DEFINITIONS:

 Low birth weight (LBW) infant: A baby whose birth weight is less than 2.5 kg
(2,500 g), regardless of gestational age.
 Very low birth weight (VLBW) infant: A baby whose birth weight is less than 1,500
g.
 Extremely low birth weight (ELBW) infant: A baby whose birth weight is less than
1,000 g.
 Appropriate-for-gestational-age (AGA) infant: An infant whose birth weight falls
between the 10th to 90th percentiles on intrauterine growth curves.
 Small-for-date (SFD) or small-for-gestational-age (SGA) infant: An infant whose
rate of intrauterine growth was slowed and whose birth weight falls below the 10 th
percentile on intrauterine growth curves.
 Intrauterine growth retardation (IUGR): Babies who do not grow adequately in
utero.
 Premature (preterm) infant: A baby born before completion of 37th weeks of
gestation, regardless of birth weight.

LOW BIRTH WEIGHT:

Low birth weight are of two clinical types:

Low birth weight

Preterm (babies born Small-for-date/small- for-gestational-

before 37 weeks) age (babies having intrauterine growth
retardation)

Preterm Neonate:
Babies born before 37 weeks of gestation are known as preterm babies.
Characteristics of Preterm:
Features Specification

Size A preterm baby is small in size, usually less than 47 cm and weight
less than 2.5 kg

Posture The preterm infant lies in a “relaxed attitude”, limbs are extended

Head The head is relatively large, sutures are widely separated and
fontanels are large

Hair Hairs of preterm are fine, fuzzy, and wooly

Skin Skin of preterm is thin, pinkish and appears shiny due to generalized
edema. It is covered with abundant lanugo and there is little vernix
caseosa

Ear In preterm infants, ear cartilage is poorly developed and ear may fold
easily
Breast The breast nodule is absent or less than 5 mm wide

Sole The sole of foot of preterm infant appears more turgid and may have
only fine wrinkles. The creases are absent

Female genitalia The female infant’s clitoris is prominent and labia majora are poorly
developed and gaping

Male genitalia In preterm male infant, the scrotum is undeveloped and not
pendulous, minimal rugae are present and testes may be in the
inguinal canal or in the abdominal cavity

Scarf sign In preterm infants, elbow may be easily brought across chest with
little or no resistance

Heel to ear The preterm infant’s heel is easily brought to the ear, meeting with no
maneuver resistance
Etiology of Preterm Birth:
The etiology of preterm birth is multifactorial and involves a complex interaction
between fetal, placental, uterine and maternal factors:
 Fetal factors
 Fetal distress
 Multiple gestation
 Erythroblastosis fetalis
 Nonimmune hydrops
 Placental factors
 Placental dysfunction
 Placenta previa
 Abruptio placentae
 Uterine factors
 Bicornuate uterus
 Incompetent cervix
 Maternal factors
 Preeclampsia
 Chronic medical illness (renal or heart disease)
 Infections [Listeria monocytogenes, group B Streptococcus, urinary tract infection
(UTI), bacterial vaginosis, etc.]
 Drug abuse (cocaine)
 Other factors
 Premature rupture of membranes
 Polyhydramnios
 Iatrogenic
 Trauma
Physiological Handicaps of Prematurity or Problems Associated with Prematurity
The problems or handicaps of preterm babies are as follows:
 Respiratory problems
 Hyaline membrane disease
 Bronchopulmonary dysplasia
 Pneumothorax
 Pneumonia
 Apnea
 Cardiovascular problems
 Patent ductus arteriosus
 Hypotension
 Bradycardia
 Gastrointestinal problems
 Poor gastrointestinal function
 Necrotizing enterocolitis
 Hyperbilirubinemia
 Incompetent cardio esophageal sphincter leading to regurgitation
 Central nervous system problems
 Intraventricular hemorrhage
 Seizures
 Retinopathy of prematurity
 Deafness
 Hypotonia
 Problems associated with renal system
 Hyponatremia/Hypernatremia
 Hyperkalemia
 Renal tubular acidosis
 Renal glycosuria
 Edema
 Other problems
 Hypothermia
 Nutritional deficiencies
 Increased susceptibility to infections

