The document discusses low birth weight infants, specifically preterm infants. It defines preterm infants as babies born before 37 weeks of gestation. Preterm infants experience difficulties adapting after birth due to organ system immaturity. Their respiratory, central nervous, circulatory, thermoregulation and gastrointestinal systems are particularly underdeveloped. This can lead to problems like respiratory distress, feeding difficulties, temperature instability, and liver/brain damage. Care of preterm infants focuses on supporting development of these vital functions.

1. “LOW BIRTH WEIGHT
INFANT”
Ms. Anju Bista
M.Sc. Nursing 2nd year
2021 Batch
1

2. Objectives:
• At the end of this session participant will
be able to know about the low birth
weight infant.
2

3. Introduction
• The normal weight of the newborn baby is 2.5
– 3.9kg and approximately 2.9 kg.
• The average gestational age of a pregnant
female is about 37-42weeks of gestation.
• A neonate with a birth weight of less than
2.5kg or 2500gm irrespective of the gestational
age are termed to be low birth weight baby.
3

4. These classifications include the following:
• Preterm: Birth before completion of the 37th
week of gestation regardless of birth weight;
also called premature birth
• Term: Birth occurring between 38 and 42
weeks' gestation
• Post-term: Birth after completion of the 42nd
week of gestation.
4

5. Low birth weight
generally includes the
preterm infants and
small for dates baby.
5

6. Introduction…
• These two groups has the different clinical
problems and prognosis.
• In Nepal about 30-49% neonates are born with
low birth weight.
• Approximately 80% of all neonates death
about 50% death of infant are related to low
birth weight.
• About 10% of all LBW babies require
admission to the special nursery care.
6

7. 7

8. Classification of neonates by birth
weight
By birth weight
• LBW infant: An infant, regardless of the gestational
age, whose weight is less than 2,500 g (5.5lb).
• Extremely low birth weight (ELBW) infant: An
infant whose birth weight is less than 1,000 g (2.2 lb).
• VLBW infant: An infant whose birth weight is less
than 1,500 g (3.3 lb).
• Moderately low birth weight (MLBW) infant: An
infant whose birth weight is 1,501-2,500 g (3.3-5.5
lb).
8

9. By Gestational age
• AGA: An infant whose weight falls between the 10th on
information from the and 90th percentiles.
• Appropriate for dates (APD) babies: babies born with
the birth weight 10th- 90th for the period of the
gestational age. They are also termed as immature,
early born or premature
• Small-for-date (SFD): An infant whose intrauterine
growth was slowed and falls below 1oth percentile.
• LGA: An infant who falls above the 90th percentile.
and delivery.
• Birth weight variations may occur in the preterm, term,
and post-term neonates.
9

10. 10

11. An illustration of how birth weight
and gestational age classifications
are related
11

12. • Weight helps assess growth, and gestational age
helps assess maturity.
• A newborn of 40 weeks' gestation who weights
less than 2,500 g (below the 10th percentile for
weight or length) would be mature but under
grown.
• This disorder is called intrauterine growth
retardation, in which the fetus rate of growth does
not meet expected norms; the newborn is
classified as SGA
12

13. • A newborn of 36 weeks' gestation who weighs
3,500 g (above the 90th percentile for weight)
would be immature but overgrown.
• Such LGA newborns are typical for diabetic
mothers.
• Although this newborn has attained average
term weight, it is actually premature, with
incomplete maturation of organ systems.
13

14. Introduction
Dysmaturity (Intrauterine Growth Retardation
{IUGR} / Small for Date / Chronic Placental
Insufficiency)
Small for Gestational Age
• Infant whose weight is at or below 10th %.
• Is a high risk condition.
• Results from failure to thrive.
14

15. DEFINITION:
• It is said to be present in those babies whose
birth weight is below the 10th percentiles of
the average of the gestational age.
• Dysmaturity can occur in preterm, term or post
term babies.
15

16. Types of Dysmaturity
Based on the clinical evaluation & ultrasound
examination the small fetuses are divided into:
I. Fetuses that are small & healthy. The birth
weight is less than 10th percentile for their
gestational age. normal subcutaneous fat &
usually have uneventful neonatal course.
16

