Comprehensive care for Preterm & Low birth weight babies

Vincent Mary. S1, Shalini H S2, Shwetha H K3, Vijayakumari. D4

1NICU In-Charge, Kauvery Hospital, Electronic city, Bangalore

2Chief Nursing Officer, Kauvery Hospital, Electronic city, Bangalore

3Nursing Mod, Kauvery Hospital, Electronic city, Bangalore

4Nurse Educator, Kauvery Hospital, Electronic city, Bangalore

Abstract

Preterm birth and Low birth weight are major global health concerns and important contributors to neonatal morbidity and mortality. Prematurity and LBW often overlap, as many preterm infants are also underweighting at birth. These babies require special attention because their organs are immature and they are more vulnerable to complications such as respiratory distress, hypothermia, feeding problems, infections, hypoglycemia and long-term developmental issues. Advances in neonatal care have significantly improved survival rates of preterm and LBW babies. However, comprehensive and continuous care is essential to ensure optimal growth, development and quality of life. This article discusses the essential components of comprehensive care for preterm and LBW babies.

Key words: Preterm birth; World Health Organization (WHO); Low Birth Weight (LBW)

Introduction

Preterm infants are born at less than 37 weeks gestational age and low birth weight infants are born with a birth weight below 2.5kg regardless of gestational age. An estimated 15 million newborns are born preterm and more than 20 million are born low birth weight each year. Prematurity and low birth weight remains the leading cause of death in newborns and children under-five years.  Preterm and LBW infants have a higher risk of developmental disabilities including cerebral palsy and retinopathy of prematurity. The consequences of prematurity and low birth weight may continue into adulthood, increasing the risk of adult-onset chronic conditions such as obesity and diabetes.

According to the World Health Organization (WHO), a preterm baby is defined as any infant born alive before the completion of 37 weeks of gestation. In India, where approximately 3.5 million babies are born prematurely annually, these infants are categorized by gestational age: extremely preterm (<28 weeks), very preterm (28 to <32 weeks), and moderate/late preterm (32 to <37 weeks).

According to the World Health Organization (WHO), a Low Birth Weight (LBW) baby is defined as any newborn weighing less than 2,500 grams (5.5 pounds) at birth, regardless of gestational age. In India, LBW is a major public health issue, with 95.6% of such cases in developing countries.

Preterm infants are highly vulnerable, requiring immediate and specialized care to prevent complications like respiratory distress syndrome and infections. It is a critical indicator of neonatal survival, health, and development. LBW babies have up to 20 times higher risk of death. Reducing LBW is a key target in India to improve maternal health, nutrition, and socioeconomic factors.

Key factors for Preterm and Low Birth Weight (LBW) in India

Maternal Nutritional & Physical Factors: Severe iron deficiency anemia, low pre-pregnancy weight, poor nutritional status, and short stature.

Medical Conditions: Hypertension, diabetes, infections (e.g., malaria, syphilis, HIV), and kidney disease.

Obstetric Factors: Multiple pregnancies (twins), previous history of preterm birth, short interval between pregnancies, and premature rupture of membranes.

Socio-economic & Care Factors: Lack of or inadequate antenatal care, young maternal age, poverty, and high-stress levels.

Environmental Factors: Substance abuse, including smoking or tobacco use.

Case Study

Maternal History

  • 24 years old with Primigravida at 28 weeks + 4 days of gestation. Mother had booked case and was fully immunized. VDRL, HIV and HbsAg – Non-Reactive.
  • Indication – PPROM with NST abnormalities.
  • Mother’s Blood Group – ‘O’ Positive.
  • LMP – 04/11/2024.
  • EDD – 11/08/2025.
  • Antenatal Ultrasound Scan: Nil.

