Implication in Premature

Baby Health Care

PENATALAKSANAAN BAYI PREMATURE
DENGAN RESPIRATORY DISTRESS
SYNDROME
DISTRIBUTION OF CHILD AND
NEONATAL DEATHS BY CAUSE

Vidyasagar Narang A.
Perinatal and Neonatal Care in Developing Countries.
Neonatal-Perinatal Medicine 2015
CURRENT UPDATE
ON PRETERM
INFANTS
 OVERVIEW
Preterm is defined as babies born alive before 37 weeks of pregnancy are
completed.

There are sub-categories of preterm birth, based on gestational age:

Extremely preterm (<28 weeks)
Very preterm (28 to <32 weeks)
Moderate to late preterm (32 to <37 weeks)

Induction or caesarean birth should not be planned before 39 completed

weeks unless medically indicated.
 BOYS GIRLS

A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants.
Fenton and Kim BMC Pediatrics 2013, 13:59
 THE PROBLEM

An estimated 15 million babies are born too early every year.

That is more than 1 in 10 babies.
Almost 1 million children die each year due to complications of preterm
birth.
Many survivors face a lifetime of disability, including learning
disabilities and visual and hearing problems.
Globally, prematurity is the leading cause of death in children under
the age of 5.
And in almost all countries with reliable data, preterm birth rates are
increasing..
THE PROBLEM

There is a dramatic difference in survival of premature babies

depending on where they are born

More than 90% of extremely preterm babies (< 28 weeks) born in

low-income countries die within the first few days of life; yet < 10%
of babies of this gestation die in high-income settings

In low-income settings, half of the babies born at or below 32

weeks (2 months early) die; in high-income countries, almost all of
these babies survive.
 Why does preterm birth
happen?

Most preterm births happen spontaneously, but some are due to

early induction of labour or caesarean birth, whether for medical or
non-medical reasons.

Common causes of preterm birth include multiple pregnancies,

infections and chronic conditions such as diabetes and high blood
pressure; however, often no cause is identified.

There could also be a genetic influence.

Better understanding of the causes and mechanisms will advance

the development of solutions to prevent preterm birth.
 Where does preterm birth happen?

• More than 60% of preterm births occur in Africa and South Asia

• The 10 countries with the greatest number of preterm births:

1. India: 3 519 100 6. The United States of America: 517 400
2. China: 1 172 300 7. Bangladesh: 424 100
3. Nigeria: 773 600 8. The Philippines: 348 900
4. Pakistan: 748 100 9. The Democratic Republic of the Congo: 341 400
5. Indonesia: 675 700 10. Brazil: 279 300
 Where does preterm birth happen?
In the lower-income countries, on average, 12% of babies are born
too early compared with 9% in higher-income countries.

The 10 countries with the highest rates of preterm birth per 100 live births:
1. Malawi: 18.1 per 100
2. Comoros: 16.7
3. Congo: 16.7
4. Zimbabwe: 16.6
5. Equatorial Guinea: 16.5
6. Mozambique: 16.4
7. Gabon: 16.3
8. Pakistan: 15.8
9. Indonesia: 15.5
10. Mauritania: 15.4
 Distribution of child and THE MOST COMMON COMPLICATIONS
neonatal deaths by cause OF PREMATURE BIRTHS:
Respiratory Distress Syndrome (RDS)
Apnea and Bradycardia
Pneumonia
Inability to maintain body heat
Jaundice
Infection – Sepsis
Intraventricular hemorrhage (IVH)
Immature gastrointestinal and
digestive system
Necrotizing Enterocolitis (NEC)
Patent Ductus Arteriosus (PDA)
Retinopathy of Prematurity (ROP)
Vidyasagar Narang A. Perinatal and Neonatal Care in Developing Countries. Bronchopulmonary Dysplasia (BPD)
Neonatal-Perinatal Medicine 2015
 HMD → RDS
• Hyaline Membrane Disease (HMD):
A respiratory disease of the newborn,
especially the premature infant

• The word "hyaline" comes from the Greek word "hyalos"

meaning "glass or transparent stone such as crystal”

• HMD is now commonly called Respiratory Distress Syndrome

(RDS)

• It is caused by a deficiency of a molecule called

surfactant
 Guidelines to improve
preterm birth outcomes

WHO has developed new guidelines with recommendations for improving outcomes of
preterm births.

The guidelines include interventions provided to the mother – for example steroid injections
before birth, antibiotics when her water breaks before the onset of labour.

