Case report Low Birthweight1Anamnesis Pasien datang dengan keluhan sesak sejak 2 jam SMRS, keluhan muncul sesaat setelah pasien lahir. Pasien lahir belum cukup bulan ( 6 bulan) dengan BB 1600 gram pasien tidak langsung menangis pada saat lahir Pemeriksaan fisik : Nadi 150x/mnt , Nafas 60x/mntDiagnosis kerja : premature dengan asfiksia beratTindakan: pasang infus , pasang ogt, pasang oksigen 2 tpm Pemeriksaan penunjang dl dan gds

27 Agustus 2015Cefotaxim 2x 75 mgAmikacib 1x20 mg2Hasil labWBC : 13,6 ribuRBC : 4.09 juta/mm3HGB : 16.1 g/dlHCT : 46.7%MCV : +114.2 flMCH : +39.4 pgMCHC : 34.5g/dlPLT : AG 176 ribu/mm3LYM : 51.9 % ( 7.1 )GDS : 46 mg/dl

28 agustus 2015BB = 1390gr

S = demam (-), muntah (-), merintih (-) O = Heart rate 160x/mnt, RR 49x/mnt A = sepsis neonatorumP = cefotaxim 2x75 mg amikacin 1x20mg D5 n1/2 160CC (7 TPM) termoregulasi cairan oral 100cc/ hari 29 agustus 2015BB = 1410gr

S = demam (-), muntah (-), merintih (-), sianosis (+)O = Heart rate 160x/mnt, RR 41x/mnt KU= sedang, gerak aktif, menangis kuatA = sepsis neonatorum, post asfiksia , BBLR kurang bulan,apnuP = cefotaxim 2x75 mg amikacin 1x20mg D5 n1/2 160CC (8 TPM) termoregulasi cairan oral 120cc/ hari o2 per nasal prongs 1 tpm30 agustus 2015BB = 1320gr

S = demam (-), muntah (-), merintih (-), sianosis (-)O = Heart rate 166x/mnt, RR 44x/mnt KU= sedang, gerak aktif, menangis kuatA = sepsis neonatorum, post asfiksia , BBLR kurang bulan,post apnuP =aminophylin 1x12 ( setelah 8 jam 3x6 mg ) cefotaxim 2x75 mg amikacin 1x20mg D5 n1/4 (10 TPM) termoregulasi cairan oral 140cc/ hari ( per sonde 20cc/3 jam )31 agustus 2015BB = 1320gr

S = demam (-), muntah (-), merintih (-), sianosis (-)O = Heart rate 162x/mnt, RR 41x/mnt KU= sedang, gerak aktif, menangis kuatA = resiko ketidakseimbangan nutrisiP =aminofusin 1x20mg aminofed 1% 60cc/2 jam aminophylin 1x12 ( setelah 8 jam 3x6 mg ) cefotaxim 2x75 mg amikacin 3x6mg D5 n1/2 (9 TPM) termoregulasi cairan oral 140cc/ hari ( per sonde 20cc/3 jam )Hasil labBILIRUBIN TOTAL : 7.1 mg/dlBILIRUBIN DIRECT : 0.4 mg/dl 1 September 2015BB = 1380gr

S = demam (-), muntah (-), merintih (-), sianosis (-)O = Heart rate 162x/mnt, RR 41x/mnt KU= sedang, gerak aktif, menangis kuat, o2 terpasangA = resiko ketidak seimbangan nutrisiP =observasi D10 100ccAminofusin 150ccASI/PASI 10 cc/ 3 jamApialys 1x 5 tetesMaltofer 1x5 tetes2 September 2015BB = 1310gr

S = demam (-), muntah (-), merintih (-), sianosis (-)O = Heart rate 162x/mnt, RR 41x/mnt KU= lemas, gerak aktif, menangis kuat, o2 terpasangA = BBL/BKB/SMK/ Sepsis, apnea of prematurity, post asfiksia beratP =observasi D10 120ccAminofusin 120ccASI/PASI 8 cc/ 3 jamApialys 1x 5 tetesMaltofer 1x5 tetes3 September 2015BB = 1310gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih (-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbnO = Heart rate 150x/mnt, RR 40x/mnt, continuous murmur (+)A = BBL/BKB/SMK/ Sepsis, apnea of prematurity, post asfiksia berat, SUSP. PDAP =observasi D10 120ccAminofusin 120ccASI/PASI 8 cc/ 3 jamApialys 1x 5 tetesMaltofer 1x5 tetesKonsul bagian jantungCaptopril 3x0.1 mgHasil labBilirubin Total : 21.2 mg/dlBilirubin Direct : 1.4 mg/dlIndirect hb fe12Hasil labWBC : 8,6 ribuRBC : 4.64 juta/mm3HGB : 17.4 g/dlHCT : 50.0%MCV : 107.8 flMCH : 37.5 pgMCHC : 34.8g/dlPLT : AG 220 ribu/mm3

