LONG CASE REPORT

A preterm female neonate with late onset sepsis, low birth weight,
and small for gestational age

Susilowati

Local Board Evaluation

Surakarta, February 9th 2021

INDONESIAN COLLEGE OF PEDIATRICS

2021

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 PATIENT’S RECORD
Candidate: Susilowati

I. Identity
Patient name : Baby Mrs. S Father’s name : Mr. T
Gender : Female Age : 42 years old
Birth date : 7th January 2021 Occupation : Construction laborer
Age : 0 day old Mother’s name : Mrs. S
Date of admission : 7th January 2021 Age : 38 years old
Date of examination : 7th January 2021 Occupation : Housewife

II. History taking

1. Chief complaint
Preterm, low birth weight, small for gestational age (history taking was taken from patient's father
and the doctor who assisted in the delivery process)
2. History of present illness
A female-neonate was born by caesarean section from a 38 year old multigravid woman with
gestational age (GA) of 34+3 weeks due to impending eclampsia. The birth weight (BW), birth length
(BL), and head circumference (HC) were 1500 grams, 42 cms, 29 cms, respectively. The baby cried
immediately with spontaneous breathing, no nasal flare, no retraction, acyanotic and moved actively.
Her heart rate, respiratory rate, oxygen saturation, and body temperature were 148 bpm, 56 times per
minute, 94% and 36.5 o C, respectively. The amniotic fluid was clear, APGAR scores at the 1st and 5th
minutes were 6 and 7, respectively. The new Ballard score was 26 appropriate for 34-36 weeks of
gestational age, and Ponderal index was 2.0. Soon after birth, the baby received intramuscular injection
of vitamin K on her left thigh and gentamicin eye ointment on both eyes. Hepatitis B immunization
was delayed due to low birth weight. She was transferred to neonatal high care unit (NHCU) inside
transport incubator after STABLE criteria were fulfilled.
In NHCU, she moved actively, cried vigorously with no breathing difficulty and stable
thermoregulation. She was placed in incubator and had enteral nutririon. She passed the meconium on
the first day.
On the day of examination, the baby moved actively, cried vigorously, she had poor sucking
reflex. We planned to give breastmilk 5-10 ml/kgBW/day via enteral route. Daily targeted calorie
intake was 115 kcal/kgBW. There was neither erythema nor discharge from umbilical cord.

3. Family history
a. The mother had hypertension
b. No history of diabetes mellitus in the family
c. No history of preterm or low birthweight delivery in the family
Conclusion : Risk factor disease from her mother

