Care of the Low Birth Weight/Preterm Infant (Chapter 9)

Learning Objectives

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

List the main problems associated with low birth weight (LBW) /preterm baby.
Describe the management of the feeds for a LBW/preterm baby.
Describe the steps involved in tube feeding.
Counsel the mother on discharge on home care and follow up.

You also find sections on

KMC
cup feeding

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

In 2018, WHO estimated that 10.5% of babies in Malawi are born with low birth weight of whom the majority are premature; therefore all health care providers must be familiar with the care of this group of infants.

A neonate who weighs less than 2500g 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 aby is premature or SGA, as the management is slightly different. SGA babies are symmetrically small.

Remember, they could also be both premature and SGA. There are maturity charts or scoring systems that can help to decide the gestation age of a baby. .

Categories of Low Birth Weight Babies
Low birth weight infants – less than 2500g Very low birth weight infants – less than 1500g at birth Extremely low birth weight – less than 1000g at birth

Common problems in LBW, preterm and SGA neonates:

Increased risk of:

Hypothermia
Inability to breastfeed
Hypoglycaemia
Infection/Sepsis
RDS: Respiratory Distress Syndrome
Polycythaemia
Apnoea
Hyperbilirubinaemia
Retinopathy of prematurity

How to estimate the gestational age:

Often the gestational age of newborns 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 (Parkin Score

	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 palpable breast tissue	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 growthretardation is anindication to refer a pregnant woman to hospital before the baby is born (in-utero transfer).

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 1500 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 monitoring and 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 keeping the mother and baby together and using Kangaroo Mother Care.

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

A sick neonate with danger signs.
A LBW neonate who is not gaining weight.
Neonate who is unable to feed from the breast or by cup.

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

The definition of Continuous Kangaroo Mother Care (KMC) is care of a preterm infant carried skin-to-skin with the mother. Its key features include early, continuous, and prolonged skin-toskin contact between the mother and the baby, and exclusive breastfeeding (ideally) or feeding with breast milk. Mortality, hypothermia, rates of infection, and readmission are lower in neonates nursed in continuous KMC when compared with conventional care. Weight gain will be faster with KMC compared to conventional care. All newborns weighing 2000 g or less at birth should be provided with as much continuous KMC as possible.

Intermittent KMC is the practice of skin-to-skin care alternated with the use of a warming crib, radiant warmer, or an incubator care for the baby. Intermittent KMC is associated with reduced rates of hypothermia and infection compared to conventional care.

In Malawi, there are three categories of KMC:

Facility KMC – recommended for all neonates with a birth weight of < 1500 grams.
Ambulatory KMC – babies weighing 1500 – 1800 grams after discharge from a facility but who continue to be followed up by that facility.
Community KMC – babies > 1800 grams and clinically stable who are cared for in the community.

If neither continuous nor intermittent KMC is possible then an overhead radiant warmer, incubator, or warming crib may be used to keep the baby warm. The room where a LBW baby is nursed should be kept warm (25^oC). The baby should wear a hat to cover the head. Wet clothing should be changed frequently to keep the baby warm and dry. Regular monitoring of axillary temperature should be done.

Key Facts for Providers and Mothers/Guardians: Skin-to-skin contact (Kangaroo Mother Care)
If there are no signs of distress, a mother can provide a warm environment with Kangaroo care for the baby at home or hospital. Place the baby, with a nappy, socks and hat, upright inside mothers’ clothing against mother’s bare skin between her breasts, with the infant’s head turned to one side. Tie the infant to the mother with a cloth and cover the mother and infant with the mother’s clothes. Twins can practice KMC together on the mother’s chest. Let the baby suckle at the breast as often as s/he wants, but at least every 2 hours. Mother should sleep propped up so that the baby stays upright. If environmental temperature is low add a blanket to mother’s wrap. When mother wants to bathe or rest, ask the father or another family member to ‘Kangaroo’ the baby or wrap the infant in several layers of warm clothing, covered with blankets, and keep in a warm place. If the feet of the baby feel cold, s/he requires extra warmth.