Hasil radiologiPDA left to right shuntASD left to right shunt

4 September 2015BB = 1390gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih (-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbnO = Heart rate 152x/mnt, RR 40x/mnt, continuous murmur (+)A = BBL/BKB/SMK/ Sepsis, apnea of prematurity, post asfiksia berat, PDA+ASDP =observasi D10 120ccAminofusin 120ccASI/PASI 10 cc/ 3 jamApialys 1x 5 tetesMaltofer 1x5 tetesFototherapy per 6 jam Raber jantungCaptopril 3x0.1 mg5 September 2015BB = 1370gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih (-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbnO = Heart rate 152x/mnt, RR 40x/mnt, continuous murmur (+)A = BBL/BKB/SMK/ Sepsis, apnea of prematurity, post asfiksia berat, PDA+ASD, P =observasi D10 120ccAminofusin 120ccASI/PASI 10 cc/ 2 jamApialys 1x 5 tetesMaltofer 1x5 tetesFototherapy per 6 jam Raber jantungCaptopril 3x0.1 mg6 September 2015BB = 1490gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih (-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbnO = Heart rate 152x/mnt, RR 40x/mnt, continuous murmur (+)A = PDA+ASD P =observasi D10 120ccAminofusin 120ccASI/PASI 10 cc/ 2 jamApialys 1x 5 tetesMaltofer 1x5 tetesRaber jantungCaptopril 3x0.2 mg7 September 2015BB = 1490gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih (-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbnO = Heart rate 152x/mnt, RR 40x/mnt, continuous murmur (+)A = PDA+ASD P =observasi ASI/PASI 15 cc/ 2 jamApialys 1x 5 tetesMaltofer 1x5 tetesRaber jantungCaptopril 3x0.2 mg8 September 2015BB = 1400gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih (-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbnO = Heart rate 150x/mnt, RR 40x/mnt, continuous murmur (+)A = PDA+ASD P =observasi ASI/PASI 15 cc/ 2 jamApialys 1x 5 tetesMaltofer 1x5 tetesRaber jantungCaptopril 3x0.2 mg9 September 2015BB = 1380gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih (-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbnO = Heart rate 150x/mnt, RR 40x/mnt, continuous murmur (+)A = PDA+ASD P =observasi ASI/PASI 15 cc/ 2 jamApialys 1x 5 tetesMaltofer 1x5 tetesRaber jantungCaptopril 3x0.4 mgLOW BIRTHWEIGHT ? Birthweight ?Birthweight is the first weight of the foetus or newborn obtained after birth. For live births, birthweight should preferably be measured within the first hour of life before significant postnatal weight loss has occurred. World Health Organization, International statistical classification of diseases and related health problems,

DefinitionLow birthweight is weight at birth of less than2,500 grams (5.5 pounds). This is based on epidemiologicalobservations that infants weighing less than2,500 g are approximately 20 times more likely to diethan heavier babies. More common in developing thandeveloped countries, a birthweight below 2,500 gcontributes to a range of poor health outcomes.United Nations Childrens Fund and World Health Organization, Low Birthweight: Country,regional and global estimates. UNICEF, New York, 2004.BIRTH WEIGHT CLASSIFICATIONKlasifikasi menurut berat lahir 1. bayi berat lahir rendah < 2500 gr2. bayi berat lahir cukup/normal > 2500- 4000 gram3. bayi berat lahir lebih > 4000 grKlasifikasi menurut masa gestasi / umur kehamilan : 1. bayi kurang bulan < 37 minggu2. bayi cukup bulan 37 42 minggu3. bayi lebih bulan > 42 mingguBuku ajar neonatologi ikatan dokter anak indonesia Epidemiology