17. Types of Dysmaturity
II. Fetuses where growth is restricted by
pathological process (true IUGR) : Depending
upon the relative size of their head, abdomen &
femur, the fetuses are subdivided into:
• Symmetrical or Type I.
• Asymmetrical or Type II.
17

18. 18

19. 19

20. 20

21. 21

22. a. Symmetrical
(20%):
• Symmetrical FGR occurs with an
insult on the fetal growth in early
gestation.
• size of the head, body weight and
length are all equally reduced.
• fetus is affected from the noxious
effect very early in the phase of
cellular hyperplasia.
• This form of growth retardation is
most often caused by structural or
chromosomal abnormalities or
congenital infection (TORCH).
b. Asymmetrical
(80%)
• The fetus growth is
affected in later months
during the phase of
cellular hypertrophy.
22

23. Features of symmetrical &
asymmetrical IUGR fetuses
Symmetrical Asymmetrical
Uniformly small. Head larger than abdomen.
Ponderal index (Birth weight / Crown- heel length) – normal. Low.
Etiology: genetic disease or infection – (Intrinsic to fetus Chronic placental insufficiency – (Extrinsic to fetus)
Total cell number – less
Cell size - normal
Normal
Smaller
Neonatal course: complicated with poor prognosis Usually uncomplicated having good prognosis
23

24. 24

25. CAUSES
• Unknown (40%): about 40% cases remains
unknwon.
• Fetal cause:
1. Chromosomal Disorders:
Usually result in early onset IUGR.
Trisomies 13, 18, 21 contribute to 5% of IUGR
cases.
Aneuploidy.
Triploidy.
Turner's syndrome
25

26. Fetal Cause:
2. Congenital Infections:
The growth potential of fetus may be severely impaired
by intrauterine infections.
• Viruses- rubella, CMV, varicella and HIV
rubella is the most embryotoxic virus, it cause capillary
endothelial damage during organogenesis and impairs
fetal growth.
CMV causes cytolysis and localized necrosis in fetus.
• Protozoa- like malaria, toxoplasma, have also been
associated with growth restriction.
26

27. Fetal Cause:
3. Structural Anomalies :
• All major structural defects involving
CNS,CVS, GIT, Genitourinary and
musculoskeletal system are associated with
increased risk of fetal growth restriction.
• If growth restriction is associated with
polyhydramnios, the incidence of structural
anomaly is substantially increased.
27

28. Fetal Cause:
4. Genetic Causes:
• Maternal genes have greater influence on fetal
growth.
• Inborn errors of metabolism like genesis of
pancreas, congenital lipodystrophy,
galactosemia, phenylketonuria also result in
growth restriction of fetus.
28

29. Maternal cause(1):
Constitutional small women, maternal genetic
& racial factors.
Poor maternal nutrition before & during
pregnancy
Poor maternal weight gain during pregnancy.
 Diminished uterine blood flow due to pre-
eclampsia, toxemia, & hypertension.
29

30. Maternal cause(2):
Mal absorption syndrome/malnutrition.
Low blood oxygen as in heart disease.
Toxin: alcohol, smoking, chronic renal failure,
chronic UTI, etc
30

31. Placental Causes:
• Placenta is the sole channel for nutrition and
oxygen supply to the fetus.
Single umbilical artery.
Placental hemangiomas have all been
associated with fetal growth restriction
31

32. Placental cause:
• Placental & cord abnormalities such as chronic
placental abruption, infarction, small placenta,
velamentous insertion of cord, etc
32

33. SIGNS OF DYSMATURITY
• Posture: Tonic or flexed as term baby.
• Appearance: Look like an old person.
• Skin: Pink, dry & wrinkled skin.
• Lanugo: Scanty lanugo.
• Vernix: Lots of vernix.
• Fontanelle & suture: Normal wideness
of suture & fontanelle, skull bone as
normal baby.
• Ear: Normal ear pinna.
• Planter creases: Dark & plenty of
planter creases. 33

34. SIGNS OF DYSMATURITY
• Nails: Pink colored soft nails.
• Activity: Active like term.
• Sucking: Good & strong sucking ability.
• Cry: Strong & loud cry.
• Breast: Breast tissues palpable.
• Genitalia:Female: Labia majora covers the
labia minora & clitoris.
Male: Descended testes.
34