Key Facts for Providers and Mothers/Guardians:
Skin-to-skin contact (Kangaroo Mother Care)

If there are no signs of distress, a mother can provide a warm environment with Kangaroo care for the baby at home or hospital. Place the baby, with a nappy, socks and hat, upright inside mothers’ clothing against mother’s bare skin between her breasts, with the infant’s head turned to one side. Tie the infant to the mother with a cloth and cover the mother and infant with the mother’s clothes. Twins can practice KMC together on the mother’s chest.

Let the baby suckle at the breast as often as s/he wants, but at least every 2 hours. Mother should sleep propped up so that the baby stays upright. If environmental temperature is low add a blanket to mother’s wrap. When mother wants to bathe or rest, ask the father or another family member to ‘Kangaroo’ the baby or wrap the infant in several layers of warm clothing, covered with blankets, and keep in a warm place. If the feet of the baby feel cold, s/he requires extra warmth.

Feeding the LBW Infant:

Breast milk is the preferred milk because it has a high electrolyte and protein content necessary for rapid growth of the baby. The antibodies and other anti-infective factors in mother’s milk are very necessary for the survival of a preterm baby.

Scheduling of enteral feeds:

Weight	Ideal Feeding Regime
<1500 g or < 32 weeks	Feed every two hours
>1500 g or > 32 weeks	Feed every three hours

Key Facts for Providers and Mothers/Guardians: Feeding LBW/Premature Infants
Feeding should be scheduled because preterm infants rarely demand feeds. Work out a schedule with the mother for her to follow. LBW babies may take longer on the breast.

Birth weight, gestation, presence or absence of sickness, and individual feeding efforts of the baby determine the decision as to how a LBW neonate should receive fluids and nutrition. The gestational age is one of the most important determinants, as coordinated sucking and swallowing does not develop until about 34 week’s gestation.

Likely route of feeding according to age:

Birth weight/ Gestational age	<1500 grams / <32 weeks	1500-1800 grams / 32-34 weeks	>1800-2500 grams / >34 weeks
1-3 days of life	Tube feeds	Tube feeds or cup	Breastfeed, if unsatisfactory use cup
3 days-3 weeks of life	Tube or cup	Breastfeed, if unsatisfactory use cup	Breastfeed

Those unable to feed directly on the breast, but who are clinically stable, can be given expressed breast milk (EBM) by oro-gastric tube or cup feeds. The mother should express her own milk into a clean container. In order to promote lactation, and enable the baby to learn to suck, all babies more than 1500 grams and 32 weeks of gestation should be put on the breast for 5-10 minutes before cup or tube feeding.

Is the baby able to breastfeed effectively?

When offered the breast, the baby roots, attaches well and sucks effectively. S/he is able to suck long enough to satisfy needs.

Is the baby able to accept feeds by alternative methods?

When offered cup feeds, the baby opens the mouth, takes milk, and swallows without coughing or spluttering.
S/he is able to take an adequate quantity to satisfy needs.

Is the baby getting enough breastmilk?

The best way to find out is to see how fast the baby grows over a few days. Babies need different amounts of breast milk to grow at the same rate. Too fast growth and too slow growth can cause health problems. The key measure of optimal feeding is the weight pattern of the baby. The ideal weight gain is similar to the average weight that a foetus gains in the uterus, about 15-20g/kg/day.

Judging adequacy of nutrition:

A Preterm LBW	Baby may lose up to 15% cumulative weight during the first week of life. Birth weight is usually regained by the end of the 2nd week of life. Maybe longer in very premature babies. Observe for causes of inadequate feeding: Insufficient breast milk Inadequate amounts prescribed if tube or cup fed (has the amount been increased appropriately)? Mother sick and so unable to come for every feed Orphan Structural abnormality e.g., cleft palate/lip Persistent hypothermia due to low environmental temperature, which diverts energy from growth to heat production (may be a sign of underlying sepsis) Poor positioning and attachment Maternal mental health conditions e.g., postpartum depression
SGA Babies	Should not have any appreciable weight loss at all and they should start gaining weight early.

A Preterm LBW

Baby may lose up to 15% cumulative weight during the first week of life.
Birth weight is usually regained by the end of the 2nd week of life. Maybe longer in very premature babies.

