Course:KIN366/ConceptLibrary/Low Birth Weight Newborns

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KIN 366
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Instructor: Dr. Shannon S.D. Bredin
Email: shannon.bredin@ubc.ca
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Low Birth Weight (LBW) is defined as a birth weight of less than 2500 grams (88 ounces), regardless of gestational age (Vohr & Msall, 1997)[1]. For comparison, an average weight is about 3500 grams or 122 ounces (Vohr & Msall, 1997)[1]. Low birth weight is associated with developmental delays in newborns, affecting their motor, cognitive, and physiological milestones (Vohr & Msall, 1997)[1]. Sixty per cent of neonatal deaths (2.5 million infant deaths) each year is associated with LBW, caused by IntraUterine Growth Restriction (IUGR), preterm delivery, or genetic abnormalities (Vohr & Msall, 1997)[1]. This emphasizes the devastating impact that maternal and neonatal under-nutrition has on newborns (Vohr & Msall, 1997)[1].

Classifications

Newborns are classified based on their weight in relation to other newborns of the same gestational age (Vohr & Msall, 1997)[1]. Health professionals categorize newborns as either; Large for Gestational Age (LGA), Small for Gestational Age (SGA), or Appropriate for Gestational Age (AGA) (Vohr & Msall, 1997)[1]. Newborns that are LGA, have weights that exceed the 90th percentile, while SGA newborns have weights below the 10th percentile (Vohr & Msall, 1997)[1]. Those newborns with weights between the 10th and 90th percentiles are classified as AGA (Vohr & Msall, 1997)[1].

Three Subcategories exist under Small for Gestational Age newborns, including; Low Birth Weight (LBW), Very Low Birth Weight (VLBW), and Extremely Low Birth Weight (ELBW) (Vohr & Msall, 1997)[1].

Low Birth Weight Babies

Low Birth Weight (LBW) babies weigh from 1500 – 2500 grams, and are usually preterm, with gestational ages of 32 – 37 weeks (Vohr & Msall, 1997)[1].

Very Low Birth Weight Babies

Very Low Birth Weight (VLBW) babies weigh from 1000 – 1500 grams, and are usually very preterm, with gestational ages of 27 – 32 weeks (Vohr & Msall, 1997)[1].

Extremely Low Birth Weight Babies

Extremely Low Birth Weight (ELBW) babies weigh less than 1000 grams, and are usually the youngest surviving preterm newborns, with gestational ages as low as 21 - 23 weeks (Vohr & Msall, 1997)[1]. ELBW is a rare phenomenon, as the majority of newborns with such a weight are almost always still born (Vohr & Msall, 1997)[1].

Treatment

Treatment for low birth weight babies (LBW, VLBW, and ELBW) involves Kangaroo Mother Care (KMC), maternal counseling, and frequent hospital visits (Dollberg & Hoath, 2001)[2].

Kangaroo Mother Care

KMC is essential for all newborns under 2000 grams, and implements three fundamental steps; skin-to-skin contact, exclusive breastfeeding, and support to the dyad (Dollberg & Hoath, 2001)[2]. Skin-to-skin contact between the mother and infant’s chests most effectively transfers the body heat necessary for survival that LBW babies are unable to produce, due to both a lack of visceral fat, and delayed metabolic development in the womb (Dollberg & Hoath, 2001)[2]. The next component is exclusive breastfeeding, which requires that the newborn feed directly from the mother’s nipples, and not from bottles of formulated powdered breast milk, or old machine-pumped breast milk, as the suckling action is thought to enhance infant development (Heller, O’Shea & Yao, 2007)[3]. Finally, support for the dyad involves ensuring that the child and mother are never separated, and that they receive all the support they require without undue hardship (such as large fees) (Tommiska, Tuominen & Fellman, 2003)[4]. Each country approaches the third aspect of support for the dyad differently (Tommiska et al., 2003)[4]. For instance, in Canada if a newborn qualifies as having a LBW, these additional services are covered by their medical plans, while in other countries, families are charged based on the complication of deliveries, or even audit to have their delivery at home due to these fees or personal beliefs (ie. water births) (Tommiska et al., 2003)[4].

Maternal Counselling

Maternal counseling and education ensures that mothers are most effectively able to care and provide for their newborn (Hack, Taylor & Drotar, 2005)[5]. Mothers are counseled on optimal breastfeeding, techniques for prevention of illness, and identification of clinical signs in their newborn (Hack et al., 2005)[5].

