APPROACH TO NEONATE

WITH LOW BIRTH

WEIGHT
DR. JANAK PATHAK
RESIDENT 1ST YEAR
 BIRTH WEIGHT
• First Weight of fetus or newborn after birth.
• The single most important single most determinant of
survival, growth and development of an infant.
• Reflects the health status of mother during adolescent,
pregnancy and quality of ANC.
• Fetus weighing 500 g or less when it is not capable of
independent survival which is attained at around 22 weeks
which is considered as abortion(WHO).
• The right to safe motherhood and reproductive health act,
2075 (2018) also consider pregnancy termination upto 28
weeks as legal termination in special circumstances
 DEFINITION
• Babies weighing less than 2500gm irrespective of
gestational age
• Preterm low birth weight
• Term low birth weight (SGA/IUGR)
• Grading
Birth Grading Gestational Grading
Weight Age ( Weeks)
(grams) <28 Extremely Preterm
<1000 Extremely Low
Birthweight <32 Very Preterm
<1500 Very Low 32 to <34 Moderate Preterm
Birthweight
34 to <37 Late Preterm
<2500 Low ≥ 37 Term
Birthweight
 SMALL FOR GESTATIONAL AGE AND INTRA UTERINE
GROWTH RESTRICTION

• Though used interchangeably, they are the different concepts.

• SGA
• a neonate whose birth weight or birth crown heel length
is < 10th centile for GA or
• < 2 SD below the mean for the GA
• IUGR denotes diminished growth velocity in the fetus as
documented by at least two intrauterine growth assessments
( like failing off its own growth velocity )
 RISK FACTORS OF PRETERM DELIVERY
• Fetal • Maternal
• Fetal distress • Prev preterm birth
• Chromosomal abnormality • Short interpregnancy interval
• Multiple gestation • Preeclampsia
• Erythroblastosis • Cyanotic heart disease, renal/
• Nonimmune hydrops thyroid disease
• Infection
• Placental
• Obesity
• Placental dysfunction
• Drug use (cocaine)
• Placenta previa
• Young or advanced maternal age
• Abruptio placenta
• Lower Socioeconomic Status
• Uterine • Hard physical work
• Bicornate uterus
• Incompetent cervix
 RISK FACTOR FOR INTRAUTERINE GROWTH
RETARDATION
• Fetal
• Chromosomal Disorders
• Chronic fetal infections ( TORCH)
• Irradiation
• Multiple Gestation
• Pancreatic Hypoplasia
• Insulin deficiency
• Placental and Cord Abnormality
• Decreased placental weight, cellularity or both
• Decrease in surface area
• Structural abnormality ( Bilobed, Circumvallate,
hemangioma )
• Cord: single Umbilical artery, velamentous or marginal
insertion
• Placental separation
• Maternal correlates
• Low socioeconomic and nutritional status
• Placental dysfunction- PIH
• Chronic systemic diseases- HTN, chronic heart disease,
collagen vascular disease, diabetes
• Maternal infections UTI, malaria, TB, genital colonization
• Previous pregnancy history
• Primipara- higher risk for IUGR
• Previous abortions, still births- risk
• Inter pregnancy interval of < 13mo
• Antenatal care and low weight gain
• Maternal Substance abuse
• Assisted Reproductive Technique
 PROBLEMS OF PRETERM LBW
Short term
• Temperature regulation (hypothermia)
• Respiratory : RDS, AoP, pulmonary hemorrhage
• GI : feeding intolerance, NEC
• Infection
• CVS : PDA, hypotension, PPHN
• CNS : ROP, IVH, periventricular white matter disease, PA
• Others : electrolyte, mineral & acid-base imbalance,
anemia of prematurity
 PROBLEMS OF PRETERM LBW
Long term
• Recurrent hospitalization : • Short Bowel Syndrome,
d/t RSV, asthma, GERD, AGE Malabsorption, malnutrition,
• BPD, Pulmonary • Chronic kidney disease,
Hypertension hypertension, obesity, DM,
• Impaired cognitive skills, ischemic heart disease,
motor delay, cerebral palsy, infertility.
Spastic diplegia, seizure • Growth impairment
• Vision & sensory loss • Behavioral & psychological
problems ; ADHD
 PROBLEMS OF SGA BABIES
• Congenital malformations
• Severe birth asphyxia
• Meconium aspiration
• Hypothermia, hypoglycemia
• Pulmonary hemorrhage
• Polycythemia due to chronic hypoxia
• Poor growth potential on F/U
• Vulnerability to infections
• Increased risk of development of diabetes, hypertension,
coronary artery disease in later life
Problems Preterm LBW SGA

