Low Birth Weight baby

Low Birth Weight

Low Birth Weight (LBW) and prematurity are major contributors to infant mortality in India and they account for largest number of hospitalizations in Neonatal Care Unit.

Definition of LBW

According to WHO, baby weighing 2500 gm or less at birth irrespective of his period of gestation is called Low Birth Weight (LBW).

Low birth weight (LBW) is defined as a birth weight of less than 2500 g (up to and including 2499 g), as per the World Health Organization.

Incidence

In India, 30-40% of all births are LBW. Out of this 8-10% are preterm and 20-30% are small for date. Approximately 10% of Indian babies are less than 2000 gm at birth.

Causes of LBW

The high incidence of LBW are due to poor socio-economic condition, illiteracy, maternal malnutrition and anaemia, maternal illness like diabetes mallitus, hypertension, low maternal weight, teenage pregnancy, too frequent child birth, maternal smoking and drug addition, multiple pregnancy, placental dysfunction, antepartum haemorrhage, Pregnancy Induced-Hypertension, acute emotional stress, premature onset of labour, intrauterine infections, congenital malformations, etc.

Classification

LBW babies are classified as:

a) Preterm Babies: They are born before 37 completed weeks of gestation. They weight between 10th-90th percentile of mean weight for their gestational age.

b) Small for Date (SFD) Babies: They are born at term but their growth rate was retarded. They are also called Intra-Uterine Growth Retardation (IUGR) baby. They weigh less than 10th percentile below mean weight for their gestational age. SFD baby may be have delivered prematurely, they are both Preterm and SFD.

Clinical Features of LBW Baby

A) Physical Characteristics

Weight less than 2500 gm.
Length less than 47 cm.
Head circumference less than 33 cm.
Chest circumference less than head circumference by more than 3 cm.
General activity poor and weak cry.
Attitude relaxed and limbs extended with poor tone.
Sucking, swallowing, cough and moro reflexes are sluggish or incomplete.
Skin shiny, loose, thin, delicate, pink with scanty vernix and plenty lanugo.
Less subcutaneous fat and oedema.
Head larger than body, skull bones are soft, sutures and fontanelles are wide.
Ears are soft and flat, cartilage not fully developed.
Eyes remain closed and protruding.
Hairs are scanty, woolly and fuzzy.
Face is small with small chin, and less buccal fat.
Breast nodules are absent or less than 4 mm, nipples and areola are flat.
Abdomen full, soft and round with prominent veins.
Nails are short and not grown up to finger tips.
Deep creases over palms and soles are absent.
Genitalia - in male, testes are undescended and scrotum poorly developed. In female, labia minora is exposed due to poorly developed labia majora, clitoris is hypertrophied.

B) Physiological Handicaps

Alteration of respiratory function:- Respirations are rapid, shallow, irregular with periods of apnoea and cyanosis, cough and gag reflex are weak or absent. Primary atelactasis is common and hyaline membrane disease may develop. These are due to weak respiratory muscles, poor expansion of lungs, inefficient respiratory centre and deficiency of surfactant in the alveoli.
Impaired thermoregulation:- The LBW baby has poor control over thermoregulation. There may be variations of body temperature and hypothermia may develop. These are due to poorly developed heat regulating centre, large body surface area in relation to body weight, poor insulating subcutaneous fat, poor muscular activity and less brown fat.
Disturbance in food and nutrition:- Sucking and swallowing reflex are poor, capacity of stomach is less, cardio-oesophageal sphincter is incompetent leading to regurgitation and aspiration. There is lack of digestive enzymes which leads to inadequate digestion and absorption of essential nutrients resulting malnutrition. They are prone to develop iron deficiency anaemia and deficiency of Vitamin A, D, E, & K.
Lack of immunity: - Inefficient immunological system of LBW babies makes them susceptible to infections, cellular immunity and antibody level are low. Incubator care, resuscitation and invasive procedures are the source of infections for LBW baby.
Metabolic disturbances: - hypoglycaemia, hypocalcaemia, hypoxia, acidosis may develop in LBW babies due to poor metabolic function, poor glycogen store, delayed feeding and birth asphyxia.
Inefficient hepatic function:- Hepatic insufficiency of LBW babies results in hyperbilirubinemia and kernicterus as unconjugated bilirubin is not effectively converted to conjugated bilirubin by enzymatic action. Physiological jaundice is severe in LBW baby as immature liver is not able to cope with the bilirubin produced by haemolysis. Poor Vita K Synthesis in liver and poor prothrombin production leads to hemorrhagic disease.
Impaired renal function:- Due to deficiency of nephron and low glomerular filtration rate, acidosis develops as acid base balance is not well maintained in LBW baby. They may be dehydrated due to inability to conserve water and urination may be delayed.Inadequate renal clearance along with poor hepatic function makes the LBW baby more vulnerable to drug toxicity due to poor detoxification of drugs.
Inefficient neurological function: -There is absent or incomplete Moro reflex or traction reflex in LBW baby. They have poor cough reflex, sucking and swallowing reflex. Immaturity of nervous system leads to poor reflex, lethargy and inactivity.
Other -handicap conditions may present in LBW baby: These are hypofunction of bone morrow, weak and fragile blood vessels leading to haemorrhagic problems. LBW baby is more prone to develop retinopathy due to higher concentration of oxygen which constrict retinal arteries and result anoxic damage and retinal detachment. This condition is termed as retrolental fibroplasia which can cause blindness.

