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Bayi risiko tinggi

Mei Neni Sitaresmi


Bayi Risiko tinggi?
Bayi yang terpapar/mempunyai kondisi
yang akan meningkatkan risiko
morbiditas dan mortalitas
Faktor:
Ibu: kehamilan risiko (pre-eclamsia/
eklamsia), DM, TB, HIV, ibu demam
Komplikasi persalinan: persalinan lama,
tindakan
Bayi: asfiksia, kelainan bawaaan, bayi
prematur, BBLR, ketuban pecah dini
EPIDEMIOLOGI
130 million babies born every
year
4 million die in the neonatal
period
99 % in low-income countries
1 % in high-income countries
(WHO, 2005)
EPIDEMIOLOGI
Neonatal mortality rate
(NMR):
4/1000 live births in high-
income countries
33/1000 in low-income
countries
Main causes of death:
INFECTIONS
prematurity
EPIDEMIOLOGI
Direct Causes of Neonatal Deaths
World Health Organization.
State of the Worlds Newborns 2001

Infections 32%
Asphyxia 29%
Complications of prematurity
24%
Congenital anomalies 10%
Other 5%
EPIDEMIOLOGI
NEONATAL
MORTALITY
BBLR
BBL < 2.500 gram
Mudah hipotermia perawatan metode kanguru
(PMK)
Stabil, tidak mengalami kesulitan nafas
Tidak mengalami kesulitan minum
Ibu/ keluarga bersedia
4 komponen PMK:
Posisi
Nutrisi
Dukungan
Pemantauan ( nafas: 40 sd 60; suhu; tidak ada tanda
bahaya, ASI- nutrisi cukup)
Perawatan Metode Kanguru
(PMK)
Apa itu perawatan metode kanguru
Perawatan pada bayi baru lahir dengan kontak kulit bayi
dengan kulit pendekapnya untuk mempertahankan dan
mencegah bayi kehilangan panas.
Gunakan tutup kepala bayi/topi
Keuntungannya untuk bayi
Bayi menjadi hangat
Bayi lebih sering menetek
Bayi tidak rewel
Kenaikan berat badan lebih cepat

Keuntungan untuk ibu


Hubungan kasih sayang lebih erat
Ibu bisa bekerja sambil menggendong bayinya
Perawatan pada bayi baru lahir dengan kontak kulit
prematur
Neonatalmorbiditybybirthweightandgestationalage.
Penyulit bayi prematur
Belum matur nya sistem
Hipotermia
Hipogllikemia
Masalah pernafasan dan kardiovaskuler
Reflek hisap, menelan, dan absobsi GI
Sistem imun
Ikterik, anemia
hipotermia
Cegah hipotermia
awasi hipotermia
Badan, tangan dan kaki dingin (< 36.5)
Nafas cepat, lambat, sianosis perifer
Menangis lemah
Menyusu lemah
hipoglikemia
Hipoglikemia yang tidak tertangani dengan cepat
akan menyebabkan kematian atau kerusakan sarat
yang permanen sequel (gangguan
perkembangan)
Hipoglikemia:
Neonatus glukosa darah < 45 mg/dl
Prematur < 35 mg/dl
Risiko meningkat:
Prematur, KMK
Ibu DM
Infeksi
hipotermia
Manifestasi klinis
Letargi
Reflek hisap lemah tidak mau menetek
Hipotonia
Tremor kejang
Nafas tidak teratur apneu
Sianosis
Hipotermia
Iritabel
Menangis melengking menangis lemah
pencegahan
Termoregulasi
IMD
KMC
Minum
Menetek langsung
Asi peras disendoki
OGT: ASI / ASI donor/ formula
Terapi:
D10%: 2 cc/kg BB/dalam 5 menit
Minum oral/ OGT
sepsis
Onset dini
< 72 jam
Akuisis bakteri dari ibu selama hamil
atau persalinan
Late onset
> 3 hari
Infeksi nosokomial
RISK FACTOR

Early Onset Sepsis


Prolonged rupture of membranes >18 h
Maternal chorioamnionitis
Foul smelling amniotic fluid
Handling by untrained midwife
Maternal urinary tract infection
Premature labor
RISK FACTOR

Maternal fever during labor 38C


uterine tenderness
leucocytosis
fetal tachycardia

High risk of neonatal sepsis

CHORIOAMNIONITIS
RISK FACTOR Late Onset
Sepsis
Prematurity/ LBW
In hospital
Invasive procedures- ventilator, IV lines,
central lines, urine catheter, chest tube
Contact with infectious disease - doctors,
nurses, babies with infections,
Not fed maternal breast milk
POOR HYGIENE in NICU
PATOGENESIS
Kolonisasi GBS di serviks
Cairan amnion yang terinfeksi
Aspirasi inokulum pada saat transit di
vagina
Penyebaran hematogen dari ibu
Sepsis onset awal
Infeksi nosokomial
Kolonisasi
Sepsis onset lanjut
Early onset sepsis
Gram negative bacilli
E.coli
Klebsiella
Enterococcus BACTERIOLOGY
GBS
Late onset sepsis
Bacterial Gram negative bacilli
Pathogens Pseudomonas
Responsible for Klebsiella
Sepsis in Staph aureus
Developing
Countries Coagulase negative
staphylococci
IMMUNOLOGY

