Nursing Care of low birth weight

babies, PRETERM, IUGR.

NURSING CARE OF LOW BIRTH
WEIGHT BABY
INTRODUCTION:
Previously, the birth weight of 2500gm or less was taken as index of
prematurity with out taking any consideration of the gestational period or
any other factor. But infants born at term or post term may weight less
than 2500gm and occasional a baby of diabetic mother may weight much
more than 2500gm even before 37 weeks. Thus, the inclusion of all the
babies weighing less than 2500gm without due consideration to the
gestational period seems inappropriate.

DEFINITION:
low birth weight as one whose birth weight is less than 2500gm
irrespective of the gestational age .

Very low birth infants weight 1500gm or less and

extremely-low birth infant weight 1000gm or less.

INCIDENCE:
In India about 30 to 40 percent neonates are born LBW. Approximately
80% of all neonatal deaths and 50% of infants death are related to LBW.

High incidence of LBW babies in our country is due to higher number of

babies with IUGR (SMALL FOR DATE) rather than preterm.

The baby with a birth weight of less than 2000gm is more vulnerable and
need special care.

About 10% of all LBW babies require admission to the special care
nursery.

TERMINOLOGY:
LOW BIRTH WEIGHT : Weight of 2500gm

Very low birth weight baby: babies with a birth weight of less than
1500mg.

Extremely low birth eight babies: babies with a birth weigh of less
than 1000gm.
 Preterm baby/ immature baby/ premature baby: baby born with a
gestational age of less than 37 completed week

Term baby: a baby born with a gestational age of 37 to 41 weeks is

called as term baby.

Post term baby: a baby born with a gestational age of 42 weeks or more
is called as term baby.

TYPES OF LBW:
A low birth weight baby includes both
1. preterm
2. Small for dates (SFD) babies.

Classification of babies on the basis weight alone and gestational

age with birth weight.

Gestational age Birth weight

Pre term -Small for date

-Appropriate for date

-Large for date

-small for date

Term -Appropriate for date

-Large for date

-Small for date

Post term -Appropriate for date

-Large for date

PRE TERM baby :

Definition:
Baby born with a gestational are of less than 37 completed week.

INCIDENCE OF LBW BABIES:

 It constitutes 2/3 of LBW.

20 to 25% in the developing countries.

10% in the developed countries.

CAUSES FOR PRE TERM:

Spontaneous causes:

Constitutional: acute emotional stress, trauma.

Low maternal weight gain and poor socioeconomic condition,

Very young and unmarried mothers, too frequent child birth,
history of previous preterm baby,

Maternal nutrition: anemia, maternal malnutrition

Maternal diseases: Ante partum hemorrhage, cervical

incompetence, threatened abortion, bicarnuate uterus, chronic
and systemic diseases, and infection,

Spontaneous causes:

Toxins: cigarette smoking, and drug abuse during pregnancy,

Fetal causes: multiple pregnancy

congenital malformation.

Induced causes:

Maternal diabetes mellitus and severe heart diseases. Placental

dysfunction with unsatisfactory fetal growth.

Eclampsia, severe pre eclampsia, and hypertension. Fetal hypoxia and

fetal distress,

severe Rh incompatibility,

improper diagnosis of maturity in elective deliveries

CLINICAL FEATURE OF PRETERM:

Length- <44cm

weight-2500gm or <2500gm.

Head circumference disproportionately exceeds than that of the chest.

The skin is thin, red and shiny, due to lack of subcutaneous fat and
covered by plentiful lanugos and vernix caseosa.

Pinnae of the ear are soft.

The eyes are kept closed.

 Muscle tone is poor.

Plantar creases are not visible before 32 weeks.

The testis is undescended,

The labia minora is exposed, and there is a tendency of herniation.

The nail is not grown up to the finger tips.

Reflexes are poor.

IUGR
Definition
Babies with a birth weight less than 10th percentile for their gestational
age.

INCIDENCE OF SFD:
comprises about 1/3 of LBW.

2 to 8% in developed countries.

5% among term babies.

15% among post term babies.

