RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,
BANGALORE,KARNATAKA
A STUDY TO ASSESS KNOWLEDGE, ATTITUDE AND PRACTICE
REGARDING EXPRESSION AND STORAGE OF BREAST
MILK BY MOTHERS ADMITTED IN POSTNATAL
WARDS OF SELECTEDHOSPITALS
AT KOLAR,KARNATAKA.
PROFORMA SYNOPSIS FOR REGISTRATION OF SUBJECT
FOR DISSERTATION
MS. BEENA.N.H
AE&CSPAVANCOLLEGE OF NURSING
KOLAR,KARNATAKA
RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,
BANGALORE,KARNATAKA,
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS(IN BLOCK LETTERS) / BEENA.N.H.
AE&CSPAVANCOLLEGE OF NURSING
KOLAR, 563101
KARNATAKA
2 / NAME OF THE INSTITUTION / AE&CSPAVANCOLLEGE OF NURSING,
KOLAR
3 / COURSE OF STUDY,
SUBJECT / MScNURSING
OBSTETRICS AND GYNECOLOGY
4 / DATE OF ADMISSION / 30-5-2007
5 / TITLE OF THE TOPIC / ASTUDY TO ASSESSKNOWLEDGE,ATTITUDE AND PRACTICE REGARDING EXPRESSION AND STORAGE OF BREAST MILK BY MOTHERS ADMITTED IN POSTNATAL WARDS OF SELECTED HOSPITALS AT KOLAR KARNATAKA.
6.BRIEF RESUME OF INTENDED WORK
INTRODUCTION
The healthy citizen is the strong pillars of a nation. Mothers play a vital
role in preparing healthy citizen. Mother’s breast is the pitcher for her baby, the mother’s
milk will give the most precious components for the growth and development of the baby.
Breast milk helps to lower the risk and protect against many diseases. Human milk is treated as a baby fluid for infection control purposes. Standard precautions were used when handling breast milk1. Breast feeding is the first food for the baby and it is very important for the mother to start breast feeding with in half an hour of birth2
( Farooq Fazilli,2007)
A low birth weight baby is one with a birth weight of less than 2500 gmsLBW is one of the major causes for high infant mortality rate. Birth weight is the most sensitive and reliable indication for the risk to survival of baby and its healthy growth and development3.
Early initiation of breast feeding provides skin-to-skin contact and warmth the babies, particularly premature and LBW. It makes use of the babies sucking reflex to establish lactating. The clinical issues encompass the typically developing preterm infant, who requires special supports to develop the skills needed for successful sucking skills4.
Though babies have a natural sucking reflex, they still have to learn how to feed and may occasionally resist feeding from the breast. Medical conditions of the infant for the inhibition of breast feeding include poor sucking reflex due to pre-term and LBW. So breast milk has to be expressed and stored and has to be fed with spoon or paladay to the new born5.
Expression and storage of breast milk is the act of squeezing milk from the breast either by hand or with a manual or electric pump and Store in bottles or containers to feed the baby6.
Mothers of preterm infants must feed their babies by expressing the breast milk. 7. Teach the mother about the expression and storage of breast milk.While expressing wash hands and keep breast pump parts thoroughly washed, rinse and sterilize in order to prevent any bacteria from developing in the milk6. Direct manual expression of milk into sterilized, wide mouthed feeding bottles or cups, after washing the hands and wash the breasts with soap and water, appears to be the most suitable method. Contamination by this method is less than with pumps and involves no cost8. Gentle massage to be given to stimulate the milk glands. Encourage pumping at least every 3 hours for a total time of not more than 15 minutes at each section.
Mother should be explained about the four methods of human milk expression. The four methods included are the Egnell electric pump, the Loyd B pump, the Evenflo system, and manual expression. Most of the mothers use either manual expression (by hand) or electric pump method9.
To store breast milk safely, choose containers are sterile and airtightStore breast milk in plastic feeding bottles with secure tops to seal in keeping freshness. Also can use plastic bags made especially for storing milk6. Mothers are taught to mention the date, time and label each container of breast milk with hospital-medical record number. Name alert tags are placed on breast milk storage container of infants. Some mothers chose to hand express but most mothers uses breast pumps to facilitate milk expression. All breast milk containers, including bottles and syringes must be labeled with proper patient identification10.
Fresh milk is safe in the refrigerator for 48 hours. Frozen milk can be stored for 2 months in a -40C ,refrigerator freezer for 6 months in a -200C freezer10, at room temperature not warmer than 77 degrees F/25 degree C-for 4 hours, in a cold box with refreezable ice packs up to 24 hours6. Repeated freezing, throwing and heating can alter the fat composition, especially the triglycerides. To defrost frozen milk, place it in a pan of water or de frost in the refrigerator. Never microwave breast milk. It kills the nutrients in breast milk 11.
After using the pump, the breast shields and valves should be washed with hot soapy water and rinse well. Airs dry on a clean towel. The hand soap should be provided in each patient’s room. Pump part should be sterilized daily. This can be doneincentral processing if the mother is in the hospital for more than 48 hours. Electric breast pump is cleaned with disinfectant wipe before it is taken to another patient12.
