LONG CASE REPORT

LOW BIRTH WEIGHT BABY AND

HYALINE MEMBRANE DISEASE

BY

RANTI ADRIANI
No BP: 1150304212

PROGRAM OF SPECIALIST DOCTOR EDUCATION I

DEPARTMENT OF PEDIATRICS
FACULTY OF MEDICINE ANDALAS UNIVERSITY
 DIAGRAM OF EXAMNATION TIME

January 1, 2018 January 6, 2018 - January 11, 2018 January 15, 2018

Child begin to be Examination and Report

treated at NICU monitoring begins until
of MD hospital the end of monitoringby
examinees

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 LOCAL EVALUATION PATIENT STATUS
Monday, January 15, 2018
Name of Exam Participant: Ranti Adriani
No. BP: 1150304212

I. Patient Identity

Name : Baby FW Father'sname : Mr . Jh

Gender : Male Age of father : 35 years old
Chronological age : 6 days Education : Junior High School
Date of birth : Desember Work : Farmer
31, 20 17
Address : SS City Mother'sname : Mrs. FW

Mother's age : 33 years old

No.Medicalrecords : 9428XX Education : Junior High School
Hospital admission : December 31, 2017 Work : House wife
Patient was accepted by the participant on 6 January 2018 at 13.00 WIB
date
Duration of stay : Until now

II. Anamnesis (Alloanamnesis done with the mother and father of the patient and
through the medical record)
Chieft complaint
Grunting since birth
Current History of the disease
Patient was born on December 31, 2017 at 8 p.mat MD Hospital from mother with
G 4 P 3 A 0 L 2 through sectio caesaria on maternal indication of placenta previa
totalis. Mother came to RSUD S‘s emergency room because the blood out of the
genitals soaking 1 sheet of sarong and no abdominal pain 10 hours before the patient was
born. Maternal blood test results in RSUD S were hemoglobin 7.8 g/d L ,
leucocytes 15.270/mm3, platelets 264.000/mm 3, PT 10.2 seconds, APT T 35.2 seconds ,then
mother referred to MD Hospital.At MD Hospital, mother was in conscious state, blood
pressure 100/60 mm Hg, pulse rate 100 times/minute, respiratory rate 20 times/minute,
looked pale and bleeding was still going on. Baby’s Heart rate was 150-160x/minute, and no

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uterine’s contractions. Mother received IVFD RL 2 lane treatment, injection of
dexamethasone 2 ampoule IV, ceftriaxone 1 gram IV injection (1x administration), 2
pouchfresh blood transfusion. The result of repeat blood test before cesarean action were 9.6
g/dl, leukocyte 34.790/mm3, platelets 250.000/mm3, PT 10.1 seconds, APTT 35.4
seconds and HbsAg negative .
Patient was delivered at 33-34 weeks gestation ( Ballard Score ), birth weight 1900
gram, birth length 45 cm, head circumference 30 cm , with value of American Pediatric
Gross Assessment Record ( APGAR ) was 5 at the first minute and 7 at the fifth minute. The
patient didnot breath spontaneously at birth, with heart rate less than 100 times per
minute. The patient was directly wrapped in plastic and dressed in a cap, warmed
under infant warmer, head positioned and ventilated with positive pressure ventilation
(PPV) 20-30 times in 30 seconds. Heart rate was more than 100 times per minute in the first
minute, the patient started crying with grunting and bluish on the fingertips and legs,
60 % oxygen saturation with Downe score 5 (medium respiratory distress). The patient
wasthen given T piece rescucitation with positive end expiratory pressure (PEEP) 7, oxygen
saturation reached 88-92 % after 5 minute and retraction decreased. Temperature was 36.8°C
with capillary refilling time of less than 2 seconds and glucose at 100 mg/dL. Patient was
given injection of vitamin K11 mg intramuscular (im), then wrapped in a
warm blanket, education provided to the family and the patient was transferred to neonatal
intensive care unit (NICU) room.
Patient was diagnosed aspreterm new born, appropriate gestational age, suspected of
hyaline membrane disease (HMD), differential diagnosed with neonatal pneumonia, and
suspected early-onset neonatal sepsis . Patients was treated in incubator at a temperature
of 35, 5 ° C, and nasal installation continous positive airway pressure ( CPAP ) with
PEEP 8 and FiO 2 (fraction oxygen) 40 %. Oxygen saturation after the installation of CPAP
76-82%, retraction of the chest wall and shortness of breath was still there,
(epigastric retraction, respiratory rate 6 to 8 times / min, and water entry sound
decreased). Patient was performed intubation and ventilator PSPV PIP 14 PEEP 6mode was
installed, Respiratory rate (RR) 40x/min, FiO2 60% and thoracic x-ray examination. The
results of thoracic x-ray examination found a picture of the opacification with air
bronchogram in both lung fields and the hazy heart border, especially on the right side,
the impression corresponding to grade III-IV of HMD. Temporary, patient was fasted, given
total parenteral nutrition with liquid protein glucose (PG)1 80 ml/kg/
day + micronutrient with glucose infusion rate (GIR) 6,1 mg/kgBW/min , protein 1.5

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gr/kg/day. First lineantibiotics was ampicillin sulbactam 2 x 90 mg (50 mg/kgBW/time,
interval every 12 hours) and gentamicin 1 x 8 mg (5 mg/kgBW/time every 24 hours)
intravenously (iv).
At the age of 5 hours, the patient mounted a ventilator PSIMV PIP 14 mode, PEEP
6, RR 40x/min and FiO2 60%. Oxygen saturation 89 -91 %. The left lung breath sound wasas
same as the right. surfactant was given with a dose of 4 cc/kgBB = 8 cc through
intratracheal in 4 divided doses. During the administration of surfactant, the condition of the
baby was stable, with oxygen saturation 90-93 %.Repeat thoracic x-ray examination after
surfactant administration showed the impression of thoracic x-ray improved than before, no
more opacification with air bronchograms in both lung fields, heart border was clear.
At the age of 12 hours, the patient was still mounted ventilator PSIPV PIP 14 mode,
PEEP 6, RR 35x / minute and FiO2 35 % . 90-95% oxygen saturation, spontaneous breath
was present and adequate. Blood gas analysis obtained pH: 7.45; pCO 2 : 23.3 mmHg,
pO 2 : 67.6 mmHg; HCO3- : 16.6 mmol / L; BE: -4,7 mmol / L; SO2 : 78.9%, with the
impression: compensated metabolic acidosis with hypokarbia. The PEEP ventilator setting
was lowered to 5, planned extubation measures if the patient was stable.
At the age of 22 hours extubation was performed on the patient. Patient was
installed NCPAP PEEP 6, FiO2 35%, patient appeared less active and shortness of
breath decreased with minimal retraction in epigastrium,Downe score 1, no apneu
found. Urine and meconium were out, oxygen saturation between 90-94%, capillary refilling
time <2 seconds, given trophic feeding with breast milk 6x2 ml/OGT (orogastric tube).
On the second and third day treatments patient wasinstalled CPAP with PEEP 6
and FiO 2 25%, oxygen saturation between 90-95%. No shortness of breath. The patient still
got parenteral fluid PG2 80 cc/kg withGIR 6.1 mg/kgBW/min, protein 2 gr/kg/day and
lipids 1.5 gr/kg/day. Installation of peripheral inserted central catheter (PICC) was
performed and parenteral fluid was given through a PICC. Patients have been breastfed per
OGT 12x 2,5 cc (15 cc/kgBW). Tolerance to drink was good. Fluid balance was +15 ml with
diuresis 2.1 ml/kg/hour. There was no yellowish and oedema.
On the day of the fourth and fifth treatment, patient was still installed CPAP with
PEEP 5 and FiO 2 2 1%, oxygen saturation between 90-95%. No shortness of breath. Patients
got parenteral fluid PG2 + micronutrient: 114 cc/kg/day via PICC , protein 2,5 gr/kg/day, and
li pid 2 gr/kg/day , breast milk per OGT 12x 7.5 cc ( 47 cc/kgBW) with total calories of 57
kcal /kg/day. The abdomen looked distend with touchy tile. there were defecation and no
vomiting . Fluid balance was + 22 ml with diuresis 3.9 ml/kg/hour. Clinical observations are

5
performed on the patient, increasing the supply of enteral nutrition and monitoring drinking
tolerance.
On the sixth day , the patient was still installed CPAP with PEEP 5 and FiO 2 21%,
oxygen saturation between 91-96 %. No shortness of breath. The patient still received
parenteral fluid PG2 + micronutrient: 86cc /kgb/hour through PICC , protein 3 gr/kg/day, and
lipid 2 gr/kg/day , breast milk per OGT 12x 10 cc (63 cc/kgBW). Total calories obtained 101
kcal/kg/day . Abdomen was not appeared distend. There was defecation and no
vomiting . Fluid balance was + 15 ml with diuresis 2,9 ml/kg/hour. The patient looked pale
and yellowish on the face. Patient was planned for repeat blood examination.

