BREASTFEEDING TSEK!

A public health education campaingn of the Department of Health (DOH) carrying the message BREASTFEEDINF TSEK! (Tama, Sapat at Eksklusibo) is a public health education campaign of DOH to encourage mothers to 'exclusively breastfeed' their babies and to educate them about the health benefits of breastfeeding. 

‘Exclusive breastfeeding’ means that mothers feed the baby nothing else but breast milk—no water, other liquid, infant formula, or food.

Called “Communication for Behavioral Impact (COMBI) on Exclusive Breastfeeding for six (6) months,” this comprehensive campaign was developed by DOH with the National Nutrition Council, the World Health Organization, the UNICEF, and other partner agencies. Breastfeeding from the first hour of life and exclusively until six months is one of the most effective strategies to prevent infant deaths. 

EINC Do’s and Don’ts:

Unnecessary Intervention: Giving Pre-lacteals or Artificial Milk Substitutes

It is a common practice in Philippine hospitals to give pre-lacteals like glucose water as a trial of feeding to newborns, or to give artificial milk substitutes to babies while the mother’s milk flow is not yet established.  This delays the mother’s breastmilk letdown, and the ease of feeding from the bottle decreases the newborn’s urge to suckle, two factors that will create a vicious cycle that causes caregivers to continue pre-lacteal feeding, thus undermining the success of breastfeeding. This practice also exposes the newborn to different types of infectious agents and challenges an already weak premature or immature gastrointestinal system.  These were clearly evident in a study by Rashid done in rural Bangladesh, where 94.7 % of newborns were fed either honey, animal milk and sugar (non-exclusively).  In these newborns, the overall mean time of initiating breastfeeding was 35.9 hours (SD ± 28.4). Pre-lacteal feeding delayed breastfeeding by 32.1 hours (p<0.0001), and more newborns fed honey (17.2%) experienced episodes of diarrhea in the first 3 months compared to those who were not fed pre-lacteals (13.77%) (RR 1.25, p<0.01).  Giving artificial milk substitutes is a practice that has serious consequences on the baby’s health and wellbeing. 

Recommended Practice: Initiation of Breastfeeding

The benefits of breastfeeding for the health and wellbeing of the mother and baby are well documented.  WHO recommends initiation of breastfeeding within an hour after birth but in many countries, the rates of early initiation of breastfeeding remain low.  In the Philippines, breastfeeding is initiated within the first hour of life in only 54% of deliveries.

A recent trial by Edmond has shown that early initiation of breastfeeding could reduce neonatal mortality by 22%.  In developing countries, early initiation of breastfeeding can reduce deaths due mainly to diarrhea and lower respiratory tract infections in children. 

Dr. Natividad R. Clavano in a 1982 landmark study, followed a cohort of 9886 infants born at the Baguio General Hospital to assess the relationship of neonatal deaths and diarrhea with feeding patterns. Ninety per cent of the 138 infants with diarrhea were formula fed, 6% were on mixed and 4% on exclusively breastfeeding.  Ninety six per cent of the 67 infant deaths were formula fed, 1% were mixed- and 3% were exclusively breastfed.  After formal breastfeeding policies and rooming in practices were implemented, exclusive breastfeeding increased and deaths among clinically infected newborns dropped by 95.3%.  In another prospective cohort study by Yoon et al, 9942 children in Cebu were followed using longitudinal data from 1988-1991. In the first six months of life, failing to initiate breastfeeding (or ceasing to breastfeed) resulted in an 8-10 fold increase in the rate of diarrheal death.

