Low Birthweight Infant

8/12/2019 Low Birthweight Infant

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THE LOW

BIRTH WEIGHT INFANT

Julniar M TasliHerman Bermawi


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1. Student must be able to understand the definition

and classification of low birth weight infant.

2. Student must be able to recognize risk factors

which predispose of low birth weight infant.

3. Student must be able to diagnose low birth weight

infant.

4. Student must be able to manage low birth weight

infant.

OBJECTIVE


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NEWBORN INFANT CLASSIFED

ACCORDING TO :

1. Birthweight# < 2500 g : Low birthweight (LBW)

# < 1500 g : Very low birthweight (VLBW)

# < 1000 g : Extremely low birthweight (ELBW)

2. Gestational age# < 37 weeks : Preterm

# 3742 weeks : Term

# 42 weeks : Post term

3. Size for gestasional age# Weight beween 90th& 10thcentile for gestation : AGA

# Weight < 10thcentile for gestation : SGA

# Weight > 90thcentile for gestation : LGA


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b Ballards Score

Ballards Score


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FIGURE 3-2. Classification of newborns (both sexes) by intrauterine growth and gestational age. (Reproduced, with permission, from Battaglia FC, Lubchenco LO: A

practical lassification for newborn infants by weight and gestational age. J Pediatr1967;71:159; and Lubchenco LO et al: Intrauterine growth in length and head circumferenceas estimated from live births at gestational ages from 26 to 42 weeks. Pediatrics 1966;37:403. Courtesy of Ross Laboratories, Columbus, Ohio 43216.)


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THE LOWBIRTH WEIGHT INFANT

Definition :A low birth infant baby is one who weight lessthan 2500 grams at birth

The low birth infant divided into two clinical

types :1. The preterm infant ( prematurity )2. The small for gestational age infant

( small for dates, light for dates )


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1. Premature or preterm :# A baby born before the 37thweek of

pregnancy.# May not be ready to live outside the uterus

and may have difficulty initiating breathing,sucking, figting infection and stay warm.

2. Small for gestational age( SGA ) :# A baby who did not grow well enough in the

uterus during fregnancy.# The baby usually full-term and often to

breath and suck well.


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FACTORS ASSOSIATED WITH

LOW BIRTH WEIGHT

1. Fregnancy in women who :

# Age less than 20 years

# Have birth that are less than 3 year apart or

have many fregnancy ( five or more )

2. Women who :

# Had a LBW baby before# Are under weight and have poor nutrition.

# Have health problem ( hypertension, anemia )


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FACTOR ASSOSIATED WITH

LOW BIRTH WEIGHT

3. Women who have pregnancy problem such as :# Severe anemia# Pre-eclampsia or hypertension# Infection during pregnancy ( Urinary tract infection,

HIV/AID, malaria )# Multiple gestation

4. Babies who have :# Congenital or genetic abnormalities

# An infection while in uterus ( TORCHsinfection )


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THE PRETERM INFANT

( PREMATURITY )

WHO defines a preterm birth : < 37 completed weeks

gestation (< 259 days).

Incidence of preterm deliveries : ?

33% small for gestational age, have different problems

from the appropriate for gestational age preterm infant.

The paediatrician have an objective test for determine :

# Gestational age : New Ballard examination

# Size for gestational age : Lubchenco chart


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CLINICAL CHARACTERISTIC

1. Skin : Maybe reddenes. The skin may thin soblood vesel are easiliy see.

2. Lanugo : There is a lot of this fine hair all over the

babys body

3. Limbs : The limb are thin and may be poorly flexed orfloopy due to muscle tone

4. Head size : The head appears large in proportion to the

body. Fontanella are smooth and flat

5. Genital : Male, the testes may not be descended andscrtum may be small. Female, The clitoris and labia

minora may be large

6. Sole of feet : Creased are located only in the anterior t

hird of the sole, not all over, as in term newborn


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SPECIFIC PROBLEMS

1. Birth asphyxia

2. Thermal instability

3. Lack of primitive survival reflexes, suck, swallow, andgag with high incidence of milk aspiration.

4. Jaundice5. Pulmonary disease : apnoe, hyaline membrane disease,

transient tachypnoea of newborn, pneumothorax,pneumonia, Wilson-Mikity syndrome andbronchopulmonary dysplasia.

6. Metabolic disturbances: hypoglycaemia, hypocalcaemia,hypomagnesaemia, hyponatraemia, hypernaetremia.


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7. Patent ductus arteriosus : congestive heart failure.