Family History of Disease

The three elder siblings were born enough months. The third patient's sister was died aged 40
days, possibly due to a perinatal infection. No allergy history.

Impression: no family history of preterm birth.

Historyof Pregnancy

Patient is the fourth child of 4 siblings. Mother's last pregnancy was 16 months ago
and mother was not using contraceptive drugs before. During pregnancy the mother felt
healthy, irregular control to the midwife, with antenatal care visit (ANC) only 3 times.
Mother never controled to obstetrician and never performed ultrasound during pregnancy.
Mother regularly took vitamins given by midwife and never consumed drugs and herbs, not
smoking and never got irradiation. Mother did not experience vaginal discharge and fever
during pregnancy and never suffered from hypertension, diabetes, and other diseases before
becoming pregnant.
Mother regularly ate during pregnancy, frequency 3 times per day, spend 1
serving/times with the composition of more carbohydrates. The last weight before delivery
was 60 kg, with weight gain during pregnancy was not optimal ie 5 kg. Mother was with
antepartum hemorrhage during control to midwife on 31 December 2017.

Impression:
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- ANC was not optimal

- Possible antepartum bleeding as the cause of preterm birth.

Socio-Economic History and Environmental Conditions

Mother of 33 year old patient, Moslem, the last education finished at junior high
school, M ethnic, working as housewife. The father of 35-year-old patient, Muslim, the last
education finished at junior high school, M ethnic, working as a farm laborer with income
Rp.1.000.000 / mounth. The patient was born as the fourth child of the first marriage of both
parents. The family lives in a permanent house with a cement floor, consisting of 2 bedrooms,
1 living room and no bathroom. The family use public toilet facilities (toilet washing
defecation). The yard of the house is quite spacious. The source of drinking water comes
from PAMSIMAS (drinking water and community-based sanitation program). Rubbish is
burned. Ventilation of the house is quite good, electricity facilities are from PLN. The cost of
patient care is borne by the state (BPJS).

Impression: Patients come from low socioeconomic class, with poor hygiene and
environmental sanitation.

Immunization history

Patient has never been immunized since birth.

Impression: the basic immunization of hepatitis B can not be given because the patient
is seriously ill

Nutritional history

Patient was receiving parenteral nutrition from birth in the form of PG1 fluid with a
given parenteral nutritional calorie was 40 kcal / kgBW / day on the first day, gradually
increased to 57 kcal/kgBW/day on the fourth day and 101 kcal/kgBW/day on the sixth day.
Patient haas beenbreastfed from the second day of treatment (trophic feeding) and gradually
increased in accordance with drinking tolerance

Impression: patient get nutrition with insufficient caloric count and have not received
full enteral nutrition
History of Growth and Development

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Growth
Patient was born with birth weight 1900 grams and 45 cm of birth length, at chronological
age of 6 days, body weight 1930 grams and body length 45 cm.

Impression: patient growth can not be assessed yet

Development
Not ratedyet
Impression: the development can not be assessed.

III. Physical Examination As Case (January 6, 2018)

General conditin: looked severely ill with spontaneous and visible movements less active
Vital signs
Heart rate : 142 times per minute, regular
Breathing rate : 48 times per minute, regular, sufficient depth
Downe score: 1 (minimum epigastric retraction)
Axillary temperature : 36.8 0C
Blood pressure : 51/30 mmHg with MAP 37
Oxygen saturation : 92-96% (CPAP installed with PEEP 5, FiO2 21%)
Nutritional & anthropometric status
Birth weight : 1900 gram (P10 - P50 Fenton curve)
Body length : 45 cm (P50 - P90 Fenton curve)
Head circumference : 30 cm (P10 - P50 Fenton curve)
Clinical impression: suitable for neonates less than 33-34 weeks of age (Fenton curve)

Another physical examination

Skin : felt warm, no visible cyanosis, visible jaundice of level I, lanugo still exist

Head : round symmetry, no lesions and deformity, open anterior fotanel, flat, 2x2 cm

size, head circumference 30 cm (normosefal)

Hair : black, smooth and thin

Face : symmetrical, does not appear dysmorphic, does not appear paresis cranial
nerve

Eyes : the conjunctiva is not pale, the sclera is not jaundiced, there is no palpebra

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 oedema, isochore pupils, 3 mm diameter, good light reflex

Ears : Softpinna, slow recoil

Nose : installed nasal prong CPAP

Mouth : no oral cyanosis, oral mucosa and lips installed OGT

Neck : no enlarged lymph nodes are found

Chest : symmetrical in both static and dynamic states, minimal epigastric retraction,

dotted areola, flat edge, <0.75 cm diameter

Lungs : bronchovesikuler breath sounds, good water entry, no ronki or wheezing

Cardiac : no viseble ictus cordis, regular heart sound, no noise or rhythm

Abdomen : no visible bulge, visible several large blood vessels, well groomed cord,

hiperemis found and pussy on umbilicus, palpable flat and weak, liver palpable

¼-¼, flat surface, sharp edge, chewyconsistency, lien not palpable, abdominal

circumference 26 cm, normal positive bowel sounds

Back : no sacral dimple

Perianal : no abnormalities

Genitalia : both testicles fall well

Extremities : warm acral, capillary refilling time less than 2 seconds, no leg edema, Moro
+

/ + reflex, palmar grasp + / +, plantar grasp + / +,negative rooting reflex and

suction, symmetric movement, no paresis.

LABORATORY RESULT
Table 1. Complete peripheral bloood count (CBC)
Date Januari 1, 2018
Hb (g/dL) 15,2
Leukocyte (/mm3) 16.730
Hematocrit (vol%) 46
Trombocyte (/mm3) 256.000

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WBC differential count
I/T rasio
Reticulocyte (%)
Periphral blood smear
0/0/7/60/28/5
0,1
5,2 %
Erythrocytes: normochromic anocytosis
leukocytes: sufficient quantities, atypical
lymphocytes (+)
platelets: moderate amounts, morphology
within normal limits

IV. Summary
A male patient, 6 days old, admitted to hospital with chief complain was grunting
immediately after birth. This newborn was delivered by section ceasaria whose mother with
total placenta previa and leukocytosis. He was born in 33-34 weeks gestational age, 1900
grams weight birth, 45 cm body length, and 30 cm head circumference. The APGAR score
were obtain at one and five minutes of life, which results were 5 and 7, respectively.
In the beginning of treatment, NCPAP PEEP 8 FiO2 40% was given to this newborn,
although he still remain difficult to breath and oxygene saturation only reached 76-82%. This
patient was intubated to support his respiratory system, and ventilator modus PSIMV PIP 14
PEEP 6, Respiratory rate (RR) 40x/min, FiO2 60% was applied. Chest x-ray was performed
and revealed a hyaline membrane disease grade III-IV. He was given surfactant intrathecal.
Rrepeated x-ray showed improvement after surfactant administration. Then he was extubated
at 22 hours old and installed CPAP PEEP 6 FiO2 35%,. After this attempt, breathlessness was
reduced and Downe score was 1. Along with this condition, in day-5 of hospitalization the
abdomen seemed distended resulted in postponing the increasing volume of enteral feeding
until well-toleranted.
Physical examination obtained general appearace was less active, heart rate was 142
times per minutes, and repiratory rate was 48 times per minutes, the depth is sufficient with
downe score was 1, temperature was 36,8oC, oxygene saturation is between 92-96%, CPAP
PEEP 5 and FiO2 21% was installed. Patient seemed uncyanotic, icterus grade I, lanugo
remained. The head was symmetris, anterior fontanelle was flat and unbulged, there was no
lesion caused by birth trauma and as well deformity. Based on eye examination found no
pallor conjunctiva nor scleral icterus. Chest examination revealed symmetrical chest
expantion and minimum epigastric retraction, there was no any abnormality foundduring
heart examination. Undistented abdomen, hepar ¼- ¼, unpalpated lien, normal abdominal
bruits were found during abdominal axamination. Warm acral, Moro reflexwas +/+, palmar

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grasp was +/+, plantar grasp was +/, rooting and sucking reflex was negative, and capillary
refilling time was <2 seconds.

