UNIVERSITY OF THE GAMBIA

SCHOOL OF MEDICINE AND ALLIED HEALTH SCIENCES

DEPARTMENT OF NURSING AND REPRODUCTIVE HEALTH

PEDIATRIC NURSING MODULE

LOW BIRTH WEIGHT SECONDARY TO PREMATURITY

COMPLICATED BY HYPOTHERMIA

(A CASE STUDY)

Tobiloba A. Omotosho 2130019

DECEMBER, 2015
TABLE OF CONTENTS

ACKNOWLEDGMENT………………………………………………………………………………………………………………………..iv
ABSTRACT…………………………………………………………………………………………………………………………………….…..v

CHAPTER 1…………………………………………………………………………………………………………………………………………1

1.0 INTRODUCTION……………………………………………………………………………………………..…………1

1.1 AIM OF THE STUDY………………………………………………………………………………..…………………3

1.2 OBJECTIVES OF THE STUDY……………………………………………………………………………………….3

1.3 LITERATURE REVIEW…………………………………………………………………………………………………4

1.3.1 NATURE OF LBW………………………………………………………………………………………….4

1.3.2 CLASSIFICATION…………………………………………………………………………………………10

1.3.3 ETIOLOGY…………………………………………………………………………………………………..11

1.3.4 RISK FACTORS…………………………………………………………………………………………….12

1.3.5 SOCIO-ECONOMIC FACTORS………………………………………………………………………13

1.3.6 ENVIRONMENTAL FACTORS………………………………………………………………..……..14

1.3.7 TESTING AND DIAGNOSIS FOR LBW……………………………………………………………15

1.3.8 MANAGEMENT…………………………………………………………………………………..……..15

1.3.9 PREVENTION………………………………………………………………………………..……………18

CHAPTER 2……………………………………………………………………………………………………………………………..……….20

2.0 BACKGROUND OF CLIENT……………………………………………………………………………………….20

CHAPTER 3………………………………………………………………………………………………………………………………….……21

3.0 ADMISSION DETAILS…………………………………………………………………………………….…………21

3.1 CONTINUING CARE…………………………………………………………………………………………………21

3.2 NURSING DIAGNOSIS…………………………………………………………………………………………..…23

3.2.1 NURSING CARE PLAN……………………………………………………………….………………..23

3.2.2 INVESTIGATIONS …………………………………………………………………….…………………27

3.2.3 MEDICATIONS ……………………………………………………………………………….………….28

CHAPTER 4…………………………………………………………………………………………………………………….…………………30

4.0 DISCHARGE DETAILS…………………………………………………………………………………….…………30

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CHAPTER 5…………………………………………………………………………………………………………………………….…………32

5.0 DISCUSSION……………………………………………………………………………………………………………32

5.1 SUMMARY……………………………………………………………………………………………………………..33

5.2 CONCLUSION………………………………………………………………………………………………………….33

5.3 RECOMMENDATIONS……………………………………………………………………………………………..34

REFERENCES…………………………………………………………………………………………………………………………………….35

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ACKNOWLEDGEMENT

I acknowledge the effort of those who have contributed to the success of this case study. I

thank God for giving the strength and grace to start and conclude it and I thank the patient

and her mother, for their willingness and cooperation.

Furthermore, I will like to give special gratitude to the Nurse-In-Charge of the Neonatal

Ward of the Edward Francis Small Teaching Hospital for her assistance.

In addition, I appreciate the efforts of my lecturers; Mr. T. Senghore, Mrs. J. Sey-Sawo and

Mr. Ousman Jammeh for their support, understanding and encouragement.

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ABSTRACT

Birth weight is the most important factor that affects infant and child mortality. Low birth

weight neonates with 2000g or less birth weight constitute about 10% of live births with

perinatal mortality as high as 32.4%. Epidemiological maternal factors include extremes of

age and parity, poor antenatal care, low socio-economic status, illiteracy and underweight

short women. Etiological factors are obstetric complications, hypertensive disorders etc.

Prematurity and intrauterine growth restrictions are the two leading causes of low birth

weight (LBW). Preventive measures include improvement of economic status and education

about health and safe pregnancy. Proper antenatal care for early detection of high risk cases,

timely management of complications and adequate facilities for neonatal care can reduce the

perinatal morbidity and mortality.

This case study was conducted on one patient at the neonatal ward of EFSTH with the aim of

identifying the causes, diagnosis, complications, prevention, treatment and nursing

management of LBW and also, to understand the relationship between LBW and preterm

birth. Information regarding patient’s background, maternal obstetric history dietary habit of

patient’s mother, family history, home environment etc was collected through clerking and

from the patient’s folder.

Findings revealed that probable causes for LBW in this patient included maternal poor

nutrition, high parity, inadequate antenatal care etc. Patient was placed on antibiotics which

was always changed every four days and expressed breast milk given by cup. Before

discharge, patient had certified the necessary physiologic competencies for discharge and her

mother was educated on how to continue care at home.

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 CHAPTER 1

1.0 INTRODUCTION

World Health Organization (WHO) has defined low birth weight neonate as any neonate

weighing less than 2500g at birth. The definition helps in identifying neonates requiring

special care. According to the International Classification of Diseases (ICD-10), low birth

weight (LBW) is defined as a birth weight of a live-born infant of less than 2,500 g (5 pounds

8 ounces) regardless of gestational age. Subcategories include very low birth weight

(VLBW), which is less than 1500 g (3 pounds 5 ounces), and extremely low birth weight

(ELBW), which is less than 1000 g (2 pounds 3 ounces) (Subramanian, K. N., 2007). Normal

weight at term delivery is 2500–4200 g (5 pounds 8 ounces – 9 pounds 4 ounces).

In developing countries, adoption of this standard will result in unusually high incidence of

low birth weight neonates and many of them would not require special care. In India, it is

common observation that neonates weighing 2000g or less show increased risk or perinatal

mortality and morbidity and require special care. By common consensus therefore,

pediatricians in India accepted 2000g as the dividing line between low birth weight neonates

and normal neonates (Yerushalmy, J., 1967; Chowdhury, N. N. & Sikdar, K. A., 1982).

Preterm defines those neonates born before 37 completed weeks from the first day of last

menstrual period. Small for gestational age is used to describe those neonates below the tenth

percentile (Rangnekar, A. & Biswas, B., 1990). Exact cause of low birth weight (LBW) may

not be known in many of the cases. Maternal factors are height, weight, age and parity.

Coincidental medical conditions are anaemia, malnutrition, cardiac disease and fevers due to

recurrent infections like malaria, Infective hepatitis and chronic diarrhea or dysentery.

Uterine conditions which may cause prematurity are uterine malformations, incompetent

cervix and fibromyoma. Fetal factors are multiple pregnancy, congenital malformations,

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chronic fetal infections and chromosomal disorders. Placental factors are placenta previa,

abruption placentae, infarction or infections and idiopathic placental insufficiency. Other

associated factors include low socio-economic status (Battaglia, F. C. et al, 2010).

This case study was carried out as part of the requirements for Pediatric Nursing Course of

the Department of Nursing and Reproductive Health, University of The Gambia. The case

study involves choosing a particular patient with a medical or surgical condition of interest.

Then, a comprehensive health data was collected in a systematic and organized manner aimed

at getting to know the disease condition of the patient better.