8. Intracranial haemorrhage, especially intraventricularhaemorrhage and subarachnoid haemorrhage.

9. Susceptibility to infection

10. Gastrointestinal intolerance and necrotizing enterocolitis

11. Opthalmic problems : retrolental fibroplasia, myopia,strabismus

12. Surgical lesions : undescended testes, inguinal andumbilical hernia

13. Haematological problems : haemorrhagic disease ofprematurity, disseminated intravascular coagulation,iron deficiency anaemia

14. Renal immaturity : inability to concentrate urine, andinability to excrete an acid load with low renalbicarbonate threshold results in late (feeding) metabolicasidosis .


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SUPORTIVE CARE

Resuscitation

The Obstetrician and Paediatrician should ideally function

as a perinatal team during premature labor appropriate

assessment of perinatal asphyxia and resuscitation can be

performed.

Monitoring

Heart rate and respiratory rate, blood pressure and

temperature must be monitored continuously


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Monitoring Total intake-output of fluids should be recorded every 24

hours in critically ill infants.

Head circumference is measured twice weekly and plottedon a percentile graph.

Daily weights are measured and recorded.

Thermoregulation

Body temperature must be maintained in the normal range

(36,5-37,0C per axilla) by nursing infant in incubator.


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Feeding

Infants < 34 weeks gestation should be fed via an oro-gastric/naso-gastic tube.

Prematures with small gastric volumes require frequent

feeding (every 2 hours) and should be started on2ml/kg/feed and increased in increment of 1-2ml/kg/everyfeed, as tolerated.

Gastric aspirate must be checked before the next feed.

The preterm infant should ideally be fed his own mothers

expressed breast milk.


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Parenteral fluids

Sick babies and infants < 1500 g may need parenteralfeeding

Parenteral fluid requirements can only be determined byclose observation of urine-output, urine osmolality, bodyweight and electrolytes.

In general, fluid volumes for healthy preterm infants givenenterally are: 60ml/kg-day 1; 80ml/kg-day 2; 100ml/kg-day

3; 120ml/kg-day 4; 140ml/kg-day 5; 160ml/kg-day 6;180ml/kg-day 7.


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Electrolytes

Preterm infants receiving parenteral fluids should receivesmaintenance electrolytes after they have passed urine.

Normally they require: sodium 2,5-3,0 mmol/kg/day;

potassium 2,0-2,5 mmol/kg/day; calcium 45mg/kg/day.

Vitamins

A single intramuscuar dose 0,51,0 mg IM Vit.K1 at birth

Preterm babies being fed with breast milk or vitaminfortified formulae will all need additional vitamin C (by

day 3) and vitamin D.


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Respiratory Distress Syndrome (RDS)

RDS should be managed with humidified oxygen given in acontrolled fashion via a head box, nasl CPAP ormechanical ventilation.

Babies of birthweight < 2000g with RDS should bemanaged in an intensive care nursery.

Jaundice

Extremely common in the preterm infant and must befollowed with frequent bilirubin estimations.

The treatment sheet provides guidelines for managementof hyperbilirubinaemia.


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Anemia

The venous haematocrit should be maintained at > 40% inall sick babies.

All preterm infants < 2500 g or 34 weeks gestation shouldreceive supplemental iron in a dose of 30 mg daily from theage of three weeks.


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THE SMALL FOR

GESTASIONAL AGE INFANT

INSIDEN

Varies between countries, usually :

3-7% of all infants are SGA

20% of stillborn infants are SGA

25% of SGA Infants are Type I

75% of SGA infants are type II


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ETIOLOGY

The causes SGA infants can be classified as

extrinsic and intrinsic in origin

1. ExtrinsicExtrinsic mechanisms operate during the latter

half of pregnancy and may be associated with

placental insufficiency. Fetal growth is affected

because of inadequate supply line of nutriensand/or oxygen.


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a. Maternal Factors

# Maternal hypertension e.g. essential,

pregnancy induced, renal.

# Vascular disease, e.g. DM, cardiac, renal,

sickle cell and collagen disease

# Smoking, narcotic abuse


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b. Placental and uterine factors# Abnormal placentation

# Placental infarct, fibrosis, haemangioma

# Premature placental separation# Single umbilical artery

# Uterine crowding e.g. multiple

pregnancy, uterine abnormalities


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2. Intrinsic

The intrinsic group implies that there is something

wrong with the fetus at the time of conception or duringthe first semester.

a. Constitutional e.g. parental stature, racial,

ethnic

b. Chromosomal anomaly e.g. Trisomy 13, 18,21, Turners Syndrome

c. Fetal infections e.g. TORCH

d. Maternal drugs e.g. chronic alcoholism,

cytotoxic, heroin addictione. Primordial dwarf, e.g. achondroplasia, Russel

Silver Dwarf


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CLINICAL FINDING

IUGR can be suspected by: poor maternal weight

gain, suboptimal uterine growth, low or fallingoestriol levels, reduced growth of biparietal

diameter on serial USG

Physical apperanceof babies in the intrinsic

groupwill be characteristic of the spesificaetiology e.g. Toxoplasma, rubella, achondroplasia


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The growth failure in the extrinsic group is

greatest for weight, then length and head

circumference is least affected. There is little

subcutaneous fat, the skin may be loose and thin,muscle mass is decreased, especially buttock and

thighs, and the infant often exhibit wide eye,

anxious faces.


