LONG CASE REPORT

A preterm female neonate with respiratory distress syndrome, early

onset neonatal sepsis, patent ductus arteriosus, and low birth weight

Vita Pramatasari Harti

National Board Evaluation

Jakarta, August 21th 2022

INDONESIAN COLLEGE OF PEDIATRICS

2022
 PATIENT’S RECORD
I. IDENTITY

Patient name : Baby Mrs. I (II) Father’s name : Mr. R

Sex : Female Age : 34 years old
Birth date : June 11th, 2022 Occupation : Civil servant
Age : 0 day old Mother’s name : Mrs. I
Date of admission : June 11th, 2022 Age : 32 years old
Date of examination : June 11th, 2022 Occupation : Housewife
II. HISTORY TAKING
1. Chief complaint
Breathlesness (history taking was taken from patient's mother and the doctor who
assisted in the delivery process)
2. History of present illness
A female-neonate was born by caesarean section from a 32 years old
multigravid woman on the 33+5 weeks of gestational age (GA) due to 20-hour
premature rupture of membrane (PROM), gemelli, and fetal distress. Her birth
weight (BW), birth length (BL), and head circumference (HC) were 1600 grams, 41
cms, 29 cms, respectively. She did not cry immediately and had weak muscle tone.
Initial steps of neonatal resuscitation was performed, then she gained her
spontaneous breathing. She had nasal flaring, subcostal retraction, grunting, and
cyanosis. Her heart rate, respiratory rate, oxygen saturation, and body temperature
were 146 bpm, 46 bpm, 97% and 35.8oC, respectively. She received early nasal
continues positive airway (nCPAP) in delivery room with positive end expiration
pressure (PEEP) 7 and FiO2 30%. The amniotic fluid was cloudy. APGAR scores at
the 1st and 5th minutes were 5 and 7. The new Ballard score was 24 appropriate for
32-34 weeks of GA. Soon after birth, she received intramuscular vitamin K on her
left thigh and gentamicin eye ointment on both eyes. Hepatitis B immunization was
delayed due to her low birth weight. She was transferred to neonatal high care unit
(NHCU) in a transport incubator with single nasal prongs after STABLE criteria
were fulfilled.
In NHCU, she looked more active, decreased work of breathing, mild
subcostal retraction with Downes score of 1, poor sucking reflex, stable
thermoregulation and normal blood glucose. She was placed in incubator, with
oxygenation by nasal canule 0.5 lpm. Orogastric tube (OGT) was installed with no
gastric aspirate. Umbilical venous catheterization was performed. Complete blood
count, C-reactive protein (CRP), blood smear, blood culture, and antibiotic
sensitivity examinations were performed. She also received the first line (IV)
antibiotic (ampicillin and gentamicin) and aminophylline. She passed the meconium
and urine on the first day. We educated the parents regarding their baby condition
and the management plan.

2
3. Family history
• No history of hypertension or hyperglycemia during pregnancy
• No history of diabetes mellitus or liver disease in the family
• No history of multiple gestation, preterm or low birthweight delivery in the
family
Conclusion: no hereditary disease risk factor from family
Pedigree Patient is the third child in the family.
I

II

Mr. R, 34 y.o. Mrs. I, 32 y.o.

III
J, 3 y.o. Baby Mrs. I (I),
Baby Mrs. I (II), 0 day old
0 day old
4. Patient personal and social history
a. Pregnancy history
Underwent routine antenatal care with obstetrician, had gemelli pregnancy.
The mother had fever on the labor day. She got steroid administration one
time before delivery. Conclusion: high risk pregnancy.
b. Delivery history
Born by C-section at 33+5 weeks of GA with APGAR score 5-7 and cloudy
amniotic fluid. Conclusion: abnormal delivery.
c. Postnatal history
Received antibiotic eye ointment and vitamin K1 injection. Conclusion:
normal postnatal history.
d. Nutritional history
Parenteral nutrition with D10% (GIR 5.5 mg/kgBW/minute) 5.3 ml/hour.
Conclusion: adequate parenteral nutrition
e. Growth and development history
Growth history: Born at 33+5 weeks of GA with BW of 1600 grams (p10<
BW/GA<p50 Fenton, p10<BW/GA<p25 Lubchencho), BL of 41 cms
(p10<BL/GA<p50 Fenton, p10<BL/GA<p25 Lubchencho), HC of 29 cms
(p10<HC/GA<p25 Fenton, HC/GA=p10 Lubchencho), chest circumference
of 28 cms, mid upper arm circumference of 9 cms. The New Ballard score
was 24 appropriate for 32-34 weeks GA.
Development history: Unable to be evaluated.
Conclusion: low birth weight, moderate preterm, appropriate for gestational
age.
f. Immunization history
No Hepatitis B immunization due to her low birth weight (<2000 grams).
Conclusion: Incomplete immunization.
g. Basic needs history
Parents were very concerned about their child’s condition. Her mother
wished to breastfeed directly anytime. She always visited her at NHCU and