CAUSES FOR SFD BABIES:

Maternal causes:

Constitutional: small women, maternal genetic and radical back ground

Maternal nutrition: glucose, amino acid and oxygen deficiency

Maternal diseases: anemia, hypertension, thromphillia, heart disease and

chronic renal disease

Toxins: alcohol, smoking, cocaine, heroine, drugs.

Fetal causes:

Structural anomalies (renal or cardiovascular), chromosomal

abnormalities,

TORCH infection,

multiple pregnancy

Placental causes:

Chronic placental insufficiency, placenta previa, abruption, circumvallates,

infarction and mosaicism
 CLINICAL FEATURES OF SFD:
Length is unaffected,
weight is about 600 gm below at birth.
dry and wrinkled skin because of less subcutaneous fat.
thin meconium stained vernix caseosa
Scapoid abdomen,
Plantar crease are well defined.
Thin umbilical cord.
All these give a baby old man appearance
The baby is alert, active
has normal crying.
Reflexes are normal

NURSING CARE OF LOW BIRTH WEIGHT BABIES

Nursing care of low birth weight includes:
1. Care at neonatal intensive care unit,
2. Maintenance of breathing,
3. Maintenance of stable body temperature,
4. Maintenance of nutrition and hydration,
5. Gentle early stimulation,
6. Prevention, early detection and prompt management of complication,
7. vaccinization of LBW
8. Transport of sick LBW baby.
9. Family support discharge, follow- up and home care,

Care at neonatal intensive care unit:

1. The NICU should be warm, free from excessive sound smoothing light.
2. Protection from infection should be ensured by aseptic measures and
effective hand washing.
3. Rough handling and painful
procedure should be avoided.
4. Baby should be placed
on soft comfortable,
nestled and cushioned bed.
4. Continuous monitoring of the babys clinical status are vital aspects of
management which depends upon the gestational age of the baby.
5. Baby can be placed in prone
position during care.

2. Maintenance of breathing:
1. Baby should be positioned with neck slightly extended and air passage to
be cleared by gentle suctioning to remove the secretion, if needed.
Precaution should be taken to prevent aspiration of secretion and feeds.
2. Concentration of oxygen to be maintained to have saO2 between 90 and
95% and paO2 between 60 and 80 mm of Hg.
3. Babys respiration rate, rhythm, signs of distress, chest retraction, nasal
flaring, apnea, cyanosis, oxygen, saturation, etc. to be monitored at
frequent interval.
2. 4. Tackling stimulation by sole flaring can be provided to stimulate
respiratory effort.
3. 5. Chest physiotherapy by percussion, vibration and postural drainage
may be needed to loosen and remove respiratory secretion.
4. 6. Desirable level of arterial blood gas values should be I) Pao2 55-65 mm
Hg .ii) PaCO2 35-45 mmHg and iii) PH 7.35-7.45.

3. Maintenance of stable body temperature.

Baby should be received in a prewarmed radiant warmer or incubator.
Environmental temperature should be maintained according to babys
weight and age.
Babys skin temperature should be maintained 36.5 to 37.5 degree
celcious.
Baby birth weight of less than 1200gm should be cared in the NICU
incubator with 60 to 70 % humidity, oxygen and thermonutral
environment for better thermal control and prevent heat loss.
Alternatively the baby should be managed under radiant warmer with
protective plastic cover.
The baby as to be placed naked. If it I possible maintain temperature of
the entire room.
The baby cot should be kept warm. Rubber hot water bottle may be
usable for the purpose. The bottle should be filled with hot but not boiled
water. Those should be covered with cloths.
The temperature of the cot should be checked so as to maintain it up to
85F.
Kangaroo mother care can be provided when the babys condition
stabilized. Baby should be clothed with frock, cap, socks, and mittens
while giving kangaroo care.
Bathing should be delayed.

