http://doi.org/10.33698/NRF0331-Sujata, Karobi Das, Kanaya Mukhopadhaya, Sukhwinder Kaur, Minakshi Rohilla
ABSTRACT
Introduction: Exclusive breast milk feeding plays a signicant role in reducing the neonatal and child mortality and morbidity. It has many benets for both the mother and neonate. Objective: To assess the practices of exclusive breast milk feeding, kangaroo mother care (KMC) and non nutritive sucking (NNS) among mothers of preterm neonates. Methodology: This was a pilot project conducted among mothers of preterm neonates. Mothers delivered in the period of gestation <34 weeks were included in study. The mothers of preterm babies with congenital deformities and multiple pregnancy were excluded. Data was collected from 21 mothers in neonatal units through face to face interview by using interview schedule composed of socio-demographic data of the mothers, obstetrical history of the mothers and clinical prole of preterm neonates. Mothers and babies were followed up to 7 days for the assessment of feeding details, kangaroo mother care and non nutritive sucking practices by using neonatal care record sheets. Results: The results showed that early initiation of EBM only was done by 33.3% mothers whereas 66.6% mothers gave formula feed only or mixed feeding (EBM+ formula feed) to their babies on day 1. The number of babies received exclusive EBM increased from day 1 to day 7 and the number of babies received formula feed only decreased from day 1 to 7 and the number of babies received mixed feed (EBM+ formula feed) remained same. Volume of expressed breast milk only(EBM), formula milk only and mixed feed (EBM+ formula feed) (ml/day) increased from day 1 to day 7. KMC was started by 28.5% and NNS was started by 21 % by the mothers on day 3. Only 9.5% preterm babies gained weight. Conclusion: There is inadequate practice of early initiation of EBM, KMC and NNS, so need was felt for regular teachings on these aspects to the mothers of preterm babies in the neonatal units.
Key words: Exclusive breast milk feeding, Formula feed, Mixed feeding, Preterm neonate
Address for correspondence:
Sujata Tutor
National Institute of Nursing Education PGIMER, Chandigarh.
Introduction:
It is a well known fact that mother’s milk is the best gift for the baby. World Health Organization suggested that exclusive breastfeeding should be practiced for rst six months for positive health of preterm babies and the mothers.1 The benets of exclusive breastmilk feeding have been seen in terms of cognitive abilities, psycho- social development, school performance and linear growth among older children.2 cognitive outcomes.4 The initiation of Kangaroo Mother Care (KMC) and breast feeding are interrelated aspects in preterm babies. Early initiation of KMC compared with late initiation of KMC effects both short-term and long-term Lactoferrin and oligosaccarides are the exclusive breast milk feeding. 5 In benecial components of breast milk and considered to prevent the infections in infants. Most of the studies suggest that feeding expressed breast milk to the preterm neonates decrease the chances of sepsis, necrotizing enterocolitis and m o r t a l i t y. I t a l s o i m p r o v e s t h e neurocognitive and cardiovascular out comes at the long term. But feeding of preterm neonates is a big challenge for the mothers as they are physiologically and neurologically unripe and have poor muscle tone. Due to lack of coordination of swallowing/sucking reex, preterm babies are not able to take appropriate nutrition, hence it is considered as a most signicant neonatal health problem. It is also associated with neonatal mortality as well as with short and long term morbidities of the preterm neonates. Therefore, improving breast milk feeding practices should be a priority in developing countries.3
Most of the preterm infants, especially very preterm with extremely low birth weight, are not fed sufcient amounts of nutrients. This may lead to abnormal growth pattern and results into growth-restriction after birth. Numerous studies have shown that under nutrition, especially of protein, at critical stages of development produces short stature, organ growth failure, and both neuronal decits of number and dendritic connections which leads to behavioral and Madagascar, Nagai et al. (2011) reported that most of comorbidities in preterm infants can be avoided with delicate care, giving special emphasis on Kangaroo Mother Care, thermoregulation, prevention of infection and exclusive breast milk feeding.6 Along with KMC, Non Nutritive Sucking (NNS practice i.e.putting the baby on empty breast) in neonatal units is also very helpful in establishment and maintenance of exclusive breast milk feeding. NNS helps the neonate to strengthen the muscle tone of oral cavity and improvement of sucking reex. Hence, the need was felt to assess the practices of exclusive breast milk feeding, KMC and NNS in preterm neonates and its impact on improvement of breast milk feeding rates during the hospital stay.
