Postnatal Care Module: 8. Special Care for Preterm and Low Birth Weight Babies

Study Session 8  Special Care for Preterm and Low Birth Weight Babies

Introduction

In this study session you will learn about the extra and special attention needed by preterm and low birth weight babies. We will explain the many reasons why they need special care, and how to give it, and also how to counsel mothers and other family members on looking after them. The focus is on managing the problems of feeding preterm and low birth weight babies, and of keeping them warm. In particular, you will learn about a relatively recent and highly successful method of maintaining the body heat of early or tiny babies, known as Kangaroo Mother Care.

Learning Outcomes for Study Session 8

When you have studied this session, you should be able to:

8.1  Define and use correctly all of the key words printed in bold. (SAQ 8.2)

8.2  Explain why preterm or low birth weight babies need special care, and list the common complications they may develop. (SAQ 8.1)

8.3  Classify preterm and low birth weight babies on the basis of gestational age and birth weight, and in each case identify the appropriate management strategy (SAQ 8.2)

8.4  Describe how you would counsel the mother on feeding a preterm or low birth weight baby. (SAQ 8.3)

8.5  Describe how to protect preterm and low birth weight babies from hypothermia, including counselling the mother and other family members on Kangaroo Mother Care. (SAQ 8.4)

8.1  Why do preterm or low birth weight babies need special care?

Preterm and low birth weight babies are at increased risk of dying from hypothermia, infection, breathing problems and immaturity of their vital organs. As a result they may be unable to adapt to life outside the uterus. The key reasons why they need special care are summarised in Box 8.1.

Box 8.1  Characteristics of preterm and low birth weight babies

  • Parts of their nervous system are not yet well developed.
  • They have little fat under the skin; especially their brown fat is low. Brown fat is very important to generate heat for the newborn baby; it is found mainly over the shoulders, back, kidneys, neck and armpits.
  • They lie very still so they can't generate heat by moving much.
  • They have a high ratio of surface area to body weight compared to that of a child or adult, so they lose heat quickly from their skin.
  • They have immature lungs so they have breathing problems.
  • They don't have much immunity so they will be extra vulnerable to infection.
  • The veins in their brain are thin and immature and are prone to bleeding.
  • They may be too weak to feed well.

An example of why preterm and low birth weight babies need special care is that they have a very poor resistance to fight infectious disease, because their immune system is not yet well developed. Therefore, on top of what is required for all babies, you and the mother need to be meticulous about hygiene and other infection prevention measures (described in Study Session 6). Everyone who handles the baby should wash their hands very thoroughly first and handle the baby very carefully. You can easily damage the soft and thin immature skin of the preterm or low birth weight baby, creating an entry point for infection.

8.2  Classification of preterm and low birth weight babies

The lower the birth weight and gestational age of the newborn, the higher the risk of complications and death and the more special care he or she needs. The special care they will need should take into account the classification of early and tiny babies, as described below.

8.2.1  Classification on birth weight

In relation to birth weight, most preterm babies are low birth weight or very low birth weight, as classified below:

Low birth weight: Babies born with birth weight between 1,500-2,499 gm. These babies can usually be managed safely at home with some extra care and support.

Very low birth weight: Babies born with birth weight less than 1,500 gm. A life-threatening problem in such tiny babies is that suckling, swallowing and breathing are not well coordinated, so they require special attention in order to feed them adequately and safely. They also have great difficulty in maintaining their body temperature, so they are at increased risk of hypothermia. These babies need advanced life support and should be referred immediately to a hospital with special care facilities for very tiny babies. However, at the present time, such facility-based care may not be accessible to rural families in some parts of Ethiopia.

8.2.2  Classification on gestational age

A premature baby is a baby born before 37 completed weeks of pregnancy. Based on the gestational age, preterm babies are further classified as follows:

Preterm baby: Babies born between the gestational ages of 32-36 weeks of gestation, as calculated from the mother’s last normal menstrual period (LNMP date). These babies can usually be managed safely at home with some extra care and support, which you will learn later in this study session.

