Low birth weight babies psm parks
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Low Birth Weight (LBW) - Park's Textbook of Preventive and Social Medicine
Definition
Low birth weight (LBW) is defined (by international agreement) as a birth weight of less than 2.5 kg (up to and including 2499 g), measured preferably within the first hour of life, before significant postnatal weight loss occurs.
Additional weight classifications:
- Very low birth weight (VLBW): < 1500 g
- Extremely low birth weight (ELBW): < 1000 g
"The birth weight of an infant is the single most important determinant of its chances of survival, healthy growth and development."
- Park's Textbook of Preventive and Social Medicine, p. 625
Classification by Gestational Age
| Category | Gestational Age |
|---|---|
| Preterm | < 37 completed weeks (< 259 days) |
| Term | 37–41 completed weeks (259–293 days) |
| Post-term | ≥ 42 completed weeks (≥ 294 days) |
Sub-categories of preterm:
- Extremely preterm: < 28 weeks
- Very preterm: 28 to < 32 weeks
- Moderate to late preterm: 32 to < 37 weeks
Two Main Groups of LBW Babies
- Preterm babies (short gestation) - intrauterine growth may be normal for gestational age; common cause in developed countries with low LBW rates
- Fetal growth retardation / SGA (Small for Gestational Age) - common cause in developing countries like India where LBW rates are high
Incidence / Epidemiology
- Globally: >15 million preterm births in 2015; more than 1 in 10 babies born prematurely
- Prematurity is the 2nd leading cause of death in children under 5 and the single most important cause of neonatal death
- India has the highest absolute number of preterm births globally: 35,19,100 per year
- India's LBW prevalence: ~18.6% (Rapid Survey on Children 2014) vs. ~4% in some developed countries
- In India, majority are due to fetal growth retardation (not prematurity)
-
90% of extremely preterm babies (< 28 weeks) in low-income countries die within first few days; <10% die in high-income countries
Causes / Risk Factors
Causes of Preterm Birth
Two broad subtypes:
- Spontaneous preterm birth - spontaneous onset of labour or following pPROM (pre-labour premature rupture of membranes)
- Provider-initiated preterm birth - induction of labour or elective caesarean before 37 weeks for maternal/fetal indications
Specific risk factors:
- Maternal factors: malnutrition, anaemia, short stature, very young age, high parity, close birth intervals, smoking, infections during pregnancy
- Hard physical labour during pregnancy
- Obstetric factors: multiple pregnancy, antepartum haemorrhage, hypertension
- Socioeconomic factors: poverty (poorer families at higher risk)
Causes of Fetal Growth Retardation (FGR / IUGR)
- Maternal malnutrition and anaemia (most significant in India)
- Infections during pregnancy
- Chronic maternal illness
- Placental insufficiency
Problems / Complications of Preterm/LBW Babies
| System | Complications |
|---|---|
| Temperature | Instability - inability to stay warm (low body fat) |
| Respiratory | Hyaline membrane disease (RDS - lack of surfactant), Bronchopulmonary dysplasia, Apnea (in ~50% of babies ≤30 weeks) |
| Cardiovascular | Patent ductus arteriosus (PDA), Low/high BP, Low heart rate |
| Blood/Metabolic | Anaemia (may need transfusion), Jaundice (liver immaturity), Hypocalcaemia, Hypoglycaemia |
| Gastrointestinal | Feeding difficulty (poor suck-swallow coordination before 35 weeks), Necrotizing enterocolitis (NEC) |
| Neurological | Intraventricular haemorrhage (IVH), Periventricular leukomalacia (PVL), Poor muscle tone, Seizures, Retinopathy of prematurity (ROP) |
| Infections | Increased susceptibility; may require antibiotics |
Long-term Consequences
- 80% of newborn mortality occurs in LBW babies
- Permanent impairment of physical and mental growth
- Stunting, wasting, undernutrition in later childhood
- Disability for life in survivors of extremely preterm birth
- Increased susceptibility to infections
Prevention of LBW
"Experts opine that LBW rates could be reduced to not more than 10% in all parts of the world. Interventions have to be cause-specific."
- Park's Textbook, p. 625
Direct Intervention Measures
Identify pregnant women "at risk" and reduce the risk:
Nutrition interventions:
- Nutritional supplementation for pregnant women (especially iron and folate)
- Correction of anaemia before and during pregnancy
- Balanced protein-energy supplementation
Antenatal care:
- Early registration and regular antenatal checkups
- Treatment of infections (especially UTI, malaria)
- Tetanus immunization
- Monitoring of weight gain
Reducing workload:
- Reduction of heavy physical labour during pregnancy
- Rest periods for pregnant women
Other measures:
- Spacing of pregnancies (family planning)
- Discouraging early marriage and early pregnancy
- Stopping smoking
- Treatment of hypertension and other maternal illnesses
Indirect Intervention Measures (Social measures)
- Improvement in socioeconomic status
- Female education and literacy
- Raising age at marriage
- Improving nutritional status of women in general (not just during pregnancy)
- Reducing poverty
Management of LBW Babies (Care after birth)
- Warmth: Prevention of hypothermia - Kangaroo Mother Care (KMC) is highly effective and recommended by WHO
- Feeding: Breast milk is preferred; nasogastric tube feeding if sucking reflex is poor
- Infection prevention: Strict aseptic precautions
- Monitoring: Blood glucose, jaundice, weight gain
- Referral: To neonatal intensive care if needed for respiratory support, etc.