Birth History

Mode of DeliveryLSCS Presentation, Cephalic
Date & Time of Delivery23.05.2025 at 12:25pm Birth Weight: 970gm.
SexFemale
Apgar scores at 1min - 7/10 at 5min -8/10
Baby's Blood Group 'A' Positive

Course in The Hospital

28 weeks + 4 days extreme preterm baby delivered through LSCS, cried immediately & had respiratory distress from birth, shifted to NICU, started on BCPAP with FiO2 25 / PEEP 6 / Flow 6. In view of respiratory distress, (tachypnea intercostal, subcostal chest retractions grunt) with increased FiO2 requirement, 1 dose of Surfactant (CUROSURF) given via INSURE technique, later bubble CPAP support with FiO2 25% and PEEP-6 continued. Baby is on BCPAP with FiO2 21 / flow 6 / PEEP 6, tolerating a gap of 4 hours.

Sepsis: In view of positive risk factors for sepsis, (prolonged premature rupture of membranes, leaking P/V and respiratory distress) IV antibiotics Inj. Augmentin and amikacin commenced, stopped at Day 6 of life after negative blood culture reports. Prophylactic fluconazole IV changed to oral fluconazole on day -7 of life. On DOL-9, bradypnea noted. Repeat sepsis marker showed elevated total count. It started on Inj.Piptaz and Amikacin. Culture report negative. Urine leucocyte esterase negative, nitrite +, bacilli +, USG KUB was normal. Therapeutic dose of Inj. Fluconazole and started on NIV, with setting of – FiO2 21 / PEEP 6 / PIP 16/ RR 35 / Ti 0.5. Antibiotics stopped after 7 days. Baby was on CPAP 20 days.

Apnea of Prematurity: Few Apneas episodes at 1st 2 days of life treated with IV Capnea (Caffeine Citrate) loading dose and followed by maintenance doses and CPAP support continued.

Nutrition: Under strict aseptic precautions UAC and UVC were inserted. Baby was started with total parenteral nutrition with 10% dextrose, Amino Ven and intralipids. IV calcium gluconate added in maintenance fluid. Tropic feeds started on day 2 of life, which slowly increased to full feeds via orogastric tube. Vitamin D3 and supplements added. On DOL-9, in view of sepsis and bradypnea, IVF restarted at 75ml/kg/day. Gradually feeds graded up and reached full feeds on DOL12. Baby on 172ml/kg/day full feeds 37ml Q2H and HMF 1 sachet in every 2 feeds in EBM.

Jaundice: In view of serum bilirubin levels under phototherapy range double surface phototherapy given for 24hrs on DOL3.

Screening

  • Neurosonogramdone on DOL2, DOL7 and DOL14 showed right side grade- I germinal matrix hemorrhage.
  • 2D echo on 26/05/2025 – Small mid muscular VSD- left to right shunt. PFO/ Small OS left to right shunt.
  • 2D echo on 06/06/2025 – PFO / Small OS ASD left to right shunt, VSD absent, PAH + (physiological).
  • ROP on 16/06/2025 – Moderate TAR, Zone 2A, no plus, review after 3 weeks.

Anthropometry at Discharge

Discharge Weight1.715kg
Head Circumference30 cm.
Length43 cm.
Chest Circumference29 cm.
Weight at the time of discharge1715g
FeedingDBF +PALLADA

Baby stay was uneventful. Hence baby is being discharged.

Discussion

Comprehensive nursing care for preterm (<37 weeks) and low birth weight (LBW, <2500g) infants focuses on maintaining a thermoneutral environment, ensuring respiratory stability, providing specialized nutrition, and preventing infection. Key interventions include Kangaroo Mother Care (KMC), gentle handling, developmental care, and involving parents in care to support growth and neurodevelopment.

Thermoregulation (Keeping Baby Warm) 

  • Prevent Cold Stress: Preterm infants have limited subcutaneous fat and immature thermoregulation.
  • Kangaroo Mother Care (KMC): Skin-to-skin contact is the most effective way to maintain temperature, stabilize heart rate/breathing, and promote bonding.
  • Environmental Control: Use radiant warmers or incubators to maintain a stable, warm environment.
  • Prevent Heat Loss: Use warm linens, provide hats, and delay the first bath for at least 48 hours.