Very preterm baby: Babies born between the gestational ages of 28-31 weeks as calculated from the LNMP date. Like very low birth weight babies and for the same reasons, they have problems in feeding and maintaining their body temperature. If possible, they should be referred urgently for specialist care at a hospital.

Table 8.1 summarises the classifications we have just described, and the actions you should take.

Table 8.1  Classification of newborn babies according to birth weight and gestational age.
Birth weight and gestational age Classification Action
Weight less than 1,500 gm Very low birth weight Refer URGENTLY to a hospital, making sure to keep the baby warm on the journey
Gestational age less than 32 weeks Very preterm Keep the newborn baby warm and refer it soon.
Weight 1,500 to 2,500 gm Low birth weight If there is no other problem:counsel on optimal breast feeding, prevention of infection and keeping the baby warm
Gestational age 32-36 weeks Preterm As above for low birth weight babies
Weight equal to or above 2,500 gm; gestational age equal to or above 37 weeks Normal weight and full term As above for low birth weight and preterm babies

8.3  Counselling on how to feed preterm and low birth weight babies

The breast milk produced by the mothers of preterm babies is even more nutritious than the milk produced by mothers whose babies were born at full term. Therefore, a preterm mother’s milk is the best milk for the preterm or low birth weight baby and it should not be discarded, as no other milk can replace its benefits.

8.3.1  Breastfeeding and cup feeding

During the first week of the baby’s life, the mother needs extra support from you and from the family to encourage her to initiate exclusive breastfeeding and maintain it until her tiny baby is able to suckle without any problem. Babies born between 34-36 weeks of gestation can usually suckle breast milk adequately, but very preterm babies may have difficulty breastfeeding. Breastfeeding a very preterm baby is a challenge. The frequency of feeding should be every two hours, including through the night.

If babies born before 34 weeks cannot suckle adequately, they can be fed expressed breast milk using a small very clean cup. (We describe how to do this in the next section.) Tiny or early babies who are able to suckle breast milk may also need feeding with additional expressed breast milk from a cup occasionally, to make sure they are getting enough nourishment. All babies who are on cup feeding have to be given around 60 ml/kg/day (that is 60 ml of breast milk for every kilogram of the baby’s weight every day) and increase this by 20 ml/kg/day as the baby demands more feeding.

Extremely preterm babies born before 32 weeks of gestation may not be able to breastfeed at all and need to be started on intravenous fluids. This is one of the reasons why all babies less than 32 weeks of gestation should be referred to health facilities immediately.

8.3.2  Tips to help a mother breastfeed a preterm or low birth weight baby

A mother’s breast is offered to a baby to feed on.
Figure 8.1  Offer the whole breast to encourage the baby to breastfeed.

Express a few drops of milk on the baby’s lip to help the baby start nursing. Offer the whole breast, not just the nipple, so the baby can get a good mouthful (Figure 8.1). Give the baby short rests during a breastfeed; suckling is hard work for a preterm or tiny baby.

If the baby coughs, gags, or spits up milk when starting to breastfeed, the milk may be spurting out too fast for the little baby. Teach the mother to take the baby off the breast if this happens. Hold the baby against her chest until the baby can breathe well again. Then put it back to the breast after the first gush of milk has passed.

If the preterm baby does not have enough energy to suck for long, or its sucking reflex is not strong enough, teach the mother how to express her breast milk by hand and then feed it to the baby from a cup.

8.3.3  Expressing breast milk

Expressing breast milk can take 20-30 minutes or longer to start with, but it gets quicker with practice. First tell the mother to wash her hands and her breasts with soap and water, and dry them with a very clean towel. Then prepare a cleaned and boiled cup or jar with a wide opening. If she is unable to boil the whole container, pour some boiling water into it and leave it there until just before she is ready to put milk into it; then pour the water away. This will keep the milk safe from bacteria.