Key Points for Exams (PSM/Community Medicine)
| Point | Value |
|---|---|
| Definition of LBW | < 2500 g (up to and including 2499 g) |
| Measured at | Within first hour of life |
| India's LBW prevalence | ~18.6% |
| Most common cause in India | Fetal growth retardation |
| Most common cause in developed countries | Prematurity |
| Leading cause of neonatal death | Prematurity |
| % neonatal deaths in LBW babies | 80% |
| Target LBW rate globally possible | ≤ 10% |
| Best method of keeping LBW warm | Kangaroo Mother Care (KMC) |
- Park's Textbook of Preventive and Social Medicine, pp. 625-626, 735
Bfhi
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Baby-Friendly Hospital Initiative (BFHI)
Park's Textbook of Preventive and Social Medicine
Background
- Launched by WHO and UNICEF to improve infant and young child nutrition by promoting breastfeeding
- WHO's efforts to promote breastfeeding have been ongoing since 1993
- It is estimated that breastfeeding could prevent deaths of at least 1 million children per year
- BFHI has proved highly successful in encouraging proper infant feeding practices starting at birth
- Supported by major professional medical and nursing bodies in India
- Implementation guidelines were revised in 2018
The Ten Steps to Successful Breastfeeding (2018 Revised Guidelines)
The Ten Steps summarize a package of policies and procedures that facilities providing maternity and newborn services should implement to support breastfeeding:
Critical Management Procedures (Step 1 - divided into 3 parts in 2018 revision)
| Step | Description |
|---|---|
| 1a | Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly (WHA) resolutions |
| 1b | Have a written infant feeding policy that is routinely communicated to staff and parents |
| 1c | Establish an ongoing monitoring and data-management system |
Staff Competency
| Step | Description |
|---|---|
| 2 | Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding |
Antenatal
| Step | Description |
|---|---|
| 3 | Discuss the importance and management of breastfeeding with pregnant women and their families |
Postnatal / Delivery Room
| Step | Description |
|---|---|
| 4 | Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth |
| 5 | Support mothers to initiate and maintain breastfeeding and manage common difficulties |
| 6 | Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated |
Rooming-in and Feeding on Demand
| Step | Description |
|---|---|
| 7 | Enable mothers and their infants to remain together and practice rooming-in 24 hours a day |
| 8 | Support mothers to recognize and respond to their infant's cues for feeding |
Avoiding Artificial Nipples
| Step | Description |
|---|---|
| 9 | Counsel mothers on the use and risks of feeding bottles, teats and pacifiers |
Discharge Planning
| Step | Description |
|---|---|
| 10 | Coordinate discharge so that parents and their infants have timely access to ongoing support and care |
Additional Requirements for "Baby-Friendly" Hospitals in India
Baby-friendly hospitals in India are also expected to adopt and practice guidelines on other interventions critical for child survival, including:
- Antenatal care
- Clean delivery practices
- Essential newborn care
- Immunization
- Oral Rehydration Therapy (ORT)
Related Legislation in India
The Government of India enacted the Infant Milk Substitutes, Feeding Bottles and Infant Food (Regulation of Production, Supply and Distribution) Act, 1992 (IMS Act), which came into force on 1st August 1993 - in view of the vulnerability of young infants to the risks of breast milk substitutes.
Key Points for Exam
| Point | Value |
|---|---|
| Launched by | WHO and UNICEF |
| Year WHO began promoting breastfeeding | 1993 |
| Lives saved by breastfeeding | At least 1 million children/year |
| Last revision of BFHI guidelines | 2018 |
| Step 1 (2018) | Divided into 1a, 1b, 1c (new addition vs older 10 steps) |
| Step 4 | Immediate skin-to-skin contact after birth |
| Step 6 | No water/formula unless medically indicated |
| Step 7 | Rooming-in 24 hours a day |
| India legislation | IMS Act 1992 (in force 1st Aug 1993) |
Park's Textbook of Preventive and Social Medicine, p. 626
Note on 2018 revision: The older version had a simple Step 1 ("Have a written breastfeeding policy"). The 2018 revision expanded Step 1 into three sub-steps (1a, 1b, 1c) to include the International Code of Marketing compliance and a monitoring system. This is a common exam point.
National health policy 2017
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National Health Policy 2017 (NHP 2017)
Park's Textbook of Preventive and Social Medicine
Background / Context
India's previous health policies were NHP 1983 and NHP 2002. After 14 years of NHP 2002, four major contextual changes necessitated a new policy:
- Changing health priorities - Maternal and child mortality rapidly declined, but growing burden of NCDs and infectious diseases
- Emergence of a robust healthcare industry - Growing at double-digit rate
- Catastrophic health expenditure - Growing incidence; one of the major contributors to poverty
- Rising economic growth - Enabling enhanced fiscal capacity
Primary Aim
"To inform, clarify, strengthen and prioritize the role of the Government in shaping health systems in all its dimensions - investments in health, organization of healthcare services, prevention of diseases and promotion of good health through cross sectoral actions, access to technologies, developing human resources, encouraging medical pluralism, building knowledge base, developing better financial protection strategies, strengthening regulation and health assurance."
