- Low birth weight babies are at high risk of mortality and morbidities. They require specialized management in the hospital as well as after discharge. - Key aspects of management include maintaining temperature, careful monitoring for problems, starting feeds appropriately based on stability and maturation, and ensuring adequate weight gain through breastfeeding or other feeds along with nutritional supplements. - Growth must be closely monitored to detect any problems in feeding or weight gain early to improve outcomes for these high-risk infants.

1. Management of Low Birth Weight
babies
Dr. Keshav Chandra

2. Learning objectives
• To understand the types and causes of LBW
• To learn how to differentiate Preterm LBW
from Term LBW infants
• To recognize the problems of LBW neonates
• To learn the principles of management

3. Low birth weight (LBW)
 Definition: Birth weight
< 2500 g irrespective of their
period of gestation
 Incidence: ~ 30% of neonates in
India

4. Categories of LBW babies
 LBW – Birth weight < 2.5 KG.
 VLBW – Birth weight < 1.5 KG.
 ELBW – Birth weight < 1.0 KG.
 High incidence of LBW babies in our country is
accounted for by a higher number of babies with
IUGR(small-for –dates) rather than the preterm babies.
.

5. LBW: Significance
• LBW babies account for about 75%
neonatal deaths and 50% infant deaths
• LBW babies are more prone to:
– Malnutrition
– Infections
– Neurodevelopmental delay
LBW babies have higher mortality and morbidities

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

7. Intrauterine growth chart
400
800
1600
1200
2000
2400
2800
3600
3200
4000
4400
31 33 35 42 44 45
PRETERM TERM POST-TERM
APPROPRIATE FOR DATE
SMALL FOR DATE
LARGE FOR DATE
90th percentile
10th percentile
37 39
Gestation (weeks)
Birthweight(grams)

8. Causation: LBW
Etiology of prematurity
 Low maternal weight, teenage / multiple
pregnancy
 Previous preterm baby, cervical incompetence
 Antepartum hemorrhage, acute systemic
disease
 Induced premature delivery
 Majority unknown

9. Etiology of SFD / IUGR
 Poor nutritional status of mother
 Hypertension, toxemia, anemia
 Multiple pregnancy, post maturity
 Chronic malaria, chronic illness
 Tobacco use
Causation: LBW
Teaching Aids:NNF LBW-9

10. LBW (Preterm) : Problems
 Birth asphyxia
 Hypothermia
 Feeding difficulties
 Infections
 Hyperbilirubinemia
 Respiratory
distress
 Retinopathy of
prematurity
 Apneic spells
 Intraventricular
hemorrhage
 Hypoglycemia
 Metabolic acidosis

11.  Birth asphyxia
 Meconium aspiration syndrome
 Hypothermia
 Hypoglycemia
 Infections
 Polycythemia
LBW (SFD/IUGR) : Problems

12. Management
• Antenatal management:-
 Mother is an ideal transport incubator – high risk
mother should be referred for confinement to a centre
equipped with good quality obstetrical & neonatal
care.
 Arrest of labour – Rest, sedation& tocolytic agents –
Isoxsuprine.
• Assessment lung maturity:- by L/S ratio or
phosphatidyl glycerol level in amniotic fluid (before
the induction of premature labour), when it is
required in the interest of mother or fetus.

13. Antenatal steroid – Less than 34 Weeks GA
• - Betamethasone – 12 mg IM
24 Hourly – 2 Doses
OR
• - Dexamethasone – 6 mg IM
12 Hourly – 4 Doses
- Optimal effect –After 24 hrs of last dose
- Therapeutic effect lasts for 7 days.

14. Labour Room Optimal Care
 Transfer mother to a well-equipped centre before delivery of
an anticipated LBW baby.
 Skilled person needed for effective resuscitation.
 Prevention of hypothermia - topmost priority.
 Delay clamping of cord – Improves iron store & decrease
incidence & severity of HMD.
• Promptly dry , cover & warm.
• Resuscitation with T-piece resuscitator
• Elective intubation & prophylactic Surfactant administration –
In ELBW (by INSURE method)
• Early CPAP–if retraction
• Rescue surfactant –in NICU
• VIT-K – 0.5 mg IM.

15. LBW: Indications for hospitalization
• Birth weight less than 1800 gm
• Gestation less than 34 weeks
• Neonate who is not able to take feeds from the
breast or by katori- spoon (irrespective of birth
weight and gestation)
• A sick neonate (irrespective of the birth weight or
gestation)
Teaching Aids:NNF LBW-15

16. •Babies > 1.8 kg. & > 35 Weeks GA
• If stable – Transfer to mother.
• Have close supervision in post natal ward.

17. Management in postnatal ward
• Monitoring:-
- By specially trained nurses.
- vital signs with the help of a multichannel vital
sign monitor (HR, RR, SPO2, NIBP, ECG & TEMP).
- Look for the colour, tone, cry,reflexes and activities.
- Tissue perfusion – suggested by
- pink colour
- CRT < 2 sec
- warm & pink extremities
- normal BP
- U.O - > 1.5 ml/kg/hour
- absence of metabolic acidosis
- lack of disparity between Pao2 & Sao2.