Observe for causes of inadequate feeding:

Insufficient breast milk
Inadequate amounts prescribed if tube or cup fed (has the amount been increased appropriately)?
Mother sick and so unable to come for every feed
Orphan
Structural abnormality e.g., cleft palate/lip
Persistent hypothermia due to low environmental temperature, which diverts energy from growth to heat production (may be a sign of underlying sepsis)
Poor positioning and attachment
Maternal mental health conditions e.g., postpartum depression

SGA Babies

Should not have any appreciable weight loss at all and they should start gaining weight early.

If nutrition supply of the baby is found to be inadequate due to reduced milk supply of the mother, there are several ways to increase the milk production:

Increase the rate of breastfeeding/expression of both breasts to at least three hourly even at night and ensure both breasts are emptied completely on each occasion.
Increase the intake of nutritious food and increase the amount of liquids of the mother.
Ask the mother to rest sufficiently.
Treat any underlying illness in the mother.

Maintenance feeds by gastric tube or by cup – see wall charts.

Key Facts for Providers and Mothers/Guardians: Breast Milk Expression
It is useful for all mothers to know how to express their milk. Expression of breast milk is required in the following situations: To maintain milk production and for feeding the baby who is premature, low birth weight or sick and cannot breast feed for some time. To relieve breast problems e.g., engorgement. Technique of expression – teach mother to: Wash her hands with soap and water thoroughly before expression. Sit or stand comfortably and hold the clean container near her breast. Put a thumb on her breast above the nipple and areola, and her first finger on the breast below the nipple and areola, opposite the thumb. She supports the breast with her other fingers. Press her thumb and first finger slightly inwards towards the chest wall. Press her breast behind the nipple and areola between her fingers and thumb. She must press on the lactiferous sinuses beneath the areola. Sometimes in a lactating breast it is possible to feel the sinuses. They feel like soft peanuts. If she can feel them, she can press on them. Press and release, press and release. This should not hurt – if it hurts the technique is wrong. At first no milk may come, but after pressing a few times, milk starts to drip out. Press the areola in the same way from the sides, to make sure that milk is expressed from all segments of the breast. Avoid rubbing or sliding her fingers along the skin. The movements of the fingers should be more like rolling. Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express milk. Express one breast for at least 3-5 minutes until the flow slows; then express the other side; and then repeat both sides. She can use either hand for either breast. Explain that to express breast milk adequately may take 20-30 minutes. Having the baby close or handling the baby before milk expression may help the mother to have a good let-down reflex. It is important not to try to express in a shorter time. To stimulate and maintain milk production she should express milk frequently – at least 8 times in 24 hours.

Key Facts for Providers and Mothers/Guardians:
Breast Milk Expression

It is useful for all mothers to know how to express their milk. Expression of breast milk is required in the following situations:

To maintain milk production and for feeding the baby who is premature, low birth weight or sick and cannot breast feed for some time.
To relieve breast problems e.g., engorgement.

Technique of expression – teach mother to:

Wash her hands with soap and water thoroughly before expression. Sit or stand comfortably and hold the clean container near her breast.
Put a thumb on her breast above the nipple and areola, and her first finger on the breast below the nipple and areola, opposite the thumb. She supports the breast with her other fingers.
Press her thumb and first finger slightly inwards towards the chest wall.
Press her breast behind the nipple and areola between her fingers and thumb. She must press on the lactiferous sinuses beneath the areola. Sometimes in a lactating breast it is possible to feel the sinuses. They feel like soft peanuts.
If she can feel them, she can press on them. Press and release, press and release.
This should not hurt – if it hurts the technique is wrong. At first no milk may come, but after pressing a few times, milk starts to drip out.
Press the areola in the same way from the sides, to make sure that milk is expressed from all segments of the breast.
Avoid rubbing or sliding her fingers along the skin. The movements of the fingers should be more like rolling.
Avoid squeezing the nipple itself. Pressing or pulling the nipple cannot express milk.
Express one breast for at least 3-5 minutes until the flow slows; then express the other side; and then repeat both sides. She can use either hand for either breast.
Explain that to express breast milk adequately may take 20-30 minutes. Having the baby close or handling the baby before milk expression may help the mother to have a good let-down reflex. It is important not to try to express in a shorter time. To stimulate and maintain milk production she should express milk frequently – at least 8 times in 24 hours.

