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Kangaroo Mother Care Method

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Title: Kangaroo Mother Care Method


1
Kangaroo Mother Care Method
  • Feeding strategies for preterm and Low birth
    infants
  • Module 3

2
Table of contents
  1. Introduction and goal of the KMC feeding strategy
  2. Suction in newborns
  3. Breastfeeding preterm infants
  4. Adaptation to the KMC feeding strategy
  5. Feeding modes in preterm infants
  6. Feeding preterm infants from the breast
  7. Alternative feeding methods
  8. Stimulation of feeding in preterm infants
  9. Milk extraction
  10. Maternal difficulties to breastfeed
  11. Problems with insufficient milk production
  12. Transition from hospital to home after discharge
  13. Preterm infant formula

3
KMC Components
  • 1st Kangaroo position
  • The infant is placed almost naked in strict
    upright ventral position between the mothers
    breast, in direct contact with her skin, as long
    as possible
  • 2nd Kangaroo Feeding and Nutrition strategy
  • Ideally exclusive breastfeeding to have a weight
    gain similar to the growth during the intra
    uterine life ( 15 g/Kg/day )until full term
  • 3rd Early Discharge and strict ambulatory
    follow up
  • Discharge in kangaroo position regardless of
    weight and gestational age when the child is
    able to coordinate sucking, swallowing and
    breathing , gaining weight for 3 days and have
    parents informed , trained and ready to come to
    follow up visits

4
Introduction
  • The kangaroo nutrition strategy is intended for
    children who are in the stable growth period,
    after the transition period until the infant
    reaches full term
  • This period is considered similar to the period
    of intra uterine growth which may have occurred
    if the infant was not born prematurely
  • Children during this period face a double
    challenge having to grow at the rate they would
    have grown while still in utero, and to recover
    from the deficits accumulated during the
    transition period
  • KMC feeding strategy focusses on successful
    breastfeeding

5
Breast milk is the must
  • Human milk is species-specific ,and all
    substitute feeding preparations differ markedly
    from it, making human milk uniquely superior from
    infant feeding.
  • Exclusive breastfeeding is the reference or
    normative model against which all alternative
    feeding methods must be measured with regard to
    growth, health , development , and all short and
    and long terms outcomes.
  • In addition, human milk-fed preterm infants
    receive significant benefits with respect to
    protection and improved development outcomes
    compared with formula fed preterm infants

6
Goals for the KMC Nutrition
  • Obtain adequate growth and short term nutrient
    retention, which allow the preterm infant to come
    close to the intra uterine growth charts and to
    the fetal composition of reference
  • Decrease neonatal morbidity by improving food
    tolerance reduce the incidence of necrotizing
    enterocolitis (NEC) and minimize nosocomial
    infection
  • Achieve a nutrition that contributes to optimal
    short and long term neurological development
  • Reduce atopy and allergy index
  • Decrease the potential risk of hypertension,
    cardiovascular disease and hypercholesterolemia
    in adulthood
  •  For the preterm infant, milk from the infants
    own mother is the must and will be used
    whenever possible the mothers milk is always
    supplemented with A, D, E and K vitamins up to
    term. Mother milk may be also fortified and
    supplemented whenever it may be necessary

7
Nutrition goal to the KMC method
  • Obtain adequate growth and short term nutrient
    retention, which allow the preterm infant to come
    close to the intra uterine growth charts and to
    the fetal composition of reference
  • The goal is to reach a weight gain similar to the
    usual growth during the intra uterine life 15
    g/kg/ day until full term 
  • If this goal is not reached through exclusive
    breast feeding it is necessary to identify and to
    correct conditions which may explain inadequate
    weight gain
  •  Once the abnormal condition is corrected, growth
    must improve. If not, or if there was no any
    secondary cause for inadequate growth, breast
    milk should be fortified or supplemented with
    special preterm formula