The mother should sit comfortably and lean slightly towards the container. Show her how to hold the breast in a ‘C-hold’ (her hand is shaped like a big letter C; Figure 8.2a). Press the thumb and fingers back toward the chest wall (Figure 8.1b), then role the thumb forward as if taking a thumb print, so that milk is expressed from all areas of the breast. Express the milk from one breast for at least three to four minutes until the flow slows and then shift to the other breast. Thinking about feeding her baby while she expresses her milk may help the milk to flow out more easily.

Breastmilk being expressed by hand from the breast.
Figure 8.2  Expressing breast milk (a) Hold the breast in a C-shaped grip; (b) roll the fingers and thumb backwards and then forwards so milk spurts from the nipple into a sterilised container.

Important! Expressed breast milk that cannot be kept cool, or that is stored for more than six hours, should be thrown away

Breast milk can be saved at room temperature for up to six hours if the room is not very hot and the milk is stored in a sterilised container. Or it can be stored for longer in a refrigerator, if the mother has one. Wherever it is stored the milk must be warmed to body temperature before it is fed to the baby. To warm up the stored breast milk, put the container to stand for a while in a bowl of warm water. Never boil breast milk! Boiling destroys nutrients and antibodies.

8.3.4  Show mothers how to cup feed the baby

A woman is feeding a tiny baby from a cup.
Figure 8.3  Cup feeding a tiny baby takes care and patience.

Show the mother and other family members how to hold the baby closely sitting a little upright. Hold a small very clean cup half-filled with expressed breast milk to the baby’s lower lip (Figure 8.3). When the baby becomes awake and opens its mouth, keep the cup at the baby’s lips letting the baby take the milk slowly. Give the baby time to swallow and rest between sips. When the baby takes enough and refuses any more, put the baby up to the shoulder and ‘burp’ her or him by rubbing the baby’s back to expel air that may have been swallowed with the milk.

  • What are the special tips and skills about breastfeeding that you may need to explain or teach the mother of a preterm baby?

  • You should tell her about the importance of always using her own breast milk to feed the baby; putting a few drops of milk onto the baby’s lip to encourage it to start suckling; how to express her breast milk and store it safely; and how to cup feed the baby.

8.4  Special care to keep preterm and low birth weight babies warm

Preterm and low birth weight babies have great difficulty in maintaining their body temperature. They very easily lose heat, and hypothermia is life-threatening in their delicate condition. You should always follow the warm chain principle for any baby, whatever its weight or age, as you learned in Study Session 7, but in addition, early and tiny babies should get the following special care:

  • Immediately after the birth, put the baby in skin-to-skin contact with the mother, followed by Kangaroo Mother Care, which is described below.
  • Extra blankets or any extra local cloth made of cotton are needed to cover both the mother and the baby. An important thing to remember (which is often forgotten) is that the baby’s head needs to be well covered. This is because more than 90% of the heat loss is through the head if it is left uncovered.
  • There should be an extra heat source in the room where the preterm baby is looked after.
  • Delay bathing for at least 48 hours after delivery, and always use warm water.
  • Initiate breastfeeding or cup feeding as early as possible and feed the baby at least every two hours.
  • What else might you check in terms of ensuring that the baby is kept warm?

  • You will remember from Study Session 7 that it is important that the baby is not in a draft – so check that doors and windows are closed.

8.5  Kangaroo Mother Care

Kangaroo Mother Care (KMC), called after the way that kangaroos look after their young, has been shown to be an extremely effective method of caring for preterm and low birth weight babies. It involves holding a newborn in skin-to-skin contact, day and night, prone and upright on the chest of the mother, or another responsible person if the mother is unable to do it all the time.

Evidence from using KMC to support preterm and low birth weight babies shows that it results in greater stability of the baby’s heart rate and breathing, lower rates of infection and better weight gain. In the mother it results in increased breast milk supply, and she is more likely to succeed in exclusive breastfeeding.