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4. Family tree

II

Mr. T, 42 y.o Mrs. S, 38 y.o

III

14 y.o 10 y.o
Baby Mrs S, 0 day old
5. Patient personal and social history
a. Pregnancy history
Underwent routine antenatal care with midwife and obstetrician, on hypertensive medication. The
mother had no history of fever, abnormal vaginal discharge, frequent urinating and pain in
urinating. Due to impending eclampsia the pregnancy was terminated early.
Conclusion: high risk pregnancy.
b. Delivery history
No history of prenatal steroid administration. Born by C-section at 34+3 weeks of gestational age
with APGAR score 6-7-8 and clear amniotic fluid.
Conclusion: high risk neonate
c. Postnatal history
Received antibiotic eye oinment and vitamin K injection.
Conclusion: normal postnatal history
d. Nutritional history
• Enteral nutrition : Breastmilk 5-10 ml/kgBW/day
• Parenteral nutrition with D15.8% (GIR 6 mg/kgBW/minute) 3.4 mL/hours, amino acid 10%
(1.5 gram/kgBW/day) 22.5 mL/day, and lipid 20% (1gram/kgBW/day) 7.5mL/day, calsium
gluconate 10% (60 mg/kg/day) 90 mg/day.
Conclusion: adequate enteral and parenteral nutrition.
e. Growth and development history
Growth history: Born at 34+3 weeks of GA with BW of 1,500 grams (BW/A<p3 Fenton,
BW/GA<p10 Lubchencho), BL 42 cms (p10<BL/A<p50 Fenton, p10<BL/GA<p25 Lubchencho),
Head circumference 29 cms (p10<HC/A<p50 Fenton, HC/GA=p10, Lubchencho)
Development history: Unable to be evaluated.
Conclusion: low birth weight and small for gestational age
f. Immunization history
No Hepatitis B immunization due to her low birth weight (1,500 grams).
Conclusion: incomplete basic immunization according to Ministry of Health program.
g. Patient basic needs
Parents are very concern about her condition. Her mother wished to breastfeed directly whenever
possible. Her mother always stays closed with her whenever possible. Patient basic needs were
fullfilled well by the parents shown by their care and love.
Conclusion: Well fullfilled
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 h. Socioeconomical and environment condition
The family monthly income is about 2.500.000 IDR. The health expense is covered by state
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: Cried vigorously, opened eyes spontaneously and moved actively.
2. Vital signs
Heart rate : 146 times/minute, regular, strong pulse
Axillary temperature : 36.8oC
Respiratory rate : 55 times/minute, regular, adequate depth
Oxygen saturation : 97% 97%
97% 97%
3. Anthropometric status:
Body weight (BW) : 1.500 grams (BW/A<p3 Fenton)
Body length (BL) : 42 cms (p10<BL/A<p50 Fenton)
Head circumference : 29 cms (p10<HC/A<p50 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. Isochoric pupils, no anemic conjunctiva,
no icteric sclera. Soft notched ears lobes with no discharge. No nasal flare. No bluish lips
and mucosa.
3. Neck: No enlargement of lymph node.
4. Chest: Normal thorax without retraction.
5. Heart: Ictus cordis not visible, ictus cordis palpable at 4th intercostal space on the left mid-
clavicle line, normal heart sound S1-S2 normal intensity, no murmur.
6. Lungs
Front/Back Right Left
Inspection : Symmetric Symmetric
Palpation : Tactile fremitus unable to be Tactile fremitus unable to be
evaluated evaluated
Percussion : Resonant Resonant
Auscultation : Normal vesicular breathing, Normal vesicular breathing,
no rales, no wheezing no rales, no wheezing
7. Abdomen: No distension, 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 sec, and strongly palpable
dorsal pedicle artery.
10. Neurological status examination
• Movement : symmetrical without limited ROM
• Tone : good muscle tone
• Deep tendon reflex : positive in both knees
• Babinsky reflex : positive in both feet
• Moro reflex : positive
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 • Tonic neck reflex : positive
• Palmar grasp reflex : positive
• Plantar reflex : positive
• Rooting reflex : positive
• Sucking reflex : negative

IV. Diagnostic supporting examination

1. Laboratory finding (January 7th 2021)
Hemoglobin 17.2 g/dl, platelet 222,000/ul, erythrocyte 4,260,000/ul, hematocrit 48%, leucocyte
15,300/ul, eosinophil 0.4%, basophil 0.1%, neutrophil 77.8%, lymphocyte 16.10
%, monocyte 5.6%, RBG 109 mg/dl
2. Peripheral blood smear (January 7th 2021)
Erythrocyte : normocytic, normochromic
Leucocyte : within normal limit, neutrophilia, I/T ratio 0.06
Thrombocyte : within normal limit

V. Summary
A female-neonate was born by caesarean section from a 38 years old multigravid woman with
gestational age (GA) of 34+3 weeks due to impending eclampsia. Her mother took anti-hypertensive
drug. The mother had no history of fever, abnormal vaginal discharge, frequent urinating or pain in
urinating. There is no history prenatal steroid administration.
The birth weight (BW), birth length (BL), and head circumference (HC) were 1500 grams, 42
cms, 29 cms, respectively. The amniotic fluid was clear, APGAR scores at the 1st and 5th minutes
were 6 and 7, respectively.
The new Ballard score was 26 appropriate for 34-36 weeks of gestational age, and Ponderal
index was 2.0 The baby cried vigorously, moved actively, and there was no retraction. The respiratory
rate, the heart rate, the temperature and the oxygen saturation were 56 bpm, 148 bpm, 36,5o C, 94%
respectively. After STABLE she was transferred to neonatal high care unit using incubator transport.
She received enteral nutrition due to poor sucking reflex. We educated the parents regarding their
baby’s condition