8
Nutritional Supplements
  • Kangaroo children who are not getting weight
    being fed by breast milk with or without hind
    milk and who do not present any pathologies, may
    receive a supplement, for a limited period of
    time in order to avoid losing the initial growth
    potential and preventing them to become
    malnourished
  • Supplement starts with 25 to 30 of the daily
    quantity, based on 180 to 200 ml /kg/day
  • The mother must give the supplement using a
    syringe, a cup or a dropper but not a baby bottle
    and always before nursing the infant, so that the
    baby only takes what he needs from the breast

9
Suction in Newborns
  • The tongue fills the oral cavity and protrudes
    outside the mouth in response to the rooting
    reflex, it goes beyond the limit of the gums,
    envelops the nipple-areola complex, compressing
    it against the hard palate and making an
    undulating back and forth movement tongue
    slither which generates positive pressure
  • Lips have a sealing function generating negative
    pressure during suction by being everted and
    well adapted to the mothers breast, they provide
    a hermetic seal
  • Eminences in the inner side of the lips have an
    anti-slid function
  • Bichats fat pads in the cheeks, prevent them to
    collapse due to negative pressure
  • The nipple is elongated to allow the ejected milk
    to flow laterally to the air way on a zone called
    comfort zone, in the union of soft and hard
    palate

10
Feeding Reflexes (1)
  • Fetus in utero sucks and swallows amniotic fluid
  • The rooting reflex explored by rubbing, stroking
    or touching the corner of the mouth
  • The infant turn his lips, head and open his
    mouth to follow and "root" in the direction of
    the stimulus
  • This helps the infant to find the breast opening
    widely the mouth allowing a correct attachment
  • It is present from week 32 of gestation.
  • The suction reflex is assessed by placing a
    finger inside the infants mouth
  • The infant begins to suck placing his tongue
    under the finger and applying pressure against
    the palate
  • The sucking reflex appears and develops in
    parallel with the rooting reflex.
  • The suckling reflex creates negative pressure
    which associated to the positive pressure of the
    palate allows suction, swallowing and breathing.

11
Feeding Reflexes (2)
  • The swallowing reflex is visualized by the
    movements of the larynx
  • It refers to the set of actions allowing the
    passage of solid or liquid from the mouth to the
    stomach
  • It appears from week 16 of gestation
  • Non-nutritive suction (NNS) as stimulation is
    recommended to develop suction reflexes
  • At 34 weeks of gestational age, the
    suction/breathing pattern approximates 11

12
Suction Disorders in Preterm Infants  
  • Oral motor dysfunction (OMD) is the alteration
    of the infant' capacity to attach himself to the
    breast it can be primary or secondary and may
    generate functional and anatomical distortions
  •  Primary OMD due to transitory or permanent
    neurological problems or to anatomical
    abnormalities
  • Hypertonicity when suckling , the infant bites
    the nipple
  • massaging the babys gums before nursing, and
    straddling him on the mothers lap while
    breastfeeding are recommended
  • Hypotonicity infants with low vitality falling
    asleep while nursing
  • The dancer hand position and milk extraction
    are recommended
  • Secondary OMD occur when original sucking and
    swallowing reflexes are modified due to use of
    artificial teats or bottles
  • This causes pain for the mother and inhibiting
    the let-down reflex making milk extraction
    difficult.
  • It can be corrected by massaging the childs
    mouth with the finger pad, applying pressure on
    his tongue and gradually withdrawing the finger

13
Prerequisites to Adaptation to the KMC Nutrition
  • The kangaroo adaptation to the nutrition of a
    preterm infant is a process of social and
    physical adjustment for the mother and family to
    the Kangaroo Mother Care Method
  • It is done through an education process with
    social and emotional support
  • It is vital for the success of the kangaroo
    nutrition
  • Existing open door policy for parent to stay with
    their child
  • The mother should be recognized as the babys
    primary care provider
  • her stay next to her child should be done
    comfortable
  • The health team is a central person to advocate
    and promote satisfactory breastfeeding
  • The support given during the breastfeeding period
    should
  • Develop the mothers confidence ,paying attention
    to the mothers problems,
  • Provide precise and practical information about
    the childs needs
  • Offer options and allow the mother to make
    decisions
  • Give timely pertinent information on technical
    and scientific content

