low birth weight babies

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Management of low birth weight babies:

Management of low birth weight babies By dr. karthik

principles:

principles Prenatal consultation Care at birth Thermal protection Feeds and nutrition Fluids and electrolytes Monitoring and early detection of complications Appropriate management of specific complications

Prenatal consultation:

Prenatal consultation Parental education Arrest of premature labour - ethanol - magnesium sulphate - isoxsuprine - ritodrine - terbutaline - indomethacin - sympathomimetic drugs Induction of premature labour

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Antenatal corticosteroids:- Decreases the incidence of -RDS - intraventricular hemorrhage - necrotizing enterocolitis Betamethsone / dexamethasone C.I - PPROM with chorioamnionitis

Care at birth:

Care at birth Suitable place of delivery Appropriate place of care prevention of hypothermia Efficient resuscitations

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Optimal management at birth:- - delayed clamping of cord - elective intubation - dried, covered , warm - vitamin K injection

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Monitoring :- - vital signs - activity , behaviour , colour - tissue perfusion - signs - fluids , electrolytes , ABG’S - tolerance to feeds - RDS , PDA , NEC , apnoeic attacks - weight gain velocity

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Provide in utero milieu:- - bed - avoid excessive light , sound , rough handling - warmth and asepsis - prevent evaporative skin - nutrition Position of the baby – prone position

Thermal protection:

Thermal protection Delay bathing Kangaroo mother care Warm room Oil and liquid paraffin Cellophane or thin plastic sheet External heat source Frock , cap , socks , mittens

Feeding of low birth weight babies:

Feeding of low birth weight babies Goals of nutrition:- Achieve well defined short term growth and nutrient retention - mimic intrauterine growth curves - mimic reference fetal composition

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2. Prevent neonatal morbidities - improve feeding tolerance - reduce necrotizing enterocolitis - minimize nosocomial infections 3.Optimize long-term outcome - optimize neurodevelopmental outcome - reduce rates of allergy and atopic diseases - impact adult onset diseases like HTN.

Nutritional requirement:

Nutritional requirement Nutrients Recommendations ( per 100 kcal) Water 125 – 170 ml Energy 100 kcal Protein 2.5 – 3.0 g carbohydrate Lactose 3.2 – 9.8 g oilgomers 0 – 7.0 g fats Linoleic acid 0.44-1.7 g Linolenic acid 0.11-0.44g Vit A 583-1250 IU Vit D 125- 333 IU Vit E 5-10 IU Vit K 6.66-8.33 Calcium 100-192mg Phosphorous 50- 117mg

Limitations of LBW infants to feed:

Limitations of LBW infants to feed Inadequate feeding skills Significant illness Higher fluid requirements Low body stores of various nutrients 5 . Feed intolerance

Choice of milk:

Choice of milk Human milk and lbw infants:- - mothers of premature infants VS mothers of term infants Human milk is first choice - 180 ml /kg/day - 130cal/kg/day - 2.25 g/kg/day Expressed breast milk

Artificial feeds for LBW:- :

Artificial feeds for LBW:- In sick mothers/contraindication to breast feeding Formula feeds: Preterm formula –

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b. Term formula – in infants > 1500g at birth 2.Animals milk

Methods :

Methods Breast feeding Katori -spoon/ paladai feeding

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Gavage / tube feeding Intravenous fluids

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Depends on:- Whether the infant is sick or not - sick infant - ? - start on IV fluids - healthy LBW infant - enteral feeding

2. Feeding ability:

2. Feeding ability Maturation of oral feeding skills and choice of initial feeding method in LBW infants Gestational age Maturation of feeding skills Initial feeding method < 28 wks No proper sucking efforts No propulsive motility in gut I . V fluids 28 – 31 wks Sucking bursts develops No coordination b/w suck, swallow and breathing Orogastric tube / spoon / paladai 32 – 34 wks Slightly mature sucking pattern Coordination Spoon / paladai / cup > 34 wks Mature sucking pattern More coordination Breast feeding

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> 34 wks Initiate breast feeding Observe if: Positioning and attachments are good Able to suck effectively and long enough(10-15min) Breast feeding Spoon / paladai feeding yes No

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32 – 34 wks Start feed by spoon / paladai observe if:- Accepting well without spilling/coughing Able to accept adequate amount Spoon / paladai feeding OG / NG tube feeds yes No

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28 – 31 wks Start feed by OG / NG tube Observe if vomiting / abdominal distension occurs Start IV fluids Gastric tube feeding < 28 wks yes No

Progression of oral feeding in preterm:

Progression of oral feeding in preterm Infants on IV fluids Infants on OG tube feeds Start trophic feeds by OG tube and monitor for feed intolerance Try spoon feeds once / twice a day , also put on mothers breast and allow NNS Gradually increase thee feed volume , taper and stop IV fluids Gradually increase the frequency and amount of spoon feeds ,reduce OG feeds accordingly If hemodynamically stable If accepting well At 30 – 32 wks PMA If accepting spoon feeds well Cont….

