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New Born Care: Our Perspective |
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Benjamin M Sagayaraj, Nidhi Sharma, Lal D. V. 1. Associate Professor, Department of Paediatrics, Saveetha Medical College, Saveetha Nagar, Thandalam, Chennai, India. 2. Associate Professor, Department of Obstetrics and Gynaecology, Saveetha Medical College, Saveetha Nagar, Thandalam, Chennai, India. 3. Senior Resident, Department of Paediatrics, Saveetha Medical College, Saveetha Nagar, Thandalam, Chennai, India. |
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| Correspondence
Address : Dr. Benjamin M. Sagayaraj Associate Professor No 11/2 APPU Street , Second lane, Mylapore Chennai 600004, India. Phone: 9445560392 Email: getdrben@yahoo.com |
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| ABSTRACT |  | |||||||||||||||||||||||||||||||||||||||||||||
A low birth weight baby is a clinical and diagnostic challenge. The neonatologists are faced with numerous neonatal intensive care unit protocols. This study was designed to review the literature of past twenty five years regarding management of neonatal jaundice, sepsis, anaemia, hypoglycaemia, jaundice and hypoxic encephalopathy in a low birth weight newborn. The low birth weight newborn baby should be intubated electively if signs of respiratory distress appear. There should be an early Doppler of cerebral arteries to predict the ischemic changes in neonatal brain. Probiotic therapy with Bifidobacterium bifidus and Streptococcus thermophillus protects against necrotizing enterocollitis and results in incresed weight gain. Newborn intravenous lines should not be flushed with normal saline ampoules containing benzyl alcohol as preservative, as this increases the fluidity of neonatal blood brain barrier and predisposes to neonatal jaundice. Erythropoietin subcutaneous injections are most rewarding in low birth weight babies with neonatal anaemia. There is also increase in weight. Kangaroo care is useful in management of neonatal hypothermia and is also an immunological boast as the baby gets colonized with favorable microorganisms of maternal skin. | ||||||||||||||||||||||||||||||||||||||||||||||
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| Keywords : Anaemia, Hypothermia, Intensive care, Jaundice, Low birth weight, Neonatal | ||||||||||||||||||||||||||||||||||||||||||||||
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| INTRODUCTION | | |||||||||||||||||||||||||||||||||||||||||||||
Low birth weight may be the outcome of either preterm delivery (before 37 weeks of gestation) or retarded fetal (intrauterine) growth (1). The problems of the intrauterine growth retarded babies are due to uteroplacental insufficiency and inadequate substrata transfer leading to birth asphyxia, hypothermia, meconium aspiration, polycythemia, hypoglycemia, hypocalcaemia, thrombocythemia. On the other hand, the preterm complications are caused by anatomic and physiological immaturity. There is respiratory distress due to delayed alveolar clearance of alveolar fluid and surfactant deficiency. Postnatal circulatory adaptation is delayed due to pulmonary hypertension, systemic hypotension and delayed closure of the three fetal shunts (ductus venosus, ductus arteriosus and foramen ovale). Liver immaturity and reduced substrate explain the high prevalence of jaundice and deficiency of coagulation factors. Immature vascular development in retina and central nervous system predisposes to retinopathy and intraventricular hemorrhage. Immature skin and mucosa barrier and immature cellular and humoral immunity predisposes to neonatal sepsis and nosocomial infections. Gastrointestinal mucosa is immunologicaliy immature. Besides this there is inappropriate bacterial gut colonization, this results in necrotizing enterocolitis. A growth restricted preterm baby is (clinically and diagnosticly a challenge) because the dual problems of retardation and prematurity are superimposed. The proportion of low birth weight has increased in the past twenty years. This increase is attributed to changes in the frequency of multiple births, increase in obstetrical interventions, and improved ascertainment of early preterm births and increased use of ultrasound for estimation of gestational age. Unfortunately the documentation of low birth weight babies is not proper (2). There has been considerable advances in neonatal care in past 25 years. However, low birth weight babies have an altogether altered developmental, metabolic, and nutritional status. Routine NICU protocols have to be modified for these babies with special needs [3-8]. LOW BIRTH WEIGHT PROBLEMS The risk to a low birth weight newborn baby can be classified as: 1) Early risk: In the delivery room and neonatal life. The nursery neurobiological events of a low birth weight baby are incidence of neonatal septicemia, low blood pH, seizures, intraventricular leukomalacia and hypoglycemia. These factors correlate well with deficits in Bayley scale of infant development, mental developmental index and psychomotor development index (9). Relative importance of individual factors can be assessed as neurobiological risk score. This score correlates well with mental, motor, neurological outcomes (10). 