Objective
To assess the practices of Exclusive breast milk feeding, Kangaroo mother care and Non Nutritive sucking among mothers of preterm neonates in neonatal units of a tertiary care hospital in North India.
Materials and methods
This was a pilot project conducted among mothers of preterm neonates to assess the practices of Exclusive breast milk feeding, KMC and NNS in neonatal units of PGIMER, Chandigarh, India. The neonatal units (Neonatal intensive care unit, Neonatal nursery and extension labor room nursery) are fully equipped with modern facilities for caring the preterm neonates. There are 65 beds for neonates in all areas of neonatal units. Mothers of preterm neonates <34 weeks gestational age were included in the study. The mothers of preterm babies with congenital disorders and twin pregnancy were excluded.
The permission for conducting the study was taken from Head, Obstetrics and Gynecology department and Neonatology department, PGIMER, Chandigarh. Ethical clearance for conducting the study was taken from Institute Ethics Committee, PGIMER, Chandigarh. Data was collected through face to face interview using an interview schedule and observation method from mothers. Interview schedule comprised of sociodemographic prole, obstetrical history of the mothers and clinical prole of their babies. Neonatal care record sheet was used for recording the amount of milk intake, KMC and NNS practices by observation on daily basis. Mothers were asked for early expression of breast milk, frequency of expression of breast milk and volume of milk expression in sterile containers. Intake of volume of milk (EBM, formula milk, mixed feeding) were recorded from the record sheets. KMC and NNS practices by the mothers were assessed daily by observation method and from the records. Mothers and their preterm babies were followed till 7 days for feeding datails, KMC and NNS practices and recorded in neonatal care record sheet. Descriptive statistics were used for analyzing the results. Calculations were carried out using SPSS (Statistical Package for Social Science Program) 21 version. The descriptive and inferential statistical measures were used to analyze the data.
Results
Table 1 depicts the socio-demographic prole of the mothers. Education status of 14.3% mothers was upto primary and same percentage of mothers were educated upto middle school, high school. Twenty three percent mothers were educated up to senior secondary. Two third of the mothers were in the age (range) of 20-25 years (66.7%). As per Kappuswamy scale, 42.9% of mothers were from the Upper middle II class.
Table 1. Sociodemographic profile of the mothers
N=21
| Variables | n(%) |
| Age (range) of the mother
20-25 years 26-30 years 31-35 years |
14(66.7)
04(19.0) 03(14.3) |
| Educational status
Illiterate Primary Middle school High school Senior secondary Graduate |
04 (19.0)
03 (14.3) 03 (14.3) 03 (14.3) 05 (23.8) 03 (14.3) |
| Socioeconomic status (Kappuswamy scale) Upper I
Upper MiddleII Lower middle III Upper lower IV and lower V |
01( 4.8) 09(42.9) 05(23.8) 06(28.5) |
Table 2 depicts the obstetrical history of the mothers. Nearly half of the mothers (47.6%) were 1st or 2nd gravida. More than half of the mothers (57.1%) were having previous breast feeding experience. Most of the mothers (80%) were diagnosed with antenatal comorbidities such as gestational hypertention (14.2%), pre-eclampsia (23.8%), gestational diabetes mellitus (23.8%), Oligohydroamnios (14.2%). The cause of preterm labour in 28.5 % mothers was premature rupture of membranes. More than half of the mothers (59.1%) had preterm normal vaginal delivery and 36.4% had lower segment caesarian section.