4. Maintenance of nutrition and hydration:

caloric needs of non-growing LBW babies during first week of life are 60
kcal/ kg/ day on 7th is to be stepped up gradually to 100 on 14th day and
about 120-150 on 21st day, to maintain satisfactory growth.
Human milk is the first choice of nutrition for all LBW babies. Colostrums,
hind milk, foremilk, and preterm milk help faster growth of baby.
if breast milk is not available cows milk in proportion of 1:1 (milk: water)
for 1st month and 2:1 during second month is an alternative substitute.
One teaspoon glucose should be added to 50ml of milk prepared for the
first 10 days and there after reduced to 1 teaspoon to 100ml milk.
Those babies who have good sucking and swallowing reflexes should start
breastfeeding as early as possible.
Expressed breast milk can be given through spoon and bowl at 2 hours
interval. Katoris-spoon or palady can also be used for feeding the preterm
babys.
 Gavages or nasogastric tube feeding can be given with EBM to all babies
with poor sucking reflex.
Intravenous dextrose less than 1200 gm or sick babies.
Starvation to be avoided and early enteral feeding should be started as
soon as the baby is stable.
Commencement: early feeding between 1-2 hours of birth is now widely
recommended, the interval of feeding ranges from hourly in extreme
prematurity to 3 hourly feeds in babies born after 36 weeks. The baby
when kept in the cot, should be placed on one side with the head raised a
little to prevent regurgitation.
Additional suplimentation: supplement of minerals and vitamin after 2
weeks should be started.
1. Vitamin-A-25000IU
2. vitamin-D- 600IU
3. vitamiv-C- 50mg.
4. Vitamin-B1- 0.5mg.
5. Folic acid- 65mg.
6. Calcium and phosphorus supplementation also essential. a liquid
preparation of iron 1-2mg/kg/day should be given in the second or 3ed
week.
7. IV gamma globulin therapy (400mg/kg/dose) may be given to prevent
infection in selected cases.
8. Very LBW babies ( <1500gm, <32 weeks gestation) need vitamin-E.

Fluid requirement for LBW babies.

Days <1000gm 1000 -1500gm >1500gm

1st and 2nd 100-120ml 80-100ml 60-80ml

3ed and 4th 130-140ml 120-130ml 90-100ml

5th and 6th 150-160ml 140-150ml 110-120ml

7th and 8th 170-180ml 10-170ml 130-140ml

9th day on wards 190-200ml 180-190ml 150-160ml

The first day the fluid requirement ranges from 60 to 100ml/kg ( the
difference from each categories being 20ml/kg each)
 The daily increment in all group is around 10 to 15 ml per kg till day 9.
Need extra requirement in case of phototherapy (20-40ml/kg/day) and
radiant warmer (40-80ml/kg/day)

5. gentle and early stimulation, Prevention, early detection

and prompt management of complication:
The baby should be observed for respiration, skin temperature, heart rate
and skin color, activity feeding bahaviour, passage of meconium or stool
and urine, condition of umbilical cord, eyes and oral cavity and Any
abnormal signs like edema, bleeding, vomiting, etc. biochemical and
electronic monitoring should be done if needed.
Weight recording should be done daily in sick babies or at alternative
days. Position should be checked at every 2 hours. Baby should be placed
in right side after feeding to prevent regurgitation and aspiration.
Mother should be allowed to take care of baby whenever condition
permits.

6. vaccinization of LBW:
If the LBW baby is not sick, the vaccination schedule is the same as for
the normal babies. BCG, OPV, and HBV vaccine should be given at the
time of discharge.

7. Transport o sick LBW babies:

It is essential to provide warmth during transport cold injury.
The baby should be clothed and placed in a pre warmed basket or box.
But a transport incubator is ideal.
Hot water rubber bottle may be used as heat source. However make sure
to cap them tightly and wrap 2 layers of towel to avoid direct contact with
the baby.
Mother of the baby should also be transferred to the hospital along with
the baby as for as possible. This will allay her anxiety and ensure breast
milk feeding of the baby.