During this study, I conducted an interview with the patient’s mother as a primary source for

history-taking. Also, health management related to aspects of care relevant to this condition

was conducted. The overall goal is to understand the process and management of the patient’s

condition.

The reasons for conducting this study are; to identify the causes, complications, nursing

management, prevention and treatment of low birth weight (LBW), to understand its

relationship with preterm birth, its effects and to identify factors responsible for LBW.

It was conducted within the periods of October and November, 2015 in the Neonatal Ward at

Edward Francis Small Teaching Hospital (EFSTH), Banjul. The exercise was conducted by a

4th year Bachelor of Nursing student with the support of the Nurse-in-charge of the ward, the

doctor and the patient’s mother. This case study was carried out as part of the clinical work in

the pediatric nursing module and a 21day old Gambian female child who was diagnosed with

Low Birth Weight (LBW) secondary to prematurity, complicated by hypothermia was the

patient studied.

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When a baby is born weighing less than 2,500 grams (5 lbs, 8 ounces), he or she is

considered to have a low birth weight. In some cases, babies born prematurely or with

intrauterine growth restrictions (two leading causes of low birth weight) may see an increase

in risks for complications such as mental retardation, vision loss, and/or learning problems.

Currently, about one in twelve babies are born with a low birth weight. However, that number

has greatly decreased due to advancements made in prenatal care (Kulich, E., 2015). An

article titled “Low Birth Weight in Newborns” written by Boston Children Hospital explained

that the primary cause is premature birth, being born before 37 weeks gestation; a baby born

early has less time in the mother's uterus to grow and gain weight, and much of a fetus's

weight is gained during the latter part of the mother's pregnancy. Nearly all low birth weight

babies need specialized care in the Neonatal Intensive Care Unit (NICU) until they gain

weight and are well enough to go home. Fortunately, there is a 95 percent chance of survival

for babies weighing between 3 pounds, 5 ounces and 5 pounds, 8 ounces. During pregnancy,

a baby's birth weight can be estimated in different ways: the height of the fundus, ultrasound

etc. Prevention of preterm births is one of the best ways to prevent babies born with low birth

weight and prenatal care is a key factor in preventing preterm births and low birth weight

babies.

1.1 AIM OF THE CASE STUDY

To identify the causes, diagnosis, complications, prevention, treatment and nursing

management of low birth weight (LBW). Also, to understand the relationship between LBW

and preterm birth, its effects and factors responsible for LBW.

1.2 OBJECTIVES OF THE CASE STUDY

 To identify factors responsible for LBW in neonates.

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  To understand the causes, effects and complications of LBW.

 To identify its diagnostic procedures and preventive measures.

 To examine proffered and preferred methods of treatment and management.

 To understand the relationship between LBW and Preterm birth.

1.3 LITERATURE REVIEW

1.3.1 NATURE OF LOW BIRTH WEIGHT

Children have different health care problems than adults and the problems may depend on

age and development. The leading cause of death in neonates (birth – 28days of age) are

congenital anomalies, low birth weight (LBW), respiratory distress syndrome (RDS) and

maternal complications of pregnancy.

Congenital
anomalies 114.0

Disorders relating to
short gestation and LBW 102.8

RDS 33.9

Maternal complications
of preganancy 30.7

Number of deaths per 100,000 live births

Ball, J. W. & Bindler, R. C. (2003); 3rd ed. A Neonatal Mortality.

Low birth weight (LBW) has been defined by the World Health Organization (WHO) as

weight at birth less than 2500 g. Globally, more than 20 million infants are born with LBW.

The number of LBW babies is concentrated in two regions of the developing world: Asia and

Africa. Seventy-two percent of LBW infants in developing countries are born in Asia where

most births also take place, and 22 per cent are born in Africa. India alone accounts for 40 per

4
cent of LBW births in the developing world and more than half of those in Asia. There are

more than 1 million infants born with LBW in China and nearly 8 million in India. Latin

America and the Caribbean, and Oceania have the lowest number of LBW infants, with 1.2

million and 27,000, respectively (WHO/UNICEF, 2004). The global prevalence of LBW is

15.5%, which means that about 20.6 million such infants are born each year, 96.5% of them

in developing countries. There is significant variation in LBW rates across the United Nations

regions, with the highest incidence in South-Central Asia (27.1%) and the lowest in Europe

(6.4%).LBW can be a consequence of preterm birth (defined as birth before 37 completed

weeks of gestation), or due to small size for gestational age (SGA, defined as weight for

gestation <10th percentile), or both. In addition, depending on the birth weight reference

used, a variable but small proportion of LBW infants are born at term and are not SGA.

Intrauterine growth restriction, defined as a slower than normal rate of fetal growth, is usually

responsible for SGA. LBW thus defines a heterogeneous group of infants: some are born

early, some are born at term but are SGA, and some are both born early and SGA (WHO,

2011). According to Simhan & Caritis, 2007, four different pathways have been identified

that can result in preterm birth and have considerable evidence: precocious fetal endocrine

activation, uterine overdistension, decidual bleeding, and intrauterine inflammation/infection.

Being small for gestational age can be constitutional, that is, without an underlying

pathological cause, or it can be secondary to intrauterine growth restriction, which, in turn,

can be secondary to many possible factors. For example, babies with congenital anomalies or

chromosomal abnormalities are often associated with LBW. Problems with the placenta can

prevent it from providing adequate oxygen and nutrients to the fetus. Infections during

pregnancy that affect the fetus, such as rubella, cytomegalovirus, toxoplasmosis, and syphilis,

may also affect the baby's weight (Simhan, H. N. & Caritis, S. N., 2007). A study of low birth

weight neonates conducted in 2000 in a Military hospital in Devlali by Lt. Col. Bathnagar, P.

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K. revealed that out of 5211 babies, 552 (10.59%) were weighing 2000g or less, with 303

(54.90%) preterm and 249 (45.10%) small for date. Distribution of etiological factors

revealed obstetric complications (22.06%), hypertensive disorders (16.10%) and in 42.14%

cases, no obvious cause could be detected. 7.36% had hemorrhages associated with

pregnancy and placenta praevia (81.08%) and threatened abortion (18.92%). Out of obstetric

complications, twin pregnancy constituted 44.14% and premature rupture of membranes

(PROM) 35.43%. The study therefore concluded that low birth weight neonate is a common

clinical problem and is associated with high perinatal mortality and morbidity albeit these is

preventable to a large extent by early detection of pathological state and treatment,

improvement of economic status, educational status, avoiding teenage pregnancy, proper

antenatal and intranatal care and specialized neonatal care. According to Dr. Edward Kulich,

it’s important to know that not all babies born with a low birth weight have a condition or

problem. Some babies are just born small. In these cases, it is not abnormal and not a cause

for concern. Doctors may expect a baby with low birth weight if the mother’s uterus is small,

if she has a small frame, or if the ultrasound shows the baby is smaller than normal (Kulich,

E., 2015).

