So far we have been talking about more or less the healthy full-term babies. Unfortunately, a significant proportion (33 per cent) of the babies born in the Asian countries are low birthweight, either as a result of growth retardation of the foetus or due to birth much before the expected date of delivery. In the first case, the baby is termed small for dates (weight low compared to the gestational age) and in the second he is designated as preterm or premature.
According to WHO, a newborn with a birth weight of 2.5 kgs (5½ lb) or less (irrespective of the period of gestation) is classified as a low birthweight baby (LBW). He needs extra care.
Experience in the developing countries (and that includes India) shows that babies with weight between 2,000 gms and 2,500 gms often possess good potential for growth and health and may be managed as we manage normal newborns. Somewhat extra care will, however, be of advantage to them.
The newborns weighing less than 2,000 gms are, however, high risk babies. They are highly vulnerable and both anatomically as well as functionally immature. Mortality is high in this category of babies. They are put under intensive care in the so-called nursery, within the maternity unit. Remember, in order to protect the inmates against infection, visitors are not allowed to the nursery. The mother, too, stays a little away in the adjoining room.
Let me clarify another point. The LBW babies are of two types: first – those born around expected time of delivery (around 40 weeks) and second – those born much before expected time of delivery (before 37 weeks). The latter babies are also termed premature or preterm.
How he looks
The baby is small in size; the head looks very large for his body. The face looks small, buccal pad of fat is absent and eyes are protruding. Ear cartilage is either absent or deficient.
Hair is fuzzy and woolly with profuse lanugo over the body. The cheese-like skin covering, vernix, is scanty. Also, the skin has little subcutaneous fat, looks thin and excessively pink. Deep sole creases and breast nodule are absent.
Scrotum is underdeveloped. Testicles are not found in it. In baby girls, clitoris is hypertrophied and labia minora is prominently visible.
His reflexes are poor; so is his general activity.
The smaller the baby, the weaker is his hold on life.
The immaturity of his brain leads to poor activity and lethargy. Breathing difficulties may cause blue spells. Your doctor may need to resuscitate him.
His temperature regulatory mechanism is inadequate. Subnormal temperature (hypothermia) is seen in a large majority of such babies and may prove fatal. At times, he may develop high fever (hyperthermia) too.
Incoordination in sucking and swallowing causes vomiting and choking. The capacity of the stomach is small and he can tolerate only very small amount of feeds. Digestive upsets are common. As a result of poor tone of the muscles, abdominal distension is common.
Since liver enzymes are rather immature in such a baby, blood bilirubin level is relatively high and stays high for a prolonged time. This will be apparent to the mother as a prolongation of the physiological jaundice over a longer period. Also, high blood bilirubin is more likely to cause damage to his brain than in a healthy baby.
Incidence of a particular type of congenital heart disease, patent ductus arterious, is higher in preterm babies.
He is more prone to develop dehydration and ankle swelling (oedema).
For various reasons, he is susceptible to develop many metabolic disturbances such as hypolycemia, a condition in which blood sugar level is reduced.
He is prone to develop various nutritional deficiencies such as
His resistance to infections is low.
Since liver and kidneys are not functioning adequately, he is more susceptible to the toxic effects of drugs.
The low birthweight baby sleeps nearly all through day and night. He lives without making much motion and cries very little.
Now that you have been told about the special problems of the low birthweight baby, it is easy to understand that his needs are also special. His care is based on the principle of managing any newborn with certain modifications.
Before we touch on those special features of care let us recapitulate the special needs of the low birthweight infant. First, his breathing must not only be established but also well maintained. Secondly, his body heat should be maintained. Thirdly, he must be adequately fed. Fourthly, he must be protected against infection. Lastly, any kind of physical tiredness should not be inflicted on him.
Now, it becomes easy to understand why such a baby should be born in a well-equipped centre where good resuscitation facilities are available. It is customary for a senior obstetrician and a child specialist to be present in the labour room when such a delivery is anticipated. It is a practice to clamp the low birthweight baby’s cord fairly late and to squeeze it to the baby’s side before it is ligated. This gives the baby a good deal of extra iron stores.
Once the doctors are convinced that he is breathing properly and fluid and blood have been sucked out of his throat and mouth, he is immediately removed into a prewarmed incubator in which his body heat can be preserved and he can rest without external disturbance and also have a great deal of protection against infection. Most centres nurse the incubator babies without clothes so that it is easy to notice development of jaundice, cyanosis, etc.
He is left undisturbed. Visitors are not allowed. His mother may, however, be permitted to come and touch him. For this, she is trained to take strict aseptic precautions.
He is not given a bath until he is at least 2 kg in weight.
As for feeding, the details will be given in chapter 11. As a rule, if he can suck well and swallow well, breastfeeding should be the choice. In others, the doctors may like to give feeds through a nasogastric tube or by intravenous drip if the baby is less than 1,200 gms in weight.
Also remember, there is no sense in delaying the first feed. That can be dangerous. There is a distinct advantage in giving the first feed as soon as the baby has recovered from the shock of “birth”. It is rarely more than two to six hours.
Discharge from hospital and home care
Ideally speaking, a low birthweight baby should be discharged from the hospital when he has gained his weight, is able to feed satisfactorily, shows stable temperature control under normal room temperature and is free from disease. In our overcrowded hospitals and nurseries, it is usually difficult to fulfil the first criteria. Most babies are discharged when they reach 1,600 to 1,800gms in weight and show evidence of steady weight gain.
The mother should, however, make sure that she is fully trained to feed the baby, knows how to maintain aseptic environment around the baby and has learnt the ways and means to keep the baby warm.
At home, she must see to it that the handling of the baby by the visitors is discouraged.
If home visiting facilities by the doctor, lady health visitor or a public health nurse are available, she must make good use of these to assess the baby’s progress as also for further advice.
Low birthweight baby and drugs
As I pointed out earlier, the low birthweight baby reacts poorly to most of the drugs. Your doctor, as you will notice, is likely to avoid medication to him unless it is urgently needed. He would skip administering drugs like chloramphenicol, sulphonamides and vitamin K to him. When he indeed prescribes, the dose is usually one half of that recommended for the normal newborn.