Breastfeeding for

babies with Necrotizing

Enterocolitis
B.Wirastari Marnoto
Symphonic 2015

Necrotizing Enterocolitis
necrotizing enterocolitis (NEC), is an
aquired condition of diffuse necrotic
injury to the mucosal and submucosal
layers of the gut.
the necrosis could extend to the
muscular bowel wall,with potential for
perforation
hydrogen gas pockets are found in the
intramural layers of the gut
it involves mostly the terminal ileum
and proximal colon.

Clinical signs and

symptoms
clinical signs range from mild feeding
intolerance to catastrophic disease with
gut perforation, peritonitis and c-v
collapse.
symptoms might be insidious/ subtle,
such as gastric residues, abdominal
distention, bloody stools, or a sudden
deterioration
Age of onset :
approx 20 days in prems < 30 wk
gestation
approx 5 days in neonates > 34 wks
gestation

Bell's clinical staging

( 1978)
Stage I : suspect NEC
clinical signs and symptoms ,
nondiagnpstic radiograph
Stage II : definite NEC
Clinical signs and symptoms
Pneumatosis intestinalis
Stage III : advanced NEC : critically ill
pneumatosis or pneumo
peritoneum
on radiograph

Incidence
the incidence varies but stated most
often as 3 per 1000 live births
preterm infants account for 70% to 90%
at 36 wks gestation there is a sharp
decline
NICHD USA (2001), the overall
incidence of proven NEC was 7% in
VLBW (400 to 1500 g) and 15% for
infants 501 to 600g.
countries with low incidence of
prematures (Japan, Sweden) have lower
prevalence

NEC in fullterm infants

NEC is rare in fullterm infants
In a 25-year period, Chandler found
only 23 of 226 NEC cases were fullterms, also diagnosed with CHD
( hypoplastic left heart, aortic
stenosis), Down syndrome, bowel
atresia , gastroschisis, volvulus
mesenteric ischemia caused by the
widepulse pressure with low diastolic
pressure
in the surgical cases, a direct injury to
the gastric mucosa

NEC : a disease of
premature infants ?
The incidence of NEC is highest in
infants less than 30 weeks, but rare in
full term babies
is it caused by the immaturity of GI
organs?
the exact pathogenesis is still unclear
3 factors are implicated as major
factors: gastrointetinal immaturity ,
enteral feedings, and bacterial invasion
researchs progessed to the molecular
stage

NEC in Premature infants

Risk factors:
GI immaturity
Immature host defense mechanism
aggressive enteral feedings
PDA/Indometacin therapy
mucosal injury (hypoxic-ischemic)
bacteria in GI lumen
NICU overcrowding

Nutrition for immature GI

tract
Should be :
easily digested
contains
immunoglobulins
built up host
defence
mechanism
protects against
pathogens

Breastmilk for NEC

Lucas (1990) compared infants fed only
formula (NEC 7.2%), formula (+)
expressed breastmilk (NEC 2.5%) and
only breastmilk (NEC 1.2%).
The same results recently by Sisk
(2007), Meinzen-Derr (2008), Sullivan
(2010)
Other experimental studies
evaluating NEC in breastfed compared
to formula fed infants, consistently
report a lower incidence in the
breastmilk group

Donor Human Milk for

NEC
Schanler in a randomized trial
comparing donor milk with preterm
formula observe no protective effect
Pasteurization damaged immune
properties -Holder
pasteurization( 62.5 C, 30 mins) :
sIgA and lysozyme activities drop 20%
flash heating (72C, 6 mins), drop 50%

Breastmilk is protective
against NEC
At birth the neonatal intestine is
virtually sterile, and then quickly
became colonized by a variety of
bacterial species
Healthy fullterms gut is colonized
mostly by "good" Gram positive
micro organism (probiotics ),
Lactobacillus and bifido bacteria
in preterms, the predominant
microorganism are coliforms,
enterococci and bacteroides.

Breastmilk is protective
against NEC
Blakely, then later Sakata and Gewolb
found that in very preterm infants
Bifidobacteria were undetectable in
the first 1-2 weeks and were
predominant by the 3rd week of life
the presence of a potentially
pathogenic bacteria, scant "normal
flora" and the immature gut
increasethe risk for NEC
many clinicians advocate the use of
pro and prebiotics as prophylaxis for
NEC

Breastmilk is protective
against NEC
In a meta analysis of 9 randomized trials,
Al Faleh concluded that probiotics can
reduce the incidence of NEC in
prematures
Breastmilk contains Oligosaccharides
(prebiotic) that promotes the growth of
bifiobacterias, which produce ascetic and
lactic acid that in turn inhibits the
growth of many pathogenic organisms,
and also stimulates the growth of mucosal
barriers

Non nutritive components of

breastmilk
Trophic factors
Anti infections
Immunoglobulins Epidermal Growth
Lactoferrin
Factor
Lysozyme
Lactoferrin
Nucleotides
Insulin-like GF
Defensins
Hormones : Steroid,
Mucins
Pituitary, Thyroid
Oligosaccharides
Toll-like receptors Cells : Neutrophils,
Macro phages, T Cytokines
lymphocytes

Protective properties of
breastmilk
VLBW infants are born before placental
transfer of immunoglobulins
Nature supplies immune modulators
through breastmilk
a high concentration of sIgA in collostrum
a high level of
lactoferrin : depriving microorganism of iron
lysozyme : bactericidal enzym
defensins : antibiotic activity in BM
neutrophils

The first food for a sick

baby should be breastmilk !

Antenatal education and

information
even today, not all pregnant women
know the advantages of
breastfeeding.
midwifes and obstetricians should
spare time to inform and motivate
antenatal classes
the importance of colostrum
correct positioning and latching
how to express breastmilk by hand

The 7 Breastfeeding
contacts

Increasing the use of

mother's milk in NICU
Lowenstein : the barriers to overcome
are
staff attitudes and beliefs
Plan a continuous quality improvement
project, and include breastfeeding at
discharge as a key succes indicator
Key persons : the medical director,
head physician and nurse, lactation
consultant, social worker, dietitian,
motivation expert
doctors and nurses are introduced to
basic breastfeeding skills

Increasing the use of

mother's milk in NICU
Then shift the focus on motivating
skills, including role playing
Communication with parents begun on
1st day of admission, continued with
education
Mothers practice supervised
expressing BM. When a mother brings
EBM, she is given a flower sticker to
put on the information board around
her baby's name
activities to promote BF are recorded
in a specialsheet

Increasing the use of

mother's milk in NICU
What we need
A friendly NICU
A pumping room:
hospital grade
breastpumps, sink, sofa
/chair, refrigerator
a board for informations
Fulltime lactation
consultant (s)
Continuous refreshing
counselling skills

Antenatal Colostrum
Diabetic mothers are encouraged to express
colostrum beginning at 36-37 wks
pregnancy
reasons : -baby at risk for hypoglycemia

the

- lactogenesis II usually delayed

- formula feeding might increase

risk for later DM

Mothers are given relevant information and if
they agree, education on the technique of
sterile breastfeeding collection

Antenatal Colostrum
Contraindication
History of prem labour
currently threatened
labour
cervical incompetence
multiple pregnancies
contraction while
pumping
unfortunately this could
not apply for (usually)
sudden premature births

THANK YOU

 before

after

 All neonates should

be breastfed
(gambar bayi netek
baik besar, kecil,
campur2

Breastfeeding the very sick Neonates

Breastfeeding the very sick

Neonates