VI . Working diagnosis
1. Neonatal infection (P 39)
2. Preterm (P 07.30) Low birth weight (P 07.1)
3. Asymmetric small for gestational for age (P 05.1)

VII. Problem list

1. Low birth weight, preterm, small for gestational age
• History of hypertension
• A late preterm infant, the birth weight 1,500 grams
• New Ballard score of 26 appropriate for 34-36 weeks for gestational age
• Fenton growth chart :
- Body weight (BW) : 1,500 grams (BW/A<p3 Fenton, BW/GA<p10 Lubchencho)
- Body length (BL) : 42 cm (p10<BL/A<p50 Fenton, p10<BL/GA<p25 Lubchencho)
- Head circumference : 29 cm (p10<HC/A<p50 Fenton, HC/GA=p10, Lubchencho)
• Ponderal index : 2.0
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 2. Neonatal infection
• Maternal risk factor: C-section due to impending eclampsia
• Neonatal risk factor: preterm, low birth weight
• Clinical symptoms: feeding difficulties
• Blood culture and sensitivity results were still on process

VIII. Management plan

1. Emergency management
No emergency plans
2. Diagnostic investigation
a. Waiting for blood culture result
b. Complete blood count evaluation and acute-phase reactants
c. Head ultrasonography, echocardiography, thyroid function test
3. Medical management
Ampicillin (50 mg/kgBW/day) 35 mg/12 hours IV
4. Nutrition and fluid management
a. Parenteral nutrition
• Total fluid (80 ml/kgBW/day) 120 ml/day, increased gradually 10-20 ml/kg/day up to
140-160 ml/kgBW/day
• Total calories (50 kcal/kgBW/day) 75 kcal/day increased gradually 25-30
kcal/kgBW/day up to 110-130 kcal/kgBW/day
• Carbohydrate : Dextrose started with GIR 6 mg/kgBW/minute. D15.8%. Increased
GIR gradually 1-2 mg/kgBW/day
• Protein : Amino acids 10% started 1.5 gr/kgBW/day, 22.5 mL/day. Increased
gradually 0.5-1 gr/kgBW/day until 3.5-4 gr/kgBW/day.
• Fat : lipid 20% started 1 gr/kgBW/day, 7.5 mL/day. Increased gradually 0.5-1
gr/kgBW/day until 2.5-3.5 gr/kgBW/day.
• Electrolyte : in 24 hours Ca2+ 60-90mg/kgBW/day. Sodium (Na+) and potassium
(K+) after first diuresis, with dose 0-2 mmol/kgBW/day
b. Enteral nutrition with breast milk started from 7.5-15 mL/day on the first day, with total fluid
135- 200mL/kgBW/day. Total calorie target: 115-120 kcal/kgBW/day
c. Evaluate the accpetability, tolerance and effectiveness
5. Monitoring
a. General conditions and vital signs
b. Fluid intake, nutritional intake, and body weight were measured daily
c. Response to the therapy, and adverse events daily
d. Plan to do high risk baby morbidity screening
e. Neurodevelopmental impairment
f. Laboratory monitoring with indication
6. Communication, information, and education
a. Explain the condition, management, and complication of preterm and low birth weight baby
(infection, maintaining body temperature, feeding problem, impaired vision, hearing
disorders)
b. Explain the exclusive breastfeeding, the methods to express milk, and how to store the
expressed breastmilk
c. Explain the need for growth and developmental screening and monitoring of the baby
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 d. Explain the vaccination program
e. Educate the family to keep personal and environmental hygiene especially in taking care the
baby

