Management of Low Birth Weight Babies

1. Management of Low Birth Weight Babies

2. 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 NH- 2

3. Low Birth Weight (LBW) Definition: Birth weight <2500 g Incidence : ~30% of neonates in India NH- 3

4. 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 NH- 4

5. 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 Types of LBW Two types based on the etiology NH- 5

6. 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 NH- 6

7. LBW: Causation Etiology of SFD / IUGR • Poor nutritional status of mother • Hypertension, toxemia, anemia • Multiple pregnancy, post maturity • Chronic malaria, chronic illness • Tobacco use NH- 7

8. LBW: Identification of types Prematurity • Date of LMP • Physical features • Breast nodule • Genitalia • Sole creases • Ear cartilage / recoil NH- 8

9. Preterm vs Term LBW Breast nodule PretermTerm NH- 9

10. Identification: Preterm LBW Male genitalia PretermTerm PretermTerm NH- 10

11. Identification: Preterm LBW Female genitalia PretermTerm NH- 11

12. Identification: Preterm LBW Sole creases PretermTerm NH- 12

13. Identification: Preterm LBW Ear Cartilage PretermTerm NH- 13

14. LBW: Identification of SFD/IUGR SFD / IUGR • Intrauterine growth chart • Physical characteristics • Emaciated look • Loose folds of skin • Lack of subcutaneous tissue • Head bigger than chest by >3cm NH- 14

15. Classification of neonates LFD AFD SFD NH- 15

16. SFD / IUGR vs Term appropriate for date ( AFD) 2.1 Kg - IUGR 3.2 Kg - AFD NH- 16

17. LBW (Preterm) : Problems • Birth asphyxia • Hypothermia • Feeding difficulties • Infections • Hyperbilirubinemia • Respiratory distress • Apneic spells • Intraventricular hemorrhage • Hypoglycemia • Metabolic acidosis NH- 17

18. LBW (SFD) : Problems • Birth asphyxia • Meconium aspiration syndrome • Hypothermia • Hypoglycemia • Infections • Polycythemia NH- 18

19. LBW: Issues at birth • Transfer mother to a well-equipped centre before delivery • Skilled person needed for effective resuscitation • Prevention of hypothermia - topmost priority NH- 19

20. LBW: Need for referral/admission • Birth weight <1800 g • Gestation <34 wks • Unable to feed* • Sick neonate* * Irrespective of birth weight and gestation NH- 20

21. Keeping warm at home Skin-to-skin contact Warm room, fire or heater Convection Evaporation Radiation Conduction Prevent heat losses Baby warmly wrapped NH- 21

22. Keeping warm at home Well covered newborn NH- 22

23. Keeping warm in hospital Radiant warmer Skin-to-skin contact Heated water-filled mattress Air-heated Incubator NH- 23

24. Deciding the initial feeding method Two factors • Hemodynamically stable or not? • Feeding ability NH- 24

25. Deciding the initial feeding method 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 Presence of any one of these signs = UNSTABLE If unstable, start intravenous (IV) fluids NH- 25

26. Deciding the initial feeding method Feeding ability NH- 26

27. Action Assessment Manage as per guidelines for sick neonates* No Is the baby clinically stable? Y e s Start intravenous fluids Is birth weight more than 1250 g? No Y e s Is the baby able to breastfeed effectively? • When offered the breast, the baby roots, attaches well and suckles effectively • Able to suckle long enough to satisfy needs Yes Initiate breast feeding No Is the baby able to accept feeds by alternative methods? Give oral feeds by cup/spoon/ paladai Yes • 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 Start intra-gastric tube feeds No NH- 27 * Assess daily for clinical stability ; once stable, assess for initial feeding method

28. Gavage feeding NH- 28

29. Katori-spoon feeding NH- 29

30. Progression of oral feeds Based on two factors • Stable or not? • Maturation of feeding ability NH- 30

31. Progressingfrom initial feeding method Baby on IV fluids Assess for stability If 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 • Put on breast Continue till the baby is on full spoon feeds Baby on oral feeds byspoon/paladai Make him suckle at breast Put him on breast more frequently Baby on breastfeeding Teaching Aids: ENC Continue breastfeeding

32. Choice of milk Breast milk • Perfectly adapted to the infants’ needs • Consistent evidence: • Reduces infections and NEC • Improves neurodevelopmental outcomes • Long term effects on BP, lipid profile and pro-insulin levels NH- 32

33. Choice of milk • 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 NH- 33

34. Nutritional supplements • 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 NH- 34

35. Nutritional supplements NH- 35

36. Nutritional supplements NH- 36

37. Feed volumes * If the infant is on intravenous fluids, do not increase beyond 140 -150 ml/kg/day NH- 37

38. Assessing feeding adequacy Ask: • how many times the infant feeds in 24 hours? • 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 NH- 38 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

39. Assessing feeding adequacy • 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 Ask: • how many times the infant feeds in 24 hours? • the volume of each feed given by spoon/cup/paladai NH- 39 Observe: • is he spluttering/spitting the milk • is he tiring or takes too long to take the required amount

40. Assessing feeding adequacy 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 weight NH- 40

41. Growth monitoring Growth charts • Until 40 weeks: Dancis, Ehrenkranz • After 40 weeks: WHO charts NH- 41

42. Growth monitoring for PT neonates Modified Dancis chart NH- 42

43. 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 NH- 43