3.  Birth weight is the single most important marker of
adverse perinatal and neonatal outcome.
 Babies with a birth weight of less than 2,500g,
irrespective of their gestation are classified as low
birth weight babies.
These include both preterm and small-for-dates
babies.

4.  Preterm infants (also called premature infants) are those
born before the beginning of 38th week of gestation.
 Moderately preterm infants are those born between 32
and 36 completed weeks of gestation.
 Late preterm infants fall in the moderately preterm
group.
 Very preterm infants are those born before 32
completed weeks of gestation. (Mehrban Singh, 2010)

5.  About 10 to 12 percent of Indian babies are born
preterm ( less than 37 completed weeks) as
compared to 5 to 7 percent incidence in the west.
 These infants are anatomically and functionally
immature and therefore their neonatal mortality is
high.

6.  The mechanisms initiating normal labour are not
clearly understood and much less is known about
the triggers that initiate labour before term.
Spontaneous
Induced

7.  Poor socio-economic status
 Low maternal weight
 Chronic and acute systemic maternal illness
 Antepartum hemorrhage
 Cervical incompetence
 Maternal genital colonization and infections

8.  Cigarette smoking during pregnancy
 Threatened abortion
 Acute emotional stress
 Physical exertion
 Sexual activity
 Trauma
 Bi-cornuate uterus
 Multiple pregnancy
 Congenital malformations

9.  The labour is often induced before term when there is
impending danger to mother or foetal life in-utero.
Maternal diabetes mellitus
Placental dysfunction as indicated by unsatisfactory
foetal growth
Eclampsia
Foetal hypoxia
Antepartum haemorrhage and
Severe rhesus iso-immunization.

11.  Their size is small with
relatively large head.
 Crown-heel length is
less than 47 cm
 Head circumference is
less than 33cm but
exceeds the chest
circumference by more
than 3cm.

12.  The general activity is
poor
 Their automatic reflex
responses such as moro
response, sucking and
swallowing are sluggish or
incomplete.
 The baby assumes an
extended posture due to
poor tone.

13.  Disproportionately
large head size
 Sutures are widely
separated and the
fontanels are large
 Small chin, protruding
eyes due to shallow
orbits and absent
buccal pad of fat.

14.  Optic nerve is often un-
myelinated but presence of
papillary membrane makes
its visualization difficult.
 Ear cartilage is deficient or
absent with poor recoil.
 Hair appear woolly and fuzzy
and individual hair fibres can
be seen separately.

15.  skin is thin, gelatinous,
shiny and excessively
pink with abundant
lanugo and very little
vernix caseosa.
 Edema may be
present.

16.  Subcutaneous fat is
deficient and breast
nodule is small or
absent.
 Deep sole creases are
often not present.

17.  In male testes are
undescended and
scrotum is poorly
developed.

18.  In female infants, labia
majora are widely
separated exposing
labia minora and
hypertrophied clitoris.

20.  Immaturity of central
nervous system is
expressed as inactivity
and lethargy, poor
cough reflex and
in-coordinated sucking
and swallowing

21.  Resuscitation difficulties at
birth and recurrent apneic
attacks.
 Retinopathy of prematurity .
 Vulnerable for intra-
ventricular – periventricular
hemorrhage and leuco-
malacia
 Inefficient blood brain barrier

22.  Cuboidal alveolar lining-
poor alveolar diffusion of
gases
 Hyaline membrane
disease
 Breathing is mostly
diaphragmatic, periodic
and associated with
intercostal recessions

23.  Pulmonary aspiration
and atelectasis
 They are vulnerable to
develop chronic
pulmonary
insufficiency

24.  The closure of ductus
arteriosus is delayed.
 In grossly immature
infants( less than 32
weeks) EKG shows left
ventricular
preponderance.
 Risk to develop thrombo-
embolic complications
and hypertension.

25.  Due to poor and
incoordinated sucking and
swallowing.
 Animal fat is not tolerated as
well as the vegetable fat.
 Regurgitation and aspiration
are common.
 Hypoglycaemia

26.  Abdominal distention and
functional intestinal
obstruction
 Entero-colitis
 Immaturity of the glucuronyl
transferase system in the liver
leads to hyper-bilirubinemia.
 Development of kernicterus
at lower serum bilirubin
levels.

27.  Hypothermia is invariable.
 Excessive heat loss due to
relatively large surface area
due to paucity of brown fat
in the baby who is
equipped with an
inefficient thermostat.