3
 frequently provided breastmilk. Conclusion: well fullfield
h. Socioeconomical and environment condition
Her father is a civil servant with monthly income of ± 3,000,000 IDR. Her
health expense is covered by health insurance (BPJS). They live in a good
ventilated house in a village near primary healthy care. Conclusion: middle
income family with good living environment.
III. PHYSICAL EXAMINATION
A. General examination
1. General condition: spontaneous eye opening, inactive movement
2. Vital signs
Heart rate : 142 bpm, regular, strong pulse
Axillary temperature : 36.6 oC
Respiratory rate : 44 bpm, regular, adequate depth
Oxygen saturation : 97% on right upper extremity and 95% on left
lower extremity
3. Anthropometric status:
The BW was 1600 grams (p10 <BW/GA <p50 Fenton), BL was 41 cms
(p10 <BL/GA <p50 Fenton), HC was 29 cms (p10 <HC/GA <p25
Fenton)
B. Regional Examination
1. Skin: No pale, no dry skin, no cyanosis, no jaundice, no cutis marmorata
2. Head: Normal shape and size, no dysmorphic face. Isocoric pupils, no
anemic conjunctiva, no icteric sclera. Soft notched ears lobes with no
discharge. No nasal flare.
3. Neck: No enlargement of lymph node.
4. Chest: Normal thorax with subcostal retraction.
5. Heart: Invisible ictus cordis, palpable at 4th intercostal space on the left,
midclavicle line, normal heart sound S1-S2 normal intensity, no murmur
6. Lungs
Anterior/ Right Left
Posterior
Inspection : Symmetric Symmetric
Palpation : Tactile fremitus unable to Tactile fremitus unable to
be evaluated be evaluated
Percussion : Resonant Resonant
Auscultation : Normal vesicular Normal vesicular
breathing, no rales, no breathing, no rales, no
wheezing wheezing

7. Abdomen: No distension, positive bowel sound with normal frequency,

tympanic percussion, no enlargement of liver and spleen.
8. Genitalia: female sex with no abnormalities.
9. Extremities: Warm extremities, capillary refill time of 2 second, and
strongly palpable dorsal pedicle artery.
10. Neurological examination
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 Movement : symmetrical without limited ROM
Tone : good muscle tone
Deep tendon reflex : positive in both knees
Babinsky reflex : positive in both feet
Moro reflex, asymmetric tonic neck reflex, palmar grasp reflex, plantar
reflex, and rooting reflex were positive. Sucking reflex was negative.
IV. Diagnostic supporting examination
1. Laboratory finding (June 11th, 2022)
Hemoglobin: 17.5 g/dl, platelet: 273,000/ul, erythrocyte: 4,470,000/ul,
hematocrit: 50%, MCV 111.2 /um, MCH 39.2 pg, MCHC 35.3 g/dl, RDW
15.3%, MPV 8.5 fl, PDW 17%, leucocyte: 12,900/ul, eosinophil 0.2%,
basophil 0.4%, neutrophil 52.7%, lymphocyte 39.3%, monocyte 7.4%, RBG:
69 mg/dl, blood type: A, rhesus (+)
2. Peripheral blood smear (June 11th, 2022)
Erythrocyte: normocytic, normochromic, erythroblasts (+)
Leucocyte: within normal amount, lymphoblasts (-), neutrophil vacuolization
(+), atypic lumphocyte, I/T ratio 0.21
Thrombocyte: within normal amount, macro thrombocyte (+), clumping (-),
even distribution
Conclusion: infection process
3. X-Ray examination
Lung: reticulogranular pattern with air
bronchogram in both lungs.
Heart: normal in size and shape, sharp
costophrenic angles, normal hemidiaphragm,
trachea is in the midline, normal skeletal system.
Abdomen: no obstruction, no dilatation, no
pneumatosis intestine. Corpus, pedicles, and
intervertebral spatial are good. Umbilical catheter
tip projected in 12th right posterior rib. OGT tip in
the gaster.
Conclusion : 2nd grade of hyaline membrane
disease
V. SUMMARY
A female neonate was born by C-Section at 33+5 weeks of gestational age
due to 20-hour PROM, gemelli, and fetal distress. The BW, BL, and HC were
1600 grams, 41 cms, and 29 cms respectively. The amniotic fluid was cloudy. She
did not cry immediately and had weak muscle tone. Initial steps of neonatal
resuscitation was performed, then she gained her spontaneous breathing. She had
nasal flaring, mild subcostal retraction, grunting, and cyanotic. APGAR scores at
the 1st and 5th minutes were 5 and 7, respectively. Her heart rate, respiratory rate,
oxygen saturation, and body temperature were 146 bpm, 46 bpm, 97% and 35.8 oC,
respectively. The baby received early NCPAP in delivery room with PEEP 7 and
FiO2 30%. After STABLE criteria were fullfilled she was transfered to NHCU in a
transport incubator with nasal prongs.
In NHCU her work of breathing decreased with Downes score of 1. New