35. Problems of SGA baby:
1. Perinatal asphyxia : SGA babies tolerate the
stress of labor poorly. They are at risk of
asphyxia.
2. Meconium aspiration: Intrauterine hypoxia
can cause meconium to be passed in utero
leading to meconium aspiration syndrome.
35

36. Problems of SGA baby:
3. Persistent pulmonary hypertension:
Chronic intrauterine hypoxia
• can lead to thickening of smooth muscles of
pulmonary vasculature leading to
• pulmonary hypertension which manifests as
central cyanosis
36

37. Problems of SGA baby:
4. Polycythemia: Polycythemia and high blood
viscosity can occur secondary to chronic hypoxia
in utero.
5. Metabolic complications: Include both
hypoglycemia (due to decreased stores of
glycogen) and hyperglycemia (due to altered
insulin secretion in VLBW babies) and
hypocalcemia.
6. Decreased immunity : Due to neutropenia and
low IgG levels predisposing to infections.
37

38. Problems of SGA baby:
7. Other problems: Include congenital
anomalies, hypothermia, feed intolerance,
thrombocytopenia, acute tubular
necrosis/renal insufficiency and pulmonary
hemorrhage.
8. Risk of poor postnatal growth. Recurrent
infections and hospitalization.
38

39. Problems of SGA baby:
9. Long term outcome: Includes neuro-
developmental morbidities like hyperactivity,
short attention span and learning problems.
39

40. DETAILED MANAGEMENT
• Hospitalization.
• Warmth.
• Establishment of respiration.
• Maintenance of body temperature.
• Maintain nutrition & feeding.
• Mothering & expert nursing care.
• Prevention of infection.
• Observation.
• Emotional support to family
40

41. PREMATURITY
• A baby born before 37 WOG calculating from
the first day of LMP is arbitrarily defined as
preterm baby.
• Preterm infants (born at <37 completed weeks
of gestation) have difficulty in adapting to
extrauterine environment because of
immaturity of the organ systems
41

42. On the babies born preterm:
• 84% are born between 32 and 36 weeks of
gestation.
• 10% are born between 28 and 31 weeks of
gestation.
• 6% are born at less than 28 weeks of gestation.
• Premature infants born between 34 and 37
weeks of pregnancy are often called late
preterm or near-term infants.
42

43. Incidence
• Preterm baby consistutes 2/3rd of low birth
weight babies.
• The incidence of low birth weight baby is
about 30=40% in the developing countries as
such incidence of preterm baby is about 20-25
%.
43

44. 44

45. CAUSES
1. Maternal factors:
• Medical diseases during
pregnancy as heart
disease, anemia, HTN,
renal disease, etc.
• Maternal infection as
hyperpyrexia, trauma.
• Maternal malnutrition.
• Complications of
pregnancy as APH.
• Incompetence of cervix.
• Polyhydramnios.
• Previous history of
premature delivery.
• Physical exertion.
• Heavy smoking & drug
addiction.
• Maternal age below 20
years or age over 35
years.
45

46. Causes Of preterm
2.Fetal factors:
Multiple pregnancy.
IUGR.
Congenital
malformation.
Rh incompatibility.
3. Iatrogenic:
Improper diagnosis
of maturity in
elective deliveries.
46

47. Causes
4.Medical factors:
Uncontrolled DM in mother.
Severe cardiac illness, toxemia.
Fetal hypoxia & distress.
Severe iso-immunization in mother or hydrops
fetalis
47

48. CHARACTERISTICS
Weight is 2500 gm or less & length is usually less
than 44 cm.
Posture: Hypotonic, poor reflex, assume extended
posture due to poor muscle tone.
Appearance: Looks tiny but healthy.
Skin: Thin, shiny & excessive pink with abundant
lanugo & vernix.
Edema may be present.
Subcutaneous fat is deficient.
Breast nodules are small or absent.
48

49. CHARACTERISTICS(2)
Deep sole creases are often not present
Face & Head: Face is small & head is
large in proportion to the body.
Soft skull bone. Sutures are widely
separated & fontanelles are large.
Microganthia & retroganthia present,
protruding eye due to shallow orbit &
absent of buccal pads of fat.
Hair appears wooly & fuzzy &
individual hair fibers can be seen
separately.
49

