CHAPTER 2

THEORITICAL REVIEW

2.1 Review of Theoretical low Birth Weight ( LBW)

2.1.1 DefinitionAccording to the (Atikah 2010) infants of low birth weight (LBW)

babies are born weighing 2,500 grams is less than regardless of

pregnancy. infants of low birth weight (LBW) can be two (2) categories,

infants with very low birth weight (BBLSR) with birth weight 1000 to

1500 grams birth weight and extremely low (BBLASR) with a birth

weight less than 1,000 grams. (Atika 2010)

Generally low birth weight infants (LBW) is associated with gestational

age were not enough months (prematurely) that caused dismaturitas.

which means lair term infants (gestational age 38 weeks), but the smaller

birth weight of pregnancy, which did not reach 2,500 grams. (Atika

2010). All infants with a birth weight equal to or less than 2500 grams

lair called low weight infants (LBW) asrining (2013).

Can be concluded that Low Birth Weight (LBW ) infant who are born

weighing less than or equal to 2500 grams, regardless of the gestational

age, well with masses 38 weeks gestation and infant born with less than

27 weeks gestation.

According to Anik (2013), Classification of newborns based on

gestational age or age of gestation, that is:

2.1.1.1 preterm infant (preterm infants: gestational age of less than 269

days (37 grams)

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2.1.1.2 terms of infant (term infants: gestational age 259-293 days (37-

41 grams)

2.1.1.3 post-term infant (baby over a month, 254 days of gestation or

more 42 grams /or more)

Based on the this classification, according to (Anik, 2013), low Birth

Weight (LBW) can be grouped into:

2.1.1.4 Premature pure.

are infants with gestation <37 mg or 259 days and the weight in

accordance with the pregnancy or can be called in

accordance preterm neonates during pregnancy.

2.1.1.5 Dismaturitas.

Infants born weighing less than the weight that should for the

gestation, the

baby could mean retardation growth and a small baby for

pregnancy (KMK)

2.1.2 Etiology

The causes of LBW is multifactoral, among other things sorely lacking

maternal nutrition during pregnancy, impaired growth in the womb

( fetal growth is low ), placenta factors, infections, mothers uterine

abnormalities, trauma,(NANDA 2012)

According to (Atika 2010) the factors causing LBW among others are:

2.1.2.1 The Mother Factors:

a. Nutrition during pregnancy is lacking.

b. Age when the pregnancy is less than 20 years old or over

35 years.

c. Pregnancy and birth range is too close.

d. Job is too heavy.

e. Maternal chronic diseases such as hypertension, heart

disease, vascular disorders, active smokers, HIV/AIDS.

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2.1.2.2 The pregnancy factor:

a. Pregnant with hidromnion, Gemelli pregnancy, antepartum

b. Haemorrhage.

c. Pregnancy complications such as preeclampsia, eclampsia,

premature rupture of membranes.

d. Placenta previa

2.1.2.3 The fetal factors:

a. Congenital defects, infection inside the uterus.

b. Factor is still unknown.

c. Chromosomal abnormalities (trisomy autosomal)

d. Aplasia of the pancreas

2.1.2.4 The environmental factors

a. Residing in the highlands.

b. Exposed to radiation.

c. Exposure to toxic substances.

2.1.3 Pathophysiology

Placenta previa, solucio placenta And premature rupture of membranes

could result in placenta insufficiency so as not to transfer nutrient to the

fetus and can causes premature birth or low birth weight. Volume

maternal malnutrition can lead to decreased blood and lowers blood to

the placenta this causing placenta insufficiency and reduced transfer of

nutrient to the fetus causing the occurrence of LBW. In response to cold

stimulations, the baby’s body will issue a stimulation norepenefrin

metabolism of fat reserves to produce a calorie of fat which is then

carried by the blood to the tissue.

Cold stress can lead to hypoxia, metabolic acidosis and hypoglycemia.

Increased metabolism in response to cold stress will increase the calorie

and oxygen. When oxygen is available can not meet the needs, reduced

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oxygen tension (hypoxia) and this will make the situation worse because

lung volume (immature lungs)

Cold stress will be responded by releasing norepenefrin baby causes

pulmonary vasoconstriction. Consequently decrease pulmonary

ventilation effectiveness tat reduced blood oxygen levels. This condition

glucose metabolism and causes anaerobic glycolysis leading to increased

latic acid, the same conditions that produce the fatty acid metabolism

increasing contribution acidosis. Failure eliminate anaerobic metabolism

of glucose metabolism more than aerobic thereby accelerating the

occurrence of hypoglycemia.