Small-for-Date/Small-for-Gestational-Age Babies:
A baby whose birth weight falls below the 10 th percentile on intrauterine growth curves is
known as small-for-date or small-for-gestational-age.
Classification of Small-for-Date:
Small-for-date or SGA babies are of three types:-
1. Malnourished SFD babies: Growth arrest in later part of pregnancy leads to
reduction in cell size but not cell number, resulting in small and malnourished baby.
Such baby looks marasmic and has less subcutaneous fat and poor muscle mass.
2. Hypoplastic SFD babies: Growth retardation in early part of pregnancy leads to
reduction in number of body cells resulting in hypoplastic SFD babies. These babies
are proportionately smaller in all parameters including head size.

3. Mixed: When adverse factors operate during early and mid-pregnancy, reduction in
both cell number and size occurs leading to mixed SFD baby.

Etiology of Small-for-Date Baby/Intrauterine Growth Retardation:

Intrauterine growth retardation may be fetal response to following factors:-
 Fetal factors
 Chromosomal anomalies
 Infections (congenital rubella, syphilis)
 Infarction
 Multiple gestation
 Pancreatic hypoplasia
 Insulin deficiency
 Placental factors
 Placental weight or cellularity (size)
 Infraction
 Abruptio placentae
 Infection of placenta
 Maternal factors
 Toxemia of pregnancy
 Hypertension or renal disease
 Hypoxemia (cyanotic cardiac or pulmonary disease)
 Malnutrition
 Short stature of mother
 Primipara or grand multipara
 Young mother (below 20 years)
 Smoking, alcohol or drug abuse
Problems of Small-for-Date Infants:
Problem Pathogenesis (Reason)

Intrauterine Hypoxia, acidosis, infection, lethal anomaly

Birth asphyxia Uteroplacental perfusion during labor + chronic fetal hypoxia-

acidosis, meconium aspiration syndrome

Polycythemia and Erythropoietin level due to intrauterine fetal hypoxia

hyper viscosity of
blood

Hypothermia Hypoglycemia, poor subcutaneous fat and hypoxia

Congenital Chromosomal-genetic defects, oligohydramnios, TORCH

malformations [toxoplasmosis, other agents (syphilis, varicella-zoster,
parvovirus B19), rubella, cytomegalovirus, and herpes simplex]
infection

PRINCIPLES OF MANAGEMENT OF LOW BIRTH WEIGHT:

