Low Birth Weight Babies s Dr rafeza khanam

Low Birth Weight Babies s Dr. rafeza khanam assoc. professor paediatrics department mcwh

Key facts, WHO 2013 15 million babies born preterm in Bangladesh ¡ 1 million dies annually from preterm birth complication ¡ Preterm birth is the leading cause of death in children U 5 ¡ 75% of them could be saved without ICU ¡ Incidence of LBW -24% ¡

Bangladesh statistics, BDHS 2011 Under 5 mortality rate 53 per 1000 live birth ¡ IMR-43 per 1000 live birth ¡ NMR-32 per 1000 live birth ¡ LBW- [2007 -2011] : 22% ¡

DEFINITION Liveborn infants delivered before 37 wk from the 1 st day of the last menstrual period are termed premature by the World Health Organization. ¡ LBW (birthweight of 2, 500 g or less) is due to prematurity, poor intrauterine growth (IUGR, also referred to as SGA), or both. ¡

Spectrum of LBW Birth weight Low Birth weight <2500 gm Very LBW <1500 gm Extremely LBW <1000 gm Incredible LBW <750 gm

LBW: Significance 75% neonatal deaths and 50% infant deaths occur among LBW infants ¡ LBW babies are more prone to: ¡ l l l Malnutrition Recurrent infections Neurodevelopmental delay LBW babies have higher mortality and morbidity

Types of LBW 2 types based on the origin Preterm ¡ ¡ < 37 completed weeks of gestation Account for 1/3 rd of LBW Small-for-date (SFD) / intra uterine growth retardation (IUGR) ¡ ¡ < 10 th centile for gestational age Account for 2/3 rd of LBW neonates

Causation: LBW Etiology of prematurity ¡ ¡ ¡ ¡ Low maternal weight, teenage / multiple pregnancy Lack of regular ANC Previous preterm baby, cervical incompetence Antepartum hemorrhage, acute systemic disease Induced premature delivery Fetal malformation Majority unknown

Causation: LBW Etiology of SFD / IUGR ¡ Poor nutritional status of mother ¡ Hypertension, toxemia, anemia ¡ Multiple pregnancy, post maturity ¡ Diabetic vasculopathy, chronic illness ¡ Tobacco use ¡ TORCHS infection ¡ Chromosomal disorder

LBW: Identification of types Prematurity Date of LMP ¡ Physical features ¡ l l Breast nodule Genitalia Sole creases Ear cartilage / recoil

Identification: Preterm LBW Breast nodule Preterm Term

Identification: Preterm LBW Male genitalia Preterm Term

Identification: Preterm LBW Female genitalia Preterm Term

Identification: Preterm LBW Sole creases Preterm Term

Identification: Preterm LBW Ear Cartilage Preterm Term

LBW: Identification of types SFD / IUGR ¡ Intrauterine growth chart ¡ Physical characteristics l l Emaciated look Loose folds of skin Lack of subcutaneous tissue Head bigger than chest by >3 cm

Intrauterine growth chart 90 th percentile Birth weight (grams) LARGE FOR DATE APPROPRIATE FOR DATE 10 th percentile SMALL FOR DATE PRETERM Gestation (weeks) POST-TERM

Preterm baby around 36 wks

Parameters Preterm IUGR Weight for age Corresponds to gestational age Less than the gestational age Alertness Less alert Movement Usually less Comparatively more Skin Thin, shiny, edematous Dry, loose thick, peeling of epidermis Ear lobule soft Like that of normal baby Breast buds Less developed Well developed Crease at soles Less more Labia majora Widely separated normal Limbs Limp semiflexed Abdomen Distended with visible coils of intestine Usually lie that of a fully term baby

Identification: SFD / IUGR 2. 1 Kg - IUGR 3. 2 Kg - AFD

LBW (Preterm) : Problems ¡ Birth asphyxia ¡ Apneic spells ¡ Hypothermia ¡ ¡ Feeding difficulties Intraventricular hemorrhage ¡ Hypoglycemia ¡ Metabolic acidosis ¡ Patent ductus arteriosus(PDA) ¡ ¡ NEC Infections Hyperbilirubinemia Respiratory distress syndrome

LBW (SFD) : Problems Birth asphyxia ¡ Meconium aspiration syndrome ¡ Hypothermia ¡ Hypoglycemia ¡ Infections ¡ Polycythemia ¡

Problems of LBW Late onset…… ¡ Rickets ¡ Retinopathy of prematurity ¡ Delayed growth & development ¡ Cerebral palsy or other neurological deficit

Investigations RBS ¡ S electrolytes ¡ S calcium ¡ S bilirubin ¡ CBC without ESR **Investigations depends upon the clinical situation of LBW babies ¡