2) Late risk: Long term developmental outcomes. The increased survival of low birth weight babies has resulted in an increased incidence of cerebral palsy. There are 2 postulated hypotheses (11). One theory is that as more low birth weight babies survive, they suffer the complications of extreme prematurity like periventricular leukomalacia, intraventricular hemorrhage, respiratory distress and sepsis resulting in postnatal brain damage in an otherwise normal infant. Another hypothesis is that cerebral palsy and preterm birth have similar pathophysiology in antenatal period and that these babies who were compromised well before birth are now surviving. Environmental enrichment programs are most effective in moderately low birth weight child who comes from a lower socio economic status (11). CARE OF THE LOW BIRTH WEIGHT BABIES Appropriate resuscitation/ respiratory care Perinatal asphyxia is recognized as a major cause of neonatal morbidity and mortality in the developing countries. The effects are more pronounced among low birth weight babies. Delivery room policies have changed extremely. Until 1994, the low birth weight infants were intubated immediately after delivery, when presenting the slightest signs of respiratory distress or asphyxia. Later the guidelines were to do the continuous (15-20 seconds) pressure control (20-25cm H2O) inflation of the lungs using a nasal pharyngeal tube, followed by continuous positive airway pressure ( 4 to 6 cm H2O ) applied to all extremely low birth weight immediately after delivery to establish a functional residual capacity and perhaps to avoid elective intubation and mechanical ventilation (12). Literature search suggested no difference in the initial ventilator settings, ventilator days. The mortality and morbidity rates were found similar in extremely low birth weight babies with primary endotracheal intubation and mechanical ventilation in the delivery room as compared to infants with secondary endotracheal intubation and mechanical ventilation attributed to respiratory distress syndrome later in the intensive care unit. Extremely low birth weight babies which did not require endotracheal intubation and mechanical ventilation had no increased incidence of bronchopulmonary dysplasia or periventricular leukomalacia and intraventricular hemorrhage. It was inferred that individualized intubation strategy is safe as compared to routine immediate intubation of all extremely low birth weight babies. Neonatal hypoglycemia and Feeding In low birth weight babies there is reduced reserve. Besides, increased utilization during birth, hypoxia results in neonatal hypoglycemia. This is defined as a serum glucose level <30mg/100mg in the first few hours of birth. The highest incidence of hypoglycemia (67%) occurred in preterm low birth weight. It was 25% in term low birth weight babies and 18% in post term low birth weight babies (13). Early initiation and frequent (2 to 3 hourly) feeding with breast milk is the most cost effective strategy in the prevention of hypoglycemia. Breast milk promotes ketogenesis and has a lower insulogenic effect [14, 15]. Alternative feeds can be utilized in maternal HIV infection. In preterm neonates fortification of breast milk is essential. Micronutrients supplementation with vitamins and minerals promote better assimilation and weight gain. Total parenteral nutrition can be continued till 100ml/kg/day, and is supplied by the entral route. The amount of feeding is increased slowly and stopped if any signs of feeding intolerance (vomiting, abdominal distension and increased gastric residual volume) appear. Prevention of Necrotising Enterocolitis At birth the basic body tries to develop an intricate symbiotic equilibrium between bacterial environment and its own immune system-an equilibrium that results in the preferential colonization of the gastrointestinal tract by a variety of “favorable” gram positive microorganisms most notably Lactobaccillus and Bifidobacterium. In contrast, the low birth weight new born’s intestine tends to be colonized by coliforms, enterococci and bacteroids. Bifidobactium and Lactobaccillus are found in the stools of <5% extremely low birth infants within the first month of life (16). Probiotics strengthen the intestinal mucosal barrier which impedes the translocation of pathogenic bacilli in IL-10 knocked out mice. It was postulated that probiotics decrease cytokine production both systemically and at mucosal surface (17). The pathogenesis of necrotizing enterocolitis is multi factorial. Prematurity, formula feeding, intestinal ischemia and bacterial colonization activate aninflammatory cascade accumulating in bowel necrosis (18). We speculated to create fresh suspension (0.5 teaspoon) of probiotic powder (ABC Dophilus) diluted in 3ml of mother’s milk daily along with regular feeds. This provides | ||||||||||||||||||||||||||||||||||||||||||||||
| CONCLUSION | | |||||||||||||||||||||||||||||||||||||||||||||
Neonatologists are in a clinical quandary with respect toNICU protocols. This study was designed to compare various articles on aggressive and conservative management strategies for low birth weight babies. By articulating the various research publications in terms of peculiar metabolic and developmental requirements of low birth weight babies, an approach has been developed. Standardization of clinical methods and educating the paramedical staff is important for the success of any medical intervention. Training of mid-level health personnel on appropriate care of the low birth weight and providing management protocols/algorithms is of great importance. Record keeping for care audit and ongoing research is important. | ||||||||||||||||||||||||||||||||||||||||||||||
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