Follow-Up Appointments

Finally, a series of regular follow-up appointments are scheduled at ages six hours, two days, and every week following for a minimum of six weeks (Hack et al., 2005)[5]. Each visit consists of a general check-up, and injection of 1 milligram of 1M Vitamin K in the anterior mid thigh (Hack et al., 2005)[5]. Administration of Vitamin K to newborns has been proven to prevent Hemorrhagic Disease of the NewBorn (HDNB), and is often deficient in low birth weight babies (Hack et al., 2005)[5]. HDNB presents with spontaneous bleeding, gastrointestinal hemorrhage and ecchymosis, and intracranial hemorrhage (Hack et al., 2005)[5]. The practice of routine administration of Vitamin K to newborns is a practice founded in Canada, and has since spread to other countries (Hack et al., 2005)[5]. In the past there have been claims that doing so increased the chances of developing cancer, but has been since disproven (Hack et al., 2005)[5].

Statistics

To illustrate the prevalence of Low Birth Weight (LBW) in Canada, below are a few statistics from the Human Resources and Skills Development Canada (HRSDC) website. Note all statistics unless otherwise noted are from the year 2010 (Employment and Social Development Canada, n.d.)[6].

  • LBW affects 6.2% of newborns in Canada (Employment and Social Development Canada, n.d.)[6].
  • Infant girls were more likely to have a LBW in comparison to infant boys – 6.7% of infant girls, compared to 5.7% of infant boys (Employment and Social Development Canada, n.d.)[6].
  • The highest prevalence of LBW children were delivered by mothers aged 35 – 49 years of age (7.6%) (Employment and Social Development Canada, n.d.)[6].
  • By province, the Northwest Territories had the lowest prevalence of LBW newborns (3.7%), and Nunavut had the highest (7.6%) (Employment and Social Development Canada, n.d.)[6].
  • In 2009, Canada had the lowest percentage of infants born with a LBW among G7 countries (Employment and Social Development Canada, n.d.)[6].
    • France (6.6%), Germany (6.9%), Italy (7.0%), United Kingdom (7.4%), United States of America (8.2%), and Japan (9.6%) (Employment and Social Development Canada, n.d.)[6].
  • From 1979 – 2010, the percentage of LBW newborns ranged from 5.5% - 6.2% with no clear trend (Employment and Social Development Canada, n.d.)[6].
  • From 1979 – 2010, the percentage of LBW newborns ranged from 5.1% - 5.7% for boys, and 5.9% - 6.7% for girls (Employment and Social Development Canada, n.d.)[6].

Causes

Although the exact cause of low birth weight in babies has not been discovered, it is often associated with one or more of the following infantile characteristics; premature birth, maternal disease, and other environmental factors (Waugh et al., 1996)[7]. LBW is twice as prevalent in African-American babies than Caucasian babies (Waugh et al., 1996)[7].

Preterm Birth

Preterm births are defined as a birth that occurs prior to 37 weeks gestation (Lasswell, Barfield, Rochat & Blackmon, 2010)[8]. Preterm newborns (preemies) are often associated with smaller birth weights, developmental delays, and stillbirths (Lasswell et al., 2010)[8]. There is no specific known cause for preterm deliveries, but it tends to be associated with poor maternal health, diabetes, and maternal age (under 19 or above 40) (Lasswell et al., 2010)[8]. Protocol tends to require preemies to spend their first few days in Neonatal Intensive Care Unit (NICU) to limit the environmental stresses on them (Lasswell et al., 2010)[8]. The warmth, nutrition, and protection of enclosed NICU cribs helps facilitate further development, while allowing health professionals to closely monitor them for other possible complications, such as hyperbilirubinemia, apnea, anemia, low blood pressure, and respiratory distress syndrome (Lasswell et al., 2010)[8]. Post NICU discharge, preemies have been shown to exhibit delays in nervous system development, such as in motor skills like smiling, sitting, and walking (Lasswell et al., 2010)[8].

IntraUterine Growth Restriction/ Fetal Growth Restriction

IntraUterine Growth Restriction (IUGR) or Fetal Growth Restriction (FGR) is defined as insufficient growth of a baby during pregnancy, often due to poor maternal nutrition, or inadequate oxygen supply to the fetus (Waugh, O’Callaghan & Tudehope, 1996)[7]. IUGR is clinically diagnosed as a baby being Small for Gestational Age (SGA), meaning that their weight falls below the 10th percentile for their gestational age during pregnancy (determined through Ultrasound) (Waugh et al., 1996)[7]. Post-delivery, infants diagnosed with being SGA are generally also diagnosed with LBW (Waugh et al., 1996)[7]. Mothers presenting with prenatal clinical Vitamin B12 deficiencies (< 200pg/mL), are 35% more likely to deliver a newborn diagnosed with low birth weight (Waugh et al., 1996)[7].

