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PRESENTASI JURNAL

Pemberian Air Susu Ibu Menurunkan Kejadian

Enterokolitis NekrotikansHerrmann, K., Carroll K. An Exclusively human milk diet reduces necrotizing

enterocolitis. Breastfeed Med. May 1, 2014; 9(4): 184–190.

Ananta Fittonia Benvenuto

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PENDAHULUAN

• Kejadian NEC meningkat dengan adanya BBLR dan umur gestasi muda, cenderung menurun setelah 32 minggu

• Resiko NEC berhubungan dengan pemberian asupan (pemilihan susu, kuantitas, dan waktu pemberian)

• Rekomendasi AAP (American Academy of Pediatric) : ASI direkomendasikan bagi bayi prematur, untuk mengurangi kejadian NEC

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PENDAHULUAN

• Keunggulan ASI :– Mengurangi kejadian NEC, sepsis, dan kematian– Meningkatkan toleransi makan dan pencapaian

lebih awal untuk asupan enteral sepenuhnya– Meningkatkan pertumbuhan jangka panjang dan

neurodevelopment• Hipotesis : pemberian ASI hingga 33 minggu

PMA menurunkan kejadian NEC yang berhubungan dengan asupan enteral

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Bahan dan Metode

• Lokasi dan Pengumpulan Data– NICU di daerah Midwestern Amerika Serikat.– Penelitian observasional meliputi 2 kelompok kohort

• Kohort kontrol : semua bayi yang masuk NICU < 33 minggu (1 januari 2004 - 30 juni 2010)

• Kohort ASI : semua bayi yang masuk NICU < 33 minggu (1 juli 2010 - 31 desember 2012)

– Identifikasi dari database RM elektronik NICU– Dikumpulkan secara retrospektif dari kedua

kelompok

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• Asupan Enteral– Neonatolog merekomendasikan ASI untuk semua

neonatus yang lahir < 33 minggu – ASI dikeluarkan dengan pompa elektrik rumah

sakit – Apabila volume ASI kurang, digunakan ASI donor– Target volume pemberian makan secara enteral

150-160ml/kg/hari hingga 33 minggu– Penggunaan susu dicatat setiap hari

Bahan dan Metode

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• Asupan Enteral– Setelah 33 minggu PMA atau 1 minggu setelah

pemberian asupan ASI penuh, bayi yang mendapat ASI donor diganti dengan susu buatan, dengan atau tanpa ASI

– Setelah 33 minggu PMA dan minimum 1 minggu asupan enteral penuh orangtua yang melanjutkan ASI diberikan fortifikasi susu sapi.

– Pembiayaan dibebankan pada RS, tidak ada dukungan komersial dan tidak sedikitpun dari keluarga

Bahan dan Metode

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• Nutrisi Parenteral– Nutrisi parenteral diberikan segera setelah lahir

(age 1–2 hours)– Nutrisi parenteral dihentikan bila asupan enteral

mencapai 140mL/kg/day. – Pemberian cairan parenteral melalui kateter

umbilikus. – Asupan enteral tetap diberikan .

Bahan dan Metode

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• NEC– NEC stage 2 atau lebih, berdasarkan klasifikasi Bell

et al. – Kasus potensial NEC diidentifikasi dari RM

elektronik

Bahan dan Metode

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• Penggunaan Darah– Transfusi PRC • Ada blood loss, Hb < 12 gr/dl, dan butuh

bantuan respirasi. • Tidak ada blood loss, Hb < 10 gr/dl

–Pemberian asupan tetap dilanjutkan

Bahan dan Metode

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• Statistical analysisχ2 test, Mann–Whitney U test, and analysis of

variance methods menggunakan program VassarStats.

Bahan dan Metode

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• Etika Penelitian Subyek Manusia– Regulasi Federal Amerika Serikat menyatakan

penelitian bebas dari persetujuan Institutional Review Board ketika melibatkan evaluasi kualitas makanan sehat

– ASI dianggap sebagai makanan sehat untuk bayi prematur.

– Orangtua diberikan persetujuan tertulis untuk penggunaan ASI donor dan fortifikasi berbasis ASI

Bahan dan Metode

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HASIL

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Tabel 1.Kohort ASI sama dengan kohort kontrol yang mendapat produk susu sapi sebelum 33 minggu

Data are mean (SD) or number (%) values as indicated.EHM, exclusively human milk; PDA, patent ductus arteriosus; UAC, umbilical arterial catheter; UVC, umbilical venous catheter.

