REPRODUCTION SYSTEMMEDICAL FACULTYHASANUDDIN UNIVERSITY

PBL MODULE 1

LOW BIRTH WEIGHT BABY

GROUP 6

Sri Mahtufa Riski C11109759

Agung Pratama Putra C11109774

Jefman Efendi Marzuki C11109789

Sudarman Arung Tiku C11109803

Fiska Angelina Hasan C11109810

Eva Satya Nugraha C11109824

Noor Syaza BT Ismail C11109845

Siti Fatimah BT Shafee C11109859

Nor Farhana BT Omar C11109870

Dewi Fatmasari Surianto C11109885

Dwiatmananda Ekasari C11107030

Saron Angreany C11107089

Reproduction SystemMedical Faculty Hasanuddin University

20111

CASE

SCENARIO I

A baby boy came with his mother to emergency apartment of hospital with chief complaint weakly sucking. From history taking, the baby was born December 25th, 2010 with birth weight 2200 gram, birth length 47cm. Last menstrual period of the mother April 1st, 2010. From physical examination, the baby axillaries temperature 36.2C.

KEY WORDS

1. Baby boy

2. Weakly sucking

3. Birth weight 2200 gram

4. Birth length 47 cm

5. Born on December, 25th2010

6. Last menstrual period on April, 1st 2010

7. Baby axillaries temperature 36.2C

QUESTIONS

1. How old the baby when his mother gives birth?

2. What is the etiology of weakly sucking?

3. How is the normal weight, length, temperature in new born baby?

4. What is the etiology of Low Birth Weigth?

5. What is the effect of Low Birth Weigth?

6. How the management of Low Birth Weigth Baby?

7. What is the physiology of birth?

2

1. How old the baby when his mother gives birth?

Last menstrual period April 1st 2010

Baby born on December 25th 2010

APRIL 29 DAYS 4 WEEKS 1 DAY

MAY 31 DAYS 4 WEEKS 3 DAYS

JUNE 30 DAYS 4 WEEKS 2 DAYS

JULY 31 DAYS 4 WEEKS 3 DAYS

AUGUST 31 DAYS 4 WEEKS 3 DAYS

SEPTEMBER 30 DAYS 4 WEEKS 2 DAYS

OCTOBER 31 DAYS 4 WEEKS 3 DAYS

NOVEMBER 30 DAYS 4 WEEKS 2 DAYS

DECEMBER 25 DAYS 3 WEEKS 4 DAYS

GESTATIONAL AGE 38 WEEKS 2 DAYS

2. What is the etiology of weakly sucking?

• Premature

Prematurity refers to the broad category of neonates born at less than 37 weeks' gestation. Although the estimated date of confinement (EDC) is 40 weeks' gestation, the World Health Organization (WHO) broadened the range of full term to include 37-42 weeks' gestation.

Premature newborns have many physiologic challenges when adapting to the extrauterine environment. Most articles in the neonatology section discuss in detail the most serious of these problems. Serious morbidities occur in extremely low birth weight (ELBW) infants.

Cause of Premature

1. Pre-Eclampsia / Eclampsia3

These disorders frequently appear during pregnancy and called the disease of pregnancy. The common symptoms are high blood pressure, swelling that never healed, and if the mother can continue seizures constantly.

2. Placenta PreviaThe condition of pregnant women with placental location covering the birth canal, including high risk pregnancies so that babies born prematurely.

3. Fetal Growth RetardationFailure in the growth of the baby or have stunted growth in the womb, in this case the growth of babies in the womb quite slow, so the baby should be removed from the womb of the mother.

4. Infesction / Chorio AmnionitisOne condition that causes babies to be born prematurely is an infection of the membranes covering the baby. This can occur when the sac containing the baby and amniotic fluid rupture or burst to be born prematurely.

5. Multiple GestationIn the womb there are twins and can not accommodate the mother's womb, resulting in premature labor

6. Poly Hydramnios / Fetal malformationToo much amniotic fluid can also cause babies to be born prematurely

7. Uterine AbnormalitiesAbnormally shaped uterus, have abnormal uterine shape can also trigger

premature birth. There are some women who have abnormalities in her uterus, but gives the same result, namely infants have a smaller space to grow compared with the normal form of the uterus

• Fetal growth restriction

If the cause of IUGR is extrinsic to the fetus (maternal or uteroplacental), transfer of oxygen and nutrients to the fetus is decreased. This causes a reduction in the fetus stores of glycogen and lipids.This often leads to hypoglycemia at birth.