Intrauterine hypoxia + ++

Birth asphyxia + +++

Aspiration in utero + +++

HMD +++ -

Apneic attack +++ -

Inability to +++ -
suck/swallow

Aspiration of feeds ++ -

Enterocolitis ++ +
Problems Preterm LBW SGA

Symptomatic + +++
hypoglycemia
Hypothermia +++ +
Polycythemia + +++

hyperbilirubinemia +++ +

Infections +++ ++

Congenital malformation + +++

Intraventricular +++ -
Hemorrhage
Pulmonary hemorrhage + +++
 PROGNOSIS

Problem Preterm lbw SFD

Immediate High mortality Better but increased
when compared with
normally grown babies

Future physical and Good if no perinatal Poor if symmetric and

mental development complications occur severe IUGR.
Increased risk of
hypertension,
coronary artery
disease and DM
 HISTORY
• Maternal history
• Age, height
• Socioeconomic status
• Dietary history
• Medical/surgical history
• Renal disease- prematurity, IUGR
• Congenital/acquired heart disease
• Anemia
• Hypertension , prior cervical surgery
• Previous pregnancy
• Abortions, fetal demise, neonatal deaths, prematurity,
malformations, apnea
• Short inter-pregnancy period
• Current pregnancy
• Weeks of gestation, Multiple gestation
• Bleeding during pregnancy, headache, blurring of vision
• H/O Fever, rash
• Oligo/polyhydramnios
• Weight gain during pregnancy <7kg-iugr
• Excess physical activity- IUGR
• Medical or Surgical Condition
• Maternal substance abuse-smoking, alcohol
• Labor, delivery and neonatal history
• Need of resuscitation
• Apgar

• Family history
• Developmental and metabolic disorder
• Sibling death and its cause
• Consanguinity
 EXAMINATION
• General
• Temperature ,color, evidence of meconium staining,
jaundice, petechiae
• Heart Rate, CRT
• Skin texture, Subcutaneous fat
• See for any congenital anomalies
• Tone and reflexes, posture
• Length , chest circumference
• Old man face
• Head and face
• HC, Anterior Fontanel
• Sutures, fontanels- wide, hair, ear recoil, chin
• Ear : hearing evaluation
• Eye
• Retinopathy of prematurity, shallow orbit, protruding
eyes
• Cardiorespiratory system
• Color, RR, signs of distress, apnea
• Continuous murmur
• Abdomen – abdomen distension, decreases bowel sounds,
functional intestinal obstruction due to hypotonia,
hepatomegaly
• Anthropometry
Genitals
• Male
• In full term : well developed scrotum, well pigmented and
pendulous
• In preterm : small scrotum , few or no rugosities,
undescended testes
• Female
• In full term : labia majora completely cover labia minora
• Preterm : labia majora widely separated and labia minora
protruding
THE EXPANDED NEW BALLARD SCORE
 INVESTIGATION

• CBC
• Polycythemia :, IUGR
• Thrombocytopenia : sepsis
• Anemia : preterm
• Serum electrolytes, serum bilirubin
• F/o AKI, NNJ

• Pulse oximetry
• Low oxygen saturation in asphyxiated baby

• Hearing and ophthalmological assessment

• ABG
• Acidosis
• Chest radiograph
• Low lung volume
• Diffuse ground glass appearance in preterm RDS
• Echocardiography
• Structural cardiac abnormality
• Neurosonogram
• ICH, PVL
 MANAGEMENT/CARE OF LBW

• Antenatal management
• Delivery room Management
• Routine care
• Management of complication
• Ante natal management
• Primary care is aimed to reduce the incidence of
preterm labor by reducing the high-risk factors.
• Secondary care includes screening tests for early
detection and prophylactic treatment (e.G. Tocolytics).
• Tertiary care is aimed to reduce the perinatal morbidity
and mortality after the diagnosis (e.G. Use of
corticosteroids).
• Delivery room management
• Delayed cord clamping- iron store
• Prompt drying, covered, keep under radiant warmer
• Vitamin K, transfer to NNW
• Blood sugar monitoring
• Routine care
• Provide warmth
• Clear airway
• Dry
• Keep with mother
• Ongoing evaluation

