CRS BBLR I

Identitas Pasien
No RM : 838027
Masuk Pelayanan : 21/10/2020 Jam 10.30
Penerimaan melalui : IGD VK
Nama : Bayi Nyonya R (1)
Jenis kelamin : Perempuan
TTL : Sumedang, 21/10/2020
Umur : 1 hari
Identitas Orang Tua
Nama Ibu : Nyonya R
Usia Ibu : 34 tahun
Alamat : Babakan Sawah RT/RW 002/012 Kelurahan Jingkang
Kecamatan Tanjungmedar Kabupaten Sumedang Jawa Barat 45354
Pekerjaan : Petani
Agama : Islam
Kewarganegaraan : Indonesia

Nama Ayah : Tuan W

Usia Ayah : 39 tahun
Alamat : Babakan Sawah RT/RW 002/012 Kelurahan Jingkang
Kecamatan Tanjungmedar Kabupaten Sumedang Jawa Barat 45354
Pekerjaan : Belum bekerja
Agama : Islam
Kewarganegaraan : Indonesia
Anamnesis
Riwayat Penyakit Sekarang
Pada hari Rabu, 21 Oktober 2020 jam 10.20 telah lahir spontan gemeli I, letak kepala, bayi perempuan hidup, dari Nyonya R G2P2A0
gravida 34 minggu, lahir tidak segera menangis, APGAR Score 6,7,8, cacat (-), anus (+), mekonium (-), PCH (+)

Riwayat Kehamilan Sekarang

Nyonya R melakukan kunjungan ke bidan sebanyak 2 kali dan ke dokter sebanyak 1 kali, tidak menerima imunisasi TT dan Hepatitis B.
Persalinan ditolong oleh bidan dan ketuban normal.
Pemeriksaan Fisik
Antropometri Head to Toe
Panjang badan : 44 cm Keadaan Umum : State 5, refleks hisap (+), BAB (+), BAK (+)
Berat badan : 1740 gram Kepala : Bentuk simetris, UUB belum menutup
Lingkar kepala : 39 cm Mata : Sklera ikterik (-), konjungtiva anemis (-)
Lingkar lengan atas : 8 cm Hidung : Deformitas (-), PCH (+)
Lingkar dada : 26 cm Mulut : Celah bibir (-), POC (-)
Lingkar perut : 25 cm Leher : Retraksi suprasternal (-), pembesaran KGB (-)
Toraks : Bentuk dan gerak simetris, retraksi dinding dada (-)
Tanda-Tanda Vital Pulmo : Bronkovesikular ka= kir, mengi (-) , suara mengorok (-)
Tekanan darah : tidak diperiksa Cor : S1,S2 reguler, murmur (-)
Nadi : 140x/menit Punggung : Benjolan (-), cekungan (-)
Pernafasan : 40x/menit Abdomen : Datar, lembut, BU (+), hepar just palpable, tali pusat
Suhu : 35°C terpotong, tanda inflamasi (-)
Saturasi : 99% Urogenital : Labia mayor dan labia minor menonjol, anus (+)
EKstremitas : Jumlah jari lengkap, akral hangat, CRT <3”
Ballard Score
Dubowitz Score

