Maternity Pablo Picasso 1905

Pemberian ASI Eksklusif

Dewi Robinar Bagian Kesehatan Anak RSUD AA Pekanbaru 2009

 ASI

menguntungkan biologis, fisiologis, psikologis & ekonomi. ASI sebagai makanan alamiah sesuai kebutuhan Keputusan Menteri Kesehatan RI tentang pemberian ASI Eksklusif

Rekomendasi WHO (2001 )

Pemberian ASI eksklusif ( ASIE ) selama 6

bulan Pemberian ASI sampai 2 tahun bersama makanan lain yang adekuat dan sesuai usia.

Alasan ( Penelusuran literatur )

Pertumnuhan bayi ASIE 6 bulan tidak kurang

dari ASIE 4 bulan Morbiditas bayi dengan ASIE 6 bulan lebih kecil daripada ASIE 4 bulan ASIE 6 bulan dapat digunakan sebagai Metode KB (LAM )

Manfaat bagi ibu

Mencegah perdarahan postpartum & mempercepat involusi uterus Mencegah anemia defisiensi zat besi Mempercepat ibu kembali ke berat sebelum hamil Menunda kesuburan Menimbulkan perasaan dibutuhkan Mengurangi kemungkinan kanker payudara dan ovarium

Manfaat bagi bayi

Komposisi sesuai kebutuhan Kalori dari ASI memenuhi kebutuhan bayi sampai 6 bulan ASI mengandung zat pelindung Perkembangan psikomotorik lebih cepat Menunjang perkembangan kognitif Menunjang perkembangan penglihatan Dasar untuk perkembangan emosi yang hangat Dasar untuk perkembangan kepribadian yang percaya diri

Manfaat bagi keluarga

Mudah pemberian Mengurangi biaya rumah tangga Mengurangi biaya pengobatan

Manfaat ASI ditinjau dari :

1.
2.

Aspek gizi ASI Aspek imunologik

Aspek Gizi ASI

Makanan alamiah Perubahan komposisi ASI 3 stadium Kolostrum ( minggu 1 )
Warna kekuningan Volume : 2 20 ml/x menyusu ( 3 hari

pertama ) Protein > karbohidrat / lemak Ig > ASI matur Pencahar yang baik

ASI peralihan ( ASI transisional )

Hari ke 7 14 ( sp minggu ke 5 ) Ig & protein total makin menurun Laktosa, lemak, vitamin & kalori total

meningkat

ASI Matur
Setelah ASI peralihan Volume tahun 1 : 400 800 ml/hari

Volume tahun 2 : 200 450 ml/hari

Volume bila frekuensi pemberian

Komposisi ASI Matur

Karbohidrat

Laktosa (70%) fermentasi suasana asam Kadar konstan dr lemak ASI mengandung protease mudah dicerna Asam Amino : Sistin somatik Taurin otak Sumber energi utama Untuk pertumbuhan normal Asam lemak Pelarut vitamin

Protein

Lemak

Vitamin Garam dan mineral

Aspek Imunologik
Mendapat ASI jarang sakit Zat kekebalan :
1.

2.

Faktor pertumbuhan Laktobasilus bifidus suasana asam menghambat pertumbuhan E. coli ( Goldman dan Smith, 1973 ) Laktoferin Protien terikat zat besi dari ASI Khasiat : Menghambat pertumbuhan Stafilokokus, E. coli, jamur candida. Konsentrasi dalam kolostrum sangat tinggi ( Lawrence, 1989; Roberts, 1989 )

3.
4.

Faktor anti Statfilokokus ( Gyorgy dkk., 1971 ) Antibodi

IgG, IgM, IgA, SIgA, IgD dan IgE Terbanyak di kolostrum, SIgA ( 90 % ) - (Lawrence, 1989; Roberts, 1989 ) Khasiat SIgA : Membentuk lapisan permukaan usus melindungi kuman patogen

5.

Laktobasilus bifidus suasana asam menghambat pertumbuhan E. coli ( Goldman dan Smith, 1973 ) Komplemen ( C3 dan C4 ) Mempunyai daya opsonik, anafilatoksik dan kemotaksis

6.

Lisozim Khasiat : bakteriolitik antiviral

Imunitas selular Makrofag ( 90 % ) dan limfosit ( 10 % ) Hormon dalam ASI 15 macam hormon ( Roberts, 1989 )

7.

8.

9.

Laktoperoksidase antibakteri Streptokokus

Manajemen Laktasi
Adalah upaya-upaya yang dilakukan pada periode kehamilan ( antenatal ), periode segera setelah lahir ( perinatal ) dan periode selama menyusui ( pascanatal ) untuk menunjang keberhasilan menyusui.

ANTENATAL Periode kehamilan

a. b.