5
 Ballard score was in-line with 32-34 weeks GA. She was placed in incubator, with
oxygenation by nasal canule 0.5 lpm. OGT was installed and umbilical
catheterization was performed. The laboratory examination revealed hemoglobin
17.5 g/dl, platelet 273,000/ul, leucocyte: 12,900/ul (ANC 6,798; ALC 5,070),
neutrophil vacuolization, atypical lymphocyte, macro thrombocyte, and IT ratio
0.21. Babygram obtained 2nd grade hyaline membrane disease. Her parents were
given the education regarding their baby’s condition, and the management plans.
VI. DIFFERENTIAL DIAGNOSES
1. Respiratory distress syndrome (P 22.0) dd neonatal pneumonia (P23.9)
2. Early onset neonatal sepsis (P 36.9)
3. Moderate preterm (P07.30), low birth weight (P07.1), appropriate for
gestational age (P 07.1)
VII. WORKING DIAGNOSIS
1. Respiratory distress syndrome (P 22.0)
2. Early onset neonatal sepsis (P 36.9)
3. Moderate preterm (P07.30), low birth weight (P07.1), appropriate for
gestational age (P 07.1)
VIII. PROBLEM LIST
1. Respiratory distress syndrome
a. History taking (prematurity, cesarean delivery, multiple gestation)
b. Clinical signs (nasal flare, grunting, retraction)
c. Chest X-ray (reticulogranular pattern with air bronchogram in both lungs)
2. Early onset neonatal sepsis
a. Risk factor from mother: 20-hour PROM, leukocytosis, multiple gestation
b. Risk factor from baby: prematurity, low birth weight
c. Clinical symptoms: respiratory distress, hypothermia, lethargy
d. Laboratory examination: ANC <7,800, neutrophil vacuolization, atypical
lymphocyte, macro thrombocyte, IT ratio > 0.2, Rodwell hematological
score 3
e. Blood culture and antibiotic sensitivity results were still on process
3. Low birth weight, moderate preterm, appropriate for GA
Fenton growth chart, Lubchenco growth percentile, New Ballard score
IX. MANAGEMENT PLAN
1. Emergency management
Early nasal CPAP PEEP 7 FiO 2 30% supported with 90-95% oxygen
saturation target.
2. Diagnostic investigation
a. Blood culture and sensitivity analysis
b. Complete blood count evaluation and acute-phase reactants
c. Newborn screening for preterm baby (echocardiography, cranial ultrasound,
ROP screening, screening for hearing impairment, and thyroid function).
3. Medical management
a. Ampicillin (50 mg/kgBW/12 hours)= 80 mg/12 hours IV
b. Gentamicin (4.5 mg/kgBW/36 hours) = 8 mg/36 hours IV
c. Aminophylline loading dose (8 mg/kgBW) = 12 mg slow IV push,

