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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



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.



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.



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)



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



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



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 -



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



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



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



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)



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



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



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



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.





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





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



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



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



TABLE 1. Maternal Characteristics According to BM

Feeding



TABLE 2. Neonatal Characteristics by BM Quintiles



TABLE 3. Outcomes at 30 Months’CA Within BM

Feeding (ml/kg per Day) Quintiles



TABLE 4. Summary of the Overall Effect of BM on

Outcome With Consumption Measured in Continuous

10-mL/kg per Day Units



FIGURE 1. Mean and PDI scores at 18 and 30 months

according to any BM feeding. a Adjusted P values

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