How to develop and sustain NEC

free NICU?

Rosalina D Roeslani
Neonatology Division
Dept of Child Health
Cipto Mangunkusumo Hospital, Jakarta
 Aim
• Risk factor for NEC
• Probiotic
• Breast milk preparation
• Formula preparation
 Introduction
• Despite significant research, NEC is still one of
the most commonly acquired intestinal &
surgical emergency in VLBW infants
• The incidence of NEC is inversely proportional
to birth weight: 11,5 % 400-750 gr, 4% 1251-
1500 gr. Mortality rate 10-50 %
 Pathophysiology of NEC
• Has not been clearly elucidated
• Immaturity of the gastrointestinal (GI) tract:
– Motility
– Digestive function
– Circulatory regulation risk factor
– Barrier function
– Immune defense
 Hypothesis
• Enteral feeding, in the presence of immature
intestinal and pathogens colonization
provokes an inappropriately accentuated
inflammatory response by the immature
intestinal epithelial cells of preterm neonate
Probiotic &
severe NEC
Probiotic & mortality
Probiotic
& severe
NEC (BW
<1500 gr)
Probiotic & severe NEC (BW < 1000 gr)
Species
Probiotic & NEC
Time of initiation prebiotic & NEC
Duration & NEC
Result
 How intervention might work ?
• Increased barrier mucosa (Mattar2001,Orrhage
1999)
• Competitive exclusion of potential pathogens (Reid
2001)
• Modification of host response to microbial product
(Duffy 2000)
• Augmentation of Ig A mucosal response,
enhancement nutrition that inhibits the growth of
pathogen & up regulation of immune response
(Link-Amster 1994)
 Breast milk & NEC

Pemberian ASI menurunkan risiko NEC ↓: 79 %

(95% CI 24-94 %)

Boyd CA. Journal Donor breast milk versus infant formula for preterm infants:
systematic review and meta-analysis
 Study in Cipto Mangunkusumo
hospital
• ANALYSIS ON THE IMPACT OF THE DIFFERENCE
OF EXPOSURE TO INITIAL OXYGEN
CONCENTRATION IN RESUSCITATION OF
PREMATURE INFANTS AGAINST
BRONCHOPULMONAL DYSPLASIA, MUCOSAL
INTEGRITY AND INTESTINAL MICROBIOTA
• Risma Kerina Kaban, Agus Firmansyah, Asril
Aminullah, Suhendro, Rianto Setiabudy, Abdurahman
Sukadi, Sri Widia A. Jusman M. S., Badriul Hegar
Syarif, Rinawati Rohsiswatmo, Budiman Bela
 Table 3. Micro biota in neonate receiving FIO2 30 vs 50 %

FiO2 30% FiO2 50% Nilai p

Bakteri anaerob fakultatif Klebsiella pneumoniae I 14,05 (0,00-27,45) 14,10 (0,00-32,55) 0,949
(n = 40/41)

Klebsiella pneumoniae II 25,65 x102 (0,28x102- 20,48x103 (77,15- 0,533

(n=36/38) 24,32x105) 15,67x105)

Acinetobacter sp I 0,00 (0,00-0,00) 0,00 (0,00-0,00) 0,980

(n = 40/41)
Acinetobacter sp II 0,00 (0,00-0,98) 0,83 (0,00-9,58) 0,132
(n=36/40)
Bakteri anaerob Lactobacillus sp I 0.39 (0,00-1,89) 0,31 (0,00-2,02) 0,866
(n = 40/41)
Lactobacillus sp II 1,12 (0,29-3,57) 1,75 (0,57-9,06) 0,220
(n=36/38)
Bifidobacteria sp I 24,55 (9,46-69,47) 22,60 (10,90-49,65) 0,664
(n = 40/41)
Bifidobacteria sp II 84,7 (24,22-392,75) 122,50 (37,50- 0,574
(n=36/38) 382,00)
 Concerns
• Do we have to prepare sterile enteral feeding
to prevent NEC?
• Ready to feed formula vs powder formula
• Osmolality : breast milk + HMF
 How to prepare sterile breast milk
• MOM : do we have to do the pasteurization ?
or just education how to express it or express it
in NICU?
Methods of expressing EBM
 Breastmilk
• Colostrum : neonate will receive colostrum
with in 6 hours of live
• Oral care (oral immune therapy)
• During the first few days after birth, open tight junctions of
the mammary gland epithelium allow for paracellular
transport of many bioactive immune substances from the
mother’s circulation into the colostrum
• Colostrum contains increased concentrations of secretory Ig
A, growth factors, lactoferrin, anti-inflammatory cytokines,
pro-inflammatory cytokines & others
• Preterm
• Immunoprotective factors
• Closure of the tight junction in the mammary ephitelium
might be delayed
 Result
Urinary level of secretory IG A & lactoferrin at 1
week: significantly higher