28.  Infections are the important
cause of neonatal mortality.
 The low levels of IgG
antibodies and inefficient
cellular immunity
 Excessive handling, humid
and warm atmosphere,
contaminated incubators
and resuscitators expose
them to infecting organisms.

29.  The blood urea nitrogen is
high due to low glomerular
filtrate rate.
 The renal tubular ammonia
mechanism is poorly
developed thus acidosis
occurs early.
 They vulnerable to develop
late metabolic acidosis
especially when fed with a
high protein milk formula.
 Concentration of urine is
poor.

30.  Preterm has to pass
4 to 5 ml of urine excrete
one milliosmole of solute
Baby gets dehydrated.
 The solute retention and
low serum proteins explain
occurrence of edema in
preterm infants.

31.  Poor hepatic
detoxification and
reduced renal
clearance make a
preterm baby
vulnerable to toxic
effects of drugs

32.  Develop anemia around 6
to 8 weeks of age.
 Deficiencies of folic acid
and vitamin E.
 Develop haemolytic
anemia, thrombocytopenia
and edema 6 to 10 weeks
of age.
 Osteopenia and rickets

33.  These babies are prone
to develop :
Hypoglycaemia
Hypocalcemia
Hypoprotenemia
Acidosis and
Hypoxia.

35.  Bed rest and sedation.
 Tocolytic agents
Sympathomimetic agents-beta-2-adrenergic
receptors.
Isoxsuprine (duvadilan)-beta-1 and beta-2 receptors.
Ritodrine
Salbutamol and terbutaline -beta-2 receptor
 Magnesium sulphate
 Indomethacin

36.  Maturity of fetus should be ascertained by
examination of amniotic fluid for phosphatidyl
glycerol or L/S ratio.
 Corticosteroids should be administered to the
mother to enhance fetal lung maturity.

37.  Inj.betamethasone 12mg IM
every 24 hours --2 doses or
dexamethasone 6mg IM
every 12 hours for 4 doses.
 The optimal effect is seen if
delivery occurs after 24
hours of the initiation of
therapy and its therapeutic
effect lasts for 7 days.

39.  Delayed clamping of cord.
 Elective intubation of extremely LBW babies (<1000g).
 Should be promptly dried, kept effectively covered and
warm.
 Vitamin K 1mg ( 0.5mg in babies < 1500g) should be
given intra-muscularly.
 Transferred by the doctor or nurse to the NICU as soon as
breathing is established.

40.  Vital signs .
 Activity and behaviour.
 Colour.
 Tissue perfusion.
 Fluids, electrolytes and ABG’s.
 Tolerance of feeds .
 Watched for development of
RDS, apneic attacks, sepsis,
PDA, NEC, IVH, etc.
 Weight gain velocity.

41.  The vital signs should be stable.
 The healthy baby is alert and active, looks pink
and healthy, trunk is warm to touch and
extremities are reasonably warm and pink.
 The baby is able to tolerate enteral feeds and
there is no respiratory distress or apneic attacks
and baby is having a steady weight gain of 1-1.5 %
of his body weight every day.

42.  Create a soft, comfortable,
“nestled” and cushioned bed.
 Avoid excessive stimuli.
 Effective analgesia and
sedation.
 Provide warmth.
 Ensure asepsis.
 Prevent evaporative skin losses.

43.  Provide effective and safe
oxygenation.
 Partial parenteral nutrition
and give trophic feeds
with expressed breast milk
(EBM).
 Provide rhythmic gentle
tactile and kinaesthetic
stimulation.

44.  Thermo-neutral environment.
 Application of oil or liquid
paraffin on the skin.
 Should be covered with a
cellophane or thin
transparent or thin
transparent plastic sheet.
 Provide partial
kangaroo0mother-care.

45.  Oxygen should be administered
with a head box when SpO2 falls
below 85% and it should be
gradually withdrawn when SpO2
goes above 90%.
 The lowest ambient concentration
and flow rates should be used to
maintain SpO2 between 85-95%
and PaO2 between 60-80 mm Hg.

46.  Early phototherapy is
adviced to keep the serum
bilirubin level within safe
limits in order to obviate the
need for exchange blood
transfusion.

47.  The handling should be bare
minimum.
 Vigilance should be
maintained on all
procedures.
 Early diagnosis and prompt
treatment of infections.

49.  Intra-venous dextrose solution (
10% dextrose in babies >1000g
and 5% dextrose in babies
<1000g).
 Trophic feeds with EBM through
NG tube.
 Condition is stabilized - enteral
feeds.

