Birth weight is the single most important marker of
adverse perinatal and neonatal outcome.
Babies with a birth weight of less than 2,500g,
irrespective of their gestation are classified as low
birth weight babies.
These include both preterm and small-for-dates
Preterm infants (also called premature infants) are those
born before the beginning of 38th week of gestation.
Moderately preterm infants are those born between 32
and 36 completed weeks of gestation.
Late preterm infants fall in the moderately preterm
Very preterm infants are those born before 32
completed weeks of gestation. (Mehrban Singh, 2010)
About 10 to 12 percent of Indian babies are born
preterm ( less than 37 completed weeks) as
compared to 5 to 7 percent incidence in the west.
These infants are anatomically and functionally
immature and therefore their neonatal mortality is
The mechanisms initiating normal labour are not
clearly understood and much less is known about
the triggers that initiate labour before term.
Poor socio-economic status
Low maternal weight
Chronic and acute systemic maternal illness
Maternal genital colonization and infections
The labour is often induced before term when there is
impending danger to mother or foetal life in-utero.
Maternal diabetes mellitus
Placental dysfunction as indicated by unsatisfactory
Antepartum haemorrhage and
Severe rhesus iso-immunization.
Their size is small with
relatively large head.
Crown-heel length is
less than 47 cm
Head circumference is
less than 33cm but
exceeds the chest
circumference by more
The general activity is
Their automatic reflex
responses such as moro
response, sucking and
swallowing are sluggish or
The baby assumes an
extended posture due to
large head size
Sutures are widely
separated and the
fontanels are large
Small chin, protruding
eyes due to shallow
orbits and absent
buccal pad of fat.
Optic nerve is often un-
myelinated but presence of
papillary membrane makes
its visualization difficult.
Ear cartilage is deficient or
absent with poor recoil.
Hair appear woolly and fuzzy
and individual hair fibres can
be seen separately.
skin is thin, gelatinous,
shiny and excessively
pink with abundant
lanugo and very little
Edema may be
Subcutaneous fat is
deficient and breast
nodule is small or
Deep sole creases are
often not present.
In male testes are
scrotum is poorly
In female infants, labia
majora are widely
labia minora and
Immaturity of central
nervous system is
expressed as inactivity
and lethargy, poor
cough reflex and
Resuscitation difficulties at
birth and recurrent apneic
Retinopathy of prematurity .
Vulnerable for intra-
ventricular – periventricular
hemorrhage and leuco-
Inefficient blood brain barrier
Cuboidal alveolar lining-
poor alveolar diffusion of
Breathing is mostly
and associated with
They are vulnerable to
The closure of ductus
arteriosus is delayed.
In grossly immature
infants( less than 32
weeks) EKG shows left
Risk to develop thrombo-
Due to poor and
incoordinated sucking and
Animal fat is not tolerated as
well as the vegetable fat.
Regurgitation and aspiration
Abdominal distention and
Immaturity of the glucuronyl
transferase system in the liver
leads to hyper-bilirubinemia.
Development of kernicterus
at lower serum bilirubin
Hypothermia is invariable.
Excessive heat loss due to
relatively large surface area
due to paucity of brown fat
in the baby who is
equipped with an
Infections are the important
cause of neonatal mortality.
The low levels of IgG
antibodies and inefficient
Excessive handling, humid
and warm atmosphere,
and resuscitators expose
them to infecting organisms.
The blood urea nitrogen is
high due to low glomerular
The renal tubular ammonia
mechanism is poorly
developed thus acidosis
They vulnerable to develop
late metabolic acidosis
especially when fed with a
high protein milk formula.
Concentration of urine is
Preterm has to pass
4 to 5 ml of urine excrete
one milliosmole of solute
Baby gets dehydrated.
The solute retention and
low serum proteins explain
occurrence of edema in
clearance make a
vulnerable to toxic
effects of drugs
Develop anemia around 6
to 8 weeks of age.
Deficiencies of folic acid
and vitamin E.
and edema 6 to 10 weeks
Osteopenia and rickets
These babies are prone
to develop :
Bed rest and sedation.
Isoxsuprine (duvadilan)-beta-1 and beta-2 receptors.