IX. Prognosis
Ad vitam : bonam
Ad functionam : dubia ad bonam
Ad sanationam : dubia ad bonam

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X. Follow Up
Day 2-3 Day 4-5 Day 6-9
S/ Cried vigorously, opened eyes spontaneously, active S/ Inactive movement, poor sucking reflex, total 10 ml gastric S/ Inactive movement, poor sucking reflex, fever, total 12 ml
movement, poor sucking reflex, no fever, no vomit residue/day gastric residue/day

O/Heart rate: 142 bpm, respiration rate: 50 bpm, body temperature Heart rate 178: bpm, respiration rate 58 bpm, body temperature
O/ BW 1490 gram, heart rate: 140 bpm, respiration rate: 36.8° C, Downes score 0. oxygen saturation: 98%, kramer 2, 36.3o-38° C, oxygen saturation: 98%, Downe score 0, kramer 2,
52 bpm, body temperature: 37° C, oxygen saturation: nutritional achievement 75-78%, BW 1,470 grams, random blood nutritional achievement 85%, BW 1,460-1525 grams, random
96%, nutritional achievement 40-60%, random blood glucose 80-90 mg/dl blood glucose 85-97 mg/dl
glucose 90 mg/dl
Lab examination (12/01/21): Hb 16.7 g/dl, platelet 95,000/ul, Hct Echocardiography: PFO
Diagnosis 49%, leucocyte 4,900/ul, eosinophil 1.8%, basophil 1.8%, neutrophil Head USG: no abnormality, no bleeding
1. Neonatal infection (P 39) 75%, lymphocyte 16%, monocyte
2. Preterm (P 07.3), low birth weight (P 07.1), 5.4%, Na 138 mmol/L, K 4.8 mmol/L, Ca 1.20 mmol/L, Diagnosis
3. Asymmetric small for gestational for age (P05.1) hsCRP 2.95 mg/dL, I/T ratio: 0.3 1. Late onset neonatal sepsis (P 36.9)
Total bilirubin 7.51 mg/dl, indirect bilirubin 6.59 mg/dl and direct 2. Etiological diagnosis: acyanotic congenital heart disease,
Treatment bilirubin 0.95 mg/dl Anatomical diagnosis: Patent Foramen Ovale, Functional
1. Diet: 1-3 ml breastmilk increased gradually every 3 TSH 2.22 uIU/mL, FT4 28.2 pmol/L diagnosis: Ross I (Q 25.0)
hours via OGT Blood culture: no growth 3. Preterm (P 07.3), low birth weight (P 07.1), asymmetric
2. Infusion D18% = D1/4NS 52 ml + D40% 31ml + small for gestational for age (P 05.1)
KCl 3 ml + Ca gluconas 5 ml = 3.9 ml/hour (GIR 6) Diagnosis
3. Aminosteril 10% 1.5-2 g/kgBW/day IV 1. Late onset neonatal sepsis (P 36.9) Treatment
4. Lipid 20% 1-1,5 g/kgBW/day IV+ Vitalipid 1 ml 2. Preterm (P 07.3), low birth weight (P 07.1), 1. Breastmilk 5-7 ml every 3 hours
5. Ampicillin (50 mg/kgBW/day) 35 mg/12 hours IV 3. Asymmetric small for gestational for age (P 05.1) 2. Infusion D11% = D1/4NS 80 ml + D40% 20 ml + KCl 3 ml
6. Thermoregulation management + Ca gluconas 5 ml = 106 ml/day = 4.4 ml/hour (GIR 6)
Treatment 3. Aminosteril 10% (4 gr/kgBW/day) IV
Plan 1. Breastmilk 3-5 ml every 3 hours 4. Lipid 20% (2 gr/kgBW/day IV) + Vitalipid 1 ml
Wait for blood culture and sensitivity result 2. Infusion D11% = D1/4NS 80 ml + D40% 18 ml + KCl 3 ml + 5. Cefoperazone (50 mg/kgbW/12 hours) 75 mg/12 hours IV
Head ultrasonography Ca gluconas 5 ml = 104 ml/day = 4.3 ml/hour (GIR 6) 6. Amikacin (7.5 mg/kgBW/12 hours) 7.5 mg/12 hours IV
Echocardiography 3. Aminosteril 10% (2,5-3 gr/kgBW/day) IV
Thyroid function test 4. Lipid 20% (2 gr//kgBW/day IV) + Vitalipid 1 ml Plan
Blood examination evaluation 5. Ampicillin (50 mg/kgbW/day) 35 mg/12 hours IV Wait for blood culture and sensitivity result
6. Gentamicin (4 mg/kgBW/day) 6 mg/24 hours IV Blood examination evaluation