6
 then maintained with (3 mg/kgBW/8 hours) = 5 mg/8 hours IV

X. NUTRITION AND FLUID MANAGEMENT

1. Enteral nutrition with breast milk started from 5-10 mL/kgBW/day when the
baby on stable condition, with total fluid 150- 180 mL/kgBW/day.
2. Parenteral nutrition
 Total fluid (80 ml/kg/day) = 130 ml/day and increased gradually 10- 20
ml/kg/day until 140-160 mL/kg BW/day in 7 - 10 days.
 Total calories (50 kcal/kg/day) = 80 kcal/day and increased gradually 25-30
kcal/kg/day, targeting 90-100 kcal/kg/day.
 Carbohydrate: Dextrose started with GIR 5.5 mg/kg BW/minute. Increased
GIR gradually 1-2 mg/kg BW/day.
 Protein: Amino acids 10% started 2 g/kg BW/day, 32 mL/day. Increased
gradually 0.5-1 g/kg BW/day until 3.5-4 g/kg BW/day.
 Fat: lipid 20% started 1 g/kg BW/day, 8 mL/day. Increased gradually 0.5-1
g/kg BW/day until 2.5-3.5 g/kg BW/day.
 Electrolyte: in 24 hours calcium (Ca2+) 60-90 mg/kg BW/day. Sodium
(Na+) and potassium (K+) after first diuresis, with dose 0-2 mmol/kg
BW/day.
3. Evaluate the acceptability, tolerance, and effectiveness
XI. MONITORING
1. General conditions, vital signs, oxygen saturation, Downe’s score
2. Daily fluid intake, nutritional intake, and body weight
3. Daily response to the therapy and adverse events
4. Neurodevelopment
5. Laboratory on indication
XII. COMMUNICATION, INFORMATION, AND EDUCATION
1. Explained the parents about the disease, therapy, diagnostic procedures and
the complications of infection, respiratory problems, preterm and low birth
weight, and prognostic of patients.
2. Educated the parents about Kangaroo Mother Care (KMC) and exclusive
breastfeeding in prematurity
3. Explained the need for growth and developmental screening and monitoring
every 3 months until 2 years old.
4. Explained the vaccination program scheduled according to the chronological
age.
5. Educated the parents to keep personal and environmental hygiene especially
in handling the baby.
XIII. PROGNOSIS
Ad vitam : dubia ad bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam

7
 XIV. FOLLOW UP
Day 2-3
Moved more actively, weak sucking reflex, no fever, no
seizure, no jaundice
Cried vigorously, opened eyes spontaeously, move
actively
Heart rate: 140-150 bpm, respiratory rate: 40-50 bpm,
hypothermia temperature: 35.9-37.3°C, SaO2 97-99%,
Downe score 1
BW 1550 g, Fluid balance: -25 until +10 ml/day, diuresis:
2.6-3.4 ml/kgBW/hour, nutritional achievement: 60-70%
(from orally 5%)
Diagnosis:
1. Respiratory distress syndrome (P 22.0)
2. Early onset neonatal sepsis (P 36.9)
3. Moderate preterm (P07.30), low birth weight (P07.1),
appropriate for gestational age (P 07.1)
Treatment:
1. O2 nasal cannula 0.5 lpm
2. Diet: breast milk 3- 5 mL/3 hours
3. Dextrose 16% = D5-½ NS 55 ml + D40% 30 ml + KCl
7.46% 3 ml + calcium gluconate 10% 3 ml + sodium
glycerophosphat 1 ml, infusion rate 4 ml/hours (GIR 7) IV
4. Amino acids solution 10% 3 g/kgBW/day IV
5. Lipid 20% 2 g/kgBW/day IV
6. Ampicillin (50 mg/kgBW/12hours) = 90 mg/12 hours IV
7. Gentamicin (4,5mg/kgBW/36 hours) = 8 mg/36 hours IV
8. Aminophylline (3 mg/KgBW/8 hours) 5 mg/8 hours IV
Plan:
Waiting for blood culture result
Echocardiography
Plan:
Day 4-5 Day 6-7
Weak sucking reflex, jaundice, no fever, no seizure Improved jaundice, sucking reflex (+), no fever, no seizure
Cried vigorously, opened eyes spontaeously, move actively Cried vigorously, opened eyes spontaeously, move actively
Heart rate 120-130 bpm, respiratory rate 40-50 bpm, body temperature 36.6- Heart rate 120-140 bpm, respiratory rate 40-50 bpm, body
37.4°C, SaO2 97-99%, Downe score 1, icteric Kramer III temperature 36.5-37.4°C, SaO2 97-99%, Downe score 0, icteric
BW 1600 g, Fluid balance: -15.8 until +29.3 ml/day, diuresis 3.7-4.3 Kramer I
ml/kgBW/hour, nutritional achievement: 69-71% (from orally 9%)
BW 1650 g, Fluid balance: +5 until +10 ml/day, diuresis 2.5-3.3
Laboratory result (June 16 , 2022):
th
ml/kgBW/hour, nutritional achievement: 72-75% (from orally
Hb: 15.2 g/dl, platelet: 308,000/ul, erythrocyte: 4,200,000/ul, Hct: 42%,
leucocyte: 10,800/ul, eosinophil 2.71%, basophil 0.52%, neutrophil 38.6%, 16%)
lymphocyte 47.5%, monocyte 10.7%, AST 27μ/L, ALT 10μ/L, total Head ultrasonography: within normal limit
bilirubin total 11.38mg/dl, unconjugated 10.54mg/dl, conjugated 0.84mg/dl,
albumin 4.1 g/dl, trigliceryde 108 mg/dl, RBG 95mg/dl, hsCRP 0.6mg/dl,
Diagnosis:
Na 138mmol/L, K 4.8mmol/L, Cl 109mmol/L, Ca 1.30mmol/L, TSH 3.16
uIU/ml, Free T4 10.46 pmol/l 1. Respiratory distress syndrome (P 22.0)
Blood culture: no bacterial growth 2. Early onset neonatal sepsis (P 36.9)
Echocardiography: Patent ductus arteriosus (PDA) 2 mm and patent 3. Patent Ductus Arteriosus (Q 25.0), Patent Foramen Ovale (Q
foramen ovale (PFO) 1.5 mm, LA/LV dilatation 21.1)
4. Neonatal jaundice associated with preterm delivery (P 59.0)
Diagnosis: 5. Moderate preterm (P07.30), low birth weight (P07.1),
1. Respiratory distress syndrome (P 22.0) appropriate for gestational age (P 07.1)
2. Early onset neonatal sepsis (P 36.9)
Treatment:
3. Patent Ductus Arteriosus (Q 25.0), Patent Foramen Ovale (Q 21.1)
1. O2 nasal cannula 0.5 lpm
4. Neonatal jaundice associated with preterm delivery (P 59.0)
5. Moderate preterm (P07.30), low birth weight (P07.1), appropriate for 2. Diet: breast milk 5 - 10 mL/3 hours
gestational age (P 07.1) 3. Dextrose 17% = D5-½ NS 64 ml + D40% 37 ml + KCl 7.46% 3
ml + calcium gluconate 10% 3 ml + glycophosphat 1 ml,
Treatment infusion rate 4.5 ml/hours (GIR 8) IV
1. O2 nasal cannula 0.5 lpm 4. Amino acids solution 10% 4 g/kgBW/day IV
2. Diet: breast milk 5 - 10 mL/3 hours 5. Lipid 20% 3 g/kgBW/day IV
3. Dextrose 17% = D5-½ NS 60 ml + D40% 38 ml + KCl 7.46% 3 ml + 6. Ampicillin (50 mg/kgBW/12 hours) = 90 mg/12 hours IV
calcium gluconate 10% 3 ml + sodium glycerophosphat 1 ml, 7. Gentamicin (4,5mg/kgBW/36 hours) = 8 mg/36 hours IV
infusion rate 4.3 ml/hours (GIR 8) IV 8. Aminophylline (3 mg/KgBW/8 hours) 5 mg/8 hours IV
9. Ibuprofen (10 mg/kgBW) = 15 mg for the first dose, then (5
4. Amino acids solution 10% 4 g/kgBW/day IV
5. Lipid 20% 3 g/kgBW/day IV mg/kgBW) = 7.5 mg for the second and third doses orally with
6. Ampicillin (50 mg/kgBW/12 hours) = 90 mg/12 hours IV 24-hour interval
7. Gentamicin (4,5mg/kgBW/36 hours) = 8 mg/36 hours IV
8. Aminophylline (3 mg/KgBW/8 hours) 5 mg/8 hours IV Plan:
9. Ibuprofen (10 mg/kgBW) = 15 mg for the first dose, then (5 mg/kgBW) Increase oral intake, wean oxygen support, screening for ROP and
hearing impairment
= 7.5 mg for the second and third doses orally with 24-hour interval
10. Light theraphy 24 hours
8
Increase oral intake, wean oxygen support