Respiratory Support and Monitoring 

  • Monitor Vitals: Closely monitor oxygen saturation, respiratory rate, and heart rate for apnea or bradycardia.
  • Respiratory Support: Administer nasal CPAP (Continuous Positive Airway Pressure) or oxygen as ordered for respiratory distress syndrome.
  • Positioning: Maintain a neutral, flexed position to minimize heat loss and maximize lung function.

Nutrition and Feeding

  • Initiate Feeding: Start enteral feedings early, usually with breast milk or formula via feeding tube (nasogastric/orogastric).
  • Slow Progression: Gradually increase intake to prevent gastrointestinal complications like necrotizing enterocolitis (NEC).
  • Support Breastfeeding: Assist mothers with pumping or direct breastfeeding as soon as the baby is stable.

Infection Prevention

  • Strict Hand Hygiene: Adhere to rigorous handwashing protocols before and after touching the infant.
  • Aseptic Technique: Maintain sterile, or clean, techniques for all procedures (IV lines, tube feedings).
  • Minimize Handling: Reduce handling to prevent fatigue and infection risk.

Developmental and Skin Care

  • Minimal Handling & Noise Reduction: Minimize stress by reducing bright lights and loud noise, which supports neurological development.
  • Skin Integrity: Use delicate adhesive tape and keep skin clean and dry to prevent skin breakdown.
  • Pain Management: Assess pain levels during procedures and use non-pharmacological methods (e.g., sucrose, breastfeeding) to manage discomfort.

Parent Education and Support

  • Empower Parents: Involve parents as primary caregivers, allowing them to participate in diaper changes, feeding, and temperature monitoring (Family Integrated Care).
  • Education: Educate parents on warning signs, kangaroo care techniques, and the importance of follow-up visits.

Complication Monitoring

  • Monitor for common complications: respiratory distress syndrome (RDS), infection/sepsis, NEC, intraventricular hemorrhage, and retinopathy of prematurity (ROP).

Key Discussion Points for Case Management

  • Assessment & Risk Factors: Determine gestational age, birth weight category (LBW <2.5kg, VLBW <1.5kg), and maternal factors such as prenatal care, infection, hypertension, or nutritional status.
  • Respiratory Care: Address Respiratory Distress Syndrome (RDS) through surfactant therapy, oxygen management, and respiratory support.
  • Thermoregulation: Prevent hypothermia, as these infants have low fat reserves and a high surface area-to-body weight ratio.
  • Nutritional Support: Manage immature suck/swallow reflexes, potential for parenteral nutrition, and early initiation of enteral/breastfeeding.
  • Infection Control: High vulnerability to neonatal sepsis due to underdeveloped immune systems.
  • Long-Term Complications: Monitor for Retinopathy of Prematurity (ROP), bronchopulmonary dysplasia (chronic lung disease), and neurocognitive impairments.
  • Post-Discharge Care: Continued monitoring of growth, neurological development, and risk of adult-onset chronic diseases.

Key Considerations for Caregivers

  • Kangaroo Mother Care (KMC): Essential for warmth, bonding, and weight gain.
  • Developmental Care: Minimizing handling stress, reducing noise/light in the NICU.
  • Parental Education: Training in signs of danger, feeding difficulties, and infection prevention.

Conclusion

Preterm and Low birth weigh babies represent a vulnerable group requiring specialized and comprehensive care. Their survival and long-term health depend on early stabilization, effective thermal management, adequate nutrition, infection prevention, respiratory support & continuous monitoring. Simple interventions such as Kangaroo Mother Care & exclusive breastfeeding have proven highly effective in improving survival and developmental outcomes. In addition, family involvement, proper discharge planning and regular follow up play a crucial role in ensuring healthy growth and development. With improved neonatal care practices and increased awareness among healthcare providers and parents, the survival rates and quality of life of preterm and low birth weight babies can be significantly enhanced.

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