In the 51-hospital observational study, newborns were washed at a median of 8 minutes, put to the breast at a median of 10 minutes of life but removed at 12 minutes.  Thus only 2 minutes were allowed for their first colostrum feed. 272 (56.5%) were transferred to a nursery. They were weighed at a median of 13 minutes, examined at 17 minutes, taken to the nursery at 20 minutes, given eye prophylaxis at 20 minutes and Hepatitis B and vitamin K injections, the first of which at 22 minutes. They were reunited with their mothers at a median of 2 hours 35 minutes. 47 (9.8%) initiated breastfeeding after 2 hours but prior to discharge.  From these studies, it is evident that institutional routines are depriving our newborns of the benefits of early breastfeeding. 

Early initiation of breastfeeding may reduce neonatal mortality by decreasing the ingestion of infectious pathogens. Early breast milk also provides many immunocompetent factors, including immunoglobulins and lymphocytes that may stimulate humoral or cell-mediated immune systems), and it may also prime the gastrointestinal tract and decrease intestinal permeability and translocation of infectious pathogens, including HIV. 

Edmond et al conducted an observational cohort study of 10,942 breastfed singleton neonates (born between 1 Jul 2003 and 30 Jun 2004 in rural Ghana), who survived to day 2, and whose mothers were visited in the neonatal period.  Verbal autopsies were used to ascertain the cause of death in 130 neonates who died from day 2 to day 28. Ninety three died of infection and 47 of non-infectious causes.  The risk of death as a result of infection increased with increasing delay in initiation of breastfeeding from 1 hr to day 7; overall late initiation (after day 1) was associated with a 2.6-fold risk (adjusted OR 2.61 95% CI 1.68, 4.04).  Partial breastfeeding was associated with a 5.7-fold adjusted risk of death as a result of infectious disease (adj OR 5.73 95% CI 2.75, 11.91).  

Such is the impact of early initiation of breastfeeding and healthcare providers and policy makers need to prioritize this simple preventive strategy. Factors that will promote breastfeeding initiation include: implementation of the Baby Friendly Hospital Initiative Ten Steps to Successful Breastfeeding; avoidance of the use of intramuscular narcotic analgesia, particularly near the end of the first stage of labor; not separating mothers and babies after birth for routine procedures; and routinely placing healthy newborns on their mothers’ chest/abdomen on skin-to-skin contact.

Sources:

Lauer JA et al, Deaths and years of life lost due to suboptimal breastfeeding among children in the developing world: a global ecological risk assessment. Public Health Nutrition 2006; 9: 673-685.

The state of the world’s breastfeeding: report card. Initiation of breastfeeding within one hour. New Delhi: International Baby Food Action Network Asia. www.world breastfeedingtrends.org/reportcard/RC-IB.pdf/

Clavano N. Mode of feeding and its effect on infant mortality and morbidity. J Trop Pediatr. 1982;28 :287 –293.

Yoon PW, Black RE, Moulton LH, Becker S.  Effect of not breastfeeding on the risk of diarrheal and respiratory mortality un children under two years of age in Metro Cebu, the Philippines.  Am J Epidemiol.1996. 143:1142-1148.

Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS.  Effect of early infant feeding practices on infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana.  Am J Clin Nutr.  2007; 86:1126-31.

Brandtzaeg P. Mucosal immunity: integration between the mother and the breast fed infant. Vaccine 2003;21:3382–6.

Goldman AS. The immune system of human milk: antimicrobial, antiinflammatory and immunomodulating properties. Pediatr Infect Dis J 1993;12:664–71.

Goldman AS, Garza C, Nichols BL, Goldblum RM. Immunologic factors in human milk during the first year of lactation. J Pediatr 1982;100: 563–

Goldman AS. Modulation of the gastrointestinal tract of infants by human milk. Interfaces and interactions. An evolutionary perspective in symposium: bioactivity in milk and bacterial interactions in the developing immature intestine. J Nutr 2000;130(suppl);426S–31S.