The goal of reducing low birth weight incidence by at least one third between 2000 and 2010

is one of the major goals in ‘A World Fit for Children’, the Declaration and Plan of Action

adopted by the United Nations General Assembly Special Session on Children in 2002. The

reduction of low birth weight also forms an important contribution to the Millennium

Development Goal (MDG) for reducing child mortality. Activities towards the achievement

of the MDGs will need to ensure a healthy start in life for children by making certain that

women commence pregnancy healthy and well nourished, and go through pregnancy and

childbirth safely. LBW is therefore an important indicator for monitoring progress towards

these internationally agreed-upon goals (UNICEF, 2004). A newborn infant weighing less

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than 2500g at birth is termed as low birth weight (LBW) neonate. Low birth weight in a

newborn infant results from intrauterine growth restriction (IUGR) or prematurity (Saili, A.,

2008). Low birth weight neonates are further classified as very low birth weight (VLBW

<1500 g) and extremely low birth weight (ELBW <1000 g) infants. Majority of LBW

neonates in our country weigh between 2000-2499 g. According to the National Neonatal

Perinatal Database of the National Neonatology Forum, India; the incidence of LBW in

tertiary care centers is 32.8percent with only 14% neonates weighing less than 2000 g

(National Neonatology Forum of India, 2001). LBW is the most significant factor

contributing to neonatal mortality and morbidity. These neonates are at higher risk of

asphyxia, sepsis, hypothermia, and feeding problems, etc. Common illnesses tend to be more

severe and last longer in this group. LBW-SGA infants have a narrow thermo-neutral range.

The large head to body ratio and greater surface area along with a thin layer of subcutaneous

fat leads to a rapid heat loss. On the other hand, the heat production is also compromised due

to hypoglycemia, and hypoxia. It is thus critical that the LBW-SGA neonate is resuscitated

and nursed in a thermo-neutral environment. The resuscitation must be prompt and the

neonate dried and placed under a warmer. The wrapping of pre-terms (<28wks) in plastic

bags or plastic wrappings (food grade) is currently recommended during resuscitation to

maintain temperature. Subsequently, the neonate should be covered well. The concept of

Kangaroo mother care or the skin to skin care is an economical, acceptable and practical way

for maintaining temperature of the LBW neonates. It has the added advantage of providing

adequate nutrition through frequent breast feeds (Suman-Rao, P. N. et al, 2008). Apart from

immediate problems, LBW neonates are prone to long term disorders like infections,

malnutrition, and neuro-developmental disabilities. Babies who are small or disproportionate

at birth also have an increased risk of developing coronary heart disease, non-insulin

dependent diabetes mellitus, stroke, and hypertension during adult life. It is postulated that

7
these diseases are programmed by inadequate supply of nutrients to the developing fetuses

(Barker hypothesis) (Barker, D. J. P., 1998). Thus, measures to increase the birth weight of

babies constitute a priority area in developing nations.

Howa low weight baby is affected depends on what caused the low birth weight, and whether

the baby was premature when born (Kendig, 2007; Rogers and Piecuch 2009). Most babies

who are term and who have a low birth weight have no ongoing problems. Most are simply

small because it runs in the family. However, some problems may happen if a baby is born

prematurely, such as the baby having: Breathing problems, called respiratory distress

syndrome (RDS); An increased risk of infection; Low blood sugar (hypoglycemia), and

problems with feeding; Difficulty with keeping warm (Kendig 2007); Too many red blood

cells, which can make the baby’s blood too thick (polycythaemia). Claims that babies who

have a low birth weight have lower intelligence, go on to do poorly at school, or have health

or behavior problems, are based on mixed evidence. So it's hard to predict how an individual

child will do in the future. Much depends on how severe the baby's low birth weight is. The

lower the birth weight, and the more premature the baby, the more pronounced the problems

tend to be. Some factors can reduce the risk of developmental problems, such as if the baby is

breastfed and has good family support (Rogers and Piecuch 2009, Viera and Linhares 2011).

In an article titled “Low birth Weight in Newborns”, Boston Children’s Hospital stated that

babies are weighed within the first few hours after birth and the weight is compared with the

baby's gestational age and recorded in the medical record. A birth weight less than 5 pounds,

8 ounces is diagnosed as low birth weight and babies weighing less than 3 pounds, 5 ounces

at birth are considered very low birth weight. The overall rate of these very small babies is

increasing, primarily because of the increase in multiple birth babies, who tend to be born

earlier and weigh less. More than half of multiple birth babies have low birth weight. An

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Infant Follow-Up Program was designed for infants born very prematurely, who weigh less

than 3.3 lbs and are at high risk for development and motor delays and other problems

resulting from prematurity. This program follows children from the time of discharge until

they reach age 3 to 4. The multi-disciplinary Infant Follow-Up team includes pediatricians,

neonatologists, pediatric psychologists, physical therapists, social workers and if needed,

pediatric neurologists. It was further noted that LBW is a concern because if a baby has a low

birth weight, such baby may be at increased risk for complications. The tiny body is not as

strong, and they may have a harder time eating, gaining weight and fighting infections.

Because there is so little body fat, a hard time staying warm in normal temperatures may be

experienced. Because many babies with low birth weight are also premature, it is can be

difficult to separate the problems due to the prematurity from the problems of just being so

tiny. In general, the lower a baby's birth weight, the greater the risks for complications. The

following are some of the common problems of low birth weight babies: low oxygen levels at

birth, inability to maintain body temperature, difficulty feeding and gaining weight, infection,

breathing problems, such as respiratory distress syndrome (a respiratory disease of

prematurity caused by immature lungs), neurologic problems, such as intraventricular

hemorrhage (bleeding inside the brain), gastrointestinal problems such as necrotizing

enterocolitis (a serious disease of the intestine common in premature babies), and Sudden

Infant Death Syndrome (SIDS) (Boston Children’s Hospital, 2015).

The incidence of low birth weight in a population is defined as the percentage of live births

that weigh less than 2,500 g out of the total of live births during the same time period. The

low birth weight incidence rate therefore is:

Number of live born babies

with birth weight less than 2,500g X 100
Number of live births

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For industrialized countries, the main sources of information on LBW are service-based data

and national birth registration systems. For developing countries, LBW estimates are

primarily derived from national household surveys, as well as data from routine reporting

systems. Prior to about 1990, most estimates of LBW for developing countries were based on

data compiled from health facilities. However, such estimates are biased for most developing

countries because the majority of newborns are not delivered in facilities and those that are

delivered in health facilities are a selected sample of all births. As an alternative to facility-

based data, information on birth weight has been collected systematically since about 1990

from mothers participating in nationally representative household surveys, mostly the USAID

supported Demographic and Health Surveys (DHS) and the UNICEF-supported Multiple

Indicator Cluster Surveys (MICS) (WHO & UNICEF, 2004).

1.3.2 CLASSIFICATION

According to the International Classification of Diseases (ICD-10), low birth weight (LBW)

is defined as a birth weight of a liveborn infant of less than 2,500 g (5 pounds 8 ounces)

regardless of gestational age. Subcategories include very low birth weight (VLBW), which is

less than 1500 g (3 pounds 5 ounces), and extremely low birth weight (ELBW), which is less

than 1000 g (2 pounds 3 ounces) (Subramanian, K. N., 2007). A pediatrician at the Johns

Hopkins University School of Medicine, Marilee C. Allen, in his article “Development and

Follow-Up of Premature and Low Birthweight Infants” explained birth weight as having 4

categories:

LBW <2500 gms (5 lbs 8oz) Low Birthweight

VLBW <1500 gms (3 lbs 5oz) Very Low BW

ELBW <1000 gms (2 lbs 3oz) Extremely Low BW

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ILBW <750 gms (1 lb 10oz) Incredibly Low BW

<600 gms (1 lb 5oz)

<500 gms (1 lb 2 oz) (Allen, M. C., 2015).