Low birth weight (LBW) are relatively less able to survive because of

the structure of the immature anatomy and physiology and biochemical

function has not worked as older infant. The shortage affect the infant’s

ability to regulate and maintain body temperature within normal limits,

because the temperature control center in the brain is not yet mature, the

lack of subcutaneous fat and body surface relatively wide will cause the

body to lose heart more. Shivering response in infant less or non-

existent, so baby cannot increase body heart through activity. Beside skin

reflex control is still lacking. (Asrining, 2013)

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2.1.4 Pathway (NANDA 2012)

Prematurity Dismature

Maternal factors of age (<20 years) parity, race, infertility, pregnancy history is not good, abnormal uterus, etc.

Placental factors: vascular disease, multiple pregnancy, malformations tumors.

factor of fetal abnormalities, chromosomal malformations TORCH, multiple pregnancy.

Disturbance factor the exchange of substances between mother and infant.

intra-uterine growth

retardation

wall of lower part of the uterus is weak

open uterus before

pregnancy

infants born prematurely

body weight <2500 grams

immature digestive mechanical function

sucking and

swallowing

reflexes

weak

digestive and absorption disorders

lungs function is not prematur

coordination between suction and swallowing reflexes by closing the epiglottis is not well developed

Nutrition less than body

requirement

Ineffective breathing pattern skin thin, transparent

and sub-cutaneous fat little

asfiksia

Invansive action OGT/ NGT Intravenous

risk of impaired skin integrity

central regulation of body temperature has not been regularly

ineffective thermoregulation

immunological system is not well developed

special care /

incubator

Acute pain

Risk of infection immature central nervous

system

separated from parents

periventricular hemorrhage

Change of family process

developmental retradation

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2.1.5 Sign And Symptom

According to Anik ( 2013) low birth weight infant (LBW) highly

variable and that is most evident in infant with gestational age shortened.

As for the traits of characteristics of Low Birth Weight ( LBW) are:

2.1.5.1 General Proportions.

Preterm infants have large heads in proportion to body size.

Head basic the circumference equal to or less than 33 cm.

lanugos air is still a lot. Body length generally equal to less than

40 cm, chest circumference equal to or less tan 30 cm, weight

equal to less tan 2500 grams.

Thorax is relatively small, while the abdomen is relatively large

and small limbs compared to other body members.

2.1.5.2 Activity

Weak muscle tone and the lower the gestational age, the less

thechild’s activity.

2.1.5.3 Control Of Temperature

Preterm infant tend to have subnormal. This was caused by poor

heat production and increased heat loss. Heat loss will increase

due to the relatively large body surface and the absence of

subcutaneous fat, as well as the immature state of the heat

regulating center.

2.1.5.4 Respiratory System

Infant respiratory muscles are week and underdeveloped

respiratory center as well as the lack of production of

surfactants to reduce surface tension of the lungs. Nasal

passages are very narrow and injury to the nasal mucosa easily

occur. Ineffective cough reflex which causes fluid inhalation.

2.1.5.5 The Circulatory System

Heart is relatively small at birth, in some preterm infant it works

slow and weak, especially in the blood vessels. Often poor

peripheral circulation and blood vessels too weak wall of first

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on intracranial hemorrhage seen in preterm infant. Systolic

pressure of preterm infants is 45-60 mmHg, while the diastolic

pressure varies from 30-45 mmHg. Pulse varies between 100-

160 / min

2.1.5.6 Digestive System

The lower of gestational age, the more weak sucking and

swallowing reflex, the smallest infants are unable to swallow

effectively. Digestive depends on development of the digestive

tract. Leading to weak intestinal distension and he onset the

digested material retention. The liver is relatively large but

underdeveloped which predisposes to jaundice.

2.1.5.7 Urinary System

Renal function is less efficient because of a declining

glomerular filtration rate that results in a decreased ability to

concentrate urine, and the become slightly. Less easy developed

tubules causing disruption of lower and electrolyte balance.