Mental Fisik

Gizi Ibu Persiapan Payudara sejak hamil 6 bulan

Fisiologi Laktasi
Refleks pada ibu a. Refleks Prolaktin b. Refleks Aliran Refleks pada bayi a. Rooting reflex b. Refleks mengisap c. Refleks menelan

Proses Laktasi
Isapan / menyusu Stimulasi syaraf sensoris puting susu Syaraf sensoris afferent Sistem saraf pusat hipotalamus Pars anterior hipofise prolaktin Aliran darah Kelj sekretori epitel Produksi susu Pars posterior hipofise Oksitosin Aliran darah Sel mioepitel Let-down reflex ( Applebaum, 1975 )

PERINATAL Saat lahir

a. b. c. d. e.

Tanpa pemberian susu formula prelakteal, air gula atau madu Inisiasi Laktasi : Segera disusukan setelah lahir Rawat Gabung Tidak memberi dot Susui bayi dari kedua payudara secara bergantian

PASCANATAL
a. b. c.

d.
e.

Perhatikan teknik/cara menyusui yang baik dan benar MP-ASI setelah bayi umur 4 bulan Konsultasi ke klinik laktasi Berikan ASI sampai umur 2 tahun Menyapih secara bertahap

The Remarkable First Hour of Life

When healthy infants are placed skin-to-skin on their mothers abdomen and chest immediately after birth, they exhibit remarkable capabilities. They are alert. They can crawl, stimulated by mothers gentle touch, across her abdomen, reaching her breast. They begin to touch and massage the breast finally, he or she attaches to the breast and first feeds.
22

1. Sensory inputs
1.1. Olfactory Babies preferred their mothers unwashed breast to her washed breast, soon after birth. (Varendi et al, 1994). Besides secreting milk and colostrum, the nipple and areola are dense in glands that perhaps secrete attractive odors. (Makin and Porter, 1999). 1.2. Visual Illingworth (1987) stating that a newborn baby shows more interest in a black and white pattern than in a blank grey card. Newborns can recognize their mothers face (Bushnell et al, 1989) and can follow it for a short distance (Brazelton and Cramer, 1199)
23

1.3. Taste Amniotic fluid on the infants hands probably also explains part of the interest in suckling the hands and fingers. The baby uses the taste and smell of amniotic fluid on its hands to make a connection with a certain lipid substance on the nipple related to the amniotic fluid (Klaus and Kennel, 2001). 1.4. Auditory Newborn infants prefer the sound of the maternal voice and also suckle for longer when they hear it (DeCasper and Fifer, 1980; Fifer and Moon, 1994). They can discriminate the language heard in utero from another language (Mehler et al, 1988) The rhythmic sound of the mothers heart-beat can also have a calming influence on the baby. (Salk L, 1960; Salk L, 1962).

24

1.5. Touch
Skin to skin touch provides heat and variety of other tactile impuls Helps maintain temperature (Christensson et al, 1992) Facilitates metabolic adaptations especially sugar levels and acid-base balance (Christensson et al, 1992) Results in less crying (Christensson et al, 1992; Christensson et al, 1995) Facilitates bonding (Widstrm et al, 1990) Causes oxytocin release in the mother Improves immediate and long term breastfeeding success: (Righard and Alade, 1990; WHO, 1998; DeChateau and Wiberg, 1977)

25

2. Central component
The newborns brain is optimally ready to integrate various sensory inputs and other components of the breast crawl soon after birth. Widstrm et al (1987) recorded a state of wakefulness during the Breast Crawl according to Brazeltons Neonatal Behavior Assessment Scale (BNBAS). At 15 minutes, the childrens median state was 4. Alertness gradually decreased until 150 minutes after birth, when they were all asleep.

26

3. Motor outputs :
3.1. Orofacial Around 30-40 minutes after birth, the newborn begins making mouthing movements, sometimes with lip smacking. Suckling of hands and fingers is commonly seen. After attaching successfully, newborns continued to suckle for 20 minutes (Righard and Alade, 1990).

27

3.2. Lower & Upper limb

The Stepping Reflex helps the newborn to push against her mothers abdomen to propel her towards the breast. Pressure from the infants feet on the abdomen may also help to expel placenta and reduce uterine bleeding (Klaus and Kennel, 2001).

28

The ability to move its hand in a reaching motion enables the baby to claim the nipple. This helps to stimulate, elongate and protract the nipple (Klaus and Kennel, 2001). When the baby massages the breast and subsequently suckles, a large oxytocin surge is induced from the mothers pituitary gland into her bloodstream. This also
helps in the manufacture of prolactin.