Polycythemia can occur secondary to increased erythropoietin production caused by the chronic hypoxemia. 

Hypothermia, thrombocytopenia, leukopenia,hypocalcemiaand  lmonary hemorrhage are often results of IUGR.

If the cause of IUGR is intrinsic to the fetus, growth is restricted due to genetic factors or as a sequela of infection.

• Low muscles tones

Children with normal muscle tone are expected to achieve certain physical abilities within an average timeframe after birth. Most low-tone infants have delayed

4

developmental milestones, but the length of delay can vary widely. Motor skills are particularly susceptible to the low-tone disability. They can be divided into two areas, gross motor skills, and fine motor skills, both of which are affected. Hypotonic infants are late in lifting their heads while lying on their stomachs, rolling over, lifting themselves into a sitting position, remaining seated without falling over, balancing, crawling, and walking. Fine motor skills delays occur in grasping a toy or finger, transferring a small object from hand to hand, pointing out objects, following movement with the eyes, and self feeding.

Speech difficulties can result from hypotonia. Low-tone children learn to speak later than their peers, even if they appear to understand a large vocabulary, or can obey simple commands. Difficulties with muscles in the mouth and jaw can inhibit proper pronunciation, and discourage experimentation with word combination and sentence-forming. Since the hypotonic condition is actually an objective manifestation of some underlying disorder, it can be difficult to determine whether speech delays are a result of poor muscle tone, or some other neurological condition, such as mental retardation, that may be associated with the cause of hypotonia. Additionally, lower muscle tone can be caused by Mikhail-Mikhail syndrome, which is characterized by muscular atrophy and cerebellar ataxia which is due to abnormalities in the ATXN1 gene.

• Early mother-baby separation after birth

So there is no contact of baby and mother, this is make no action for give Early Initiation of ASI.

• Prolonged medication during labor

Prolong medication during labor especially for anasthesi effect could make the smooth mucle cann’t work optimally.

• Decrease of swallowed reflex

In the normal fetus we found that the swallow reflex at 34 weeks of pregnancy, the amnion enter to the alveolus for stimulating airways before the swallow refleks occur, the swallow reflex triggered by liquid is propelled toward pharynx, and pharyngeal.

3. How is the normal weight, length, temperature in new born baby?

• Normal birth weight for new born baby is 2500gr to 4500gr

• Normal birth length in new born baby is 48-52cm (in baby boy) and 46-51cm (in baby girl)

5

• Normal axillary temperature in new born baby is 36.5 – 37.5 C

4. What is the etiology of Low Birth Weigth?

• Genetic abnormality inherited from mother

• Placenta and uterus insuffiency

• Fetus and uterus condition

• Multiple gestational or premature

• Intrauterine growth restriction

• Drug and alcohol use

• Umbilical collapse

5. What is the effect of Low Birth Weigth?

• Experienced respiratory disease syndrome

• Bleeding in the brain

• Heart and intestinal problem

• Vision loss

6. How the management of Low Birth Weigth Baby?

• Ultrasound (circumferences of head and abdomen of fetus)

• Doopler’s method (sound waves to measure blood flow)

• Mother weight gain (small maternal in pregnancies will make the small baby at birth)

• Gestational assessment (baby are weight within the few hours of birth)

7. What is the physiology of birth?

Parturition is the rather formal term for birth, and labor is the sequence of events that occur during birth. The average gestation period is 40 weeks (280days), with a range of 37 to 42 weeks (see Box 21–5: Premature Birth). Toward the end of gestation, the placental secretion of progesterone decreases while the estrogen level remains high, and the myometrium begins

6

to contract weakly at irregular intervals. At this time the fetus is often oriented head down within the uterus (Fig. 21–6). Labor itself may be divided into

three stages:

First stage—dilation of the cervix. As the uterus contracts, the amniotic sac is forced into the cervix, which dilates (widens) the cervical opening. At the end of this stage, the amniotic sac breaks (rupture of the “bag of waters”) and the fluid leaves through the vagina, which may

7

now be called the birth canal. This stage lasts an average of 8 to 12 hours but may vary considerably.