Urine interleukin –B level at 2 week was

significantly lower

Salivary transforming growth factor –B1 &

interleukin-8 at 2 week lower

A significant reduction in the incidence of clinical

sepdis (50% vs 90 % P 0,03)
 Flowchart Collection and Transportation of
Colostrum or EBM for Newborn
Colostrum collected from DD to D4
Expressed Breast Milk

1st colostrum wi/ 6

hrs after delivery No
Yes
Yes
Attach Attach
(2.1) 1”Colostrum Label & (2.3) Colostrum/ BM
(2.3) Colostrum/ BM Identification Label Identification Label

Yes
Maturity ≤ 32 wks or
BW ≤ 1.5 kg
No
Send by schedule Attach
(2.2) label for ‘Preterm ≤ 32 weeks

Yes No
Send within 1 hr No
Yes
Store in freezer Keep in room temperature Store in fridge (4°C) and send
wi/ 4 hours
Colostrum collected in syringe
 Storage of the colostrum
• Colostrum can be kept in the
designated refrigerator at 40 C
compartment for 72 hours
• Colostrum for the storage must
be capped with a sterile cap and
put in a clean tray
 Transportation Colostrum
• Schedule for colostrum transport every 4
hours
– 00.00, 04.00, 08.00, 14.00, 16.00
– Box with ice
• Colostrum transported by special staff or
family member
• Labeling colostrum is important
• Keep the colostrum cold but
never freeze
 Administration of Colostrum
Infants not allowed to be fed Infants allowed to be fed
• Prescribe : 0.1 ml colostrum instil • Prescribe : volume and
over bilateral buccal mucosa frequency of colostrum via
• Administer every 4 hrs schedule as gastric tube
followed
– 0am,4am,12pm,4pm,8pm • Treat colostrum as the
• Before administration  check Expressed Breast Milk with
patients’ identity on label the principle of consuming
• Instil 0.1 ml colostrum to each side prior to EBM
of buccal mucosa (total: 0.2 ml • Record in I/O chart
colostrum)
– Every 4 hourly for the initial 5 days
or until feeding starts
• Record in I/O chart
• Vital signs observation
 Handling Expressed Breast Milk

Similar to Can be kept frozen

colostrum Hold in sterile cups if it is not
(expression and or bottles consumed
labeling) immediately

Separate carefully Thaw in a 4°C

Feed the infant
by nurses in fridge and
while the milk is
syringes after consumed wi/ 24
still cool
thawing hrs
 How to express breast milk
• Use sterile bottle/cup/syringe
• Wash hands
• Clean the nipple with pre-boiled water
• Squeeze & dischard the initial few drops
• Clean the nipple again with pre-boiled water
• Express directly in to the sterile
bottle/cup/syringe
• Monitor expression time < 30 min
• Cover up & proper label
• Put into freezer
 Important: possible increase in
bacterial multiplication
• Temperature not cold enough before
transport : explain on the reason for reject of
partially thawed milk, ensure the milk is frozen
state before transport.
• Partially thawed before arrival: use insulation
box, add plenty of ice cube in the box
encircled the bottle
• Expired milk after thawing at 40C : enter &
check the time of thawing before use
 …important
• Excessive warming before feed: never take out
the EBM too early from fridge, no milk
warmer for EBM
• Contamination by environment: maintain
clean environment around infant
Formula powder preparation

Pour water in Ad powder

Mix it
to bottle formula

Distribute the
Put the bottle
formula in the
to blast chiller
cool box
1. Pour boiled water to
dispenser.
2. The water
temperatureat
arround 80°C.
3. Pour the water in to
the bottle.
4. Ad powder milk.
5. Shake them well gently
6. Put the bottle in the
blast chiller (4°C) for 1
hour
7. distribute it with cool
box
 Formula storage
Put the botle (formula) in
the refrigerator.
Ready to fed
 Conclusion
• Preventing NEC : Probiotic & breast milk
• Preparation of EBM safe (sterile)
Thank You…