Case report Low

Birthweight

Anamnesis

27 Agustus
2015

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/mnt

Diagnosis kerja : premature dengan asfiksia berat

Tindakan: pasang infus , pasang ogt, pasang oksigen 2

tpm

Pemeriksaan penunjang dl dan gds

Hasil lab
WBC : 13,6 ribu
RBC : 4.09 juta/mm3
HGB : 16.1 g/dl
HCT : 46.7%
MCV : +114.2 f
MCH : +39.4 pg
MCHC : 34.5g/dl
PLT : AG 176 ribu/mm3
LYM : 51.9 % ( 7.1 )
GDS : 46 mg/dl

28 agustus 2015

BB = 1390gr

S = demam (-), muntah (-), merintih (-)

O = Heart rate 160x/mnt, RR 49x/mnt
A = sepsis neonatorum
P = cefotaxim 2x75 mg
amikacin 1x20mg
D5 n1/2 160CC (7 TPM)
termoregulasi
cairan oral 100cc/ hari

29 agustus 2015

BB = 1410gr

S = demam (-), muntah (-), merintih (-), sianosis (+)

O = Heart rate 160x/mnt, RR 41x/mnt KU= sedang, gerak aktif, menangis kuat
A = sepsis neonatorum, post asfiksia , BBLR kurang bulan,apnu
P = cefotaxim 2x75 mg
amikacin 1x20mg
D5 n1/2 160CC (8 TPM)
termoregulasi
cairan oral 120cc/ hari
o2 per nasal prongs 1 tpm

30 agustus 2015

BB = 1320gr

S = demam (-), muntah (-), merintih (-), sianosis (-)

O = Heart rate 166x/mnt, RR 44x/mnt KU= sedang, gerak aktif, menangis kuat
A = sepsis neonatorum, post asfiksia , BBLR kurang bulan,post apnu
P =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 2015

BB = 1320gr

S = demam (-), muntah (-), merintih (-), sianosis (-)

O = Heart rate 162x/mnt, RR 41x/mnt KU= sedang, gerak aktif, menangis kuat
A = resiko ketidakseimbangan nutrisi
P =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 lab
BILIRUBIN TOTAL : 7.1 mg/dl
BILIRUBIN DIRECT : 0.4 mg/dl

1 September 2015

BB = 1380gr

S = demam (-), muntah (-), merintih (-), sianosis (-)

O = Heart rate 162x/mnt, RR 41x/mnt KU= sedang, gerak aktif, menangis kuat, o2 terpasang
A = resiko ketidak seimbangan nutrisi
P =observasi
D10 100cc
Aminofusin 150cc
ASI/PASI 10 cc/ 3 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes

2 September 2015

BB = 1310gr

S = demam (-), muntah (-), merintih (-), sianosis (-)

O = Heart rate 162x/mnt, RR 41x/mnt KU= lemas, gerak aktif, menangis kuat, o2 terpasang
A = BBL/BKB/SMK/
Sepsis, apnea of prematurity, post asfiksia berat
P =observasi
D10 120cc
Aminofusin 120cc
ASI/PASI 8 cc/ 3 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes

3 September 2015

BB = 1310gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih
(-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbn
O = Heart rate 150x/mnt, RR 40x/mnt, continuous murmur (+)
A = BBL/BKB/SMK/
Sepsis, apnea of prematurity, post asfiksia berat, SUSP. PDA
P =observasi
D10 120cc
Aminofusin 120cc
ASI/PASI 8 cc/ 3 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes
Konsul bagian jantung
Captopril 3x0.1 mg

Hasil lab
Bilirubin Total : 21.2 mg/dl
Bilirubin Direct : 1.4 mg/dl

Hasil lab
WBC : 8,6 ribu
RBC : 4.64 juta/mm3
HGB : 17.4 g/dl
HCT : 50.0%
MCV : 107.8 f
MCH : 37.5 pg
MCHC : 34.8g/dl
PLT : AG 220 ribu/mm3

Hasil radiologi

PDA left to right shunt

ASD left to right shunt

4 September 2015

BB = 1390gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih
(-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbn
O = 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 120cc
Aminofusin 120cc
ASI/PASI 10 cc/ 3 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes
Fototherapy per 6 jam
Raber jantung
Captopril 3x0.1 mg