 Care at birth
 Select a suitable place for delivery which has optimum facilities for handling LBW
baby.
 In case, premature labor is indicated administer betamethasone (12 mg IM, two
doses at interval of 18 hours) or hydrocortisone 100 mg to the mother, as they help
in improving the lung maturity and reduces the incidence of hyaline membrane
disease in newborn.
 Avoid administration of sedatives to the mother, as they can depress baby’s
respiration.
 A good episiotomy should be given to prevent intracranial birth injury.
 Delayed cord clamping to help improve iron stores of baby and prevent anemia.
 Efficient resuscitation.
 Administration of vitamin K 0.5 mg IM to reduce incidence of hemorrhage in
baby.
 Prevent hypothermia.
 Appropriate place of care
 If birth weight>1,800 g-home care, if baby is well.
 If birth weight 1,500-1,800 g-secondary level new born unit (Level II)
 If birth weight <1,500 g-tertiary level new born care (Level III)
 Thermal protection
 Delay bathing up to 48-72 hours of birth or even more till the baby is stable.
 Maternal skin-to-skin contact or kangaroo care.
 Warm delivery room.
 External heat source.
 Nutrition
 Intravenous fluids for very small babies and those who are sick.
 Expressed breast milk with nasogastric tube or katori, and spoon.
 Direct breastfeeding, if possible for the baby to suck and swallow.
 Monitoring and early detection of complications
 Weight and other clinical signs.
 Electronic monitoring like heart rate, temperature, oxygen saturation, etc.
 Biochemical monitoring like hemoglobin, serum bilirubin, blood sugar, etc.
 Appropriate management of specific complications especially infection. Nursing
interventions following these principles are as follows:
 Nursery care: At birth, measures are needed to clear the airway, initiate breathing,
care of umbilical cord and eyes and administration of vitamin K. Special care is
required to maintain a patent airway and oxygen saturation in blood.
 Thermal control: Survival rate of LBW infants is higher when they are cared for
in thermo-neutral environment. Incubators or radiant warmers should be used to
maintain normal body temperature. Also kangaroo mother care (KMC) can be
given to stable LBW babies.
 Fluid requirement: Fluid needs of infants vary according to their gestational age,
environmental conditions, and disease states. Assuming minimal water loss in stool
of infants not receiving oral fluids, their water needs are equal to insensible water
loss and excretion of renal solutes. Fluid intake in term infants is usually started at
60-70 mL/kg on day 1 and increased to 100 – 120mL / kg by day 2-3. Preterm
infants may need to start with 70-80 mL/kg on day 1 and advance gradually to 150
mL/kg/day. Daily weight, urine output, and serum urea, nitrogen and sodium levels
should be monitored carefully to determine water balance and fluid needs.
 Feeding and nutrition: Preterm LBW babies have some limitations that would
make breastfeeding difficult. The limitations include (a) inability to suck
effectively, (b) inability to coordinate sucking and swallowing, and (c) inability to
 coordinate swallowing and breathing. Because of these limitations, some LBW
babies cannot be given any oral feeds while some might require gavage feeding.
Birth weight can be used as a guide to decide appropriate method of feeding.
 Discharge and follow-up
 Before discharge, the baby is evaluated for any complication of prematurity.
 Nutrition supplements including multivitamins, iron, calcium, and vitamin D are
started.
 Baby should be immunized with Bacillus Calmette-Guérin (BCG), hepatitis B
(HepB), and oral polio vaccine (OPV) at birth.
 Parents are instructed regarding regular feeding of baby.
 Mothers are instructed regarding routine care of baby like prevention of
hypothermia and infections, proper feeding, maintenance of personal hygiene,
growth monitoring, etc.
 All the danger signs are explained to the parents in detail with information
regarding whom to contact. Danger signs include:
- Feeding difficulty
- Lethargy
- Hypothermia or hyperthermia
- Tachypnea
- Chest in drawing
- Convulsions
 Follow-up should be planned within 3-7 days of discharge to ensure that baby has
adjusted in home environment.

STRATEGIES TO REDUCE INCIDENCE OF LOW BIRTH WEIGHT BABIES:

 Women should be considered as the creator of progeny and accorded due health
care, education, status, and empowerment in society.
 Provide optimal nutrition and health care to girl children throughout their life
cycle.
 Impart family life and mother craft education to teenage boys and girls.
 Avoid early marriage and teenage pregnancy. Provide pre-pregnancy health
checkup, general and nutritional guidance and essential vaccines.
 Ensure interpregnancy interval of at least 3 years. Provide optimal and good
quality antenatal care to all pregnant women.
  Enhance caloric intake, ensure balanced protein intake, and provide supplements of
iron, folic acid, and micronutrients during pregnancy.
 Avoid smoking, tobacco chewing, and substance abuse especially during
pregnancy.
 Early recognition and management of incompetent cervix, pregnancy-induced
hypertension (PIH), placental dysfunction, malaria, tuberculosis, UTI, diarrhea,
dysentery, genital colonization and bacterial vaginosis, etc.
 Avoid physical labor, emotional stress, and sex during third trimester.

CONCLUSION:
Low birth weight babies have high survival rate if they are managed well at the initial
stage of their problem and get cured. If there is no incidence of hypoxia and apneic
episode then these infants are neurologically also normal.
 BIBLIOGRAPHY

1. Datta. P. A textbook of PEDIATRIC NURSING. Fifth edition. New Delhi:

Jaypee Brothers Medical Publication;2022. Page no. 99

2. Sharma. R. Essentials of PEDIATRIC NURSING. Third edition. New Delhi:

Jaypee Brothers Medical Publication;2022. Page no. 108