Environmental Factors

The environmental factor “Low socioeconomic status” has often been associated with mothers whom deliver infants with a low birth weight (Voss, Jungmann, Wachtendorf & Neubauer, 2012)[9]. It has been found that mothers of lower socioeconomic status tend to have less complete diets in comparison to their counterparts of a higher socioeconomic status (Voss et al., 2012)[9]. Research has also identified that mothers of lower socioeconomic status are far less likely to purchase prenatal vitamins such as folic acid, calcium, and iron, which have been known to aid fetus development (Voss et al., 2012)[9]. Other environmental factors such as the blood toxins nicotine, alcohol, and illicit drugs are often associated with newborns with LBW (Voss et al., 2012)[9].

Developmental Complications

Birth to Six Months

Newborns with LBW are at an increased risk for immediate complications such as low oxygen levels at birth, inability to maintain body temperature, and sudden infant death syndrome (SIDS) (Steward & Pridham, 2002)[10]. Fortunately, once newborns with LBW fully develop in the Neonatal Intensive Care Unit (NICU), these complications tend to resolve themselves (Steward & Pridham, 2002)[10].

Six Months to Thirty-Six Months

During the first years, babies with LBW tend to have difficulty feeding and gaining weight, and have an increased susceptibility to infection and disease (O’Shea, Allred & Kuban, 2012)[11]. Commonly associated diseases include; respiratory distress syndrome (respiratory disease due to premature lungs), intraventricular hemorrhage (bleeding in the brain), and necrotizing enterocolitis (intestinal disease) (O’Shea et al., 2012)[11].

Throughout the Life

As newborns with LBW require additional time to develop post-delivery, attainment of developmental milestones such as walking tends to be delayed in comparison to newborns having term deliveries (Anderson & Doyle, 2003)[12]. For instance, it has been noted that children who have a LBW tend to significantly lag behind classmates in verbal thinking, speech, reading, writing, handwriting, mathematics, general facts, basic motor generalizations, and social behavior (Anderson & Doyle, 2003)[12]. Difficulties in these areas continue to persist even when children with a LBW receive personalized curriculums, additional educational resources, and one-on-one teaching (Anderson & Doyle, 2003).[12]

Further, since the premature retina of children with LBW has not yet fully vascularized at birth, growth of abnormal blood vessels, retinal detachment, and blindness may be observed (Clemett & Darlow, 1999)[13]. Infants should see a pediatric ophthalmologist every two weeks until the retina has properly vascularized: usually around 6 months (Clemett & Darlow, 1999)[13]. Further, it has been found that babies with LBW are more likely to be diagnosed with high blood pressure, diabetes, and heart disease later in life in comparison to their term delivered counterparts (Clemett & Darlow, 1999)[13].

Practical Applications

Knowledge of the clinical basis of low birth weight in newborns will likely contribute to a more optimal program delivery by practitioners working with these populations of children.

Academics

For parents of a newborn with a LBW, it is recommended that they attend all information sessions, clinical appointments, and possibly delay their child’s entry into school (Groen-Blokhuis, Middeldorp, van Beijsterveldt & Boomsma, 2011)[14]. By attending all information sessions, parents will better be able to identify risk factors that may indicate an increased likelihood of a clinical condition such as retinal detachment (Clemett & Darlow, 1999)[13]. Further, they will be better equipped with specialized resources, knowledge, and extra services necessary for ensuring LBW newborns’ full development (Groen-Blokhuis et al., 2011)[14]. By ensuring that both mother and newborn attend all clinical appointments will allow health professionals to administer supplemental nutrients, monitor the newborn without having to occupy a hospital bed, and follow-up in a timely manner regarding any concerns (Groen-Blokhuis et al., 2011)[14]. Finally, by delaying the child’s entry into school will give the child ample time to fully develop (something term babies do in the womb) (Groen-Blokhuis et al., 2011)[14]. By doing this, it has been shown to reduce stress, frustration, and school drop out rates for LBW children (Groen-Blokhuis et al., 2011)[14]. When these children attend school with others of the same age, they tend to lag behind in verbal thinking, speech, reading, writing, handwriting, mathematics, general facts, basic motor generalizations and social behaviors, which are not augmented by personalized tutors or curriculums (Groen-Blokhuis et al., 2011)[14]. Many LBW children are homeschooled as a result, allowing them to proceed at their own pace academically (Groen-Blokhuis et al., 2011)[14]. Although this may appear to solve the issue of lagging behind others their age, these homeschooled children do not get nearly as much exposure to other children, organized sport, and other figures of authority such as teachers (Groen-Blokhuis et al., 2011)[14]. As a result, these children tend to continue to struggle socially, and are thought to have an increased predisposition to depression, anxiety, and destructive behaviors throughout their life (Groen-Blokhuis et al., 2011)[14]. A possible solution may start in mainstream school a year later, so that they can have the opportunity to catch up developmentally and perform optimally (Groen-Blokhuis et al., 2011)[14].