50. CHARACTERISTICS (3)
Ear cartilage is deficient with poor
recoil. Ear pinna soft & flat.
Planter creases: Not so dark & very
few in number.
Nails: Bright pink colored nail beds
& very soft nails.
Limbs: Thin.
Activity: Less activity of limbs.
Sucking: Unable or poor sucking
ability.
Cry: Weak & feeble cry.
50

51. CHARACTERISTICS (3)
Breast: No breast tissue palpable.
Chest: Small & narrow and the abdomen large.
Genitalia: In male, testes are un-descended;
scrotum poorly pigmented & has few
rugorisities.
In female, labia majora are widely separated
exposing labia minora & clitoris.
Reflex: Moro, sucking, swallowing, & other
reflexes are absent or sluggish.
51

52. 52

53. 1. Alternation of respiratory
functions:
• Respiration of preterm neonate are rapid , shallow
irregular with periods of apnea and cyanosis.
• Coughs and gag reflex are weak or absent.
Pulmonary aspiration, atelectasis , hyaline
membrane disease are common.
• Chronic pulmonary insufficiency, weak
respiratory, poor development and expansion of
lungs, inefficient respiratory center and deficiency
of surfactant in the alveoli are responsible for
respiratory problems and resuscitation difficulties
at birth
53

54. 2. Immaturity of central nervous
system:
• The preterm infants are inactive, lethargic and
having poor cough reflex.
• Sucking and swallowing reflexes are
incordinated leading to feeding difficulties.
• These babies are prone to kernicterus and brain
damage at lower serum bilirubin level due to
inefficient blood brain barrier.
54

55. 3. Disturbance of circulatory
functions:
• In preterm neonates, the closure of ductus
arterious may be delayed, the peripheral
circulation is inadequate.
• Weak and fragile blood vessels and hypo
function of bone marrow may result
hemorrhagic problems.
55

56. 4. Impaired thermoregulation:
• Preterm infants are more prone to get
hypothermia due to poorly developed heat
regulating center
large body surface area in regulation to body
weight, poor insulating subcutaneous fat and less
brown adipose tissue.
56

57. 5. Ineffective gastrointestinal and
hepatic functions:
• Sucking and swallowing reflex are poorly
developed in preterm infants.
• Capacity of stomach is less and cardio
esophageal sphincter is incompetent and
results in aspiration and regurgitation.
• Abdominal distension and functional intestinal
obstruction are found due to hypotonia.
57

58. Contd…
• Hypoglycemia is also common due to poor
hepatic glycogen stores and delayed feeding.
• Neonates are more prone to malnutrition, iron
deficiency anemia and other vitamin
deficiency due to poor absorption of nutrients.
• Poor vitamin k synthesis in liver and poor
prothrombin production leads to hemorrhagic
disorders.
58

59. 6. Metabolic disturbances:
• Preterm neonates are more prone to develop
hypoglycemia, hypocalcemia, hypoxia,
acidosis and hypoproteinimia due to poor
metabolic functions.
59

60. 7. Increased susceptibility to
infections :
• Preterm neonates are 3 to 10 times more
vulnerable to infections than normal neonates.
• Insufficient cellular immunity and low grade
IgG antibody level makes them more
susceptible to infections.
60

61. 8. Impaired renal function:
• Due to low glomerular filtration rate and
reduced concentrating ability the preterm are
more prone to develop acidosis.
• Dehydration, delayed urination, edema as well
as renal failure can be developed as
complication.
61

62. 9. Drug toxicity:
• Poor hepatic detoxification and reduced renal
clearance lead to toxic effects of drug unless
precautions are followed during
administration.
62

63. Management
• Management depends on the birth weight of
the baby:
• Requires special care at
home
<1.8 kg otherwise
normal
• Requires hospital care
1.5kg -1.8kg
• Management in NICU
(Neonatal ICU)
< 1.8 kg
63

64. Principal management of LBW in
hospital
1. Correction of hypothermia
2. Correction of hypoglycemia
3. Detection of other complication
4. Treatment of other complication
5. Follow up with all vitals sign being monitored
64

65. Therapeutic Management:
 When a preterm delivery is expected the
NICU is alerted and the team of neonatal
specialists are present at the time of delivery
 Resuscitation is done if needed in the labor
room the in infant is transferred to NICU in an
incubator
 Measurements taken and vitamin K is given
65