Plan
Waiting for head ultrasonography (USG), echocardiography

PlanLight thera

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 Day 10-11 Day 12-14
S/ active movement, sucking reflex improves, fever tends to decrease, total 5 ml gastric S/ Cried vigorously, opened eyes spontaneously, active movement, good sucking reflex, no fever, no
residue/day vomitting

Heart rate: 160 bpm, respiration rate: 54 bpm, body temperature 36.3o-37.4o C, oxygen Heart rate 150 beats per minute, respiration rate 50 times per minute, body temperature 37°, oxygen
saturation 99%, Downe score 0, nutritional achievement 87% (oral 35%), BW 1,550 saturation 99%, Downe score 0, nutritional achievement 85% (oral 63%), BW 1,600-1650 grams
grams, random blood glucose 80-90 mg/dl
Diagnosis
Lab examination (17/01/21): Hb 13.2 g/dl, platelet 58,000/ul, Hct 38%, leucocyte 1. Late onset neonatal sepsis due to Staphylococcus haemolyticus (P 36.9)
9,200/ul, eosinophil 1.8%, basophil 1.8%, neutrophil 75%, lymphocyte 16%, monocyte 2. Etiological diagnosis: acyanotic congenital heart disease, Anatomical diagnosis: Patent Foramen
5.4%, Na 138 mmol/L, K 4.8 mmol/L, Ca 1.20 mmol/L, Ovale, Functional diagnosis: Ross I (Q 25.0)
hsCRP 2.07 mg/dL 3. Preterm (P 07.3), low birth weight (P 07.1), asymmetric small for gestational for age (P 05.1)
Blood Culture : Staphylococcus haemolyticus (resistant to ampicillin and gentamicin,
sensitive to vancomycin, ciprofloxacin and tigecycline) Treatment
1. Breastmilk 20 – 30 ml every 3 hours (160 ml/KgBW/day)
Diagnosis 2. Infusion D51/4NS 4 ml/hours IV
1. Late onset neonatal sepsis due to Staphylococcus haemolyticus (P 36.9) 3. Aminosteril 10% 2.5 g/kgBW/day IV decreased gradually then stopped
2. Etiological diagnosis: acyanotic congenital heart disease, Anatomical diagnosis: 4. Lipid 20% 0.5 g/kgBW/day IV decreased gradually then stopped
Patent Foramen Ovale, Functional diagnosis: Ross I (Q 25.0) 5. Vancomycin (10 mg/kgBW/8 hours)
3. Preterm (P 07.3), low birth weight (P 07.1), asymmetric small for gestational for age 6. Zinc (1.4-2.5 mg/kgBW/day) 1.5 mg/day PO
(P 05.1) 7. Multivitamin 1 ml/day PO
8. Thermoregulation management
Treatment
1. Breastmilk 7-10 ml every 3 hours Plan
2. Infusion D13% = D1/4NS 87 ml + D40% 27 ml + KCl 3 ml + Ca gluconas 3 ml = Initiate KMC
120 ml/day = 4,9 ml/hour (GIR 6) ROP and BERA ROP and BERA screening
3. Aminosteril 10% (4 gr/kgBW/day) IV
4. Lipid 20% (2 gr//kgBW/day IV)+Vitalipid 1 ml
5. Change antibiotic to Vancomycin (10 mg/kgBW/8 hours) 15 mg/8 hours