Second stage—delivery of the infant. More powerful contractions of the uterus are brought about by oxytocin released by the posterior pituitary gland and perhaps by the placenta itself. This stage may be prolonged by several factors. If the fetus is positioned other than head down, delivery may be difficult. This is called a breech birth and may necessitate a cesarean section (C-section), which is delivery of the fetus through a surgical incision in the abdominal wall and uterus. For some women, the central opening in the pelvic bone may be too small to permit a vaginal delivery. Fetal distress, as determined by fetal monitoring of heartbeat for example, may also require a cesarean section.

Third stage—delivery of the placenta (afterbirth). Continued contractions of the uterus expel the placenta and membranes, usually within 10 minutes after delivery of the infant. There is some bleeding at this time, but the uterus rapidly decreases in size, and the contractions compress the endometrium to close the ruptured blood vessels at the former site of the placenta. This is important to prevent severe maternal hemorrhage.

Referrence: Essentials of Anatomy and Physiology,5th edition, Valerie C. Scanlon, PhD, Tina Sanders, page 486-481

Differential Diagnosis

DD MACROSOMIA

LGA APPROPRIATE GA

SGA LBW

DEFINITION Baby have the weight > 4500gr at birth

Baby have the weight > 4200gr at birth

Baby have the weight in btw 2500gr-4200gr at birth

Baby have the weight < 2500gr at birth

Baby have the weight < 1500gr at birth

ETIOLOGY -gestational diabetes

-prolonged pregnancy

- Increase blood glucose

-gestational diabetes

-prolonged pregnancy

- Increase blood glucose

- Controlled blood glucose

- normal BMI in pregnant women

- - taking care of diet intake in pregnancy

- Maternal factors:

• High blood pressure

• Chronic disease eg”: kidney disease

-smoking

- Using of drugs/ medication

- Alcoholism

- Chronic

8

- Chronic disease eg: kidney disease.

- Chronic disease eg: kidney disease.

• Advanced diabetes

- uterus/placenta

• Decrease blood flow

• Placenta abruption

-fetus:

• Multiple gestation (twins or more)

• infection

disease

Risk that might occur

-dystocia

-broken collar bone

-increase incidence of birth defect

-hypoglycemia

-respiratory distress

-no risk -decrease of oxygen level

-hypoglycemia

-difficulty to get warm

-Weakly sucking

decrease of oxygen level

-hypoglycemia

-difficulty to get warm

-respiratory problem

Prevention - Taking care of diet intake in pregnancies

- Control of blood sugar

- Avoid drugs and alcohol

- Taking care of diet intake in pregnancies

- Control of blood sugar

- Avoid drugs and alcohol

-prenatal care is important

- - Taking care of diet intake in pregnancies

- Control of blood sugar

- Avoid drugs and alcohol

-prenatal care is important

- Taking care of diet intake in pregnancies

- Control of blood sugar

- Avoid drugs and alcohol

-prenatal care is important

Treatment - Careful of any injuries

- Check the

-Check the blood glucose level

-normal checkup for the baby

-Temperature controlled

-Temperature controlled

9

blood glucose level

- recommend to early labour

-recommended to early labor

-Tube feeding -Tube feeding

Differential Diagnosis

1.Macrosomia

Fetal macrosomia describes a fetus or infant thm is larger than expected for the same age and gender, or has a birth weight above the 90th percentile. It is also referred to as large for gestational age (LGA). Macrosomia is osually defined as a fetus with an estimated weight of more than 4,500 gr.uns (9 Ib, 15 oz). Some medical professionals ose an estimated weight of over 4,000 gr.uns (8 Ib, 13 oz) to define macrosomia. However, the birth weight is never known with certalnty until after delivery.

FREQUENT SIGNS AND SYMPTOMSAlthough there arc usually no specific signs or symptoms, maternal size frequently

suggests that the fetus is over grown (especially if the mother hilS gestational diabetes mellitus). Maternal size alone cannot establish the diagnosis. Fetal macrosomia is nonnally diagnosed by the obstetric provider.

CAUSES

Fetus gains more weight than is expected.

RISK INCREASES WITH

o Maternal diabetes (mnst frequent risk factor).• Heavy women have a greater risk of giving birth to excessivelylarge infants.• Macrosomia in a prior infant.o Multiparity Olaving had a child previously).o Post·term pregnancy (42 weeks and beyond).• About onc-third of macrosomic infants are born to mothers without any risk factors.

PREVENTIVE MEASURES

· Little is known about the prevention of macrosomia except with diabetic patients.

