MODULE 4: LOW BIRTH WEIGHT BABYScenario 2

GROUP 10

Scenario 2

A girl baby, 3 days old, referred from midwife to hospital with face and

body looked yellow. From alloanamnesis the baby was born 3 days ago by midwife with birth eight

1500 gr and gestational age 8 months when she was born. Her

mother smokes tobacco regularly.

Keywords

A girl baby, 3 days old Jaundice Birth weight 1500 gr Gestional age 8 months Mother smokes tobacco regularly

Clarification of words Low birth weight babies: an infant whose birth weight is less than

2500g regardless of gestational age. Premature (preterm) babies: an infant born before completion of 37th

week of gestation regardless of birth weight.

Questions1. What is the normal physiology of fetal development?2. What are the causes of low birth weight baby?3. What are the causes of premature baby?4. What is the epidemiology of low birth weight baby?5. What is the classification of gestational age?6. Does the baby weight suits her gestational age?7. What are the pathophysiology of jaundice?8. What are the relationship between jaundice and low birth

weight baby?9. What are the classification of jaundice?10. What are the contents of cigarette that affect the fetal

development?11. What are the relationship between smoking and low birth

weight baby?

Epidemiology Low Birth Weigth Baby

At least 17 million infants are born every year with LBW, representing about 16% of

all newborns in developing countries.

Nearly 80% of all affected newborns with LBW at term are born in Asia.

Factors of low birth weight infants Genetics- Infants with a black

mother and father have the lowest mean birth weights

- infants born to two white parents have the highest weights.

- Newborns with mixed-race parents have intermediate birth weight distributions

 Age- mothers under the age of

18 or over the age of 35

Nutrition- Non adequate supply of

nutrients Prenatal Care- higher for women who do

not receive prenatal care Smoking- Smokers inhale nicotine

and carbon monoxide- which reach the baby

through the placenta - prevent the fetus from

getting nutrients and oxygen needed to grow

Causes for Premature Birth Multiples pregnancy Previous premature

birth Short period between

pregnancies Pre-eclampsia HELLP Syndrome Smoking   Uterine or cervical

abnormalities Recurring infections

Chronic illnesses Abortion Mother’s age PPROM “Preterm

Premature Rupture of Membranes”

Placental risks & causes – Placenta Previa and Placental Abruption

Risks from smoking during pregnancy Effects on mother Effects on babies

Difficulty getting pregnant

Placenta separates from the womb too early, causing bleeding

Placenta covers the cervix, causing complications

Water breaks too early

Miscarriage

Baby born to small Baby born too early Sudden infant death

syndrome Fetal death Infant death Certain birth defects,such as:

Cleft lip/palate Clubfoot Gastroschisis Some heart defects

Crypyorchidism

Battaglia and Lubchenco Grafic

Clasification of Gestasional Age Pure Prematurity : Gestasional Age Less than

37 weeks with appropriate weight Small For Date : The weight is less than the

Gestasional Age Large For Date : The Weight of the baby more

than the should gestasional age Apropriate For Date : The Weight and the

Gestasional Age is Apropriate

Jaundice in Infant Infant jaundice is a yellow

discoloration in a newborn babies’ skin and eyes

Common cause : immature liver of the babies to get rid of bilirubin in bloodstream

Classifications of jaundice in infants Physiological

jaundice:  occurring in most

newborns due to immaturity of

the baby's liver → slow processing of bilirubin

2 to 4 days of age disappears by 1 to 2

weeks of age

Pathological jaundice:  Criterias :

Jaundice appear <24 hours or >14 days of life

Increases in the level of total bilirubin by more than 8.5 umol/l (0.5 mg/dL) per hour or (85 umol/l) 5 mg/dL per 24 hours

Total bilirubin more than 331.5 umol/l (19.5 mg/dL)

Direct bilirubin more than 34 umol/l (2.0 mg/dL)

Breastfeeding jaundice: 

not enough breast milk - difficulty with breastfeeding

Breast milk jaundice:  in 1% to 2%

of breastfed babies caused by substances

produced in the mother's breast milk that cause hyperbilirubinemia

starts after the first 3 to 5 days

slowly improves over 3 to 12 weeks.

PHYSIOLOGY OF BILIRUBIN METABOLISM

Stage 1 : Production of bilirubin I

• Degradation Hb

Stage 2 : Transport of bilirubin I into liver

• Bilirubin I + albumin(transporter)

Stage 3 : Conjugation of bilirubin I

• Bilirubin I is converted to Bilirubin II • With the aid of protein Y+Z, oxygen, glucose

Stage 4 : Excretion• Stercobilin & Bilirubin I• Bilirubin I will be converted back to bilirubin II in

enterohepatic cycle• Stercobilin will be excreted via faeces

PATHOPHYSIOLOGY OF JAUNDICE

1. During stage 1 ( production of bilirubinI)i)preterm babiesii)infectioniii)blood incompatibility

2. During stage 2 (transport of bilirubin I)i) hypoalbuminemia

3. During stage 3 (conjugation of bilirubin I)i) hypoglikemia

JAUNDICE IN PRETERM BABIES IU : immature liver & RBC system Postnatal : slow development of liver & RBC

system Lifespan RBC preterm babies ↓ (50-60 days)