United Nations Childrens Fund and World Health Organization, Low Birthweight: Country,regional and global estimates. UNICEF, New York, 2004.Etiology 1. obstetric complicationA. multiple gestationB. incompetenceC. PRO ( premature rupture of membrane )D. PIH ( pregnancy induce hypertension ) E. placenta previa F. premature history2. Medical ComplicationA. maternal diabetesB. chronic hypertensionC. tractus urinarius infection Etiology (2) Comparison of Normal resting posture small and term babiesSmall babiesTerm babies

World Health Organization.Managing newborn problems: a guide for doctors, nurses, and midwivesComplications Small babies are prone to complications. Some problems that small babies are particularly susceptible to include:feeding difficulty ( common problems )abnormal body temperature (incubator / kangaroo mother care )breathing difficultynecrotizing enterocolitisjaundice of prematurityAnaemialow blood glucoseANEMIA If the haemoglobin is lessthan 8 g/dl (haematocrit less than 24%), give a blood transfusion (pageP-31).To prevent iron deficiency anaemia, give small babies an oral ironpreparation to give elemental iron 2 mg/kg body weight once daily fromtwo months of age up to 23 months of age.

LOW BLOOD GLUCOSE Infuse 10% glucose at the daily maintenance volume according to thebabys age29FEEDING AND FLUID MANAGEMENT OF SMALL BABIESSmall babies often have difficulty feeding simply because they are not mature enough to feed well. Good feeding ability can usually be established by 34 to 35 weeks post-menstrual age. Until that time, substantial effort may be needed to ensure adequate feeding. Provide special support and attention to the mother during this difficult period- her breast milk is the best food for the baby;- breastfeeding is especially important for a small baby;- it may take longer for a small baby to establish breastfeeding;- it is usually normal if the baby:- tires easily and suckles weakly at first;- suckles for shorter periods of time before resting;- falls asleep during feeding;- pauses for long periods between sucklingExplain to the mother that:

30FEED AND FLUID VOLUMES FOR SMALL BABIES WITHOUT MAJOR ILLNESS1.75 TO 2.5 KGAllow the baby to begin breastfeeding . If the baby cannot be breastfed, give expressed breast milk using an alternative feeding method. Use Table C-4 to determine the required volume of milk for the feed based on the babys age.

FEED AND FLUID VOLUMES FOR SMALL BABIES WITHOUT MAJOR ILLNESS (2)1.5 TO 1.749 KG Give expressed breast milk using an alternative feeding method every three hours according to Table F-3 until the baby is able to breastfeed.

FEED AND FLUID VOLUMES FOR SMALL BABIES WITHOUT MAJOR ILLNESS (3)1.25 TO 1.49 KG Give expressed breast milk by gastric tube every three hours according to Table F-4. Progress to feeding by cup/spoon as soon as the baby can swallow without coughing or spitting.

FEED AND FLUID VOLUMES FOR SMALL BABIES WITHOUT MAJOR ILLNESS (4)*LESS THAN 1.25 KG Establish an IV line , and give only IV fluid (according to Table F-5, ) for the first 48 hours. Give expressed breast milk by gastric tube every two hours starting on day 3, or later if the babys condition is not yet stable, and slowly decrease the volume of IV fluid while increasing the volume of oral feeds according to Table F-5 . Progress to feeding by cup/spoon as soon as the baby can swallow without coughing or spitting.

*same with babies with illnessFEED AND FLUID VOLUMES FOR SMALL BABIES WITH ILLNESSSICK BABIES1.75 TO 2.5 KG If the baby does not initially require IV fluid , allow the baby to begin breastfeeding. If the baby cannot be breastfed, give expressed breast milk using an alternative feeding method . Determine the required volume of milk for the feed based on the babys age (Table C-4 ) If the baby requires IV fluid:- Establish an IV line, and give only IV fluid (according to Table F-6) for the first 24 hours- Give expressed breast milk using an alternative feeding method every three hours starting on day 2, or later if the babys condition is not yet stable, and slowly decrease the volume of IV fluid while increasing the volume of oral feeds according to Table F-6.

FEED AND FLUID VOLUMES FOR SMALL BABIES WITH ILLNESS (2) 1.5 TO 1.749 KG Establish an IV line,and give only IV fluid (according to Table F-7) for the first 24 hours. Give expressed breast milk by gastric tube every three hours starting on day 2, or later if the babys condition is not yet stable, and slowly decrease the volume of IV fluid while increasing the volume of oral feeds according to Table F-7. Progress to feeding by cup/spoon as soon as the baby can swallow without coughing or spitting.

