full breastfeeding infants feces was higher than mixed feeding infants.
Keywords: Secretory Immunoglobulin A, Full Breastfeeding, Mixed Feeding
Affiliasi penulis : 1. Poltekkes Kemenkes Kalimantan Timur, 2. Bagian Obstetri Ginekologi RSUP Mdjamil Padang, 3. Bagian Perinatologi RSUP Mdjamil Padang
Korespondensi Nursyahid Siregar,
Email:
[email protected] Telp: 085261492244
PENDAHULUAN
Neonatal Mortality Rate (AKN) 2010 in Indonesia reached 19 per 1,000 births. These numbers were the same as in 2007 and only 1 point decline compared to Demographic and Health Survey Indonesia (SDKI) in 2002-2003, which was 20 per 1,000 births. The concern to reduce neonatal mortality (0-28 days) becomes important because it had a contribution to the 59% of infant mortality1. Based on the SDKI in 2012, the highest proportion of the death cause of infants aged 0-12 months was diarrhea with 42%, followed by pneumonia with 24, meningitis/encephalitis 9%, digestive tract disorders 7%, heart abnormalities and hydrocephalus 6%, sepsis 4%, tetanus 3%, and others (malnutrition, TB, measles) by 5%2.
Newborn babies have immature and inadequate immune systems at the time of birth. The human immune system begin to form and develope during the fetus period. The baby's immune system develops during at least the first 2 years of life. Overall, the baby has a limited capability to respond effectively and quickly to the microorganisms and that cause the baby continuously vulnerable to infections 3.
sIgA intestinal mucosa was important in the early life to eliminate pathogens and the development of oral tolerance againstcommensal bacteria in the gut. Although the IgA can be detected in feces of infantsbreastmilkin the first few weeks of life, the baby's ability to produce IgA during this period are still limited. Passive immunity is provided for infants by the IgA and other antimicrobial peptides in breastmilk, especially colostrum. Breastmilk also provides a source of living bacteria that helps in the formation of early intestinal microbiota. There is a mutual relationship between the intestinal IgA and commensal intestinal bacteria because the microbial exposure stimulates the production of IgA in infants and in turn the IgA plays a role to control the composition of the infant microbiota. The production of IgA in infants who was given the formula milk was slower and have lower levels in the first year of life4.
The benefits of breastmilk for neonates showed in baby's immunity. The Nurmiati and Besral5 study find the fact that the duration of breast feeding greatly affects the survival rate of infants in Indonesia. The baby who have breastfeeding within six months duration or more have survival rate 33.3 times better than infants who are breastfed less than 4 months, and babies who are breastfed for 4-5 month has survivability 2.6 times better than the babies who are breastfed less than 4 months after controlled by the number of toddlers in the family and the place to live. The results of Jafarzadeh6 study showed that the children who were given breastmilk had the levels of IgA saliva significantly higher than children who were given formula milk. The study of Bridgman7 showed that there was a relation between the levels of fecal IgA of infant within 4 months after birth with the breastfeeding status, IgA levels rise with exclusive breast feeding. Also, according to IDAI8 breastmilk contains different anti substance cellular or humoral, so neonatal who were given breastmilk have lower mortality and morbidity than the neonatal who were given formula milk.
Based on West Sumatera Health Profile in 2014 9, the rate of exclusive breastfeeding was 62.6%, and was higher than national (54.3%) and global rate (39%). However, we still need more effort to reach the target rate for exclusive breastfeeding, that is 80%. Based on Padang public health office report in 2015, Koto Tangah and Kuranji are two districts with the highest rate of exclusive breastfeeding and highest incidence of diarrhea. In koto tangah, exclusive breastfeeding rate was 69.58% and diarrhea incidence was 766 cases. While in Kuranji, exclusive breastfeeding rate was 75% and diarrhea incidence was 389 cases.
High rate of gastrointestinal infection, caused by neonate's gastrointestinal immaturity, high rate of consuming formula milk, or both, is a health problem that the solution must be found immediately. This study aims to investigate the difference of immunoglobulin A secretory level between neonate's fecal who received exclusive breastfeeding and who did not receive exclusive breastfeeding.
METODE
This is an observational cross-sectional study with Pretest dan Post-test Control Group Design. The study sample is neonates aged 0 to 28 days who received exclusive breastfeeding and did not receive it in the working area of Koto Tangah and Kuranji Community Health Centre. The amount of the sample was 38, consist of 19 neonates who received exclusive breastfeeding and 19 neonates who did not receive it. Sample was collected using consecutive sampling technique. Instrument used in this study is questionnaire and ELISA. 100 mg Neonates fecal was collected and put into a sterile bottle, and then carried to Biomedical Laboratory, Medical Faculty Andalas University to be saved at -800C until total sample was fulfilled. The data obtained was analyzed using independent t-test.