2
1
2

1
3

3 1

3 2

3
2

16

2
Ballard Score : 16
Dubowitz Score :9 9
Skor Akhir : 25
Usia Gestasi : 34 minggu
Grafik Lubchenko
BB : 1740 gram
Usia gestasi : 34 minggu
Persentil : 10-25%
Interpretasi : AGA (Sesuai Masa Kehamilan)
Diagnosis
Diagnosis Kerja :
BBLR + Problem feeding e.c. BBLR + Preterm Infant + AGA (Appropriate for Gestational Age) + Lahir Spontan + Gemeli 1
Tatalaksana
Vit K 1 mg injeksi IM
Zalf mata
Hep B (ditunda)
ASI ad lib (4x10 cc)
Bila refleks hisap jelek pasang OGT
RGP
CRS BBLR II
Identitas Pasien
No RM : 838027
Masuk Pelayanan : 21/10/2020 Jam 10.50
Penerimaan melalui : IGD VK
Nama : Bayi Nyonya R (2)
Jenis kelamin : Perempuan
TTL : Sumedang, 21/10/2020
Umur : 1 hari
Identitas Orang Tua
Nama Ibu : Nyonya R
Usia Ibu : 34 tahun
Alamat : Babakan Sawah RT/RW 002/012 Kelurahan Jingkang
Kecamatan Tanjungmedar Kabupaten Sumedang Jawa Barat 45354
Pekerjaan : Petani
Agama : Islam
Kewarganegaraan : Indonesia

Nama Ayah : Tuan W

Usia Ayah : 39 tahun
Alamat : Babakan Sawah RT/RW 002/012 Kelurahan Jingkang
Kecamatan Tanjungmedar Kabupaten Sumedang Jawa Barat 45354
Pekerjaan : Belum bekerja
Agama : Islam
Kewarganegaraan : Indonesia
Anamnesis
Riwayat Penyakit Sekarang
Pada hari Rabu, 21 Oktober 2020 jam 10.25 telah lahir spontan gemeli II, letak kepala, bayi perempuan hidup, dari Nyonya R G2P2A0
gravida 34 minggu, lahir tidak segera menangis, APGAR Score 6,7,8, cacat (-), anus (+), mekonium (-), PCH (+)

Riwayat Kehamilan Sekarang

Nyonya R melakukan kunjungan ke bidan sebanyak 2 kali dan ke dokter sebanyak 1 kali, tidak menerima imunisasi TT dan Hepatitis B.
Persalinan ditolong oleh bidan dan ketuban normal.
 Head to Toe
Pemeriksaan Fisik Keadaan Umum : State 5, refleks hisap (+), BAB (+), BAK (+)
Kulit : Pink, lembut, verniks kaseosa (+)
Kepala : Bentuk simetris, UUB belum menutup
Antropometri
Mata : Sklera ikterik (-), konjungtiva anemis (-), edem periorbital (-)
Panjang badan : 43 cm
Hidung : Deformitas (-), PCH (+)
Berat badan : 1600 gram
Mulut : Celah bibir (-), POC (-)
Lingkar kepala : 39 cm
Leher : Retraksi suprasternal (-), pembesaran KGB (-)
Lingkar lengan atas : 9 cm
Toraks : Bentuk dan gerak simetris, retraksi dinding dada (-), areola datar,
Lingkar dada : 26 cm
tidak menonjol
Lingkar perut : 24 cm
Pulmo : Bronkovesikular ka= kir, mengi (-) , suara mengorok (-)
Cor : S1,S2 reguler, murmur (-)
Tanda-Tanda Vital
Punggung : Benjolan (-), cekungan (-), lanugo banyak
Tekanan darah : tidak diperiksa
Abdomen : Datar, lembut, BU (+), hepar just palpable, tali pusat
Nadi : 134x/menit
terpotong, tanda inflamasi (-)
Pernafasan : 36x/menit
Urogenital : Labia mayor dan labia minor menonjol, sekret vagina (+),
Suhu : 35°C
lubang uretra (+), anus (+)
Saturasi : 99%
EKstremitas : Jumlah jari lengkap, akral hangat, CRT <3”, plantar crease
hanya di bagian anterior
Ballard Score
Dubowitz Score

