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Persistent Beneficial Effects of Breast Milk
Ingested in the Neonatal Intensive Care Unit
on Outcomes of Extremely Low Birth Weight
Infants at 30 Months of Age
Shanty Djajakusli
Journal Reading
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ABSTRACT
BACKGROUND. We previously reported beneficial effects of
breast milk ingestion by infants with extremely low birth weightin the NICU on developmental outcomes at 18 months’corrected age. The objective of this study was to determinewhether these effects of breast milk in infants with extremely lowbirth weight persisted at 30 months’ corrected age.
METHODS. Nutrition data, including enteral and parenteral
feeds, were prospectively collected, and 30 months’ correctedage follow-up assessments were completed on 773 infants withextremely low birth weight who participated in the NationalInstitute of Child Health and Human Development NeonatalResearch Network Glutamine Trial. A total of 593 ingested somebreast milk during the neonatal hospitalization, and 180 ingestednone. Neonatal feeding characteristics and morbidities and 30-
month interim history, neurodevelopmental outcomes, andgrowth parameters were analyzed. Children were divided intoquintiles of breast milk volume to evaluate the effects of volumeof human milk ingested during the NICU hospitalization.
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RESULTS. At 30 months, increased ingestion of breast milk wasassociated with higher Bayley Mental Developmental Index scores,higher Bayley behavior score percentiles for emotional regulation,and fewer rehospitalizations between discharge and 30 months.There were no differences in growth parameters or cerebral palsy.For every 10 mL/kg per day increase in breast milk, the Mental
Developmental Index increased by 0.59 points, the PsychomotorDevelopmental Index by 0.56 points, and the total behaviorpercentile score by 0.99 points, and the risk of rehospitalizationbetween discharge and 30 months decreased by 5%.
CONCLUSIONS. Beneficial effects of ingestion of breast milk in theNICU persist at 30 months’ corrected age in this vulnerable
extremely low birth weight population. Continued efforts must bemade to offer breast milk to all extremely low birth weight infantsboth in the NICU and after discharge.
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INTRODUCTION
Infants with extremely low birth weight (ELBW)
risk of neurodevelopmental disability &rehospitalization → discharge NICU
High risk neonates in the NICU → limit exposure
breast milk (BM)
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AIMS
Identify whether beneficial effects of BM ingestion inthe NICU in our cohort of infants with ELBW
~ developmental & behavior test scores
↓ rehospitalization rates at 30 months’ CA
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METHODS1433 infants enrolled at 12 sites of the National Instituteof Child Health & Human Development Neonatal
Research Network, Glutamine Trial →
October 14, 1999 - June 25, 2001
279 ~ 18-month assessment were unable to participate,195 infants expired before discharge, 20 infants expiredbefore 30 months, resulting in 939 eligible children.
The final 773 (82.3%) of 939 infants with ELBW whom30-month follow-up data were collected
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Infants → seen only at 18 vs seen at 18 & 30 mo
mothers ~ household, income <$20.000
Nutrition data were collected daily during thehospitalization until the infants were on full enteral feeds(≥462 kJ [110 kcal]/kg per day) for 72 hours.
The total volume of BM feeds (cc/kg/day) for the durationof hospitalization was calculated.
593 (77%) BM + 180 (23%) BM -
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The 30-month assessment
interim medical history
a developmental evaluationneurologic assessment
physical examination including growth parameters
The Bayley Scales of Infant Development II (BSID II)→ the mental scale, motor scale, & behavior rating scale
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Neurodevelopmental impairment was defined as thepresence of any of the following :
MDI <70, PDI <70, blind eyes, hearing impairment,
cerebral palsy
Statistical analyses → the Research Triangle Institute &using SAS (SAS Institute, Inc, Cary NC).
Bivariate analyses for group differences consisted of ttests, Χ2, Kruskal-Wallis, or Fisher’s exact tests
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Infants were divided into quintiles of BM ingestionadjusted for confounders to identify threshold effects ofBM on neonatal and 30-month outcomes.
Study participation was approved by each site’s
institutional review board, and informed consent wasobtained
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RESULTS
Maternal characteristics of the cohort evaluated at 30months (Table 1)
Infant birth weight and gestational age were similaramong the BM quintile groups and no-BM group (Table2)
The study outcomes by quintile of BM ingestion and theno-BM group at 30 months of age (Table 3)
The analysis of BM as a continuous measure confirmedsignificant independent effects of BM on all 4 of theprimary outcomes at 30 months (Table 4)
Differences were identified at 30 months for Bayley MDI& PDI between the BM & no-BM groups (Figure 1)
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DISCUSSION
Report of 18-month outcomes → identified no
differences in neonatal morbidities, days to firstenteral feed, or days of hospitalization whencomparing the BM to the no-BM group
Ingestion of BM (>80th percentile) ~ significantlylower numbers of days to achieve full enteral feedsand length of stay compared with the no-BM group
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Beneficial effects of BM were the significantly earlier
attainment of full enteral feeds by 1 week and earlierdischarge by 2 weeks
improved digestion & absorption of nutrients host
defense mechanisms ↑
↓ illness severity - NICU
↑ evidence that nutrition plays a major role and to bebased in the beneficial effects of components of BM,including arachidonic acid and docohexanoic acid
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Children BM group at 30 months’ CA → have more
optimal Bayley behavior scores for emotional regulation,motor quality, and total behavior scores.
