*Maternity Pablo Picasso 1905

Pemberian ASI EksklusifDewi RobinarBagian Kesehatan Anak RSUD AA Pekanbaru2007

ASI menguntungkan biologis, fisiologis, psikologis & ekonomi.ASI sebagai makanan alamiah terbaikKomposisi ASI berubah sesuai kebutuhanKeputusan Menteri Kesehatan RI tentang pemberian ASI Eksklusif

Rekomendasi WHO (2001 )Pemberian ASI eksklusif ( ASIE ) selama 6 bulan Pemberian ASI sampai 2 tahun bersama makanan lain yang adekuat dan sesuai usia.Alasan ( Penelusuran literatur )Pertumnuhan bayi ASIE 6 bulan tidak kurang dari ASIE 4 bulanMorbiditas bayi dengan ASIE 6 bulan lebih kecil daripada ASIE 4 bulanASIE 6 bulan dapat digunakan sebagai Metode KB (LAM )

Manfaat bagi ibuMencegah perdarahan postpartum & mempercepat involusi uterusMencegah anemia defisiensi zat besiMempercepat ibu kembali ke berat sebelum hamilMenunda kesuburanMenimbulkan perasaan dibutuhkanMengurangi kemungkinan kanker payudara dan ovarium

Manfaat bagi bayiKomposisi sesuai kebutuhanKalori dari ASI memenuhi kebutuhan bayi sampai 6 bulanASI mengandung zat pelindungPerkembangan psikomotorik lebih cepatMenunjang perkembangan kognitifMenunjang perkembangan penglihatanDasar untuk perkembangan emosi yang hangatDasar untuk perkembangan kepribadian yang percaya diri

Manfaat bagi keluargaMudah pemberianMengurangi biaya rumah tanggaMengurangi biaya pengobatan

Manfaat ASI ditinjau dari :Aspek gizi ASIAspek imunologik

Aspek Gizi ASIMakanan alamiahPerubahan komposisi ASI 3 stadiumKolostrum ( minggu 1 )Warna kekuninganVolume : 2 20 ml/x menyusu ( 3 hari pertama )Protein > karbohidrat / lemakIg > ASI maturPencahar yang baik

ASI peralihan ( ASI transisional )Hari ke 7 14 ( sp minggu ke 5 )Ig & protein total makin menurunLaktosa, lemak, vitamin & kalori total meningkatASI MaturSetelah ASI peralihanVolume tahun 1 : 400 800 ml/hariVolume tahun 2 : 200 450 ml/hariVolume bila frekuensi pemberian

Komposisi ASI MaturKarbohidratLaktosa (70%) fermentasi suasana asamProteinKadar konstan dr lemak ASImengandung protease mudah dicernaAsam Amino : Sistin somatik Taurin otakLemakSumber energi utamaUntuk pertumbuhan normalAsam lemakPelarut vitaminVitaminGaram dan mineral

Aspek ImunologikMendapat ASI jarang sakitZat kekebalan :Faktor pertumbuhanLaktobasilus bifidus suasana asam menghambat pertumbuhan E. coli ( Goldman dan Smith, 1973 )LaktoferinProtien terikat zat besi dari ASI Khasiat :Menghambat pertumbuhan Stafilokokus, E. coli, jamur candida. Konsentrasi dalam kolostrum sangat tinggi ( Lawrence, 1989; Roberts, 1989 )

Faktor anti Statfilokokus ( Gyorgy dkk., 1971 )AntibodiIgG, IgM, IgA, SIgA, IgD dan IgETerbanyak di kolostrum, SIgA ( 90 % ) - (Lawrence, 1989; Roberts, 1989 ) Khasiat SIgA :Membentuk lapisan permukaan usus melindungi kuman patogenLaktobasilus bifidus suasana asam menghambat pertumbuhan E. coli ( Goldman dan Smith, 1973 )Komplemen ( C3 dan C4 )Mempunyai daya opsonik, anafilatoksik dan kemotaksis

LisozimKhasiat :bakteriolitikantiviral

Imunitas selularMakrofag ( 90 % ) dan limfosit ( 10 % )

Hormon dalam ASI15 macam hormon ( Roberts, 1989 )

Laktoperoksidaseantibakteri Streptokokus

Manajemen LaktasiAdalah upaya-upaya yang dilakukan pada periode kehamilan ( antenatal ), periode segera setelah lahir ( perinatal ) dan periode selama menyusui ( pascanatal ) untuk menunjang keberhasilan menyusui.