2
1
3

1
3

3 2

2 2

2
2

15

2
Ballard Score : 15
Dubowitz Score : 10 10
Skor Akhir : 25
Usia Gestasi : 34 minggu
Grafik Lubchenko
BB : 1600 gram
Usia gestasi : 34 minggu
Persentil : 10-25%
Interpretasi : AGA (Sesuai Masa Kehamilan)
Diagnosis
Diagnosis Kerja :
BBLR + Problem feeding e.c. BBLR + Preterm Infant + AGA (Appropriate for Gestational Age) + Lahir Spontan + Gemeli 2
Tatalaksana
Vit K 1 mg injeksi IM
Zalf mata
Hep B (ditunda)
ASI ad lib (4x10 cc)
Bila refleks hisap jelek pasang OGT
RGP
 CSS BBLR
(WHO, Riskesdas, Ponek-Asuhan Neonatal Esesial)
DEFINISI
BBLR (Berat Badan Lahir Rendah) adalah bayi dengan berat lahir kurang dari
2.500 gram

BBLRS (Berat Badan Lahir Sangat Rendah) → < 1500 gram

BBLARS (Berat Badan Lahir Amat Sangat Rendah) → > 1000 gram
EPIDEMIOLOGI
Sekitar 10,2% bayi, lahir dengan berat badan lahir > 2500 gram (Riskesdas 2013)
● Di dunia 15 - 20% BBLR dari semua kelahiran (WHO)
● Variasi besar kelahiran BBLR di berbagai bagian di dunia:
- Asia Timur dan Pasifik 6%
- Afrika Sub-Sahara 13%
- Asia Selatan 28%
EPIDEMIOLOGI
BBLR mempunyai mortilitas dan morbiditas yang lebih tinggi

● Angka kematian bayi baru lahir di Indonesia sekitar 26 bayi per 1000 kelahiran
hidup, dan 30,3% disebabkan BBLR dan prematuritas (SKDI 2012)
● Angka kematian bayi baru lahir di Indonesia mencapai 35 bayi per 1000 kelahiran
hidup, dan 29% disebabkan BBLR dan prematuritas (SKDI 2014-2015)
EPIDEMIOLOGI
75% kematian bayi baru lahir, terjadi pada miggu pertama kehidupan
25 - 45% kematian bayi baru lahir, terjadi dalam 24 jam pertama kehidupan

SKRT 2011 RISKESDAS 2017

Asfiksia 29% Gangguan pernapasan 35,9%

BBLR/prematuritas 27%
Tetanus 10%
Masalah pemberian ASI 10%
Masalah hematologi 6%
Infeksi 5%
BBLR/prematuritas 32,%
Sepsis 12%
Hipotermia 6,3%
Kelainan darah/ikterus 5,6%
Kelainan kongenital 1,4%
ETIOLOGI
1. Kelahiran prematur
- Induksi dini persalinan atau SC karena alasan medis dan non medis
- Spontan; trauma, aktivitas fisik berlebihan, infeksi
1. Pertumbuhan Janin Terhambat / IUGR / SGA
Kehamilan ganda, infeksi, dan kondisi kronis
2. Gabungan keduanya
 ETIOLOGI
Prematur (< 37 minggu) Pertumbuhan Janin Terhambat / IUGR

- Kulit tipis/transparan/lunak seperti gelatin - Organ-organ tubuh sudah matang

- Lanugo banyak atau tidak ada sama sekali - Wajah kurus, seperti tua
- Lemak subkutan sedikit - Kulit tebal, keriput, lemak subkutis tipis
- Pembuluh darah terlihat jelas pada abdomen - Pembuluh darah abdomen tidak terlihat jelas
- Areolar belum terbentuk dan grandula tidak teraba - Areolar sudah terbentuk dan grandula teraba
- Telinga lunak - Telinga rekoil cepat
- Testis tidak terab - Testis teraba
- Labia minor menonjol - Labia minor tertutup labia mayor
- Edema pada ekstremitas, lipat plantar halus - Lipat plantar jelas
- Otot hipotonik
MASALAH YANG MUNGKIN TERJADI PADA
BBLR
Ketidakstabilan Suhu Tubuh

Ganggua Napas - Defisiensi surfaktan paru yang mengarah ke RDS

- Risiko aspirasi akibat refleks menelan dan refleks batuk yang
buruk, daya hisap & telan yang tidak terkoordinasi
- Toraks lunak dan otot respirasi lemah
- Pernapasan periodik dan apnea