Plan
Increase oral intake

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VII. Case Analysis Diagram
Problems Diagnosis Therapy & monitoring Prognosis

Risk factors of the mother: impending

eclampsia, hypertension, advanced 1. Adequate fluid & nutrition (enteral,
maternal age (LoE 2B, B parenteral feeding)
Recommendation) 2. Thermoregulation support
3. Kangoroo mother care
(LoE 2A, recommendations A)
Born at 34+3 GA by C-section delivery preterm, low birth
due to impending eclampsia, birth weight, asymmetrical
weight 1,500 grams, small for small for gestational age Monitoring:
gestational age (Lubchenko chart). 1.Daily fluid and calories intake
Ponderal index 2 2. The body weight, body length, and head Ad vitam:
circumference measurement ad bonam
Risk factor : preterm, low birth 3.High risk baby screening
(LoE 1A, 1a recommendations). Ad functionam:
weight, parenteral nutrition,
Late onset sepsis Dubia ad bonam
intravascular catheterization
Clinical manifestation : fever,
Ad sanationam:
lethargy, feeding intolerance Dubia ad bonam
symptoms
1. Ampicillin and Gentamicin as first line
Supporting examination : platelet
antibiotic
95,000/ul, leucocyte 4,900/ul, IT 2. After blood culture revealed adjusting
ratio: 0.3, hsCRP 2.95 mg/dL, antibiotic to vancomycin
peripheral blood smear supported 3. Nosocomial infection prevention
infection
Blood culture : Staphylococcus Etiological
haemolyticus diagnosis: acyanotic
(LoE 2B, B Recommendation) congenital heart
disease, Anatomical
diagnosis: Patent
Echocardiograophy revealed Patent Foramen Ovale Monitoring:
Foramen Ovale with diameter 0.2 cm Functional diagnosis: Plan for evaluation next 3 months
balanced heart space Ross I

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VIII. Case Discussion
A female neonate was admitted to NHCU due to preterm, low birth weight and small for gestational
age. The baby was born spontaneously from a 38 years old mother in 34+3 weeks GA by caesarean
section due to impending eclampsia. We can diagnose preterm from gestational age confirmed by
Ballard score of 26 which equal to 34-36 weeks GA. The birth weight of 1500 gram is similar to
BW<p3 in Fenton curve. Our patient was categorized as preterm and low birth weight.1,2
Many factors are associated with small gestational age (SGA). Including maternal factors such
as age, preeclampsia, hypertension, chronic disease, malnutrition and infection. Placental factor like
placenta previa, abruption placenta and placental insufficiency as well as fetal factors which may be
derived from abnormal chromosomes and genetic disorders.3,4 In our case the mother had impending
eclampsia leading to early termination. Preeclampsia corelates with 5% decrease of birth weight (95%
CI 3-6%), and Small gestational age (OR, 2.06 (95% CI, 1.79–2.39)).5 (LoE 2B, B Recommendation)
Infants with SGA have an increased risk for perinatal asphyxia, hypothermia and
hypoglycaemia during their first days of life. In SGA preterm population, bronchopulmonary
dysplasia, pulmonary hypertension and necrotising enterocolitis are more common as compared to
appropriate gestational age (AGA) population. Early management of the SGA neonates comprise
hypothermia prevention, the use of pressure-controlled ventilator if needed, and close blood glucose
monitoring.6,7 This patient was placed in incubator for keeping her warm, and routinely checked for
temperature, blood glucose and sign of respiratory distress.
Overall survival rate of low birth weight is 85%. Long term monitoring is necessary to monitor
the growth, cognitive development, motor function, language and visual as well as hearing
impairment. Growth parameters used for low birth weight (LBW) are body weight, length and head
circumference, which will be plotted based on Fenton curve until gestational age of 40 weeks or length
of 45 cm.8,9 (LoE 1A, 1a recommendations). Many neonates with SGA are supposed to have long
term survival because of the plasticity of the developing brain and medical care improvements.
However, in some newborn, insults can cause varying degrees of long-term neurodevelopmental
impairment. Long term complications in high risk neonates are associated with growth,
developmental, neurological, hearing and visionary problems. A systematic review study has reported
the prevalence of each impairment per insult and overall 82% of the survivors followed up and
assessed for 6-60 months. The three most common impairments are learning difficulties, cognitions,
and developmental delay (59%), followed by cerebral palsy (21%), hearing impairment (20%), visual
impairment (18%), and behavioural problems (11%). (LoE 1B, recommendations 1B). A child born
with SGA should have routine length, weight, and head circumference measurements every 3 months
for the first year of life and every 6 months thereafter. Children who do not manifest significant catch-
up growth in the first 6 months of life or those who remain short by 2 year of age may have other
conditions that limit growth which should be identified and managed.10-12
Neonatal infection are classically divided into two distinct clinical syndrome: early onset
sepsis (EOS) and late onset sepsis (LOS). The clinical presentation of neonatal sepsis varies
tremendously and the signs are often non-specific so that it is difficult to diagnose. Late onset sepsis
(LOS) is usually more insidious compared to early onset sepsis (EOS) but it can be fulminant at times.
it is usually not associated with early obstetric complications. In addition to bacteremia, these infants
may have identifiable focus. The most prevalent bacterial causing LOS are the Staphylococcus aureus
(S. aureus), and Staphylococcus coagulase negative (SCoN).13,14 High prevalence of late-onset sepsis
can be caused by a combination of environmental and host factors including, the immature neonatal
immune system, a compromised skin barrier, the need for invasive procedures, the use of total
parenteral nutrition, the prolonged use of invasive apparatus and long hospital stay. Study by Berlak

