care of low birth weight baby

 Care of Low Birth Weight Infants (At risk baby)

Weight <2.0 kg, abnormal body temperature, poor feeding.

Low birth weight infants are two clinical types;

1. Pre term

Babies born before 37 weeks.

2. Small for dates/ small for gestation age

(Babies having intra-uterine growth retardation)

Whose birth weight falls below 10th percentile on intrauterine growth curve.

Etiology of Preterm Birth

1. Fetal factor

Fetal distress

Multiple gestation

(Carrying more than one baby at a time)

Erythroblastosis fetalis; destruction of RBC by maternal IgE antibodies.

Non immune hydrops

Excessive accumulation of fetal fluid with in fetal.

2. Placental factor

Placenta dysfunction

Placenta previa

(Placenta covers opening in mother's cervix).

Abruptio placenta

(Placenta detached from womb (uterus).

3. Uterine factor

Bicornuate uterus

(Impairment due to fusion of mallerian ducts).

Incompetent cervix

(Uterus shaped irregularly; heart shaped)

4. Maternal factor

Chronic medic illness

Pre eclampsia

Infection

Rug abuse

5. Other factors

Premature rupture of membranes

Trauma

Iatrogenic 

Problem associated with prematurity

1. Respiratory problems

Hyaline membrane disease; Respiratory distress syndrome

Bronchopulmonary dysplasia; problem with baby lung tissue develop.

Pneumothorax

Pneumonia

Apnea

2. Cardiovascular problem

Hypotension

Bradycardia

Patent ductus arteriosus; medical condition in which ductus arteriosus fails to close after birth.

3. Gastrointestinal problems

Poor gestational function

Necrotizing enterocolitis

Hyperbilirubinemia

Incompetent cardioesophageal sphincter leading to regurgitation.

4. Central nervous system problems

Intraventricular hemorrhage

Sizures

Retinopathy of prematurity (abnormal blood vessels grow in retina)

Deafness

Hypotonia (weak muscle tone)

5. Problems associated with renal system

Hyponatremia/Hypernatremia

Hyperkalemia

Renal tubular acidosis

Renal glycosuria

Edema

6. Other problems

Hypothermia

Nutritional deficiencies

Increase susceptibility to infections.

2. Small-for-dates/ small-for-gestational-age /IUGR

Etiology

1. Fetal factor

Chromosomal Abnormality

Infection; congenital rubella, syphilis

Infarction

Multiple gestation

Pancreatic hypoplasia

Insulin deficiency

2. Placental factor

Placental weight or size

Infarction

Abruptio placenta

(Placenta separates from inner wall of uterus)

3. Maternal factors

Toxemia of pregnancy (pre-eclampsia)

Hypertension or renal disease

Hypoxemia (low level oxygen)

Malnutrition

Smoking

Alcohol or drug abuse

Primi or grand multipara

Types of small-for-dates/ small-for-gestational-age babies/IUGR

1. Malnourished small for dates infants

Growth arrest in later part of pregnancy leads to reduction in cell size but not in number, resulting in small and malnourished baby.

Looks marasmic, has less subcutaneous fat and poor muscle mass.

2. Hypoplastic small for dates infants

Growth retardation in early part of pregnancy lead to reduction in number of body cells resulting arrest development of organ.

Baby smaller in all parameters including head size.

3. Mixed small for dates gestational infants

Reduction 8n both cell number and size.

Problems of small for dates infants

1. Intrauterine problems

Hypoxia

Acidosis

Infection

2. Birth Asphyxia

Uteroplacental perfusion during labour and chronic fetal hypoxia; acidosis, meconium aspiration syndrome

3. Polycythemia and Hyperviscosity of blood

Increase erythropoietin level due to Intrauterine fetal hypoxia.

4. Hypothermia

Hypoglycemia 

Poor subcutaneous fat less brown fat

Hypoxia

5. Congenital malformation

Chromosomal genetic defects

TORCH infection

(Toxoplasmosis, Other agent; syphilis, Rubella, Cytomegalovirus, HSV -2 (Herpes simplex -2))

Oligohydramnios (too little amniotic fluid around baby during pregnancy).

Care of Low Birth weight infant (at risk baby)

 Kangaroo mother care (KMC)

KMC is method of care of low birth weight babies. This include early prolonged and continuous skin to skin contact with mother and frequent breast feeding.

KMC increase survival of low birth baby.

Component of KMC 

Component of KMC are;

1. Skin to skin contact

2. Exclusive breastfeeding

1. Skin to skin contact

Early, continuous and prolonged skin to skin contact between mother and her baby.

Infant placed on her mother's chest between the breast.

2. Exclusive breastfeeding

Baby on KMC is breastfeed exclusively. 

Skin to skin contact promotes lactation and thus facilitates exclusive breastfeeding.

Principles of management low birth weight infant

1. Care at birth

Administer Betamethasone, Hydrocortisone to mother; improving lung maturity; prevent Respiratory distress syndrome.

