http://doi.org/10.33698/NRF0300-Lakhwinder Kaur, Raman Kalia, Indarjit Walia
Abstract: An operational study was conducted for promotion of breast feeding among neonates admitted in Neonatal Surgical Intensive Care Unit of PGIMER, Chandigarh. Physical area of unit, breast feeding policy, manpower, all the neonates along with their mothers and breast feeding practices were the study subjects during the month of December 2005 to February 06. Based upon existing breastfeeding practices, system was developed, operationalized and also monitored for promotion of breast feeding. At the end a study, breast feeding policy document and a separate mothering room was available in the unit. Whole manpower was involved actively for promotion of breast feeding in unit. As system was operationalized number of mothers accompanied their neonates in NSICU had increased from 69% to 95%. Inclined trend was observed in the exclusive breast feeds received by neonates from 60% to 88%. At the time of discharge, all neonates received exclusive breast feed. Based on these findings it is concluded that system was operationalized successfully for promotion of breast feeding among neonates.
Keywords: Promotion, breast feeding, system, manpower, neonates.
Introduction:Breast milk is accepted as the unique, natural and nutritious food, provided by the nature for newborn.1Breast feeding is universally recognized as the best form of nutrition for infants including ill and preterm infants as it fulfils specific nutritional needs.2 It fosters the bond between mother and infant as well as providing the best sources of nutrients. WHO (1991) defines Breast feeding as the child has received breast milk (direct from the breast or expressed)’.3 Research in the united states, Canada, Europe and other developed countries, among predominantly middle-class populations provides strong evidence that human milk feeding decreases the incidence and/or severity of diarrhea, lower respiratory tract infection, Otitis media, bacteremia, bacterial meningitis, botulism, urinary tract infection, and necrotizing enterocolitis among neonates. Number of studies has shown protective effect of human milk feed against sudden infant death syndrome, insulin-dependent diabetes mellitus, crohn’s disease, ulcerative colitis, lymphoma, allergic diseases and other chronic disease of digestive system. Breast feeding has also been related to possible enhancement of cognitive development.4 It also reduces mortality and morbidity rate of neonates worldwide. Literature shows that in India, infant mortality rate can be reduced(19%) by achieving 90% target of exclusive breast feeding in first 6 months of life.5 This practice is to be initiated soon after birth of neonate and should be supported thereafter. There are many barriers which interfere with the success of breast feeding. These barriers are inappropriate hospital practices, poor knowledge of health professionals, lack of knowledge of mothers and medical-surgical problems of neonates. Inappropriate Hospital practices such as the separation of mother and infant soon after birth when bonding and suckling reflexes are strong, delay in getting the infant to the breast, increased level of anxiety in the mother which has direct effect on lactation. Provision of formula feed, following rigid feeding schedule based on clock rather than on neonate’s demand, use of prelacteal feeds is also associated with lower rates of partial and exclusive breast feeding.6 Medical-surgical conditions of neonates also affect the success of breast feeding. Conditions such as tracheoesophageal fistula, gastrosiasis, cleft lip, cleft palate, gastro esophageal reflux, intestinal obstruction, anorectal malformation, spina bifida, pneumonia, pulmonary hypertension, or hypoxic ischemic encephalopathy, where physiological status of neonate is altered, restricts breast feeding. Sucking-swallow in coordination is also seen common in these neonates as they receive narcotics and sedations.7
Breast feeding is considered beneficial for surgical neonates also, as it fosters recovery from illness (disease), reduces the mortality rate, prevents bacterial infections, reduces certain immunological disorders, promotes immunity & mother-neonate bonding etc. As surgical neonates are not able to initiate breast feeding early, because of surgical interventions and recovery phase, mothers are unable to maintain lactation (may be due to mother-neonate separation, unaware of importance of breast feeding, lack of family support and facilities in hospital), resulting in cessation of lactation and neonate is devoid of breast feeding. Certain actions are being taken in medical units of neonates for promoting breast feeding; special efforts are needed in neonatal surgical unit also. Thus every effort should be made for maintaining lactation so that surgical neonate should take breast feed only, when his physiological status allows him. From the clinical experience, it was recognized that surgical neonates are devoid of breast feeding because more attention is paid to the surgery of neonates and little attention for maintaining lactation. Literature is devoid of studies reflecting interventions for promotion of breast feeding in surgical neonatal units. Need was recognized to develop, operationalize and evaluate the effect of system on promotion of breast feeding in NSICU. This study was undertaken with the objective: to operationalize a system for promotion of breast feeding among neonates admitted in surgical intensive care unit. For the development and operationalization of the system, concepts of “Bertlanffy’s general system theory” were applied i.e. input, through put, output and feedback.