10
 revealed that parenteral nutrition was the only independent risk factor for coagulase-negative-
staphylococcus sepsis (OR: 3.5, 95% confidence interval: 1.4-8.6). (LoE 2B, B Recommendation)
15-16
. Our patient was diagnosed with late onset sepsis on as during the treatment she experienced
fever, lethargy, feeding intolerance symptoms on > 72 hours of age and supported by laboratory
findings result leucocyte of 4,900/ul , platelet of 95,000 /ul, hsCRP level of 2,95 mg/dl, peripheral
blood smear supported the infection process with IT ratio 0,4 and Staphylococcus haemolyticus in
her blood culture.
Breastmilk is considered the best choice of enteral feeding for late preterm infants. However,
supplementation of breastmilk may be indicated to promote optimal growth. Preterm formulas can be
used for supplementation of breastmilk or as a breastmilk substitute but there is little evidence for their
use in the late preterm infant. Feeding difficulties are common and some infants require intravenous
nutritional support soon after birth. Others require tube feeding until full sucking feeds are
established.17,18 Our patients also experienced poor sucking reflex there for we applied orogastric tube
and parenteral nutrition.
Patent Foramen Ovale (PFO) is a common problem in preterm. Patency of < 4 mm around
fossa ovalis is defined PFO. Approximately 61.4% PFO have spontaneous closure. Asymptomatic
PFO of < 5.0 mm may not require follow-up. However, patients with a foramen ovale of ≥ 5 mm
(even asymptomatic) should be followed up using thoracic echocardiography at 2 years of age, and
further follow- up is required if it remains unclosed.19,20 Our patient has PFO of 2 mm, thus no therapy
is needed but only monitoring.
Retinopathy of prematurity (ROP) is a vascular disease of retina characterised by abnormal
vascular proliferation in the developing retinas of premature infants. Prematurity is the single most
factor consistently shown to be associated with its development. The significant risk factors for ROP
are small gestational age, low birth weight, septicaemia, respiratory distress syndrome, intraventricular
haemorrhage, continuous positive pressure ventilation, apnea, oxygen therapy and phototherapy.
Screening and close monitoring by ophthalmologists to diagnose, treat and prevent visual impairment
or blindness are necessary. (LoE 1A, 1a recommendations).21
Kangaroo Mother Care (KMC) is conventionally initiated in a baby who is stable. Preterm
infants receiving KMC have less episodes of apnea, hypothermia, septicaemia, and better mortality
survival rate. Retrospective cohort study showed that KMC can decrease the incidence of
neurodevelopmental sequel and also objective data from brain MRI appear increasing grey matter
component in cerebral cortex due to enlargement nucleus caudate. (LoE 2A, recommendations A).22