Motor Milestones

Aside from academia, children with a LBW also lag behind in motor milestones (Marlow, Wolke & Bracewell, 2005)[15]. Every child lags differently depending on how much they developed in the womb, how facilitative their first few years were to development, and genetics (Marlow et al., 2005)[15]. The magnitude of development in the womb can be roughly calculated by their gestational age (Marlow et al., 2005)[15]. Warmth, nutrition, and clinical intervention are three of the big contributing factors that characterize an optimal environment for LBW infant development (Marlow et al., 2005)[15].

They tend to lack visceral fat and have a lower metabolism than term babies, which is why external warmth is essential to decrease the stress on their fragile bodies (Marlow et al., 2005)[15]. Warmth can come from the mother (Kangaroo Mother Care), an incubator in NICU, or a series of warm towels (Marlow et al., 2005)[15]. NICU incubation is the most commonly selected option, as it provides the most versatile microclimate that is monitored by health professionals (Marlow et al., 2005)[15].

In terms of nutrition, health professionals advise that mothers feed their newborn breast milk directly from the breast, and supplement with intravenous nutrients in the first few months if the infant has not developed the suckling or root reflexes (Heller et al., 2007)[3]. The root reflex is when the baby moves their mouth towards a tactile sensation on their lip (Heller et al., 2007)[3]. This functions to assist them in finding the nipple in normal feeding behavior (Heller et al., 2007)[3]. The suckling reflex is characterized by a suckling motion by the baby upon tactile sensation on the roof of their mouth (Heller et al., 2007)[3]. Premature, and LBW babies commonly have a weak or immature root and suckling reflexes – not allowing them to feed for up to 15 weeks (if born at 21 weeks gestation) (Heller et al., 2007)[3]. These children are often kept in NICU for intravenous feeding to maximize their chances of survival (Heller et al., 2007)[3].

Finally, early clinical intervention as a result of regular check-ups has proven to enhance the duration, and quality of life for VLBW, and ELBW newborns (Kobaly, Schluchter & Minich, 2008)[16]. Individuals who had a LBW are predisposed to a variety of clinical conditions due to the fragility of their bodies, physiological and neurological prematurity, and increased instance of improperly developed structures in more severe cases (Kobaly et al., 2008)[16].

Recommendations For Practitioners

For practitioners involved in childhood movement, when working with LBW children they must recognize that the majority of these populations develop at a similar rate to term babies, but exhibit a delay in attainment of milestones (Saigal, Hoult & Streiner, 2000)[17]. In order to provide an optimal environment, practitioners should provide developmentally appropriate tasks, rather than push the child to perform at the level of others of the same age (Saigal et al., 2000)[17]. This is because these children tend to exhibit delays in development (thus a five year old LBW child may be at the same developmental state as a four year old term child) (Saigal et al., 2000)[17]. Pushing the five-year-old LBW child to perform at the same standard as a five-year-old term child would cause unnecessary stresses, and actually hinder development (Saigal et al., 2000)[17]. Once practitioners have identified the child’s developmental stage, they should formulate and implement a unique program that focuses on working on these developmentally appropriate motor skills, and psychological concepts (Saigal et al., 2000)[17]. The goal of practitioners should be first to provide an environment that facilitates development that is appropriate for the child’s level of maturity, second to enhance the child’s performance to meet age appropriate standards, and third to ensure psychological wellbeing (Saigal et al., 2000)[17]. Psychological wellbeing is essential as even when a LBW child seems to have caught up developmentally, they may still lag in some more subtle aspects such as social behaviors and cues, resulting in them being out casted and ridiculed (Blaymore-Bier & Pezzullo, 1994)[18]. This may result in them dropping out to be homeschooled, which leads to another set of complications in development; including a lack of socialization, which is a paradox in itself (Blaymore-Bier & Pezzullo, 1994)[18].