Research methods
This descriptive study was conducted in Advanced Pediatric Center of Post Graduate Medical Education and Research (PGIMER), Chandigarh during the months of December 2005 – February 2006.PGIMER is a central govt. owned autonomous institute. It was established in 1962 as a referral center and tertiary level institute to provide diagnostic, therapeutic and rehabilitative services in various specialties and super specialties. In 1996, Advanced Pediatric Center was attached to PGI as exclusive child care center. The center houses all the diagnostic, curative, follow up and rehabilitative services to children under one roof. It has six floors and four (A, B, C, D) Blocks. Neonatal Surgical Intensive Care Unit is located at 6th floor, ‘B’ block in APC. It has bed strength of 28 patients. Target population includes area of unit, breast feeding policy, manpower, all the neonates along with their mothers and breast feeding practices during the month of December 2005 to February 06. Methods used for collecting data were observation, semi structured interview schedule and record analysis of feeding charts. Data was collected with the help of neonatal record and observation cum activity record sheet for system functioning. Tool was checked for validity and reliability. A written permission was sought from the competent authority for the conduct of study. Cooperation of manpower, families of neonates was also ensured.Present study was conducted in four phases. In the first phase (4th December-25th December, 2005), observational visits were made in the unit for twenty two consecutive days. Through observations and interviews of the health team, it was learnt that no policy document on breast feeding existed in the unit. No separate room for mothers was available for breast feeding however all of them recognized the need of a separate room in order to maintain privacy. Twenty six neonates were admitted in the unit during this phase of the study. Oral feeds were recommended to eighteen neonates and eight neonates were not allowed to receive oral feeds due to surgical interventions. It was found that number of exclusive breast feedings, mixed feedings and toned milk feedings received by neonates were 60%, 12% and 28% respectively. At the time of discharge, 75% neonates received breast feed and 25% received toned milk feed as their mothers Could not accompany them. During this period, 69% mothers accompanied their neonates and 31% could not because of postpartum sickness. Other reasons for their not being present in unit were lack of information conveyed by health team members (62.5%), cultural practices (25%) and cesarean section (12.5%). Based upon these findings, need for development of system was recognized.In the second phase of the study, system was developed which included: development of breast feeding policy document (in consensus with health team of NSICU), arrangement of physical facilities, development of educational aides on breast feeding and plan to seek mothers’ presence in NSICU. Policy document was developed by holding meetings with pediatric surgeons and nursing personnel working in NSICU. In the third phase of study (26th December, 2005 to 28th February, 2006), actions were taken for the operationalization of system i.e. communicating breast feeding policy to the health team of the NSICU, providing physical facilities to mothers and assisting mother and neonate for breast feeding. All health team members were involved to follow the policy guidelines. Mothers were assisted and encouraged for exclusive breast feed and maintenance of lactation. Individualized care was given to each neonate and his/her family for promotion of breast feeding.During operationalization of the system, fifty five neonates were admitted in NSICU. Age of neonates ranged from 0-26 days with mean age 6.8+6.1 days. Neonates were admitted with congenital anomalies of GI Tract (61.6%) and were hospitalized for 1-10 days (60%).Oral feeds were recommended to fifty one (93%) neonates. Total 3894 feeds were received by neonates, out of these 3435 (88%), 299 (8%) and 160 (4%) had breastfeed, mixed feed and toned milk respectively. Four neonates were not allowed to breastfeed because of surgical interventions. At the time of discharge, all neonates received breastfeed. During the last two weeks of study, no neonate received toned milk feed. During neonates’ hospitalization, fifty two (95%) mothers accompanied them in NSICU. Among the present mothers 24(46%) came along with neonates and 28 (54%) mothers came after 24 hours of neonate’s hospitalization in NSICU. Only three mothers (5%) could not accompany their neonate in NSICU because of cesarean section (67%) and cultural practices (33%).Evaluation of the system was carried out in the fourth phase of study. Department of pediatric surgery accepted the policy document on breastfeeding (developed during the study period) and it was available in NSICU at the end of study. In the beginning no separate room was available for mothering the neonate, whereas at the end of study, separate room with facilities of bed with mattress (2), chair (3), wash basin with soap (1) and screen (1) was available. Similarly no educational aides on breast feeding were displayed at the start of study but as system was operationalized, three posters were displayed in mothering room. The strength of the manpower remained same throughout the study period. (Table 2)
Table 1: Comparison of facilities for promotion of Breastfeeding in NSICU
| Policy document – 1
Mothering room – 1 *bed 2 *chair 3 *screen 1 *washbasin with soap – 1 Educational Aides on breast feeding – 3 Man power 48 48 |
Facilities Start of study End of study
Manpower participated actively towards the promotion of breastfeeding during phase III and their active involvement continued till the end of the study (Table 2).
Table 2: Comparison of Involvement of Health professionals in Breastfeeding of Neonates
| Before system’s operationalization | During system’s operationalization |
| Manpower encouraged for mother’s presence only when oral feed was recommended to the neonate. | Manpower encouraged mother’s presence at the time of neonates admission |
| No information conveyed for maintenance of lactation. | Information conveyed for maintenance of lactation |
| Passive involvement of health personnel towards promotion of breast feeding | Active involvement of health personnel with mothers and family for promotion of breast feeding |
it was observed that 69% mothers accompanied their neonates at the start of study where as 95% mothers accompanied their neonates at the end of the study. (Fig.1) Regarding reasons for mothers not accompanying neonate in the unit, at the start of the study (phase-I), eight mothers could not come because of postpartum sickness. Other reasons were no information conveyed by health team (62.5%), cultural practices (25%) and cesarean section (12.5%). As the system was operationalized, families were motivated to bring mothers in NSICU. It was found that fifty two (95%) mothers accompanied their neonates and three (5%) mothers could not due to cesarean section (67%) and cultural practices (33%). (Table3).
Table 3: Comparison of reasons for mothers not accompanying their neonates
| Reason Phase I Phase III |
n= 8(%) n=3 (%)
| No information conveyed by health team 05 (62.5) –
Cesarean Section 01 (12.5) 02(67) Cultural Practices 02 (25.0) 01 (33) |
Regarding the observations on type of oral feed received by neonates number of breast feeds (BF) increased from 60% to 88%as the system was operationalized. Number of toned milk feeds (TM) and mixed feeds (BF+TM) received by neonates decreased from 28% to 4% and12% to 8% respectively. (Figure2). At the time of discharge, 75% neonates received breast feed in the assessment phase whereas all neonates received breast feed as system’s operationalization was carried out (phase-III). (Figure 3).