2.1.5.8 Nervous System

Development of the nervous system is largely dependent on the

degree of maturity. In premature infant more reflex and general

tonic neck reflex and tendon reflex are generally less well.

According to Anik (2013) the signs and symptoms of general of low

birth weight LBW) are:

a. Weight less than 2,500 grams

b. Body length less than or equal to 45 cm.

c. Chest circumference of less than or equal to 30 cm.

d. Head circumference less than 33 cm. gestational age less than 37

weeks

e. Vernik caseating little / no.

f. Fatty tissue under the skin a little.

g. Soft skull bones easy move.

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h. Weak cry.

i. Thin skin, red and transparent.

j. Hypotonic muscle tone.

k. The location of the ear decreases.

l. Enlargement of one or two kidneys.

m. Small head size.

n. Feeding problems (swallowing reflex and suck less).

o. Anemia

p. Hyper billirubinemia.

q. Thermoregulation.

2.1.6 Examination Support

2.1.6.1 Diagnostic examination according to Anik (2013) For Low

Birth Weight (LBW) are :

a. white blood cell count: 18.000/mm3, neutrophils increased to

23,000 24.000/mm3, first day after birth (decreased when

sepsis).

b. Hematocrit (Ht): 43% - 61% (an increase of up to 65% or

more indicates polycythemia, decreased levels indicate

anemia or hemorrhagic prenatal).

2.1.6.2 Examination level of bilirubin:

a. Normal bilirubin levels in preterm infants is 10 mg / dl, with

6 mg / dl on the first day of life, 8 mg / dl 1-2, and 12 mg / dl

in 3-5 days.

b. Hiperbilirubin occurs because the maturation of liver

function.

2.1.6.3 Examination glucose levels :

a. Destrosix: The first drops of glucose for 4 -6 hours after birth

an average of 40-50 mg / dl increased by 60-70 mg / dl on the

third day.

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b. monitoring of electrolytes (k Na.. CI): usually within normal

limits.

c. blood gas monitoring as needed.

d. shake test.

2.1.7 Medical Management

2.1.7.1 According to Anik (2013) general management of infants born at

low birth weight (LBW) which need to be prepared and in

anticipation of the treatment are :

a. Baby's body temperature regulation:

Regulation of body temperature in the show to reach a neutral

temperature environment in accordance with the protocol

with less regulation means the baby's body temperature by

using an incubator babies placed in incubators with

temperature:

infants <kg is 350c

infants from 2 to 2.49 kg is 340c

and incubator temperature can be scaled 1c per week for

infants over 2 kg. If no incubator, heating can be done by

wrapping the baby and put the bottles warm surroundings.

b. Oxygen therapy and help ventilation

c. Maintain the balance of fluids and electrolytes to replace the

WL (insensible water loss) and maintain the good hydration

and electrolyte concentrations of glucose and normal plasma.

d. Giving of adequate nutrition:

nutrition of preterm infants with low birth weight may require

careful feeding, and some even requiring intake LBW with

sonde or parenteral nutrition. way of providing nutrition in

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infants with low birth weight is the amount of fluid

administration first 1-5 ml / hour. the amount of fluid that is

given at 60 ml / kg / day. When giving of drink to note in

order to avoid penemonia aspiration is to put the baby on the

right side to petrified gastric emptying, or in a half-sitting

position on his lap.

Or by elevating the head and shoulder 300 in a crib. At the

time of drinking it should be considered whether the baby's

skin color to blue and the presence of respiratory problems or

stomach bloat. To prevent bloated stomach, the baby was

given a sip, slowly and carefully. The addition of milk should

not be more than 30 ml - 5 ml each time feedings. After

drinking in the seat the baby or put on the shoulder for 10-15

minutes to remove the air in the stomach

e. Hyperbilirubinemia management:

Hyperbilirubinemia usually can be treated effectively with

careful monitoring bilirubin levels and implementation of

light therapy.

f. Prevention and treatment of infection:

prevention of infection in low birth weight can be done is to

separate the infants who become infected with HIV-

uninfected infants. And wash your hands before and after

holding the baby as well as other measures such as, clean the

baby bedding, baby room cleaning, bathing the baby,

umbilical cord hygiene and wear clean / sterile for the

officers. And for visitors only be seen from the glass.

use of antibiotics for the treatment of infections appropriate

doses. and when there is a strong suspicion of infection

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indicated the baby broad spectrum antibiotics can be given.

