Infant feeding in a TFP

The benefits of breastfeeding are widely-know. In conditions characteristic of most emergencies breastfeeding becomes even more important for infant nutritional health and survival. However there are times when alternatives to breastmilk are necessary. It is important that they are used appropriately and do not replace breastmilk unnecessarily. Up until about 6 months breastfed infants' nutritional security is critically linked to the maternal supply of milk. This is why it is so important to protect that supply. However mothers and health workers' confidence in breastfeeding is often shaken when they see a malnourished infant attached to the breast. If there is a rush to rehabilitate the infant forgetting about the mother then there is a risk of discharging a healthy infant with no secure supply of 'food'. Mary Corbett as part of her MSc thesis carried out a study to assess the effectiveness of rehabilitating malnourished infants while maintaining or improving maternal milk supply.

This study was conducted in a therapeutic feeding centre run by Action Contre la Faim (ACF) in Liberia between mid May and mid July 1998. Twenty-five severely malnourished infants with weight for length less than 70% and less than 6 months of age were included in the study. A combination of breastmilk and supplemental milk was used to rehabilitate these infants using a special technique adapted for the study: -the "Supplemental Suckling" technique. This technique has been used previously in well babies.

On admission a detailed history was taken to ascertain the main reasons why the infants were not gaining weight. Routine medications were commenced as per protocols used for malnourished children over six months old. These included Vitamin A and a broad spectrum antibiotic.

The infant was started on three hourly breastfeeds. A supplemental feed was given after one hour following each breast feed. The tip of a naso-gastric tube was attached to the mother's breast at the nipple with the other end of the tube in the cup of supplemental milk (F100 diluted). The breast was offered to the infant. When the baby was attached to the breast it was important to ensure that the tip of the naso-gastric tube was in the infant's mouth. When the baby suckled at the breast the milk was sucked up the tube and then ingested by the infant. The amount given was calculated individually for each infant as per body weight (see below for calculations).

All supplemental milk consumed was recorded. Infants were weighed daily. Records were maintained of any vomiting or diarrhoea. It was assumed that the extra suckling at the breast would stimulate an increase in breastmilk output

To estimate required caloric intake from breastmilk it was necessary to calculate energy needs for body maintenance, Basal Metabolic Rate (BMR), and expected weight gain for each infant. It was assumed that 110 kcal/kg were required for BMR but for infants with high fevers it was estimated that extra energy was required, increasing the BMR to 120 kcal instead of 110kcal. It was assumed that five calories were required for each gram of weight gained. The calories supplied by the supplemental milk (enough for maintenance) were established. It was assumed that the balance of calories taken was from breastmilk and would be used for catch-up growth. Finally deductions were made for any vomiting or diarrhoea. Once the infants reached 85% weight for height the supplemental milk was reduced by half the amount for one day and then stopped completely. The infants remained in the centre for a minimum of 4 more days and were exclusively fed breastmilk.

Results
Of the 25 patients admitted one was excluded from the study as the mother was dead while three others were subsequently excluded due to insufficient data as they had been admitted late in the study. During the study a total of 16 infants were discharged exclusively breastfeeding and gaining weight while five were transferred to the local hospital.

With the combined supplemental milk and breastmilk the mean of all the infants maximum daily weight gain was 17.9g/kg/day. Normal weight gain for this age group would be 2g/kg/day while 5g/kg/day would be the minimum weight gain for catch up growth for malnourished infants with 10g/kg/day being the target to aim for. The mean weight gain for the period when the infants were receiving both supplemental feeding and breastfeeding was 14.7g/kg, while the mean weight gain for the period on exclusive breastfeeding was 9.4g/kg/day. This suggests that the weight gain although reduced on exclusive breastfeeding was still adequate for maintenance and catch-up growth. The mean breastmilk output on exclusive breastfeeding reached 204ml/kg (sd 31) with the volume ranging from 390ml to 1131mls but this considerable difference was due to differences in weights of the infants. The mean number of days on supplemental feeding was 13 days.

Tips

Supplemental Suckling Technique

The cup is kept at least 20-30cms below the level of the baby's mouth so that the baby can control the flow of milk from the tube. If the presence of the tube is discouraging the baby from attaching: slip the tube into the mouth once the infant is suckling. Be patient: it may take one to two days for the mother and baby to adapt to this technique.

Calculating the amount of supplemental milk given

Calorie requirements for infants <6 months: For body maintenance without growth requirements = 110kcal/kg/day For each additional gram of weight gain an extra 5kcals are required Feed amount required: Breast-milk or supplemental milk contains 70Kcals per 100mls approx. Therefore amount of breastmilk/supplemental milk required =(110*100)/70 160mls/kg/day Calculate enough supplemental-milk needed for body maintenance (BMR) to allow for situations where breast milk is extremely low. Example of Supplemental-milk calculation: Infants weight = 3.5 kg Supplemental milk required = 160 x 3.5 = 560mls in 24hrs Amount of Supplemental-milk per feed = 560mls / 8 feeds = 70mls per feed As the infant's weight increases the calorie requirements will increase but the supplemental feed will remain the same. The breast-milk produced will increase due to stimulation using the supplemental suckling technique. The infant will receive the calories needed to grow and catch up from the breastmilk.

Feeding Practices

Mothers should offer breastfeeds to babies at least three hourly. Make sure that baby is attached correctly and mother is comfortable. Baby should empty one breast before the second is offered so that both the fore and hind milk is removed. (Emptying the breast stimulates the production of more milk thus improving breast-milk output.) Mothers should offer alternate breasts at the start of each feed. (This ensures both breasts are emptied at each alternative feed). Monitor breastfeeds encouraging and supporting mothers and checking the babies' position and attachment. Give first time mothers extra support to build up their confidence in their ability to breastfeed.

Confidence building

Explain the benefits of breastfeeding to the mother. Spend time with the mother encouraging and answering questions. Explain to the mother the principle of breast-milk quantity being determined by the demand/supply mechanism. Reassure mothers, informing them that most mothers in fact can produce adequate milk supply (more than 99%), even if underweight. Other mothers in the TFP using this supplemental suckling technique are of great support and encouragement to new admissions. Encourage women to talk about experiences. Regularly update mothers on their infant's progress in the programme. Ensure all health staff working in the centre are well informed of the principles and techniques of breastfeeding and supportive to the mothers. Regular training and support for staff is essential.

1 Corbett M. Severe Malnutrition in the Infant less than 6 months: Use of Supplemental Suckling Technique. Department of Medicine & Therapeutics. Fosterhill, Aberdeen.

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