CURRICULUM VITAE

Prof. Dr. dr. Sjarief Hidajat Effendi, Sp. A(K)

Formal education
1976 Dokter Umum, Universitas Padjadjaran
1986 Dokter Spesialis Anak, Universitas Padjadjaran
1992 Konsultan Neonatalogi, Kolegium IDAI
2002 Doktoral, Universitas Padjadjaran

Working Experience
Guru Besar Divisi Neonatalogi SMF Ilmu Kesehatan Anak Universitas
Padjadjaran
Ketua AcademicLeadership Grant (ALG) FK. UNPAD
Ketua Penanganan Bayi Kembar Siam
Koordinator Ilmiah Perinasia Pusat
 General Preterm Growth And Development

Prof. Dr. Sjarief Hidajat Effendi, Sp.A(K)

UKK NEONATOLOGI PP IDAI

Annual Neonatology Update 4th “Stabilisasi Neonatus dan Rujukan”
Hotel Harris Convention City Link Bandung, 10-11 Mei 2018
Preterm infants

• Indonesia
• 15.5 per 100 life birth (WHO,
2010)

• Preterm birth in Hasan Sadikin

General Hospital, Bandung is
42.44% (2013), 38,78% (2015)

World Health Organization. Preterm birth per 100 births 2010

Data fetomaternal RSHS 2015 [not published]
Causes of neonatal deaths
in Indonesia

Mortality profiles. Geneva, World Health Organization, 2007

4
 Preterm baby and long term effects
• Moderate to severe mental
retardation

25% • Sensorineural hearing loss

• Cerebral palsy
• Epilepsy

• Learning disabilities,
• Low average IQ scores, ADHD
• Neuropsychological deficits, visual

50-70% motor integration, temperament

difficulties, language delays,
emotional problems and regulatory
disorders

Preterm Birth: Causes, Consequences, and Prevention

Richard E. Behrman, Adrienne Stith Butler, Editors, Committee on Understanding Premature Birth and Assuring Healthy Outcomes
Nutritional problem of preterm infant

Greater Organ
morbidity immaturity

• Gavage feeding
NEC
•  Motility &
absorption

Smaller
Greater nutritional
nutritional
requirement and IWL reserve
 Definition
• Preterm birth is defined by WHO  all births before 37
completed weeks of gestation or fewer than 259 days since the
first day of a woman’s last menstrual period.
• Preterm birth can be further sub-divided based on gestational
age:
• extremely preterm (<28 weeks),
• very preterm (28 - <32 weeks) and
• moderate preterm (32 - <37 completed weeks of gestation).
Moderate preterm birth may be further split to focus on late
preterm birth (34 - <37 completed weeks).

Blencowe et al. Reproductive Health 2013, 10(Suppl 1):S2

Blencowe et al. Reproductive Health 2013, 10(Suppl 1):S2
 Incidence
• A recent systematic approach to this problem has
estimated a worldwide incidence of 11.1 per 100
live births in 2010.
• 15 million preterm births worldwide.
• Estimates varied by region with a low of 7.4% in
central and eastern Asia to a high of 13.3% in
southern Asia.
• In Indonesia, 779.000 babies are born too soon
each year and 25,900 children under five die due to
direct preterm complications.
Tielsch JM. Global incidence of preterm birth. Nestle Nutr Workshop Ser. 2015;81:9-15
 Mortality
• Perinatal mortality is inversely proportional to gestational
age with the highest rates near the limit of viability.

Fawley G. Special conciderations in the premature and ex-premature infant. Anaethesia and Intensive Care Medicine. 2016
In industrialised countries
- preterm birth is responsible  70% of neonatal mortality
- 75% of neonatal morbidity
- Contributes to long-term neurodevelopmental problems, pulmonary
dysfunction and visual impairments

• Short-term Morbidity Premature Birth:

• Respiratory distress syndrome (RDS)
• Bronchopulmonary dysplasia (BPD)
• Sepsis Neonatorum
• Necrotizing Enterocolitis (NEC)
• Patent ductus arteriosus (PDA)
• Retinopathy of prematurity (ROP)
• Periventrikel and intraventricular hemorrhagic (PIH)
• Periventricular leukomalacia (PVL)
• Long-term Morbidity Premature Birth:
• neurodevelopment impairment (NDI)
• chronic health problems
• developmental disabilities
• school failure
• behavior and psychiatric problems
 Typical Feeding Progression
Gestational Age (Weeks)
24 25 26 27 28 29 30 31 32 33 34 35 36 37 38
Pacifier Sucking (non-nutritive suck)

Gag Reflex
Rooting Reflex Early Intermediate Mature

Coordinate Suck,
Nutritive Suck Swallow, Breathe

TPN for 1-2 weeks as enteral Gradually start breast/ Infant nippling
feeds advance via tube bottle per infant cues all feeds
How fast should the premature infant grow?