14
Breastfeeding preterm infants
  • The American Academy of Pediatrics recommended
    officially since 2005 administering breast milk
    from the babies own mothers, to preterm and
    other high-risk babies
  • Since then, breastfeeding has been the
    recommended mode of enteral nutrition for preterm
    and LBW infants
  • Breast milk has digestive enzymes, direct
    immune protective, immunomodulation, antioxidant
    and anti-inflammatory factors, hormones bioactive
    factors and multiple cellular elements
  • Breast milk allows a better cognitive ability
    development, better neurobehavioral organization
    and decrease infection
  •  Benefits of breast milk are recognized but it is
    still difficult to establish successful
    breastfeeding in Neonatal Units due to
  • the fragility of preterm babies and their
    illnesses
  • their different nutritional needs , the
    complexity of their care
  • Infant- mother separation and mother anxiety
    jeopardizing regular milk production
  • No open door policy allowing parents to stay with
    children
  • Fixed schedules for feeding
  •  

15
Characteristics of preterm breast milk
  • The Colostrum is produced during the first 3 - 4
    days of life
  • It is a thick, yellowish liquid of high density
  • From birth to day 3, the volume is from 2 to 20
    ml per feeding
  • It contains less lactose, fat and water soluble
    vitamins than mature milk but more protein, E, A
    and K vitamins carotene and zinc
  • Preterm colostrum contains more immunoglobulin A,
    lysozyme, lactoferrin and cells
  • Mature milk The mature milk not only vary from
    woman to woman but also from one breast to the
    other, from one nursing to the next and, varies
    also during the same feeding. The hind milk is
    richer in fat
  • The preterm mothers milk contains 2 time more
    proteins, more sodium , it provides important
    amounts of taurine, glycine, leucine and
    cysteine, more fat , more calories and more
    calcium and phosphorus
  • Only during the first 4 weeks after birth ,
    mothers of preterm babies produce milk with a
    special composition that adapts to the estimated
    nutritional requirements of their children

16
Feeding modes for preterm infants
  • Feeding based on maternal milk from his own
    mother plus vitamins A,D,E and K
  • Exclusive, with no fortifiers or supplements
  • Fortified (fortifiers added to extracted milk)
  • Supplemented with artificial milk for preterm
    infants
  • Supplemented with fortified and pasteurized human
    milk from a donor (preterm or full term)
  • Feeding based on artificial formula for preterm
    infants
  • Exclusive or supplementary use of other forms or
    oral or enteral nutrition protein hydrolysats,
    element and semi-element preparations
  • For infants less than 1500g or born before 32
    weeks GA breastfeeding is probably not sufficient
    to cover the calcium, phosphorus and
    occasionally, protein requirements and milk must
    be fortified with these elements  

17
Feeding on schedule preterm infants
  • Preterm babies do not demand to be fed until they
    reach full term nursing must be done on a
    schedule rather than on demand
  • Infants weighing less than 2000 g or less than
    37 weeks of GA, need short intervals between
    feedings in order to receive enough nutrients and
    to allow for adequate thermoregulation, growth
    and development
  • Feeding intervals must be approximately every 1
    hour and ½ during the day and 2 hours during the
    night
  • Controlling the frequency of feedings is useful
  • Decrease energy loss by suction
  • Provide the needed nutrients in sufficient
    quantities
  • Create a routine for mother and child
    strengthening their bond
  • Give the mother a clear timeline.

18
Breastfeeding a preterm infant (1)
  • The transfer of maternal milk to the infant
    depends of the interaction between the volume of
    breast milk, the let-down reflex and the preterm
    infants suction
  • Check signs of readiness for breastfeeding
  • Gestational age ?32 weeks
  • Baby able to coordinate breathing, sucking and
    swallowing
  • Babys health is clinically stable (no serious
    breathing problems)
  • Baby can suckle with rare episodes of apnoea and
    bradycardia
  • Apparent signs of being alert/ready to attach
  • Breastfeeding a small baby requires patience and
    dedication because he/she
  • Suckles for a short time then rests
  • Can fall asleep while breastfeeding
  • Can take frequent pauses making breastfeeding
    longer
  • Is not always awake for breastfeeding