18. Monitoring –contd..
• fluids, electrolytes , blood sugar & ABGs.
• tolerance of feeds – vomiting, gastric residuals,
abdominal girth.
• look for RDS, Apnoea, Sepsis, PDA, NEC, IVH .
• weight gain velocity – 10-15 gm/kg/day
• frequency of monitoring depends on gestational age
&clinical status.

19. Provide in–utero milieu in NICU
• Aim is to create uterus like baby – friendly ecology in
nursery.
• Create a soft, comfortable, nestled & cushioned bed.
• Avoid excessive light, sounds, handling & painful procedures.
• Provide warmth
• Ensure asepsis
• Prevent evaporative skin losses by effectively covering the
baby.
• Effective and Safe oxygenation.
• Provide partial parenteral nutrition & trophic feeds with
EBM.
• Provide tactile & kinesthetic stimulation like skin to skin
contact, interaction , music, caressing & cuddling.

20. Maintainance of Temperature
• LBW babies should be nursed in a thermoneutral
environment with a servo sensor to maintain skin
temp of 36.5 C.
• ELBW baby should be covered with a cellophane
sheet to prevent convective and evaporative heat
loss from skin.
• Stable LBW baby should be covered with perspex
shield or effectively clothed with a frock, cap, socks
and mittens.

21. LBW: Keeping warm at home
Birth weight (Kg) Room
temperature (0C)
1.0 – 1.5 34 – 35
1.5 – 2.0 32 – 34
2.0 – 2.5 30 – 32
> 2.5 28 - 30
Skin-to-skin contact Warm room, fire or heater
Prevent heat losses Baby warmly wrapped
Conduction
Radiation
Convection
Evaporation

22. Well covered newborn
LBW: Keeping warm at home

23. Keeping warm in hospital
 Skin-to skin method
 Warm room, fire or
electric heater
 Warmly wrapped
Heated water-filled mattress Air-heated Incubator
Radiant warmerSkin-to-skin contact

24. KMC
• Mother should be encouraged to provide
partial KMC to prevent hypothermia, to
promote bonding and breast feeding.

25. Starting KMC based on Birth weight
<1200g 1200 to 1800g >1800g
May take days to
weeks before KMC
can be initiated
May take a few days before
KMC can be initiated
KMC can be initiated
immediately after birth

26. 21Kangaroo Care

27. Oxygen therapy
• Oxygen should be administered only when
indicated, given at lowest ambient
concentration preferably blended with air.
• oxygen concentration adjusted so as to keep
the saturation level the same as that used
during NICU care for all babies <32 weeks
(suggested target of 90% to 95%).

28. Fluid and Electrolyte
• The fluid requirement of LBW babies is higher due to
greater insensible fluid losses because of larger surface
area, faster breathing rate and more use of radiant
heaters.
 Fluid : - Babies wt >1000gm – 10% dextrose IV.
 ELBW(< 1000 gm) – 5% dextrose IV.
@80-100 ml/kg/day from day 1.
-From Day 2 onward fluid containing electrolyte should be
given.
- Daily increment 15 ml/kg till day 7
- Add extra 20-30 ml/kg for infants under radiant warmer

29. Fluid requirement of neonates( ml /kg/day)
Day
of life
Birth Weight
> 1500 gm < 1500 gm <1000 gm
1 60 80 100
2 75 95 115
3 90 110 130
4 105 125 145
5 120 140 160
6 135 155 175
7 150 170 190

30. Deciding the initial feeding method
Two factors
1. Hemodynamically stable or not?
2. Feeding ability

31. Deciding the initial feeding method
Is (s)he stable?
• Fast breathing (RR>60/min)
• Severe chest in-drawing
• Apnea
• Requirement for oxygen
• Convulsions
• Fever (>37.50C) or low temperature (<35.50C)
• Abnormal state of consciousness
• Abdominal distension
If unstable, start intravenous (IV) fluids
Presence of any one
of these signs = UNSTABLE

32. Deciding the initial feeding method
Feeding ability
Gestational
age
Maturation of feeding skills Initial feeding
method
< 28 weeks No proper sucking efforts
No gut motility
Intravenous fluids
28-31 weeks Sucking bursts develop
No coordination between
suck/swallow and breathing
OG tube feeding with
occasional spoon/paladai
feeding
32-34 weeks Slightly mature sucking pattern
Coordination begins
Feeding by
spoon/paladai/cup
>34 weeks Mature sucking pattern
More coordination between breathing
and swallowing
Breastfeeding

33. Manage as per guidelines
for sick neonates*
Give oral feeds by
cup/spoon/ paladai
Is the baby able to breastfeed
effectively?
Is the baby able to accept feeds
by alternative methods?
When offered the breast, the baby roots,
attaches well and suckles effectively
Able to suckle long enough to satisfy
needs
Is the baby clinically stable? No
Yes
Yes
Y
e
s
No
Is birth weight more than 1250 g?
Y
e
s
No
Start intra-gastric
tube feeds
Start intravenous
fluids
Initiate breast
feeding
No
ActionAssessment
* Assess daily for clinical stability ; once stable, assess for initial feeding method
When offered cup or spoon feeds, the baby
opens the mouth, takes milk and swallows
without coughing/ spluttering
Able to take an adequate quantity to satisfy
needs

