Extremely low birth weight

(ELBW) infant
By Dr Hannan Yusof
 definition
 Extremely low birth weight (ELBW) is defined
as a birth weight less than 1000 g
 usually born at 27 weeks' gestational age or
younger
 Infants born at less than 1500 g are termed
very low birth weight (VLBW)
 Infants whose weight is appropriate for their
gestational ages are termed appropriate for
gestational age (AGA)
 Infants who are heavier than expected are large
for gestational age (LGA)
 smaller than expected are considered small for
gestational age (SGA)
 Mortality and Morbidity

 study by the National Institute of Child Health

and Human Development (NICHD) Neonatal
Research Network was undertaken to relate
other known risk factors with likelihood of
survival and impairment.
 NICHD study
The study reported that 83% of infants born at
22-25 weeks' gestation received intensive care
(consisting of mechanical ventilation). Of all
study infants whose outcomes were known at
18-22 months,
 49% died,
 61% died or had profound impairment,
 73% died or had impairment.
 NICHD study
 The report suggested the following 4 factors
should be considered in addition to gestational
age when determining the likelihood of
favorable outcome with intensive care
 Sex: Female sex has the more favorable
outcome.
 Exposure to antenatal corticosteroids (with
favorable effect)
 Single or multiple birth: Single birth has a
favorable effect.
 Birth weight: Increasing increments of 100 g
each add to favorable outcome potential.
Clinical Features
 Thermoregulation
 As a result of a high body surface area–to–
body weight ratio, decreased brown fat stores,
nonkeratinized skin, and decreased glycogen
supply, infants with extremely low birth
weights (ELBWs) are particularly susceptible
to heat loss immediately after birth.
Hypothermia may result in hypoglycemia,
apnea, and metabolic acidosis.
 Hypoglycemia
 Fetal euglycemia (maintenance of normal
blood glucose levels) is maintained during
pregnancy by the mother via the placenta.
Infants with extremely low birth weights have
difficulty maintaining glucose levels within
reference range after birth, when the maternal
source of glucose has been lost
 Hyperbilirubinemia
 Most infants with extremely low birth weights
develop clinically significant
hyperbilirubinemia (jaundice) that requires
treatment. Hyperbilirubinemia develops as a
result of increased RBC turnover and
destruction in the context of an immature liver
that has physiologically impaired conjugation
and elimination of bilirubin
 Respiratory distress syndrome and
chronic lung disease
 An early complication of extreme prematurity
is respiratory distress syndrome (RDS) caused
by surfactant deficiency. Clinical signs include
tachypnea (>60 breaths/min), cyanosis, chest
retractions, nasal flaring, and grunting.
 Surfactants
 decrease the surface tension of the smaller
airways so that the alveoli or the terminal air
sacs do not collapse, which results in less need
for supplemental oxygen and ventilatory
support.

 administered as prophylaxis or as rescue

intervention after RDS
 surfactants
 Prophylactic use in infants younger than 28
weeks' gestation has been shown to decrease
short-term ventilatory needs; neither strategy
has resulted in a decreased incidence of
chronic lung disease (BPD).

 if used as prophylactic treatment, surfactants

should be administered as soon after birth as
possible
 A study by Geary et al
Infants who are not immediately intubated are usually maintained
with nasal continuous positive airway pressure (CPAP), which
has been shown to improve endogenous surfactant production.
These infants are intubated and given surfactant only if they fail
the initial trial of CPAP, as evidenced by increasing PaCO 2,
increasing respiratory distress, or persistently high oxygen
requirement.

This approach could decrease the incident of chronic lung disease

 Patent ductus arteriosis
 In the fetus, oxygenation of the blood is
accomplished by the placenta, making blood
flow through the lungs unnecessary. The
ductus arteriosus is a conduit between the left
pulmonary artery and the aorta that results in
shunting of blood away from the lungs while
the infant is in utero
 PDA
 In full-term newborns, the PDA typically
closes within 48 hours of birth because of
oxygen-induced constriction. However, the
PDA in preterm infants is less responsive to
this effect of oxygen, and as many as 80% of
infants with extremely low birth weights have
a clinically significant PDA
 Infection

 Infection remains a major contributing factor

to the morbidity and mortality of infants with
extremely low birth weights and can present at
any point in the clinical course. Early onset
infection (occurring within the first 72 h of
life) may present with immediate respiratory
distress shortly after birth or after an
asymptomatic period
 Sign of infection
 temperature instability (hypothermia or
hyperthermia),
 tachycardia or bradycardia
 decreased activity, poor perfusion, apnea,
 feeding intolerance
 increased need for oxygen or higher ventilatory
settings
 metabolic acidosis.
 Infection - 2
 The most common causes of early sepsis in the
immediate newborn period are group B streptococci
(GBS) and Escherichia coli. Nosocomial sources of
infection include coagulase-negative staphylococci
(CoNS) and Klebsiella and Pseudomonas species,
which may be resistant to the antibiotics typically
started for early-onset sepsis, necessitating a
different treatment regimen. Methicillin-resistant
Staphylococcus aureus is also becoming more
common.
 Infection 3
 Fungi, most commonly Candida albicans, are
frequently a cause of late-onset sepsis in
infants with extremely low birth weights and
may manifest with the above-mentioned
symptoms and thrombocytopenia, particularly
if the infant has been exposed to broad-
spectrum antibiotics.
 Necrotizing enterocolitis
 is a disease of the premature GI tract that
represents injury to the intestinal mucosa and
vasculature and is the most common intestinal
emergency in the preterm infant. Incidence of
NEC is directly correlated with decreasing
gestational age, occurring in 1-8% of infants
admitted to the NICU and in 1-3 infants per
1000 births.
Nec – intra op finding
 Bell's objective criteria for NEC
 symptoms -apnea, bradycardia, and abdominal
distention
 Radiographic findings include stacked bowel
loops, pneumatosis intestinalis (presence of gas
in the bowel wall), portal venous gas, and free
air indicating perforation of the bowel (an
ominous sign of impending deterioration).
the presence of pneumatosis intestinalis
 Preventing NEC
 The role of enteral feeding is controversial.