2. Appropriate place for care

3. Thermal protection

4. Nutrition

5. Monitoring and early detection complication

6. Prevention for infection

Feeding of Low birth weight babies <2000 grams

Low birth babies are often born prematurely (before 37 weeks). After birth, all low birth weight baby (LBWB) gradually develop the ability to breast feed.

Make breastfeeding limitation include;

1. Inability to suck effectively

2. Inability to coordinate sucking and swallowing

3. Inability to coordinate swallowing and breathing

Birth weight <1200 grams; preferred method of feeding, need IV fluids initially then initiate Oro-gastric tube (Gavage) feeding gradually.

1201-1500 grams; some need spoon/ paladai feeds, expressed breast milk, some need Oro-gastric feeding initially.

1501-2000 grams; most babies accept breast feeding, while some need paladai feeds.

>2000 grams; breastfeed as normal birth weight babies with monitoring.

LBWB who able to breastfeed directly; 

directly breastfeed.

LBWB who are not able to breastfeed directly; 

Expressed breast milk either by Oro-gastric tube or by spoon/paladai.

Paladai feeding; small bowel with long pointed tip.

Oro-gastric tube feeding/nasogastric feeding; Oro gastric tubes are useful for preterm babies, particularly those with respiratory distress.

Care of at risk neonates

At risk, neonates has one or more following feeding;

1. Weight <2000 grams

2. Babies with moderate or severe hypothermia.

3. Cried late (>1 min) but within 5 minutes of birth.

4. Sucking poor, but not absent.

5. Respiratory rate over 60 breaths/minutes but no chest retraction.

6. Jaundice present, but no staining of palms/ soles.

7. Temperature (axillary) 36.0 -36.4 degree Celsius.

8. Depressed sensorium, but is arousable.

9. Diarrhea or vomiting or abdominal distension.

10. Umbilicus draining pus or pustules on skin.

11. Fever

Care Provided at Risk Neonates

1. Warmth

2. Prevent hypothermia

a. Normal temperature; 36.5-37.5 degree Celsius

b. Cold stress; 36.0-36.4 degree Celsius

Treat hypothermia, use room heater.

c. Hypothermia; <36.0 degree Celsius

Requires immediate exposure to radiant warmer or heater.

2. Stabilization 

Prevention for hypothermia

3. Feeds 

Direct breastfeeding 

Expressed breast milk

Oro-gastric tube feeding

4. Specific therapy 

a. Umbilical redness/ pus discharge

Local application of 1% gentian violet.

Syrup;Cotrimoxazole 

b. Skin pustules

Local application of 1% gentian violet.

3. Pneumonia

RR>60 breaths/minutes, no chest retraction

Syrup; Cotrimoxazole

Or Syrup; Amoxicillin

5. Monitoring

Monitored every 2 hours, sign to be monitored;

Temperature, sucking, sensorium, respiration, cyanosis, abdominal distension, convulsion, bleeding, diarrhea, vomiting, apnea.

6. Re-evaluation

After stabilization or specific therapy, baby re-evaluated for improvement.

2 cardinal sign;

Normal temperature will be (36.5-37.5 degree Celsius).

Baby will accept feeds well.

Other sign;

Rapid Breathing, depressed sensorium, abdominal distension.

7. Communication

Communication with family and mother.

Management of at risk and sick neonates.

Prepare note regarding baby's condition and care.

If baby condition improved and is to be sent home. Explain care of the baby at home.

If baby doesn't improve or worsen, explain the need for referral and cause during transport.

8. Follow up

Advice about Follow up/visits/ baby referred or sent home.

9. Advice should give to mother and family regarding home care.

a. Keep the baby warm;

Clothed head and limbs.

Dried quickly if urine or stool is passed.

Maternal contact (skin to skin contact); promotes lactation and close mother baby bonding.

Baby bathed when weight of baby is over 2000 grams and no at risk.

b. Provide exclusive breast milk feeding

At risk baby can suck adequately on breasts.

Babies may provided expressed breast milk by spoon/paladai.

Explain method of manual expression of breast milk and feeding with spoon.

c. Continue the prescribed treatment if baby advised.

Local gentian Violet application on cord umbilical sepsis are skin for pustules.

Prescribed oral Cotrimoxazole for mild pneumonia.

Observe progress of baby. Signs of well being of the at risk neonates are;

1. Baby accepts feeds well.

2. Baby has warm trunk, warm and pink soles and palms.

Monitor danger sign; features present or persistent or have reappeared and re-evaluated without delay.

d. Counsel and educate the mother and family.

Health care team explain condition of baby to mother.

Signs of improvement and 9f worsening.

e. Follow-up

Follow up baby weight. A gain of 10-15 gram/kg per day is expected after 7 to 10 days of age.

Immunization provided.

Seen again after 2 and 7 days by heath workers.