Laboratory investigation found no leukocytosis with IT ratio 0,1. Early plain chest
radiography showed hyaline membrane disease grade III-IV and showed any improvement in
later investigation as well. Patient was given total parenteral nutrition with PG1 80 ml/kg/day
which was increased daily. Patient was also fed enterally and administered 1st line antibiotic.

V. Problems
a. Low birth weight infant
b. Premature delivery
c. Respiratory distress due to hyaline membrane disease (HMD) grade III-IV
d. Unvaccinated child
e. Neonatal icterus grade I which suspected due to prematurity with differential
diagnosis due to early-onset neonatal sepsis (NSO)
f. Leukocytosisin mother
g. Antepartum hemmorhage in mother

VI. Working diagnosis

1. Low birth weight (1900 grams), preterm labor, appropriate for gestational age
(ICD P07.1)
2. Hyaline membrane disease grade III (ICD P22.0)
3. Suspected early-onset neonatal sepsis (EOS)(ICD P36.9)

VII. Management Plan

1. Emergency treatment
a. Airway: maintaining adequate airway, maintain clear airway, considering intubation in
repeatitive apnea or inadequate spontanous ventilation
b. Breathing: CPAP installation with PEEP 5 and 21% of FiO2, maintaining the oxygene
saturation more than 88% to keep brain oxigenated.
c. Circulation: gradual enteral nutrition support, assesing feed tolerance and
administration of parenteral feeding, electrolyte correction in electrolyte imbalance.
d. Temperature: incubator care, maintaining the temperature between 36,6°C to 37,5°C.

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 e. Sugar: parenteral and enteral feeding adminitration is based on individual need.
MaintainingGIR for at least 6 mg/kg/min, giving IV bolus of dextrose 10% for
hypoglicemia treatment
2. Diagnostic prosedure plan
a. Complete blood count
b. Blood culture
3. Pharmacological therapy plan
a. Ampicillin-sulbactam 2x 90 mg (IV)
b. Gentamicin 1x8 mg (IV)
4. Pediatric nutrition care
a. Assessment:
Cronological age : 6 days, 34 weeks of gestational age, birth weight : 1900 grams
(P10-P50based on Fenton chart), body length : 45 cm (P50-P90based on Fenton chart),
head circumference: 30 cm (P50-P90based on Fenton chart), clinical impression :
preterm infant (PTI)-approprite for gestational age (AGA), low birth weight (LBW)

b. The need of calory that should be given:

RDA : 120kcal/kg/day
Absolute RDA : 1,9 x 120 kcal/kg/day = 228 kcal /day
IdealRDA : 2,1 kg x 120 kcal/kg/day = 156kcal/day
BMR : 1,9 x 60 kcal/day = 114 kcal/day
Stress-factor : 1,5
BEE : BMR x Stress-factor=114 kcal/day x 1,5= 171kcal/day
c. Diet formulation : parenteral nutrition and breast milk
d. Route of administration : Intravena and per enteral
e. Currently given : IVFD PG2+micronutrient: 86 cc/kg/daywhich contain
dextrose 11%, protein 3 grams/kg/day and enteral nutrition of breast milk 12 x 10 cc
per enteral (63 cc/g/day), with total calories summarised is 86 kcal/day (occupying
50% of BEE).
f. Nutrition plan : enteral nutriton, like breat milk, will be given gradually to meet
Recommended daily allowance (RDA) that still considering feed tolerance. In attempt
to catch intrauterine growth, PG2 that consists of dextrose 11%, protein 3
grams/kg/day, and fat 2 grams/kg/dayis given, with maximum amount of fluid
allowed is 150 ml/kg/day and minimum caloric target is 120 kcal/kg/day.

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 g. Monitoring and evaluation : acceptability, tolerance, increase caloric intake gradually
5. Monitoring plan
a. Vital sign and clinical manifestation (vital sign, respiratory distress evaluation,
clinical assessment of sepsis).
b. Laboratoy evaluation : sepsis work up (full blood count, IT ratio, CRP andblood
culture).
c. Evaluation of parenteral and enteral nutrition administration, as well as feed tolerance
and vitamin and iron supplementation under fullfeed condition.
d. Gradual monitoring of body weight (daily), body length (weekly), head circumference
(monthly).
e. Morbidity screening test plan toward high risk infant, including visual, hearing,
neurological disturbance screening trough head USG, anemia of prematurity, and
osteopenia of prematurity.
f. Developmental evaluation using Fenton chart and denver developmental screening
test (DDST II) assessment.
6. Immunisation plan
Immunisation administration is done based on recommendation of Ikatan Dokter Anak
Indonesia. Immunisation to premature infantsare given adjusted to the cronological age.
Hepatitis B1 vaccination is postponed until the infantsare stable.
7. Communication, information, and education (Komunikasi, informasi, dan edukasi-KIE)
The explanation about the baby’s condition is explained carefully to the familiy,
especially that the baby was born prematurely with low birth weight accompanied by
respiratory distress and risk of infection due to the prematurity. The most common
complication is hyaline membrane disease, which is a respiratory disturbance that occurs
soon after birth caused by deficiency of surfactant that physiologically maintain
intrapulmonary pressure from collapse. History of pregancy, gestational age assessment,
physical examination, and chest plain film are provide the information for diagnosis.
Chest plain film will give the feature of hyaline membrane disease grade to determine
therapy, and surfactant still remain the major therapy. Other complication often found is
repetitive apnea caused by unmatured respiratory center in brain stem, thus the patient
still need respiratory device support after surfactant administration.Low birth weight
infants have the high risk to get severe infection, especially if there was risk of vertically
transmitted infection intrauterin, so that, further examination will be necessary to prove
infection and choose the precise antibiotic. Low birth weight infants also have high risk

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 of growth and developmental disturbance that the adequate nutritional support should be
begin immadiately from the very early life to prevent body weight decrease after birth.
Monitoringanother complications shoud be done to evaluate visual and hearing function,
disturbance or hemmorhage of brain, bone density, anemia probability, and heart
anomaly. Sustainable stimulation should be begin immadiately after recovery to prevent
developmental distubances.

VIII. TREATMENT MONITORING (January 7th - January12nd, 2018)

Day-7 of hospialization ( January 7th, 2018)
S Patient had no brethlessness, there was no desaturation, there wasno
fever, there wasno seizure, seemed pale and jaundice reahced abdomen,
intake was adinnistered via OGT 12x10 cc, well-toleranted. Defecation
and urination was normal, fluid balance was+15 ml, diuresis was2,9
ml/kg/h

O Patient seemed less active, respiratory rate 42 times per min, heart rate
129 times per min, regular. Temperature 36,7 °C, body weight 1930
grams.