WHO EURO, 2002
19
Breastfeeding a preterm infant (2)
  • Reassure the mother that she is able to feed her
    baby
  • Train the mother to watch the baby completes at
    least 6 suctions, alternated with pauses to
    breathe
  • The weight test can be used to determine the
    volume of ingested breast milk, but it may stress
    the mother, daily weight is enough
  • Actively counsel her to
  • Feed the baby every 1½ -2 hours
  • Wake the baby up for feeding
  • Keep the baby at the breast longer
  • Let the baby takes long pauses and breastfeed
    more slowly
  • Do not interrupt breastfeeding if the baby is
    still trying to suckle
  • Express some milk before the baby attaches if
    milk flow needs to be reinforced
  • Breastfeed the baby with hind milk if the baby
    does not gain weight

WHO, 2003
20
Oral breastfeeding through suction -1
  • Skin-to-skin contact has a positive effect on
    milk production, even before suckling begins
  • Putting children to the breast for the non
    nutritive suction, increases the rooting response
    and stimulates the suckling functions
  • Direct oral breastfeeding
  • Promote the milk let-down reflex by a gentle
    massage of the breast
  • Awake the baby and placed him in a recommended
    nursing position
  • The mother must surround the base of her breast
    with 4 of the 5 fingers and place the 5th finger
    on the edge of the areola forming the letter C
  • The mother must hold the childs neck base to
    control it and to bring the baby close to the
    breast, offering him a secure position and orient
    the nipple in the direction of the childs nose
    , stimulating the rooting reflex
  • When the baby naturally tilts his head back and
    opens his mouth wide, the mother must bring him
    to the breast in one single swift and gentle
    motion of her hand or arm

21
Oral breastfeeding through suction -2
  • The babys lower lip must be turned outward, the
    tip of his nose near the mothers breast, his
    chin touching it. The child will be able to
    breathe effortlessly.
  • Nursing must not cause pain
  • The newborn will begin suckling, according to his
    maturity, from 5 to 15 successive suctions,
    followed by a breathing pause as long as the
    suckling period, and then resuming the activity
  • 10 minutes after beginning nursing, it is
    possible for the child to fall asleep or to slow
    down the suckling rate.
  • Once the baby is awake, he can settle again to
    resume nursing or to make sure he is satisfied

22
Breastfeeding Techniques
  • The breastfeeding technique is a
    procedure by which suckling is carried out
  • The mothers position
  • The mother can nurse sitting or lying down
  • The mother should be in a comfortable and
    relaxed position able to hold the baby close to
    her without undue effort, her feed be supported
  • Check the infants position
  • The babys head and body must be perfectly line
    up
  • The babys face must face the mothers chest,
    with his nose in front of the nipple
  • The babys body must be close to the mothers ,
    turned towards her
  • If the baby is newly born, the mother must cradle
    him with one arm and give support to the
    buttocks, not just to the head and shoulders
  • Check the Infant attachment to the breast
  • The mouth is wide open
  • The chin touches the breast (or close to)
  • The lower lip turn outwards
  • More areola is visible above the infant top lip

23
Nursing Positions for preterm infants -1
  • The preterm baby must be nursed in a position
    supporting his head and neck to prevent the
    obstruction of airway causing apnea and
    bradycardia during breastfeeding

Football or watermelon position The baby faces
the mother while his body is tucked under one of
her arm. The babys upper back rests on the
mothers forearm, while she holds his neck with
her hand. The babys hips rest against the back
of the chair or bed.
Crossed or inverse cradling position The hand
opposite the breast offered to the baby is placed
behind the babys head, in order to support and
guide it. The hand of the same side may support
the breast.
24
Nursing Positions for preterm infants -2
Modified football position. The baby sits facing
the mother, by her side, on the sofa or a pillow,
with his legs at his mothers side and his feet
at her back.
The dancer hand position. This is a technique
that supports the childs jaw in order to improve
the up and down excursions during suckling, made
difficult by hypotonia.
25
Alternative Feeding Methods
  • 1.Cup/spoon/syringe/dropper
  • Does not interfere with breastfeeding
  • Cup is easy to wash
  • Safe
  • Small baby gets the quantity she/he needs
  • Cup-feeding can complement breastfeeding if the
    baby is weak or tired