29

3.4. Neuro-endocrine component Oxytocin - Induce uterine contraction - Helps expel placenta - Prevents excessive bleeding - Helps mold maternal behavior Causes the mother to feel relaxed, calmer, sedated - Stimulates the release of GI hormones - Increase skin temperature (flushing) Prolactin - The milk-making hormone - Mothering hormone
30

Infants massage of mothers breast ........... Fingers sucking Breast sucking Maternal oxytocin (Log conc)

Oxytocin level in a mother in relation to the infants massage like hand movements on mothers

Mattthiesen A, Arvidson A, Nissen A, Moberg K. Postpartum Maternal Oxytocin Release by Newborns: Effect of Infant Hand Massage and Sucking; 2001. Birth, 2001, 28.
31

D. ADVANTAGES OFFERED BY THE BREAST CRAWL

4.1. For the Baby 4.1.1. Warmth Compared temperatures of newborns kept in skin-to-skin contact in the Breast Crawl position with those kept in a cot in the first few hours after birth, the former had better body and skin temperatures. (Christensson et al, 1992)

32

Maternal and neonatal temperature changes from the moment of STS contact (time = 0) to 20 min after initiation of STS contact. The last measurement (marked X) was carried out 10 min after the newborn had been taken away from the STS position, wrapped in dry cloth. Bars above and below symbols indicate 95% confidence intervals

Bergstrom A, Okong P, Ransjo-Arvidson A-B; Immediate maternal thermal response to skin-to-skin care of newborn;2007
33

4.1.2. Comfort
Christensson et al (1992) compared crying between babies kept in the Breast Crawl position with those kept in a cot next to the mother during the first 90 minutes after birth. The infants in the cot cried for a significantly longer time than the babies in Breast Crawl position during all observation periods.

34

Crying duration at various time intervals

Group
At 25-30 mins

Time Interval
At 55-60 mins At 85-90 mins

Babies in skinto-skin contact (Breast Crawl) Babies in cot

60 sec

0 sec

10 sec

1094 sec

985 sec

760 sec

Christensson et al, 1992 35

4.1.3. Metabolic adaption

Babies kept in the Breast Crawl position had higher 90 minute blood sugar levels and more rapid recovery from transient acidosis at birth, as compared to babies separated and kept in a cot next to the mother (Christensson et al, 1992).

36

4.1.4. Quality of attachment

Compared kept in uninterrupted and interrupted STS contact for 1 hour, the former had better and attached corectly (Righard and Alade, 1990). These findings are crucial because the early suckling pattern is of prognostic value for the duration and success of breastfeeding

4.2. For the Mother

Expulsion of placenta and reduction of post partum haemorrhage

37

Duration of placental delivery of the earlybreastfeeding and control groups

Duration of placental delivery 5-10 min
11-20 min
a Significantly

Early-breastfeeding (n=36)
30 (83.3%)a 6 (16.7%)

Control (n=36)
15 (41.7%)a 21 (58.3%)

different from 11-20 min (p<0.05)

Bilgik D, Guler H, Cetin A, 2004 38

Duration of placental delivery from the beginning of early breastfeeding

Duration of placental delivery

5-10 min
Duration of early-breastfeeding 2-9 min

11-20 min

25 (92.6%)a

2 (7.4%) 4 (44.5%)

>10 min 5 (55.5%) a Significantly different from >10 min (p<0.05)

Bilgik D, Guler H, Cetin A, 2004

39

E. HINDERING FACTORS

Separation on the Breast Crawl Drugs Routinely procedures directly after delivery - Suctioning - Weighing - Bathing - Wrapping - Vitamin K injection - Eye treatments

40

Penyimpanan ASI
Suhu ruang: 770 F / 250 C: 6 sampai 8 jam
1000 F / 380 C: tidak aman

Wadah terinsulasi dengan ice pack: 24 jam

Lemari pendingin 390 F / 40 C 24 - 48 jam (sampai dengan 5 hari?)

Penyimpanan ASI
Lemari es/freezer dengan pintu terpisah: 00 F / -180 C : 3 sampai 6 bulan Freezer di dalam lemari pendingin: 50 F / -150 C : 2 minggu saja

Freezer ekstra dingin yang sering dibuka: -40 F / -200 C : 6 sampai 12 bulan

Mencairkan ASI

Cairkan ASI beku dengan slow defrost selama satu malam dalam lemari pendingin. Rendam susu dalam mangkuk berisi air suam kuku hingga hangat. Panas berlebihan akan memodifikasi atau menghancurkan enzim dan protein. Cairkan keseluruhan ASI dalam wadah karena lemaknya terpisah selama proses pembekuan. Jangan pernah menggunakan microwave untuk mencairkan atau menghangatkan ASI. Setelah dicairkan, ASI harus digunakan dalam waktu 24 jam.

44

50

51

52