34. Gavage feeding

35. Paladai feeding

36. Progression of oral feeds
Based on two factors
• Stable or not?
• Maturation of feeding ability

37. Baby on IV fluids
Assess for stability
If stable
Introduce small amounts
of intra-gastric tube feeds Baby on intra-
Gastric tube feeds
Monitor daily for signs
of feeding readiness
• Offer small amounts of
oral feeds by spoon/paladai
Make him suckle at breast
Put him on breast more
frequently
Baby on
breastfeeding
Continue breastfeeding
Baby on oral feeds
byspoon/paladai
• Put on breast
Continue till the baby is
on full spoon feeds

38. Choice of milk
Breast milk
• Perfectly adapted to the infants’ needs
• Consistent evidence:
o Reduces infections and NEC
o Improves neurodevelopmental outcomes
o Long term effects on BP, lipid profile and pro-insulin levels

39. Choice of milk
The best milk for a LBW infant is his/her own
mother’s milk
• In case mother’s milk is not available, then the choices in
order of preference are:
• Expressed donor milk (only where milk banking available)
• Infant formula (standard/pre-term formula)
• Animal milk: e.g. cow’s milk.

40.  BW >1500 g
– Iron: from 2-3 months
– Multivitamin: from 2 weeks of life (for vitamin D)
 BW <1500 g
– Calcium & phosphorus
– Vitamin D & E; other vitamins
– Iron
– Zinc
Nutritional supplements

41. Recommended supplements for infants >1500g
Nutrient Route Dose When
Iron Enteral 2 mg elemental
iron/kg/day (maximum 15
mg/day)
From 4 wk of life till of age of 2
yr
Vitamin D Enteral 400-800 IU/day From 2 wk of age till age of 2
yr.
Nutritional supplements

42. Supplements for breast milk fed infants <1500g
Nutrient Route Dose When to start? When to stop?
Calcium Enteral 140-160
mg/kg/day
once infant is on 100
ml/kg/day of EBM
Until 40 weeks
post-menstrual age
Phosphorus Enteral 70-80 mg/kg/day - do - Until 40 weeks
post-menstrual age
Zinc and
vitamin A,
B6 , etc
Enteral 1 ml/day - do -
Vitamin D Enteral 400 IU/day - do - - do -
Iron Enteral 2 mg/kg/day Started at 4 weeks of
life
Till 2 yr of age
Nutritional supplements

43. Ask:
 how many times the infant feeds
in 24 hours?
Observe:
 the infant’s attachment and
suckling
 if the infant seems to tire or if the
mother takes the infant off the
breast before completing a feed
 look for sore nipple / breast
engorgement
• Feeding less than 8 times in 24
hours
• Poor attachment and
ineffective suckling
• The baby tires or the mother
takes him off the breast before
completion of feeds
• Mother having sore nipple or
breast engorgement
Features that indicate
inadequate
breastfeeding
Assessing feeding adequacy

44. Ask:
 how many times the infant feeds
in 24 hours?
 the volume of each feed given
by spoon/cup/paladai
Observe:
 is he spluttering/spitting the milk
 is he tiring or takes too long to
take the required amount
• If each feed volume is less
than that indicated
• Feeding the baby less
frequently than recommended
• If there is excessive spilling
during feeds
• Takes too long to finish the
required amount
Features that indicate
inadequate spoon
feeding
Assessing feeding adequacy

45. Growth monitoring of LBW infants
Weight pattern
• Loses 1 to 2% weight every day initially
• Cumulative weight loss 10% in term LBW & 15% in preterm
LBW in 1st 7 day of life
• Regains birth weight by 10-14 days
• Therafter wt gain should be atleast 15- 20 gm/kg/day till a et
of 2-2.5 kg is reached. After this a gain of 20-30 gm/day is
considered appropriate.

46. Discharge of LBW infants
• Criteria for discharging a LBW infant:-
- reach 34 wk of gestation and are above 1600 gm
- show consistent wt gain for at least 3 consecutive days
- hemodynamically stable
- on full enteral feed(breast feed/ paladai/spoon)
- not on any mediction(except vitamins and iron)
- parents confident enough to take care of baby at home

47. Growth monitoring
Growth charts
– Until 40 weeks: Dancis, Ehrenkranz
– After 40 weeks: WHO charts

48. Growth monitoring for PT neonates
Modified
Dancis
chart

49. Key messages
• LBW infants - at risk of high mortality and
significant morbidities
• Two major types of LBW - Preterm and
IUGR/SGA
• Morbidities different in both types
• Choice of feeding method - based on the
feeding ability of the infant
• Breast milk – milk of choice, irrespective of
the feeding method