• Third trimester growth: 10-15 gram/kg/day

• Optimal growth postnatally for ELBW: 18 g/kg/day
• Most premies are growing about 1 oz/day at
discharge
• Growth for ELBW (<1 kg) and VLBW (<1.5 kg)
infants often below standard curves
• Need to plot based on adjusted gestational age
• Growth often below but parallels the curve
• May see “catch up” over time
• Preservation of head growth
 How many calories?
• VLBW infants (birth weight < 1.5 kg)
• 120-125 kcal/kg/day enterally to match third trimester
growth while in hospital
• Post discharge may need similar amounts until about 2
months past the due date
• Larger prematures
• 100-110 kcal/kg/day enterally
• Most prematures go home on ad lib feeds
• Need 8+ feeds per day
 Growth Charts
Recommended growth charts:
• 2013 Fenton growth charts from birth to ~50 wks
• WHO growth charts from term to 24 months
• CDC growth charts from 24 months to 18 yrs old
 Fenton Growth Grids
http://ucalgary.ca/fenton/2013chart
 Neurodevelopment

Preterm infants born <32 weeks  risk of developing neurodevelopmental

disabilities, with rates of cerebral palsy as high as 5% to 15%
Infants at risk:
• Extremely premature infants < 1.5 kg
• < 1 kg and/or <= 28 weeks especially at risk
• Post intraventricular hemorrhage
• Grade III-IV
• Post-hemorrhagic hydrocephalus
• Increasing risk with lower gestational age
• Chronic lung disease (BPD)
• Short gut syndrome
Brain Development

Iliodimitri Z et al. "Brain Injury in Preterm Infants." Neonatal Care Book.(2012)

 Pathogenesis of cerebral white matter injury
in the premature infant

Deng, W. Neurobiology of injury to the developing brain. Nat.Rev.Neurol.6, 328-36. 2010.

Mechanisms of brain injury in preterm neonates
In the EPICure study comprising infants born
at <26 weeks

The mean (SD) Mental Developmental Index (MDI)

• 84 (12) at 18 months of corrected age.
• 19%  severe (<55) MDI.
• 11%  moderate (<70) mental impairment.

Annales Nestlé 2005;63:39-56

 Neurodevelopment:
Monitoring and referral
• Developmental assessment at visits
• Monitor head circumference
• Motor assessment
• Developmental milestones
• Speech and hearing
• Reassurance about normal development
• Corrected gestational age
• High Risk Infant Follow up Clinic
 Infants with BPD
BPD  defined as oxygen requirements at 36 postmenstrual weeks
• 53% to 86% of infants born  23 weeks
• 34% to 77%  24 weeks and
• 33% to 70%  25 weeks
• Home care needs:
• Oxygen, Diuretics, Respiratory treatments
• Risk for respiratory infections
• RSV, other viruses, pertussis
• Long term pulmonary problems
• Cardiovascular complications of BPD:
• Pulmonary hypertension and cor pulmonale
• Growth failure
• Higher oxygen consumption, increased work of breathing
• Neurodevelopmental sequelae
 Infants discharged on home O2

• Parents need to be well prepared for infant’s care

• Stationary and portable O2 sources
• Ancillary equipment: nasal cannula, oxygen tubing,
suction equipment, aerosol equipment
• Is the patient relatively stable off O2?
• Pulmonary outpatient follow up
 Retinopathy of prematurity (ROP)

• Retinopathy of prematurity (ROP)  primarily occurs

in premature babies.
• It causes abnormal blood vessels to grow in the retina,
the layer of nerve tissue in the eye that enables us to
see.
• This growth can cause the retina to detach from the
back of the eye, leading to blindness.
 Retinopathy of prematurity (ROP)
• Primarily affects premature infants weighing about (1250 grams)
• or born < 31 weeks of gestation.
• The smaller a baby is at birth, the more likely that baby is to develop
ROP.
• ROP occurs in over 16% of all premature births.
• In babies weighing less than 1,700 grams at birth, over 50% will
develop ROP.
• In the United States, over 2,100 children annually experience the
complications of ROP.
ROP: stage 3

ROP: stage 4, partial retinal detachment

 Prevention and treatment of ROP

• Role of VEGF production by peripheral retina

• Maintain targeted SPO2 85-93% while at risk
• Timely and appropriate eye exams
• Laser ablation of the peripheral retina
• Avastin intra-vitreal injection
 Complications of ROP
• Retinal detachment
• Blindness
• Distortion of the retina
• Macular dragging results in loss of acuity
• Late complications of severe ROP can occur post
discharge:
• Macular dragging
• Retinal detachment
 What is the pediatrician’s role in ROP

• Assure that the patient who should have an eye

exam is indeed seen by a qualified pediatric
ophthalmologist
• Assure that recommended outpatient f/u eye
exams are obtained
• Provide information to parents and/or make
appropriate referrals
• Increase risk of myopia and strabismus in
premature infants
• Referral to appropriate services for patients with
visual impairment
 Hearing loss

• Rates of hearing impairment in very low

birthweight and extremely low birthweight infants
are generally  reported within a range of 1–7%
• Very low birthweight infants  have central
auditory processing disorders
• Difficult  to discriminate simple speech sounds and
limit auditory memory span
• These difficulties may have a detrimental effect on the
acquisition of language skills and learning at school

P. S. SUTTON AND G. L. DARMSTADT, Preterm Birth and Neurodevelopment, 2013

 Hearing testing
• Hearing test prior to discharge
• Repeat prior to discharge if first test fails
• Risk factors for hearing loss
• Prematurity
• Ototoxic drugs (aminoglycosides, furosemide)
• Severe hyperbilirubinemia
• Hypoxic-ischemic insult
• Prolonged ventilation and oxygen needs
• Hypocarbia on blood gases
 Conclusion
• Preterm birth is an important perinatal health problem
across the globe.
• Preterm infants needs adequate nutritional support
from the first day of life to avoid EUGR
• Neonatal nutrition is a major determinant in the short-
and long-term outcomes of preterm neonates.
• To identify successful early development interventions
for preterm infants, current research points to the need
for randomized controlled trials combined with long-
term follow-up studies focusing on both motor and
cognitive outcomes.
THANK YOU