26
Alternative feeding techniques Cup-Feeding
Technique
  • Measure the quantity of milk needed into a cup
  • Hold the baby in semi-upright position
  • Touch the babys lips with the cup
  • Do not pour the milk into the babys mouth
  • Allow the baby to lap or sip the milk and swallow
    at own rate
  • The baby stops feeding when his/her mouth closes
    and doesnt show further interest in feeding

WHO EURO, 2002 BMJ, 2004
27
Gavage-Feeding Technique (1) Used to feed very
low-weight or sick baby
  • Tube insertion
  • Select a thin gastric tube
  • Measure the distance from the tip of nostril to
    the lower tip of the ear and from the ear to the
    stomach
  • Mark this distance on the tube
  • Insert the tube gently into the stomach through
    the nose
  • Check the correct position of the tube by
  • Aspirating some stomach content, or
  • Blowing air (1-2 ml) in the stomach and listening
    with stethoscope
  • Leave the tube in the stomach maximum 3 days

WHO, 2003
28
Gavage-Feeding Technique (2)
  • Use colostrum or expressed breast milk
  • During gavage feeding
  • Mother holds syringe 5-10 cm above baby milk
    runs down tube by gravity
  • Stimulate the babys suckling reflex and taste
  • Encourage mother-baby skin-to-skin contact
  • Feed slowly over 15-20 minutes
  • Intermittent feeding for at least 15-20 minutes
    is considered to be similar to physiological
    feeding
  • When it is possible, start cup-feeding
  • Continuous enteral milk infusion method requires
    constant monitoring of the babys tolerance

WHO, 2003 Premji S et al, 2004
29
Teach the Mother Colostrum/Milk Expression
Techniques
If the mother extracts manually her milk, it is
recommended to extract it 8 to 10 times a day
Mothers must extract their milk until it no
longer flows, usually after 10 or 15 min The last
drops have a high lipid concentration and may
significantly contribute to caloric intake
WHO EURO, 2002 BMJ , 2004
30
Hygiene for milk extraction
  • Breast milk is not sterile since it has its own
    micro flora
  • The mother must follow strict hygienic measures
  • Hand washing with soap and water and brush under
    the fingernail
  • Wash the milk container, with hot soapy water and
    rinse it with boiled water
  • The container must have a wide opening and a cap
  • it must be made of glass or hard polycarbonate
    suitable for food preservation
  • it must never be a polypropylene bag because of
    the risk of liberating toxic substances into the
    milk
  • Previous cleansing of the nipples is not
    necessary
  • It is also unnecessary to discard the first drops
    of milk
  • Recommend the mother not to talk during
    extraction and only touch the exterior of the
    containers and the breasts.

31
Manual milk extraction technique
  • a) Stimulating the let-down reflex The mother
    may stimulate gently the breast
  • She may roll it gently between thumb and index
    finger, or have a pleasant beverage , or might
    imagine herself as a fountain of milk
  • With practice, the mother gets used to stimulate
    the let-down reflex
  • b) Locating the milk ducts The mother is asked
    to gently feel her breast, 3-4 cm behind the
    nipple to find the milk ducts similar to a cord
    with knots or a string of peas
  • The mother must place her hand as to form the
    letter C, with her thumb over the milk ducts and
    the index in the opposite side
  •  c) Compression over the breast ducts The
    mother applies pressure on the milk ducts with
    her thumb and index finger. Then, she releases
    the nipple and repeats the motion of pressure and
    release until milk begins to drip
  • - When the milk flow diminishes, the thumb and
    index finger are moved around the areola towards
    another section and the pressure-release motion
    is repeated
  • - When the flow stops, the technique is
    repeated on the other breast