Table 2: Obstetrical history of the mothers
Table 3: Profile of neonates
|
N=21
N=21
| Variables | n(%) | |
| Gravida | ||
| 10(47.6) | ||
| 1-2 | ||
| 3-4 | 07(33.3) | |
| >5 | 04(19.0) | |
| Previous breast feeding experience | 12(57.1) | |
| Medical illness during pregnancy | ||
| 3 (14.2) | ||
| Gestational hypertention | ||
| Pre-eclampsia | 5 (23.8) | |
| Hypothyroidism | 4 (19.0) | |
| Gestational diabetes mellitus | 5 (23.8) | |
| Oligohydroamnios | 3(14.2) | |
| Premature rupture of membranes | 06(28.6) | |
| Mode of delivery | ||
| 13(62.0) | ||
| Preterm normal vaginal delivey | ||
| Lower segment cesarian section | 08(38.0) |
Table 3 depicts the prole of the preterm neonates. More than half of the neonates were males (57.1%) while others were females (42.9%). Nearly half (47.6%) of the babies were within the range of 31-32 weeks of gestational age. Gestational age of the babies ranged from 28-34 weeks with the mean period of gestation 31±1.2 weeks. Among them 42.9 % were having period of gestation between 33-34 weeks. Mean birth weight of preterm neonates was 1306 ± 189.2 grams (range of 1000-1800gm). Most of the babies (76.1%) had birth weight within the range of 1001-1500 gram. *Mean ±SD (Range)=31±1.2 (28-34)weeks
**Birth weight Mean ±SD (Range)=1306 ± 189.2 (1000-1800) grams
Table 4 shows the number of preterm babies on expressed breast milk only (EBM), formula milk only and mixed feed. One third of the mothers (33.3%) had early initiation of expression of milk and given EBM to their babies on day 1. Whereas nearly half of the babies (47.6%) had received the formula milk only and only 19% babies had received the mixed feed (EBM+ Formula milk) immediately after the birth on day 1. The number of preterm babies on expressed breast milk (EBM) increased from day 1 (33.3%) to day7 (42.9%). The number of preterm babies on formula milk decreased from day 1 (47.6%) to day7 (38.0%). Number of babies on mixed feed ( EBM+ Formula milk) remained almost same from day 1 to day 7 i.e.19 % with few uctuations in between.
Table 5 depicts volume of expressed breast milk only (EBM), formula milk only and mixed feed (ml/day). From day 1 to day 7 mean volume of expressed breast milk increased from 10±24 ml to 82±108 ml, mean volume of formula milk increased from 10±10 ml to 71±60 ml and mean volume of mixed feed increased from 10±17 ml to 78±43 ml) (ml/day) increased from day 1 to 7.
Table 6 describes number of mothers started KMC and NNS. The number of mothers started KMC and NNS increased
from day 1 to day 7. KMC and NNS started from day 3 by 1 mother only, gradually other mothers also started KMC and NNS and only 28.5% mothers started KMC and 19 % started NNS to preterm neonates till day 7.
Table 4: Number of preterm babies on expressed breast milk only (EBM), formula milk only and mixed feed (EBM+ Formula milk ).
N=21
|
Day of life |
EBM only
n (%) |
Formula milk
only n (%) |
Mixed feed (EBM+ Formula milk )
n (%) |
| Day 1 | 7 (33.3) | 10 (47.6) | 4 (19) |
| Day 2 | 8(38.0) | 9 (42.9) | 4 (19) |
| Day 3 | 8 (38.0) | 10 (47.6) | 3 (14.3) |
| Day 4 | 7 (33.3) | 10 (47.6) | 4 (19) |
| Day 5 | 9 (42.9) | 8 (38.0) | 4 (19) |
| Day 6 | 9 (42.9) | 9 (42.9) | 3 (14.3) |
| Day 7 | 9 (42.9) | 8 (38.0) | 4 (19) |
Table 5: Volume of milk ml/day (EBM only, formula milk only, Mixed feeding) received by preterm babies from day 1 to 7.