Skin : warm when palpated, icterus kramer grade II-III

Head : anterior fontanelle opened, flat, unbulged
Eyes : no palpebral edema, pale conjunctiva, scleral icterus
chest : simetrical chest movement, minimum epigastric retractionwas
inspected, heart and pulmoner was normal
Abdomen: not distended, hepar ¼ - ¼ and lien wasunpalpated,
abdominal bruit (+) normal, abdominal circumference 26 cm
Ekstemities : acrals were warm, capillary refilling time< 2 seconds
A Hyaline membrane diseasegrade III post surfactant
Low birth weight infant 1900 grmas
Hyperbillirubinemia ec susp prematurity, DD/ ec sepsis
P  CPAP PEEP 5, FiO2 21%
 IVFD PG2 86 ml/kg/day+micronutrient 6,9 cc/h (calory: 32
kcal/kg/day)
 Ampicillin-sulbactam 2 x 90 mg IV
 Gentamicin 1x 8 mg IV
 Breast milk 12 x 10 cc/OGT (63 cc/kg, 42 kcal/kg/day)
 Plan to perform DK, cross match, weaning CPAP
E Result of blood examination :
Hb : 11,5 gr/dl
Leukocyt : 23.290 /mm3
Trombocyt: 301.000/mm3
Differential count : 0/5/14/46/20/15

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 Reticulocyt: 0,6 %
IT ratio : 0,23
IM ratio : 0,3
Clinical Impression : increase of IT ratio and IM ratio
action :administer 2nd line antibiotic  none
administer 3rd line antibiotic  meropenem 3 x75mg IV

Total Billirubin: 8,7mg/dl

Direct Billirubin: 0,4 mg/dl
Indirect Bilirubin: 8,3 mg/dl
Clinical Impression: hiperbilirubinemia
action : needless of phototherapy
Day-8 of hospialization ( January 8th, 2018)
S Baby had no brethlessness, no fever, and no seizure. No bloated
abdomen. Intake was obtain per oral, well-toleranted. Jaundice reahced
abdomen, no additional jaundice from yeterday. Defecation and
urinationwas normal, fluid balance was +22 ml, diuresis was 3,17
ml/kg/h.

O Patient seemd less active, heart rate 142 times per min, regular,
respiratory rate 42 times per min. Temperature 37 °C, O2 saturation was
92-94%, body weight was 1950 grams.

Skin : warm when palpated, icterus kramer grade II-III

Head : anterior fontanelle opened, flat, unbulged
Eyes : no palpebral edema, unpale conjunctiva, scleral icterus
chest : simetrical chest movement, minimum epigastric retractionwas
inspected, heart and pulmoner was normal
Abdomen: not distended, hepar ¼ - ¼ and lien was unpalpated,
abdominal bruit (+) normal, abdominal circumference 26 cm
Ekstemities : acrals were warm, capillary refilling time< 2 seconds
A Hyaline membrane diseasegrade III post surfactant
Low birth weight infant 1900 grmas
Hyperbillirubinemia ec susp prematurity, DD/ ec sepsis
P  CPAP PEEP 5, FiO2 21%
 IVFD PG267 ml/kg/day= 130 cc +micronutrient5,4 cc/h
(calory: 25cal/kg/day)
 Breast milk6x12cc/6x15 cc(83 cc/kg/day, 56 kcal/kg/day)
 Meropenem 3 x75mg IV
 Gentamicin 1x8mg IV

Day-9 of hospialization ( January 9th, 2018)

S Baby has no brethlessness, no fever, and no seizure. no additional
jaundice from yeterday. Defecation and urinationwas normal, fluid
balance was +27,5 ml, diuresis was 3,4 ml/kg/h.

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O Patient seemed less active, heart rate 123 times per min, regular,
respiratory rate 40 times per min. Temperature 37,2°C, O2 saturation
was 93%, body weightwas 1980 grams.

Skin : icterus kramer grade II-III

Head : anterior fontanelle opened, flat, unbulged
Eyes : no palpebral edema, unpale conjunctiva, scleral icterus
chest : simetrical chest movement, minimum epigastric
retractionwasinspected, heart and pulmoner was normal
Abdomen: not distended, hepar ¼ - ¼ and lien was unpalpated,
abdominal bruit (+) normal, abdominal circumference 26 cm
Ekstemities : acrals were warm, capillary refilling time< 2 seconds
A Hyaline membrane diseasegrade III post surfactant
Low birth weight infant 1900 grmas
Hyperbillirubinemia ec susp prematurity, DD/ ec sepsis
P  CPAP PEEP 5, FiO2 21%
 IVFD PG255 ml/kg/day= 108 cc +micronutrient4,5 cc/h
(21cal/kg/day)
 Breast milk12x15cc(95 cc/kg/day, 64cal/kg/day)
 Meropenem 2x75mg IV
 Gentamicin 1x 8mg IV

Day-10 of hospialization ( January 10th, 2018)

S Still supported by CPAP PEEP 5 5 FiO2 21%, seems less active, no
additional jaundice compared to yesterday. Intake per oral, wel-l-
toleranted, there is no recidual. fluid balance is +24 ml, diuresis is 2,9
ml/kg.
O Patient seems less active, heart rate 136 times per min, regular,
respiratory rate 40 times per min. Temperature 36,6°C, O2 saturation is
92-94%, body weight is 1950 grams.

Skin : warm when palpated, icterus kramer grade II

Head : anterior fontanelle opened, flat, unbulged
Eyes : no palpebral edema, unpale conjunctiva, scleral icterus
chest : simetrical chest movement, no epigastric retractios, heart and
pulmoner was normal
Abdomen: not distended, hepar ¼ - ¼ and lien was unpalpated,
abdominal bruit (+) normal, abdominal circumference 26 cm
Ekstemities : acrals were warm, capillary refilling time< 2 seconds
A Hyaline membrane diseasegrade III post surfactant
Low birth weight infant 1900 grmas
Hyperbillirubinemia ec susp prematurity, DD/ ec sepsis
P  Plan to weaning CPAP
 performDK, blood gas analysis, electrolte and albumin
assessment

16
  IVFD PG2 = 50 cc+ micronutrient 2 cc/h (10cal/kg/day)
 Breast milk 12 x 20 cc/OGT (126 cc/kg/day, 84 cal/kg/day)
 Meropenem 3 x75mg IV
E Result of blood examination :
Hb : 11,7 gr/dl
Leukocyte : 21.970 /mm3
Trombocyte 316.000/mm3
differential count : 0/5/2/80/12/1
IT ratio : 0,02
IM ratio : 0,025
Clinical impression : decrease in leukocyte count, IT ratio, and IM ratio
Action :sustain antibiotic therapy

Blood gas analysis:

pH 7,5; pCO2 27; pO2 156; HCO3 21,8; BE -1,5; SO2 99,6%
clinical impression: respiratory alkalosis dan hyperoxemia
action : Weaning CPAP

Natrium : 137 mmol/L

Kalium : 5 mmol/L
Calcium : 7,5 mg/dl, corrected by albumin level to 7,8 mg/dl
clinical impression: hypocalsemia
action: intravenous calcium corection

Protein total : 4,4 g/dL

Albumin: 3,1 g/dL
Globulin : 1,3 g/dL
clinical impression: Hypoalbuminemia
action: needless for correction

Blood culture : Sterile

Day-11 of hospialization ( January 11th, 2018)
S Patient without nasal canule, there is no desaturatioin, breathllessness.
Well-toleranted intake. Seem jaundice untill chest, lesses than before.
fluid balance was +21 ml, diuresis was 3 ml/kg.
O Patient seems less active, heart rate 1446 times per min, regular,
respiratory rate 41 times per min. Temperature 37°C, O2 saturation was
92-94%, body weightwas 1950 grams.