10

· Optimal blood glucose management for a pregnant woman with diabetes.· It is unclear if restricting the amount of weight gain by a pregnant woman will help prevent macrosomia.

EXPECTED OUTCOME

· Macrosomia is a common complication of pregnancy and can usually be managed successfully.· TIle majority of macrosomic infants who are delivered vaginally do very well.

POSSIBLE COMPLICATIONS

· For the mother, fetal macrosomia is associated with increased risks of cesarean section and trauma to the birth canal.o Fnr the fetus, birtil complications such as shoulder dystocia (shoulder gets stuck on ti,e way through the birtil canal) may occur. TIus can cause injury to the infant or block the infunt's ability to breath.

GENERAL MEASURES

• Diagnosis of fetal macrosomia is difficult. The measure· ment is calculated based on the estimated gestmional age of the fetus or inf.1.flt in comparison to what is considered normal height, weight, head size, and developmental level for a child of the same age and gender. The three major methods used to predict macrosomia arc: Using infonnation about the known risk factors. An estimation by Leopold's maneuvers (a physical exami· nation series offour maneuvers designed to help detennine fetal position and presenwtion). Ultrasonography to measure the weight may be helpful,but the accUiJ.CY of the results is sometimes a concern.• Management strategies for suspected fetal macrosomia will depend on your risk factors and diagnostic results. Also, special situations such as mothers with diabetes, mothers planning a vaginal birth after cesarean section, and a previous birth involving shoulder dystocia need to be considered.o Options include: planning for regular labor and delivery, elective cesarean section, or early induction of labor. You and your obstetric provider will discuss the best delivery choice depending on your individual circumstances. There are some risks assodated with each type of delivery. Some studies show that in nondiabetic women, one method is not necessarily bener in preventing problems to the mother orbaby.

MEDICATION

Usually none required.

ACTIVITY

11

No restrictions other than those medically recommended

DIET

No special diet

http://www.whcillinois.com/fetal-macrosomia.pdf

2. Large Gestational Age (LGA)

Definition/cut-off value

Birth weight greater than or equal to 9 pounds (4000 g); orPresence of large for gestational age diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by aphysician, or someone working under physician's orders.

Justification Infant mortality rates are higher among full-term infants who weigh greater than 4,000 g (greater than 9 lbs) than for infants weighing between 3,000 and 4,000 g (6.6 and 8.8 lbs). Oversized infants are usually born at term; however, preterm infants with high weights for gestational age also have significantly higher mortality rates than infants with comparable weights born at term. When large for gestational age occurs with pre-term birth, the mortality risk is higher than when either condition exists alone (1). Very large infants regardless of their gestational age, have a higher incidence of birth injuries and congenital anomalies (especially congenital heart disease) and developmental and intellectual retardation.Large for Gestational Age may be a result of maternal diabetes (which may or may not have been diagnosed before or during pregnancy) and may result in obesity in childhood that may extend into adult life.

Clarifications/Guidelines

Large for gestational age is defined as a birth weight of 9 pounds or more; a birth certificate is considered acceptable documentation of this risk criteria. The diagnosis for large for gestational age must be made by a physician and is based on an intrauterine growth reference. These reference tables are not used in the WIC clinic.Self-reporting of a diagnosis by a medical professional should not be confused with self-diagnosis, where a person simply claims to have or to have had a medical condition without any reference to professional diagnosis. A selfreported medical diagnosis (“My doctor says that I have/my son or daughter has…”) should prompt the CA to validate the presence of the condition by asking more pointed

12

questions related to that diagnosis.

www.dshs.state.tx.us/wichd/nut/pdf/153.pdf

3. Appropriate Gestational Age

This is the normal one.

4. Small Gestational Age (SGA)

Definition

Small for gestational age (SGA) means a fetus or infant is smaller in size than normal for the baby's gender and gestational age. Neonates are born weighing less than the normal minimum birth weight of 51⁄2 lb (2,500 g).