As well as for the consideration of antibiotics and anti

staphilokokus should that have experienced a large number of

procedures or who have been in care for a long time in the

hospital

g. Monitoring of a PDA (patent ductus arteriosus):

initial management of PDA in LBW usually conservative,

adequate oxygen, fluid restriction and diuretia.

2.1.8 Prognosis

According to Anik (2013) the prognosis of infants born low birth weight

(LBW) depending on the severity of prenatal problems, eg gestation (the

younger the more severe the lower the gestational age infants, the higher

the death rate) than that of the other factors that influence birth weight

low as, social, economic, parental education and care during pregnancy

and post-natal care and others.

2.1.9 Complication

According to Anik (2013) complications that can arise in low birth

weight (LBW) is as follows:

2.1.9.1 Idiopathic respiratory distress syndrome.

Idiopathic respiratory distress syndrome occurred in 10% of

preterm infants with progressive pulmonary consolidation looks

terliat due to lack of surfactant that lowers the surface tension in

the alveoli and prevent. Collapse at the time of or shortly after

birth

2.1.9.2 Takepnea in newborns.

Takepnea in newborns is the most edematous lung preterm

infants at term or within a few hours after birth, causing

tachypnea.

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2.1.9.3 Fibroplasias retrolentral.

Fibroplasias retrolentral is the high oxygen concentration in the

area of the artery that causes the growth of the fiber or fibrous

tissue at the back of the lens and retinal detachment causing

blindness.

2.1.9.4 Attacks Apnea

Apnea is an attack caused the inability of the respiratory center

or functional relationship with hypoglycemia or intracranial

hemorrhage.

2.1.9.5 Necrotizing enterocolitis (NEC).

Necrotizing enterocolitis (NEC) the occurrence of abdominal

bloating baby vomits out blood from the rectum, and loose

stools, shock and suffered intestinal perforation. This is where

the symptoms occur in infants with a history of asphyxia or

occurs after exchange transfusion.

2.1.9.6 Hypothermia.

Hypothermia is a decrease in body temperature is below

normal.

2.1.9.7 Hypoglycemia

Hypoglycemia is shortages or decrease blood sugar levels.

2.1.9.8 Breath distress syndrome.

Breath distress syndrome is the lack of surfactant in the alveoli

of the lungs due to lack work optimally make surfactant.

2.1.9.9 Hyperbilirubinemia.

Hiperbilirubinemia are increased levels of bilirubin in the blood

is worth more than the normal levels.

2.1.1 Assessment Assessment was done by a nurse can to obtain objective data and

subjective data from mother by Anik (2013) are:

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2.2.1.1 Previous health history

a. Whether the mother had experienced chronic illness,

hypertension, diabetic toxemia,

b. Mother had experienced a menstruation, pervious

c. pregnancy and history about psychosocial like mother

nutrition (malnutrition, caffeine consumption, drug use,

smoking,alcohol consumption, etc).

2.2.1.2 Mother history.

a. Maternal age below 16 years or above 35 years.

b. low socioeconomic backgrounds

c. lack of nutrition during pregnancy

d. Genetic consultation ever undertaken

2.2.1.3 History of pregnancy

a. Have had multiple pregnancies

b. Pregnancy distance is too close

c. Hard abortion history

d. No treatment before pregnancy

2.2.1.4 Physical Assessment

a. Circulation

1) Pulse apical my quickly and regularly or irregularly

within the normal range (120-160 seconds per

minute).

2) Heart murmur that can be heart to determine ductus

arteriosus (PDA).

b. Breathing

1) May be shallow, irregular and intermittent

diaphragmatic breathing or periodic (40-60 times /

minute)

2) Breathing nostrils, supraexsternal or subternal

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retractions, also the degree of cyanosis which max

exist.

3) There is a gizzard sounds on auscultations,

indicating syndrome respiratory distress.

c. Hematology

1) low birth weight (LBW) has predisposing factors in

hematologic problems

2) low birth weight (LBW) has an easy fragile

capillaries, low plasma prothrombin formation of red

blood cells is slow, and hemolysis.

d. Gastrointestinal

1) The digestive tract is not functioning LBW as in term

infants

2) Lack of coordination of sucking and swallowing until

the age of 24-35 weeks.

