ight million low birth weight (LBW) infants
constituting one third of the total annual births are born each year in
India as a result of intrauterine growth restriction and/or prematurity
[1]. Combined efforts of the obstetricians and neonatologist along with
advancement in technology and perinatal care have greatly improved the
survival rates of LBW infants over the last two decades. However, these
infants remain at risk of developing a wide array of complications not
only in the immediate neonatal period but also in later life. Although
most organs are immature, brain in particular is especially susceptible
to the perinatal insult which leads to high rates of long-term
neurodevelopmental disabilities.
There is a paucity of data on long term neurological
outcome of LBW infants from our own country. The only study from India
which has prospectively followed the cohort of LBW infants weighing <
2000 grams from birth to adulthood found that 5% had mental retardation,
4.8% had cerebral palsy and 1.5% had sensorineural hearing loss at 3 yrs
of age; and 17% had intelligence quotient (IQ) less than 70 at 6 years
of age. Also the preterm small for gestational age (SGA) children had
the lowest IQ among preterm AGA and term AGA infants [2-4]. Nair, et
al. [5] found significantly lower self-esteem scores at 13 years of
age.
Strategies to ensure neurological intact survival
start right from the antenatal interventions. Treatment with antenatal
steroids has not only shown short term neonatal benefits including
reduction of cerebroventricular hemorrhage, but also associated with
less developmental delay and a trend towards reduction in the risk of
cerebral palsy between 2 to 6 years of age [6]. Magnesium sulfate
therapy in women at risk of preterm birth has reduced the risk of
cerebral palsy and gross motor dysfunction in their child [7].
Therapeutic hypothermia is the most established neuroprotective therapy
available for hypoxic ischemic encephalopathy (HIE); however it is still
not being used much in developing countries including India due to
issues like availability of the therapeutic window, effect of natural
hypothermia while transportation and the safety concerns. Erythropoietin
administration in term newborns with HIE has resulted in improved
neurologic examinations, as well as decreased death, disability and
incidence of cerebral palsy at 18 months [8], but more data are required
in this field.
Kangaroo mother care (KMC) has been a big boon in
resource limited set ups like ours and also shown to improve
neurological outcome [9]. Similarly promotion of prolonged and exclusive
breastfeeding has shown to improve the child’s cognitive development at
6.5 years of age [10]. Another simple intervention is the strict
maintenance of the oxygen saturation in the desired range specifically
to prevent retinopathy of prematurity (ROP). The available evidence
supports the target saturation to be in the range between 90-95% due to
the concern of increased mortality with the lower targets range of
85-89% [11].
An important aspect while monitoring LBW infants is
to anticipate and timely intervene for the common morbidities like
hypoglycemia, hypothermia, respiratory distress, jaundice, sepsis and
meningitis which add not only to the mortality but also leads to
neurodevelopmental impairment. Ventilation per se is an
independent risk factor affecting the brain development. Continuous
positive airway pressure (CPAP) is the preferred initial mode for
stabilizing preterm infants with respiratory distress as compared to
mechanical ventilation but the available data has shown no difference in
the composite outcome of death or neurodevelopmental impairment at 18-22
months of corrected age [12]. Apart from these established modalities,
various other therapies have been tried to improve long-term
neurological outcome. Caffeine therapy was found to decrease the
incidence of cerebral palsy and cognitive delay at 18 to 21 months of
age in VLBW infants but the follow up at five years was no longer
associated with a significantly improved rate of survival without
disability [13].
Short of universal hearing screening in our country,
at least high risk LBW infants should be definitely screened for any
hearing impairment before discharge from the hospital. This is because
early intervention in hearing-impaired infants improves language and
communication skills thus improving the long term outcome. ROP is
emerging as one of the leading causes of preventable childhood blindness
in India. ROP screening and timely intervention in at risk LBW infants
will help in combating this problem to a large extent and will improve
the visual outcome. Prior to discharge, a detailed medical and
neurological assessment should be done and early intervention should be
started in the NICU itself. All health facilities caring for sick
neonates must have a structured follow up program and formal
developmental assessment must be performed at regular intervals with the
help of a multidisciplinary team.
Neurodevelopmental morbidities remain high and have
not kept pace with the improvements in the survival of LBW infants.
Survival and short term morbidities are no longer considered as the end
points to measure perinatal outcomes. Target should be to achieve the
best antenatal, neonatal and postnatal care supplemented with good
follow up services with early intervention programs to achieve the best
potential of LBW infants. Research to prevent and/ or reduce the LBW
infants should continue. This should be supplemented with the
improvement in the psychosocial risk factors encountered by the children
in their early years of life. With upcoming Sick Newborn Care Units in a
big way in our country, there is a need to develop long term follow up
program to middle age and beyond not only to assess the
neurodevelopmental outcome but also its impact on the family and the
society. Further, these programs should also determine the morbidities
related to cardiovascular, respiratory and metabolic disorders too to
give these LBW infants a complete intact survival.
1. State of India’s newborns. Available at:
http://www. healthynewbornnetwork.org/sites/default/files/resources/
India-SOIN.pdf. Accessed on 20 May 2013.
2. Chaudhari S, Kulkarni S, Barve S. Neurologic
sequelae in high risk infants - A three year follow up. Indian Pediatr.
1996;33:645-53.
3. Chaudhari S, Bhalerao MR, Chitale A, Pandit AN,
Nene U. Pune low birth weight study–a six year follow up. Indian Pediatr.
1999;36:669-76.
4. Chaudhari S, Otiv M, Chitale A, Pandit A, Hoge M.
Pune low birth weight study–cognitive abilities and educational
performance at twelve years. Indian Pediatr. 2004;41: 121-8.
5. Nair MK, Chacko DS, Paul MK, Nair L, George B,
Kumar GS. Low birthweight babies–outcome at 13 years. Indian Pediatr.
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7. Doyle LW, Crowther CA, Middleton P, Marret S,
Rouse D. Magnesium sulphate for women at risk of preterm birth for
neuroprotection of the fetus. Cochrane Database Syst Rev.
2009;1:CD004661.
8. Zhu C, Kang W, Xu F, Cheng X, Zhang Z, Jia L,et
al. Erythropoietin improved neurologic outcomes in newborns with
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9. Ohgi S, Fukuda M, Moriuchi H, Kusumoto T, Akiyama
T, Nugent JK, et al. Comparison of kangaroo care and standard
care: behavioral organization, development, and temperament in healthy,
low-birth-weight infants through 1 year. J Perinatol. 2002;22:374-9.
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Platt RW, Matush L, et al. Breastfeeding and child cognitive
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Poets C, Rabi Y, et al. Effects of targeting higher vs lower
arterial oxygen saturations on death or disability in extremely preterm
infants: a randomized clinical trial. JAMA. 2013;309:2111-20.
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WA, Gantz MG, Walsh MC, et al. Neurodevelopmental outcomes in the
early CPAP and pulse oximetry trial. N Engl J Med. 2012;367:2495-504.
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RE, AsztalosEV, et al. Survival without disability to age 5 years
after neonatal caffeine therapy for apnea of prematurity. JAMA.
2012;307:275-82.