InformationUltrasound is used to find out if a fetus is smaller-than-normal for age (intrauterine growth restriction). The most widely used definition of SGA is birth weight below the 10th percentile.A fetus with intrauterine growth restriction will be small in size and can have problems such as: Increased red blood cells (polycythemia) Low blood sugar (hypoglycemia) Low body temperature (hypothermia)

ReferencesBaschat AA, Galan HL, Ross MG, Gabbe SG. Intrauterine growth restriction. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics: Normal and Problem Pregnancies. 5th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2007:chap 29.

http://wrongdiagnosis.pubs.righthealth.com/topic/Small_for_gestational_age/overview/adam20?fdid=Adamv2_002302&section=Full_Article

Etiology

Maternal factors:

• high blood pressure

• chronic kidney disease

• advanced diabetes

13

• heart or respiratory disease

• malnutrition, anemia

• infection

• substance use (alcohol, drugs)

• cigarette smoking

Factors involving the uterus and placenta:

• decreased blood flow in the uterus and placenta

• placental abruption (placenta detaches from the uterus)

• placenta previa (placenta attaches low in the uterus) infection in the tissues around the fetus

Factors related to the developing baby (fetus):

• multiple gestation (twins, triplets, etc.)

• infection

• birth defects

• chromosomal abnormality

5. Very Low Birth Weight (VLBW)

Causes :The primary causes of VLBW are premature birth (born <37 weeks gestation, and

often <30 weeks) and intrauterine growth restriction (IUGR), usually due to problems with placenta, maternal health, or to birth defects. Many VLBW babies with IUGR are preterm and thus are both physically small and physiologically immature.

Risk Factors :Any baby born prematurely is more likely to be very small. However, other factors

that can contribute to the risk of VLBW include:

• Race: African-American babies are twice as likely as Caucasian to be VLBW. Black infants (16% of US live births) account for 37% of ELBW infants.• Age: Teen mothers (especially if <15 years old) have a much higher risk of having VLBW infant.• Multiple birth babies are at increased risk of being VLBW because they often are premature. More than 50% of twins and other multiple gestations are VLBW.

14

• Maternal health: Women exposed to drugs, alcohol, and cigarettes during pregnancy are more likely to have LBW or VLBW babies. Mothers of lower socioeconomic status are also more likely to have poorer pregnancy nutrition, inadequate prenatal care, and complications of pregnancy. All are factors that can contribute to VLBW.

Neonatal Complication : Are markedly increased in VLBW, and especially ELBW, infants. Because most VLBW infants are also premature, it may be difficult to differentiate problems due to prematurity from those due to very small size. In general, the lower a baby's birthweight, the greater are the risks for complications. However, some complications of prematurity (e.g., risk of RDS) are lessened by the stress of mild to moderate intrauterine growth restriction. Clinical problems associated with VLBW and ELBW include:

1. Hypothermia: LBW infants have higher body surface area:body weight ratios, decreased stores of brown fat and glycogen, and may not be able to conserve or generate body heat. Clinical problems associated with hypothermia include hypoglycemia, apnea, increased O2 consumption and metabolic acidosis. Prevention of hypothermia increases survival of the infants. Methods of preventing heat loss include:• Drying the infant at birth to prevent evaporative heat loss• Warmed blankets or plastic wrap to prevent convective and radiant heat loss during transport• Swaddling to preserve body heat in larger infants, and radiant heater or a heated incubator to maintain a neutral thermal environment for smaller infants.

2. Hypoglycemia due to decreased stores of glycogen and fat. Hypothermia and hypoxia aggravate this due to increased metabolic demands and anaerobic glycolysis.

3. Perinatal asphyxiaEspecially among growth retarded infants because of compromised O2 delivery in

utero.

4. Respiratory problems:• Respiratory Distress Syndrome, due to surfactant deficiency • Apnea of prematurity

5. Fluid and electrolyte imbalances Due to increased insensible water loss (due to ↑ surface area/body weight, thin skin),

impaired renal function. They are at risk for dehydration, fluid overload, hypernatremia, hyponatremia, hyperkalemia (especially ELBW), hypocalcemia, hypermagnesemia (iatrogenic from maternal treatment). Compromised renal function may impair tolerance of free water, bicarbonate resorption, potassium secretion, or urinary concentrating capacity.

6. Hyperbilirubinemia

15

• Indirect (unconjugated) hyperbilirubinemia due to bruising or hemorrhage, ↓ RBC survival, hepatic immaturity, delayed enteric feedings and ↓ gut motility. With IUGR, risk factors may include infection and/or polycythemia.• Direct (conjugated) hyperbilirubinemia as a complication of parenteral nutrition.

