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 infant’s 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
Term
Post term
|
-Small for
date
-Appropriate
for date
-Large for
date
-small for
date
-Appropriate
for date
-Large for
date
-Small for
date
-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 baby’s 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. Baby’s 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 baby’s weight and age.
–
Baby’s
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 85’F.
–
Kangaroo
mother care can be provided when the baby’s 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 hour’s 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:
•
Baby’s
condition and progress to be explained to the parent’s 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.
·
Baby’s
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 baby’s 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 baby’s 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.
High Risk babies often take a little longer to reach full health due to early complications at childbirth. Ankura Hospital High Risk Clinic for Newborn in Hyderabad.
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