Journal Reading

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

ABSTRACT
BACKGROUND. We previously reported beneficial effects of

breast milk ingestion by infants with extremely low birth weight

in the NICU on developmental outcomes at 18 months
corrected age. The objective of this study was to determine
whether these effects of breast milk in infants with extremely low
birth weight persisted at 30 months corrected age.
METHODS. Nutrition data, including enteral and parenteral
feeds, were prospectively collected, and 30 months corrected
age follow-up assessments were completed on 773 infants with
extremely low birth weight who participated in the National
Institute of Child Health and Human Development Neonatal
Research Network Glutamine Trial. A total of 593 ingested some
breast milk during the neonatal hospitalization, and 180 ingested
none. Neonatal feeding characteristics and morbidities and 30month interim history, neurodevelopmental outcomes, and
growth parameters were analyzed. Children were divided into
quintiles of breast milk volume to evaluate the effects of volume
of human milk ingested during the NICU hospitalization.

 RESULTS. At 30 months, increased ingestion of breast milk was

associated 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 Psychomotor
Developmental Index by 0.56 points, and the total behavior
percentile score by 0.99 points, and the risk of rehospitalization
between discharge and 30 months decreased by 5%.
CONCLUSIONS. Beneficial effects of ingestion of breast milk in the
NICU persist at 30 months corrected age in this vulnerable
extremely low birth weight population. Continued efforts must be
made to offer breast milk to all extremely low birth weight infants
both 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 in

the NICU in our cohort of infants with ELBW

~ developmental & behavior test scores

rehospitalization rates at 30 months CA

METHODS

1433 infants enrolled at 12 sites of the National Institute

of 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 expired
before 30 months, resulting in 939 eligible children.

The final 773 (82.3%) of 939 infants with ELBW whom

30-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 the
hospitalization 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 duration
of hospitalization was calculated.
593 (77%) BM +

180 (23%) BM -

 The 30-month assessment

interim medical history

a developmental evaluation
neurologic 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 the

presence 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 t
tests, 2, Kruskal-Wallis, or Fishers exact tests

 Infants were divided into quintiles of BM ingestion

adjusted for confounders to identify threshold effects of

BM on neonatal and 30-month outcomes.
Study participation was approved by each sites
institutional review board, and informed consent was
obtained

RESULTS
Maternal characteristics of the cohort evaluated at 30

months (Table 1)
Infant birth weight and gestational age were similar
among the BM quintile groups and no-BM group (Table
2)
The study outcomes by quintile of BM ingestion and the
no-BM group at 30 months of age (Table 3)
The analysis of BM as a continuous measure confirmed
significant independent effects of BM on all 4 of the
primary 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 first

enteral feed, or days of hospitalization when
comparing the BM to the no-BM group
Ingestion of BM (>80th percentile) ~ significantly

lower numbers of days to achieve full enteral feeds

and 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 earlier

discharge by 2 weeks

improved digestion & absorption of nutrients host

defense mechanisms
illness severity - NICU
evidence that nutrition plays a major role and to be
based 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 first
year 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 CA
are on cognition & behavior

CONCLUSIONS
On the basis of findings of persistent effects of BM on
cognition at 30 months CA, we reiterate our
recommendation that efforts must be made to
introduce all of the mothers to the benefits of BM.
Efforts should be initiated not only by the obstetrician,
neonatologist, lactation consultant, and primary care
provider but should begin before pregnancy with
supports after discharge from the birthing hospital. To
optimize efforts, the introduction of the concept of
breastfeeding can be considered in elementary
school as part of healthy-living education.

KOMPOSISI ASI MATUR DIBANDINGKAN

DENGAN ASI PREMATUR
ZAT
GIZI

HARI KE
3-5

HARI KE
8-11

HARI KE
15-18

HARI KE
26-29

Matur

Prematur

Matur

Prematur

Matur

Prema- Matur
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

Sumber : CH Anderson : Human milk feeding. Pediatr Clin North Am 32:335-52,1985

Prematur

KOMPOSISI KOLOSTRUM & ASI MATUR

DIBANDINGKAN DENGAN SUSU SAPI
KOMPOSISI

KOLOSTRUM ASI MATUR

(HARI 1-5)
(>30 HARI)

SUSU
SAPI

Energi (kcal/dl)

58.0

70.0

65.0

Lemak (g/dl)
Asam lemak tak jenuh rantai
panjang (% total lemak)

2.9
---

4.2
14

3.8
3

Protein (g/dl)
Kasein (g/dl)
-Lactalbumin(g/dl), Whey
Laktoferin (g/dl)
IgA (g/dl)

2.3
0.5
--0.5
0.5

0.9
0.4
0.3
0.2
0.2

3.3
2.5
0.1
Trace
0.003

Laktosa (g/dl)

5.3

7.3

4.7

Vitamin A (RE) (g/dl)

151

75

40

Kalsium (mg/dl)
Natrium (mg/dl)
Zat besi (mg/dl)

28
48
---

30
15
0.08

125
47
0.05

Sumber : CE Casey, KM Hambidge : Nutritional aspects of human lactation. In : MC Neville, MR Neifert (eds.),
Lactation: physiology, nutrition and breastfeeding. New York : Plenum, 1983 : 203-4

PROPERTI

ASI

SUSU SAPI

SUSU
FORMULA

Kontaminan 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
ASI

Whey: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 motor

development index
Mean = 100; standard deviation = 15
Mental and motor ages also obtainable
Administration time : 45 minutes
Description of test
Mental scale measures a childs development in the
areas of shape discrimination, attention, fine motor
dexterity, imitation, comprehension of directions, naming,
and problem solving
Motor scale measures sitting, standing, walking,
grasping, walking up and down steps, and other gross
motor skills

CLASSIFICATION OF INTELLECTUAL
LEVEL
IQ RANGE

INTERPRETATION

130 and above

120 to 129
110 to 119
90 to 110
80 to 89
70 to 79
69 and below
52 to 69
36 to 51
20 to 35
Less than 20

Very superior
Superior
Above average
Average
Below average
Borderline retarded
Mentally retarded
Mildly (educably) retarded
Moderately (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 MonthsCA 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