Overall, since a relationship exists between birth weight, prematurity and gestational age, a

classification that incorporates both would explain better.

Premature infants may be classified by weight independent of gestational age:

Low birth weight LBW <2,500 g (<5 lb 8 oz)

Very Low birth weight VLBW <1,500 g (<3 lb 5 oz)

Extremely Low birth weight ELBW <1,000 g (<2 lb 3 oz)

Infants may also be classified by weight for a specific gestational age:

Small for gestational age SGA Weight <10th percentile

Appropriate for gestational age AGA Weight 10-90th percentile

Large for gestational age LGA Weight >90th percentile

March of Dimes. Medical resources.

http://www.marchofdimes.com/professionals/medicalresources_lowbirthweight.html.
WHO Statistical Information Systems (WHOSIS). 2011.
http://www.who.int/whosis/indicators/compendium/2008/2bwn/en/index.html.

1.3.3 ETIOLOGY

The etiology of LBW is multifactorial. Maternal malnutrition and anemia are the most

important causes responsible for reduced birth weight in developing nations. Other maternal

factors playing a part include young age at conception, multiple pregnancies, pregnancy

induced hypertension, infections, substance abuse etc. Genetic factors also play a role (Saili,

A., 2008). According to Dr. Kulich, two main causes for a baby to be born at a low birth

weight are premature birth and intrauterine growth restrictions (IUGR). Premature birth is a

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term for a baby born before 37 weeks of pregnancy. Sixty-seven percent of all low birth

weight babies are premature births. Many people refer to these newborns as “preemies”. The

earlier the baby is born, the less he or she will weigh. Babies born weighing less than 3

pounds, 5 ounces are at extremely high risk for health problems at the moment of birth, in the

days and weeks after birth, and during their lifetime. Premature babies born closer to term

tend to need supervision for a few days, but are statistically in good shape, with mild or no

health problems. However, late preterm infants have a significantly higher mortality rate than

term infants and may be deceptively well looking. Intrauterine growth restriction babies are

also known as growth-restricted, small-for-gestational age, or small-for-date babies.

Sometimes a mother goes full term in her pregnancy and still gives birth to a low birth weight

baby. In most cases, these babies are relatively healthy, just small. The parent’s genetics or

other factors such as the expectant mother’s lifestyle while she was pregnant may be reasons

why a full term baby is born with a low birth weight. There are two major kinds of

intrauterine growth restriction infants, symmetrical and asymmetrical, with symmetrical

having a greater frequency of medical issues. Other factors for low birth weight babies

include: Previous pregnancy resulted in a low birth baby or premature birth; Multiple fetuses

(twins, triplets, etc.); Uterus abnormalities; Cervix abnormalities; Maternal chronic health

problems during pregnancy; Maternal high blood pressure; Maternal diabetes; Smoking;

Alcohol or drug usage or abuse; Infections in the mother; Infections in the fetus; Inadequate

maternal weight gain; African-American women and; All women under 17 are at an

increased risk of delivering a low birth weight baby (Kulich, E., 2015).

1.3.4 RISK FACTORS

Age at delivery, short birth interval, inadequate antenatal care, poor maternal nutrition, high

parity, history of abortion, still birth and low birth weight babies in previous deliveries; come

12
out as major factors associated with LBW in newborns (Joshi, H. S. et al, 2008). Other

factors that can also contribute to the risk of low birth weight include: Mother's age - Teen

mothers (especially those younger than 15) have a much higher risk of having a baby with

low birth weight; Multiple birth babies; Babies of mothers who are exposed to illicit drugs,

alcohol and cigarettes; Mothers of lower socioeconomic status (Boston Children’s Hospital,

2015).

1.3.5 SOCIO-ECONOMIC FACTORS

Micheal D. Kogan, explained in his article “Social Causes of LBW” that social factors can

affect low birth weight and other adverse pregnancy outcomes is neither new nor a revelation.

Indeed, it was noted in 1910 that: An examination of population change tables from the town

of Viipuri in Finland indicated a clear association between social class and infant mortality in

both the preindustrial period (1819-1868) as well as the period of industrialization (1869-

1918). The medical literature is rife with studies elucidating the association between lower

social class' or other social factors and either increased risk of low birth weight or infant

mortality throughout various parts of the world. Although many of these studies have simply

highlighted the association between social factors and low birth weight, there has been some

speculation as to the possible reasons. It has been suggested that poverty could affect

maternal health status at the time of conception through lower physiologic reserves, or that

less healthy women are more likely to be concentrated in the lower social classes. Other

potential causes could be variation in the quality and quantity of medical care, diet, housing

conditions, lower social support, unemployment, increased exposure to toxic agents, or

differences in risk of infectious diseases. Four theories concerning the link between social

factors and adverse pregnancy outcomes were examined. The first is termed the artefact

theory. This theory suggests that reported inequalities in health are artefacts of the ways in

13
which social class are defined and measured. The second theory, natural or social selection,

holds that people who are unhealthy or potentially unhealthy are 'selected' for low status

occupations or drift downwards into them, while healthy people are selected upwards. The

third theory states that material deprivation affects health directly, while the fourth theory

says that material deprivation works indirectly, either through the individual's behavior, lack

of medical services, or a poor diet. It was further suggested that the third and fourth theories

should be examined together as material deprivation, culture, and behavior which suggests

that social class has an effect on health outcomes because people at the bottom of the social

scale suffer material deprivation and are part of a culture in which the predominant forms of

health behavior are considered harmful. Still another corollary suggests that material

deprivation produces inappropriate behavior, e.g. a 'culture of poverty'. The Black Report

suggested that the answer lies in one of these three versions of the material deprivation theory

(Kogan, M. D., 1995).

1.3.6 ENVIRONMENTAL FACTORS

While active maternal tobacco smoking has well established adverse perinatal outcomes such

as LBW, that mothers who smoke during pregnancy are twice as likely to give birth to low-

birth weight infants. Review on the effects of passive maternal smoking, also called

environmental tobacco exposure (ETS), demonstrated that increased risks of infants with

LBW were more likely to be expected in ETS-exposed mothers (Knopik, V. S., 2009).

Regarding environmental toxins in pregnancy, elevated blood lead levels in pregnant women,

even those well below 10ug/dL can cause miscarriage, premature birth, and LBW in the

offspring. The combustion products of solid fuel in developing countries can cause many

adverse health issues in people. Because a majority of pregnant women in developing

countries, where rate of LBW is high, are heavily exposed to indoor air pollution, increased

14
relative risk translates into substantial population attributable risk of 21% of LBW (Pope, D.

P. et al, 2010). A correlation between maternal exposure to CO and low birth weight has been

reported that the effect on birth weight of increased ambient CO was as large as the effect of

the mother smoking a pack of cigarettes per day during pregnancy (Lewtas, J., 2007).