Skin : warm when palpated, icterus kramer grade II

Head : anterior fontanelle opened, flat, unbulged
Eyes : no palpebral edema, unpale conjunctiva, scleral icterus
chest : simetrical chest movement, no epigastric retractios, heart and
pulmoner was normal

17
 Abdomen: not distended, hepar ¼ - ¼ and lien was unpalpated,
abdominal bruit (+) normal, abdominal circumference 26 cm
Ekstemities : acrals were warm, capillary refilling time< 2 seconds
A Hyaline membrane diseasegrade III post surfactant
Low birth weight infant 1900 grmas
Hyperbillirubinemia ec susp prematurity, DD/ ec sepsis
P  IVFD PG2 = 25 cc+ micronutrient1,1 cc/h
 Breast milk6 x 20 cc/ 6 x 25 cc (138 cc/kg/day, 93cal/kg/day)
 Meropenem 3 x75mg IV

IX. Prognosis

Prognosis ad vitam : dubiaad bonam

Prognosis ad fuctionam : dubia ad bonam
Prognosis sanationam : dubia ad bonam

XII. Scheme of Disease Progression dan Treatment

December 31th, 2017 5 hours old 12 hours old

Patients born by caesarean PSIPV mode

18 PSIPV mode ventilator PIP
section, birth weight was1900 ventilator PIP 14 14 was still applied, PEEP 6,
gram, long birth of 45 cm, 33-34 was applied, PEEP RR was 35x / min, FiO2 was
weeks gestation, APGAR score 6, RR was 40x / 35%, O2 saturation 90 -95%.
was 5/7. Infection risk factors: min, FiO2 was
19
XIII . Conceptual Framework
Risk

Pregnant woman with plasenta previa and leukocytosis

Low birth weight, premature

Disorder

Hyaline Intolerances Hyperbilirubinemia Sepsis Hypocalcemia

Membrane neonatoru
Disease m

Chest xray Serum Septic work Serum

Diagnosis

bilirubine up, blood calcium

culture, IT
ratio CRP
Therapy

Oxygen Gradual Clinical Supportive Calcium

therapy enteral observation antibiotic correction
nutrition IV
Prognosis

Bonam Bonam Bonam Bonam Bonam

20
XII. Case Analysis
There have been reported a case of a baby boy with a diagnosis of 1900 gramslow
birth weight, moderate premature with hyaline membrane disease grade 3-4, and early-onset
of suspected neonatorum sepsis. The baby was born through cesareansectio with birth weight
of 1900 grams and 45 cm long birth with 33-34 weeks gestation.

Prematurity is the second leading cause of death in the under-5 age group and the
leading cause of death in the first month of life. WHO data stated that from 1990 to 2010
there was an increase in the incidence of preterm labor, and Indonesia was ranked fifth in a
row of 10 countries that contributed in 60% of preterm labor in the world.1 Data from WHO
in 2012 noted that the incidence rate of preterm birth in Indonesia in 2010 was 15.5 per 100
live births1 and Basic Health Research (Riskesdas) data of 2013 stated the number of months
of birth in Indonesia in 2013 is 10.2% 2
Premature infant or preterm infant is a baby born at gestational age less than 37
weeks counted from the first day of the last menstrual period. Based on gestational age,
preterm infant is divided into extremely preterm (<28 weeks), very preterm (28 - <32 weeks)
and moderate / late preterm (32 - <37 weeks). Based on the birth weight of premature infants
can also be grouped into: (1) birth weight> 1500 grams to <2500 grams categorized as low
birth weight (LBW), (2) birth weight> 1000 grams to <1500 grams categorized as very low
birth weight (VLBW), (3) birth weight <1000 grams categorized as extremely low birth
weight (ELBW).3 This case is a baby girl with 33-34 weeks gestation (Ballard score) with
birth weight of 1900 grams, and can be categorized as preterm, late preterm, based on
gestational age according to Lubchenko curve.
The sociodemographic characteristics that affect the incidence of preterm birth in
Indonesia are women giving birth at a young age, low educational status, living in rural areas,
no history of miscarriage, first childbirth, no complete pregnancy checkup, and complications
during pregnancy tend to be at greater risk incidence of premature birth.2 Most of these
sociodemographic characteristics are consistent with the patient's condition.
Various conditions can lead to premature birth. Some maternal factors associated
with preterm birth are fertility treatments during pregnancy, inadequate Ante Natal Care
(ANC) visits, antepartum bleeding, uterine pain, urinary tract infections, use of traditional
medication and abnormal vaginal discharge during pregnancy.4Premature risk factors
associated with this patient, were the presence of antepartum bleeding and inadequate ANC
visits. Patients made only three ANC visits during pregnancy to the local midwife.

21
 Premature infants anatomically and physiologically differ from mature infants in
terms of maturity of organ system function, so preterm delivery is usually accompanied by
various morbidities such as low birth weight, respiratory distress, cardiovascular disorders,
neurologic abnormalities, immune immaturity that causes infection, hematopoesis disorders,
metabolic disorders such as hyperbilirubinemia, impaired vision and hearing function, as well
as growth and development problems. Treatment of LBW started by providing appropriate
resuscitation according to the condition of the neonate at birth.3
Premature birth and LBW often require breathing support in the delivery room to
reduce premature death in premature infants. Infants with apnea or breathlessness should be
given positive pressure ventilation, as well as in infants with spontaneous breath, central
cyanosis and heart rate above 100 times per minute who have been receiving free flow
oxygen therapy but are not improving. Effective ventilation will rapidly increase the rate of
heart rate back to normal range. If the baby's heart rate stays less than 60 times per minute
even after adequate positive pressure ventilation are provided, chest compression should be
given.5.6
At the beginning of delivery in the delivery room, the patient's spontaneous
breathing was inadequate and the heart rate was <100 x / min, thus receiving a breathing
supportby a positive pressure ventilation for 30 s, followed by T-piece rescucitator after
adequate spontaneous breathing, the saturation was after the administration of T-piece
rescucitator with PEEP 7.
Early administration of CPAP or intubation may be given in the delivery room of
preterm infants with varying degrees of respiratory distress. Early CPAP deployment can be
provided with PEEP pressure of 5-8 cmH2O while monitoring the baby's breathing effort.
CPAP can be provided through a face shield attached to a T-piece resuscitator at an ideal
facility or Jackson Rees at a limited facility. When the baby is transported to ward, CPAP can
be maintained using nasal prong.5
Premature babies are at greater risk for hyperoxic injury than in full term infants.
When giving resuscitation to a very premature baby, it is recommended not to use 100%
oxygen and it is advisable to mix oxygen using a blender. During the transition phase after
birth, oxygen saturation must increase from 60% to 80% in 5 minutes, and reach 85% after 10
minutes. Premature babies under 32 weeks gestation will usually be stable with CPAP
administration with minimal oxygen fractionation. If premature infants fail to maintain
oxygen saturation of 88-92% even after early CPAP therapy up to PEEP 8 cmH2O and
oxygen fraction of 40%, then surfactant is recommended to be given in the delivery

22
room.5,7In this case, the patient received a breathing supportusing T- piece resuscitator with
100% oxygen fraction because there is no T-piece oxygen blender resuscitator in the delivery
room.
Patients experiencing respiratory distress after birth are thought to be due to Hialin
Membrane Disease (HMD) with a differential diagnosis of neonatal pneumonia.
Hypertensive membrane disease or Respiratory distress syndrome (RDS) in neonates is a
condition of pulmonary insufficiency shortly after birth caused by surfactant deficiency due
to immature lung structure. Surfactants are substances produced by pneumocytes type 2 cells
and reduce the surface tension of the alveoli when air enters. Surfactant also protects
pulmonary epithelial cells and plays role in the lung development process. Surfactants begin
to be produced at 24-28 weeks of gestation and their production reaches an optimum point at
35 weeks of gestation. Lack of surfactant leads to decreased compliance and lung surface
resistance, and increasing the risk of alveolar collapse during expiration resulting in reduced
gas exchange area.This results in hypoxia, hypercapnia and atelectasis.5 Symptoms of
respiratory distress in HMD generally occur soon after birth. These symptoms rapidly
deteriorate and can be fatal if not treatedas soon as possible.8
EuroNeoSat Annual Report for very low Gestational Age Infants 2010 found that
the incidence of HMD reached 92% in neonatus with gestational age of 24-25 weeks, 88% at
gestational age of 26-27 weeks, 76% at 28-29 weeks of gestation and 57% in gestational age
of 30-31 weeks9. The incidence in moderate premature infants, the frequency of HMD was
9.9%, 4.6% and 1.6%, respectively, at 34, 35 and 36 weeks.10 (Level of evidence 2) Other
risk factors that increased the incidence of HMD were male sex, perinatal asphyxia, infants
born to diabetic mothers, chorioamnionitis and babies born from caesarean surgery.10,11
Incidence of HMD increased in problematic pregnancy at late-preterm and full term
pregnancy.10 Intrauterine chronic stress, premature rupture of membranes, maternal
hypertension and maternal toxemia, intrauterine growth restriction (IUGR), and antenatal
glucocorticoids and tocolytic agents before delivery will reduce the risk of RDS. 11 In this
case, the patient was male, born to the mother with a placenta previa with cesarean delivery at
33 to 34 weeks of gestation (late preterm), so that the patient remains at risk for HMD even if
the patient's mother had dexamethasone before delivery.
Based on the radiological feature, Bomsel divides the HMD into 4 stages ie degree
I if there is a slight reticulogranular splotch and a slight air bronchogram, degrees II if a
homogeneous reticulocranular patch is found in both the lung field and the bronchogram
water image is more clearly visible, and extends to the periphery covering the heart shadow