Weight Place of Care

>1.8 kg Special Care at home
1.5 to 1.8 kg Requires Hospital Care
<1.5 kg Neonatal ICU
• MANAGEMENT OF COMPLICATION
• Prevention of hypothermia
• Thermoneutral environment
• Maintain core temp at 36.5-37c
• Humidity 40-60%- prevent heat loss, prevent
irritation/drying respiratory passage
• Methods
• Warm chain
• Incubator and radiant warmer
• KMC
• Clothing and bedding inn
• Prevention of infection
• Prophylactic antibiotics
• Separate nurses for feeding and toilet attending
• Barrier nursing to prevent cross infection

• Correction of electrolytes abnormality

• Oxygen therapy must balanced against risk of damage to
eyes.
• Phototherapy
• Fluid requirement
• Depends on the days of life
 FEEDING
• Problems
• Poor suck and swallowing until 34wk
• Poor gag reflex
• Immature, incompetent esophagogastric sphincter
• Decreased enzyme secretion

• Categorization of baby for deciding initial feeding

method
• Sick Neonate : Assisted ventilation, shock requiring
ionotropic support, seizures, symptomatic hypoglycemia,
hypocalcemia, electrolyte abnormality, cardiac failure, NEC
• Healthy Neonate
 • CHOICE OF INITIAL FEEDING METHOD IN LBW

Gestational Age Maturation of Feeding skills Initial feeding method

<28 weeks No proper sucking efforts IV fluids
No propulsive motility of gut

28 to 31 weeks Sucking bursts develop NG Or OG feeding with

No coordination between suck/swallow occasional spoon/ paladai
and breathing feeding

32 to 34 weeks Slightly mature sucking pattern Feeding by spoon/

Coordination between breathing and paladai/cup
swallowing begins

>34 weeks Mature sucking pattern Breastfeeding

More coordination between breathing
and swallowing
 DANGER SIGNS

• History of difficulty in feeding

• Movement only when stimulated
• Temperature below 35.5 or 37.5 or more
• Respiratory rate more than 60 breaths per minute
• Severe chest indrawing
• History of convulsion
• Bleeding, icteric upto palm and soles
• Vaccination
• Preterm – able to mount satisfactory immune response
like FT
• Dose should not be reduced
• Studies have shown poor seroconversion in PT <2kg
babies
• 1st vaccine in baby of HBsAg negative mother to be
delayed until baby is achieves a weight of 2 kg.
 CRITERIA FOR DISCHARGE
• Resolution of acute life threatening illness
• Stable temperature regulation
• Gain of weight with enteral feeding
• Free of significant apnea
• Absence of danger signs
• Hearing and ophthalmological assessment
• Parenteral knowledge, skill and confidence in care of baby
• Absence of significant morbidity & baby is not needing any
iv abs.
• Nutritional supplement started
 HOME MANAGEMENT
• Feeding
• Exclusive breast feeding
• Thermal protection
• Proper wrapping of baby
• Maintenance of room temperature
• Kangaroo mother care
• Prevention of infection
• Gentle handling, hand hygiene
• Immunization
• Follow up
 ON F/U

• Common infective illness, RAD, hypertension

• Feeding and nutrition
• Immunizations
• Physical growth, anemia, nutritional status,
osteopenia/rickets
• Neuromotor development, cognition
• Eye evaluation
• Hearing assessment
• Behavior problems, language disorder, learning disabilities
 PREVENTION OF LBW
• Improvement of women literacy
• Avoidance of early marriage and teenage pregnancy
• Ensuring inter-pregnancy interval of at least 3yrs
• Good quality antenatal care
• Enhanced calorie intake, supplementation of iron and folic
acid during pregnancy
• Avoiding smoking, tobacco during pregnancy
• Early detection of pregnancy related complications
• Avoidance of physical labor during pregnancy during 3rd
trimester
 REFERENCES

• Avery’s disease of newborn , 11th edition.

• Nelson textbook of pediatrics , 21st edition
• Cloherty and stark’s manual of neonatal care
• Uptodate
• Ghai essential pediatrics. 9th edition
• Dc dutta’s textbook of obstretrics, 8th edition