50. Fluid requirements are higher in LBW infants due
to:
 Greater insensible water losses
 Faster breathing rates
 Decreased ability to concentrate urine
 Greater use of radiant warmers
 Greater use of phototherapy units

51. Birth weight
(g)
Fluid rate
(ml/kg/day)
500 - 600 140 - 200
601 - 800 120 - 130
801 - 1000 90 - 110
1000 - 1500 80 - 100
>1500 60 - 80
*on first 2 days of life

52.  Fluid rate can be increased by 10-20 ml/kg/d
to gradually reach 150 ml/kg/d
 Fluid requirements need to be individualized
for each baby
 Enteral nutrition has to be considered once
the baby is stable

53. Infants with BW ≤ 1000 g
Infants with BW ≤ 1500 g, done in
conjunction with slowly advancing enteral
nutrition
Infants with BW 1501-1800 g for whom
enteral intake is not expected for > 3 days

54.  Glucose : 6 - 8 mg/kg/min
 Amino acids : 1.5 - 2 g/kg/d
 Lipid : 0.5 - 1 g/kg/d
 Sodium : 2 - 4 mEq/kg/d
 Potassium : 2 - 3 mEq/kg/d
 Chloride : 2 - 4 mEq/kg/d

55. Trophic feeding/ Gut priming
Practice of feeding very small amounts of enteral nourishment
to stimulate development of the immature GIT
Advantages:
Improves GI motility
Enhances enzyme maturation
Improves mineral absorption
Lowers incidence of cholestasis
Shortens time to regain birth weight

56.  Breast milk or ½ or full strength preterm formula at
10ml/kg/d by intermittent gavage/ continuous
nasogastric drip
 Increase by 10-15 ml/kg/d to reach 150ml/kg/d
 Increments not >20 ml/kg/d
 IV fluids can be stopped once 120ml/kg/d is reached
 On reaching 150ml/kg/d,calorie density can be
increased

57. PRETERMS
 <1200 g/ <32 wks: IV fluids for first 2-3 days, once
stable start gavage feeding
 1200-1800 g/ 32-34 wks: Start gavage feeding, once
vigorous start spoon/ breast feeding
 >1800 g/ >34 wks: Start breast feeding directly; if
trial feed takes>20 mins or intake is less than
required, switch to gavage feeding

58. Advantages:
 Higher concentrations of amino acids
 Higher concentrations of essential fatty acids
 Lower renal solute load
 Specific bio-active factors provide immunity
 Promotes intestinal maturation

59. Disadvantages:
Low concentrations of Vitamin
D, Ca, P
Inadequate iron

60.  Energy : 130 - 175 Kcal/kg/d
 Protein :3.4 - 4.2 g/kg/d
 Fat :6 - 8 g/kg/d
 Na :3 - 7 mEq/kg/d
 Cl :3 - 7 mEq/kg/d
 K :2 - 3 mEq/kg/d
 Ca :100 – 220 mg/kg/d

61.  Multivitamin drops.
 Iron supplementation.
 Vitamin E supplementation.
 Supplements of calcium
(220mg/day) and
phosphorus (100mg/day).

62.  Gentle touch, massage,
cuddling, stroking and flexing.
 Rocking bed or placing a
preterm baby on inflated
gloves.
 Soothing auditory stimuli.
 Visual inputs.

63. Kangaroo care is placing a
premature baby in an upright position on a
mother’s bare chest allowing tummy to
tummy contact and placing the premature
baby in between the mother’s breasts.
The baby’s head is turned so that the ear is
above the parent’s heart.

64.  Body temperature
 Mothers have thermal synchrony with their baby.
 The study also concluded that when the baby was
cold, the mother’s body temperature would increase
to warm the baby up and vice versa.

65.  Breastfeeding:
Kangaroo care allows easy access to the breast and
skin-to-skin contact increases milk let-down.

66.  Increase weight gain
Kangaroo care allows the baby to fall into a deep
sleep which allows the baby to conserve energy for
more important things. Increased weight gain
means shorter hospital stay.

67.  Increased intimacy and attachment

68.  A single dose of
dexamethasone 0.2mg/kg IV at
4 hours of age.
 Inhaled steroids.

69.  Nosocomial infections
 Hypothermia
 Respiratory distress syndrome
 Aspiration
 Patent ductus arteriosus
 Chronic lung disease
 NEC & IVH
 ROP & Late metabolic acidosis
 Nutritional disorders
 Drug toxicity

70.  Loss is upto a maximum of 10
to 15 percent.
 Regain their birth weight by
the end of second week of
life.
 Excessive weight loss, delay in
regaining the birth weight or
slow weight gain- suggest
baby is not being fed
adequately or unwell and
needs immediate attention.