Specific Quantitative Goals and Objectives
Goals are organized under 3 broad components:
A. Health Status and Programme Impact
1. Life Expectancy and Healthy Life
| Goal | Target Year |
|---|---|
| Increase life expectancy at birth from 67.5 to 70 | 2025 |
| Establish regular tracking of DALY index | 2022 |
| Reduce TFR to 2.1 at national and sub-national level | 2025 |
2. Mortality by Age / Cause
| Indicator | Target | Year |
|---|---|---|
| Under-5 mortality | 23 per 1000 live births | 2025 |
| MMR | 100 per 1,00,000 live births | 2020 |
| Infant Mortality Rate (IMR) | 28 per 1000 live births | 2019 |
| Neo-natal mortality | 16 per 1000 live births | 2025 |
| Still birth rate | Single digit | 2025 |
3. Reduction of Disease Prevalence/Incidence
| Disease | Target |
|---|---|
| HIV/AIDS | Achieve 90:90:90 target by 2020 (90% know status, 90% on ART, 90% virally suppressed) |
| TB | Achieve 90:90:90 target by 2020; cure rate >85% in new sputum positive patients; elimination by 2025 |
| Leprosy | Achieve and maintain elimination by 2018 |
| Kala-azar | Elimination by 2017 |
| Lymphatic filariasis | Elimination in endemic pockets by 2017 |
| Blindness | Reduce prevalence to 0.25/1000 by 2025 |
| NCDs (CVD, cancer, diabetes, chronic respiratory) | Reduce premature mortality by 25% by 2025 |
B. Health Systems Performance
1. Coverage of Health Services
| Goal | Target | Year |
|---|---|---|
| Increase utilization of public health facilities | By 50% from current levels | 2025 |
| Antenatal care coverage | Sustained above 90% | 2025 |
| Skilled attendance at birth | Above 90% | 2025 |
| Full immunization by 1 year of age | More than 90% of newborns | 2025 |
| Family planning need met | Above 90% at national and sub-national level | 2025 |
| Hypertensive and diabetic individuals with controlled disease | 80% at household level | 2025 |
2. Cross-Sectoral Goals Related to Health
| Goal | Target | Year |
|---|---|---|
| Reduction in current tobacco use | 15% reduction | 2020 |
| Reduction in current tobacco use | 30% reduction | 2025 |
| Reduction in stunting of under-5 children | 40% reduction in prevalence | 2025 |
| Safe water and sanitation for all | (Swachh Bharat Mission) | 2020 |
| Reduction of occupational injury | By half from current 334 per lakh agricultural workers | 2020 |
C. Health Systems Strengthening
1. Health Finance
| Goal | Target | Year |
|---|---|---|
| Government health expenditure as % of GDP | From 1.15% to 2.5% | 2025 |
| State sector health spending | >8% of their budget | 2020 |
| Households facing catastrophic health expenditure | Decrease by 25% | 2025 |
2. Health Infrastructure and Human Resources
- Ensure availability of paramedics and doctors as per IPHS norms in high-priority districts by 2020
- Increase community health volunteers to population ratio as per IPHS norm in high-priority districts by 2025
- Establish primary and secondary care facility as per norms in high-priority districts by 2025
3. Health Management Information
- District-level electronic database of health system components by 2020
- Strengthen health surveillance system and establish disease registries by 2020
- Establish federated integrated health information architecture, health information exchanges, and national health information network by 2025
Key Policy Thrusts of NHP 2017
- Universal Health Coverage (UHC) - Assuring quality health services to all without financial hardship
- Health and Wellness Centres (HWCs) - NHP 2017 envisioned HWCs as the foundation of India's health system (1.5 lakh HWCs under Ayushman Bharat)
- Medical pluralism - Encouraging AYUSH systems alongside allopathy
- Strengthen primary health care as the backbone of the system
- Reduce out-of-pocket expenditure and catastrophic spending
- Cross-sectoral action - Health in All Policies approach
Exam Quick Summary Table
| Point | Value |
|---|---|
| Previous health policies | 1983, 2002 |
| Health expenditure target (% GDP) | 1.15% → 2.5% by 2025 |
| Life expectancy target | 67.5 → 70 by 2025 |
| TFR target | 2.1 by 2025 |
| IMR target | 28 by 2019 |
| U5MR target | 23 by 2025 |
| MMR target | 100 by 2020 |
| NMR target | 16 by 2025 |
| SBR target | Single digit by 2025 |
| TB elimination | 2025 |
| Kala-azar elimination | 2017 |
| Leprosy elimination | 2018 |
| HIV/AIDS target | 90:90:90 by 2020 |
| Tobacco reduction | 15% by 2020, 30% by 2025 |
| Stunting reduction | 40% by 2025 |
Park's Textbook of Preventive and Social Medicine, pp. 977-978
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