9
XV. Case Analysis Diagram
Problems
Risk factor of mother:
20-hour PROM, leukocytosis, multiple
gestation
Risk factor of infant:
prematurity, low birth weight
Born at the 33+5 weeks of gestational age by
C-section delivery due to 20-hour PROM,
gemelli, and fetal distress, birth weight of
1,600 grams
No vigorous cry, inactive movement, Apgar
score 5-7-8, respiratory distress (Downe
score 3)
Lab: ANC <7,800, neutrophil
vacuolization, atypical lymphocyte, macro
thrombocyte, IT ratio >0.2, elevated CRP
Chest X-ray : reticulogranular pattern with
air bronchogram in both lungs
Blood culture : No growth
Preductal saturation 97%
Post ductal saturation 95%
No heart murmur
Echocardiography: PDA, LA/LV dilatation
Diagnosis
1. Adequate fluid and nutrition (from enteral and
parenteral feeding)
Preterm, low birth weight,
appropriate for gestational
age
Early onset sepsis
Respiratory distress
syndrome
Etiological diagnosis:
acyanotic congenital heart
disease
Anatomical diagnosis: PDA
Functional diagnosis: Ross I
Therapy & monitoring Prognosis
2. Thermoregulation support
Monitoring:
- fluid and calories intake per day
- body weight daily, weight gain
Plan:
KMC, Newborn screening for preterm baby,
Growth and development monitoring
1. Intravenous antibiotic therapies
(Ampicillin and Gentamicin)
2. Monitor the therapy outcome, Ad vitam: dubia ad bonam
adverse effects
Ad functionam: dubia ad
bonam
Ad sanationam: dubia ad
bonam
1. CPAP PEEP 7 FiO2 30%
2. Aminophylline (3 mg/Kg BW/8 hours)
3. Evaluate work of breathing and
Downes score
4. Target oxygen saturation 90-95%
Ibuprofen (10 mg/kgBW) = 15 mg for the first
dose, then (5 mg/kgBW) = 7.5 mg for the
second and third doses orally with 24-hour
interval
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XV. CASE DISCUSSION
A preterm female neonate was admitted to NHCU. She was born from a 32
years old mother in 33+5 weeks GA by caesarean section due to 18-hour premature
rupture of membrane (PROM), gemelli, and fetal distress.
A study by Waldemar showed that history of previous preterm birth,
hypertension, oligohydramnios, preeclampsia, PROM, antepartum bleeding,
multiple gestation, diastolic blood pressure ≤ 60 mmHg and fetal growth restriction
were considered as significant risk factors for preterm birth.1 Early detection and
treatment of diseases or disorders during pregnancy as well as health care quality
improvement may reduce preterm prevalence rate.2 Moderately preterm neonates
(29–33+6 weeks), which constituted 22% of all preterm births, are at risk for
substantial short-term morbidity.3 Neonates born moderate and late preterm
(MLPT), are born during a sensitive period for brain development, with a
compatible greater risk of morbidity and mortality than neonates born at full term. 4
A systematic review found that a small effect size (g = 0.38) was found in MLPT
showing poorer intellectual performance compared with those born at term.
Moderate and late preterm neonates are also 1.4 times more likely to develop
psychotic disorders when they are adult compared to term infants (LoE 1A,
recommendations A).4
Our patient was noted with breathlessness upon birth. The most common
causes of respiratory distress in neonates are transient tachypnea of the newborn
(TTN), neonatal sepsis, meconium aspiration syndrome, respiratory distress
syndrome (RDS), and neonatal asphyxia.5,6 Our patient has the risk factors for RDS
as she is a preterm infant, born by cesarean delivery and multiple gestation. She was
grunting, with nasal flare and had subcostal retraction. The diagnosis was supported
by the finding of a reticulogranular pattern with air bronchogram in both lungs on
her chest x ray. A large systematic review showed that preterm infants are 17.3
times more likely to develop respiratory distress syndrome than term neonates.
Aminophylline is commonly administered to prevent apnea episode in
prematurity. Respiratory management after birth resuscitation depends on the
7

