Issuesinmanagingtheprematureor lowbirthweightinfant.

Objectives
Reviewtherecentevidenceonbest practiceincareofthelowbirthweight/ practice in care of the low birth weight / prematureinfant.

Standardsofcare Standards of care

Cleanenvironment Staffandcarershavegoodhandhygiene Abilitytomaintaintemperature Ability to maintain temperature Appropriateoxygentherapy Provisionofappropriatenutrition Provision of appropriate nutrition promotionofbreastfeeding Ability to offer phototherapy Abilitytoofferphototherapy Inclusionofmother(carer)aspartnerin care

Ifyoucantprovidethebasicsyoudont needthese. d h

Warmthandasafeenvironment? Warmth and a safe environment?

F Forwrappedbabies<2.0kg,theroomtemperature d b bi 2 0k th t t mayneedtobe32330Ctopreventthebabygetting cold Ifthebabyiscolditusesenergytostaywarm,this:
Cancausehypoglycaemia Stopsthebabygainingweight

Eveninwarm,coastalregionsnighttime temperaturesarerarely>280C Thesmallerthebabythegreatertheneedforan activelywarmedenvironment. actively warmed environment

KangarooCare Isnowrecommended g inpreferenceto incubatorcare

Stable prematureor SGAbaby SGA baby
1200gupwards

Accommodation Willingmother Supportivestaff

KangarooCare doesitwork?
I Incomparisontostandardcareitseems i t t d d it Kangaroocareresultsin:
Mayreducemortality Reducedrisksofnosocomialinfectionand severeillness ill Improvedweightgain Highersuccessinestablishingbreastfeeding Greatermaternalsatisfaction Morerapiddischarge

Feeding&FluidsinNewborns Feeding & Fluids in Newborns

Background
FeedingVLBW,AsphyxiatedandSGAmaybe complicatedbyintoleranceofenteralfeeds andhighratesofNEC
RiskfactorsforNEC Prematurity / SGA Prematurity/SGA Asphyxia Feedingofanytype g y yp Formulafeeds ?Cross infection

Tofeedornottofeed? To feed or not to feed?

WithholdFeeds Inadequategrowth Risksofprolongedivs RisksoflongLoS Ri k f l L S EarlyFeeds Intolerance RisksofNEC Risksofdiarrhoea Ri k f di h

Wedonothaveivnutrition We do not have iv nutrition 10%dextrosehas<50%thecaloriesofEBM

Recommendations
Assessshortlyafterbirth: Weight1500g?Asphyxia?SevereRDS?
Weight1500g Weight 1500g or Weight>1500gwith AsphyxiaorsevereRDS h Stable&Weight> Stable & Weight > 1500g

Immediatefull enteral feeds Withholdfeedsfor24 hours&introduce cautiously

Fullfeeds increaseoverthefirstweek Full feeds increase over the first week

Age Day 1 Day 2 Day 3 y Day 4 Day 5 Day 6 Day 7
Total Daily Fluid / Milk Vol.

60 mls/kg/day 80 mls/kg/day 100 mls/kg/day 120 mls/kg/day g y 140 mls/kg/day 160 mls/kg/day 180 mls/kg/day

Weight (kg) Day 1 Day 2 Day 3 Day 4 y Day 5 Day 6 Day 7

1.5 1.6 1.7 1.8 1.9 2.0 1 5 to 1 6 1 7 to 1 8 1 9 to 2 0 12 15 19 24 28 32 36 14 18 23 27 32 36 41 15 20 25 30 35 40 45

Tablegives3hourlyfeedvolumes

Fullintravenousfluids Full intravenous fluids

Age Day 1 Day 2 Day 3 y Day 4 Day 5 Day 6 Day 7
Total Daily Fluid / Milk Vol.