3) Spinkter incompetent cardiac

4) Slow gastric emptying time.

5) Less able to absorb fats and protein digest

6) Decrease or not the coordination of motility in the

digestive system.

e. Genitourinary

1) On low birth weight (LBW) can not excrete the

metabolism on the urine and maintain fluid balance,

acid-base and electrolyte.

2) LBW baby female who is a prominent clitoris, labia

majora undeveloped.

3) Baby male who is a prominent yet LBW scrotum with

small rugae. testicles have not dropped in the scrotum.

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f. Neurological

1) Reflexes and movement on neurological tests appear

not resistant, the return movement of partially

developed.

2) Swallow, suck and cough very weak or ineffective.

3) No neurological signs or decline.

4) Eyes may be closed if it has not reached the gestational

age 25-26 weeks.

5) Unstable body temperature or hypothermia occur.

6) Shaking, seizures and eye swirling usually temporary

but may also indicate a neurological disorder.

g. Temperature

1) Lack of subcutaneous fat, causing a decrease in body

temperature and hypothermia occurs.

2) Absence of reflex control of skin capillary blood

vessels.

3) Inadequate immature muscle activity and body

temperature regulation center in the brain.

h. Skins

1) On LBW have any signs of skin looks shiny and dry.

2) Skin looks red, pink, yellowish. cyanosis or mixture.

3) Looked little vernik caseating.

4) Lanugo hair looked around or in the whole body.

5) Body looked thin, transparent skin looks, smooth and

shiny.

6) looked short nails, yet passes fingertips, sparse hair

and\ even no.

7) Looked pteki or ecchymosis on the skin

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i. Activity and rest

1) In infants of low birth weight (LBW) maybe 2-3 hours

of sleep a day the first few days, an average of 20

hours and cries still audible entry, inactivity, tremors.

2.2.1.5 Assessment response of parents

a. Response

1) Response of parents who have babies born with low birth

weight (LBW) the premature normally be sad, anxious

and afraid of losing her baby.

2) Problems in the family

Ineffective family coping because the baby's condition is

critical so that takes care of the old and the lack of

parental knowledge about how to care for LBW infants

in hospital after discharge from the hospital or the

ministry of health facilities

2.1.2 Nursing Diagnosis

Nursing diagnosis in low birth weight (LBW) by Nanda (2013) are:

2.11.1.1. Risk of imbalance in body temperature related to the failure of

maintaining body temperature, decreased subcutaneous fat

tissue

2.11.1.2. Ineffective of infant feeding patterns related to prematurity

2.11.1.3. Imbalance nutrition less than body requirements related to

inability to receive nutrients, gastrointestinal peristalsis

immaturity

2.11.1.4. Ineffective breathing pattern related to the immaturity of

neuromuscular respiratory and decreased of lungs

expansion

2.11.1.5. Risk of infection related to immunological defenses

inadequate

2.12 Planning

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Nursing action plan based on the nursing diagnoses according to

(Nanda, 2013) are as follows:

1.11.1. Risk of imbalance in body temperature related to the failure of

maintaining body temperature, decreased subcutaneous fat

tissue

Intervention:

a. Put the baby in the incubator or wearing warm enough

clothes and head cover

Rational : To keep the body temperature to remai stable

b. Monitor Axillary temperature

Rational : To observe regular body temperature

c. Monitor for signs of hyperthermia

Rational: To avoid dehydration in infants because of

excessive hot temperatures

d. Monitor serum glucose

Rational: To find out the baby's condition during a

Eugilekimia

e. Monitor for signs of cyanosis

Rational : To prevent cyanosis

2.11.1.2. Ineffective of infant feeding patterns related to prematurity

Intervention :

a. Monitor the baby's ability to suck

Rational: To knowing readiness baby for brast feeding

b. Monitor the infant's ability to reach out breast nipple

Rational: Knowing the baby to suckle reflex interest

c. Instruct the mother to eat nutritious foods during

breastfeeding

d. Rational: To improve the nutrition and protein levels in

breast milk are in need of a baby during the growth process

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d. Advise mothers for not limited breastfeed time Rational: To