severity of distress which is usually assessed with Downe’s score. 8 In treating

neonate with RDS, basic supportive care comprising thermoregulatory, circulatory,
fluid, electrolyte and respiratory is essential. Since most cases of RDS is self-
limited, the goal of treatment is to minimize abnormal physiologic variation and
superimposed iatrogenic problems.9,10 Severe respiratory distress requires initial
endotracheal intubation and followed by mechanical ventilator support to relieve
symptoms. Moderate one can improve by using CPAP (Continues Positive Airway
Pressure) or NIPPV (Non-Invasive Positive Pressure Ventilation). Meanwhile the
mild one just needs nasal cannula as the oxygenation support.11 Our patient
required nasal CPAP at 2 hours stabilization period. Early initiation of CPAP in the
management of RDS in premature neonates, can significantly reduce the need for
mechanical ventilation (MV) and surfactant therapy, with minimum associated
complications.12 A study by Subramaniam et al. suggested that early CPAP may
reduce the need for mechanical ventilation and surfactant (LoE 1B, A
11
 Recommendation).11 It also reduces collapse of surfactant-deficient alveoli and
improves both residual capacity and ventilation-perfusion matching. The amount of
required CPAP usually decreases after 72 hours of age and most neonates can be
immediately weaned from CPAP.11,12 The Downe’s score of our patient improved
during the evaluation, thus we decided to switch to nasal cannula for oxygenation
support. We need to be aware of the complication after using pressured
oxygenation. Therefore evaluations for air leak syndrome like pneumothorax,
pneumomediastinum, pneumopericardium, and interstitial emphysema,
bronchopulmonary dysplasia, and skin or mucosal injury are necessary. Bashir et al.
study reported that nasal mask is better than nasal prong or rotation interface in
reducing nasal injury as the complication of CPAP in preterm neonate (LoE 1B,
recommendations A).13
Neonatal sepsis is a clinical syndrome of systemic disease accompanied by
bacteremia occurring in the first month of life. Early onset sepsis (EOS) occurs in
the 1st week of life, although some experts limit the definition to infection
occurring within first 72 hours of life. It is generally the consequence of infection
caused by organisms acquired during perinatal period.14,15 Risk factors of EOS are
prematurity, low birth weight, asphyxia, invasive procedure, congenital anomaly,
18-hours premature rupture of membrane, maternal peripartum infection, fetal and
intrapartum distress, multiple gestation, and metabolic factors such as acidosis,
hypoxia, metabolic disorder, and immune defects.14-16 Sign and symptoms of
neonatal sepsis are unspecified. Clinical features of sepsis include poor feeding,
lethargy, poor reflexes, hypothermia or hyperthermia, and abdominal distension.
The gold standard for diagnosing EOS is culture proven infection occurring at the
first 72 hours of life. Most neonatal sepsis (60-70%) is not cultured-proven and its
result may be affected by insufficient blood volume, low colony count bacteremia,
prenatal antibiotic use, or treatment with antibiotic before obtaining culture
sample.14,15,17 Many hematologic scoring systems have been made to establish the
diagnosis of neonatal sepsis and Rodwell hematologic scoring is the most
commonly used.18 Current serum biomarker such as presepsin (CD-14) is the most
accurate biomarker followed by procalcitonin, IL-8, and IL-6 for early diagnosis
and management of EOS. The combination of these biomarkers is highly
recommended. (LoE 1B, recommendations A)19
In our patient, we found several risk factors for neonatal sepsis like mother
with 18 hours premature rupture of membrane, leukocytosis, multiple gestation,
prematurity, and low birth weight. The clinical manifestations we could find
including lethargy, hypothermia, and respiratory distress. The laboratory findings
that suggested sepsis in our patient were ANC <7,800, neutrophil vacuolization,
atypical lymphocyte, macro thrombocyte, and ratio of immature to total
polymorphonuclear cells (I/T) ratio >0.2. Rodwell hematological score was 3.
Eventhough the blood culture showed sterile bacterial growth, we obtained
abnormal C-reactive protein (CRP) value. We did not perform lumbar puncture in
this patient due to the absence of CNS symptoms. We initiated first line empirical
antibiotic comprising ampicillin and gentamicin for 7 days.

12
XVI. Journals used as Evidence Based Practice (EBP)

1. de Gamarra-Oca LF, Ojeda N, Gomez-Gastiasoro A, Pena J, Ibarretxe-Bilbao N, et al.

Long-term neurodevelopmental outcomes after moderate and late preterm birth: a
systematic review. J Pediatr. 2021;237:168-76. (LoE 1A, recommendations A)
Conclusion: Despite inconsistency due to the methodologic differences between the
selected studies, MLPT showed minor long-term effects into adulthood. However, more
studies are needed, because prematurity seems to confer some vulnerability to
biological and environmental factors that enhance susceptibility to adverse
neurodevelopment outcomes.

2. Subramaniam P, Ho J, Davis P. Prophylactic nasal continues positive airway pressure to

preventing morbidity and mortality in very preterm infant (review). Cochrane Database
Syst Rev. 2016;(6):CD001243.
Conclusion: There is insufficient evidence to evaluate prophylactic CPAP compared to
oxygen therapy and other supportive care. However when compared to mechanical
ventilation prophylactic nasal CPAP in very preterm infants reduces the need for
mechanical ventilation and surfactant and also reduces the incidence of BPD and death
or BPD.

3. Bashir T, Murki S, Kiran S, Reddy VK, Oleti TP. ’Nasal mask’ in comparison with
‘nasal prongs’ or ‘rotation of nasal mask with nasal prongs’ reduce the incidence of
nasal injury in preterm neonates supported on nasal continuous positive airway pressure
(nCPAP): A randomized controlled trial. PLoS One. 2019;14:e0211476.
Conclusion: CPAP with nasal masks significantly reduces nasal injury in comparison
with nasal prongs or rotation of nasal prongs and nasal masks. However, the type of
interface did not affect the nCPAP failure rates.