60 mls/kg/day 80 mls/kg/day 100 mls/kg/day 120 mls/kg/day g y 140 mls/kg/day 160 mls/kg/day 180 mls/kg/day

Weight (kg) 1.0 - 1.1 1.2 - 1.3 1.4 - 1.5 Day 1 3 3 4 Day D 2 4 4 5 Day 3 5 5 6 Day 4 6 7 8 Day 5 6 8 9 Day 6 ay 7 9 10 0 Day 7+ 8 10 11

Tablegives1hourlyfluidvolumes

ChangingfromivfluidstoNGTfeeds
Weight (kg)
Age Day 1 Day 2 Day 3 y Day 4 Day 5 Day 6 Day 7
Total Daily Fluid / Milk Vol.

60 mls/kg/day 80 mls/kg/day 100 mls/kg/day 120 mls/kg/day g y 140 mls/kg/day 160 mls/kg/day 180 mls/kg/day

1.0 - 1.1 1.2 - 1.3 IVF NGT IVF NGT mls 3hrly mls 3hrly per hr feed per hr feed 3 2 1 1 0 0 0 0 5 10 15 18 21 24 3 3 2 2 1 0 0 0 5 10 15 20 25 30

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7+

Tablegives1hourlyivfluidvolumes Table gives 1 hourly iv fluid volumes and3hourlyNGTfeedvolumes

Transition
Standardregimenstarts:
<1.5kgat5mlsfeedsonDay2 1.5 2.0kgat7.5mlsfeedsonDay2 >2 0kg at 10mls feeds on Day 2 >2.0kgat10mlsfeedsonDay2
Weight (kg) (k ) 1.0 - 1.1 IVF NGT mls 3hrly per hr feed 3 2 1 1 0 0 0 0 5 10 15 18 21 24

Onday3thefeedvolumeis increasedbythesameamount: increased by the same amount:

Day 1 Day 2 Day 3

<1.5kgis10mls(5+another5) Day 4 1.5 2.0kgis15mls(7.5+another7.5) Day 5 g ( ) y

Theprocessisrepeateduntilonfull volumefeedsforweight

Day 6 Day 7+

Unsafetogiveivfluids? Unsafe to give iv fluids?

If it is not safe to give iv fluids then start ngt Ifitisnotsafetogiveivfluidsthenstartngt feedsimmediately. Day 1 iv fluid rate for a 1 3kg infant = 3mls Day1ivfluidratefora1.3kginfant=3mls everyhour Th f Thereforefluidamountneededin3hrs= fl id d d i 3h 3x3mls=9mls Sogive9mlsEBMbyngtevery3hoursfora 1.3kgbaby. g y

WhichFeed Which Feed

Colostrum lowfat,highproteinandminerals. 10%dextrosehas<50%theenergyofbreastmilk BreastmilklowerstheriskofNEC Oralglucosesolutionscancausediarrhoea < 30% mothers exclusively breastfeed to 6 weeks <30%mothersexclusivelybreastfeedto6weeks. Exclusivebreastfeedingto6monthsmightsave 1.3mlivesayear 1 3m lives a year Soweneedtopromoteexclusive breastfeeding

WhichFeed? Which Feed?

If EBM is inadequate in volume then IfEBMisinadequateinvolumethen formulafeed(ideallyapretermformula) shouldbeusedtosupplementEBMuntilit should be used to supplement EBM until it isadequate. Formulaisbetterthanivfluidsinawell l i b h i fl id i ll baby asgrowthiscritical butavoid formula i h fi f l inthefirstweekinVLBWbabies. k i VLBW b bi

Questions?

Summary
Basic hygiene warmth feeding and oxygen Basichygiene,warmth,feedingandoxygen aremoreimportantthanhightechnology. Familiesmustbeengagedincare Families must be engaged in care Kangaroocarehasconsiderablepotential y Earlyintroductionoffeedsinareaswhereiv fluidsarehardtomanage Usebreastmilk Simple,stepwiseapproachtoincreasing feeding.