1.3.7 TESTING AND DIAGNOSIS FOR LOW BIRTH WEIGHT

During pregnancy, a baby's birthweight can be estimated in different ways. The height of the

fundus (the top of a mother's uterus) can be measured from the pubic bone. This measurement

in centimeters usually corresponds with the number of weeks of pregnancy after the 20th

week. If the measurement is low for the number of weeks, the baby may be smaller than

expected. Ultrasound (a test using sound waves to create a picture of internal structures) is a

more accurate method of estimating fetal size. Measurements can be taken of the fetus' head

and abdomen and compared with a growth chart to estimate fetal weight. Babies are weighed

within the first few hours after birth. The weight is compared with the baby's gestational age

and recorded in the medical record. A birth weight less than 5 pounds, 8 ounces is diagnosed

as low birth weight (Boston Children Hospital, 2015).

1.3.8 MANAGEMENT

If a baby is born with low birth weight, he or she may need to spend additional time in the

hospital for close monitoring. This can last days, weeks, or months depending on how much

the baby weighed at birth, the reason for the low birth weight, and how long it takes such

baby to reach the appropriate weight to go home. In most cases, an ultrasound can inform the

doctor before the baby is born that he or she is not gaining enough weight. The doctor may

want to monitor the fetal heart rate and/or perform additional ultrasounds to monitor the

baby’s progress. Unfortunately, the only treatment while a mother is pregnant is to monitor

15
and wait. Occasionally, a baby may need to be born prematurely in order to save its life or the

mother’s life due to other medical factors (Kulich, E., 2015). According to Boston Children’s

Hospital (2015), care for low birth weight babies may include: care in the Neonatal Intensive

Care Unit (NICU), temperature controlled beds, special feedings, sometimes with a tube into

the stomach if a baby cannot suck and other treatments for complications.

"Kangaroo mother care" is a method of care of preterm infants weighing less than 2 kg. It

includes exclusive and frequent breastfeeding in addition to skin-to-skin contact and support

for the mother-infant dyad, and has been shown to reduce mortality in hospital-based studies

in low- and middle-income countries. The WHO document Kangaroo mother care: a

practical guide provides guidance on how to organize services in health facilities and on what

is needed to provide effective "Kangaroo mother care" (WHO, 2015). The nutritional

management of LBW-SGA neonates is complex. A rapid glucose supply can lead to

hyperglycemia, but amino-acid intolerance is not exaggerated. There is reluctance in feeding

SGA infants as aggressively as their deprived state would indicate. It needs to be ascertained,

if aggressive feeding is tolerated and whether it results in nutritional rehabilitation and a

better outcome (MacDonald, M. G. et al, 2005).

2011 WHO Recommendations on optimal feeding of low birth weight infants

No. Recommendations* Type of

recommendation
What to feed?
a. Choice of milk
1. Low-birth-weight (LBW) infants, including those with very low birth weight Strong
(VLBW), should be fed mother’s own milk.
2. LBW infants, including those with VLBW, who cannot be fed mother's own milk Strong
should be fed donor human milk (recommendation relevant for settings where safe situational
and affordable milk-banking facilities are available or can be set up).
3 LBW infants, including those with VLBW, who cannot be fed mother's own milk or Weak situational
donor human milk should be fed standard infant formula (recommendation relevant
for resource-limited settings).
VLBW infants who cannot be fed mother's own milk or donor human milk should
be given preterm infant formula if they fail to gain weight despite adequate feeding
with standard infant formula.

16
4. LBW infants, including those withVLBW, who cannot be fed mother's own milk or Weak situational
donor human milk should be fed standard infant formula from the time of discharge
until 6 months of age (recommendation relevant for resource-limited settings).
5.** milk should not routinely be given bovine milk-based human milk fortifier Weak situational
(recommendation relevant for resource-limited settings).
VLBW infants who fail to gain weight despite adequate breastmilk feeding should
be given human-milk fortifiers, preferably those that are human milk based.
b. Supplements
6.** VLBW infants should be given vitamin D supplements at a dose ranging from 400 Weak
i.u to 1000 i.u. per day until 6 months of age
7.** VLBW infants who are fed mother’s own milk or donor human milk should be Weak
given daily calcium (120-140 mg/kg per day) and phosphorus (60-90 mg/kg per
day) supplementation during the first months of life.
8.** VLBW infants fed mother’s own milk or donor human milk should be given 2-4 Weak
mg/kg per day iron supplementation starting at 2 weeks until 6 months of age.
9. Daily oral vitamin A supplementation for LBW infants who are fed mother's own Weak
milk or donor human milk is not recommended at the present time, because there is
not enough evidence of benefits to support such a recommendation.
10 Routine zinc supplementation for LBW infants who are fed mother's own milk or Weak
donor human milk is not recommended at the present time, because there is not
enough evidence of benefits to support such a recommendation.
When and how to initiate feeding?
11. LBW infants who are able to breastfeed should be put to the breast as soon as Strong
possible after birth when they are clinically stable.
12.** VLBW infants should be given 10 ml/kg per day of enteral feeds, preferably Weak situational
expressed breast milk, starting from the first day of life, with the remaining fluid
requirement met by intravenous fluids (recommendation relevant for resource-
limited settings).
Optimal duration of exclusive breastfeeding
13. LBW infants should be exclusively breastfed until 6 months of age. Strong
How to feed?
14. LBW infants who need to be fed by an alternative oral feeding method should be fed Strong
by cup (or palladai, which is a cup with a beak) or spoon.
15.** VLBW infants requiring intragastric tube feeding should be given bolus intermittent Weak
feeds.
16.** In VLBW infants who need to be given intragastric tube feeding, the intragastric Weak
tube may be placed either by oral or nasal route, depending upon the preferences of
health-care providers.
How frequently to feed and how to increase the daily feed volumes?
17. LBW infants who are fully or mostly fed by an alternative oral feeding method Weak situational
should be fed based on infants’ hunger cues, except when the infant remains asleep
beyond 3 hours since the last feed (recommendation relevant to settings with an
adequate number of health-care providers).
18.* In VLBW infants who need to be fed by an alternative oral feeding method or given Weak
intragastric tube feeds, feed volumes can be increased by up to 30 ml/kg per day
with careful monitoring for feed intolerance.
*None of the recommendations address sick LBW infants and infants with birth weight less
than 1.0kg.
**These recommendations specifically address infants with birth weight between 1.0kg and
1.5kg

Fig 3: WHO (2011). Recommendations on optimal feeding of low birth weight infants

17
1.3.9 PREVENTION

According to Boston Children’s Hospital (2015), prevention of preterm births is one of the

best ways to prevent babies born with low birth weight. Prenatal care is a key factor in

preventing preterm births and low birth weight babies. At prenatal visits, the health of both

mother and fetus can be checked. Also, because maternal nutrition and weight gain are linked

with fetal weight gain and birth weight, eating a healthy diet and gaining the proper amount

of weight in pregnancy are essential. Furthermore, mothers should avoid alcohol, cigarettes

and illicit drugs, which can contribute to poor fetal growth, among other complications.

Kulich, E. (2015) suggested that the most important thing any mother can do is to see her

health care provider on a regular basis. Regular check-ups can ensure that both mother and

baby are healthy, growing, and developing properly. The health care provider can also help

the expectant mother to manage any illnesses, conditions, or mental health issues she may

have while she is pregnant. He further noted that, Folic Acid plays a major role when

preventing any type of birth defects or health problems. Four hundred micrograms of folic

acid daily (usually starting before conception) can reduce the chances of a baby being born

with low birth weight and/or other health factors like neural tube defects. If a mother smokes,

a good time to quit is when she finds out she’s pregnant. Most health care providers say it’s

best to quit smoking three months before conception, but not all pregnancies are planned. For

mothers with a previous infant with a neural tube defect, 1 gram of folic acid a day is

recommended, and folic acid supplementation should be ongoing, as a mother should be

taking folic acid at least 3 months prior to conception.