IX. Journals used as Evidence Based Practice (EBP)

1. Panaitescu AM, Baschat AA, Akolekar R, Syngelaki A, Nicolaides KH. Association of chronic
hypertension with birth of small for gestational age neonate. Ultrasound in Obstetrics &
Gynecology. 2017 Sep;50(3):361-6 (LoE 2B, B Recommendation)
Conclusion : Preeclampsia corelates with 5% decrease of birth weight (95% CI 3-6%), and Small
gestational age (OR, 2.06 (95% CI, 1.79–2.39)).
2. Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for
preterm infant. BMC pediatr. 2013;13;59 (LoE 1A, 1a recommendations).
Conclusion : Growth parameters used for LBW are body weight, length and head circumference,
which will be plotted based on fenton curve until gestational age 40 weeks or length of 45 cm
3. Mwaniki MK, Atieno M, Lawn JE, Newton CR. Long term neuro developmental outcomes after
intrauterine and neonatal insults: a systemic review. Lancet. 2012; 4;379(9814):445-52 (LoE 1B,
recommendations 1B).
Conclusion : Developmental delay 59%, cerebral palsy 21%, hearing impairment 20%, visual
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 impairment 18%, behavioural problems 11%
4. Charpak N, Tessier R, Ruiz JG, Hernandez JT, Uriza F, Villegas J, et al. Twenty-year follow up of
kangaroo mother care versus traditional care. Pediatrics. 2017;139(1)
(LoE 2A, recommendations A)
Conclusion : A 20-years retrospective cohort study showed that KMC can decrease the incidence
of neurodevelopmental sequel such as cognitive deficit, fine motor delay, auditory impairment, and
behavioural disorder significantly.
5. Azami M, Jaafari Z, Rahmati S, Farahani AD, Badfar G. Prevalence and risk factors of retinopathy
of prematurity in Iran: a systematic review and meta-analysis. BMC Ophthalmol. 2018 Apr
2;18(1):83. (LoE 1A, 1a recommendations).
Conclusion : The significant risk factors for ROP were small gestational age, low birth weight,
septicaemia, respiratory distress syndrome, intraventricular haemorrhage, continuous positive
pressure ventilation, apnea, oxygen therapy and phototherapy
6. Berlak N, Shany E, Ben-Shimol S, Chertok IA, Goldinger G, Greenberg D, Melamed R. Late onset
sepsis: comparison between coagulase-negative staphylococci and other bacteria in the neonatal
intensive care unit. Infect Dis (Lond). 2018 Oct;50(10):764-770. (LoE 2B, B Recommendation)
Conclusion : Patients with coagulase-negative-staphylococcus sepsis had lower gestational age and
younger age at onset, higher rates of parenteral nutrition exposure and normal temperature.
parenteral nutrition was the only independent risk factor for coagulase-negative-staphylococcus
sepsis (OR: 3.5, 95% confidence interval: 1.4-8.6).

12
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14
APPENDIX
1. Lubchencho growth percentile

2. Fenton growth chart

1. Ballard score

15
2. 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
3. Echocardiography

• AV-VA concordance solitus

• Systemic venous return, normal
pulmonary vein
• Patent Foramen Ovale with diameter 0.2 cm
• The heart space is balanced
• EF 65%,, LA / Ao 1.6, E / A> 1
• The aortic arch is left with no koar

16