Salbutamol and terbutaline -beta-2 receptor
Maturity of fetus should be ascertained by
examination of amniotic fluid for phosphatidyl
glycerol or L/S ratio.
Corticosteroids should be administered to the
mother to enhance fetal lung maturity.
Inj.betamethasone 12mg IM
every 24 hours --2 doses or
dexamethasone 6mg IM
every 12 hours for 4 doses.
The optimal effect is seen if
delivery occurs after 24
hours of the initiation of
therapy and its therapeutic
effect lasts for 7 days.
Delayed clamping of cord.
Elective intubation of extremely LBW babies (<1000g).
Should be promptly dried, kept effectively covered and
Vitamin K 1mg ( 0.5mg in babies < 1500g) should be
Transferred by the doctor or nurse to the NICU as soon as
breathing is established.
Vital signs .
Activity and behaviour.
Fluids, electrolytes and ABG’s.
Tolerance of feeds .
Watched for development of
RDS, apneic attacks, sepsis,
PDA, NEC, IVH, etc.
Weight gain velocity.
The vital signs should be stable.
The healthy baby is alert and active, looks pink
and healthy, trunk is warm to touch and
extremities are reasonably warm and pink.
The baby is able to tolerate enteral feeds and
there is no respiratory distress or apneic attacks
and baby is having a steady weight gain of 1-1.5 %
of his body weight every day.
Create a soft, comfortable,
“nestled” and cushioned bed.
Avoid excessive stimuli.
Effective analgesia and
Prevent evaporative skin losses.
Provide effective and safe
Partial parenteral nutrition
and give trophic feeds
with expressed breast milk
Provide rhythmic gentle
tactile and kinaesthetic
Application of oil or liquid
paraffin on the skin.
Should be covered with a
cellophane or thin
transparent or thin
transparent plastic sheet.
Oxygen should be administered
with a head box when SpO2 falls
below 85% and it should be
gradually withdrawn when SpO2
goes above 90%.
The lowest ambient concentration
and flow rates should be used to
maintain SpO2 between 85-95%
and PaO2 between 60-80 mm Hg.
Early phototherapy is
adviced to keep the serum
bilirubin level within safe
limits in order to obviate the
need for exchange blood
The handling should be bare
Vigilance should be
maintained on all
Early diagnosis and prompt
treatment of infections.
Intra-venous dextrose solution (
10% dextrose in babies >1000g
and 5% dextrose in babies
Trophic feeds with EBM through
Condition is stabilized - enteral
Fluid requirements are higher in LBW infants due
Greater insensible water losses
Faster breathing rates
Decreased ability to concentrate urine
Greater use of radiant warmers
Greater use of phototherapy units
Fluid rate can be increased by 10-20 ml/kg/d
to gradually reach 150 ml/kg/d
Fluid requirements need to be individualized
for each baby
Enteral nutrition has to be considered once
the baby is stable
Infants with BW ≤ 1000 g
Infants with BW ≤ 1500 g, done in
conjunction with slowly advancing enteral
Infants with BW 1501-1800 g for whom
enteral intake is not expected for > 3 days
Trophic feeding/ Gut priming
Practice of feeding very small amounts of enteral nourishment
to stimulate development of the immature GIT
Improves GI motility
Enhances enzyme maturation
Improves mineral absorption
Lowers incidence of cholestasis
Shortens time to regain birth weight
Breast milk or ½ or full strength preterm formula at
10ml/kg/d by intermittent gavage/ continuous
Increase by 10-15 ml/kg/d to reach 150ml/kg/d
Increments not >20 ml/kg/d
IV fluids can be stopped once 120ml/kg/d is reached
On reaching 150ml/kg/d,calorie density can be
<1200 g/ <32 wks: IV fluids for first 2-3 days, once
stable start gavage feeding
1200-1800 g/ 32-34 wks: Start gavage feeding, once
vigorous start spoon/ breast feeding
>1800 g/ >34 wks: Start breast feeding directly; if
trial feed takes>20 mins or intake is less than
required, switch to gavage feeding
Higher concentrations of amino acids
Higher concentrations of essential fatty acids
Lower renal solute load
Specific bio-active factors provide immunity
Promotes intestinal maturation
Low concentrations of Vitamin
D, Ca, P
Energy : 130 - 175 Kcal/kg/d
Protein :3.4 - 4.2 g/kg/d
Fat :6 - 8 g/kg/d
Na :3 - 7 mEq/kg/d
Cl :3 - 7 mEq/kg/d
K :2 - 3 mEq/kg/d
Ca :100 – 220 mg/kg/d
Vitamin E supplementation.
