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Aslmualaikum Wr Wb

For the first time, I would like to say thank you for the time given to me. I would to report my
case about Low birth weight infant with hyalin membrane disease.
A baby boy. Patient was hopitalized in our hospital since he was born,
with chief complaint: Grunting since birth

Current History of the disease

Patient was born on December thirty one, twenty seventeen at our Hospital from
mother through sectio caesaria on maternal indication of placenta previa totalis. Mother came
to distric hospital emergency room because the bleeding soaking one sheet of sarong and no
abdominal pain ten hours before the patient was born. Interpretation of maternal blood test
results in district hospital was anemic, then mother referred to our Hospital. In our
Hospital, mother was in conscious state, vital sign was normal but looked pale and bleeding was
still going on. Baby’s heart rate was normal, and no uterine’s contractions. Mother have been
got IVFD RL two lines treatment, dexamethasone and antiobiotic intravena and 2 pouches
fresh blood transfusion. The result of repeat blood test before cesarean action were still anemic,
leukocytosis, platelets, PT and APTT were normal and HbsAg was negative .

Patient was born at 33-34 weeks gestation, birth weight one thousand and nine hundreds
gram, birth length fourty nine cm and head circumference thirty cm , with value of American
Pediatric Gross Assessment Record ( APGAR ) was five at the first minute and seven at the fifth
minute. The patient did not breath spontaneously at birth, with heart rate less than one hundred
times per minute. The patient got rescusitation step in labour room, then patient started crying
with grunting, bluish on the fingertips and legs, retraction and breathlessness. The patient was
given T piece rescucitation with positive end expiratory pressure or PEEP 7, breathlessness and
retration was decrease, Oxygen saturation was normal. Temperature was normal with capillary
refilling time and blood glucose in normal limit. Patient was given injection of vitamin K 1
intramuscular (im) and then transferred to neonatal intensive care unit (NICU) room.

In NICU room, patients was treated in incubator at a temperature

of 35, 5 degree Celcius, and with nasal installation continous positive airway pressure ( CPAP )
but retraction of the chest wall still present, patients was desaturation and dyspnue, then
intubation was performed and ventilator PSIMV mode was installed, and we perfomed thoracic
x-ray examination.

The results of thoracic x-ray examination found appearance of the opacification with air
bronchogram in both lung fields and the heart border was unclear, especially on the right side.
the impression suitable to grade III-IV of HMD. Patient was fasted, given total parenteral
nutrition,first line antibiotics was ampicillin sulbactam and gentamicin intravenously .

At the age of 5 hours. Surfactant was given with a dose of 4 cc/kgBW = 8 cc through
intratracheal in 4 divided doses. During the administration of surfactant, the condition of the
baby was stable. We perfomed thoracic x-ray examination after surfactant administration ,
which showed the impression of thoracic x-ray improved than before, no more opacification with
air bronchograms in both lung fields and heart border was clear.
At the age of 22 hours, extubation was performed on the patient, then patient was installed Nasal
CPAP. Urine and meconium were present. trophic feeding with breast milk through
orogastric tube was given to the patient

On the second and third day treatments patient looked jaundice on his face and patient was
stable with nasal CPAP and still got parenteral fluid. Installation of peripheral inserted central
catheter (PICC) was performed and parenteral fluid was given through by PICC.

On the day of the fourth and fifth treatment patient was still installed CPAP and jaundice was
not increase than before, no fever and no apnue or desaturation. Patients got breastmilk
15 cc/kgBW per OGT but the abdomen looked bloanted. There were defecation and no
vomiting . We postponed increasing the supply of enteral nutrition and monitoring drinking
tolerance by clinical observations to the patient,

Family History of Disease

No family history of preterm birth.The third patient's sister was died aged 40 days, possibly due
to a perinatal infection.

History of Pregnancy

Patient was the fourth child of 4 siblings. Mother's last pregnancy was 16 months ago. During
pregnancy the mother felt healthy but irregular control to the midwife, with antenatal care visit
(ANC) only 3 times. Mother never controled to obstetrician and never performed ultrasound
during pregnancy. No history of vaginal discharge and fever during pregnancy and never
suffered from hypertension, diabetes, and other diseases before becoming pregnant.

Mother regularly ate during pregnancy, but body weight increased just only 5 kg. Mother was
with antepartum hemorrhage on the last control to midwife. So, Possible antepartum bleeding as
the cause of preterm birth.

Socio-Economic History and Environmental Conditions

Patients come from low socioeconomic class. Whose mother of 33 year old , The father of 35-
year-old patient, the last education of them junior high school, Mother as housewife and father
was farmer with income Rp.1.000.000 / mounth. The family lives in a permanent house but with
poor hygiene and environmental sanitation.The cost of patient care is borne by the state (BPJS).