Milk bank mandates pasteurization and freezing of the donors' milk. Most of the nutritional and immunological advantages of human milk are preserved after such treatments. Cytomegalovirus (CMV) infections in preterm infants, that were acquired from mothers expressed breast milk, are not uncommon, and require further attention 13
Expressing breast milk is also a great way to relieve engorged breasts. It also helps prolong breast feeding by keeping milk supply up2.
6.1. NEED FOR STUDY
“The lower the birth weight ,the greater is the chance of death”
Premature babies can have difficulties if their sucking reflex is still under developed and if they tire during feeds. If the baby can not be fed the breast milk from its mother’s breast, it should be fed with a cup4.
Breast milk is the best nutrition for the baby and it is protective14. Breast feeding benefits preterm infants from a nutritional, gastro intestinal,immunological.Developmental and psychological perspective7
Globally about 25 million low birth weight babies are born each year, consisting of 17% of all live births, nearly 95% of them in developing countries. The incidents of LBW varies widely between regions of the world, with levels of 32% in Southern Asia ,9% in Eastern Asia ,11-16% in Africa and 10-12 % percent in Latin America and Caribbean’s15. ( WHO)
Birth weight is the most sensitive and reliable indication for the risk to survival of baby and its healthy growth and development. Every second Indian child is under weighed. Children born LBW are 46%16. Low birth weight is one of the most serious challenges in maternal and child health in both developed and developing countries.LBW and premature babies in hospital were usually kept in incubator15.
Initiation of breast feeding with in half an hour provides skin-to-skin contact and warmth the babies particularly premature and LBW. It makes use of the babies sucking reflex to establish lactating2. Though babies have a natural sucking reflex, they still have to learn how to feed and may occasionally resist feeding from the breast. Medical conditions of the infant for the inhibition of breast feeding include poor sucking reflex due to pre-term and LBW. So breast milk has to be expressed and stored and has to be fed with spoon or paladay to the new born.
If the mother is going to be away from the baby or the baby is admitted in NICU for either a few hours or for a whole day, mother has to pump or manually express breast milk and has to be stored and it has to be send to the baby in time. This way the baby can still get the benefits of breast milk even though some one else will be feeding him when the mother is in post natal ward5.
Portion of the night and early morning feeds can be stored in the refrigerator just under the freezer compartment for a maximum of 24 hours8.
Raskin.A, Bader.D. (2003) conducted a study as mother’s breast milk is the best food for pre-term babies. Its advantages are in host defense, nutritional components and suitability for gut absorption as well as its psychological and developmental values.. Methods for storage of expressed breast milk and recommended length of storage are discussed .Milk bank mandates pasteurization and freezing of the donors milk. Most of the nutritional and immunological advantages of human milk are preserved after such treatments. Cytomegalovirus (CMV) infections in preterm infants, which were acquired from mother’s expressed breast milk, are not uncommon, and require further attention 13.
Paul VK, Singh.M, Deorari AK, Pacheco J, Taneja U.(1996) conducted a study on manual and pump methods of expression of breast milk, this study was designed to compare two methods of breast milk expression, namely, the manual and the pumping method using a hand-held cylindrical pump.The use of breast pump is more efficient than the manual system of expression of breast milk among mothers whose infants are not directly breast-fed. It is recommended that in case the mothers prefer to use the manual method, let them express as much milk as possible by this method initially, and then follow it up with a short period of pumping to ensure complete evacuation of breasts17
Indira narayanan, human milk for LBW,(1995) LBW infants who can not suck are conventionally fed by intermittent “bolus” gavage feeding with feeds given periodically every 1 to 3 hours or continuous infusion with milk for the set period taken in a syringe and given slowly, continuously with the aid of the pump. With the later method, the fat in human milk tends to separate out and remain in the syringe and tubing at the end of the feed. A trial was also carried out to determine how this fat loss could be reduced number of methods were evaluated but the simplest was to use an eccentric nozzle syringe, keep the pump titled up, take care to empty the syringe completely at the end of each feed and switch over to the intermittence ‘bolus’ feeding as soon as possible, as the fat loss was minimal.
Based on the review of literature and personal experience of the investigator during her clinical experience in the post natal ward found that many mothers are using different methods to express and store breast milk. Hence the investigator would like to find out the different opinion about knowledge, attitude and practice in expression and storage of breast milk
6.2. REVIEW OF LITERATURE
Review of literature is an essential activity of scientific research project; help to familiarize with the practical issue related to the problem and enable the researcher to avoid unintentional duplication of studies. The typical purpose for analyzing or reviewing existing literature is to generate research question to identify conceptual of theoretical tradition within the bodies of literature. Hence the investigator intending to review the literature available on expression and storage of breast milk by using both research and non-research materials.