help effectiveness in the process of breastfeeding infant

e. Monitor the increase in charging breast milk

Rational: To know the availability of water breast milk

time

2.11.1.3 Imbalance nutrition less than body requirements related to

inability to receive nutrients, gastrointestinal peristalsis

immaturity

Intervention :

a. Help baby on to meet the needs of breastfeeding

Rational : to meet the nutritional needs of income

Monitor signs TPN intolerance, especially protein and

glucose

Rational : To observe the signs of intolerance TPN

b. Follow the procedure to increase the volume

concentration of the formula

Rational : Preventing intolerance in infants

c. Increase knowledge of the importance of breast feeding

mothers to infants

Rational: Improving nutrition knowledge of mothers about

the importance of breast milk for babies

d. Monitor the baby's weight

Rational: to knowing the effectiveness of the intake of

nutrient absorption in infants

2.2.4.4 Ineffective breathing pattern related to the immaturity of

neuromuscular respiratory and decreased of lungs expansion

Intervention :

a. Prevent hyperextension of the neck position.

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Rational : The position of hyperextension can reduce the

diameter of the trachea.

b. Observation of deviation, or signs of respiratory distress.

Rational : To prevent or detect the presence of cyanosis,

apnea

c. Give the side lying position

Rational : Prevent aspiration in infants with excessive

secretions or after eating

d. Observation of respiratory distress, such as retraction,

Tachypnoea, apnea, cyanosis when low O2

Rational : To prevent the occurrence of distressbreathing

e. Keep the ambient temperature remains neutral

Rational : To keep the O2 income evenly and prevent

hypothermia

2.2.4.5 Risk of infection related to immunological defenses inadequate

Intervention :

a. Advise all health care workers to wash hands, wear a mask

and gown before nursing action

Rational : Minimize the possibility of exposure to

microorganisms that cause infections in infants

b. Use a clean / sterile when performing actions

Rational :Minimize transmission of microorganisms through

to encourage the mother to wear a gown before entering the

infant

c. Encourage the mother to wear a gown before entering the

infant spatial

Rational : minimize exposure to microorganisms from

outside

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d. Suggest mothers to wash their hands before contact with

baby

Rational : Prevent transmission of microorganisms via the

hands of mother

e. Teach mothers to breast wiping with water before feeding

baby

Rational : To be clean and healthy breasts and minimal

presence of microorganisms which can cause the baby

illness

f. Limiting the time of visit

Rational : Maximizing time care and rest on baby

2.13 Evaluation

Evaluations on low birth weight (LBW) by (Nanda, 2013) are:

1.11.1. Risk of imbalance in body temperature related to the failure of

maintaining body temperature, decreased subcutaneous fat

tissue

Evaluation result:

Normal body temperature

Body temperature of 360 – 370c

adequate hydration

Gidak seemed to shiver

DBN blood sugar

Acid-base balance DBN

bilirubin DBN

2.2.4.2 Ineffective of infant feeding patterns related to prematurity

Evaluation result:

Clients can breastfeed effectively

showed techniques to overcome breastfeeding problems

Seen satisfied baby after feeding

Mother showed positive self-esteem with breastfeeding

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2.2.4.3 Imbalance nutrition less than body requirements related to

inability to receive nutrients, gastrointestinal peristalsis

immaturity

Evaluation result:

An increase in body weight in accordance with the objectives

Ideal weight according to height

Being able to identify nutritional needs

There are no signs of malnutrition

Showed an increase in tasting and swallowing function

No weight loss

2.2.4.4 Ineffective breathing pattern related to the immaturity of

neuromuscular respiratory and decreased of lungs expansion

Evaluation result:

Demonstrate effective cough and breath sounds loc no

cyanosis and dyspenu capable of removing sputum and able to

breathe easily and do not seem pursed lips .

Showed a patent airway , breath rhythm , respiratory

frekuwensi within the normal range , there was no abnormal

breath sounds

Vital signs within normal range ( blood pressure , pulse

respiration

2.2.4.5 Risk of infection related to immunological defenses inadequate

Evaluation result:

Describing the process of transmission of the disease , factors

that influence the transmission and its management Clients are

free from signs and symptoms of infection Demonstrated ability

to prevent infection Number leokosit within normal limits

Showed healthy behavior