5 September 2015

BB = 1370gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih
(-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbn
O = 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 120cc
Aminofusin 120cc
ASI/PASI 10 cc/ 2 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes
Fototherapy per 6 jam
Raber jantung
Captopril 3x0.1 mg

6 September 2015

BB = 1490gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih
(-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbn
O = Heart rate 152x/mnt, RR 40x/mnt, continuous murmur (+)
A = PDA+ASD
P =observasi
D10 120cc
Aminofusin 120cc
ASI/PASI 10 cc/ 2 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes
Raber jantung
Captopril 3x0.2 mg

7 September 2015

BB = 1490gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih
(-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbn
O = Heart rate 152x/mnt, RR 40x/mnt, continuous murmur (+)
A = PDA+ASD
P =observasi
ASI/PASI 15 cc/ 2 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes
Raber jantung
Captopril 3x0.2 mg

8 September 2015

BB = 1400gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih
(-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbn
O = Heart rate 150x/mnt, RR 40x/mnt, continuous murmur (+)
A = PDA+ASD
P =observasi
ASI/PASI 15 cc/ 2 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes
Raber jantung
Captopril 3x0.2 mg

9 September 2015

BB = 1380gr

S = demam (-), muntah (-), merintih (-), sianosis (-), sesak (-) muntah (-), merintih
(-), kejang (-), demam (-) ,wajah kuning (-) BAB/BAK dbn
O = Heart rate 150x/mnt, RR 40x/mnt, continuous murmur (+)
A = PDA+ASD
P =observasi
ASI/PASI 15 cc/ 2 jam
Apialys 1x 5 tetes
Maltofer 1x5 tetes
Raber jantung
Captopril 3x0.4 mg

LOW 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,

Definition

Low birthweight is weight at birth of less than

2,500 grams (5.5 pounds). This is based on epidemiological
observations that infants weighing less than
2,500 g are approximately 20 times more likely to die
than heavier babies. More common in developing than
developed countries, a birthweight below 2,500 g
contributes 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 CLASSIFICATION

Klasifikasi menurut berat lahir

Klasifikasi menurut masa gestasi /

umur kehamilan :

1. bayi berat lahir rendah < 2500 gr

2. bayi berat lahir cukup/normal

> 2500- 4000 gram

1. bayi kurang bulan < 37 minggu

2. bayi cukup bulan 37 42 minggu

3. bayi berat lahir lebih > 4000 gr

3. bayi lebih bulan > 42 minggu

Buku 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 complication

2. Medical Complication

A. multiple gestation

B. incompetence

C. PRO ( premature rupture of

membrane )

D. PIH ( pregnancy induce

hypertension )

E. placenta previa

A. maternal diabetes

F. premature history

B. chronic hypertension

C. tractus urinarius infection

Etiology (2)
Placenta

Malnutriitio
n

IUG
R

Genetic
Factor

Infection

Comparison of Normal resting

posture small and term babies
Small babies

Term babies

World Health Organization.Managing newborn problems: a guide for doctors, nurses, and midwives

Complications

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 difficulty

necrotizing enterocolitis

jaundice of prematurity

Anaemia

low blood glucose

FEEDING AND FLUID MANAGEMENT OF

SMALL BABIES

Small 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

FEED AND FLUID VOLUMES FOR SMALL BABIES

WITHOUT MAJOR ILLNESS

1.75 TO 2.5 KG

Allow 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 fuid (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 fuid 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

illness

FEED AND FLUID VOLUMES FOR SMALL BABIES

WITH ILLNESS

SICK BABIES

1.75 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 fuid (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 fuid 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 fuid (according to Table F7) 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 fuid 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 fuid (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 fuid 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

BREATHING 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 fow 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 fow rate)
but no chest indrawing or grunting on expiration, suspect a congenital
heart abnormality .

SEPSIS

Establish an IV line , and give only IV fuid 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 fuid (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 F17, 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).

REFERENCE

1. Organization W, UNAIDS. Managing newborn problems.

Geneva: Dept. of Reproductive Health and Research, World
Health Organization; 2003.

2. Organization, United Nations Children s 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.