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