Gangguan GI dan Nutrisi - Refleks isap & telan yang buruk

- Motilitas usus menurun
- Pengosongan lambung lambat
- Absorbsi vitamin yang larut dalam lemak berkurang
- Defisiensi laktase pada jonjot usus
- Menurunnya cadangan mikronutrien

Gangguan Hati - Gangguan konjugasi dan ekskresi bilirubin

- Defisiensi vit. K
MASALAH YANG MUNGKIN TERJADI PADA
BBLR
Gangguan Ginjal - Ketidakmampuan untuk ekskresi beban cairan yang besar
- Akumulasi asam anorganik dengan metabolik asidosis
- Ketidakseimbangan elektrolit

Gangguan Imunologi

Gangguan Neurologis - Kejang

- Hipotonia
- Metal retardasi
- Gangguan pendengaran sensorineural
- CP
- Epilepsi
- Gangguan belajar dan konsentrasi
- IQ yang rendah
- Keterlambatan bicara
- Gangguan emosional dan tingkah laku
MASALAH YANG MUNGKIN TERJADI PADA
BBLR
Gangguan Kardiovaskular - PDA
- Hipotensi atau hipertensi

Gangguan Hematologis - Anemia

- Hiperbilirubinemia
- DIC
- HDN

Gangguan Metabolisme - Hipokalsemia

- Hipoglikemia/hiperglikemia
PEMERIKSAAN PENUNJANG

LABORATORIUM RADIOLOGI
- Darah tepi, hitung jenis - Rotgen thoraks
- Glukosa serial - USG kepala
- NA, K, Ca serial
- Bilirubin serial
- AGD
- CRP atau kultur biakan
TATA LAKSANA

> 1800 gram (> 35 mgg) (> 2000 g) > 1800 gram (> 35 mgg) < 1800 gram (< 35 mgg)

Tanpa masalah: Dengan masalah: Cenderung bermasalah karena

- Bisa minum & menyusu - Gangguan nafas sistem organ yang belum matang
- Tidak ada gagguan nafas - Gangguan minum / refleks
- Toleransi baik belum bagus
Ibu mampu merawat & menjaga - Intoleransi
bayinya - Infeksi

Perawatan di rumah + pemantauan Perawatan di RS dengan Perawatan di RS dengan fasilitas

fasilitas dan SDM yang sesuai dan SDM yang sesuai
TATA LAKSANA
PERAWATAN DI RUMAH

Mejaga suhu stabil - Ibu selalu menjaga kebersihan badan,

tangan, dan pakaian serta memakai masker
apabila sakit
- Memberikan pakaian hangan/selimut/bedong
- Menjaga suhu ruangan/kamar 26 - 28 derajat

Menjaga intake / nutrisi adekuat - Minum/menyusu ASI 8 - 10 kali/hari dengan

interval 2 jam di siang hari dan 3 - 4 jam di
malam hari
- Buang air kecil 6 - 8 kali/hari
TATA LAKSANA
PERAWATAN DI RUMAH

Menjaga kebersihan - Mandikan bayi bila suhu stabil, dengan air

hangat
- Ganti popok setiap 3 - 4 jam atau tepat
setelah bayi pup

Merawat tali pusat agar selalu bersih & kering

Memantau perumbuhan & perkembangan

Beri waktu untuk tidur Jangan bangunkan setiap jam untuk minum
TATA LAKSANA
PERAWATAN DI RUMAH