71.  Routine oxygenation without
monitoring.
 Intravenous immuno-globulins.
 Prophylactic antibiotics.
 Prophylactic administration of
indomethacin or high doses of
vitamin E.
 Unnecessary blood transfusions.
 Formula feeds.
 Rough handling, excessive light
and loud sound.

72.  It is desirable to administer 0-
day vaccines(BCG, OPV,
HBV) on the day of
discharge from the hospital.
 If mother is HBV carrier and is
e-antigen positive- hepatitis
B vaccine and hepatitis B
specific immunoglobulins
within 72 hours of age.

73.  Live vaccines should be
avoided in symptomatic HIV-
positive mothers.
 WHO recommends that BCG
and oral polio vaccine can be
given to asymptomatic HIV-
positive infants.

74.  The family dynamics are
greatly disturbed.
 The problems and issues
should be handled with
equanimity, compassion,
concern and caring attitude
of the health team.
 Encouraged to touch and
talk with her baby.
 Provide kangaroo-mother-
care.
 Emotional support and
guidance.

75.  A baby who is feeding from the
bottle or cup and is reasonably
active with a stable body
temperature, irrespective of his
weight, qualifies for transfer to the
open cot.

76.  The mother should be
mentally prepared and
provided with essential
training and skills.
 The mother- baby dyad
should be kept in step-
down nursery.
 The baby should be stable,
maintaining his body
temperature and should
not have any evidences of
cold stress.

77.  At the time of discharge,
the baby should be having
daily steady weight gain
velocity of at least 10g/kg.
 The home conditions
should be satisfactory
before the baby is
discharged.
 The public health nurse
should assess the home
conditions and visit the
family at home every week
for a month or so.

78.  Common infective illnesses,
reactive airway disease,
hypertension, renal dysfunction,
gastro-oesophageal reflux.
 Feeding and nutrition.
 Immunizations.
 Physical growth, nutritional
status, anemia, osteopenia/
rickets.

79.  Neuro-motor development,
cognition and seizures.
 Eyes: Retinopathy of
prematurity, vision, strabismus.
 Hearing.
 Behavioural problems,
language disorders and
learning disabilities.

80.  She must be explained
about the importance of
asepsis.
 Keeping the baby warm
and ensuring satisfactory
feeding routine.
 The services of postpartum
programme public health
nurse and social worker
can be utilized.

81.  The infant should be effectively covered taking care to
avoid smothering.
 Woollen cap, socks and mittens should be worn.
 The infant should preferably lie next to the mother.
 In winter, the room can be warmed with a radiant
heater or angeethi.
 A table lamp having 100 watt bulb can be used to
provide direct radiant heat.
 Hot water bottle should never come in contact with the
baby.

82.  The cot of the mother and infant should be located
away from the walls .
 The mother and health worker should be trained to
assess the temperature of the newborn baby by touch.
 The visitors and handling of the infant should be
restricted to the bare minimum.
 The hands must be washed before touching or feeding
the baby.
 The emotional urge for kissing the baby should be
curbed.
 The linen should be clean and sun-dried.

83.  Whenever feasible, breast feeding is ideal and
must be encouraged.
 When infant is unable to suck from the breast, EBM
should be given with a bottle or dropper or spoon
or paladay depending upon his maturity.
 Formula for premature babies is recommended.
 If cow’s or buffalo’s milk is unavoidable it should be
given after 3:1 dilution.
 Mother must be given detailed instructions and
practical demonstration for maintenance of bottle
hygiene to prevent contamination of feeds.

84.  The risk of neurodevelopmental
handicaps is increased 3-fold for LBW
babies and 10-fold for very LBW
babies(<1500g).
 The prognosis is good if no birth
asphyxia, apneic attacks,RDS,
hypoglycaemia and
hyperbilirubinemia.
 Preterm AFD babies catch up in their
physical growth with term
counterparts by the age of 1 to 2
years.

85.  15 to 20 % incidence of
neurological handicaps in the
form of CP, seizures, ROP,
hydrocephalus, deafness and
MR.
 There is high incidence of
minor neurologic disabilities.
 Neurological prognosis is
adversely affected by degree
of immaturity.