N=21
| Day of life | EBM only
(ml/day) M±SD |
Formula milk only
(ml/day) M±SD |
Mixed feed (EBM+ Formula milk ) (ml/day)
M±SD |
| Day 1 | 10± 24 | 10±10 | 10±17 |
| Day 2 | 17±36 | 19±16 | 16±28 |
| Day 3 | 23±45 | 27±22 | 25±40 |
| Day 4 | 44±64 | 38±29 | 40±35 |
| Day 5 | 57±79 | 52±43 | 55±46 |
| Day 6 | 73±97 | 59±49 | 64±58 |
| Day 7 | 82±108 | 71±60 | 78±43 |
*The number of preterm babies have the mean weight gain/loss by day 7. Only 9.5% preterm babies gain weight by day 7
Table 6: Number of mothers started KMC and NNS from 1 to 7 day of life
N=21
| Day of life | Mothers started KMC n (%) | Mothers started NNS n (%) |
| 1 | – | – |
| 2 | – | – |
| 3 | 1 (4.7) | 1 (4.7) |
| 4 | 2 (9.5) | 1 (4.7) |
| 5 | 2 (9.5) | 1 (4.7) |
| 6 | 5 (23.8) | 4 (19.0) |
| 7 | 6 (28.5) | 4 (19.0) |
Discussion
Feeding of preterm neonates must be given foremost importance. Expressed breast milk is the best way to full the nutritional requirements of preterm neonates. Early initiation of expressed breast milk rather than formula milk is most benecial in early growth and development. In premature babies having low birth weight, expressed breast milk feeding leads to weight gain and overall development. Exclusive breast milk feeding instead of top feed and mixed feed in preterm neonates lead to good neurocognitive capacities.2 But feeding of preterm neonates for a mother is a big challenge as they are physiologically and neurologically weak and have poor muscle tone.3Therefore it is important to assess the practices of exclusive breast milk feeding, KMC and NNS among mothers of preterm neonate.
A pilot project was conducted among 21 mothers of preterm neonates. For the assessment of exact pattern of exclusive breast milk Feeding, KMC and NNS and the mothers were followed upto 7 days. Hospital records were assessed for the collection of information.
Results of the present study have shown that only 33.3% mothers had given EBM initially on day 1 to their babies. Different ndings were reported in the pilot study done by Rodriguez et al (2016) i.e. most of (91.7%) of the preterm babies received their mother’s breast milk initially after the birth in NICU.7
Similarly the results by Berti et al. had reported that a few babies (13.3%) started with exclusive mother’s milk and (19.1%) received formula milk initially as rst feed after birth. At discharge babies on exclusive breast milk increased to 25.8% and 40.2% of babies were on formula milk.8 In the present study similar results were seen in the context of receiving rst feed by the preterm neonates initially after the birth. 33.3% babies received EBM on day 1 as rst feed after the birth. Whereas 46.7% babies had received the formula milk immediately after the birth on day 1. The number of preterm babies on expressed breast milk (EBM) increased from day 1 (33.3%) to day7 (42.9%). But the number of babies on formula milk decreased from day 1 (47.6%) to day7 (38.1%) and 19% babies were fed on mixed feeding. In a cross sectional study by Degaga et al, the results revealed that at discharge, 71.9% were exclusively breast milk fed, 20.9% used mixed feeding (Formula and mother’s own milk) whereas 7.2% fed only formula milk.9 While another study (Maruyama et al) had reported that only 8.8% neonates received breast milk feed.10
An exploratory study by Parker showed that mothers in the early initiation group produced signicantly more volume (total volume 1374.7 ml) of milk during the rst 7 days (P=0.5) as compared to the late expression group.11 In the present study results are same as volume of expressed breast milk (ml/day) increased from day 1 to day 7(Mean volume of expressed breast milk [ml/day] increased from 10± 24 to 82±108ml))
Results of a cross sectional study conducted in Iran, revealed that performing KMC was the only factor effecting exclusive breastfeeding in NICU settings. Kangaroo mother care performed by mothers in KMC group was 157(62.5%) as compared to 94 (37.5%) in conventional method care group.6 But in the present study the observations were done only for 7 days and during this period of 7 days, 28.5% mothers started KMC. Mothers started KMC (4.7%) from 3rd day as soon as the babies become stable. 4.7% mothers stared KMC by day 3.
In a study conducted by Bala et al, it has been reported that higher number of babies (56%) in intervention group were discharged who received oral stimulation by NNS as recommended to make neonate friendly neonatal units where the arrangement for mother’s comfortable stay to practice healthy neonatal care practices. The nursing staff working in the neonatal units should motivate the mothers of preterm neonates for early initiation of exclusive EBM, NNS and KMC so that the preterm neonates attain their growth at required rates and remain away from associated co morbidities.
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| Sujata, Karobi Das, Kanaya Mukhopadhaya, Sukhwinder Kaur, Minakshi Rohilla |