Elvira Gama-Martínez,1 Guillermina Romero-Quechol,2 Héctor Jaime González-Cabello,3 Marilin Martínez-Olivares2
1Puerperio Fisiológico y Alojamiento Conjunto 3 Sur, Hospital de Gineco Obstetricia 4; 2Unidad de Investigación Epidemiológica y Servicios de Salud, Coordinación de Investigación en Salud; 3Unidad de Cuidados Intensivos Neonatales, Hospital de Pediatría Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social. Distrito Federal, México
Correspondence: Elvira Gama Martínez
Date received: December 10th, 2014
Date judged: February 11th, 2015
Date accepted: June 24th, 2015
Introduction: Hospital newborn complications and the risk of nosocomial infections related to hospitalization and increases immunocompromised, in this condition of exclusive breastfeeding can help reduce morbidity and mortality this critical period.
Objective: To describe the causes that limit breastfeeding newborn hospitalized in the Neonatal Intensive Care Unit.
Methodology: Descriptive study, a structured instrument with five sections, the 1 and 2 with general data and medical history of the mother-son was applied; Sections 3, 4 and 5 information, aspects of the practice of breastfeeding and milk demand; We face to face 36 to 36 mothers of newborns hospitalized interview was conducted. For data analysis Descriptive statistics were used.
Results: 52.8% of newborns are premature and supply 50% of them; the average maternal age was 27 years, engaged in household 83.3% and 52.7% higher average education. In 68% of cases the main constraint to breastfeeding was poor reporting on conservation and transfer of breast milk to the hospital, the low milk 20%, 8% and fatigue work 4%.
Conclusions: Poor mother’s information on the conservation and transfer of breast milk is related to the non-extraction of milk, strengthening education strategies is recommended to mothers of newborn hospitalized for extraction and conservation Milk and on the benefits to immune support.
Keywords: Breast feeding; Newborn infant; Intensive Care; Hospitalization; Mothers.
Exclusive breastfeeding for the first six months of life includes wetnursing or extracted milk, but allows the newborn (NB) to receive only oral rehydration solution, drops, and syrups (vitamins, minerals, medicine).1 Early initiation, in the first hour of life, protects the newborn from infections and reduces neonatal mortality, and risk of death may increase in infants receiving only partial breastfeeding or exclusively formula feeding. Breastfeeding is the essential source of energy and nutrients during illness, reduces mortality for malnourished children, and is the healthiest way for human beings to begin life. It is ideal for nutritional and immunological benefits, as it ensures healthy biopsychosocial growth and development, helping to reduce infant morbidity and mortality, especially protection against respiratory and gastrointestinal infections, which are observed not only in developing countries but also in industrialized countries.
Breastfeeding is so important that it could save the lives of some 800,000 children under 5 annually. In countries with high prevalence of stunted growth, promoting breastfeeding and appropriate complementary feeding could prevent the deaths of some 220,000 children under 5.
The benefits in newborns are improved tolerance to food, and a 77% decrease of necrotizing enterocolitis is observed in premature babies fed exclusively breast milk, compared with infants fed with combined human milk and cow's milk formula.
It is also associated with a lower frequency in stunting and neurodevelopmental disability in premature babies.2,3
In mothers, it contributes to health and well-being, promotes quick postpartum recovery, reduces the risk of ovarian and breast cancer, and helps space pregnancies. Adults who were breastfed in infancy tend to have lower blood pressure, lower cholesterol levels, and less overweight, obesity, and type 2 diabetes.2
Optimal breastfeeding of infants under two years of age has more potential impact on child survival than any other preventive intervention, as it can prevent 1.4 million deaths of children under five worldwide. The results of a study conducted in Ghana show that breastfeeding babies during the first hour after birth can prevent 22% of neonatal deaths. Breastfed children have at least six times more chances of survival in the first few months that children not breastfed.4
The United Nations Children's Emergency Fund (UNICEF) reports that only 38% of children under six months of age are exclusively breastfed in developing countries and only 39% of children 20 to 23 months old benefit from the practice of breastfeeding.4 Thus, exclusive breastfeeding and its duration have declined significantly since the widespread introduction and promotion of various breast milk substitutes;5 this is paired with mothers’ distrust in their ability to produce milk and feeling unable to breastfeed and work, which are accentuated by existing behavior patterns in families who practice artificial feeding, and which negatively influence the actions of mothers of newborns who require this primordial food.