Essential care of LBW neonate should commence in utero and be focused on preventive

aspects. The impact of maternal nutritional supplementation in augmenting birth weight has

been studied and documented. The micronutrients rich food impacts the weight of a neonate.

18
Folic acid supplement during pregnancy has been shown to improve birth weight.

Multimicronutrient supplementation to severely undernourished women during pregnancy

has also been reported to decrease the incidence of LBW babies. Improving the nutritional

status of mother and tackling anemia in adolescent girls can go a long way in preventing birth

of low birth weight infants (Saili, A., 2008).

19
 CHAPTER 2

2.0 BACKGROUND INFORMATION OF CLIENT

Reported in this study is the case of Jainaba Barry, a 14day old neonate admitted to the

Neonatal Ward of the Edward Francis Small Teaching Hospital on the 2 nd October, 2015

because of Low Birth Weight secondary to Prematurity complicated by Hypothermia. Her

mother’s name is Fatou Camara a 34year old house wife who is Gravida 7; Para 6 + 1. They

reside in ‘Nema Su’ in an extended family setting. The mother was admitted at the Gynea

department of EFSTH while pregnant on account of pre-eclampsia. She had a total of 3 visits

to the antenatal clinic at Jammeh Foundation for Peace and Health (JFPH). According to the

mother, she started at seven months and went twice contrary to what was documented. It was

on the second visit that she was told she had pre-eclampsia. Jainaba’s mother has had no

previous medical-surgical condition before this pregnancy and she had vaginal delivery for

all of her children, although, she frequently had malaria while pregnant.

Jainaba’s mother said that she did not practice exclusive breastfeeding (EBF) for her first

five(5) babies because of inability to produce enough milk but did EBF for the 6 th child. The

food commonly eaten in her family is rice and while pregnant, she took more of rice because

she is not financially capable to ensure dietary diversification. She also took only prescribed

drugs while pregnant e.g. Fefa.

According to the patient’s folder, Jainaba was given birth to at 36weeks, delivered through

safe vaginal delivery (SVD), labor was not prolonged, no premature rupture of membrane(s)

(PROM) and had Apgar scores 9/10 and 10/10 at 1 and 5 minutes respectively. She had not

being given any immunization as at the time this study was conducted and concluded because

she was immediately referred from the labor ward to the neonatal ward.

20
 CHAPTER 3

3.0 ADMISSION DETAILS

Jainaba was admitted at the neonatal ward of Edward Francis Small Teaching Hospital on the

2nd October, 2015. Her type of admission is referral admission because she was referred from

the labor ward of same hospital on account of LBW and prematurity. Patient’s general

condition on admission was stable and not in any obvious form of distress. Problems

identified at point of admission include poor antenatal care, pre-eclampsic mother, LBW, pre-

term delivery and hypothermia

Vital signs on admission include: Temperature – 350C; Heart Rate (HR) – 124 beats per

minute (bpm); Respiratory Rate (RR) – 32 Counts per minute (cpm); Weight – 1.8kg; Blood

Sugar (BM) – 3.8mmol.

There was no record of any laboratory investigation ordered at the time of admission up until

six days after admission when hemoglobin test was ordered with a result of 14.5g/dl. Upon

admission, the plan for her included oxygen therapy; admit under a radiant warmer; IV 10%

dextrose 70mls/kg (126mls) at 2 drops per minute/ 24hrs; IV Aminophylline 5mg/kg (16mg)

STAT then 2.5mg/kg (8mg) bd; IV Ampicillin 50mg/kg (90mg) bd; IM Vitamin K 0.5mg

STAT; and cord care with surgical spirit.

3.1 CONTINUING CARE

This part discusses the results of any required laboratory investigation as well as the

significance of the results, any change of treatment regimen and the pre and post-operative

care given to the patient.

21
The vital signs (VS), weight and blood sugar (BM) of the patient was monitored daily. For

the purpose of reference and comparison, I randomly selected the VS, weight and blood sugar

for some days. On the 2nd day of admission, patient’s temperature was 36.90C and BM was

3.9mmol; 3rd day by 9am – temperature was 37.50C and BM was 5.7mmol; 6th day by 6am –

temperature was 39.60C and BM was 6.9mmol; 5 th day – HR was 152bpm, RR was 44cpm

and weight was 1.58kg; 6 th day – HR was 128bpm, RR was 46cpm, temperature was 38.9 0C

and BM was 6.9mmol; 11 th day – HR was 120bpm, RR was 40cpm, temperature was 37.10C

and BM was 5.4mmol; 14th day – temperature was 36.20C and weight was 1.68kg.

Looking at the figures above, there is no consistency to measure the state of response to

treatment but it can be seen that there was a considerable rise in the body temperature. Also,

the weight of the child, instead of increasing, initially came as low as 1.58kg from a birth

weight of 1.8kg and then rose up to 1.68kg on the 14 th day of admission. All these weights

are still too low when compared with reference standard. Furthermore, it is recommended

that antibiotics for neonates should be changed every four days to prevent developing early

resistance to any of the antibiotics. Based on this, Jainaba’s antibiotics were changed every

four days. She was placed on antibiotics which included ceftriaxone, ampicillin, amoxicillin

and gentamycin. Three days after admission, the plan for her was exclusive breast milk

(EBM) 2mls every 3hrs by cup, stop ampicillin and gentamicin and start ceftriaxone and

cloxacillin. She was moved from the radiant warmer to the cot with oxygen therapy and she

had mild jaundice and fast breathing. Two days later, she was placed on Nil per Oral and had

mild icterus, and labored breathing. The next day, the patient was in respiratory distress,

jaundiced, had nasal flaring, lower chest wall in-drawing and intercostals recession. Later in

the evening of the same day, patient had an episode of convulsion and was given IV

Phenobarbital 20mg/kg (25mg) as start dose. Eleven days after admission, patient was still

jaundiced with swollen eyelids, was on EBM 2mls every 4hrs by NG tube. Around 11:30am

22
 of the same day, patient had bleeding from the nostril and was given IV Vitamin K 2mg Stat,

then 1mg tds. Patient was eventually placed on phototherapy thirteen days after admission.

3.2 NURSING DIAGNOSIS

1. Altered body temperature (hypothermia) related to immature thermoregulation centre

secondary to less subcutaneous fat.

2. Altered breathing (dyspnea) related to poor lung maturity secondary to respiratory

distress.

