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’s 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 received intravenous steroid once
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 frequently

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 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/Posterior Right Left
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
• Movement : symmetrical without limited ROM
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 •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 insize 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 35.8oC,
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
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

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 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,
incomplete prenatal steroid administration)
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 FiO2 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,
then maintained with (3 mg/kgBW/8 hours) = 5 mg/8 hours IV

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X. NUTRITION AND FLUID MANAGEMENT
1. Enteral nutrition with breast milk started from 5-10 mL/kgBW/day when the
baby was stable, 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 Treatment
Plan:
Waiting for blood culture result
Echocardiography
Plan:
Increase oral intake, wean oxygen support
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
th
Laboratory result (June 16 , 2022):
Hb: 15.2 g/dl, platelet: 308,000/ul, erythrocyte: 4,200,000/ul, Hct: 42%, ml/kgBW/hour, nutritional achievement: 72-75% (from orally
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
3. Dextrose 17% = D5-½ NS 64 ml + D40% 37 ml + KCl 7.46% 3
gestational age (P 07.1)
ml + calcium gluconate 10% 3 ml + glycophosphat 1 ml,
infusion rate 4.5 ml/hours (GIR 8) IV
4. Amino acids solution 10% 4 g/kgBW/day IV
1. O2 nasal cannula 0.5 lpm
5. Lipid 20% 3 g/kgBW/day IV
2. Diet: breast milk 5 - 10 mL/3 hours 6. Ampicillin (50 mg/kgBW/12 hours) = 90 mg/12 hours IV
3. Dextrose 17% = D5-½ NS 60 ml + D40% 38 ml + KCl 7.46% 3 ml + 7. Gentamicin (4,5mg/kgBW/36 hours) = 8 mg/36 hours IV
calcium gluconate 10% 3 ml + sodium glycerophosphat 1 ml, 8. Aminophylline (3 mg/KgBW/8 hours) 5 mg/8 hours IV
infusion rate 4.3 ml/hours (GIR 8) IV 9. Ibuprofen (10 mg/kgBW) = 15 mg for the first dose, then (5
4. Amino acids solution 10% 4 g/kgBW/day IV mg/kgBW) = 7.5 mg for the second and third doses orally with
5. Lipid 20% 3 g/kgBW/day IV 24-hour interval
6. Ampicillin (50 mg/kgBW/12 hours) = 90 mg/12 hours IV
7. Gentamicin (4,5mg/kgBW/36 hours) = 8 mg/36 hours IV Plan:
8. Aminophylline (3 mg/KgBW/8 hours) 5 mg/8 hours IV Increase oral intake, wean oxygen support, screening for ROP and
9. Ibuprofen (10 mg/kgBW) = 15 mg for the first dose, then (5 mg/kgBW) hearing impairment
= 7.5 mg for the second and third doses orally with 24-hour interval
10. Light theraphy 24 hours
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XV. Case Analysis Diagram
Problems
Risk factor of mother:
20-hour PROM, leukocytosis, multiple
gestation, incomplete steroid administration
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
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
1. Adequate fluid and nutrition (from enteral
and parenteral feeding)
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, adverse Ad vitam: dubia ad bonam
effects
Ad functionam: dubia ad
bonam
Ad sanationam: dubia ad
1. CPAP PEEP 7 FiO2 30% bonam
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 20-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, multiple gestation, and incomplete prenatal
steroid administration. 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 morelikely to develop respiratory distress
syndrome than term neonates. Aminophylline is commonly administered to prevent
apnea episode in prematurity.7 Respiratory management after birth resuscitation
depends on the 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
Recommendation).11 It also reduces collapse of surfactant-deficient alveoli and
10
 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
20-hour 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.

11
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 pressureto

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 ofnasal 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.

12
REFERENCES

1. Waldemar AC. Prematurity and intrauterine growth restriction. In: Kliegman R,

Stanton B, St.Geme, Schor N, editors. Nelson textbook of pediatrics. Twentieth edition.
Philadelphia: Elsevier; 2016. p. 821-30.
2. Rahele Alijahan, Sadegh Hazrati, Mehrdad Mirzarahimi, et al. Prevalence and risk
factors associated with preterm birth in Ardabil, Iran. Iran J Reprod Med. 2014;12:47–
56.
3. Walsh MC, Bell EF, Kanderfer S, Saha S, Carlo WA, et al. Neonatal outcomes of
moderately preterm infants compared to extremely preterm infants. Pediatr Res. 2017;
82: 297–304.
4. 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.
5. Kommawar A, Borkar R, Vagha J, Lakhkar B, Meshram R, et al. Study of respiratory
distress in newborn. Int J Contemp Pediatr. 2017;4:490-4.
6. Iskandar RATP and Kosim MS. Gangguan napas pada bayi baru lahir. In : Setya W,
Sarosa GI, Wibowo T, Alasiry E, Hidayah D, et al, editors. Buku ajar neonatologi.
Jakarta: Badan Penerbit IDAI; 2021. p. 95-126.
7. Hendy, Wandita A, Kardana IM. Efficacy of aminophylline vs caffeine for 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.
10. Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, et al. European consensus
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 pressureto
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 cpapin 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: Badan
13
 Penerbit IDAI; 2021. p. 160-82.
17. Klingenberg C, Kornelisse RF, Buonocore G, Maier RF, Stocker M. Culture-negative
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
hematologi Rodwell untuk deteksi dini sepsis neonatorum awitan dini. Sari Pediatri.
2015;16:330-6.
19. 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.

14
APPENDIX

1. Fenton growth chart

15
 2. Lubchencho growth percentile

V V V

Conclusion : appropriate for gestational age

16
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

17
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

18