Rollins NC, Filteau SM, Coutsoudis A, Tomkins AM. Feeding mode, intestinal permeability, and neopterin excretion: a longitudinal study in infants of HIV-infected South African women. J Acquir Immune Defic Syndr 2001;28:132–9.
Rashid M et al. Prelacteal feeding delays breastfeeding initiation in rural Bangladesh, ICDDR,B Periodical

Kuwentong Unang Yakap

Kuwentong Unang Yakap chronicles the first-hand experiences, inspiring testimonial and personal anecdotes of doctors, health professionals, patients and other healthcare providers narrating their “Unang Yakap” stories.  

by Dr. Donna Capili

Sept 13, 2010. It was almost half past one o'clock in the afternoon and my stomach grumbled its complaint. I just finished clinic and was set to see my in-patients, never mind my tummy. From a distance, I heard the siren.  I didn't think any of it.  I was on my way up to the patients' rooms on the second floor when the undeniable peal of the siren seemed very tangible...I retraced my steps downwards and saw that the ambulance was by the emergency room entrance.  What could it be now?

The ambulance driver was shouting that his patient, a pregnant woman, was about to deliver her baby.  He opened the back door and my eyes zeroed in on the crowning head. I yelled for sterile gloves, clamps and clean towels.  It seemed like magic that a pair of gloves appeared in my hand.  I told my resident doctor on duty (ROD) to put on his own pair of sterile gloves. Next thing I knew, I was doing perineal support -- my right thumb and index finger formed a C-shape, pressed inward and down – picturing Dra. Cynthia's demo in my head...I didn't do any of the massage nonsense.  It was quite quick.  Lucky me! I held out my hand to hold the baby's head down as he made his entry into the world. Baby out! I slipped him into the towel and put him on mom's tummy.  The ROD started to dry and stimulate the baby. The baby then let out a scandalous cry and I knew he was going to be alright. The baby was positioned further up on mom's chest. Meanwhile, I felt for her uterus and started to massage -- no complicated digging movements but just nice and simple circular motions. A voice quipped that ice was on its way, to which I quickly added, "No ice. Don't need it." (Dr. Howard Sobel would have been so proud.)

What was the next step? Number 3: cut the cord. It was a good 3-4 minutes when that was done. Uh-oh, I hope he doesn't get too jaundiced. Now, where was I? Hmm, exclude second baby… It didn't seem like there was anyone else in there.  I asked the mom if she was just expecting a singleton to which she replied “Yes.”  Ok, so no second baby. Confidently I ordered to give her oxytocin 10 via IM please.  (Thanks to our recent meetings, I appeared to know what I was doing)

I rolled the cord unto my clamp and applied traction and counter-traction steadily.  At first, it felt like I was going to tear the placenta out of there but it didn't!  I just needed to be patient. I examined the perineum and glad to see that there was no tear (vernacular: rat-rat)! I examined the placenta and its membranes and it was "clean", smooth. 

When I finally raised my head, I saw that the baby was latched and suckling away. Yipee! A smart boy for a change! Time: about 30 minutes post delivery. He stayed with his mother and avidly breastfed. I told mom that'll be the only way we feed her baby in this (my) hospital.

Oh, did I say, that all this happened at the back of the ambulance?

Mother and baby were brought down and into the hospital. The ROD was already instructing for IV fluids. He looked stupefied when I said, "No IV." and I added, "we'll talk about the CPG for uncomplicated vaginal births later."

__________________________________________________________________

** Mother was actually en route to a provincial hospital after being asked to leave another LGU-run hospital, citing that the baby will be born preterm and they have no incubator. (certainly, they need to know about KMC).  Pediatric age was 36 weeks, birth weight 2450 grams. Both mother and baby are well and due home.**

Dr. Donna Capili completed her subspecialty training at the Hospital for Sick Children in Toronto, Canada.  She is a practicing Neonatologist in Bulacan and a Co-Convener of Team EINC.