23
with a decrease in pulmonary aeration, degree III if a collapsed collection of alveoli is found
so that both lung fields are more opaque and the heart shadow is almost invisible, and degree
IV if the whole thorax is so opaque that the heart can not be seen6. The radiological features
of this patient showed a third degree of HMD.
The goal of the therapy of HMD is to provide interventions to increase life
expectancy by reducing side effects that possibly occur. Interventions to prevent HMD
should be done prior to birth. Administration of prenatal steroids to mother may reduce the
risk of RDS and reduce the incidence of intraventricular hemorrhage and necrotizing
enterocolitis in premature infants. Prenatal corticosteroids are recommended in all
pregnancies that are at risk for birth below 34 weeks. The optimal time of corticosteroid
administration is more than 24 hours to 7 days before birth (Level of evidence 1).9The time of
pre-natal corticosteroid administration significantly affects the neonatal mortality rate. (Level
of evidence 2)12
Surfactants may be administered for prophylactic purposes given at birth or
immediately after birth in neonates who are at high risk for HMD or as therapy in neonates
who are clinically proven to have HMD. Indications of surfactant prophylaxis are neonates
with birth weight <1300 grams or gestational age <27 weeks. Prophylaxis is given in less
therapy
than 15 minutes after birth, whereas as a , the surfactant is administered before the age
of 8 hours.9 Surfactantin this patient wasadministered at 5 hours of age.
Exogenous surfactant therapy is the main therapy in neonates withHMD, to reduce
the risk of pneumothorax (pulmonary air leak) and neonatal death. The recommended dose of
surfactant is 100 mg/kgBW administered via endotracheal tube (ETT). One method of giving
surfactants is the technique of INSURE (Intubate, Surfactant, Extubate to CPAP). Other
methods that can be used for the administration of surfactants are MIST (Minimally-Invasive
Surfactant Therapy) and NIST (Non-invasive Surfactant Therapy).7,13INSURE method is
recommended in infants with CPAP failure. Exogenous surfactant in this patient was given
using INSURE technique.
A meta-analysis study in 2016, stated that surfactant-treated therapies in infants at
risk of HMD showed a decrease in mortality and air leak risk, and were considered fairly
decent and safe in both poor and developing countries.14 (Level of evidence 1).
Administration of surfactant therapy is recommended in infants with HMD at gestational age
≤26 weeks when the oxygen fraction requirement is <30% and infants> 26 weeks when the
oxygen fraction requirement is greater than 40% .9 (Level of evidence 1)

24
 Nutrients administration immediately after birth can reduce the risk of losing
weight in premature infants and minimize postnatal growth restriction. Calories on the first
day of post-birth should be able to meet the needs of basal metabolic rate (BMR) of 50
kcal/kg /day. Gradual increase of 25-30 kcal/kgBW/day until caloric adequacy is achieved
during total parenteral nutrition (NPT) of 90-100 kcal/kgBW/day and calorie intake to
achieve optimal growth during enteral nutrition is 115-120 kcal/kgBW/day. Carbohydrate
administration should start with dextrose with a glucose index rate (GIR) between 6 to 8
mg/kg/min and may be increased to 12-13 mg/kg/min according to blood glucose levels.15
Trophic feeding should be performed as soon as the baby is stable by
breastfeeding 10-20 ml/kg/day to assist in the maturation and function of the gastrointestinal
tract. If the tolerance is good, breastfeeding can be increased into 15-20 ml/kg/day.16,17
Breastfeeding soon after birth greatly affects maturity and gastrointestinal function and
facilitates colonization of Lactobacillus in the gastrointestinal tract thus inhibiting pathogenic
germ growth. Oligosaccharides, cytokines and immunoglobulins found in breast milk also
help the development of gut-associated lymphoid tissue (GALT) and T cell differentiation
that play a role in immunity and gastrointestinal tolerance thereby reducing the risk of ECN
in premature infants.18 Patients received enteric nutrition (trophic feeding) with breast milk at
24 hours of age using OGT

Tabel 1. Enteral and parental nutrition requirement in premature infants (ESPHGAN)19

Parenteral nutrition (2005) Enteral nutrition (2010)
Energy (kcal/kg/day) 100-120 110-135
Protein (g/kg/ day) 3-4 <1000 grams 4-4,5
1000-1800 grams 3,5-4
Glucose (g/kg/ day) 12-18 11,6-13,2
Fat (g/kg/ day) 2-4 4,8-6,6
Sodium (mmol/kg/ day) 3-5 1-5
Potassium (mmol/kg/ day) 2-5 2-4,5
Chloride (mmol/kg/ day) 2-5 1-5
Calcium (mmol/kg/ day) 1,3-3 3-3,5
Phosphor (mmol/kg/ day) 1-2,5 2-3

In this case the patient received total parenteral nutrition at the time of birth, with
PG1 80 cc/kgBW of fluid consisting of amino acid, dextrose, KCL, calcium gluconas and
magnesium phosphate, with GIR 6.1. At time ofadmission, patient had received 86
kcal/kgBW of parenteral fluid and breast milk. Enteral nutrition with breast milk was
increased gradually in accordance with the level of breastfeeding tolerance. .

25
 Patients were also diagnosed with suspected early-onset neonatal sepsis upon
admission and during treatment. Neonatal sepsis is divided into two groups: early onset sepsis
and slow onset. Risk factors for early onset sepsis (aged under 3 days), including maternal
factors consisting of labor and preterm birth, premature rupture of membranes,
chorioamnionitis (characterized by fever, maternal tachycardia, maternal leukocyte> 15.000 /
mm3, fetal tachycardia, foul-smelling amniotic fluid, uterine tendernes), complicated
delivery, maternal urinary tract infections, socioeconomic factors and maternal nutrition,
while infant risk factors such as perinatal asphyxia, low birth weight, underweight infants,
invasive procedures, congenital abnormalities.20 These patients had some risk factors such as
preterm birth, complicated delivery, socioeconomic factors and maternal nutrition, maternal
leukocytosis history, low birth weight and presence of invasive procedures treated in infants.
Shah et al. stated that the incidence of neonatal sepsis was associated with LBW
and significant with Odd Ratio of 4.85. LBW is relatively immune deficient, making it
susceptible to infection as well as in preterm infants.21 The adaptive immune system in
newborns still needs time to function optimally so that immunity in newborns is highly
dependent on the natural immune system and immunoglobulins derived from the mother. In
preterm infants with 32 weeks of gestation, the immunoglobulin from the mother is only 50%
and the epithelial barrier system is immature with the limitations of chemotaxis and
phagocytosis so that premature infants are at risk for severe infections that will further
suppress the immune system, especially B lymphocytes due to ongoing infection process and
antibiotic therapy given.21, 22
The diagnosis of sepsis is difficult to make because the clinical symptoms of sepsis
in neonates vary greatly. Therefore, the diagnosis criteria for sepsis in neonates is not only
based on clinical symptoms but also includes investigation of both laboratory and other
specialized examinations, as shown in the table below:

Tabel.4. Diagnosis criteria of sepsis in neonates23

Clinical variables
Unstable body temperature
Heart rate> 180/minor < 100/min
Respiratory rate> 60/min, with retraction or oxygen desaturation
Lethargy
Glucose intoleransi (glucose plasma> 10 mmol/L)
Breastfeeding intolerance
Hemodynamics variables
Blood pressure< 2SD according to infants age
Systolic blood pressure< 50 mmHg (1 day old infant)
Systolic blood pressure< 65 mmHg (< 1 month old baby)

26
Tissue perfusion variables
capillary refill > 3 s
lactic acid plasma > 3 mmol/L
Inflammation variables
Leukocytosis ( > 34.000 x 109 /L)
Leucopenia ( < 5.000 x 109 /L)
Young neutrophil > 10%
Young neutrophil/total neutrophil ratio (I/T ratio) > 0,2
Trombocytopenia < 100.000 x 109 /L
C reactive protein > 10 mg/dL or> 2SD normal range
Procalcitonin > 8,1 mg/dL atau > 2SD normal range
IL-6 or IL-8 > 70 pg/ml
16 S rRNA gene PCR: positive