In response, the World Health Organization (WHO) and UNICEF, in collaboration with international and national organizations, governments, and civil society, have developed strategies to promote, protect, and support maternal breastfeeding.6 Thus, the Global Strategy for Infant and Young Child Feeding was adopted in 2002 in order to revive the attention the world pays to the impact of feeding practices on the nutritional status, growth and development, health, and survival of infants and young children. This strategy builds on previous initiatives, including the Innocenti Declaration and the "Baby Friendly Hospital" Initiative which address the needs of all children, including those living in difficult circumstances, such as the children of mothers with HIV, infants with low birth weight, and those living in emergency situations. This is the guiding framework that WHO used to establish priorities in research and development to provide technical support to countries to facilitate its application.7
Although breastfeeding is the intervention with the most evidence of efficacy in reducing neonatal mortality, duration of breastfeeding in Mexico is about 10 months, a number that has been stable over the past decade; the percentage of exclusive breastfeeding under six months fell from 2006 to 2012, from 22.3% to 14.5%, and it was dramatic in rural areas, where it fell by half, from 36.9% to 18.5%. An additional 5% of children under six months consume formula, and the percentage of children who unnecessarily consume water in addition to breast milk increased. This is negative because it inhibits milk production and significantly increases the risk of gastrointestinal diseases. Mothers who never breast-fed their children mentioned causes that suggest ignorance or little support before and around birth to initiate and establish lactation.8
In Mexico, actions and proposals to protect, support, and promote breastfeeding have been implemented by the Secretaría de Salud in coordination with health institutions, and each institution has adopted them according to their needs. In 1991 the Comité Nacional de Lactancia Materna was formally established, which is the highest level of coordination of actions to promote breastfeeding; in that same year the institutional committee of the Hospital Amigo del Niño y de la Madre initiative was created. Thus, in 1993 staff training began through lectures and courses on breastfeeding and rooming together.9
In 2006 lactation clinics were promoted in children’s and general hospitals, the Normas Oficiales Mexicanas (NOM) established provisions on breastfeeding, including NOM-007-SSA2-2010 "For the care of women during pregnancy, childbirth, postpartum, and newborn", which emphasizes the importance of exclusive breastfeeding,10 and NOM-043-SSA2-2012 "Basic health services. Promotion and health education in dietary issues", which states that the practice of breastfeeding is influenced by health personnel and people close to them, and recommends indirect breastfeeding, when the mother has to be separated from her child, or artificial lactation for medical reasons, for which the mother should be informed about preparation, stimulation, and extraction, as well as measures for milk storage and preservation to use it as nutrition for the baby.11
The Instituto Mexicano del Seguro Social (IMSS) has also implemented important actions to encourage breastfeeding, as they have certified several hospitals with the Programa Nacional Hospital Amigo del Niño y de la Madre, integrating rooming together as well as implementing the Kangaroo Mother Program, installing human milk banks, and control of milk substitutes, since health conditions in the early years of life impact decisively and sometimes permanently on the growth and development into adulthood.
In a neonatal intensive care unit (NICU), the practice of breastfeeding has even greater challenges as the newborn is separated from his mother and this can start at birth, sometimes due to the health conditions of the newborn, sometimes for the mother’s state of health, and it is possible that the health team may pay little attention to promoting breastfeeding, although during this critical period breast milk is vital because it gives immune support and helps decrease morbidity and mortality.
Against this background it was decided to conduct this study to describe the causes that limit breastfeeding during hospitalization, in order to generate alternatives for change that will benefit the quality of care provided by the health professional to the newborn.
A descriptive cross-sectional study was conducted from February to June 2014, in the Unidad Médica de Alta Especialidad (UMAE) Hospital de Pediatría Centro Médico Nacional (CMN) Siglo XXI. The instrument was created with 75 items validated by a round of 3/3 experts; the experts were considered nurses with a bachelor’s degree with more than 10 years of experience and 5 years as pediatrics specialists. Cronbach's alpha statistical test was applied for reliability, and a pilot test was conducted on a population with similar characteristics to identify whether the questions were clear, precise, and understandable, which facilitated appropriate changes to the form and helped determine the time of the instrument, which consisted of five sections: 1) the newborn’s data and disease history, 2) the mother’s socio-demographic data and gynecological and obstetric and disease history, 3) information received on breastfeeding, 4) breastfeeding practice, and 5) milk extraction requested by NICU professional; the questions were pre-coded, dichotomous, and open.
Convenience sampling was applied using the filter of the admission and discharge log of newborns in the NICU, and all mothers who were there in the course of fieldwork were interviewed (April-May 2014). The interview was conducted by the head of research, applying the technique face to face during their time in the waiting room, while respecting the ethical standards of the Declaration of Helsinki, the Regulations of Ley General de Salud in health research, requesting their participation and informing the study subject verbally and in writing, through the informed consent letter, specifying that they retain the right to withdraw at any time, without affecting their rights in the institution, emphasizing that the information provided would be confidential and for statistical purposes.
The study variables and newborn’s health status were obtained from the medical record, and the mother’s disease and gynecological-obstetrical history was corroborated with these as well.
Descriptive statistics were used, data were captured in SPSS version 21 for information analysis and simple frequency tables, percentages, and graphs were made.