Supplements of calcium
Gentle touch, massage,
cuddling, stroking and flexing.
Rocking bed or placing a
preterm baby on inflated
Soothing auditory stimuli.
Kangaroo care is placing a
premature baby in an upright position on a
mother’s bare chest allowing tummy to
tummy contact and placing the premature
baby in between the mother’s breasts.
The baby’s head is turned so that the ear is
above the parent’s heart.
Mothers have thermal synchrony with their baby.
The study also concluded that when the baby was
cold, the mother’s body temperature would increase
to warm the baby up and vice versa.
Kangaroo care allows easy access to the breast and
skin-to-skin contact increases milk let-down.
Increase weight gain
Kangaroo care allows the baby to fall into a deep
sleep which allows the baby to conserve energy for
more important things. Increased weight gain
means shorter hospital stay.
Loss is upto a maximum of 10
to 15 percent.
Regain their birth weight by
the end of second week of
Excessive weight loss, delay in
regaining the birth weight or
slow weight gain- suggest
baby is not being fed
adequately or unwell and
needs immediate attention.
Routine oxygenation without
Prophylactic administration of
indomethacin or high doses of
Unnecessary blood transfusions.
Rough handling, excessive light
and loud sound.
It is desirable to administer 0-
day vaccines(BCG, OPV,
HBV) on the day of
discharge from the hospital.
If mother is HBV carrier and is
e-antigen positive- hepatitis
B vaccine and hepatitis B
within 72 hours of age.
Live vaccines should be
avoided in symptomatic HIV-
WHO recommends that BCG
and oral polio vaccine can be
given to asymptomatic HIV-
The family dynamics are
The problems and issues
should be handled with
concern and caring attitude
of the health team.
Encouraged to touch and
talk with her baby.
Emotional support and
A baby who is feeding from the
bottle or cup and is reasonably
active with a stable body
temperature, irrespective of his
weight, qualifies for transfer to the
The mother should be
mentally prepared and
provided with essential
training and skills.
The mother- baby dyad
should be kept in step-
The baby should be stable,
maintaining his body
temperature and should
not have any evidences of
At the time of discharge,
the baby should be having
daily steady weight gain
velocity of at least 10g/kg.
The home conditions
should be satisfactory
before the baby is
The public health nurse
should assess the home
conditions and visit the
family at home every week
for a month or so.
cognition and seizures.
Eyes: Retinopathy of
prematurity, vision, strabismus.
language disorders and
She must be explained
about the importance of
Keeping the baby warm
and ensuring satisfactory
The services of postpartum
programme public health
nurse and social worker
can be utilized.
The infant should be effectively covered taking care to
Woollen cap, socks and mittens should be worn.
The infant should preferably lie next to the mother.
In winter, the room can be warmed with a radiant
heater or angeethi.
A table lamp having 100 watt bulb can be used to
provide direct radiant heat.
Hot water bottle should never come in contact with the
The cot of the mother and infant should be located
away from the walls .
The mother and health worker should be trained to
assess the temperature of the newborn baby by touch.
The visitors and handling of the infant should be
restricted to the bare minimum.
The hands must be washed before touching or feeding
The emotional urge for kissing the baby should be
The linen should be clean and sun-dried.
Whenever feasible, breast feeding is ideal and
must be encouraged.
When infant is unable to suck from the breast, EBM
should be given with a bottle or dropper or spoon
or paladay depending upon his maturity.
Formula for premature babies is recommended.
If cow’s or buffalo’s milk is unavoidable it should be
given after 3:1 dilution.
Mother must be given detailed instructions and
practical demonstration for maintenance of bottle
hygiene to prevent contamination of feeds.