Rehospitalization rate for the BM infant group in the firstyear of life ↓ and the primary effects of BM were in
preventing admission for respiratory illness
The principal effects of BM in children at 30 months CAare on cognition & behavior
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CONCLUSIONS
On the basis of findings of persistent effects of BM oncognition at 30 months’ CA, we reiterate our
recommendation that efforts must be made tointroduce all of the mothers to the benefits of BM.Efforts should be initiated not only by the obstetrician,neonatologist, lactation consultant, and primary careprovider but should begin before pregnancy withsupports after discharge from the birthing hospital. To
optimize efforts, the introduction of the concept ofbreastfeeding can be considered in elementaryschool as part of healthy-living education.
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KOMPOSISI ASI MATUR DIBANDINGKAN
DENGAN ASI PREMATUR
ZATGIZI HARI KE 3-5 HARI KE 8-11 HARI KE 15-18 HARI KE 26-29
Matur Prema-
tur Matur Prema-
tur Matur Prema-
tur Matur Prema-
tur
Energi(kcal/dl) 48 58 59 71 62 71 62 70
Lemak
(g/dl)1.85 3.0 2.9 4.14 3.06 4.33 3.05 4.09
Protein
(g/dl)1.87 2.10 1.7 1.86 1.52 1.71 1.29 1.41
Laktosa
(g/dl)5.14 5.04 5.98 5.55 6.0 5.63 6.51 5.97
Sumb er : CH Anderso n : Human mi lk feeding. Pediat r Cl in North Am 32:335-52,1985
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PROPERTI ASI SUSU SAPI SUSU
FORMULAKontaminan bakteri Tidak ada Mungkin ada Mungkin ada bila
dicampurkan
Faktor anti-infeksi Ada Tidak ada Tidak ada
Faktor pertumbuhan Ada Tidak ada Tidak ada
Protein Jumlah sesuai dan
mudah dicerna
Terlalu banyak dan sukar
dicerna
Sebagian diperbaiki
Kasein:whey 40:60 Kasein:whey 80:20 Disesuaikan dengan
ASIWhey:Alfa Whey:Betalaktoglobulin
Lemak Cukup mengandung
asam lemak esensial
(ALE), DHA dan AA
Mengandung lipase
Kurang ALE
Tidak ada lipase
Kurang ALE
Tidak ada DHA & AA
Tidak ada lipase
Zat Besi Jumlah kecil tapi mudah
dicerna
Jumlah lebih banyak tapi
tidak diserap dengan
baik
Ditambahkan ekstra
Tidak diserap dengan
baik
Vitamin Cukup Tidak cukup Vitamin A dan
Vitamin C
Vitamin ditambahkan
Air Cukup Perlu tambahan Mungkin perlu
tambahan
Sumber : Konseling menyusui : Pelatihan untuk tenaga kesehatan. Manual Peserta. Kerjasama WHO/UNICEF/BK.PP-ASI Januari 2003
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BAYLEY SCALES OF INFANT DEVELOPMENT II
Age range : 1 to 47 months
Administration/information
Yields a mental development index and motordevelopment index
Mean = 100; standard deviation = 15
Mental and motor ages also obtainable
Administration time : 45 minutes
Description of test
Mental scale measures a child’s development in theareas of shape discrimination, attention, fine motordexterity, imitation, comprehension of directions, naming,
and problem solvingMotor scale measures sitting, standing, walking,grasping, walking up and down steps, and other grossmotor skills
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CLASSIFICATION OF INTELLECTUAL
LEVEL
IQ RANGE INTERPRETATION
130 and above
120 to 129
110 to 119
90 to 11080 to 89
70 to 79
69 and below
52 to 6936 to 51
20 to 35
Less than 20
Very superior
Superior
Above average
AverageBelow average
Borderline retarded
Mentally retarded
Mildly (educably) retardedModerately (trainably) retarded
Severely retarded
Profoundly retarded
Data from material in the manual of the Wechsler Intelligence Scale for Children-Revised,
and from Heber R. Am J Ment Defic 1961; 65:500
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TABLE 1. Maternal Characteristics According to BM
Feeding
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TABLE 2. Neonatal Characteristics by BM Quintiles
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TABLE 3. Outcomes at 30 Months’CA Within BM
Feeding (ml/kg per Day) Quintiles
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TABLE 4. Summary of the Overall Effect of BM on
Outcome With Consumption Measured in Continuous
10-mL/kg per Day Units
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FIGURE 1. Mean and PDI scores at 18 and 30 months
according to any BM feeding. a Adjusted P values