Care of Low Birthweight Infants in a Health Facility - A Case Study Approach

Background: Nearly 20 million infants are born low birthweight (LBW) ( <2500g) each year. LBW infants are born premature and/or growth restricted, and require additional care in the facility given their increased risk for morbidity and mortality. We examined the current health facility standards around feeding and care of LBW infants in three countries in Sub-Saharan Africa and South Asia.

Methods: This analysis is part of a multi-site, mixed-methods, formative Low Birthweight Infant Feeding Exploration (LIFE) study. We examined a facility needs assessment, a retrospective chart review, and a prospective in-facility observation cohort (IFO). These study activities are used to assess resources to, feeding patterns of, and care practices for the care of LBW infants (1500g - <2500g) in 12 health facilities across four study sites in India (2), Malawi (1) and Tanzania (1).

Results: Access to basic equipment and key medications varied within and between sites and was not universal; head circumference tapes, length boards, ventilators, surfactant and total parenteral nutrition were particularly limited. Staffing was a constraint in some facilities with a heavy reliance on nurses (Table 1). Limited documentation of feeding type and anthropometrics pose challenges to clinical decision-making. Health facilities promoted exclusive breastfeeding; access to breastmilk alternatives (formula, donor human milk, parenteral nutrition) or supportive tools for milk expression were minimal and often cost prohibitive.
LBW infants in our cohort can be classified into three phenotypes: term small for gestational age (SGA), preterm appropriate for gestational age (AGA), or preterm SGA. Term SGA infants were predominant in the Indian sites and preterm SGA infants predominated in the African sites. The majority of LBW infants in the cohort were female (57.4%), born vaginally (77.0%), and discharged within 7 days (85.1%), a third of which were cared for in the neonatal intensive care unit. Of the total 148 LBW infants followed up to facility discharge, 3 (2.0%) neonatal deaths occurred.
Lactation support and counselling was neither universal nor continuous. Additional barriers to exclusive breastfeeding included delayed lactogenesis, delayed initiation of breastfeeding, and poor feeding quality at discharge. Figure 1 shows that the majority of infants are exclusively breastfed, with breastmilk expression most common in the African sites. Postnatal weight loss was common with a mean weight loss of 2.4g (Standard deviation (SD): 5.8g) over the hospital stay, which was 4.4 days on average (SD: 4.5; range: 0 - 30.5).

Conclusion: Resource, capacity, and documentation constraints at the facility-level hinder the quality of care provision to vulnerable LBW infants. Without targeted lactation support and alternative feeding options (where appropriate), LBW infants will not be set up for successful feeding post-discharge and may be at increased risk for growth faltering, morbidity and/or death.