7. Anemia Due to:• Phlebotomy for laboratory tests and small total blood volume• Anemia of prematurity

8. Impaired nutritionFeeding difficulties and slow rates of weight gain due to:• Gut immaturity with decreased motility, enzyme deficiencies and ↑ risk of necrotizing enterocolitis • Delayed enteric feeding due to respiratory disease, PDA, indomethacin treatment• Infants <32-34 weeks gestation are developmentally not ready to nipple feed• Increased caloric needs (↑surface area/body weight)

9. InfectionRisks are increased because of immunologic immaturity, prolonged invasive

treatments (e.g., endotracheal tube, intravascular catheters, parenteral nutrition and prolonged, recurrent treatment with antibiotics.

10. Neurological problems• Intraventricular hemorrhage • Periventricular leukomalacia• Increased long term risks for cerebral palsy, developmental delay, learning disabilities

11. Ophthalmologic complications• Retinopathy of prematurity (ROP) •Strabismus and refractive errors

12. Hearing deficits Due to:• Prematurity itself • Hyperbilirubinemia• Meningitis • Hypotension• Ototoxic drugs (e.g., aminoglycosides, furosemide)13. Sudden infant death syndrome (SIDS)

Premature infants are at increased risk, but home monitoring has not been shown to be an effective preventive measure. Home monitoring is not recommended in absence of other

16

risk factors (e.g.. twin sibling with SIDS, two siblings with SIDS, obstructive airway problems, or craniofacial anomalies posing risks for obstructed airways).

Management: Because of the increased risk for multiple problems, these infants require meticulous

attention to all facets of their care. The following are but a brief summary of certain aspects of the care of these fragile infants:

1. Resuscitation

2. Respiratory Care: The majority of ELBW (i.e., <1,000 g) will require intubation at birth (to assist in their cardiopulmonary adaptation to extra-uterine life) and assisted ventilation for a prolonged period. They require close attention with frequent measurements of pH and blood gas tensions. In addition to surfactant deficiency, they are at risk for respiratory failure because of:• Weak chest wall •Weak muscles of respiration• Smaller alveoli (↑ tendency to atelectasis) •Decreased central respiratory drive

3. CardiovascularMost VLBW and almost all ELBW infants will require an umbilical arterial catheter

for blood sampling and blood pressure measurement. Hypotension is common. The most effective therapy is dopamine (usual starting dose is 5 mcg/kg/min). Do not automatically give fluid boluses for “decreased perfusion,” acidosis, or hypotension. Excess fluid will worsen pulmonary function and give excess Na+. Reserve volume expansion for situations where there are signs of hypovolemia

3. Oxygen therapyMaintain SpO2 in range of 85-92%. If SpO2 is > 94%, arterial oxygen tension may be

high (>100 mmHg) because of the inaccuracy of the pulse oximeter at high saturations. This puts the infants at ↑ risk for ROP. titration orders for oxygen.

4. FluidsOn the 1st day of life, preterm infants should receive restricted fluids (e.g., 60- 80

mL/kg/d). However, for ELBW infants, fluid intake should be higher (e.g., 100- 125 mL/kg/d. Follow intake and output closely, at least q12h for the first several days. 5. Electrolytes: On the 1st day, do not give Na+ or K+. To avoid hypocalcemia, start Ca gluconate at 200 mg/kg/d. Follow serum electrolytes closely.

6. Nutrition

17

Feedings on the 1st day of life are unusual for VLBW infants. Do not start feeds on the 1st day of life in ELBW infants. Trophic (gut stimulation) feedings for several days facilitate later advance of feedings. Consider early institution of TPN. Do not give IV lipids for 3-5 d, especially if there is severe pulmonary disease.

7. InfectionObtain CBC and blood culture at birth. If there are any risk factors, begin antibiotic

therapy (48 h of treatment until culture results are known).

8. GlucoseMaintain blood glucose ≥45 mg/dL. Initial IV fluid should be D10W. Some ELBW

infants may become hyperglycemic and require lower glucose intake and/or insulin.

9. Hyperbilirubinemia

10. AnemiaAssume all ELBW and many VLBW infants will need at least 1 transfusion. Obtain

parental consent in advance, discussing option for designated donor blood. Type and cross match packed cells in small volume aliquots to minimize number of donors. Start erythropoietin as described in Guidelines for Use of Erythropoietin

11. Intraventricular hemorrhage

12. Ophthalmology examination for ROP commencing at age 1 mo for infants born < 32 weeks.

http://www.ucsfbenioffchildrens.org/pdf/manuals/20_VLBW_ELBW.pdf

18