Breastfeeding Checklist

by Dr. Francesca Tatad-To

This breastfeeding monitoring form was developed when I was in private practice and needed a way to keep track of my patients’ breastfeeding progress. I realized then that nurses would simply note on the chart that the baby was ‘breastfed’ but not how many times a feeding occurred, or whether there were any feeding problems.  Mothers were too tired to remember how many times they had breastfed in the last 24 hours, or how many times they had changed their baby’s diaper.

The mothers who did bother to write down the information were spending too much time recording too many details.  With the use of this graphic chart, mothers simply had to tick off the right image each time they breastfed, changed a wet diaper, and every time their baby passed stool.

When Team EINC realized that the monitoring of well babies is a challenge in our hospitals, mainly due to the lack of health workers and the large number of patients, we translated the form into Filipino and offered it to our various centers as a monitoring tool.  But this time, we added a column for danger signs, so that mothers themselves would be prompted to check their babies regularly for any signs that may indicate a severe illness or infection, and call the attention of their health worker.

The monitoring form was first used at the Jose Fabella Memorial Hospital’s Potentially-Septic Ward, where babies who are clinically well but have risk factors for sepsis are admitted together with their mothers.  Every mother admitted to the area is provided with a copy of the form and instructed in how to fill it up.  Initially there were concerns that the form would be too complicated for the mothers, or that it would take too much time to do, or that the forms would get lost.  As it turns out, the mothers find the form a very useful tool and have taken on the task of reminding each other to fill up their forms regularly.  Mothers are now more aware of how often they should be breastfeeding, and what signs to look for to know that breastfeeding is going well.  Monitoring mother-infant dyads has become an easier task for the nurses, and doctors going on rounds review the information in the form as part of their routine examination.  A big benefit of the tool is that infants who develop signs of illness are being referred earlier, and mothers are educated regarding the signs of severe illness in newborns, so that they can identify these even if they occur after discharge.  One pleasant surprise to the staff the mothers hold on to the forms and do not lose or misplace them.

How to properly use this form:

• Day 1 begins at the time of birth and ends 24 hours later, and so on.
• Instruct the mother to shade/check one breastfeeding image every time she breastfeeds, one wet diaper image every time her baby passes urine, and one soild diaper image every time her baby passes stool
• Heavy/darker images are mandatory - meaning a mother MUST breastfeed at least 8 times a day on day 2, for example. The lighter images are extras but within normal, meaning if a child has 8 soiled diapers istead of 2, this is still normal and should not be considered diarrhea.
• If a mother and baby are able to fulfill all the “MUST Dos” for each 24 hour period, it is likely that breastfeeding is going well. If however, one or more is insufficient, the health worker should address this by closer monitoring, properly observing a feeding, and identifying underlying problems.
• Also instruct the mother to go through the list of danger signs at least once a day (more often if possible) and to call the attention of a health worker immediately should any of the danger signs be present. 

Special Section: Ten Steps to Successful Breastfeeding

Every facility providing maternity services and care for newborn infants should:

1. Have a written breastfeeding policy that is routinely communicated to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within half an hour of birth.
5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming-in – that is allow mothers and infants to remain together – 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Source: Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services, a joint WHO/UNICEF Statement published by the World health Organization.

FEATURE | Dr. Jose Fabella Medical Hospital: where optimism never runs dry

One thing is for certain -- optimism never runs dry at the Dr. Jose Fabella Medical Hospital. Dubbed as one of the world’s busiest maternity hospital, seeing an average of 60-80 births a day, “Fabella” easily brings to mind images of crowded maternity wards, a cramped Neonatal Intensive Care Unit, delivering mothers coming and going like clockwork, and babies born one after another routinely depicted in local and international media channels. At one point, it has even been infamously tagged, albeit too conveniently, as “the baby-factory” owing to large portion of babies in Metro Manila being delivered there. 