32
Mechanical milk extraction technique
  • A pump does not really pump, suction, or express
    milk from the breast
  • The negative pressure of the pump reduces the
    milks resistance to flow and allow the breast
    internal pressure to push milk outward
  • The milk let-down reflex produces an initial rise
    of the pressure inside the mammary gland, the
    periodic rise of the pressure in the ducts
    maintain a constant pressure gradient
  • Induce the let-down reflex before using the pump
  • Use only the necessary negative pressure to
    maintain the milk flow
  • Massage the breasts quadrants before and during
    extraction to increase the pressure inside the
    mammary gland
  • Take as long as necessary to avoid anxiety
  • Maintain an the pump adequately fixed to the
    breast
  • Avoid prolonged periods of continuous negative
    pressure
  • Suspend the extraction if the milk flow is
    minimal or if it stops

33
Preserving the extracted milk (1)
  • Consider 2 basic principles when storing and
    handling breast milk
  • 1.Breast milk is a live fluid it must be handled
    as if it was blood.
  • It must be packed in plastic or glass container
    to avoid contamination and to preserve its
    qualities.
  • The container must be clearly labeled, milk
    without proper labeling must never be
    administered
  • 2. All the milk to be given o a baby must be kept
    in the hospital under control
  • it is not recommended to receive milk stored
    outside of the hospital, as its quality is not
    guaranteed

34
Preserving the extracted milk (2)
  • Fresh milk
  • Colostrum at room temperature 27- 32º C( 80-90
    ºF) , 12 to 24 hours
  • Mature milk
  • - At 15º C (59ºF) 24 hours at 19-22º C (66
    -72 ºF) 10 hours 25º C (77 º F), 4 to 8 hours
    At 27- 32º C (80-90 ºF) 4 to 6 hours at
    0º C and 4ºC (32-39 º F) 5 to 8 days
  • Frozen milk ( - 18 º C 0 º F)
  • -In a freezer inside of a refrigerator 2 weeks
    in refrigerator with a freezer with a separate
    door 3 to 4 months in a separate freezer with
    a constant temperature of - 19ºC 6 months

35
Milk banks
  • When there is not enough milk for an infant from
    his own mother, milk from a donor is an excellent
    alternative
  • There are numerous milk banks in the world the
    majority of them directly linked to Neonatal
    Units.
  •  There are no international regulations but
    working guides edited by each different
    association of milk Banks
  • Safety and traceability systems have been
    established, just as strict as they are for blood
    banks
  • The milk should be safe and insure the best
    nutritional conditions
  • Milk is classified according to acidity and
    calories content
  • Pasteurization is individual, no pooling of
    different donors.
  • Comprehensive microbiologic control is performed
    only sterile milk is suitable for consumption
  • Selection criteria used for donors are similar to
    those used in blood banks
  • An extensive health survey and serology for HIV,
    hepatitis B and C and syphilis is conducted
  •  
  •  

36
Maternal difficulties to breastfeed-1
  • Nipple cracks
  • If the infant is not correctly attached to the
    breast, nipple cracks could occurs they are
    extremely painful and bleeding when feeding
  • If the crack is small or recent, it may resolve
    in 24 hours
  • By insuring an adequate attachment to the breast
  • By applying some breast milk on the areola and
    nipple, after each nursing, drying it with air
    blow dryer or exposing it to sunlight, for a few
    minutes.
  •  If the crack is extensive and deep, the mother
    must
  • Insure an adequate attachment trying different
    positions to find the less painful position and
    begin feeding from the least painful breast, a
    natural treatment based on calendula can be
    recommended
  • if there is excessive pain or bleeding worsen,
    extract the milk every 3 to 4 hours and give it
    to the baby with a cup or syringe for 24 to 48
    hours.

37
Maternal difficulties to breastfeed-2
  • Flat or inverted nipples
  • The most effective intervention is to stimulate
    and form the nipple just before nursing
  •  Massage a flat nipple or apply a cold compress
    to help the nipple come out
  • If inverted nipple teach the mother to form her
    nipple by placing her thumb 4 -5 cm behind her
    nipple and pushing backward, towards her chest
  • An extracting pump or a syringe with an inverted
    plunger might help evert the nipple before
    nursing.
  • Breast congestion or engorgement 3
    elements are involved
  • congestion and increased vascularization
  • accumulation of milk
  • edema secondary to swelling and obstruction of
    lymphatic drainage
  • Primary congestion The breasts are enlarged and
    hardened, but milk extraction is still possible.
    It is due to infrequent or insufficient nursing.
  • Secondary congestion The breasts are hard,
    painful, hot milk extraction is not possible.

