Dr Pradeep

LBW--<2500gm

Prev. 15.5%, 96.5% are born in developing world

Can be d/t preterm birth or small for gestational age

SGA- Wt. for gestation <10th centile

LBW babies are more prone to:◦ Malnutrition

◦ Recurrent infections

◦ Neurodevelopmental delay

LBW contributes 60-80% of neonatal deaths

classification group

Wt - 2000- 2500gm Term LBW

1500-2000gm Preterm (32-36 wks)

1000-1500gms Preterm <32 wks

<1000gms Preterm <28 wks

Birth asphyxia

Hypothermia

Feeding difficulties

Infections

Hyperbilirubinemia

• Respiratory distress

• Apneic spells

• Intraventricular hemorrhage

• Hypoglycemia

• Metabolic acidosis

Inadequate feeding skills

Prone to illness-prematurity

Higher fluid requirements--- higher feed volumes

Gut immaturity

Low body stores of micronutrients

Mothers own milk best for all LBW infants/Expressed breast milk

Donor breast milk

Infant formula

Animal milk

•Standard infant formula•Preterm formula < 1500 gms &

up to 2000 gms achieved

Behavior at breast Range of gestation Response when offered expressed breast milk

Occasional sucklingeffort

28-31 wks Opening mouth, tongue out of mouth, licking milk.Not able to co ordinatebreathing n swallowing

Root n attach to breast .Weak suckling attempts

32- 33 wks Opening mouth, tongue forward, licking milk,i.e -co-ordinate

Root n attach to breast 34-36 wks Able to suck at milk from cup

Is stable?

Fast breathing (RR>60/min)

Severe chest in-drawing

Apnea

Requirement for oxygen

Convulsions

Abnormal state of consciousness

Abdominal distension

Shock

If unstable, start intravenous (IV) fluids

Presence of any one of these signs = UNSTABLE

Initial feeding method in stable babies

Clinically stable

no

Start i.v fluid

yes

Birth wt > 1250 gms

Manage as sick babies guidelines

Able to breast feed effectively

Rot, attach and suckle effectively

no

yesInitiate BF

YES

NO

Able to accept feed by alternate methods-

•When offerd cup swallows without

coughing/spluttering•Adequate quantity to

satisffy needs

Give oral feeds by cup / spoon/paladay

INTRAGASTRIC FEED

yes

NO

Steps in progression feedingHow to decide the

initial feeding method

Progression of feeding low birth

wt

On exclusive breast feeding – iron has to be given 2mg /kg/day from 2- 23 months of age

Breast feed infants < 1500 gms =: when tolerating the feed -

calcium 80mg /kg /day Until 40 wks post menstrual age

phosphorous 15mg/kg/day do

Vitamin D 400 IU/Day do

Rec. fluid requirements & feed volumes

Day of life

Fluid ml/kg/d

Feed every 3 hrly (vol)

Fluid ml/kg/d

Feed every 3 hrly

Fluid ml/kg/d

Feed every 2 hrly

Day 1 60 17 60 12 60 6

Day 2 80 22 75 16 70 7

Day 3 100 27 90 20 80 8

Day 4 120 32 115 24 90 9

2000-2500gms 1500-2000gms 1000-1500gms

Rec. fluid requirements & feed volumes2000 - 2500 1500-2000 1000-1500gms

Day of life

Fluid ml/kg/d

Feed every 3 hrly (vol

Fluid ml/kg/d

Feed every 3 hrly

Fluid ml/kg/d

Feed every 2 hrly

Day 5 140 37 130 28 110 11

Day 6 150 40 145 32 130 13

Day 7 onwards

160+ 42 160 35 150 16

Breast milk should be given as trophic feed 5-10 ml / day if clinically stable

For breast feeding

•Observe•attachment/suckling/ti

redness of infants•Look for sore

nipple/engorgement

Ask mother •How many times in

24 hours feeds•Any problems

experienced by her

Assessment of feeding adequacy of alternating methods

Ask•Volume/freq in 24

hrs/spills/splutters of milkOr

•Baby take too long time to feed

ObserveSpluttering/spitting

the milkOr

Tiring of infants to take required amount

Sign of inadequate feeding

Breast feeding•<8 times in 24 hrs

•Poor attachment/ineffective suckling

•Baby tired/take him off before completion of feeds•Mother having engorged

/sore nipple

By alternative methods

•Feed vol less than indicated

•Less freq/excessive spilling

•Take long time top finish

Wt loss not more than 10% of birth wt

Start wt gaining after 2 wks

Average daily wt gain of LBW in initial 3 -4 mnths

Birth wt -<1500gms: 13.5 to 16 gm/kg/dIf > 1500gms – 10-

13 gm /kg/d

Weeks of life 2000-2500gms 1500-2000gms 1000-1500gms

Wks 3-4 100 100 -

Wks 5-6 100 100 100

Wks 7-11 200 150 100-150

Wks 12-13 250 200 150

Expected wt gain of LBW INFANTS till 3 months of agePer week

Causes of inadequate weight gain

Management of inadequate weight gain

Proper counselling of mothers and ensuring adequate support for breastfeeding their infants