86.  Obtain detailed antenatal, intra-
natal history.
 Assess the gestational age and
birth weight of the baby.
 Assess the features of clinical
immaturity.
 Assess the behaviour of preterm
neonate.
 Assessment of common
problems.

88. 1. Impaired gas exchange related to immaturity of
lungs and deficiency of surfactant
 Assess the respiratory pattern and colour of the
baby
 Observe for any apneic episode.
 Oxygen hood is often used for able to breathe
alone but need extra oxygen.
 Oxygen also may be given by nasal cannula to the
infant who breathes alone.
 Humidify the oxygen
 CPAP may be necessary to keep the alveoli open
and improve expansion of lungs

89. 2.Impaired breathing pattern : distress related to
immaturity and surfactant deficiency
 Assess the respiratory rate, heart rate and chest
retractions
 Position the child for maximal ventilatory efficiency
and airway patency
 Provide humidified oxygen
 Spo2 monitoring
 Provide suctioning
 Provide chest physiotherapy
 Administer bronchodilators
 Administer anti inflammatory medications
 Administer antibiotics

90. 3. Activity intolerance related to increased work of
breathing secondary to distress
 Arrange to provide routine care
 Schedule periods of uninterrupted rest
 Determine infant’s stress level
 Reduce nonessential lighting
 Use positioning devices

91. 4. Ineffective airway clearance related to excessive
trachea-bronchial secretions
 Assess the child’s breathing pattern
 Check the vital signs
 Provide suctioning
 Provide humidified oxygen
 Assess the ABG analysis
 Provide C-PAP using mask /hood/nasal prongs
 Observe for risks of C-PAP
 Assist in CMV with PEEP if needed

92. 5. Hypothermia related to immature thermoregulation
system
 Monitor vital signs frequently
 Wrap the baby well and keep warm
 Provide small and frequent breast feeding as tolerated
 Look for hypoglycemia
 Administer IV fluids if not tolerating the feed
 Monitor the vital signs and blood pressure
 Assess the skin tone, pallor and signs of dehydration
 Administer IV fluids

93. 6. Imbalanced nutrition less than body requirement
related to feeding difficulty, respiratory distress, or
NPO status
 Assess the sucking and swallowing ability of the
newborn
 Assess the tolerance of the child
 Monitor the blood glucose level frequently
 Administer IV fluids if not tolerating oral fluids
 Administer human milk fortifier if the child is preterm

94. 7. Fatigue related to increased demand for nutrients
and deterioration of the general condition of the
baby
 Assess the general condition of the baby
 Assess the level of activity
 Monitor the blood glucose level
 Breast fed the baby
 Check for from any part of the body
 Provide top up feed

95. 8. Risk for complications hypotension, shock, cerebral
hypoxia related to progression of the disease condition
 Assess the vital signs, respiratory rate, pulse rate,
temperature and blood pressure
 Check blood culture and sensitivity and sepsis screening
 Monitor for any signs of dehydration
 Administer IV fluids or blood as necessary
 Assess the serum electrolyte values and ABG values
 Closely monitor for the early signs and symptoms of
complications

96. 9. Anxiety of parents related to the outcome of the
newborn condition
 Assess the mental status, anxiety and knowledge of
family members
 Assess the supporting system for the family
 Assess the coping strategies of the family members
 Explain the disease process to the family members
 Explain each and every procedure to the care giver
 Provide psychological support to the family members

97. 10. Interrupted mother-child bonding related to
infectious process
 Assess the breast feeding ability including sucking
and swallowing ability
 Keep the child with the mother if possible
 Provide frequent breast feed 2 hourly
 If breast feeding is not tolerated give EBM
 Allow the mother to visit the child
 Provide kangaroo mother care in case of pre term if
tolerated

98. 11. Interrupted family process related to
hospitalization of the newborn
 Assess the mental status, anxiety and knowledge
of family members
 Encourage mother-child bonding if possible
 Assess the coping strategies of the family members
 Explain the disease process to the family members
 Explain each and every procedure to the care
giver
 Allow the family members to visit the child

99. 12. Knowledge deficit regarding care of the baby
and treatment modalities
 Assess the knowledge level of the care giver
 Explain disease condition and it’s progress to the
family members
 Educate regarding treatment and its prevention
 Educate about the monitoring of the baby
 Provide adequate explanation regarding nutritional
need of the baby
 Clarify their doubts and promote understanding

100.  Definition and incidence
 Causes of prematurity
 Clinical features
 Physiological handicaps
 Management
 Care of preterm babies
 Prognosis
 Nursing assessment
 Nursing diagnosis and interventions