Nasogastric tube feeding (NG tube)

Insertion of a nasogastric tube: The catheter is measured from the tip of the nose to the ear lobe and then to the midpoint between the xiphoid and umbilicus. Mark the position on the tube with a piece of tape. This length of the tube should be inserted through the nose. For tube feeding, use French size 5 or 6 nasogastric tubes.

Oro-gastric tube feeding (OG tube) and naso-gastric tube feeding (NGT)

Insertion of an oro-gastric tube: measure the distance between angle of mouth to earlobe, and then to the midpoint between the xiphoid and umbilicus. Mark the position on the tube with a piece of tape. This is the length of tube that is inserted.

During nasogastric or oro-gastric insertion, the head is slightly raised and a wet (not lubricated) catheter is gently passed through the nose (nasogastric) or mouth (oro-gastric) down through the oesophagus to the stomach. Its position is verified by aspirating the gastric contents and auscultating over the epigastric region. Injecting air into the tube can be dangerous.

At the time of feeding, the outer end of the tube is attached to a 10/20ml syringe (without plunger) and milk is allowed to trickle by gravity. There is no need to burp a tube-fed baby.

The nasogastric or oro-gastric tube should be left in situ for up to three (3) days.

While pulling out a feeding tube, it must be kept pinched and pulled out gently.

Tube feeding may be risky in very small babies. They have small stomach capacity and the gut may not be ready to tolerate feeds. Stasis may also result from paralytic ileus due to several conditions. Thus, tube-fed babies are candidates for regurgitation and aspiration. It is important therefore to take precautions.

Before the next feed, aspirate the stomach, if the aspirate is more than 25 percent of the last feed, the baby should be evaluated for any illness. The feeds may have to be decreased in volume or stopped and replaced with IV fluids.

Steps of oro-/nasogastric tube feeding

Before starting a feed, check the position of the tube.
For each feed take a clean syringe and remove the plunger.
Pinch the tube and connect the barrel of the syringe to the end of the gastric tube.
Pinch the tube and fill the barrel of the syringe with the required volume of milk.
Hold the tube with one hand, release the pinch and elevate the syringe to 5-10 cm above the level of the baby.
Let the milk run from the syringe through the gastric tube by gravity.
Do not force milk through the gastric tube by using the plunger of the syringe.
The milk should flow slowly into the baby’s stomach: control the flow by altering the height of the syringe; lowering the syringe slows the milk flow, raising the syringe makes the milk flow faster
Observe the baby during the entire gastric tube feed. Do not leave the baby unattended.
Avoid flushing the tube with water or saline after giving feeds.
Keep the gastric tube capped between feeds.
Progress to feeding by cup/spoon when the baby can swallow without coughing or spitting milk. This could be possible in as little as one or two days, or it may take longer than one week.
Replace the gastric tube with another clean gastric tube after 3 days, or earlierif it is pulled out or becomes blocked.

Steps of cup feeding

Baby should be awake and held sitting semi-upright on caregiver’s lap. Put a small cloth on the front of chest to catch drips of milk.

Put a measured amount of milk in the cup.
Hold the cup so that the more pointed tip rests on the baby’s lowerlip.
Tip the cup to pour a small amount of milk at a time into the baby’s mouth.
Feed the baby slowly.
Make sure that the baby has swallowed the milk already taken before giving anymore.
When the baby has had enough, he or she will close her mouth and will not take

Document the time and amount of feed that the baby received.

Prevention of Apnoea

Vitamin supplements and iron for preterm infants:

Supplement	Route	Timing and duration
Vitamin K National Guidelines	0.5 mg in preterm neonates IM 1 mg in term neonates IM	Birth
Multivitamin preparation if available	0.3-0.6 ml (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 50 mg iron in 5 mls or 10 mg 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 has gained 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. Prescribe micronutrient supplements. 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 2.5 kg 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.

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 has gained 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.
Prescribe micronutrient supplements.

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 2.5 kg 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.