Clinical features of sepsis found in this patient were lethargy, history of

breastfeeding intolerance, tacypnea, IT ratio> 0.2, young neutrophil> 10% on the seventh day
of treatment. Study conducted by Makkar et al showed an increase in IT ratio and increased
IM ratio has a high specificity in the diagnosis of sepsis. Increased IM ratio has a sensitivity
of 53% and a specificity of 97%, and an increase in IT ratio has a sensitivity of 94% and a
specificity of 95% .24
Sepsis is common in premature neonates treated in the NICU. Nearly 40-50% of
VLBW infants will develop infections during treatment due to invasive treatment and low
immunity in premature infants. Blood culture is still the gold standard of diagnosing sepsis in
neonates although 40% of them show negative results. Some studies stated that it takes at
least 1 ml of blood samples to get bacterias in the blood sample, because at a sample volume
of 0.5 ml there will be no bacteria with levels below 4 colony forming units (CFU)/ml, while
these low levels of bacteremia often found in neonates treated in the NICU because neonates
have been exposed to antibiotics, including intrauterine antibiotics.18,25 The blood cultures
depend on the laboratory's sensitivity, the technique of blood collection, the technique of
blood delivery and the initial treatment given.26 Blood culture examinations provide negative
results in 27-92% of VLBW and premature infants.25 The results of this patient's blood
culture examination were sterile.
Empirical antibiotic therapy should be promptly administered if sepsis is suspected
in the neonate. Several multicenter studies have found that the combination of penicillin
(ampicillin) and aminoglycoside (gentamicin) antibiotics is an effective empirical treatment
option for high-risk neonates with sepsis.26 A study conducted by The National Laboratory
Surveillance Data in the United Kingdom found that almost all (94 %) cultures obtained from
neonates with SNAD are sensitive to penicillin and gentamicin and 100% sensitive to

27
amoxicillin and cefotaxime. A combination of ampicillin and gentamicin may be given
before blood cultures are obtained and if within 48 to 72 hours there is no clinical
improvement, the cephalosporin group may be used as a second treatment option. (Level of
evidence 2).27 Patients were given empirical antibiotic therapy in the form of ampicillin
sulbactam and gentamicin for 7 days, but on the seventh day of treatment the patient had not
shown any significant clinical improvement. Complete peripheral blood examination and
blood culture did not support the diagnosis of SNAD, but repeated blood test at the time of
admission showed leukocytes. At that time the initial antibiotic plan was replaced by a
second line, but due to drug unavailability, antibiotics were replaced with meropenem (a
third-line antibiotic). Patients undergo clinical improvement after receiving third-line
antibiotics.
Hyperbilirubinemia is a clinical phenomenon most often found in newborns. About
60% of infants will develop hyperbilirubinemia or jaundice. Jaundice neonatorum is defined
as a clinical condition in infants characterized by jaundice on the skin and sclera due to
accumulation of excess unconjugated bilirubin.28,29 The primary source of bilirubin is
hemoglobin metabolism. Increased indirect bilirubin levels can occur when an increase in
hemoglobin metabolism resulting from maternal and infant blood incompatibility and closed
bleeding (egcephalhematoma). In addition, conditions such as severe infection or sepsis and
drugs are also risk factors. 29, 30
In premature infants, increased bilirubin is also caused by higher red blood cell
counts and shorter red blood cell life, resulting in faster turn over. On the other hand, the
process of taking bilirubin by liver cells and immature conjugation processes, as well as
enterohepatic circulation increases rapidly increased levels of bilirubin, particularly indirect
bilirubin. In addition, the presence of complications such as hypoalbumin, hypoxia,
hypoglycemia, acidosis, hypothermia, hemolysis and septicemia will cause impairment in
bilirubin transport.28,30
Investigations are necessary to determine the true levels of bilirubin and determine
the timing of phototherapy based on the hyperbilirubinemia curve for 35 or more weeks' of
gestation, or using tables made for gestational age less than 35 weeks published by the
American Academy of Pediatrics (AAP).30

Tabel 4. Rekomendasi terapi hiperbilirubinemia pada bayi premature.30

Gestasional Age Total bilirubin serumfor Total bilirubin serumfor
(week) Phototerapy (mg/dl) exchange transfusion (mg/dl)
<26 Optional : initiated when baby N/A

28
 borns
<28 0/7 5-6 11-14
28 0/7 – 29 6/7 6-8 12-14
30 0/7 – 31 6/7 8-10 13-16
32 0/7 – 33 6/7 10-12 15-18
34 0/7 – 34 6/7 12-14 17-10

In this case, the patient appeared jaundiced from the age of 6 days and an increased
indirect bilirubin was examined at 7 days. Referring to the limit of phototherapy for sick
premature babies with 34 weeks' of gestation, this patientdo not need phototherapy.
Low birth weight infants tend to have retinopathy of prematurity (ROP), visual
acuity disorder, strabismus, color vision defects, and visual field defects. The American
Academy of Pediatrics (AAP) recommends eye screening for ROP screening of infants
weighing <1500 grams or gestational age ≤ 32 weeks, infants with birth weight 1500-2000
grams, and gestational age ≥ 32 weeks with unstable clinical conditions (requires supportive
treatment for cardiorespiratory organs).31This patient with 33-34 weeks' of gestation and
1900 gram birth weight were clinically unstable, requiring ROP screening. ROP screening in
premature infants is done at 2 weeks of age or after reaching 34 weeks' of gestation and after
the condition is stable so that this patient has not done ROP examination.
The prevalence of hearing loss in high-risk babies is 10-20 times greater than for
normal babies. Infants at risk of hearing loss are infants with a family history of sensorineural
hearing loss, ear and craniofacialanomaly, intrauterine infection associated with sensorineural
hearing loss (toxoplasmosis infection, rubella, cytomegalovirus, herpes, syphilis), other
syndrome with sensorineural hearing loss such as Down syndrome, birth weight<1500 grams,
low APGAR score (0-3 at 5th minute, 0-6 at 10th minute), condition of illness requiring
treatment at NICU for 48 hours, respiratory disturbance, mechanical ventilation for ≥ 5 days,
hyperbilirubinemia at levels that requiring exchange transfusions, bacterial meningitis, and
ototoxic therapy (eg gentamicin) given >5 days.31Examination of hearing impairment can be
performed on infants and children, including tympanometry, otoacoustic emission (OAE) ,
and automated auditory brainstem response (AABR).32 Risk factors for this patient are
requiring treatment at the NICU for more than 48 hours, history of respiratory disorder and
hyperbilirubinemia.
Low birth weight babies are susceptible to neurological disorders. As much as 6-
28% of LBW had cerebral palsy, 21-36% of premature infants had transient distonia, and
71% of ELBW had mild motility impairment. The neuromotor assessment of the infant was

29
performed after 2 months after out of the hospital, and subsequent evaluation was performed
at correction age of 4, 8, 12, 18 months, 2 and 3 years.33 In addition to head
circumferencemeasurements, serial head ultrasound examination was used to identify the risk
of neurologic abnormalities and premature baby development, ie, white matter damage,
intracranial hemorrhage that progresses to hydrocephalus which is a predictor of cerebral
palsy and developmental delays. Head ultrasound examination was performed at age 5-14
days, age 15 days, until correction age 40 weeks.34 In this patient, ultrasound examination had
not been performed because the patient's clinical condition had not been stable.
Immunizations in premature infants are given according to chronological age except
for hepatitis B vaccine given when the clinical condition is stable before 30-day of
chronological age (in women with negative HBsAg status). The given dose is the same as the
full term infant. An antibody response in preterm infants who received the recommended
vaccination iss similar to the response in full term infants in almost all immunized
antigens.34This patients had not received hepatitis B immunization because the patient's
condition had not stabilized.

