Management of LBW ENC9
Management of LBW ENC9
Management of LBW ENC9
Nearly 75 percent neonatal deaths and 50 percent infant deaths occur among the low birth weight neonates. Even after recovering from neonatal complications, some LBW babies may remain more prone to malnutrition, recurrent infections, and neurodevelopmental handicaps. Low birth weight, therefore, is a key risk factor of adverse outcome in early life.
Etiology of LBW
Preterm labour occurs in teenage mothers and in the setting of low maternal weight, cervical incompetence, antepartum hemorrhage, previous fetal loss, previous preterm delivery. Sometimes, preterm labor is medically induced for the sake of the baby as in the case of Rh isoimmunisation or maternal diabetes mellitus. The cause of a majority of preterm deliveries, however, remains unknown.
Poor nutritional status of the mother and frequent pregnancies are the major causes of intrauterine growth retardation. Mothers with a weight of less than 40 kg and a height of less than 145 cm often give birth to small-for-date babies. Insufficient nutritional intake during pregnancy also has an adverse effect on fetal weight. Maternal hypertension, pre-eclampsia, post-maturity, frequent
pregnancies, multiple pregnancy, anemia, malaria and tobacco use are other causes of intrauterine growth retardation. Chronic maternal diseases of heart, kidneys, lungs or liver may also lead to intrauterine growth retardation.
Small-for-dates neonates have an emaciated look and loose folds of skin because of lack of subcutaneous tissue. These are particularly prominent over the buttocks
Remember that if a baby is preterm as well as small-for-dates, he/she would have a combination of the above mentioned features.
The basic underlying feature of the preterm LBW infant is immaturity of their organ systems. They may not establish respiration satisfactorily at birth and develop asphyxia necessitating expert resuscitation. Newborn babies keep themselves warm by active metabolism in the brown fat stores. The preterm babies lack brown fat and therefore become hypothermic at the usual ambient temperature unless specific measures are taken to keep them warm. Preterm neonates less than 34 weeks of gestation cannot coordinate sucking and swallowing. Therefore, they are unable to feed from the breast. Preterm LBW infants, especially those less than 30 weeks of gestation may not tolerate any enteral feeds initially because of gut immaturity. Preterm babies especially those less than 34 weeks have immature lungs which do not expand well after birth and are therefore unable to perform the function of gas exchange. They develop respiratory distress syndrome
characterised by rapid and labored respiration, indrawing of the chest, grunting, and cyanosis. Because of the immature respiratory control mechanisms these babies also have a tendency for apneic spells. In an apneic spell the baby stops
At home
First and foremost, the mother herself is a source of warmth for the baby. It is of immense help to nurse the baby next to the mother, day and night. Further, the room where a LBW baby is nursed should be kept rather warm (temperature between 28C to 30C in all seasons). This temperature is slightly uncomfortable for adults, but this discomfort has to be accepted for the sake of the baby. While in summer months no extra effort is required to maintain this temperature, in winter months a room heater may have to be used.
In the hospital
Apart from the above methods, overhead radiant warmer or incubator may be used to keep the baby warm. Regular monitoring of axillary temperature should be carried out in all hospitalized babies. Refer to topic on hypothermia in newborn.
Hemodynamic status
Infants with any one of the following symptom/signs would be categorized as hemodynamically unstable: Fast breathing (RR>60/min) Severe chest in-drawing Apnea Requirement for oxygen Convulsions
These infants are usually started on intravenous (IV) fluids. Enteral feeds should be initiated as soon as they are hemodynamically stable with the choice of feeding method based on the infants gestation and clinical condition (see below).
Feeding ability
The best way to decide if an infant is ready to commence breastfeeding is to observe the infant for developmental feeding signs. Criteria such as a weight or gestational age, though useful, are not accurate enough to determine when a LBW infant is ready for breastfeeding. Breastfeeding requires effective sucking, swallowing and a proper coordination between suck/swallow and breathing. These complex skills mature with increasing gestation. The fetus is able to swallow amniotic fluid by as early as 11 to 12 weeks gestation but the coordinated sucking movements are not usually present until about 28 weeks gestation. Single sucks can be recorded at 28 weeks and sucking bursts by 31 weeks gestation. A mature sucking pattern that can adequately express milk from the breast is not present until 32-34 weeks gestation. However, the coordination between suck/swallow and breathing is not fully achieved until 37 weeks of gestation. The maturation of oral feeding skills and the choice of initial feeding method at different gestational ages are summarized in the following table: Gestational age < 28 weeks Maturation of feeding skills No proper sucking efforts No gut motility Sucking bursts develop No coordination between suck/swallow and breathing Slightly mature sucking pattern Coordination begins Initial feeding method Intravenous fluids
28-31 weeks
32-34 weeks
However, it is important to remember that not all infants born at a particular gestation would have same feeding skills. Hence the ideal way in a given infant would be to evaluate if the feeding skills expected for his/her gestation are present and then decide accordingly (Figure 1).
Term LBW infants started on IV fluids (because of their sickness) can be put on the breast once they are hemodynamically stable.
However, it should be kept in mind that mother's own milk is the best and should be provided to all LBW infants unless the mother cannot or chooses not to provide breast milk.
Vitamin D
Enteral
Similarly, LBW infants >1500g are usually given about 60 ml/kg fluids on the first day of life and fluid intake is increased by about 15-20 ml/kg/day to a maximum of 160 ml/kg/day by the end of the first week of life.
Similarly, the adequacy of feeding should be assessed in those LBW infants who are being spoon-fed. Some features that indicate inadequate spoon/paladai feeding include: 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
Monitoring should be continued until breastfeeding is fully established and the baby is gaining weight. After discharge, the health worker should make follow up visits weekly during the first two months of life. At these follow-up visits, she should assess for feeding adequacy and also monitor the babys growth.
Growth charts
Using a growth chart is a simple but effective way to monitor the growth. Serial plotting of weight and other anthropometric indicators in the growth chart allows the individual infants growth to be compared with a reference standard. It helps in early identification of growth faltering in these infants. Two types of growth charts are commonly used for growth monitoring in preterm infants: intrauterine and postnatal growth charts. Of these, the postnatal growth chart is preferred because it is a more realistic representation of the true postnatal growth (than an intrauterine growth chart); it also shows the initial weight loss that occurs in the first two weeks of life. The two postnatal charts that are most commonly used for growth monitoring of preterm VLBW infants are: Wrights and Ehrenkranz charts. Once the preterm LBW infants reach 40 weeks PMA, WHO growth charts should be used for growth monitoring.