ANTENATAL Periode kehamilan

MentalFisikGizi IbuPersiapan Payudara sejak hamil 6 bulan

Fisiologi LaktasiRefleks pada ibuRefleks ProlaktinRefleks AliranRefleks pada bayiRooting reflexRefleks mengisapRefleks menelan

Proses LaktasiIsapan / menyusuStimulasi syaraf sensoris puting susuSistem saraf pusatSyaraf sensoris afferenthipotalamusPars anterior hipofiseprolaktinAliran darahKelj sekretori epitelProduksi susuPars posterior hipofiseOksitosinAliran darahSel mioepitelLet-down reflex

( Applebaum, 1975 )

PERINATALSaat lahirTanpa pemberian susu formula prelakteal, air gula atau maduInisiasi Laktasi : Segera disusukan setelah lahirRawat GabungTidak memberi dotSusui bayi dari kedua payudara secara bergantian

PASCANATALPerhatikan teknik/cara menyusui yang baik dan benarMP-ASI setelah bayi umur 6 bulanKonsultasi ke klinik laktasiBerikan ASI sampai umur 2 tahunMenyapih secara bertahap

*The Remarkable First Hour of LifeWhen healthy infants are placed skin-to-skin on their mothers abdomen and chest immediately after birth, they exhibit remarkable capabilities. They are alert. They can crawl, stimulated by mothers gentle touch, across her abdomen, reaching her breast. They begin to touch and massage the breast finally, he or she attaches to the breast and first feeds.

*1. Sensory inputs1.1. OlfactoryBabies preferred their mothers unwashed breast to her washed breast, soon after birth. (Varendi et al, 1994). Besides secreting milk and colostrum, the nipple and areola are dense in glands that perhaps secrete attractive odors. (Makin and Porter, 1999).

1.2. VisualIllingworth (1987) stating that a newborn baby shows more interest in a black and white pattern than in a blank grey card.Newborns can recognize their mothers face (Bushnell et al, 1989) and can follow it for a short distance (Brazelton and Cramer, 1199)

*1.3. TasteAmniotic fluid on the infants hands probably also explains part of the interest in suckling the hands and fingers. The baby uses the taste and smell of amniotic fluid on its hands to make a connection with a certain lipid substance on the nipple related to the amniotic fluid (Klaus and Kennel, 2001).

1.4. AuditoryNewborn infants prefer the sound of the maternal voice and also suckle for longer when they hear it (DeCasper and Fifer, 1980; Fifer and Moon, 1994). They can discriminate the language heard in utero from another language (Mehler et al, 1988)The rhythmic sound of the mothers heart-beat can also have a calming influence on the baby. (Salk L, 1960; Salk L, 1962).

* 1.5. Touch

Skin to skin touch provides heat and variety of other tactile impulsHelps maintain temperature (Christensson et al, 1992) Facilitates metabolic adaptations especially sugar levels and acid-base balance (Christensson et al, 1992) Results in less crying (Christensson et al, 1992; Christensson et al, 1995) Facilitates bonding (Widstrm et al, 1990) Causes oxytocin release in the mother Improves immediate and long term breastfeeding success: (Righard and Alade, 1990; WHO, 1998; DeChateau and Wiberg, 1977)

*2. Central componentThe newborns brain is optimally ready to integrate various sensory inputs and other components of the breast crawl soon after birth.Widstrm et al (1987) recorded a state of wakefulness during the Breast Crawl according to Brazeltons Neonatal Behavior Assessment Scale (BNBAS). At 15 minutes, the childrens median state was 4. Alertness gradually decreased until 150 minutes after birth, when they were all asleep.

*3. Motor outputs :3.1. OrofacialAround 30-40 minutes after birth, the newborn begins making mouthing movements, sometimes with lip smacking. Suckling of hands and fingers is commonly seen. After attaching successfully, newborns continued to suckle for 20 minutes (Righard and Alade, 1990).

*3.2. Lower & Upper limbThe Stepping Reflex helps the newborn to push against her mothers abdomen to propel her towards the breast. Pressure from the infants feet on the abdomen may also help to expel placenta and reduce uterine bleeding (Klaus and Kennel, 2001).

*The ability to move its hand in a reaching motion enables the baby to claim the nipple. This helps to stimulate, elongate and protract the nipple (Klaus and Kennel, 2001). When the baby massages the breast and subsequently suckles, a large oxytocin surge is induced from the mothers pituitary gland into her bloodstream. This also helps in the manufacture of prolactin.