Assessment of positioning/attachment, managing sore/flat nippleExplaining the frequency and timing of breastfeeding and spoon/ paladai feeds

Infrequent feeding is one of the commonest Mothers should be properly counselled regarding the frequency and the importance of night feed

A time-table where mother can fill the timing and amount of feeding

Giving EBM by spoon/paladai feeds after breastfeeding also helps in preterm infants who tire out easily while

Proper demonstration of the correct method of expression of milk and paladai feeding: observe how the mother gives paladai feeds; the technique and amount of spillage followed by a practical demonstration of the proper procedure.

Initiating fortification of breast milk when indicated

Management of the underlying conditions such as anemia, feed intolerance,etc.If these measures are not successful-

• Energy (calorie) content of milk by adding MCT oil, corn starch• Infants on formula feeds given concentrated feeds (by reconstituting 1 scoop in 25 mL of water)

ORb. Feed volume – to 200 mL/kg/day.

Symptoms:1. Vomiting (altered milk/bile or blood-stained)*2. Systemic features: lethargy, apnoeaSigns:1. Abdominal distension (with or without visible bowel loops)*2. Increased gastric residuals: >2mL/kg or any change from previous pattern

3. Abdominal tenderness

4. Reduced or absent bowel sounds

5. Systemic signs: cyanosis, bradycardia, etc.

Indicators of feed intolerance

MTCT accounts for most cases of hiv in children…

Without any intervention risk during breastfeeding is 5-20 %

Major risk factors are-primary infection at time of breastfeeding(viraemia)-severe disease-poor local health( mastitis, fissures, oral thrush*)-mixed feeding-prolonged feeding

Exclusive breastfeeding for first 6 months of lifeunless replacement feeding is acceptable, feasible, affordable,sustainable and safe..

When replacement feeding is acceptable, feasible,affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended.

All HIV-exposed infants should receive regular follow-up care and periodic re-assessment of infant feeding choices,

At 6 months, if adequate feeding from other sources

cannot be ensured, continue to breastfeed their infants and give complementary foods in addition,

. All breastfeeding should stop once an adequate diet without breast milk can be provided.

Process of feeding a child who is not breastfeeding with a diet that provides all the nutrients the child needs, until the child is fully fed on family food.

Could be formula based or heat treated breast milk.

Chronological age-from date of birth

Post –conception/post menstrual age-gestation at birth in wks + chronological age

Corrected age – chronological age in wks-no of wks the infant born early(40 wks)

Growth monitoring for infants up to 40 wks done by UK CHARTS. After that by WHO CHARTS

Steps of Paladai FeedingPlace the infant in up-right posture on mother’s laP

Keep a cotton napkin around the neck to mop the spillage

Take the required amount of expressed breast milk by using a clean syringe

Fill the paladai with milk little short of the brim

Hold the paladai from the sides; DO NOT put your finger

Place it at the lips of the baby in the corner of the mouth

Feed the infant slowly; he/she will actively swallow the milk

If the infant does not actively accept and swallow, try to arouse him/her with gentle stimulation

While estimating the milk intake, deduct the amount of milk left in the cup and the amount of estimated spillage

Wash the paladai with soap and water and then put in boiling water for 20 minutes to sterilize before next feed

Steps of Paladai Feeding

Steps of Intra-gastric Tube Feeding

1. Before starting a feed, check the position of the tube2. Remove the plunger the syringe (ideally a sterile syringe should be used)3. Connect the barrel of the syringe to the end of the gastric tube4. Pinch the tube and fill the barrel of the syringe with the required volume of milk5. Hold the tube with one hand, release the pinch and elevate the syringe barrel6. Let the milk run from the syringe through the gastric tube by gravity;DO NOT force milk through the gastric tube by using the plunger of the syringe7. Control the flow by altering the height of the syringe. Lowering the syringe slows the milk flow, raising the syringe makesthe milk flow faster

8. It should take about 10-15 minutes for the milk to flow into the infant’s stomach

9. Observe the infant during the entire gastric tube feed. Do not leave the infant unattended. Stop the tube feed if the infantshows any of the following signs: breathing difficulty, change in colour/ looks blue, becomes floppy, and vomiting

10. Cap the end of the gastric tube between feeds; if the infant is on CPAP, the tube is preferably left open after about half an Hour

11. Avoid flushing the tube with water or saline after giving feeds.

Steps of Intra-gastric Tube Feeding......