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SGA and IUGR are not synonymous

SGA refers to the size of the infant at birth and

not fetal growth

IUGR suggests diminished intrauterine growthvelocity

IUGR indicates the presence of a pathologic

process in-utero that inhibits fetal growth


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SGA VS IUGR A child who is born SGA is not always IUGR

Infants born after a short period of IUGR are

not always SGA

SGA:

IUGR

Constitutionally small infant


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Types of SGA infata. Symmetric:

Weight, head circumference and length all

< 2SD

b. Asymmetric:

Weight below 2 SD, but head circumference and

length preserved


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Classification

Symmetrical AsymmetricalBaby's head and length

are preserved

Occur when the fetus

experiences a problem

later in pregnancy

Baby's head and body are

proportionately small

May occur when the fetus

experiences a problem

during early development

In a normal infant, the brain weighs about three times more than the liver. In

asymmetrical IUGR, the brain can weigh five or six times more than the liver.


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Symmetric IUGR

Type I

Early onset growthrestriction

Uniform growthrestriction

Long-term growthfailure

Associated withdecreased cell number

Associated with lesscatch-up growth in thefirst year of life

Asymmetric IUGR

Type II

Late onset growth

restriction Head Sparing

Potentially reversible

Associated withdecreased cell size

Infants demonstratemore catch-up growththan symmetric IUGR infirst year of life

Types of SGA / IUGR


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DIAGNOSIS

Decreased subcutaneous fat with soft tissue,desquamated skin, meconium stained

Widened cranial sutures with large fontanelles

Thin umbilical cord Skin and sole creases more mature than GA

alert-looking and jittery

Congenital malformations Stigmata of congenital infections


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SPECIFIC PROBLEMS

1. Intrauterine : sudden fetal death, fetaldistress during labor

2. At birth: birth asphyxia, MAS often

complicated by pneumotorax


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3. Neonatal period

# Congenital malformations:There is 20 x increased incidence of

congenital malformation in SGA babies

compared with their birthweight peers

# Infections:

There is 7 x increased incidence of

infections. The intrauterine infections may

be the cause of the growth retardation, but

SGA babies are also more likely to acquire a

nursery infections


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# Hypocalcaemia: the increased

incidence of hypocalcaemia relates to

the birth asphyxia & not to SGA infant

# Hypoglycaemia : due to poor body

reserves of brown fat & glycogen.

# Polycythaemia :especially when there

has been prolonged intrauterine

hypoxia resulting in elevated levels of

erythropoertin


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# Thermal instability: maintenance of

body temperature is a problem to the

SGA infant but less so than for preterm

infant. This probably related to the large

surface area to body weight ratio.

# Respiratory Distress: may due to MAS,

Polycythaemia, massive pulmonary

haemorrage or pneumonia but not usually due

to RDS


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4. Infancy and childhood

Growth and development : in the neonatalperiod, the infant loses little weight & begins togain weight rapidly after birth. However, thisgrowth spurts is often not maintained &permanent deficit in somatic growth may persistinto childhood.


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MANAGEMENT

If IUGR suspected: monitoring of fetal &uteroplacental function will be necessary

with test such as 24 hr urinary oestriol,

serial biparietal diameters, stress & nonstress challenge test & L/S ratio of amniotic

fluid prior to early delivery

A careful decision: best methode of & time

of delivery will need to be made.


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The baby should be transferred to special care

nursery for careful observation for signs of RDS,hypoglycaemia, & temperature instability.

The SGA infants should commence feeds at 2 hr ofage, if possible & initially feeding should be every2 hr with dextrostix estimated of blood glucosebefore each feed.

The first feed should be D10% & then followed byfull strength formula.


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The infant should receive 60 ml/kg on day 1 &increased to 200 ml/kg by day 7.If the infantdevelops hypoglycaemia (dextrostix < 2,2 mmol/lor < 40 mg/dl) dispite early feeding D10% is given

by uninterrupted intravenous infusion, in theadditional to the oral feed.

A cappilary haematrocit at 4 to 6 hr of age shouldalways be performed if > 70%, venoushaematrocrit is indicated. If venous Ht > 70 or ifthe baby has symptoms polycytemia dilutionalexchange transfusion with FFP is indicated


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TERIMAKASIH

Low Birthweight Infant

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