The risk of neurodevelopmental
handicaps is increased 3-fold for LBW
babies and 10-fold for very LBW
The prognosis is good if no birth
asphyxia, apneic attacks,RDS,
Preterm AFD babies catch up in their
physical growth with term
counterparts by the age of 1 to 2
15 to 20 % incidence of
neurological handicaps in the
form of CP, seizures, ROP,
hydrocephalus, deafness and
There is high incidence of
minor neurologic disabilities.
Neurological prognosis is
adversely affected by degree
Obtain detailed antenatal, intra-
Assess the gestational age and
birth weight of the baby.
Assess the features of clinical
Assess the behaviour of preterm
Assessment of common
1. Impaired gas exchange related to immaturity of
lungs and deficiency of surfactant
Assess the respiratory pattern and colour of the
Observe for any apneic episode.
Oxygen hood is often used for able to breathe
alone but need extra oxygen.
Oxygen also may be given by nasal cannula to the
infant who breathes alone.
Humidify the oxygen
CPAP may be necessary to keep the alveoli open
and improve expansion of lungs
2.Impaired breathing pattern : distress related to
immaturity and surfactant deficiency
Assess the respiratory rate, heart rate and chest
Position the child for maximal ventilatory efficiency
and airway patency
Provide humidified oxygen
Provide chest physiotherapy
Administer anti inflammatory medications
3. Activity intolerance related to increased work of
breathing secondary to distress
Arrange to provide routine care
Schedule periods of uninterrupted rest
Determine infant’s stress level
Reduce nonessential lighting
Use positioning devices
4. Ineffective airway clearance related to excessive
Assess the child’s breathing pattern
Check the vital signs
Provide humidified oxygen
Assess the ABG analysis
Provide C-PAP using mask /hood/nasal prongs
Observe for risks of C-PAP
Assist in CMV with PEEP if needed
5. Hypothermia related to immature thermoregulation
Monitor vital signs frequently
Wrap the baby well and keep warm
Provide small and frequent breast feeding as tolerated
Look for hypoglycemia
Administer IV fluids if not tolerating the feed
Monitor the vital signs and blood pressure
Assess the skin tone, pallor and signs of dehydration
Administer IV fluids
6. Imbalanced nutrition less than body requirement
related to feeding difficulty, respiratory distress, or
Assess the sucking and swallowing ability of the
Assess the tolerance of the child
Monitor the blood glucose level frequently
Administer IV fluids if not tolerating oral fluids
Administer human milk fortifier if the child is preterm
7. Fatigue related to increased demand for nutrients
and deterioration of the general condition of the
Assess the general condition of the baby
Assess the level of activity
Monitor the blood glucose level
Breast fed the baby
Check for from any part of the body
Provide top up feed
8. Risk for complications hypotension, shock, cerebral
hypoxia related to progression of the disease condition
Assess the vital signs, respiratory rate, pulse rate,
temperature and blood pressure
Check blood culture and sensitivity and sepsis screening
Monitor for any signs of dehydration
Administer IV fluids or blood as necessary
Assess the serum electrolyte values and ABG values
Closely monitor for the early signs and symptoms of
9. Anxiety of parents related to the outcome of the
Assess the mental status, anxiety and knowledge of
Assess the supporting system for the family
Assess the coping strategies of the family members
Explain the disease process to the family members
Explain each and every procedure to the care giver
Provide psychological support to the family members
10. Interrupted mother-child bonding related to
Assess the breast feeding ability including sucking
and swallowing ability
Keep the child with the mother if possible
Provide frequent breast feed 2 hourly
If breast feeding is not tolerated give EBM
Allow the mother to visit the child
Provide kangaroo mother care in case of pre term if
11. Interrupted family process related to
hospitalization of the newborn
Assess the mental status, anxiety and knowledge
of family members
Encourage mother-child bonding if possible
Assess the coping strategies of the family members
Explain the disease process to the family members
Explain each and every procedure to the care
Allow the family members to visit the child
12. Knowledge deficit regarding care of the baby
and treatment modalities
Assess the knowledge level of the care giver
Explain disease condition and it’s progress to the
Educate regarding treatment and its prevention
Educate about the monitoring of the baby
Provide adequate explanation regarding nutritional
need of the baby
Clarify their doubts and promote understanding
Definition and incidence
Causes of prematurity
Care of preterm babies
Nursing diagnosis and interventions