HASIL
This study conducted in the region of Health Care Anak Air, Health Care Ikur Koto, Health Care Belimbing, and Health Care Ambacang from December 2016 until January 2017. The study was done to 38 neonates that meet the inclusion and exclusion criteria.
The Characteristics Of The Subject
Table 1. The Characteristics Of The Subject
Characteristics Full Breastfeeding
n=19 Mixed Feeding
n=19 n(%) Mean(SD n(%) Mean(SD Sex
Man
Women
10(52,6)
9(47,4)
6(31,6)
13(68,4) Birth weight
(gram) 3305(363 3126(369 Based on the table there are no statistical differences between gender and birth weight of neonates who full breastfeeding and mixed feeding.
The difference secretory Immunoglobulin A between feces sample of full breastfeeding and Mixed feeding infant feces
Table 2. secretory Immunoglobulin A between feces sample of full breastfeeding and Mixed feeding infant feces
Kelompok P Full
Breastfeeding
n=19
Mean(SD Mixed Feeding
n=19
Mean(SD sIgA age 0 day (ug/ml) 0,854(0,193 0,928(0,226 p=0,141 sIgA age 28 days (ug/ml) 0,783(0,154 0,383(0,209 p=0,000 Delta sIgA (ug/ml) -0,071(0,171 -0,545(0,261 p=0,000 There was no difference in average levels of fecal sIgA age 0 day between infant who got breastmilk and formula with p-value 0.05. There is a difference in average levels of fecal sIgA in age 28 days between infant who got full breastfeeding and mixed feeding with p-value 0.05. There is a difference in average delta levels of fecal sIgA between both groups with the p value 0.05.
DISCUSSION
The difference secretory Immunoglobulin A age 0 day between feces sample of full breastfeeding and Mixed feeding infant feces
Based on the statistical tests the p-value = 0.141. This means that there is no meaningful difference in the levels of fecal secretory immunoglobulin A between the neonates who received only breastmilk and the one who had not breastmilk only.
There is no difference in the level of sIgA in both groups because the neonatal stool at age 0 day taken after the baby gets the intake of breastmilk only or a mixture of breastmilk and formula. At the age of 0 day the neonatal was yet to produce the immune system itself, so the all components of immune system in neonates was received from mothers. After birth the neonates got the breastmilk which contained complete antibodies, so there is no difference in the levels of sIgA age 0 days because the neonates hasn't been able to produce endogen sIgA and the only sIgA source was breastmilk 8.
The breastmilk sIgA role in the early stages of life was in the maturing process of the digestive tract epithelium. The commensal bacteria associated directly with the GALT development such as lymphoid follicles or secretion of sIgA with unknown specification called natural sIgA. The existence of sIgA can initiate colonization of microbiota and allows the development of the immune system in a non-inflammatory conditions. In normal conditions the commensal bacteria can be recognized by TLR, the interaction seems to be important to maintain the intestinal epithelium homeostasis 8.
Breast milk contains epithelial growth factor that stimulates the maturation of gastrointestinal barrier so it can inhibit the penetration of microorganisms as well as macromolecules. Breastmilk stimulates the mucosal immune system to produce secretory IgA, which is a marker for the maturation of the immune system and may provide protection against environmental antigens. TGF-β induced over the isotope IgA and is found in breast milk. TGF-β in breast milk stimulates the production of IgA in infant 8.10.
The difference secretory Immunoglobulin A age 28 days between feces sample of full breastfeeding and Mixed feeding infant feces
The results of the statistical tests obtained the p-value = 0.000. This means that there was a meaningful difference of fecal secretory immunoglobulin A levels between the neonates who received full breastmilk or mixture breastmilk. The level of fecal sIgA in neonates who received full breastmilk was higher compared to neonates who got the mixture breastmilk.
The babies who got the breastmilk has more secretory immunoglobulin A levels than the babies who got the formula milk because the fecal secretory immunoglobulin A was influenced by the composition of breastmilk which is rich in secretory immunoglobulin A, the growth factors and the bifidogenic factors such as oligosakarida. During the 28 days the Epidermal Growth Factor (EGF) can improve the maturation of gastrointestinal barriers to prevent the penetration of pathogenic agent to the intestinal mucosal epithelium. Bifidogenic factors can increase local commensal bacteria colonization which is useful for the maturation of neonatal immune system. Also, there is already a sIgA in breastmilk that can improve the intestinal mucosa's immune system. That caused the difference between the sIgA levels of baby who got full breastmilk and mixed breastmilk. Immunoglobulin in breast milk cannot be imitated by formula milk. Breastmilk contained molecules with the antimicrobial activity and also the probiotic bacteria Lactobacillus gasseri and Lactobacillus fermentum 8.11.