Premature newborn
immature host defenses

IgG levels low


Complement activity
low
Leukocytes: less
efficient
phagocytosis
IMMUNOLOGY

Premature newborn
immature host defenses

Suboptimal IgG
antibody titers and
opsonic activity in
the premature
neonate major cause
of:
inefficient clearance
of staphylococci from
the bloodstream
SIGNS AND
SYMPTOMS

Onset
Sangat awal (very early): <24
jam
Awal/dini: <72 jam; melibatkan
paru
Lambat: >72 jam; melibatkan
SSP
Tidak khas
Distres respirasi, apnea,
unexplained requrement for
respiratory support
SIGNS AND
SYMPTOMS
Oliguria
Instabilitas temperatur
Gejala gastrointestinal: muntah,
kembung, diare, distensi, ileus, poor
feeding
Letargi, gerakan menurun (tidak aktif),
kejang
Petekie, purpura, perdarahan
Blood glucose instability
Unexplained jaundice
Sekresi purulen
Inflamasi fokal
LABORATORY FINDING
Jumlah leukosit:
Leukopenia: <5000
Leukositosis:
Hitung jenis:
Neutrofil total: <1000
Rasio imatur:total neutrofil: >0,2
Trombositopenia
KED meningkat
CRP: >2 mg%
Biakan: Darah, LCS, urin
Ro dada: pneumonia
Abnormal white blood cell
count
Total WBC count < 5000 /L, > 25,
000/L
Absolute neutrophil count: <1500/L
Immature to total neutrophil ratio > 0.2
Immature to mature neutrophil ratio >
0.2
bandform

neutrophil
DIAGNOSIS

Klinis: 4 sistem a >1 gejala


KU: Tampak sakit, letargi, tak mau minum,
hipotermi/demam, sklerema/skleredema
SCV: takikardia, edema, dehidrasi
S. Resp.: dispnea, takipnea, sianosis
SGI: muntah, diare, kembung, hepatomegali
SSP: Letargi, iritabel, kejang
Hematologi:ikterus, splenomegali, perdarahan,
leukopenia, rasio I/M > 0,2

Hasil biakan positif


IDAI
Clinical Criteria for Severe Bacterial
Infection
WHO Handbook Integrated Management of Childhood
Illnesses, 2000
Respiratory rate > 60 breaths per minute
Severe chest indrawing
Nasal flaring
Grunting
Any of these signs:
Bulging fontanelle Suspect Serious
Convulsions Bacterial Infection
Pus draining from ear
Redness around umbilicus extending to the skin
Temperature > 37.7 C (or feels hot) or < 35.5C (or feels
cold)
Lethargic or unconscious
Reduced movements
Not able to feed
Not attaching to the breast
No sucking at all
TERAPI

ANTENATAL
Antibiotik intrapartum?
PASCANATAL
Antibiotik:
Profilaksis tidak bermanfaat
Terapi: strategi? Angka keramat: 3-5-7-10-14-
21
Imunoglobulin:
Profilaksis tidak bermanfaat
Terapi hanya menurunkan kematian
Transfusi tukar:?
Tidak bermanfaat
Suportif
First line therapy in facility setting
(WHO 2003)

Ampicillin 50 mg/ kg
every 12 hours in 1st week of life
every 8 hours from 2- 4 weeks
PLUS
Gentamicin once daily.
Antibiotic resistance pattern
in developing countries
(from Vergnano S, et al. Arch Dis Child Fetal Neonatal Ed
2005)

Klebsiella spp E.coli

Ampicillin 65 100% 69 100%

Gentamicin 16 85% 30- 93%

Amikacin 0 74% 0 67%

Cefotaxime 0 86% 0 75%

Imipenem 0 6% 0%
Duration of antibiotic treatment
Septicemia
Gram negative septicemia: 14 days
Group B Strep septicemia: 10-14
days

Repeat blood culture within 24 - 48


hours of beginning treatment to
document clearance of organism.
Duration of antibiotic treatment
Meningitis

Gram negative meningitis: 21 days


minimum
Group B Strep meningitis: 14 - 21
days

Document negative culture within 24


- 48 hours of beginning treatment
Consider neuroimaging studies
Supportive Care
Temperature support
GI support - vomiting, ileus
Cardiorespiratory support
hypoxia, apnea, ARDS, shock
Hematological support: anemia,
thrombocytopenia, DIC
Neurological support- seizures
Komplikasi
Syok
Status konvulsivus
Gagal napas
Gangguan keseimbangan cairan
dan elektrolit
DIC
Abses otak
Ventrikulitis
Gagal jantung kongestif
PROGNOSIS
Mortalitas tinggi
Gejala sisa: palsi serebral, retardasi
mental, tuli.
Gangguan tumbuh kembang
Prevention of Nosocomial
Infection
Hand washing
Early feeding
Maternal breast milk
Decrease use of broad spectrum
antibiotics
Decreased use of invasive
procedures
Proper sterilization procedures
Have you washed your
hands?