Interesting Facts

  • A baby of 21 weeks gestations and extremely low birth weight (>1000g) survived - possibly one of the most premature newborns (Martin, Kung & Matthews, 2005)[19].
  • Babies born in the Eastern hemisphere tend to be lighter than babies born in the Western hemisphere (Martin et al., 2005)[19].
  • The Netherlands has the lowest instance of low birth rate babies in the world (Martin et al., 2005)[19].
  • A British mother gave birth to the heaviest naturally born baby in the world, weighing in at 13 pounds, 7 ounces (Martin et al., 2005)[19].

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Vohr, R., & Msall, E. (1997). Neuropsychological and functional outcomes of very low birth weight infants. Seminars in Perinatology, 21(3), 202-220.
  2. ↑ 2.0 2.1 2.2 Dollberg, S, & Hoath, S. (2001). Temperature regulation in preterm infants: role of the skin-environment interface. NeoReviews, 2(12), 282-291.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Heller, D., O'Shea, M., & Yao, Q. (2007). Human milk intake and retinopathy of prematurity in extremely low birth weight infants. Pediatrics, 120(1), 1-9.
  4. ↑ 4.0 4.1 4.2 Tommiska, V., Tuominen, R., & Fellman, V. (2003). Economic costs of care in extremely low birthweight infants during the first 2 years of life. Pediatric Critical Care Medicine. 4(2), 157-163.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 Hack, M., Taylor, G., & Drotar, D. (2005). Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s. Journal of American Medical Association, 294(3), 318-325.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Employment and Social Development Canada. (n.d.). Health – low birth weight. Retrieved from http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=4.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 Waugh, J., O'Callaghan, J., & Tudehope, I. (1996). Prevalence and etiology of neurological impairment in extremely low birthweight infants. Journal of Paediatric and Child Health, 32(2), 120-134.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 Lasswell, M., Barfield, D., Rochat, W., & Blackmon, L. (2010). Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis. Journal of American Medical Association, 304(9), 992-1000.
  9. ↑ 9.0 9.1 9.2 9.3 Voss, W., Jungmann, T., Wachtendorf, M., & Neubauer, P. (2012). Long-term cognitive outcomes of extremely low-birth-weight infants: the influence of the maternal educational background. Acta Paediatrica, 101(6), 569-573.
  10. ↑ 10.0 10.1 Steward, .K., & Pridham, F. (2002). Growth patterns of extremely low-birth-weight hospitalized preterm infants. Journal of Obstetrics, Gynecology, & Neonatal Nursing, 31(1), 57-65.
  11. ↑ 11.0 11.1 O'Shea, M., Allred, N., & Kuban, C. (2012). Intraventricular hemorrhage and developmental outcomes at 24 months of age in extremely preterm infants. Journal of Child Neurology, 27(1), 22-29.
  12. ↑ 12.0 12.1 12.2 Anderson, P., & Doyle, W. (2003). Neurobehavioral outcomes of school-age children born extremely low birth weight or very preterm in the 1990s. Journal of American Medical Association, 289(24), 3264-3272.
  13. ↑ 13.0 13.1 13.2 13.3 Clemett, R., & Darlow, B. (1999). Results of screening low-birth-weight infants for retinopathy of prematurity. Current Opinion in Ophthalmology, 10(3), 155-163.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 14.9 Groen-Blokhuis, M., Middeldorp, M., van Beijsterveldt, E., & Boomsma, I. (2011). Evidence for a causal association of low birth weight and attention problems. Journal of American Academy of Child and Adolescent Psychiatry, 50(12), 1247-1254.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 Marlow, N., Wolke, D., & Bracewell, A. (2005). Neurologic and developmental disability at six years of age after extremely preterm birth. New England Journal of Medicine, 352(1), 9-19.
  16. ↑ 16.0 16.1 Kobaly, K., Schluchter, M., & Minich, N. (2008). Outcomes of extremely low birth weight (< 1 kg) and extremely low gestational age (< 28 weeks) infants with bronchopulmonary dysplasia: effects of practice changes in 2000 to 2003. Pediatrics, 121(1), 73-81.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 17.5 Saigal, S., Hoult, A., & Streiner, L. (2000). School difficulties at adolescence in a regional cohort of children who were extremely low birth weight. Pediatrics, 105(2), 325-331.
  18. ↑ 18.0 18.1 Blaymore-Bier, J., & Pezzullo, E. (1994). Outcome of extremely low-birth-weight infants: 1980-1990. Acta Paediatrica, 83(12), 1244-1248.
  19. ↑ 19.0 19.1 19.2 19.3 Martin, A., Kung, C., & Matthews, J. (2005). Annual summary of vital statistics: 2006. Pediatrics, 121(4), 788-801.
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