66. Therapeutic Management:
Respiratory support: Apnea mattress – Incubator –
O2 monitoring
Temperature regulation: Incubator, and
monitoring of temperature, Humidity as
recommended
Complications such as hypoglycemia and
hypocalcaemia are frequent in the premature
infant and are managed according to specific
conditions and monitored frequently
 Respiratory distress syndrome is very common
and required respiratory support.
66

67. MANAGEMENT OF LOW BIRTH
WEIGHT BABY.
1. Optimal management at birth
• Senior pediatrician should be attending with all
preparation of resuscitation to baby.
• The cord is to be clamped quickly to prevent
hypervolemia & development of
hyperbilirubinemia.
• Promptly dry & kept warm with gentle
handling.
• Give vitamin K 1 mg to prevent hemorrhage.
67

68. 2. Maintain body temperature
• Keep the baby in incubator with temperature &
humidity maintained.
• Alternately, the baby could be managed in
radiant warmer.
• The room temperature should be 25-30˚C with
incubator temperature according to weight.
68

69. 2. Maintain body temperature (2)
• Cover the baby‘s head with clothes. Do not
expose body part unless & otherwise needed for
observation & assessment.
• If baby is receiving IV fluid or EBM, increase
volume of fluid or milk by 10% of total daily
volume/day for those under radiant warmer.
• Check the temperature of warmer & room every
hour & adjust the temperature setting accordingly.
• For extremely low birth weight baby, covered
with cellophane to prevent heat loss through
convection.
69

70. 3. Positioning
• Most baby love to lie in prone position, they
cry less & feel more comfortable. It relieves
abdominal discomfort by passage of flatus &
prevents aspiration.
• Baby should change position 2 hourly.
70

71. 4. Kangaroo Mother Care (KMC)
• If baby is not sick, encourage KMC &
exclusively breast feeding.
• KMC provides warmth to baby, will feed more
easily & episodes of apnea will be less
frequent.
71

72. 5. Oxygen therapy
• It should be administered only when indicated,
stop as soon as it is considered unnecessary. It
should be administered with head box when
SpO2 falls below 85%. It should be maintained
at 90-95% & PaO2 between 60-80%.
• The room fiO2 should be between 20-40%.
72

73. 6. Feeding & nutrition
• Babies < 1.2 kg or gestation < 30 weeks & sick
babies should start IV dextrose solution
(10% dextrose >1kg & 5% dextrose <1 kg).
• Trophic feeds with 1-2 ml EBM 2-3 hourly
through NG tube can be started to all babies
irrespective of age & weight, 2 hourly < 1kg &
3 hourly > 1.2 kg.
• Trophic feeds given in order to stimulate the
development of GI tract of premature baby
73

74. Feeding & nutrition
• When stabilized enteral feeds are begun with
EBM starting with a volume of 30ml/kg/day on
day 1
• Depending on tolerance feeds increased by 10-20
ml/kg/day every day and IVF are reduced.
• When baby is stable , EBM can be fortified with
human milk fortifier (HMF) for additional
calories and protein.
• Multivitamin drops after 2-3 weeks
• Vitamin E which is powerful antioxidant and
prevent hemolytic anemia and edema.
74

75. 6. Feeding & nutrition (2)
• Gradually increase EBM & decrease IV drip.
• After 7 days, if baby still requires feeding
using an alternative feeding method, increase
20 ml/kg/day until baby reaches 180 ml/kg of
breast milk/day.
75

76. 7. Gentle rhythmic stimulation:
• Gentle touch, massage, cuddling, stroking &
flexing preferably by mother provide useful
tactile stimuli to the baby.
• Soothing auditory stimuli as family voice,
music reduce the stress of procedure &
enhance weight gain.
• Eye to eye contact, colored objects provide
visual inputs.
76

77. 9.Utility of Corticosteroids
• In infant who did not receive antenatal
steroids in baby, a single dose of
dexamethasone 0.2mg/kg iv at 4 hrs of age is
recommended in very LBW babies.
77

78. 9 Prevention of nosocomial
infection:
• Strict hand washing before & after touching
the baby.
• Minimal handling the preterm.
• Effective treatment of suspected infection of
any origin.
78