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Infants on spoon / paladai feeds Put them on mother’s breast before each feed Observe for good attachment and effective sucking Taper and stop spoon feeds once the mother is confidant If able to breast fed adequately

How much to feed?:

How much to feed? Infants who are breastfed - on demand - every 2-3 hours Infants who are fed by spoon / paladai / intragastric tube:- - every 2 or 3 hours

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Feeding schedule for LBW infant >1200g Begin at 60-80ml/kg/day on 1 st day 1 st feed given at 2 hours then 2-3 hourly Increase by 15ml/kg everyday Maximum 180-200 ml/kg/day by 7- 10 days 1 ST day of life (ml/kg) Increased ml/kg /day 1 st week (ml/kg/day) VLBW(<1500g) 80 +10-15 160 LBW(>1500g) 60 +15-20 160

Practices ensuring sufficient milk volume in non sucking mothers:

Practices ensuring sufficient milk volume in non sucking mothers Provide free access to mother to see her neonate Provide bed to mother Encourage the involvement of mother Promote KMC Teach EBM Put baby to breast 10-12 times /day

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7.Gavage feeding 8. Build mothers confidence 9.Recording the exclusive breast feeding of the infant at discharge 10.All doctors and nurses in the nursery should be well trained

Nutritional supplementation:

Nutritional supplementation For infants with birth weight of 1500-2499 g:- Nutrients Method of supplementation Dose When to start? Till when? Vitamin D Multivitamin drop/syrup 200-400 IU/day 2 weeks of life Until 1 year of life Iron Iron drops/syrup 2mg/kg/day 6-8 weeks of age Until 1 year of life

Supplementation in VLBW infants:-:

Supplementation in VLBW infants:- Calcium 140-160 mg/kg/day Phosphorous 70-80 mg/kg/day Folate 50 mcg/kg/day Iron 2 mg/kg/day Multi nutrient supplementation can be done in two methods:- supplying the individual nutrients Fortification of the expressed breast milk with human milk fortifiers

Fluids and electrolytes:

Fluids and electrolytes Normal postnatal changes in the fluid composition Guidelines for fluid therapy:- -daily fluid requirement during 1 st week of life(ml/kg/day) - 10 % dextrose Birth weight Day 1 Day2 Day3 Day4 Day5 Day6 Day7 and onwards <1500g 80 95 110 120 130 140 150 >1500g 60 75 90 105 120 135 150

Composition per liter of fluid:

Composition per liter of fluid Fluid Sodium ( mEq ) Potassium ( mEq ) Chloride ( mEq ) Glucose(g) Other( mEq ) 10% dextrose _ _ _ 100 _ Normal saline 154 _ 154 _ _ N/2 saline 77 _ 77 _ _ N/5 in 5% dextrose 30 _ 30 40 _ 3% saline 462 _ 462 _ _ Ringer’s lactate 131 5 111 50 Lactate 29 Isolyte p 25 20 22 50 Acetate 23 7.5%sodium bicarbonate 1280 _ _ _ Bicarbonate 1280 Potassium chloride _ 2000 2000 _ _

IV fluid therapy:

IV fluid therapy Indications:- -birth weight <1200 g - gestation <30 wk - respiratory distress - feed intolerance - hemodynamic instability - GI malformations - any severe illness

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22-24 gauze canula Peripheral veins on hands , feet , ankle Risks :- Local infection Systemic infections Phlebitis Accidental fluid overload extravasation

Monitoring of fluid and electrolyte :