Imunisasi - Memulai imunisasi saat sudah stabil dan BB

2 kg
- Imunisasi di tempat yang sudah di atur, tidak
menunggu di keramaian
- Nakes yang melakukan menjaga kebersihan
dan memaikan APD yang sesuai
TATA LAKSANA
PEMANTAUAN
2. Tanda Bahaya
1. Pertumbuhan
- Letargi, gelisah, malas minum, muntah-
- BB 20 - 30 g/hari
muntah
- Tinggi badan 0,5 - 1 cm/minggu
- Hipertermi, hipotermi
- Lingkar kepala 0,5 cm/minggu
- Kuning, pucat, kebiruan
- Asupan: jenis & volum
- Berhenti napas, napas cepat, merintih
- Pengeluaran: BAB & BAK
- Diare
- Obat-obatan
- Kejang
- Tanda vital
- Tampak sakit
TATA LAKSANA
PERAWATAN DI RUMAH SAKIT

- Pengaturan suhu tubuh ditujukan untuk mencapai lingkungan suhu netral sesuai dengan
protokol, periksa suhu setiap < 4 jam
- Terapi oksigen dan bantuan ventilasi
- Terapi cairan dan elektrolit untuk menggantikan IWL (insesnsible water loss) dan
mempertahankan hidrasi yang baik
- Nutrisi dengan sonde (ASI yang diperah) atau parenteral (cairan IV)
- Memeriksa Hb
- Memeriksa glukosa setiap 4 jam pada hari pertama kemudian setiap 8 - 12 jam jika stabil
- Antibiotik spektrum luas dapat diberikan jika ada kecurigaan kuat adanya infeksi
- Terapi sesuai jika terdapat komplikasi atau masalah yang disebabkan oleh BBLR
TATA LAKSANA
TINDAK LANJUT JANGKA PANJANG

- Nutrisi yang memadai (jika memungkikan beri rujukan kepada konselor ASI)
- Imunisasi tepat waktu
- Penilaian perkembangan dengan kunjungan rutin
- Rujukan dini untuk intervensi perkembangan
- Konseling maternal untuk kehamilan berikutnya
Kangaroo Mother Care (KMC)
What it is?
Kangaroo mother care is care of preterm infants carried skin-to-skin with the mother.

It is a powerful, easy-to-use method to promote the health and well-being of infants born
preterm as well as full-term.
Key Feature

1. Early, continuous and prolonged skin-to-skin contact between the mother and the
baby
2. Exclusive breastfeeding (ideally)
3. It is initiated in hospital and can be continued at home
4. Small babies can be discharged early
5. Mothers at home require adequate support and follow-up
6. It is a gentle, effective method that avoids the agitation routinely experienced in a
busy ward with preterm infants.
Why it matters?
It has been shown to be effective for thermal control, breastfeeding and bonding in all
newborn infants, irrespective of setting, weight, gestational age, and clinical conditions.

Evidence of the effectiveness and safety of KMC is available only for preterm infants
without medical problems, the so-called stabilised newborn.
Research shows:

1. KMC is at least equivalent to conventional care (incubators), in terms of safety and

thermal protection, if measured by mortality.
2. KMC, by facilitating breastfeeding, offers noticeable advantages in cases of severe
morbidity.
3. KMC contributes to the humanization of neonatal care and to better bonding between
mother and baby in both low and high-income countries.
4. KMC is, in this respect, a modern method of care in any setting, even where
expensive technology and adequate care are available.
5. KMC has never been assessed in the home setting.
Requirement
The support binders Clothing
When to start KMC?
When a small baby is born, complications can be expected, KMC will have to be delayed
until the medical conditions improve.

● Weight 1800g or more (Gestational age 30-34 weeks or more)

○ Most cases, KMC can start soon after birth.
● Weight between 1200 and 1799g (gestational age 28-32 weeks)
○ Might take a week before KMC can be initiated.
● Weight less than 1200g (gestational age less than 30 weeks)
○ Moght take a weeks before KMC can be initiated.