79. 10.Weight record
• Accurate weihing is a sensitive index of well
being
• Most LBW babies loss weight during 1st 3 to 4
days of life up to 10-15% of birth weight.
• The weight remains stationary for next 4 to 5
days then starts to gain at a rate of 1.0 to 1.5 %
of body weight per day and regain birth weight
by the end of 2nd weeks
79

80. Immunization
• The dose is not reduced in preterm baby.
• Administer 0day vaccines on the day of
discharge.
80

81. Nursing Management Prematurity &
Dysmaturity
• Nursing assessment:
Vital signs
Activity and behavior
Color: pink, pale, grey, blue, yellow
Capillary refill over upper chest < 2 sec
ABG and electrolyte
Tolerance of feeds: vomiting, gastric residuals and
abd girth
Development of apnic attack, weight
81

82. Nursing diagnosis
1. Ineffective breathing pattern related to:
immaturity of the respiratory center, as
evidence by visible intercostal retraction.
2. Imbalanced Nutrition Less than Body
Requirements related to :decrease nutrient
deposits, immaturity of enzyme production,
weak abdominal muscles, weak reflexes.
82

83. Nursing diagnosis
3. Risk for Ineffective thermoregulation related
to : Immature CNS (central regulation of
residues, reduced lean body mass to surface
area, subcutaneous fat loss, inability to feel
cold and clammy, poor metabolic reserves).
4. Risk for infection related to immunological
defense ineffective.
5. Anxiety : parents related to : baby disease
conditions
83

84. NURSING MANAGEMENT OF
PREMATURITY DYSMATURITY (1)
• Immediate management following birth:
• Cord is to be clamped quickly to prevent
hypervolemia & later on, development of
hyperbilirubinemia.
• Cord length should be kept long (about 10-12
cm) in case exchange transfusion is required
due to hyperbilirubinemia.
84

85. NURSING MANAGEMENT OF
PREMATURITY & DYSMATURITY
(2)
• Air passage should be cleared off mucus
promptly & gently using a mucus sucker.
• Adequate oxygenation through mask or nasal
catheter
• The baby should be wrapped in sterile towel &
is laid on one side in the cot with the head
slightly lowered.
85

86. NURSING MANAGEMENT OF
PREMATURITY &
DYSMATURITY (3)
• Inj. Vit. K 1mg is to be injected
intramuscularly to prevent hemorrhagic
manifestations.
• The baby should be handled with extreme
gentleness. Preterm & dysmature babies are
both functionally immature & ―special care‖
is needed for their survival
86

87. Family support :
• The frightened seen of NICU should be
demystified.
• Family should be constantly informed and
involved in care of baby.
• Mother should be encouraged to touch and talk
with her baby and provide routine care under
guidance of nurses.
87

88. Management
88

89. Research Articles
• A Case Control Study on Risk Factors
Associated with Low Birth Weight Babies in
Eastern Nepal
• Objectives: to assess the maternal and
sociodemographic factors associated with low
birth weight (LBW) babies.
89

90. Research article…
Results: More than 50% of LBW babies were from the mothers with
height ≤145 cm while only 9.43% of NBW babies were from the
mothers with that height. Finally, after multivariate logistic
regression analysis, maternal height, time of first antenatal care
(ANC) visit, number of ANC visits, iron supplementation, calcium
supplementation, maternal education, any illness during pregnancy,
and hypertension were found as the significant predictors of LBW.
However, maternal blood group AB, normal maternal Body Mass
Index (BMI), mother’s age of 30 or more years, and starting ANC
visit earlier were found to be protective for LBW.
Conclusion: Study findings suggest that selectively targeted
interventions such as delay age at first pregnancy, improving
maternal education and nutrition, and iron and calcium
supplementation can prevent LBW in Nepal.
90

91. Reference :
• Ghai O, Paul V, Bagga A. Ghai Essential Pediatrics. 7th
ed. New delhi, India: CSB; 2012.
• Premature birth - Symptoms and causes [Internet].
Mayo Clinic. 2019 [cited 3 October 2019]. Available
from: https://www.mayoclinic.org/diseases-
conditions/premature-birth/symptoms-causes/syc-
20376730
• Care of the preterm and low-birth-weight newborn
[Internet]. World Health Organization. 2019 [cited 3
October 2019]. Available from:
https://www.who.int/maternal_child_adolescent/newbor
ns/prematurity/en/
91

92. THANK YOU
92