4. Ahmed AM, Mohammed AT, Bastawy S, Attalla HA, Yousef AA, et al. Serum
biomarkers for the early detection of the early-onset neonatal sepsis: a single-center
prospective study. Adv Neonatal Care. 2019;19:E26-32.
Conclusion: Presepsin was the most accurate biomarker followed by procalcitonin, IL-
8, and IL-6 regarding the early diagnosis and management of EONS. The combination
between these biomarkers is highly recommended.

13
REFERENCES

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Stanton B, St.Geme, Schor N, editors. Nelson textbook of pediatrics. Twentieth
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factors associated with preterm birth in Ardabil, Iran. Iran J Reprod Med.
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preventing apnea of prematurity. Paediatr Indones. 2014; 54:365-71.
8. Gomella TL, Eyal FG, Mohammed FB, editors. Respiratory management. In:
Gomella TL, Eyal FG, Mohammed FB, editors. Neonatology management,
procedures, on-call problems, diseases, and drugs. Eighth edition. New York: Mc
Graw Hill; 2020. p. 97-117.
9. Gomella TL, Eyal FG, Mohammed FB, editors. Respiratory distress syndrome. In:
Gomella TL, Cunningham MD, Eyal FG, editors. Neonatology management,
procedures, on-call problems, diseases, and drugs. Eighth edition. New York: Mc
Graw Hill; 2020. p. 1043-50.
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guidelines on the management of respiratory distress syndrome-2019 update.
Neonatology. 2019;115:432-50.
11. Subramaniam P, Ho J, Davis P. Prophylactic nasal continues positive airway pressure
to preventing morbidity and mortality in very preterm infant (review). Cochrane
Database Syst Rev. 2016;(6):CD001243.
12. Balaji RVJ, Rajiv PK, Patel VK, Kripail M. Outcome of early cpap in the
management of respiratory distress syndrome (RDS) in premature babies with ≤32
weeks of Gestation, a prospective observational study. IJNMR. 2015;3:1-6.
13. Bashir T, Murki S, Kiran S, Reddy VK, Oleti TP. ’Nasal mask’ in comparison with
‘nasal prongs’ or ‘rotation of nasal mask with nasal prongs’ reduce the incidence of
nasal injury in preterm neonates supported on nasal continuous positive airway
pressure (nCPAP): A randomized controlled trial. PLoS One. 2019;14:e0211476.
14. Gomella TL, Eyal FG, Mohammed FB, editors. Post delivery antibiotics. In: Gomella
TL, Cunningham MD, Eyal FG, editors. Neonatology management, procedures, on-
call problems, diseases, and drugs. Eighth edition. New York: Mc Graw Hill; 2020. p.
701- 18.
15. Gomella TL, Eyal FG, Mohammed FB, editors. Sepsis. In: Gomella TL, Cunningham
MD, Eyal FG, editors. Neonatology management, procedures, on-call problems,
diseases, and drugs. Eighth edition. New York: Mc Graw Hill; 2020. p. 1175-88.
16. Aminullah A and Yuniati T. Sepsis pada bayi baru lahir. In : Setya W, Sarosa GI,
Wibowo T, Alasiry E, Hidayah D, et al, editors. Buku ajar neonatologi. Jakarta:
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early-onset neonatal sepsis—at the crossroad between efficient sepsis care and
antimicrobial stewardship. Front Pediatr. 2018;6:1-9.
18. Iskandar TR, Dalimoenthe NZ, Yuniaty T, Turbawaty DK. Validitas skoring
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biomarkers for the early detection of the early-onset neonatal sepsis: a single-center
prospective study. Adv Neonatal Care. 2019;19:E26-32.

15
APPENDIX

1. Fenton growth chart

16
2. Lubchencho growth percentile

V V V

Conclusion : appropriate for gestational age

17
3. New Ballard score examination

3
1
3
1

1
3
12

2
2
3
2
1

2
12

Conclusion : appropriate for 32-34 weeks gestational age

18
4. Head Ultrasonography

No hypo/hyperechoic lesion in brain parenchymal, no midline deviation, no abnormal

calcification, no calvaria defect, no obstruction of ventricle flow, no intraventricular
hemorrhage.
Conclusion: normal

5. Echocardiography

AV-VA concordance solitus

Systemic venous return and normal pulmonary vein
PFO with diameter 1.5 mm
PDA with diameter 2 mm, bidirectional shunt
The heart space is balanced
Good contractility ventricle
LA / Ao 0.78
The aortic arch is left with a coarc (-)
LA/LV dilatation
Conclusion: Patent Ductus Arteriosus and Patent Foramen Ovale

19