Contribution: Dr Vijay Kumar, M/s Minakshi Sharma
Case Study –seriously ill low birth weight who has recovered
This is a case study of a baby who was born with low birth weight who was seriously ill during neonatal period. He was brought up by enthusiastic village based parents who are educated and in teaching profession. His life was saved and through the adoption of an integrated home based approach he has grown physically as a normal child without any stunting. He is doing exceptionally well at school at the age of 4 years. This was made possible through transitioning and support provided by SWACH staff with guidance on child nutrition, early childhood development, prevention of accidents and injuries and through immunizations, and early and appropriate response to illness with adoption of measures that would help early recovery from illness. It also illustrates how through support to the mother, lactation can be resumed and exclusive breast feeding assured after the age of 1 month.
K was born to R on 7.10.12 in a private hospital in Yamunanagar in Haryana. Both the parents are well educated and working as teachers. K was 2 kg at birth. The baby was born after 35 weeks of gestation. Breastmilk was not initiated, he had severe breathing problem and vomiting after 2 days of birth. Heart disease was suspected and all tests for heart disease were done in a large well equipped private hospital, but all the tests were negative. He was kept in ICU where he was treated with IV glucose and given oxygen. Mother was encouraged to express her milk and throw it by SWACH field staff. When he was 8 days old, K developed breathing problem again. He was very sick and he was referred to PGI Chandigarh. He was diagnosed to be suffering from bilateral fungal pneumonia (most likely hospital acquired) and he remained admitted there for a week. He was given oxygen and amphotericin B IV.
SWACH staff remained in constant contact with the family through phone and messages. During the illness the mother and child were separated. Therefore breast feeding was interrupted. On advice from SWACH, she kept on expressing her milk and throwing it out since it could not be sent to PGI Chandigarh. After 8 days, K was discharged from PGI. At the time of discharge, he was on IV amphotericin B daily and an IV line was maintained. Following discharge from the hospital, the mother resumed breast feeding. There were difficulties in breast feeding for a period of 3-4 days but as the child improved from illness and the mother felt more confident the breast feeding process improved.Contact was made with the Paediatrician in the district hospital and the doctor there agreed to administer amphotericin B IV on a daily basis as an outpatient. He was given this treatment for one week. The family was supported and guided by the doctor in SWACH. Both the parents were very positive and they followed the advice given by SWACH. Daily home visits were made by SWACH field staff for 15 days and guidance was provided on exclusive breast feeding, hands washing, observing for danger signs, immunizations and continued interaction between the mother and the child. The mother was supported and encouraged to eat well, rest and relax and interact with the child as much as she could.
After discharge from the hospital the mother started breast feeding on demand and massaged the child lightly and stroked him lovingly from head to toes3-4 times in a day. She also talked to the child in the same way as was advised by SWACH staff. K again developed breathing problem and was admitted to PGI Chandigarh for a period of 4 days. But this time, the mother insisted that she will stay with the child and continue to breastfeed him, talk to him and play with him. At 6 weeks of age the child was discharged and only vitamins were continued. SWACH staff started visiting the family on regular basis and phone contact was also made regularly.
At around 4 weeks of age (after recovery from fungal infection), the parents were able to provide visual and auditory stimulation to the child daily. They remained in contact with SWACH staff and discussed their problems on day to day basis like excessive crying, spitting of milk for which burping was advised. At 6 weeks of age K was 2.3 kg. parents continued to talk and play with the child. At 7 weeks, his weight was 2.7 kg. By now the mother was quite confident she started to like the child and she was satisfied about breast feeding. Over the next few weeks she became progressively more confident. She continued to exclusively breast feed the child. The child weight increased to 3 kg at 8 weeks of age. The major concerns of the parents were tackled on phone and by doing home visits. These concerns included constipation, spitting of milk, excessive crying and mild rashes on the skin. These concerns were treated without any medication. The family was supported and encouraged to play, copy, laugh and talk to K. The mother states that that her worries about different problems were reduced since the child became more responsive and she also got busy in playing and interacting with K.
At the age of 3 months K weighed 4.2 kg and he became active and quite playful. The mother and the baby now became quite sensitive and responsive to each other. The mother said that when she brought her face close to the baby’s face the child loved the mother’s face. She said that my child loves to be massaged. The weight of the child showed slow but regular increase to 5 kg at 4 months age. At 6 months K started to sit with support and parents were very happy. At 6 months of age the child weighed 5.8kg. At this time the mother was advised to start giving semi solid food to the child. R was told about the type of food to be given, how to give semi solid foods to the child so that he develops taste for different foods. Initially the mother faced many challenges because he would spit food, not accept it and create a lot of fuss. She got a lot of guidance and became quite patient. Slowly feeding became fun time and the mother was able to assess the likes and dislikes of the child. ASHA of the village made home visits at least once a week and sought guidance from SWACH staff. His immunizations were delayed by a couple of weeks but eventually all the vaccinations were completed as per the schedule of the Government.
R was advised by SWACH staff and ASHA to take K to anganwari centre on daily basis, so that he interacts with other children , eats and plays with them. She followed the advice and started going to anganwari centre daily. She found that AWW only provides supplementary food to the children but the AWW does not spend time with mothers to talk about play and communication with the children. Therefore she took the initiative herself (as she is a teacher). She started discussing with the mothers about how to play and communicate with the child. She did this for a few days but she stopped going to the center since she did not find this to be useful.
R was advised not to be harsh with K as she is a teacher and was in a habit of disciplining the children in the school. She was explained the dangers of harsh treatment and she agreed to the advice. Since K was loved a lot by the parents the family bought a lot of toys for K to play. When SWACH staff visited them she was told to give only one toy to the child at a time as too many toys would confuse him. The mother realized that she should play with her child and she also found out that K prefers to play with her and with household material but did not like to play with toys . K grew up very well between 1- 2 years, as this period was better with less illnesses and concerns. Parents used to spend a lot of time with K and he became very active. Regular phone contacts were made with the family and messages were sent on regular basis on the phone. When K was of two and half years of age mother wanted to send him to a private school which was very far off from home. She was advised that the child is too young and it is not a good idea to send him to school. She soon got convinced that she herself was the best teacher at this stage. She dropped the idea of sending him to school.
At the age of 2 years and 3 months K was a very active playful smart child weighing 12.2 kg. He had very good vocabulary and communicated very well. He ate food well without fuss. He was able to coordinate and play with bat and ball very well. The mother engaged him in household work which he copied. He was able to remove his clothes but had difficulty in putting them on. At this stage, he started to be toilet trained with an occasional accident. He could identify objects, fruits, vegetables, could count, recognized colors and spoke clearly. He was able to fill colors but sometimes spilled them. He played with his mother with dough and enjoyed when she makes toys and play material with toys.
The parents have started to send him to a private school in a township. He has been going to school for about one year. The mother communicates with him in English. She feels that K has become very good in understanding English and speaks many words. He knows Hindi and some Haryanvi. She says that since she started to speak to him in these languages before K was one year age the child has become very good in communication in these languages. He is trilingual. The child is very smart in mathematics also. The mother says that he is the smartest child in the village and he tops his class in the school.
The parents are very pleased with the progress that has been made by K and even though there were numerous challenges in the first couple of months of life, they have been very fortunate that the child has made very good progress. He is normal weight for age, height for age and height for weight at 4 years of age.