Monitoring of fluid and electrolyte Parameter Adequate fluid therapy Inadequate fluid therapy Excessive fluid therapy Weight Physiological wt. loss of 1-3 %/day during 1 st wk of life Excessive wt. loss(>3%/day) No wt. loss / gain Urine output Normal Decreased Increased Physical signs None Decreased skin turgor , sunken eyes , depressed anterior fontanelle Puffy eyelids dependent edema Serum sodium Normal Increased-insensible water loss Decreased – gi loss Decreased Urine specific gravity 1.005-1.012 >1.012 <1.005

Growth monitoring:

Growth monitoring Adequacy of nutrition among LBW babies Cumulative weight loss of 10 -15 % by 7 days Loss 1 – 2% everyday for 5-7 days Regain birth weight by 10-14 days Thereafter wt. gain should be at least 15 -20 g/kg/day till a weight of 2 – 2.5 kg is reached after this 20 – 30 g /day is considered appropriate

Growth charts:

Growth charts Early detection WHO growth charts

Inadequate wt . gain:

Inadequate wt . gain Causes:- Inadequate intake Breast fed infants:- - incorrect feeding method - less frequent breast feeding - not feeding in night hours Infants on spoon / paladai feeding - incorrect method - infrequent feeding - incorrect calculation - not fortifying the milk Increased demands Illness such as hypothermia / cold stress Bronchopulmonary dysplasia corticosteroids

Management steps:

Management steps Proper counselling of mothers Explaining the frequency and timing of feeding Giving EBM by spoon feeds after breastfeeding Demonstration of correct method of expression of breast milk Fortification of breast milk If these measures fail – increase energy content of milk and feed volume to 200ml/kg/day

Appropriate management of specific complications:

Appropriate management of specific complications Resuscitation :- Problems- - perinatal asphyxia - immature lungs - immature blood vessels in brain - thin skin and large surface area - hypovolemic shock

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Management : High risk resuscitation Small bags for positive pressure ventilation CPAP Food grade plastic sheet to cover baby Oxygen therapy

Temperature control:

Temperature control Problems:- Large surface area Low glycogen stores Low subcutaneous fat Management:- Frequent monitoring KMC Warm room

Infection :

Infection Problems:- Immature defenses Mechanical ventilation , umbilicalvessel catheterization Management :- Asepsis Hand washing Minimal handling

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Adequate and appropriate use of antibiotics Decreasing exposure to persons with communicable diseases

Metabolic derangements:

Metabolic derangements Problems:- Hypoglycemia Mangement :- - asymptomatic baby - symptomaatic baby – glucose infusion Hyperglycemia

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Hypocalcemia Management :- -in highrisk baby - in asymptomatic baby - in symptomatic baby Hyperphosphatemia

jaundice:

jaundice Problem:- Larger RBC volume for body . wt Immaturity of hepatic enzymes and hepatic excretory capacity Immature blood brain barrier Management :- Photo therapy Exchange transfusion

Hematological abnormalities:

Hematological abnormalities Problems:- Polycythemia Anemia Management:- Hct >75%-exchange transfusion Others-increasing fluid intake Iron supplementation

Immature organ systems in preterm:

Immature organ systems in preterm Problem and management:- Intraventricular hemorrhage Retinopathy of prematurity Hearing damage Osteopenia of prematurity RDS Associated conditions Long hospital stay

Management of common problems:

Management of common problems Hypothermia- thermoneutral environment RDS-corticosteroids , surfactant therapy Aspiration PDA-avoid over infusion Necrotizing enterocolitis -human milk Late metabolic acidosis- protein 3 g/kg/day Drug toxicity- low doses at 12 hr interval

precautions:

precautions Avoid Routine oxygen administration without monitoring IV immunoglobulins Prophylactic antibiotics Prophylactic indomethacin / high vit E Unnecessary blood transfusions Formula feeds

Discharge :

Discharge Screening tests – for ROP , ABER Nutrition supplements Immunization Weight gain velocity Baby should be feeding well Mother should be adequately trained Absence of danger signs Methods like KMC should be well known to the parents

Follow up:

Follow up Within 3-7 days after discharge Common infective illness , reactive airway disease , HTN , GER Feeding and nutrition Immunization Nutritional status , anemia , rickets Neuromotor dev. , seizures , cognition Eyes – ROP ,vision strabismus Hearing Behavior problems , language disorders

Home care:

Home care Mother should breast fed her baby, look after his toilet needs Asepsis Public health nurse , social worker services Periodic home visits Gentle rhythmic stimulation

Thank you all:

Thank you all Reference O.p ghai Meharban singh Cloherty Nelson Internet