FEED AND FLUID VOLUMES FOR SMALL BABIES WITH ILLNESS (3) 1.25 TO 1.49 KG Establish an IV line , and give only IV fluid (according to Table F-8) for the first 24 hours. Give expressed breast milk by gastric tube every three hours starting on day 2, or later if the babys condition is not yet stable, and slowly decrease the volume of IV fluid while increasing the volume of oral feeds according to Table F-8. Progress to feeding by cup/spoon as soon as the baby can swallow without coughing or spitting

It is normal for small babies to lose weight during the first 7 to 10 daysof life. Birth weight is usually regained by 14 days of life unless the babyhas been sick.38BREATHING DIFFICULTY

PROBLEMS The babys respiratory rate is more than 60 breaths per minute. The babys respiratory rate is less than 30 breaths per minute. The baby has central cyanosis (blue tongue and lips). The baby has chest indrawing (Fig. F-3). The baby is grunting on expiration. The baby has apnoea (spontaneous cessation of breathing for more than 20 seconds).

GENERAL MANAGEMENT of BREATHING DIFFICULITY

Give oxygen at a moderate flow rate. If the babys respiratory rate is less than 30 breaths per minute, observe the baby carefully. If the respiratory rate is less than 20 breaths per minute at any time, resuscitate the baby using a bag and mask . If the baby has apnoea:- Stimulate the baby to breathe by rubbing the babys back for 10 seconds;- If the baby does not begin to breathe immediately, resuscitate the baby using a bag and mask Measure blood glucose . If the blood glucose is less than 45 mg/dl (2.6 mmol/l), treat for low blood glucose . If the babys respiratory rate is more than 60 breaths per minute and the baby has central cyanosis (even if receiving oxygen at a high flow rate) but no chest indrawing or grunting on expiration, suspect a congenital heart abnormality .SEPSIS Establish an IV line , and give only IV fluid at maintenance volume according to the babys age for the first 12 hours. Take a blood sample , and send it to the laboratory for culture and sensitivity, if possible, and to measure haemoglobin. If the haemoglobin is less than 10 g/dl (haematocrit less than 30%), give a blood transfusion If the baby has convulsions, opisthotonos, or a bulging anterior fontanelle, suspect meningitis:- Treat convulsions, if present - Perform a lumbar puncture - Send a sample of the cerebrospinal fluid (CSF) to the laboratory for cell count, Gram stain, culture, and sensitivity;- Begin treatment for meningitis while awaiting laboratory confirmation.If meningitis is not suspected, give ampicillin and gentamicin IV according to the babys age and weight SEPSIS (2)After 12 hours of treatment with antibiotics or when the babys condition begins to improve, allow the baby to begin breastfeeding . If the baby cannot be breastfed, give expressed breast milk using an alternative feeding method

INITIAL MANAGEMENT OF SERIOUS JAUNDICE

Begin phototherapy if jaundice is classified as serious in Table F-16. Determine if the baby has the following risk factors: less than 2.5 kg at birth, born before 37 weeks gestation, haemolysis, or sepsis. Take a blood sample , and measure serum bilirubin (if possible) and haemoglobin, determine the babys blood group- If the serum bilirubin is below the level requiring phototherapy Table F-17, discontinue phototherapy;- If the serum bilirubin is at or above the level requiring phototherapy (Table F-17, continue phototherapy;- If the Rh factor and ABO blood group do not indicate a cause of haemolysis or if there is a family history of G6PD deficiency, obtain a G6PD screen, if possible.

INITIAL MANAGEMENT OF SERIOUS JAUNDICE (2)

KANGAROO MOTHER CARE (KMC)care of a small baby who is continuously carried in skin-to-skin contact by the mother and exclusively breastfed (ideally). It is the best way to keep a small baby warm and it also helps establish breastfeeding. KMC can be started in the hospital as soon as the babys condition permits).

REFERENCE1. Organization W, UNAIDS. Managing newborn problems. Geneva: Dept. of Reproductive Health and Research, World Health Organization; 2003. 2. Organization, United Nations Childrens Fund and World Health. Low Birthweight: Country,regional and global estimate. New York; 2004.3. Kosim M, Yunanto A, Dewi R, Irawan G. Buku Ajar Neonatologi. 4th ed. jakarta: Badan Penerbit IDAI; 2014.