Discussion
Promotion of breast feeding has become an important health issue around the world because of the physiological, psychological, social, economical and nutritional benefits of breastfeeding. Review of literature revealed number of studies reflecting breast feeding practices in community setting but no base line data is available on breast feeding status of surgical neonates. The present study was conducted in neonatal surgical intensive care unit of PGIMER, Chandigarh, 2006.in the assessment phase, most of the neonates were admitted with congenital defects of gastro intestinal system. They were hospitalized for 1-10 days 176.8%) in NSICU. Oral feeds were recommended to eighteen neonates. Among these, 13 received breast feed and 5 could not due to mothers’ non presence (3), delayed presence (1) and cessation of lactation (1). Among these neonates, eight were discharged and 75% received breast feed. On exploring the reasons for lack of breast feeding, it was found that health personnel were giving more emphasis to the surgical nursing care and had conveyed no information to mothers regarding maintenance of lactation. The American academy of physicians has recommended that the evaluation of breastfed neonates (3-5 days of age) should be done by pediatrician and experienced health care professional.4 In current study, no information regarding maintenance of lactation or breast feeding was conveyed by health personnel. As a result, toned milk feed was substituted as mother complaint of inadequate milk production. Number of breast feeds, toned with breast milk feed and toned milk feeds received by neonates during their hospitalization were 60%, 12% and 28% respectively.Reason for mothers not being present were also explored. All suffered from postpartum sickness along with this other reasons were cesarean section (12.5%) cultural practices (25%) and lack of information by health team regarding mothers’ presence (62.5%). A retrospective study identified the factors related to early termination of breast feeding: insufficient milk, anxiety, lack of motivation, stress, inconvenience and tiredness. Another study by Mikiel (2005) identified the cesarean section, use of pacifiers and separation of mother infant longer than 24 hours and health problems of infant as major factor affecting the exclusive breast feeding.8Findings of assessment phase has shown that (25%) neonates received toned milk feed at the time of discharge, thus devoid of breast feed in the initial days of life whereas WHO has recommended that no food should be given before 4-6 months of age.3No policy document on breast feeding existed in the unit. Although WHO and UNICEF has framed breast feeding policy for maternity hospitals and recommended that hospital should have a breast feeding policy which must be routinely communicated to all health personnel. Mothers should be shown how to feed and maintain lactation even if they are separated from their babies, encourage breast feeding on demand and no pacifiers to breastfeeding infants.3 Present work indicates that breast feeding practices in NSICU were not optimum and efforts should be made to change these into healthy ones. Need for developing interventions for promotion of breast feeding was recognized. Fraser (1997) carried out a survey for discovering the support; mothers would find helpful in neonatal surgical unit at Yorkhill. Study recommended the provision of quite, comfortable room for feeding, involvement of staff in giving support to mother while feeding, continue education of unit staff and involvement of breast feeding support specialist.9Being an operational study, based upon the findings of existing breast feeding practices, system was developed which included development of breast feeding policy, arrangement of physical facilities, development of educational aides on breast feeding and plan to seek mothers’ presence in NSICU. After its development, it was operationalized. Operationalization of system included communicating breast feeding policy, creating awareness regarding breastfeeding and maintenance of lactation among the mother/family of neonate, providing facilities to mothers regarding breast feeding. All the health personnel were motivated to follow the guidelines documented in the breast feeding policy and results were found encouraging. Number of studies reflected the positive result of interventions carried out in community settings for promotion of breast feeding. Two case studies conducted in Wales shown the positive impact of training given to health personnel for promotion of breast feeding.10 Kang has conducted a study in which health workers were involved in breast feeding interventional programme and programme found to be effective for promotion of breast feeding. 1 Similarly in present study health personnel were involved for promotion of breast feeding and it has shown good result at the end of study i.e. all the neonates received breast feed at the time of discharge.Although, awareness regarding importance of breastfeeding and maintenance of lactation was created among health personnel but no training programme was planned or conducted. As the study proceeded, active involvement of health personnel was observed.During the operationalization of the system, total fifty-five neonates were admitted. As the operationalization of system continued, number of mothers’ presence in unit increased to 95% as compared to assessment phase where the number was 69%. Number of breast feedings received by neonates increased from 60% to 88% at the end of study. In the beginning phase neonates were observed receiving toned milk feed whereas in the last two weeks of study, no one received it. As no related study conducted in the surgical neonatal area is available, comparison of the findings was not possible. All these findings, are suggesting that the system was established in the unit and its operationalization was done successfully.
References
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