3. Altered nutrition less than body requirement related to poor sucking reflex.

4. High risk for infection related to poor immunity.

5. Fluid volume deficit (hypovolemia) related to poor intake.

3.2.1 NURSING CARE PLAN

NURSING EXPECTE PLAN IMPLEMENTATION SCIENTIFIC EVALU

DIAGNOSIS D RATIONALE ATION
OUTCOME
1. Altered body Infant’s To 1. Place infant in incubator, 1. To maintain stable Infant
had an
temperature axillary ensure radiant warmer or warmly body temperature.
axillary
(hypothermia) temperatur that clothed in open crib. 2. Helps to quickly tempera
ture
related to e comes to infant 2. Monitor axillary temperature detect any change in within
immature and maintai regularly and for signs of body temperature for the
normal
thermoregulati remains ns a hyperthermia – redness, swift intervention. range
during
on centre within stable flushing, diaphoresis etc. 3. To decrease radiant
the
secondary to normal body 3. Check temperature of infant heat loss. period
of
less range of temper in relation to environmental/ 4. This can increase the admissi

23
subcutaneous 36.00C – ature. ward temperature. risk for developing on

fat. 37.40C 4. Avoid situations that might complications.

during the predispose infant to heat loss 5. Mother’s warmth can

period of e.g. exposure to cool air, further help keep the

admission. bathing or cold mattress. infant warm.

5. Kangaroo mother care can be

provided when the baby’s

condition stabilized.

2. Altered Airway To 1. Position for optimal air 1. To maximize Infant’s

airway
breathing remains ensure exchange – supine position is oxygenation.
remaine
(dyspnea) patent, that still recommended. 2. Hyperextension d patent
and
related to poor tissue there is 2. Baby should be positioned reduces diameter of tissue
lung maturity oxygenatio adequa with neck slightly extended but trachea. oxygen
ation
secondary to n is te avoid neck hyperextension. 3. To remove was
adequat
respiratory adequate, oxygen 3. Do gentle suctioning. accumulate mucus from
e
distress. respiratory ation. 4. Avoid routine suctioning and the nasopharynx, through
out the
rate and suction only as necessary. trachea and period
pattern are 5. Use proper suctioning endotracheal tube. of
admissi
within technique. 4. Excessive suctioning on.

appropriate 6. Infant’s respiration rate, can cause

limits and rhythm, signs of distress, chest bronchospasm.

breathing retraction, nasal flaring, apnea, 5. Improper suctioning

provides cyanosis, oxygen, saturation, can cause infection,

adequate etc. to be monitored at frequent airway damage etc.

oxygenatio interval 6. Helps to observe for

n and CO2 signs of respiratory

removal distress.

24
 during the

period of

admission.

3. Altered Infant To 1. Assist mother with 1. To establish and Infant

receive
nutrition less receives an ensure expressing breast milk. maintain lactation until
d
than body adequate that 2. Give expressed breastmilk infant can breastfeed. adequat
e
requirement amount of patient using cup or through 2. Bottle feeding is amount
related to poor calories shows nasogastric tube at 20mls every discouraged for feeding of
nutrient
sucking reflex. and good 3hrs. infants and NG tube is and
demons
essential suckin 3. Monitor the weight of the used if aspiration is
trated
nutrients; g child every day until baby evident. good
sucking
Infant reflex, become stable. 3. Provides a reflection reflex
demonstrat receive 4. Encourage placing infant on of infant’s nutritional prior to
dischar
es a steady s breast to suck as soon as infant state. ge.
weight gain adequa demonstrates presence of 4. To help the infant

during the te sucking reflex. adjust to transition from

period of nourish 5. Administer 10% glucose being fed with EBM to

admission ment through IV at 70mls/kg at 2dpm being able to suck

and patient and for 24hrs as start dose; Then, directly from the breast

demonstrat exhibit continue with 86mls every 24 and to further enhance

es good approp hrs. infant’s sucking reflex.

sucking riate 5. To prevent any risk

reflex after weight of hypoglycemia.

4weeks of gain.

admission.

4. High risk Infant To 1. The baby should be observed 1. All these are Infant
showed
for infection exhibits no ensure for respiration, skin parameters that are
no sign

25
related to poor evidence of that temperature, heart rate and skin used to monitor the of
nosoco
immunity. nosocomial infant color, activity, feeding presence or absence of
mial
infection shows behavior, passage of stool and infections. infectio
n
throughout no urine, condition of umbilical 2. To minimize during
the period eviden cord, eyes and oral cavity. exposure to infective period
of stay
of ce of 2. Ensure that all care givers organisms. in the
hospital
admission nosoco wash hands before and after 3. Helps to minimize
.
and 72 mial handling infant. risk of introducing

hours after infectio 3. Ensure that all equipment in infectious organism.

discharge. n. contact with infant is clean. 4 & 5. Same as above.

4. Prevent personnel with upper 6. Serves as

respiratory tract or prophylaxis to fight

communicable infections from against any possible

coming into contact with infant. infection. Antibiotics is

5. Ensure strict asepsis or changed after every

sterility with invasive 4days to prevent infants

procedures and equipments e.g. from developing

lumbar puncture, resistance to any

catheterization etc. antibiotic.

6. Administer antibiotics as

ordered – IV Ceftriaxone

154mg 1.5mls BD.; IV

Cloxacillin 90mg 0.4mls BD.

(NOTE: Change antibiotics

every four days)

5. Fluid Patient To 1. Administer IV fluids 1. Helps to prevent any Infant

remaine
volume deficit remains ensure according to the weight of the case of fluid over or
d well
hydrate

26
(hypovolemia) well that baby – NaCl at 21mls/kg under-load. d and
complic
related to poor hydrated infant 6hourly; 10% glucose 86mls 2. To know the amount
ations
intake and Risk and shows is not every 24 hrs. of fluid lost and gained. were
well
for no dehydr 2. Monitor Intake/Output chart. 3. Breast milk contains manage
complications. evidence of ated all nutrients as well as d.
3. Encourage breast feed and
complicatio and increase the frequency of breast lots of fluid.

n such as develo feeding. 4. To prevent blood

convulsion, ps no 4. Administer IM Vitamin K loss due to hemorrhagic

jaundice compli 2mg Start dose, then 1mg TDS diseases.

etc. cation. 5. Use phototherapy for any 5. Helps to prevent

sign of neonatal icterus development of any eye

(jaundice) and put a blindfold defect from direct

on infant’s eyes. exposure to light rays.

6. Administer IV Phenobarbital 6. Phenobarbital is an

5mg/kg BD if convulsion anti-convulsant used to

occurs. relieve any episode of

convulsion.

3.2.2 INVESTIGATIONS

TYPE PATIENT’S NORMAL FINDINGS INTERPRETATION

FINDINGS
Hemoglobin 14.5g/dl 13g/dl to 15g/dl Patient’s hemoglobin level is well

within the normal range when

compared with reference standards

C-Reactive 3mg/L 2 – 5mg/L C-reactive protein measures

Protein (CRP) general levels of inflammation in

the body. High levels of CRP are

27
 caused by infections and many

long-term diseases. Patient’s

value is within normal range,

3.2.3 MEDICATIONS

NAME OF DRUG DOSAGE RATIONALE FOR SIDE-EFFECTS OF SIDE-

AND ROUTE GIVING DRUG DRUG EFFECT
OF MANIFESTE
ADMINISTR D BY
ATION PATIENT
10% Dextrose Intravenous Dextrose was given to Increased intracranial NIL

70mls/kg at prevent any occurrence pressure,

2dpm for of hypoglycemia. Hyperglycemia, Fluid

24hrs as overload,

start dose; Hyperosmolarity etc.

Then, it was

continued at

86mls every

24 hrs.

Normal Saline Intravenous A LBW infant is at risk Swelling NIL

21mls/kg for fluid volume deficit hands/ankles/feet,

6hourly (hypovolemia) related Trouble breathing,

to poor intake. Muscle cramps/

weakness, Rash,

Itching, Severe

dizziness etc.