As well as interventions for the newborn baby – for example thermal care (e.g. kangaroo
mother care when babies are stable), safe oxygen use, and other treatments to help
babies breathe more easily.
 Quality of the evidence and Strength of
the recommendations

Recommendation 7.0:
Kangaroo mother care is recommended for the routine care of newborns weighing 2000 g or less at birth, and
should be initiated in health-care facilities as soon as the newborns are clinically stable.
 Quality of the evidence and Strength
of the recommendations

Recommendation 7.1:
Newborns weighing 2000 g or less at birth should be provided as close to continuous Kangaroo mother care as
possible.
 Quality of the evidence and Strength
of the recommendations

Recommendation 7.2:
Intermittent Kangaroo mother care, rather than conventional care, is recommended for newborns weighing
2000g or less at birth, if continuous Kangaroo mother care is not possible.
 Quality of the evidence and Strength
of the recommendations

Recommendation 7.3:
Unstable newborns weighing 2000g or less at birth, or stable newborns weighing less than 2000g who cannot be
given Kangaroo mother care, should be cared for in a thermo-neutral environment either under radiant warmers
or in incubators.
 Quality of the evidence and Strength
of the recommendations

Recommendation 7.4:
There is insufficient evidence on the e effectiveness of plastic bags/wraps in providing thermal care for preterm
newborns immediately after birth. However, during stabilization and transfer of preterm newborns to specialized
neonatal care wards, wrapping in plastic bags/wraps may be considered as an alternative to prevent hypothermia.
 Quality of the evidence and Strength
of the recommendations

Recommendation 8.0:
Continuous positive airway pressure therapy is recommended for the treatment of preterm newborns with RDS
Quality of the evidence and Strength
of the recommendations

Recommendation 8.1:
CPAP therapy for newborns with respiratory distress syndrome should be started as soon as the diagnosis is made.
 Quality of the evidence and Strength
of the recommendations
Recommendation 9.0:
Surfactant replacement therapy is recommended for intubated and ventilated
newborns with respiratory distress syndrome.
 Quality of the evidence and Strength
of the recommendations

Recommendation 9.1:
Either animal-derived or protein-containing synthetic surfactants can be used for
surfactant replacement therapy in ventilated preterm newborns with RDS
 Quality of the evidence and Strength
of the recommendations

Recommendation 9.2:
Administration of surfactant before the onset of respiratory distress syndrome
(prophylactic administration) in preterm newborns is not recommended.
 Quality of the evidence and Strength
of the recommendations
Recommendation 9.3:
In intubated preterm newborns with respiratory distress syndrome, surfactant should be
administered early (within the first 2 hours after birth) rather than waiting for the
symptoms to worsen before giving rescue therapy.
 Quality of the evidence and Strength
of the recommendations

Recommendation 10.0:
During ventilation of preterm babies born at or before 32 weeks of gestation, it is recommended to start O2 therapy
with 30% oxygen or air (if blended oxygen is not available), rather than with 100% O2
Recommendation 10.1:
The use of progressively higher concentrations of oxygen should only be considered for newborns undergoing O 2
therapy if their heart rate is less than 60 beats per minute after 30 seconds of adequate ventilation with 30% O2 or air
PHYSICAL EXAMINATION

Respiratory
distress
in
the newborn

Babies born with TTN are sick at birth, but their signs and symptoms begin to resolve nearly immediately.
Babies born with Pneumonia will be sick at birth and show little improvement until the pneumonia begins to clear; with bacterial
pneumonia this can take 2-3 days.
Babies born with RDS, continue to have worsening of symptoms until treated with exogenous surfactant or after about 48 hours of age.
 Evaluasi Distres Napas
Skor Downes’
Skor Frekuensi Sianosis Udara Masuk Merintih Retraksi
Napas
0 <60/menit Tidak Udara masuk Tidak merintih Tidak ada
sianosis retraksi
1 60-80/menit Sianosis Penurunan Dapat didengar Retraksi
hilang ringan dengan ringan
dengan O2 udara masuk stetoskop
2 >80/menit Sianosis Tidak ada Dapat didengar Retraksi
menetap udara masuk tanpa alat berat
walaupun bantu
diberi O2

Skor < 3 Distres Napas Ringan, terapi O2 nasal

Skor 4 – 5 Distres Napas Sedang, terapi CPAP
Skor > 6 Distres Napas Berat, terapi ventilator mekanik
Wood DW, Downes’ JJ, Locks HI. A clinical score for the diagnosis of respiratory failure. Amer J Dis Child 1972; 123: 227-9.
 Melalui
inkubator

Pemberian
Oksigen Oksigen

Nasal
CPAP
(Continuous
Positive
Airway
Pressure)
 Optimalisasi perawatan
bayi prematur
• Mengelola pasien sesuai PPK dan clinical pathway
• Mengendalikan infeksi pada unit perawatan bayi
• Mengoptimalkan pemberian nutrisi parenteral
• Kalori, GIR, protein, lemak diperhitungkan
Panduan Praktik Klinis
Clinical Pathway
 Optimalisasi perawatan
bayi prematur
• Mengoptimalkan pemberian nutrisi enteral
• Mempercepat pemberian nutrisi enteral
• Memberikan nutrisi sesuai kebutuhan bayi prematur
• Menjamin penyiapan nutrisi yang bersih dan tepat
dosis
 Resume medis
• Diisi tepat waktu, 1 hari sebelum pasien direncanakan pulang
• Ditulis secara lengkap dan konsisten sesuai diagnosis
• Tulisan dapat dibaca/data elektronik
• Koordinasi dokter dengan koder
• Koder mengecek kelengkapan resume pulang setiap hari
TERIMA KASIH