Managing Lactation Failure in Mothers of Inpatient SAM children

Admission historyDate of Admission 14/09/2011

Child HistoryName Shahsawar (male child)

Age 4.5 Months

Weight 3.5 Kgs

height 58cm

Z score <-4SD

Diagnosis Dysentery, dehydration, fever, presented in semiconscious state

Child’s Nutritional status Severely wasted, lethargic, feeble to suckle, refusing breast milk due to bottle feeding

Mother HistoryMother’s Nutritional status Anemic and complaining of insufficient milk production. Patient is the

ninth child and mother gives history of insufficient milk syndrome for all previous 8 children.

Mother breast feeding status

• Partial lactation failure, breast milk insufficient to satisfy baby needs.

• Baby positioning was incorrect, Inappropriate latching.• Baby’s nostrils usually stuffed, Patient removed from

breast with slight irritability and mostly bottle fed.• Breast feed was only offered 2-3 times in the day hours.

Baby was not breast fed in the night.• Mother was anemic and feeling weak.

Treatment (Child & Mother)• I/V medications were given according to SC protocol• Proper breast feeding technique was taught to the

mother and was convinced for breast feeding.• Mothers was fed with 2 sachets of plumpy-nut and

hospital food was encouraged with good water intake and Micronutrient supplementation.

• F100D was started to the child through Supplementary suckling technique 2 hourly.

Supplementary Suckling technique (SST)

Sketch diagram used to reluctance of mothers to pose for photographs due to cultural constraints in Khyber Pukhtoonkhwa

Treatment Continued….• The breast milk was assessed by expressing milk on the day of

admission and monitored on daily basis by the staff nurse noting improvement day by day. Mother gave history of breast fullness on day 2 of SST. The mother noted increase in milk production by milk dripping on day 5 after feeds. On admission baby had ineffective suckling with rapid and shallow sucks forcing the cheeks inside. The suckling improved till discharge and baby had slow deep sucks with mouth fullness and pausing while suckling.

• Baby’s weight was monitored and the quantity of F100D was halved when baby achieved 20gm/kg/day weight gain and was discontinued the following day.

• The patient was discharged when the baby maintained 10gm/kg/day weight gain on breast milk alone. The patient was discharged after 8 days of inpatient care.

Discharge statusCategory Admission Discharge

Date 14/09/2011 21/09/2011

Age 4.5 Months 4.5 Months

Weight 3.5 Kg 4.12 Kg

height 58cm 58 cm

Z score <-4SD <-3SD

Diagnosis Dysentery, dehydration, fever, presented in semiconscious state

Complications settled, baby interactive

Nutritional status Severely wasted, lethargic, feeble to suckle, refusing breast milk due to bottle feeding

Suckling re-established, 600 gm of weight gain.24gm/kg/day weight gain

Mothers nutritional status Anemic and complaining of insufficient milk production. Patient is the ninth child and mother gives history of insufficient milk syndrome for all deliveries.

Breast fullness, mother and baby satisfied, mother misconception cleared by re-establishment of Breast feeding.

Apparent ComparisonAdmission Discharge

Counseling mother….

• Diet counseling of the mother was done in support of breast feeding.

• The mother was convinced about the facts of proper breast feeding and she helped 6 admitted mothers through SST and motivational counseling.

• On discharge the mother promised to work as an activist and convince mothers in her approach.

• The home based SST technique was taught to the mother for helping other mothers in her surrounding.

Follow-up status

• Baby has gained further weight and is reacting efficiently to external stimulus

• Baby taking interest in feeding and playing.• Mother satisfied with breast feeding and loves her baby more

than ever before.• Mother has succeeded to re-establish breast feeding for three

mothers in her neighborhood through counseling, experience sharing and home based Supplementary Suckling Technique.

• On follow –up mother spoke to another admitted mother on staff request and convinced her for re-establishment of breast feeding.

Follow-up status (Anthropometry)Category Admission Discharge Follow-up

Date 14/09/2011 21/09/2011 06/10/2011

Age 4.5 Months 4.5 Months 5 months

Weight 3.5 Kg 4.12 Kg 4.5 Kg

height 58 cm 58 cm 59 cm

Z score <-4SD <-3SD <-2 SD

Diagnosis Dysentery, dehydration, fever, presented in semiconscious state

Complications settled, baby interactive

Nil complications

Nutritional status

Severely wasted, lethargic, feeble to suckle, refusing breast milk due to bottle feeding

Suckling re-established, 600 gm of weight gain.

Ascending weight continuously, 1000gm weight gain in 23 days.12.4gm /Kg/day wt gain

Mothers nutritional status

Anemic and complaining of insufficient milk production. Patient is the ninth child and mother gives history of insufficient milk syndrome for all deliveries.

Breast fullness, mother and baby satisfied, mother misconception cleared by re-establishment of Breast feeding.

Feeling healthy and confident about breast feeding by learning and teaching to others.

Shahsawar with parents on follow-up visit

Mother Comments

Packing her bag and eager to reach home, delighted Zakia begum shared her feelings with the female nutritionist and staff nurse reflecting mixed emotions of contentment with her child’s recovery and regrets on past negligence that deprived her 8 previous babies from exclusive and appropriate breastfeeding practices. Her Husband Abdul Rehman, a daily wage laborer supported his wife during the treatment period and is working as Merlin’s activist promoting the approaches that recovered his child and wife from malnutrition and lactation failure. The detailed discussion with the couple revealed multiple contributing factors preventing breastfeeding to their babies, including misconceptions related to culture, religion and elders. Zakia shared that she has been disposing off her colostrum for all her newborns on advice of elders whom considered it to be toxic and useless. This has been practiced in her family since generations. She thanked the SC staff for counseling her on the real value of mother’s milk that helped her dispel the false beliefs and taboos to bring a positive change in her behavior.

Making it possible!

On Arrival After treatment