LITERATRE RELATED ARE
1) Slusher.T,Slusher IL,Biomdo M,Bode-Thomas F,Curtis BA,Meier P, .(2007)conducted a study to compare mean daily MMV (maternal milk and volume)for mothers of premature and sick infants in special care using one of three methods of milk expression. Electronic breast pump, non-electronic pedal breast pump and hand (manual) expression.
They have studied on 65 mothers whose infants were unable to feed directly from the breast. The mothers were randomly assigned to one of three methods of milk expression .the dependent variable was measured for an average of 8.7 days.MMV for the electric and pedal pump and hand milk expression was 578 +/- 228 ml (n = 22), 463 +/- 302 ml (n = 24) and 323 +/- 199 ml (n = 19), respectively. The study revealed that there is a significant difference between electric breast pump expressions than hand-expression but not between electric and pedal pump18.
2) Pearce JL,Buchanan LF,.(2007) conducted a study on breast milk and breast feeding in very low birth weight infants. In this the feeding of 17 babies weighing than 1500 gms was examined .12 babies started breast feeding at a mean weight of 1324 gms and ten of them were fully breast fed by the mean weight of 1600gms .their weight gains were compared with bottle-fed babies receiving expressed breast milk. The increased incidence of breast feeding by mothers of both low birth weight and term babies ensures regular supplies of fresh breast milk 22.
3) Larson E,Zuill R,Zier V,Berg B, (2006) conducted a study to find out that the expressed breast milk can safely refrigerate or not. In this, the bacteriologic content of expressed milk was studied in 30 mothers at the time of expression and after 24-48 hours of refrigeration. All samples contained staphylococcus epidermises. In addition, eight other species were found, including four which were gram-negative. All samples contained less than 10(6) colonies/ml, and there were no significant differences in mean colony counts between samples expressed at home and at the hospital. They concluded that it is bacteriologically safe to refrigerate expressed breast milk for up to 48 hours19.
4) Jenifer callen,janet pinelli (2005)conducted a study on benefits of breast feeding for preterm infants through gavage feeding. The study concluded that breast feeding benefits preterm infants from nutritional, gastrointestinal, immunological developmental and psychological perspective 7.
5) Raskin.A, Bader.D. (2003) conducted a study as mother’s breast milk is the best food for pre-term babies. Its advantages are in host defense, nutritional components and suitability for gut absorption as well as its psychological and developmental values. Sucking skills usually mature around 34 weeks of gestational age.
Methods for storage of expressed breast milk and recommended length of storage are
discussed .Milk bank mandates pasteurization and freezing of the donors milk 13.
6)Ramji.s. (2002) in India conducted a study to support early enteral feeding of LBW neonates, including those who are sick or pre-term <30 weeks. Tropic feeding with human milk initiated with in 48 hours of birth at 10-15 ml/kg /day improve tolerance to graded increments of enteral feeding volumes. Tropic feeding support increments of feeding volume by 30ml/kg/day by intermittent gavage feeding. On-nutritive sucking and spoon-feeding aid earlier transition to excusive breast feeding.Human milk promotes adequate growth of most pre-term neonates 23.
7) Paul VK, Singh M, Deorari AK, Pacheco J, Taneja U.(1996)conducted a study on manual and pump methods of expression of breast milk. This study was done to compare two methods of breast milk expression, the manual and the pumping method using a hand-held cylindrical pump. It was seen that the use of breast pump (Medela) was associated with significantly higher volume of breast milk expressed per session the volume of breast milk expressed was greater by the pump method than the manual expression (on day 5 and 6 (46.8 +/- 26.3 ml vs. 31.2 +/- 15.5 ml, P < 0.01) as well as on day 8 and 9 (50.40 +/- 11.2 ml vs. 38.49 +/- 13.4 ml, P < 0.01). The use of breast pump is more efficient than the manual system of expression of breast milk among mothers whose infants are not directly breast-fed17.
Forte A,Maryberry L.J, Ferketich S(1995)they collected data about breast milk expression, collection and storage practice were by questionnaires from 51 mothers of hospitalized neonates’. They have also collected data about teaching sources, mother’s recall of breast-feeding information and areas of concern as described by mothers were identified.. The majority of mother collected breast milk in plastic containers: but only over 50% stored frozen milk in glass this is considered a less than optimal choice for storage. Over 50%of the mothers identified the need for additional information about breast feeding upon returning home from the hospital, particularly in relation to pumping and storage techniques20.
Gorric. (1994) conducted a study and came to a conclusion that expressed breast milk can be collected and stored in sterile plastic containers. After the breast milk is collected it should be cooled immediately by placing it in a refrigerator or on ice in a cooler. Whenever possible breast milk should be given fresh so that the infant receives all its benefits.
Green d,Moye L,Schreiner RL,Lemons JA (1982)conducted a study to evaluate the four methods of human milk expression. The four methods included are the Egnell electric pump, the Loyd B pump, the Evenflo system, and manual expression. The electric pump enabled mothers to express significantly more milk with adequate fat content during the expression period. No significant differences were found between the other three methods. The Egnell and electric pump are preferred for milk expression for some mothers, particularly those anticipating a prolonged need for pumping9.