*3.4. Neuro-endocrine componentOxytocin- Induce uterine contraction- Helps expel placenta- Prevents excessive bleeding- Helps mold maternal behavior Causes the mother to feel relaxed, calmer, sedated- Stimulates the release of GI hormones - Increase skin temperature (flushing)Prolactin- The milk-making hormone- Mothering hormone

*Oxytocin level in a mother in relation to the infants massage like hand movements on mothers Mattthiesen A, Arvidson A, Nissen A, Moberg K. Postpartum Maternal Oxytocin Release by Newborns: Effect of Infant Hand Massage and Sucking; 2001. Birth, 2001, 28.

*D. ADVANTAGES OFFERED BY THE BREAST CRAWL4.1. For the Baby

4.1.1. Warmth Compared temperatures of newborns kept in skin-to-skin contact in the Breast Crawl position with those kept in a cot in the first few hours after birth, the former had better body and skin temperatures.(Christensson et al, 1992)

*Maternal and neonatal temperature changes from the moment of STS contact (time = 0) to 20 min after initiation of STS contact. The last measurement (marked X) was carried out 10 min after the newborn had been taken away from the STS position, wrapped in dry cloth. Bars above and below symbols indicate 95% confidence intervals Bergstrom A, Okong P, Ransjo-Arvidson A-B; Immediate maternal thermal response to skin-to-skin care of newborn;2007

*4.1.2. Comfort Christensson et al (1992) compared crying between babies kept in the Breast Crawl position with those kept in a cot next to the mother during the first 90 minutes after birth. The infants in the cot cried for a significantly longer time than the babies in Breast Crawl position during all observation periods.

*Crying duration at various time intervalsChristensson et al, 1992

GroupTime IntervalAt 25-30 minsAt 55-60 minsAt 85-90 minsBabies in skin-to-skin contact (Breast Crawl)60 sec0 sec10 secBabies in cot1094 sec985 sec760 sec

*4.1.3. Metabolic adaption

Babies kept in the Breast Crawl position had higher 90 minute blood sugar levels and more rapid recovery from transient acidosis at birth, as compared to babies separated and kept in a cot next to the mother (Christensson et al, 1992).

*4.1.4. Quality of attachment

Compared kept in uninterrupted and interrupted STS contact for 1 hour, the former had better and attached corectly (Righard and Alade, 1990). These findings are crucial because the early suckling pattern is of prognostic value for the duration and success of breastfeeding

4.2. For the MotherExpulsion of placenta and reduction of post partumhaemorrhage

*Duration of placental delivery of the early-breastfeeding and control groupsBilgik D, Guler H, Cetin A, 2004

Duration of placental deliveryEarly-breastfeeding (n=36)Control(n=36)5-10 min30 (83.3%)a15 (41.7%)a11-20 min6 (16.7%)21 (58.3%)a Significantly different from 11-20 min (p

*Duration of placental delivery from the beginning of early breastfeedingBilgik D, Guler H, Cetin A, 2004

Duration of placental delivery5-10 min11-20 minDuration of early-breastfeeding2-9 min25 (92.6%)a2 (7.4%)>10 min5 (55.5%)4 (44.5%)a Significantly different from >10 min (p

*E. HINDERING FACTORSSeparation on the Breast CrawlDrugsRoutinely procedures directly after delivery- Suctioning- Weighing- Bathing- Wrapping- Vitamin K injection- Eye treatments

Penyimpanan ASI Suhu ruang: 770 F / 250 C: 6 sampai 8 jam 1000 F / 380 C: tidak amanWadah terinsulasi dengan ice pack: 24 jam

Lemari pendingin 390 F / 40 C 24 - 48 jam (sampai dengan 5 hari?)

Penyimpanan ASI Freezer ekstra dingin yang sering dibuka:-40 F / -200 C : 6 sampai 12 bulanLemari es/freezer dengan pintu terpisah: 00 F / -180 C : 3 sampai 6 bulan

Freezer di dalam lemari pendingin: 50 F / -150 C : 2 minggu saja

Cairkan ASI beku dengan slow defrost selama satu malam dalam lemari pendingin. Rendam susu dalam mangkuk berisi air suam kuku hingga hangat. Panas berlebihan akan memodifikasi atau menghancurkan enzim dan protein. Cairkan keseluruhan ASI dalam wadah karena lemaknya terpisah selama proses pembekuan. Jangan pernah menggunakan microwave untuk mencairkan atau menghangatkan ASI. Setelah dicairkan, ASI harus digunakan dalam waktu 24 jam. Mencairkan ASI

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