Management of LBW Keep the baby warm ¡ Maintain nutrition ¡ Protection against infection ¡ Regular hospital follow up ¡ Supplementation with vitamins & hematinic ¡ Treatment of complications ¡

KANGAROO MOTHER CARE

LBW: Keeping warm at home Skin-to-skin contact Convection Radiation Birth weight (Kg) Room temperature (0 C) 1. 0 – 1. 5 34 – 35 1. 5 – 2. 0 32 – 34 2. 0 – 2. 5 30 – 32 > 2. 5 28 - 30 Warm room, fire or heater Evaporation Conduction Prevent heat losses Baby warmly wrapped

LBW: Keeping warm at home Well covered newborn

LBW: Keeping warm in hospital Skin-to skin method ¡ Warm room, fire or electric heater ¡ Warmly wrapped ¡ Radiant warmer Heated water-filled mattress Air-heated Incubator

Protection against infection Hand washing ¡ Minimum handling ¡ No prelacteal feed ¡ Umbilical stump –open, clean & dry ¡ Avoid overcrowding ¡

Prevention of LBW Prevention of early marriage/conception ¡ Improvement of maternal health ¡ Regular & adequate ANC ¡ Early addressing & intervention of maternal diseases ¡ Early detection of high risk pregnancy & maternal steroid therapy prior to delivery ¡ Creating awareness to take care of female child ¡

LBW: Issues in delivery Transfer mother to a well-equipped centre before delivery ¡ Skilled person needed for effective resuscitation ¡ Prevention of hypothermia - topmost priority ¡

LBW: Indications for hospitalization Birth weight <1800 g ¡ Gestation <34 wks ¡ Unable to feed* ¡ Sick neonate* ¡ * Irrespective of birth weight and gestation

Guidelines for fluid requirements First day 60 -80 ml/kg/day ¡ Daily increment 15 ml/kg till day 7 ¡ Add extra 20 -30 ml/kg for infants under radiant warmer and 15 ml/kg for those receiving phototherapy ¡

Fluid requirements (ml/kg)

LBW: Fluids and feeding Weight <1200 g; Gestation <30 wks* Start initial intravenous fluids ¡ Introduce gavage feeds once stable ¡ Shift to cup-spoon feeds over next few days. Later on breast feeds ¡ * May try gavage feeds, if not sick

LBW: Fluids and feeding Weight 1200 -1800 g; Gestation 30 -34 wks* Start initial gavage feeds ¡ Cup-spoon feeding after 1 -3 days ¡ Shift to breast feeds as soon as baby is able to suck ¡ * May need intravenous fluids, if sick

LBW: Fluids and feeding Weight >1800 g; Gestation > 34 wks* Breast feeding ¡ Cup-spoon feeding, if sucking not satisfactory on breast ¡ Shift to breast feeds as soon as possible ¡

LBW: Feeding schedule ¡ Begin at 60 to 80 ml/kg/day Increase by 15 ml/kg/day ¡ Maximum of 180 -200 ml/kg/day ¡ ¡ First feed at 1 hrs of age then every 2 hourly

LBW: Feeding Gavage feeding

Cup-spoon feeding

LBW: Adequacy of nutrition 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. 5% of birth weight daily Excessive loss or inadequate weight ¡ Cold stress, anemia, poor intake, sepsis * SFD - LBW term baby does not lose weight

LBW: Supplements ¡ Vitamins : IM Vit K 1. 0 mg at birth Vit A* 1000 I. U. per day Vit D* 400 I. U. per day ¡ Iron : Oral 2 mg/kg per day from 8 weeks of age *From 2 weeks of age

Regular hospital follow up ¡ ¡ ¡ ¡ ¡ Weight Activity Temperature Signs of fluid overload/dehydration Apnoea Jaundice and its extent Evidence of sepsis Abdominal distention Passage of urine and stool

When to discharge Able to maintain temperature ¡ Absence of apnoea or bradicardia for 5 days ¡ Can take & tolerate full feeding from breast or cup-spoon ¡ Weight gaining ¡

Follow up after discharge Growth monitoring ¡ Anaemia ¡ Rickets ¡ Retinopathy of prematurity ¡ Hearing assessment ¡ Retinopathy of prematurity ¡ Milestone of development ¡

Danger signals (Early detection and referral) Lethargy, refusal to feed ¡ Less movement ¡ Hypothermia ¡ Tachypnea, grunt, gasping, apnea ¡ Seizures, vacant stare ¡ Abdominal distension ¡ Bleeding, icterus over palms/soles ¡

Transportation of LBW baby Adequate warmth ¡ Life support ¡ With mother ¡ Referral note ¡

Prognosis ¡ Mortality l l ¡ Inversely related to birth weight and gestation Directly related to severity of complications Long term l Depends on birth weight, gestation and severity of complications

Baby In Incubator

LBW: Keeping warm in hospital Overhead Radiant warmer

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