Characteristic Control cohort EHM cohort p

Birth weight (kg) 1.334 (0.436) 1.361 (0.542) 0.503

Gestational age (weeks)

29.7 (2.5) 29.6 (3.0) 0.920

Multiples 172 (39%) 64 (32%) 0.106

Small for gestational age

46 (10%) 27 (14%) 0.282

Male 225 (51%) 110 (55%) 0.306

Ethnicity

White  363 (82%) 167 (84%) 0.576

Black  45 (10%) 16 (8%) 0.388

Other  35 (8%) 16 (8%) 1

Respiratory distress syndrome

335 (76%) 167 (84%) 0.023

Surfactant administration

300 (68%) 151 (76%) 0.040

Ventilation 317 (72%) 129 (65%) 0.096

High-frequency oscillatory 

57 (13%) 38 (19%) 0.042

Jet  11 (2%) 10 (5%) 0.147

Characteristic Control cohort EHM cohort p

Postnatal steroid 66 (15%) 33 (17%) 0.815

UAC 351 (79%) 158 (79%) 1

UVC 296 (67%) 122 (61%) 0.180

PDA 91 (21%) 46 (23%) 0.467

PDA treated with indomethacin 

75 (17%) 29 (15%) 0.489

Sepsis

Clinical, culture negative 

93 (21%) 51 (26%) 0.220

Bacterial, culture positive 

40 (9%) 5 (3%) 0.004

Fungal (Candida)

6 (1%) 0 (0%) 0.185

Discharged home 387 (87%) 162 (81%) 0.053

Acute transfer 37 (8%) 25 (13%) 0.112

Died before transfer

19 (4%) 12 (6%) 0.426

Total  443 (100%) 199 (100%)  

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 Gestational age

Control cohort Exclusively human milk cohort pn %

Birth weight

SD n %Birth

weightSD

<26 41 9.3% 0.650 0.128 29 14.6% 0.590 0.132 0.189

26–27 59 13.3% 0.916 0.203 20 10.1% 0.883 0.194 0.626

28–29 102 23.0% 1.169 0.233 38 19.1% 1.177 0.245 0.050

30–32 241 54.4% 1.623 0.310 112 56.3% 1.709 0.402 0.023

All  443 100.0% 1.334 0.436 199 100.0% 1.361 0.542 0.920

Tabel 2.Distribusi usia kehamilan dan berat lahir

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HASIL

• Pemberian Asupan– Usia mendapat asupan enteral• ASI vs kontrol : 16.7 (SD 8.3) vs 17.4 (SD 10.2) hari (p=0.424).

– Usia gestasi lebih muda, asupan penuh lebih panjang (kontrol vs ASI): • 23-25 minggu : 37 (SD 6.1) vs 45 (SD 11.8) hari (p=0.189)• 26-27 minggu : 25.3 (SD 9.4) vs 27.6 (SD 7.9) hari (p=0.459)• 28-29 minggu : 18.8 (SD 7.5) vs 21.2 (SD 6.7) hari (p=0.118);• 30-32 minggu : 13.3 (SD 5.2) vs 13.1 (SD 6.2) hari (p=0.792)

16The incidence of late necrotizing enterocolitis (NEC) was reduced for infants receiving

an exclusively human milk (EHM) diet through 33 weeks postmenstrual age.

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HASIL

• NEC (Kontrol vs ASI) – Total kasus: 17 dari 443 (3.8%) vs 7 dari 199 (3.5%)– Penurunan signifikan dari NEC pada kohort ASI untuk

hari onset (p=0.042) dan onset PMA (p=0.011)– Onset NEC pada kedua kohort (p=0.009). – NEC setelah hari 7 : 15/443 bayi (3.4%) vs 2/199 (1.0%)– NEC sebelum hari 8 pada kedua kohort (p=0.092)

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PEMBAHASAN

• Tujuan utama penelitian : menentukan kejadian NEC terkait ASI.

• Pemberian ASI tanpa memberikan semua produk susu sapi dan ditargetkan pada bayi yang beresiko besar menjadi NEC

• Hasil : ASI menurunkan kejadian NEC selama fase nutrisi enteral

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PEMBAHASAN

• ASI dilaporkan secara signifikan menurunkan kejadian NEC;– Studi terdahulu kohort pembanding memiliki

baseline tinggi kejadian NEC (15.9% and 21%). – Studi saat ini, angka NEC pada kohort kontrol

cukup rendah (3.8%).

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PEMBAHASAN

• Mayoritas NEC di kohort ASI terjadi pada hari 6 dan 7

• Onset NEC setelah hari 7, selama fase nutrisi enteral, jarang pada kohort ASI (1%).

• Late-phase NEC turun secara signifikan, lebih banyak early-phase NEC

• Perlu ada penelitian lanjutan untuk mengetahui etiologi early- and late-phase NEC

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