30
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 ABBREVIATIONS
AAP = American Academy of Pediatrics
ANC = Antenatal care
APGAR = American Pediatric Gross Assessment Record
APTT = Activated Partial Thromboplastin Time
ASI = Air Susu Ibu
BERA = Brainstem Evoked Response Audiometry
BBLR = Berat Badan Lahir Rendah
BBLSR = Berat Badan Lahir Sangat Rendah
BBLASR = Berat Badan Lahir Amat Sangat Rendah
CPAP = Continuous positive airway pressure
CRP = C-Reactive protein
DDST II = The Denver Developmental screening test II
EKN = Entero Kolitis Nekrotikan
ETT = Endotracheal tube
GALT = Gut-Associated Lymphoid Tissue
GIR = Glucose Infusion Rate
IM Ratio = Immature : Mature Ratio
IT Ratio = Immature Ratio
INSURE = Intubate, Surfactant, Extubate to CPAP
IUGR = Intrauterine Growth Retardation
IVFD = Intra Venous Fluid Drip
MAP = Mean Arterial Pressure
MIST = Minimally-Invasive Surfactant Therapy
NICU = Neonatal Intensive Care Unit
NIST = Non-Invasive Surfactant Therapy
OGT = Orogastric Tube
PEEP = Positive End Expiratory Pressure
PG = Protein Glukosa
PICC = Peripherally Inserted Central Catheter
PIP = Peak inspiratory pressure
PMH = Penyakit Membran Hialin
PSIMV = Pressure-Synchronized Intermittent Mandatory Ventilation
PT = Prothrombin Time
RDA = Recommended Dietary Allowance
ROP = Retinopathy of Prematurity
RR = Respiratory Rate
SNAD = Sepsis Neonatorum Awitan Dini
OAE = Otoacoustic Emission
USG = Ultrasonography

33
Assessment of growth by gestational age

Lubchenco Chart

December 31th, 2017

Anthropometry and Nutritional status

BW(birthweght) = 1900 gr ( P25-50Lubchenco chart)
BL(Birthlength)= 45 cm ( P25-50 Lubchenco chart)
LK (head circumference) = 30 cm (P10-25 Lubchenco chart)

34
Fenton Chart

Birth weight : 1900 gram (P10 - P50 Fentonchart)

Birth length : 45 cm (P50 –P90 Fentonchart)
Head circumferece : 30 cm ( P10- P50 Fentonchart)

35
Infant rescucitaion in delivery room:
born Breathing or cring? Yes Routine care:
Is the muscle tone good? - Make sure the baby stays warm
- Dry the *
- Continue the breathing, heart rate,
andmuscle tone observation
30 s No
Initial step: (turn on the stopwatch)
- Make sure the baby stays warm
- Set the position and clear the airway
- dry* andstimulation
- reposition

Observation of breathing effort, heart rate, and muscle tone

Not breathing/breathless Spontaneous breathing

and/or HR<100/min

Respiratory distress (tacypnea, Persistent central cyanosis without

retractionor moaning) respiratory distress
30 s Positive pressure
ventilation(PPV)#
SpO2observation Continuous positive consider oxygen
airway pressure (CPAP) supplementation#
PEEP 5-8 cmH2O SpO2Observation
SpO2Observation
HR < 100 /min

Failed CPAP
PEEP 8 cmH2)
FiO2 > 40%
Adequate chest With respiratory distress
expansion? Consider intubation

Adequatechest Inadequate chest expansion,

expansionbut HR< 60x/min evaluate:
PPV (O2 100%) + chest - Baby ead position
compression (3 - Airway obstruction
Ya
compression for every 1 - Mask leak
No
breath) - Peak inspiration
Consider intubation pressureis adequate or
HR and breathing effort not
observationevery 60 s

HR< 60 x/min?

Consider intravenous drugs and fluid

36
 Assess HR, breathing effort and muscle tone every 60 s
Downe Score assessment after rescucitaion
Downe score:
Examination 0 1 2
Respiratory < 60 x/min 60-80 x/min >80 x/min
erate
Cyanosis No cyanosis Cyanosis disappear Cyanosis persists
after O2 after O2
Retraction No retraction Mild retraction Severe retraction
Air entry Air enters Mild decrease in air No air entry
entry
Moaning No moaning Heard with Heard without
stethoscope intruments

Total score: 5, moderate breathlessness

37
 Evidence-based medicine

A. Clinical Questions
How is the benefit, safety, feasibility and cost-effectiveness of using surfactant replacement
therapy?

B.Component of foreground question

Problem :hyaline membrane disease, premature birth

Intervention : use of substitute therapy for single and multiple dose of intratracheal
surfactants
Comparison : all studies comparing the advantages, safety, feasibility and cost-
effectiveness of the use of substitute therapy for single and multiple dose of
intratracheal surfactants or placebo in poor and developing countries

Outcome : the existing studies showed that SRT is effective, safe and appropriate in the
3-level neonatal unit and reduces neonatal mortality. Significant reduction in
neonatal mortality receiving SRT (relative risk (RR) 0.67, 95% (CI) 0.57 to
0.79). Significant reduction of air leaks risk (five studies: RR 0.51; 0.29 to
0.90). Another study showed a high odds ratio on BPD with OR: 1,4 to 7,5

C. Searching Methode

Searches are done with the keyword "surfactant, pulmonary surfactant". By using
limitations: published in last 5 years. An article was found to answer the clinical question
with the title: Efficacy and safety of surfactant replacement therapy for preterm neonates with
respiratory distress syndrome in low- and middle income countries: a systematic review of
american journal of perinatology 2016 volume 36 pages S35 - S47downloaded from
https://www.ncbi.nlm.nih.gov/pubmed/27109091

38
 CRITICAL APPRAISAL (META-ANALYSIS ASPECTS)
Is this study valid?

√
√ Yes Not clear No
A. Is the research questions defined clearly and specifically?

Yes. This study was a meta-analysis of 38 articles covering 5242 neonatal patients
treated in the neonatal unit level 3 from 1998 to 2013 in the poor and developing
countries.

B. Are the studies involved in the review and meta-analysis using appropriate
designs to answer the questions?

Yes, the study used observational dan experimental study

C. Is the relevant article search strategy clearly stated?

Yes. The articles studied are based on databases with the combination
keywords'surfactant, pulmonary surfactant, human studies, clinical trial
andnewborn’.In the title of the study: surfactant[Title] OR pulmonary
surfactant[Title] OR human studies[Title] OR clinical trial [Title] OR newborn[Title]

D. Is there any an assessment of the quality of the studies involved in the review and
meta-analysis?

Not stated

Is the validity of this article qualified? Yes

39
Are the valid results of this study important?

V
Yes Not clear No

A. Is the desired outcome consistent between the studies involved?

Yes.

B. What is the overall result of the meta-analysis?

studies showed a significant decrease in neonatal mortality who received SRT

(relative risk (RR) 0.67, 95% (CI) 0.57 to 0.79). Significant reduction of air leaks risk
(five studies: RR 0.51; 0.29 to 0.90). Another study showed a high odds ratio on BPD
of OR: 1,4 to 7,5.

A. How significant and precise is the result?

This meta-analysis was able to show significant results because it involves more than
100 patients (5242 patients) with a 95% confidence degree

B. How significant and precise the results are?

The existing evidence suggested that SRT is an effective, safe and viable
interventions in the 3-level neonatal unit and has the potential to reduce neonatal
mortality and also decrease the air leaks

40
Can the results of this study be applied to our population?

v
Yes Not clear No

A. Is our patient similar to the subject of the study?

Yes, including age, clinical symptoms and outcome

B. Are our conclusions on the results of the study useful when delivered to the
patient / family in the overall management?
The results of this study are useful in premature patients who have a risk of hyalin
membrane disease to determine the extent therapy and can be informed to the
patient's family.

Conclusions:

This study is valid, the results from existing studies showed that SRT is effective, safe and
feasible in the 3-level neonatal unit and reduce neonatal mortality.

41
Before Surfactant After Surfactant

Rontgen expertise:
 Simmetrical trachea
 No enlargement of the heart
 Opacitywith air bronchogram in both lungs and cardiac shilouette are not clear,
especially in right side
 Lean diapharms
 Pointed contophrenic angle both in left and right
 Intact bones
Conclusion : HMD grade III-IV

42