↓ ↑ bilirubin load in liver

↓ ↑ enterohepatic circulation of bilirubin

↓Long, persistent jaundice in preterm babies

Tobacco and LBWB• The smoke from a cigarette contains more than 4000 chemicals• Have various toxic, mutagenic and carcinogenic effects

Major content:

1. Nicotine= decrease arteries size>>hypoxia

2. Carbon monoxide = bind with hemoglobn >>oxyhemoglobin reduces>> hypoxia

3. Tar = carcinogenic >> compete for nutrition >> hypoxia

Low birth weight baby

What induced preterm labour?-Hypoxia-Placenta previa-Ketuban pecah dini

Smokes tobacco

Hypoxia

Placenta previa

Ketuban pecah dini

Preterm labour

Nicotine

Release of catelcolamine

Vasoconstriction

Less nutrition and blood

supply

Decrease fetal development

Low birth weight

Irritant from cigarrete ruptured membrane

Collagen degradation

Inflammatory mediator release

Produce protease

Initiate cervical change

Hypoxia

Increase placenta

area ( find the area with high oxygen)

Close cervix surface (high

oxygen area)

Preterm labour

Sign & symptoms of pretem labour four or more uterine contractions in one hour cervical dilatation vaginal bleeding in the third trimester heavy pressure in the pelvis abdominal or back pain watery discharge from the vagina

Diagnosis Bilirubin measurement Blood type & Rh determination Peripheral blood smear Complete blood & Reticulocytes count Direct Coomb’s test (DCT)

Anamnesis tambahan When did the jaundice start? Parent’s blood group Smoking history of father and mother Type of delivery and what induce the delivery

Treatment

Jaundice Low Birth Weight Baby

Fototherapy Transfusion therapy Drugs (examples:

phenobarbital or luminal) Breastfeeding baby

Source : Makalah ikterus neonatorum,universitas pembangunan negara

Regulation of environmental temperature → in an incubator with temperature set :

• Baby with weight < 2 kg 35 celcius of degree

• Baby with weight 2-2,5 kg 34 celcius of degreeIncubator temperature is lowered 1 degree Celsius every week until the baby can be placed on the ambient temperature around 24-27 celcius of degree.

Feeding → with a pipette a little but more often

PretermFeeding and Fluid Management of Preterm Babies

Babies without major illness: 1,75 – 2,5 kg

Allow the baby to begin breastfeeding 1,5- 1,749 kg

Give expressed breast milk using an alternative feeding method every 3 hours until the baby is able to breastfeed.

1,25 – 1,49 kg  Give expressed breast milk by gastric tube every 3

hours Progress to feeding by cup/ spoon as soon as the baby

can swallow without coughing or spitting If the baby weighs 1,25 – 1,5 kg at least 8 times /day If the baby weighs less than 1,25 kg at least 12

times/day

COMPLICATION OF LBW inability to maintain body temperature difficulty feeding and gaining weight infection breathing problems such as respiratory

distress syndrome (a respiratory disease of prematurity caused by immature lungs).

neurologic problems such as intraventricular hemorrhage (bleeding inside the brain)

gastrointestinal problems such as necrotizing enterocolitis

PREVENTION OF LOW BIRTH WEIGHT Prenatal care is a key factor. Health of both

mother and fetus can be checked. Eating a healthy diet and gaining the proper

amount of weight. Avoid alcohol, cigarettes, and illicit drugs.

COMPLICATIONS OF PRETERM BABY Short term:1. Breathing. Trouble breathing due to an

immature respiratory system2. Heart and brain problem.3. Temperature control problem. Lose body

heat rapidly; they don't have the stored body fat of a full-term infant.

4. Blood problems. are at risk as anemia and infant jaundice

Long-term complications:1. Cerebral palsy. disorder of movement,

muscle tone or posture that is caused by injury to a preterm's developing brain.

2. Impaired cognitive skills. Learning disability.

3. Vision problems. Preterm born before 30 weeks may develop retinopathy of prematurity (ROP).

4. Chronic health issues. Such as infection.5. Dental problems. Increased risk of

developing dental problems, eg delayed tooth eruption, tooth discoloration and improperly aligned teeth.

PREVENTION OF PRETERM LABOUR Weekly shots of the hormone progesterone. Seek regular prenatal care. Eat healthy food. Manage chronic condition eg DM Avoid risky substance. Quit smoking. Manage stress.

COMPLICATION OF JAUNDICE Sick or difficult to wake High-pitched crying Poor sucking or feeding Backward arching of the neck and body Fever Vomiting

PREVENTION OF JAUNDICE

1. Antenatal care

2. Avoid using drugs in pregnancy & intrapartum period :

• Sulfa furazole

• Novobiocin

• Oxytocin, etc

3. Prevent hypoxia in fetus & neonatus

4. R/ luminal for pregnant mother 1 – 2 day before labor

5. Good Ilumination

6. Early feeding

7. Prevent infection.

THANK YOU!