8. Family support discharge, follow- up and home care:

Babys condition and progress to be explained to the parents to reduce
their anxiety. Treatment plan should be discussed.
Parents should be informed about the care of baby, after discharge at
home. Need for warmth, breast feeding, general cleanliness, infection
prevention measures, environmental hygiene, and follow-up plan.
Immunization etc. should be explained to the parents.
Mostly healthy infant with a birth weight of 1800gm or more and
gestational maturity of 3weeks or more can be managed at home. Mother
should be prepared mentally and trained to provide essential care to the
preterm baby at home.
At the discharge the baby should have daily steady weight gain with good
vigor and able to suck and maintain warmth.
 Ultimate survival of the baby depends upon continuity of care. The
community health nurse should visit the family every week for a month
and provide necessary guidance and support.

PROGNOSIS:
Prognosis for survival is directly related to the birth weight and quality of
neonatal care. Long term complications may be found as neurological
handicap in the form of cerebral palsy, seizure, hydrocephalus,
microcephaly, blindness, deafness, and mental retardation. Minor
neurological disabilities are found as, behaviour problem, language
problems, learning disabilities, HDAD.

Nursing diagnosis;
1. Altered breathing dyspnea related to poor lung maturity secondary to
respiratory distress
2. Altered body temperature hypothermia related to immature
thermoregulation centre secondary to less subcutaneous fat.
3. Altered nutrition less than body requirement related to poor sucking
reflex.
4. Fluid volume deficit hypovolumia related to poor intake.
5. Parental fear and anxiety related to NICU procedures and child condition
6. High risk for complication like hypoglycemia related to poor feeding.
7. High risk for infection related to poor immunity.
8. Parental knowledge deficit regarding care of low birth weight babies
related to lack of exposure.

1. Altered breathing pattern dyspnea related to poor lung

maturity secondary to respiratory distress.

Baby should be positioned with neck slightly extended.

Tackling stimulation by sole flaring can be provided to stimulate
respiratory effort
Do gentle suctioning to remove the secretion,
Concentration of oxygen to be maintained to have saO2 between 90 and
95% and paO2 between 60 and 80 mm of Hg.
Babys respiration rate, rhythm, signs of distress, chest retraction, nasal
flaring, apnea, cyanosis, oxygen, saturation, etc. to be monitored at
frequent interval.
Chest physiotherapy by percussion, vibration and postural drainage may
be needed to loosen and remove respiratory secretion.

2. Altered body temperature hypothermia related to immature

thermoregulation centre secondary to less subcutaneous fat.

Baby should be received in a pre warmed radiant warmer or incubator.

Environmental temperature should be maintained according to babys
weight and age.
 Alternatively the baby should be managed under radiant warmer with
protective plastic cover.
The baby as to be placed naked in the warmer
The baby cot should be kept warm.
Kangaroo mother care can be provided when the babys condition
stabilized.
Baby should be clothed with frock, cap, socks, and mittens while giving
kangaroo care.

3. Altered nutrition less than body requirement related to poor

sucking reflex.

If baby is able to suck encourage breast milk.

If baby is unable to suck provide expressed breast milk with help of
paladai.
If aspiration is evident then give through NG tube.
Early enteral feeding should be started as soon as the baby is stable.
Monitor the weight of the child every day until baby become stable.
Administer 10% glucose through IV.

4. Fluid volume deficit hypovolumia related to poor intake.

Administer IV fluids according to the weight of the baby.

Monitor I/O chart.
Check body temperature to note the way of insensible water loss.
Encourage breast feed and increase the frequency of breast feeding.
Administer injection vitamin k to prevent blood loss due to hemorrhagic
diseases.
Provide 15 to 20 ml extra fluids when the child under warmer and
phototherapy.

5. High risk for infection related to poor immunity.

The baby should be observed for respiration, skin temperature, heart rate
and skin color, activity, feeding bahaviour, passage of meconium or stool
and urine, condition of umbilical cord, eyes and oral cavity
Any abnormal signs like edema, bleeding, vomiting should be noted,
Lab values (CRP), biochemical and electronic monitoring should be done.
One person as to handle the baby.
Wash hand before touching each sick baby.
Restrict number of visitors.
If baby is not too sick vaccine can be given as like healthy baby.