This study is in line with a study conducted to baby aged under 2 months, which the result of the study showed that fecal sIgA level in exclusive breastfeeding group is significantly higher than formula milk-feeding group.12
There is difference of baby's fecal sIgA level in both groups caused by the decreasing of breastfeeding practice in mix-feeding group, led to decreasing of breastmilk intake which is rich of immunoglobulin A secretory. Mix-feeding group who received formula milk had risk to exposed by pathogen bacteria which could affect baby mucosal immunity. A study by Cooke el al.,13 in sample aged 0-5 days and 5 weeks, showed that in baby aged 6 weeks, Escherichia coli bacteria was more common to find in baby who consumed formula milk (p = 0.042), while Bifidobacterium was more common to find in GI tract of breastfeeding baby.
Breast milk provides living bacteria sources which could help forming intestinal microbiota at early stage. There is mutualism relationship between intestinal IgA and commensal intestine bacteria, that is microbe exposure could stimulate IgA production on babies, and subsequently IgA will regulate the composition of baby microbiota. The production of IgA on formula milk-fed baby is slower and has lower level in first year of life.4,7 Exclusive breastfeeding group had higher fecal sIgA level because baby just received breast milk without other complementary food/drink. In other hand, breast milk sIgA could also stimulate neonates immune system.
The difference delta secretory Immunoglobulin A between feces sample of full breastfeeding and Mixed feeding infant feces
Based on statistical analysis, we got p-value = 0.000. It means there is significant difference of the delta of immunoglobulin A secretory level between breastfeeding neonates feces and mix feeding neonates feces. The delta of sIgA level in breastfeeding neonates feces is higher tan sIgA level in mix-feeding neonates.
Delta of fecal sIgA in both groups were negative that showed there were the decrease of fecal sIgA level. The decrease of fecal sIgA level on exclusive breastfeeding group was lower than mix-feeding group. This decrease was due to the amount of sIgA id different in every lactational stage. In colostrums breast milk, the amount of sIgA was 335,9 mg/100ml, while in transitional breast milk, sIgA was not found, and in mature breast milk, sIgA level decreased into 119.6 mg/100ml.11
Delta of neonates fecal sIgA level who received who received exclusive breast milk was higher than sIgA level of mix-feeding neonates because the primary source of sIgA for neonates is breast milk sIgA. The factors affecting baby's intestinal mucosal immune system are nutrition, microbe, and maternal immunity. The exposure of breast and formula milk during neonatal ages will affect sIgA level. Exclusive breastfeeding neonates will receive more breast milk sIgA compared to mix-fed neonates. Intestinal microbiota can ferment carbohydrates, so that it will produce lactate acid that will led the intestinal PH became more acid. The acid environment formed was the signal to produce baby mucosal sIgA.4,8
This study is in line with a study conducted by Bridgman et al7, which showed that there was correlation between fecal IgA level of babies aged 4 months, breastfeeding status, and exposure of before/after birth. Babies who received breast milk and newborn babies have higher average of fecal IgA level (23,11 ( 9,34 μg/g and 22,19(8.23 ug/g, P = 0,04).
The same result was also found by Man-Chin et al15 who performed fecal sIgA level examination for babies who received breast milk and who received formula milk at the age 5 days, 2 months, and 4 months. Breastfeeding babies had significantly higher fecal sIgA level compared to babies who received formula milk (P 0.05). Fecal sIgA level decreased at the age of 5 days to 2 months, and then increased at the age of 4 months. The increasing at the age of 4 months showed that babies have already had the ability to produce sIgA endogenly. Breast milk composition changes and varies among mothers.16 Colostrums breast milk is rich of immunology component and growth factor. Colostrums can affect development and maturity of baby's mucosal immune system. Generally, breast milk gives protection from infection.
Intestinal sIgA secretion does not occur during neonatal ages, but starting to increase at the age of 4 to 12 months.3IgA secretory is an important component in mucosal immune response which protecting intestinal tract form infection. There are several factors affecting baby's intestine mucosal system, include nutrition, microbe, and maternal immunity. Baby's immune system is very dependent to maternal factors. After birth, babies receive IgA from colostrums breast milk, so breast milk immunity factor can directly act at the surface of baby's intestinal mucosa. Exposure of mother's commensal bacteria antigene to newborn babies is transfer aspect of mother's immunity system to the babies. This exposure can occur through genitalia tract during vaginal delivery and during skin contact between mothers and babies (mainly when breastfeeding). These factors are expected to affect the development of baby's microbiome and change baby's intestine mucosal immunity system.4
Babies who already received breast milk have higher fecal IgA level. There is correlation between exclusive breastfeeding and baby's fecal sIgA level, so that sIgA level of breastfeeding babies are different to babies who received formula milk. Higher fecal sIgA level is followed by increasing of breastfeeding babies amount, because breast milk is the primary source of IgA for babies during several first months.8,11
Acknowledgments
Thanks to all concerned for guidance and assistance so that this study can be completed.
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Research Articles
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2017; 3(1)
