Care of the low birth weight/preterm infant

Learning objectives

After completion of this session the participant should be able to:

Why is care of the low birth weight infant so important in Malawi?

14% of babies in Malawi are born with low birth weight; therefore all health care providers must be
familiar with the care of this group of infants.

A neonate who weighs less than 2500 g is a low birth weight baby. Nearly 75% of neonatal deaths occur among low birth weight neonates. Even after recovering from neonatal complications, some LBW babies remain more prone to malnutrition, recurrent infections and neurodevelopmental handicaps.
Infants with LBW may be small due to either prematurity or intra uterine growth retardation (IUGR).
IUGR results in a baby who is small for gestational age (SGA). It is helpful to try and decide if the baby is premature or SGA as the management is slightly different. SGA babies are symmetrically small. Remember of course they may be both premature and SGA. There are maturity charts or scoring systems that can help to decide the gestational age of a baby.

Very low birth weight infants- less than 1500 g at birth.

Extremely low birth weight – less than 1000 g at birth.

Common problems in LBW, preterm and SGA neonates

Increased risk of

Often just require support and close observation

How to estimate the gestational age

Often the gestational age of newborn infants is not clear and approximations have to be made. The most accurate way to do this is to use a maturity chart. Approximate gestational age can be estimated by adding the scores of the following features shown below (Parkin Score 2)

Approximate gestational age based on physical characteristics

0 1 2 3 4
SKIN TEXTURE Very thin Thin and smooth Smooth, medium thickness
Rash and superficial peeling		 Slight thickening
superficial cracking and peeling
especially of hands and feet		 Thick
superficial or deep cracking
SKIN COLOUR Dark red Uniformly pink Pale pink Pale, nowhere really pink except ear, lips, palms, soles
EAR FIRMNESS Soft pinna
No springing back into position spontaneously		 Soft pinna along the edge
Slow spontaneous return into position		 Thin Cartilage in pinna edge
Readily springs back into position		 Firm Pinna with definite cartilage
BREAST SIZE No breast tissue palpable Breast tissue palpable on one/ both sides neither being >0.5cm in diameter Breast tissue palpable on both sides 0.5-1 cm in diameter Breast tissue palpable on both sides >1cm in diameter

SCORE 1 2 3 4 5 6 7 8 9 10 11 12
GESTATION AGE 27 30 33 34½ 36 37 38½ 39½ 40 41 41½ 42

Management at delivery of low birth weight/ premature babies

The delivery of an expected LBW baby should be in hospital. Premature labour as well as intrauterine growth retardation is an indication for referral before the baby is born of the mother (in-utero transfer), to a better equipped facility.

Deciding where a LBW baby should be managed

The mother and the family under the supervision of a health care worker can manage an otherwise healthy LBW newborn with a birth weight of 1800 grams or above at home.
Infants below this weight are at risk of hypothermia, feeding problems, apnoea, respiratory distress syndrome and necrotizing enterocolitis. The risks associated with keeping the child in hospital (e.g. hospital-acquired infections) should be balanced against the potential benefit of better care, such as reviewing the infants at least twice a day to assess feeding ability, fluid intake or the presence of any danger signs. The risk of hospital-acquired infection can be reduced by using Kangaroo Mother Care.

The indications for hospitalization of a LBW neonate include the following:

  1. A sick neonate
  2. A LBW neonate who is not gaining weight
  3. Neonate who is unable to feed from the breast or by cup

Keeping the LBW babies dry and warm (prevention of hypothermia)

See Kangoroo Mother Care

Feeding the LBW infant

See Feeding the low birth weight infant for information on amounts of feeds, N/OGT and cup feeds.

Prevention of apnoeas

See breathing difficulties in the newborn

Vitamin supplements and iron for preterm infants

Supplement Route Timing and duration
Vitamin K
National Guidelines		 0.5mg in pre term neonates IM Birth
Multivitamin preparation
if available		 0.3-0.6ml (5-10 drops)/ day (which usually provides vitamin A of 1000 iu/day and vitamin D 400 iu/day) When taking full feeds until 6 months
Iron
if available

Start iron supplements at 2 weeks of age if tolerating full enteral feeds at a dosage of 2–4 mg/kg per day until 6 months of age.

Syrup usually contains 50mg iron in 5 mls or 10mg per ml so a 2 kg baby will get 0.5 mls

 2 weeks until 6 months

Key facts for providers– discharge of the LBW/preterm infant

A well LBW baby can be discharged when:

  • S/he is fully breast fed or breast feeding supplemented by EBM by cup and gaining weight for 3 consecutive days.
  • Has not had apnoea for seven days
  • Is able to maintain normal body temperature.
  • Mother is confident of taking care of the baby

Write in the health passport

  • The birth weight and gestational age if known
  • Indicate if any problems in addition to LBW such as jaundice or sepsis.
  • Ensure HIV exposure status is known and recorded in the passport.
  • Ensure Vitamin K has been administered and recorded
  • Ensure BCG and oral polio has been received and recorded

Follow-up schedule (at home or as close to home as possible)

Scheduled visits for assessing growth and monitoring for illness. These visits should be at weekly intervals till the infant reaches 2.5kg weight.

Vaccinations in LBW/ preterm babies

If the LBW baby is not sick, the vaccinations schedule is the same as for term babies.
A sick LBW baby however, should receive these vaccines only on recovery.

Counselling for care of LBW at home.

Counsel on exclusive breast feeding, keeping baby warm and to seek health care early if they identify any of the danger signs in-between postnatal care visits. Ask the parent to repeat the danger signs so that you know they have remembered them. Discuss about her own nutrition and health.