Its portrayal in the recent news has, to a certain extent, become the standard fare in representing the generally lamentable state of healthcare delivery and population development in the country. And yet despite this, Fabella unwaveringly maintains to be a competitive institution providing safe, quality and compassionate maternal and newborn care while promoting sound research and training practices in the field of women’s health. And while its crowded wards may somewhat tell a different story, this only proves how it has persistently weathered limited funds to provide quality service to mothers and newborns who otherwise could not afford it on their own. “We try our best to manage even though we have limited resources,” Assistant Chief Nurse Edna Solis candidly relates.

FEATURE | Kangaroo Mother Care at Eastern Visayas Regional Medical Center

Upon the request of Dr. Aileen T. Riel-Espina, OIC and Chief of Hospital III of Eastern Visayas Regional Medical Center (EVRMC), in coordination with Team EINC, the Bless Tetada Kangaroo Mother Care Foundation (KMCF) conducted the KMC training program at the hospital last June 6 to 10. Participants were Nelita P. Salinas, MD, FPPS [Medical Specialist II (Pediatrics)], Ma. Gemma Ramos, MD, DPPS FPPS [Medical Specialist II (Pediatrics)], Audrey Santo, MD, DPPS [Medical Specialist I (Neonatology)], Dolores Casio, RN, MAN (Head Nurse, NICU), Lea Demetria, RN, MAN (Nurse Staff, NICU), Rachel Quilario, RSW (Social Worker II), Janet Galangue, RSW (Department Head, Social Worker Services), and Susana S. Merida, MD, FPOGS [Medical Specialist II (OB-Gyn)].

Prior to the training proper, a KMC orientation was conducted, attended by about 35 

Graduates of KMC training

medical and administrative officers of EVRMC and representatives of the local media. At Dr. Riel-Espina’s opening remarks, she stated that the institutionalization of the KMC at EVRMC to would help in better managing the problem of housing mothers with low birth-weight babies still undergoing medical interventions. She also hoped that with this training and the eventual implementation of KMC, EVRMC would be able to satisfy the accreditation requirement of the KMC Foundation. 

At the press conference that followed, Dr. Socorro Mendoza, President of Bless-Tetada Kangaroo Mother Care Foundation-Philippines, and Dr. Espina were interviewed about the concept and benefits of Kangaroo Mother Care. Dr. Mendoza mentioned that, based on worldwide experiences and a large body of scientific evidence collected, the KMC program has contributed to the reduction in the risk of death among the low birth-weight babies; higher rates of breastfeeding among mothers; adequate infant growth, especially head circumference; better mother-child bonding; and reduction of costs incurred by families and hospitals.

News | Breastfeeding under special conditions

IPA/ICM/FIGO issues a joint statement on breastfeeding, including breastfeeding by HIV- infected mothers. In light of the changing evidence on transmission risks and recommendations on the use of anti retroviral drugs for treating pregnant women and preventing HIV infection in infants, we welcome the new recommendations on HIV and infant feeding: 


1. Balancing HIV protection with protection from other causes of child mortality
2. Integrating HIV interventions into maternal and child health services. 

3. Setting national or subnational recommendations, based on evidence, for infant feeding in the context of HIV. 

4. Informing mothers known to be HIV infected about infant-feeding alternatives
5. Supporting mothers known to be HIV infected who wish to breastfeed so that they can do so safely. 

6. Providing services to specifically support mothers to appropriately feed their infants. 

7. Avoiding harm to infant-feeding practices in the general population.
8. Advising mothers who are HIV uninfected or whose HIV status is unknown. 

9. Investing in improvements in infant-feeding practices in the context of HIV.

IPA/ICM/FIGO welcome the recommendation that mothers known to be HIV infected should exclusively breastfeed their infants for the first 6 months of life, introducing appropriate complementary food thereafter, and continue breastfeeding for the first 12 months of life. Bottle feeding should be considered the best alternative only when specific conditions are met. The conditions under which bottle feeding is preferred are commonly referred to as AFASS—affordable, feasible, acceptable, sustainable, and safe—and are more specifically described in the new WHO recommendations.