8.5.1  KMC procedures

After you have explained about the KMC procedures to the mother (or another KMC provider) you should follow the steps in Box 8.1:

Box 8.1  Preparations for Kangaroo Mother Care
  • Make sure the room is clean and warm.
  • Provide privacy to the mother so she can open her clothing at the front, exposing her breasts.
  • Request the mother to sit or recline comfortably.
  • Undress the baby gently, except for cap, nappy (diaper) and socks.
  • Place the baby lying flat, facing the mother’s chest in an upright and extended posture, between the mother’s breasts, in skin-to-skin contact.
  • Turn the baby’s head to one side to keep the airways clear. Keep the baby in this position for 24 hours every day except for brief breaks.
  • Cover the baby with the mother’s shawl, or gown; wrap the baby-mother together with an added blanket, and put a cap on the baby’s head.
  • Breastfeed the baby frequently, at least 8-12 times a day.
A mother sleeping with her baby lying asleep on her chest.
Figure 8.4  The mother and baby can sleep together in KMC.

Reassure the mother that babies can receive most of the necessary daily care, including breastfeeding, while in KMC. The baby is removed from the skin-to-skin contact only for changing the diaper, general body hygiene and cord care, and to assess the baby during your postnatal visit. It is only for the first three to five days after the birth that the mother may need to lie in bed. Once the baby’s condition is stable, the mother can walk and do her routine work while the baby is in KMC, and they can sleep together in KMC at night (Figure 8.4).

8.5.2  Checking the baby is OK in KMC

At every postnatal visit you should:

  • Count the baby’s respiratory rate and make sure there is no fast breathing.
  • Observe that the baby is breastfeeding optimally.
  • Measure the baby’s temperature in the armpit and make sure it is normal.
  • If everything is OK, reassure the family but tell them to send for you immediately if there is any problem.

8.5.3  Counselling the family on the benefits of KMC

KMC may seem an unusual way of caring for the baby, so it is very important that you allow time for counselling the mother, the father and the family about what it entails, as well as about its benefits. She (and they) will need to be convinced and willing to undertake KMC for several days continuously. And the father and other members of the family will need to be ready to provide the necessary emotional and physical support to the mother while she is giving KMC.

So, what are the benefits of KMC?

  • Breastfeeding: KMC increases breastfeeding rates as well as increasing the duration of breastfeeding.
  • Thermal control: Prolonged skin-to-skin contact between the mother and her preterm/low birth weight newborn provides effective temperature control with a reduced risk of hypothermia.
  • Early weight gain: Tiny babies gain more weight on KMC than on conventional postnatal care.
  • Less morbidity: Babies receiving KMC have more regular breathing and are less likely to stop breathing. It also protects her baby against infection.

Of course it may not be possible for all mothers to take on KMC. You will need to satisfy yourself that the mother does not have any complications or medical illness which would mean that she is not strong enough to manage it on her own. If that is the case you should explore whether the father or another close member of the family might share the KMC with the mother, or give KMC exclusively if the mother is ill.

Finally, mothers who have successfully managed to give KMC have increased confidence and a deep satisfaction that they are able to do something so special for their tiny baby.

8.5.4  How long should KMC continue?

When the mother and baby are comfortable with the process, KMC should continue for as long as possible, or until the gestational age reaches term (40 weeks) or the baby’s weight reaches 2,500 gm. But if the baby weighs more than 1,800 gm and its temperature is stable, there are no respiratory problems and the baby is feeding well, it can be safely weaned from KMC before 40 weeks. And when the baby has had enough of being in KMC, it starts to communicate with the mother in its own ways, by wriggling, by moving a lot, pulling their limbs out of the wrapping and by crying until they are removed from the wrapping.

Finally, if you follow all these guidelines and help your families with preterm or low birth weight babies to care for them as described in this study session, you are sure to save some young lives. And what could be better than that!