When exactly to initiate KMC really depends on the condition of the mother and the baby.
Mother Baby

● Willingness (After Explanation) ● Babies with severe illness or

● Full-time availability to provide care
● General health
● Being close to the baby
● Supportive family
● Supportive community
All mothers can provide KMC.
requiring special treatment may wait
until recovery before KMC begins.
● Short KMC sessions can begin during
recovery.
● Continuous KMC, baby’s condition
must be stable. (Only Breathing
spontaneously)

Almost every small baby can be cared

for with KMC.
Initiating KMC
● The first session is important and requires time and undivided attention.
● Ask mother to wear light, loose clothing.
● Use a private room, warm enough for the small baby.
● Encourage mother to bring her partner or a companion of her choice.

While the mother is holding her baby, describe to her each step of KMC, then demonstrate
them and let her go through all the steps herself.
Kangaroo Position
● Place between the mother’s breasts in an upright position,
chest to chest.
● Secure him with the binder.
● The head, turned to one side, is in a slightly extended
position.
● The top of the binder is just under baby’s ear.
● Avoid both forward flexion and hyperextension of the
head.
● The hips should be flexed and extended. (frog position)
● The arms should also be flexed.
● Tie the cloth firmly enough
● Baby’s abdomen should not be constricted.
● Show the mother how to move the baby in and out of the binder.

● Explain to the mother that she can breastfeed in kangaroo position.

● Mother can easily care for twins too: each baby is placed on one
side of her chest.
● Talk to her about possible difficulties. (daily routines and baby not
feed well).
● Encourage her to ask for help if she is worried.
Caring baby in kangaroo position
● Babies can receive most of the necessary care, including feeding, while in kangaroo
position.
● They need to be moved away from skin-to-skin contact only for:
○ changing diapers, hygiene and cord care.
○ clinical assessment, according to hospital schedules or when needed.
● Daily bathing is not needed and is not recommended.
● During the day the mother carrying a baby in the KMC position can do whatever she
likes. (long stay in hospital less boring and more bearable.)
Sleeping and resting
Mother will best sleep with the baby in kangaroo position in
a reclined or semi-recumbent position, about 15 degrees from
horizontal. (decrease the risk of apnea for the baby)

If the mother finds the semi-recumbent position

uncomfortable, allow her to sleep as she prefers.

A comfortable chair with adjustable back may be useful for

resting during the day.
Length and duration of KMC
Length

Sessions that last less than 60 minutes should, however, be

avoided because frequent changes are too stressful for the baby.
(gradually increases to become as continuous as possible)

When the mother needs to be away from her baby, can be well
wrapped up and placed in a warm cot, away from draughts,
covered by a warm blanket, or placed under an appropriate
warming device, if available.

During those breaks family members can also help caring for the
baby in skin-to-skin kangaroo position.
Duration

It tends to be used until the baby reaches term (gestational age around 40 weeks) or
2500g.

Baby starts wriggling to show that it is uncomfortable, pulls the limbs out, cries and fusses
every time the mother tries to put back skin-to-skin. (This is when it is safe to advise the
mother to wean the baby gradually from KMC.)

Mother can return to skin-to-skin contact occasionally (after bath, night, cold, needs
comfort)
Monitoring baby conditions
Temperature

When starting KMC, measure axillary temperature every 6 hours until stable for three
consecutive days. Later measure only twice daily.

Below 36,5 > rewarm the baby immediately > Measure the temperature an hour later >
rewarming until within the normal range > look for possible causes of hypothermia > If no
obvious cause can be found, does not return to normal within 3 hours > assess the baby for
possible bacterial infection.
Breathing

Normal : between 30-60x/m and intervals of no breathing (apnea).

Abnormal : the intervals become too long (20 seconds or more), cyanosis, bradycardia, not
breathing spontaneously. (the more premature = the longer and more frequent the spells of
apnea)

Well-being

The onset of a serious illness in small babies is usually subtle and is overlooked until the
disease is advanced and difficult to treat. Teach the mother to recognize danger signs.

No danger sign : Hiccups, passes soft stools after feed, doesnt stool for 3 days
feeding
For the first few days a small baby may not be able to take any oral feeds and may need to
be fed intravenously. During this period the baby receives conventional care.