Ceftriaxone Intravenous Serves as antibacterial Nausea, GI upset, NIL

154mg; prophylaxis to prevent diarrhea, allergic

1.5mls; BD infection. reaction.

28
Cloxacillin Intravenous Serves as antibacterial

90mg; prophylaxis to prevent

0.4mls; BD infection.

Flagyl Intravenous Serves as antibacterial Flushing, Vomiting, Seizures

(Metronidazole) 12mg; OD prophylaxis to prevent Headache, Nausea,

infection. CNS Disturbance

(Seizures, Ataxia,

Dizziness), Anorexia,

Bloating and

Cramping etc.

Ampicillin Intravenous Serves as antibacterial Nausea, Vomiting, NIL

50mg/kg; prophylaxis to prevent Diarrhoea, Allergy

BD infection. with serious

anaphylactic reactions

and Brain and Kidney

damage etc.

Gentamycin Intravenous Serves as antibacterial Hearing loss, NIL

3.5mg/kg; prophylaxis to prevent Dizziness and Kidney

BD infection. damage etc.

Phenobarbital Intravenous An anti-convulsant Drowsiness, problems NIL

6.4mg; used to relieve with

0.1mls; OD convulsion memory/concentration

, excitement,

irritability and

headache.

NOTE: Infant was only on two antibiotics at a time which was usually changed every four

days.

29
 CHAPTER 4

4.0 DISCHARGE DETAILS

After necessary medical and nursing care and condition confirmed to be stable, Jainaba was

discharged on 27th November, 2015 by 11:45am. She was seen by the physician and her vital

signs were taken and recorded.

1. Cardiovascular System –

 Heart Rate – 142bpm; No murmurs.

2. Respiratory System –

 Respiratory Rate – 55 breaths/min, Chest is clear, No cyanosis

3. Central Nervous System –

 Sucking reflex is good, No complication

4. Others include –

 Weight – 2.4kg; BM – 6.9mmol; Temperature – 36.70C and

 Patient was referred to begin immunization,

Patient was generally stable; she could now suck and she was not pale. She was able to

maintain normal body temperature and showed sufficient mature respiratory control. Patient

was placed on syrup antibiotics and the mother was encouraged to breastfeed the child as

often as the child wants. She was given an appointment for December 10, 2015 for follow-up

care.

30
Patient’s mother was encouraged to practice excusive breastfeeding until the child was

6months as this would help the infant gain weight and prevent infections. She was also

advised to place the child in a supine position while sleeping which importance is to prevent

Sudden Infant Death Syndrome (SIDS).

31
 CHAPTER 5

5.0 DISCUSSION

Low birth weight neonates may be grossly handicapped at birth by virtue of their weight and

in some cases associated relative immaturity of vital organs and lack of immunological

response. This handicap exposes them to high risk of infection, respiratory distress syndrome

and other neonatal complications resulting in high rate of perinatal mortality and morbidity.

According to the history taken, it can be supposed that inadequate antenatal care, poor

maternal nutrition, high parity and low socioeconomic status were the risk factors that

predisposed Jainaba to having LBW. Literatures reviewed showed that age at delivery, short

birth interval, inadequate antenatal care, poor maternal nutrition, high parity, history of

abortion, still birth and low birth weight babies in previous deliveries; come out as major

factors associated with LBW in newborns. Also, studies have elucidated the association

between lower social class' or other social factors and either increased risk of low birth

weight or infant mortality throughout various parts of the world. It has been suggested that

poverty could affect maternal health status at the time of conception through lower

physiologic reserves (Rodriguez, C. et al., 1995).

The standard of care provided was similar to that described in the literatures that were

reviewed but there were few differences. Literatures suggested that high risk infants should

be managed in a neonatal intensive care unit and hospitalized preterm infants should be kept

predominantly in the supine position, at least from the postmenstrual age of 32 weeks

onward, so that they become acclimated to supine sleeping before discharge. All these were

done for the patient. Also, 3 physiologic competencies that are generally recognized as

essential before hospital discharge of the preterm infant which are oral feeding sufficient to

32
support appropriate growth, the ability to maintain normal body temperature in a home

environment, and sufficiently matured respiratory control were all fulfilled but they infant’s

weight was not up to the minimum normal birth weight of 2.5kg before discharge.

5.1 SUMMARY

When a baby is born weighing less than 2,500 grams (5 lbs, 8 ounces), he or she is

considered to have a low birth weight. In some cases, babies born prematurely or with

intrauterine growth restrictions (two leading causes of low birth weight) may see an increase

in risks for complications such as mental retardation, vision loss, and/or learning problems.

Jainaba, a 14day old neonate was admitted at the neonatal ward on account of LBW

secondary to prematurity complicated by hypothermia. The probable causes for this included

maternal poor nutrition, high parity, inadequate antenatal care etc. She was placed on

antibiotics which was always changed every four days and expressed breast milk given by

cup. Before discharge, she had certified the necessary physiologic competencies for discharge

and her mother was advised/ educated on how to continue care at home.

5.2 CONCLUSION

From the aim of this study which is to identify the causes, diagnosis, complications,

prevention, treatment and nursing management of low birth weight (LBW) and to understand

the relationship between LBW and preterm birth, its effects and factors responsible for LBW,

it can be seen that age at delivery, short birth interval, inadequate antenatal care, poor

maternal nutrition, high parity, history of abortion, still birth and low birth weight babies in

previous deliveries; come out as major factors associated with LBW in newborns. A

relationship exists between LBW and preterm birth because prematurity and intrauterine

growth restrictions are the two leading causes of LBW. During pregnancy, a baby's

33
birthweight can be estimated using the height of the fundus (the top of a mother's uterus).

This measurement in centimeters usually corresponds with the number of weeks of pregnancy

after the 20th week. Ultrasound (a test using sound waves to create a picture of internal

structures) is another accurate method of estimating fetal size. A birth weight less than 5

pounds, 8 ounces is diagnosed as low birth weight. Prevention of preterm births is one of the

best ways of preventing low birth weight babies and improving the nutritional status of

mother and tackling anemia in adolescent girls can go a long way in achieving this.

"Kangaroo mother care" is a method of care of preterm infants weighing less than 2 kg. It

includes exclusive and frequent breastfeeding in addition to skin-to-skin contact and support

for the mother-infant dyad.

5.3 RECOMMENDATIONS

Based on history taken and findings during the course of this case study, the following

recommendations are made for improvement.

It is suggested that improvement in maternal nutrition during pregnancy, avoiding close birth

spacing, delayed child bearing in young females (<20 years), universal coverage of adequate

antenatal care, are essential for reducing the LBW in newborns. This can be achieved by

including health education component for adolescents (both males and females) and pregnant

mothers in Maternal and Child health related program, especially in rural areas where literacy

rate is very low by utilizing grass route level health workers already existing in community.

Also, the antenatal care provided to pregnant women needs to be standardized. This will

facilitate the ease in caring for them and reduce risk for complications to the barest minimum.

34
REFERENCES

Allen, M. C. (2015). Development and Follow-up of Premature and Low Birth Weight

Infants. Division of Neonatology, Department of Pediatrics. The Johns Hopkins

University School of Medicine. USA.

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