake, sepsis

* SFD - LBW term baby does not lose weightTeaching Aids: ENC NH- 40

Growth monitoring

Growth charts

• Until 40 weeks: Dancis, Ehrenkranz• After 40 weeks: WHO charts


Growth monitoring for PT neonates

Modified

Dancis chart

Modified

Dancis chart


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


Documents

Management of Low Birth Weight Babies