 Breast milk has been shown to have a

protective effect but cannot prevent NEC.
 Intraventricular hemorrhage
 A hemorrhage in the brain that begins in the
periventricular subependymal germinal matrix
can progress into the ventricular system
causing IVH. Both incidence and severity of
IVH are inversely related to gestational age.
 Intraventricular hemorrhage-2
 Babies with extremely low birth weights are at
particular risk for IVH because of vulnerability
of the germinal matrix and because the
protective cerebral autoregulation present in
older babies has not yet developed
 Intraventricular hemorrhage - 3
 IVH is diagnosed using cranial
ultrasonography. Because most IVHs occur
within 72 hours of delivery, neurosonography
is usually performed on infants with extremely
low birth weights during the first week after
birth and serially thereafter, depending on
clinical scenario. Use of antenatal steroids
decreases incidence of IVH, and treatment
consists of supportive care.
 Intraventricular hemorrhage - 4
 Grade I - Germinal matrix hemorrhage
 Grade II - IVH without ventricular dilatation
 Grade III - IVH with ventricular dilatation
 Grade IV - IVH with extension into the
parenchyma
 Periventricular leukomalacia


Periventricular leukomalacia (PVL) is defined

as damage to cerebral white matter that can
result in severe motor and cognitive deficits in
infants with extremely low birth weight who
survive; it occurs in 10-15% of these infants.
 Distorted occipital horns due to
periventricular leukomalacia (PVL)
 Apnea of prematurity


Apnea of prematurity (AOP) is common in

infants with extremely low birth weights and is
defined as cessation of respiratory activity of
more than 20 seconds, with or without
bradycardia or cyanosis.
 Anemia

The physiologic anemia, also seen in term infants,

occurs earlier and is more profound in preterm infants.
Reasons for this increased severity of anemia :-
 physiologic responses to decreased oxygen

consumption ,
 blood loss secondary to phlebotomy for lab Ix,
 developmentally immature erythropoietic response to

anemia,
 decreased survival of RBCs in preterm infants
 deficiencies of folate, vitamin B-12, or vitamin E.
 Immunization of preterm infants
 The American Academy of Pediatrics (AAP)
policy states that preterm infants should receive
full doses of diphtheria, tetanus, acellular
pertussis, Haemophilus influenzae type b,
poliovirus, and pneumococcal conjugate
vaccines at the appropriate chronologic age.
Hepatitis B vaccine is recommended by the age
30 days and may be given at birth or at age 1
month as per individual unit policies
 Retinopathy of prematurity (ROP)
 is a disease of the premature retina that has not
yet fully vascularized. Changes in oxygen
exposure have been postulated to cause a
disruption in the natural course of
vascularization and may result in abnormal
growth of blood vessels, which can result in
retinal detachment and blindness.
 Follow-up Care

 Nearly all infants with extremely low birth

weights (ELBWs) require neurodevelopmental
follow-up monitoring to track their progress
and to identify disorders that were not apparent
during the hospital stay
 Specific evaluations of cognitive development,
vision and hearing ability, and
neurodevelopmental progress is extremely
important.
 Wilson-Costello study
The study said that ,neurosensory abnormality to
be as high as
 25% in infants born weighing less than 1000

g;
 14% had cerebral palsy,
 1% had blindness,
 7% had deafness
 Infants with grades III or IV intraventricular
hemorrhage (IVH) or infants with
periventricular leukomalacia (PVL), which are
cysts in brain parenchyma that are typically
seen on routine brain ultrasonography in
infants aged 4-6 weeks, are at the greatest risk
for mental retardation.
 Marlow et al in EPICure study
 infants born before 26 weeks' gestation had
significant cognitive and neurologic
impairment at school age
 38% of those infants who showed no disability
or mild disability at 30 months progressed to
moderate-to-severe disability by school age
 2003, Helsinki hospital research
 total healthcare cost for surviving infants with
extremely low birth weights to be 104,635
Euros (approximately RM 421,244.69 )
 Taking into account costs of hospitalization,
outpatient care, medication, rehabilitation and
travel, ancillary costs from daily care, cost of
parents' accommodation during hospitalization
periods, and loss of earnings until the corrected
age of 2 years
2008 , recond Cayenne turbo
RM 400,000