Complications of LBW-

LBW Baby may have various complications due to Physical and Physiological handicaps. The complications are:

Birth Asphyxia, Hyaline membrane disease (Respiratory Distress Syndrome). Interalveolar haemorrhage. Intra ventricular haemorrhage, Anaemia, Kernicterus, Cardiac failure, Renal failure, Retinopathy of Prematurity and Infections.

Prevention of LBW-

Prevention of LBW is easier than the curative management. The preventive measures are:

Detection of high risk antenatal mother and management of risk mother accordingly.
Emphasis on recommended dietary intake in pregnancy for the expected foetal weight gain.
Necessary measures to be taken to avoid preterm labour.
Efficient management of premature labour and prevention of complications.
Delivery of LBW baby must be attended by expert neonatologist for prompt management.

Management of LBW Babies-

Expert nursing care is essential for LBW baby for the recovery from various problems.

Due to high incidence of LBW babies and limited resources to care for them, the segregation of high risk LBW neonates is required for special care. They are with birth weight 2000 gm or less, inability to suck the breast and swallow, unable to regulate body temperature and to control cardio-respiratory functions.

Immediate Care of LBW Baby at Birth-

Air passage to be cleared promptly and gently.
Adequate oxygenation.
Maintenance of warmth by drying and wrapping the baby and rooming-in with mother.
Administration of vita ‘K’ to prevent haemorrhagic problems.
Initiating of breast feeding as early as possible.
Body can be cared in prone position.
Gentle handling and care in special neonatal care unit (Neonatal Intensive Care Unit).

Nursing Care of LBW Baby-

✔️ Maintenance of Respiratory Function

Position the baby with neck slightly extended.
Clear the air passage by gentle suctioning.
Monitor and record respiratory rate, rhythm, signs of distress, retractions, nasal flaring, apnoea, cyanosis etc.
Providing tactile stimulation by sole flicking to stimulate respiratory effort.
Administer oxygen therapy with bag and mask, initially in 100% concentration then reduced to 40% to prevent retrolental fibroplasia.
Provide chest physiotherapy by percussion, vibration, postural drainage to loosen and remove respiratory secretions.

✔️ Maintenance of Thermoregulation

To maintain stable body temperature and to prevent hypothermia and its related complications, the following measures to be taken:

Environmental temperature to be maintained at 30 + 2OC by air conditioner, radiant warmer, hot blowers, room heater etc. to provide thermo-neutral surroundings.
Skin temperature of the baby to be maintained at 36.5-37.5OC.
Baby need to be cared in incubater with desired level of humidity (60%-65%), oxygen and warmth.
Constant monitoring of the body’s temperature is essential, low reading thermometer is useful.
Measures to be taken to prevent heat loss during care.

✔️ Maintenance of Nutrition and Fluid

LBW baby required 120-150 kcal/kg body weight/day, water 150-200 ml/kg/day, Protein 46 gm/kg/day for first few days to meet the requirement for optimum growth.

– Early feeding should be started to prevent hypoglycaemia, hyperbilirubinemia and kernicterus.
– Frequent feeding should be given.
– In poor sucking reflex, I/V fluid and naso- gastric tube feeding may be needed. Dropper, spoon and pipette can be used to feed the LBW baby.
– Weight to be recorded daily to assess weight gain preferably before feeding, in same machine and same amount of clothing.

✔️ Prevention of Infections

Poor immunity power makes of LBW baby more prone to infections. Measures to be taken to prevent infections: –

Thorough hand washing with antiseptics must be done before touching and caring each baby.
Each neonates should have separate clothing, feeding articles, thermometer, stethoscope, etc.
All personnel working in special care unit must change their shoes and wear nursery slippers and sterile gown and mask.
Any person having any infections should not enter the neonatal care unit.
Visitors should be restricted in the unit.
Nursery floors and surfaces to be mopped with detergents or carbolic solution in every shift. Incubators and baby cots should be cleaned with soap water and antiseptics.
Clothing and linen must be autoclaved.
Infected baby should be kept in separate unit.
Baby bath to be withheld in the unit but general cleanliness to be maintained.
Any complications found to be treated promptly.

✔️ Provide Stimulation

Nurse should provide sensory stimulation to the LBW baby by talking, singing, cuddling, gentle touching during care. Visual stimulation can be provided by colourful hanging object. Baby’s position to be changed at interval. Baby should be placed on right side after feeding to prevent regurgitation and aspiration. Mother should be allowed to care the body with necessary precautions or to visit nursery to see, to touch and to handle the baby.

✔️ Informing the Parent about Infant’s Progress

Baby’s condition and progress to be explained to the parent to reduce their anxiety. Necessary treatment plan to be discussed. Parent should allow to see the baby. Care after discharge to be discussed with the parent. Parent should learn about warmth, feeding, follow up and hygienic practices at home.

The LBW baby is usually discharged from special care unit when the baby gained sufficient weight approximately 2000 gm or more, having good vigour and able to suck successfully. Ultimate survival of the baby depends upon continued care.