Summary of Study Session 8

In Study Session 8, you have learned that:

  1. Preterm and low birth weight babies are particularly vulnerable to die of infections, breathing problems and hypothermia because of their immaturity.
  2. It is important to classify preterm and low birth weight newborns immediately after birth according to their gestational age and their birth weight, and refer those who are very preterm or very low birth weight.
  3. You can effectively counsel the mother on breastfeeding the preterm and low birth weight baby, including feeding every two hours, and how to express breast milk and cup feed if the baby is not yet developed enough to suckle effectively.
  4. You can teach the mother and her family how to use kangaroo mother care (KMC) and explain the advantages to them, which include increased breastfeeding, better control of the baby’s body temperature, early weight gain, better respiration and lower infection rates.
  5. KMC continues day and night until the preterm baby reaches 40 weeks of gestational age and/or the low birth weight baby reaches at least 1,800 gm. Mothers will need extra support to cope with the demands of KMC.

Self-Assessment Questions (SAQs) for Study Session 8

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the questions below. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.

SAQ 8.1 (tests Learning Outcome 8.2)

What are the main characteristics of preterm and low birth weight babies which mean they need special care?

Answer

The main points that mean preterm and low birth weight babies need special care are:

  • The immaturity of their immune system and therefore vulnerability to infections;
  • The risk of complications in the function of their immature nervous system and lungs;
  • Their vulnerability to hypothermia, because they have little fat protection, and a high ratio of surface area to body weight, and inability to generate much heat for themselves;
  • Potential difficulties in breastfeeding, so lack of nourishment can lead to further weakness and even less protection against infection and heat loss;
  • Their vulnerability to careless handing, for example causing damage to their delicate skin, which creates further entry points for infection.

SAQ 8.2 (tests Learning Outcome 8.1 and 8.3)

Fill in the gaps in Table 8.2.

Table 8.2 Classification of newborn babies according to birth weight and gestational age, and actions to take.

Birth weight and gestational age Classification Action

Weight less than 1,500 gm

Very preterm

Low birth weight

Gestational age 32-36 weeks

If there is no other problem counsel on optimal breast feeding, prevention of infection and keeping the baby warm

Normal weight and full term

Answer

Refer back to Table 8.1 in Section 8.2.1 and compare it with the entries you wrote in Table 8.2.

SAQ 8.3 (tests Learning Outcome 8.4)

You make the first antenatal visit at 12 hours after the birth to the mother of a baby that weighs 2,000 gm. It seems able to suckle but not for long, and the mother is worried if it is getting enough breast milk. How would you advise her?

Answer

At 2,000 gm this baby has a low birth weight, but it does appear to be able to suckle. However, if the mother thinks it is not getting enough milk because it quickly tires when it suckles, you could suggest additional feeding of expressed breast milk. You will need to explain first how to express her milk and how to store it safely (re-read Section 8.3.3 if you can’t remember), and then show her how to cup feed the baby (Section 8.3.4).

SAQ 8.4 (tests Learning Outcome 8.5)

  • a.What are the key things not to do with a preterm baby in order to protect it from hypothermia?
  • b.And what are the advantages of Kangaroo Mother Care in relation to hypothermia?
Answer
  • a.To prevent heat loss in a premature or low birth weight baby, you should not:

    • bathe the baby until at least 48 hours after delivery;
    • leave the baby without a hat (90% of heat is lost through the head if uncovered);
    • leave the baby in a room with the doors or windows open;
    • forget to provide an extra heat source in the room where the baby is kept;
    • undress it completely to change the diaper.
  • b.The advantages of KMC are:

    • the baby is kept in skin-to-skin contact day and night, which provides effective warmth and temperature control;
    • the baby is only removed from skin-to-skin contact for specific purposes (changing its diaper, checking if the cord stump is drying normally), so there is little danger of it being left in a room that is too cold;
    • the baby feeds better and gains weight more rapidly (so it develops more body fat to help keep it warm);
    • the advantages of KMC can be provided by other members of the family if the mother is unwell or needs a break.