38
Maternal difficulties to breastfeed-3
  • Breast congestion or engorgement
    Treatment
  • Apply clean, warm-water compresses to the breasts
    and gently massage in a circular movement, before
    nursing
  • Extract some milk before nursing to help the
    child to attach to the breast
  • Apply cold compresses or ice bag on the breasts,
    between feedings, to relieve pain
  • The mother needs to rest and must nurse more
    often from the congested breast.
  • Insure a correct breastfeeding technique
  • Use analgesics and relaxation techniques
  • A rather untraditional but effective approach is
    to use the warm blow hair dryer to soften the
    congested breasts at the beginning of nursing.

39
Insufficient milk production
  • Breast milk production is influenced by many
    factor including the frequency and intensity of
    infants suckling, especially during the
    immediate post-partum period

Causes of low milk production Causes of low milk production
Mother Child
Insecurity and lack of confidence of the mother. Breast surgery Additional milk formula in a bottle. Incorrect position of child at the breast.
The mother is using rubber nipples or nipple shields. Nipple confusion in the child
Use of contraceptives Decrease in extracted volume.
Nursing from only one side .
Shortened feedings Presence of drowsiness
Low frequency of feedings   Low weight gain. Strict feeding schedule (Every3 hours) as in many Neonatal Units.
Maternal tiredness or illness Total or partial absence of nursing.
Discontinued night feedings   Decrease in the daily volume due to lack of stimulation.
Cracks and pain while nursing  
40
Difficulties at discharge from hospital
  • At discharge from the hospital , sometimes
    advantages of exclusive breastfeeding may be
    misunderstood by parents or health staff
  • The mother may show resistance to breastfeeding
    asking questions Why I must try to breastfeed
    my child as he was bottle fed in hospital? Is
    my baby really getting all that he needs from my
    milk?
  • When babies were bottle fed in hospitals
  • When where may be not enough time to help the
    mother to nurse her baby
  • Several factors may cause resistance to
    breastfeeding but in case of breastfeeding
    failure, especially for preterm infants, the
    responsibility lies usually on the health
    professionals and on the restrictive schedules
    used in Neonatal Units contributing to the
    mothers inability or resistance to nurse

41
Preterm infant milk formula (PBF)-1
  • The right of every mother to breastfeed her baby
    and of every baby to receive breast milk is
    becoming widely recognized
  • There are 2 main factors harming natural
    breastfeeding
  • The 1st one is the promotion of breast milk
    formula made by manufacturers
  • The 2nd one has to do with the inability of the
    health professionals to defend, protect, support
    and understand the benefits of breastfeeding

42
Preterm infant milk formula (PBF) -2
  • Preterm milk formulas are developed with modified
    cows milk or based on soy proteins
  • The proteins of the cow's milk are one of the
    nutrients producing frequent food allergies when
    administered in the 1st year of life.
  • There are some indications to the use of preterm
    baby formulas
  • The mother is disabled oncological cases,
    active TB, HIV mother
  • The mothers milk production is insufficient with
    poor gain weight. It is a medical decision
    whether to supplement breastfeeding with a
    special PBF before 40 weeks, and later, with a
    milk formula for the 1stsemester.
  • The mother does not want to nurse, regardless of
    all the advice given to her on the benefits of
    mothers milk.

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Conclusion
  • It is vital to point out that maternal
    breastfeeding represents a dynamic feeding,
    which responds to the constantly changing needs
    of the infant from his birth to the months
    following it, in contrast with formula feeding,
    which is a synonym of a static feeding
  • It is impossible to match the dynamism of
    mothers milk in relation to variation, from one
    woman to another, within the same woman and
    throughout the day nor the changes that take
    place between colostrum, transition milk and
    mature milk
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