Oral feeds should begin as soon as baby’s condition permits and the baby tolerates them.
This is usually around the time when baby can be placed in kangaroo position.

● Less than 30 weeks : Nasogastric tube

● Between 30-32 weeks : NGT + Small cup
● More than 32 weeks : Cup + Suckling from the breasts
● Between 34-36 weeks : Breasts only + supplements if necessary

Note : baby’s pause when suckling, good position.

Breastfeeding
Expressing breast milk

Hand expression is the best way to express breast milk.

To establish lactation and feed a small baby she should start expressing milk on the first
day, within six hours of delivery, if possible. (then at least every 3 hours, including during
the night.)

Mothers often develop their own style of hand expression.

If a mother is expressing more milk than her small baby needs, let her express the second
half of the milk from each breast into a different container.

If the mother can only express very small volumes at first, give whatever she can produce
to her baby and supplement with formula milk if necessary.
Expressing breast milk directly into baby’s mouth
Cup feeding Dropper feeding
Bottle feeding Dropper feeding

Breastfeeding > Expressing milk into the mouth > Cup > Dropper syringe > Bottle/
tube feeding.
Quantity and Frequency
Monitoring growth
Weight

Small babies lose weight at first, immediately after birth: weight loss of up to 10% in the
first few days of life has been considered acceptable.

Newborn babies will slowly regain birth weight, usually between 7 and 14 days after birth.
No weight loss is acceptable though after this initial period.

There is no upper limit for weight gain for breastfed infants, but the lower limit should be
no less than 15g/kg/day.

There are no universally accepted recommendations regarding frequency of growth

monitoring for LBW and preterm infants or chart.
Head Circumference

Measure head circumference weekly. Once baby is gaining weight, head circumference
will increase by between 0.5 and 1cm per week. For adequacy of head growth refer to
national anthropometric standards.
Inadequate weight gain
If weight gain is inadequate for several days, first assess the feeding technique, frequency,
duration and schedule, and check that night feeds are given. Advise the mother to increase
the frequency of feeds or to feed on demand.

Look for other reasons : Oral thrust, Rhinitis, UTI, other severe bacterial infection etc.

If despite all these efforts the baby is not gaining weight, consider supplementing
breastfeeding with preterm formula, given by cup after each feed. Return to exclusive
breastfeeding as soon as possible after the infant has gained weight for some time.

Try, if at all possible, not to discharge a small baby with formula supplements.
Stimulation
KMC is an ideal method since the baby is rocked and cuddled, and listens to the mother’s
voice while she goes about her everyday activities. Fathers too can provide such an
environment.
Discharge
Criterias:

1. the baby’s general health is good and there is no concurrent disease such as apnoea or
infection.
2. he is feeding well, and is exclusively or predominantly breastfed
3. he is gaining weight (at least 15g/kg/day for at least three consecutive days)
4. his temperature is stable in the KMC position (within the normal range for at least
three consecutive days)
5. the mother is confident in caring for the baby and is able to come regularly for
follow-up visits
Education :

1. how to apply skin-to-skin contact until baby shows signs of discomfort

2. how to dress the baby, when he is not in kangaroo position, to keep him warm at
home
3. how to bath the baby and keep him warm after the bath
4. how to respond to baby’s needs such as increasing the duration of skin-to-skin
contact if he has cold hands and feet or low temperature at night
5. how to breastfeed the baby during the day and night according to instructions
6. when and where to return for follow-up visits (schedule the first visit and give the
mother written/pictorial instructions for the above issues)
7. how to recognize danger signs
8. where to seek care urgently if danger signs appear
9. when to wean the baby from KMC
KMC at home and routine follow-up
When :

- two follow-up visits per week until 37 weeks of post-menstrual age

- one follow-up visit per week after 37 weeks

Content :

KMC, Breatfeed, Growth, Illness, Drugs, Immunization, Mothers concern, Next follow up
visit, Routine child care until 40 wks.