Patient has never been immunized since birth and hepatitis B imunisation can not be given
because the patient was seriously ill

Patient got nutrition with insufficient caloric count and have not received full enteral nutrition.
Patient was receiving parenteral nutrition from birth in and got breastmilk from the second day
of treatment (trophic feeding) and gradually increased in accordance with drinking tolerance the
form of PG1 fluid. nutritional calorie was 40 kcal / kgBW / day on the first day, gradually
increased to 92 kcal/kgBW/day on the sixth day.
Growth and development of the patient can not be assessed yet

On the sixth day we got this case : The patient still received parenteral fluid and got breast
milk per OGT and abdomen was not appeared bloated again. There was defecation and no
vomiting , but the patient looked pale and yellowish on the face. Patient was still installed Nasal

On physical examination :
General condition: looked severely ill with spontaneous and visible movements less active
Heart rate : 142 times per minute, regular
Breathing rate : 48 times per minute, regular, sufficient depth
Axillary temperature : 36.8 0C
Blood pressure : 65/40 mmHg with MAP 55
Oxygen saturation : 92-96% (CPAP installed with PEEP 5, FiO2 21%)
Nutritional & anthropometric status
Birth weight : 1930 gram (P10 - P50 Fenton curve)
Body length : 45 cm (P50 - P90 Fenton curve)
Head circumference : 30 cm (P10 - P50 Fenton curve)
based of Fenton curve patient suitable for neonates 33-34 weeks of age
Another physical examination
Skin felt warm, no 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
the conjunctiva was not pale, the sclera was jaundiced, there were non
palpebra oedema, isochore pupils, 3 mm diameter, good light reflex
Neck no enlarged lymph nodes are found
Ears Soft pinna, slow recoil
Nose installed nasal prong CPAP
Mounth no oral cyanosis, oral mucosa and lips installed OGT
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 ictus cordis not visible, regular heart sound, no noise or rhythm
Abdomen no visible bulge, visible several large blood vessels, well cord, not hiperemis
on umbilicus, palpable supel and flat. liver palpable quarter, flat surface,
sharp edge, chewy consistency, lien not palpable, abdominal circumference
26 cm, normal positive bowel sounds
Genital both testicles fall well
Back and No abnormality
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.

In the first blood examination : there was not anemic, leucocyte and platelet in normal limit. IT
ratio not increased.
We made working diagnosis for the patient with:
1. Low birth weight neonate (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)
Problems of the patient were:
a. Low birth weight infant
b. Premature delivery
c. Respiratory distress due to hyaline membrane disease (HMD) grade III-IV
d. Unvaccinated infant
e. Neonatal icterus grade I which suspected due to prematurity with differential
diagnosis due to early-onset neonatal sepsis
f. Leukocytosis mother
On Management Plan consist of:
1. Emergency treatment
a. Airway: maintaining adequate and clear airway, considering intubation if 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.
e. Sugar: parenteral and enteral feeding adminitration is based on individual need.
Maintaining GIR 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
We gave diet formulation : parenteral nutrition and breast milk, with total calories
summarised is 174 kcal/day (occupying 76 % of RDA absoute).
a. Nutrition plan : enteral nutrition, like breast milk, will be given gradually to meet
Recommended daily allowance (RDA), with maximum amount of fluid allowed is 150
ml/kg/day and minimum caloric target was 120 kcal/kg/day.
b. Monitoring and evaluation : of acceptability, tolerance, increase caloric intake gradually
c. Monitoring plan : Vital sign and clinical manifestation , Laboratoy evaluation , evaluation of
parenteral and enteral nutrition administration, Gradual monitoring of anthropometric,
Morbidity screening test plan toward high risk infant, growth and developmental
evaluation using Fenton chart and denver developmental scr eening test (DDST II)
assessment .
5. Immunisation administration is done based on recommendation of Indonesian Pediatric
association. Immunisation to premature infants are given adjusted to the cronological age.
Hepatitis B1 vaccination is postponed until the infants are stable.
6. Communication, information, and education to the family

Treatment and monitoring

On first day monitoring: Patien still depended to NCPAP, look more jaundice and pale. No fever
and stable with CPAP. On physical examination patien with icteric neonatorum grade III, we
check blood examination. The resulf of blood examination we got patien with increase of IT ratio
and IM ratio. We changed antibiotic to be Meropenem intravenously. Patient with
hyperbilirubinemia, but needless of phototherapy.

On the second and third day monitoring patient still dependent to NCPAP instalation, got
parenteral and enteral nutrinion, Enteral nutrition was increased gradually. Body weight was
increased to be 1950 gram.No apnue, no desaturation and no fever.
On forth day monitoring: Jaundice was decrease, drinking toleration was good, enteral nutrition
increased gradually. We done blood examination to evaluate treatment and nutritional
monitoring to the patient and planed to weaning from NCPAP. Patient was hypocalcemia and
we corrected intravenously.
On fifth day monitoring: clinical condition of patient improved. Patient without oxigen aid, there
was no desaturatioin, no breathllessness, well-toleranted intake and no jaundice. Blood culture
was steril. We continued treatment and monitoring and also kanggoro mother care was done to
the patient.

Prognosis of the patient : Prognosis ad vitam , ad fuctionam and sanationam was dubia et