Out of a total of 36 mothers, it was identified that 72.2% are at a low-risk reproductive age between 20 to 35 years and have completed middle school and high school in 44.4 and 27.8% respectively, 58.3% are from Mexico City and 41.7 % from elsewhere; it should be noted that 11.1% of mothers see the NB only once a day for reasons pertaining to the mother and not to hospital regulations (Table I).
|Table I. Characteristics of mothers of hospitalized newborns (n = 36)|
|< 20 years||4||11.1|
|> 35 years||6||16.7|
By exploring the obstetrical, gynecological, and medical history, it was identified that for 58.3% of mothers this was their first child, for 30.6% it was their second, and for 11.1% their third child or more. 38.9% of mothers had previously nursed a child, for periods of 0-3 months for 35.7%, 3-6 months for 28.6%, 6 -12 months for 28.6%, and more than one year for 7.1%.
Complications during pregnancy occurred in 91.7% of mothers, urinary tract infection (UTI) occurred in 84%, accompanied by other complications such as cervicovaginitis (CV) in 27.3%, severe preeclampsia (SP) in 18.2%, premature membranes rupture (PMR) in 15.2%, near miscarriage (NM), and preterm labor (PTL) in 12.1%, respectively; the combination of gestational hypertension (GHT) + CV + PTL occurred in 6.1%, and gestational diabetes, polyhydramnios, and bradycardia in 9% (Figure 1). Birth by caesarean was in 80.6% of cases.
Figure 1. Mothers’ complications during pregnancy (n = 33). UTI = Urinary Tract Infection; CV = cervicovaginitis; SP = Severe Preeclampsia; PMR = premature membrane rupture; NM = near miscarriage; PTL = Preterm labor; GHT = gestational hypertension; Other = Gestational diabetes, polyhydramnios, and bradycardia
Most newborns (63.9%) spent 0-7 days in the hospital, on average 12.5 days, by gestational age 52.8% were premature with an age < 29 days in 63.9% of cases. The main reasons for admission by specialty are: cardiology 38.9%, gastroenterology 27.8%, pulmonology 19.4%, genopathy 11.1%, and neurology 2.8% (Table II).
|Table II. Characteristics of newborns hospitalized in neonatal intensive care unit (n = 36)|
|Age of newborn (days)|
|Classification by gestational age|
|Immature NB (21-27 weeks and weight 0.5 to < 1 kg)||7||19.4|
|Premature NB (28-37 weeks and weight 1 - 2.5 kg)||19||52.8|
|Term NB (38-41 weeks and weight ≥ 2.5 kg)||10||27.8|
|< 1 kg||5||13.9|
|1 - 2.5 kg||14||39.9|
|< 2.5 kg||17||47.2|
|Length of hospital stay (days)|
|0 - 7||23||63.9|
|8 - 28||6||16.7|
|29 - 60||5||13.9|
|Reason for admission by specialty|
|NB = newborn|
52.8% of infants had surgical treatment, of which 57.9% had gastrointestinal tract surgery, 26.3% cardiological, and 15.8% neurological, nephrology, and plastic surgery; 50% had ventilatory support, 27.8% with oxygen and 22.2% with atmosphere. Of the half of the infants receiving enteral or oral feeding, 66.7% had mixed feeding (breast milk and formula), 27.8% only formula, and 5.5% breast milk only; the predominant route of feeding was by orogastric probe in 77.8% of the NB and bottle (suction) in 16.6%; the reasons for fasting in NB included: postoperative period in 33.3%, respiratory and hemodynamic pattern disorders in 27.8 and 22.2% respectively, and diagnostic studies and awaiting surgery in 11.1%.
Regarding the mothers’ practices in using and conserving breast milk, 54% use the breast pump for extraction, 62.5% do it at home, and 37.5% do it in the NICU; 50% keep it refrigerated, and 33% throw it away (Figure 2).
Figure 2. Mothers’ breast milk use and conservation practices (n = 24). BM = breast milk; NICU = neonatal intensive care unit
The top reasons mentioned by mothers for limited breast pumping were little or no milk production in 67%, fatigue in 17%, and work and the newborn fasting in 8%, respectively (Figure 3).
Figure 3. Reasons reported by the mother for limiting breast milk extraction (n = 12). BM = breast milk; NB = Newborn
The mothers’ milk was requested with a prescription for enteral or oral feeding in 72.2%, it was requested by the nurses in 44.4%, and by medical staff in 27.8%.
During the interview, 4.2% of mothers sought information on how to improve manual milk extraction, 20.8% help producing more milk, and 70.8% help with keeping breast milk (freezing, thawing, and transfer). A special need was about how to breastfeed a newborn with a cleft lip and palate, with 4.2%.
As for maternal occupation, it was reported that the mother’s work is the most common cause for not breastfeeding,12,13 the results reflect that 10% of mothers who work outside the home do not have a reason not to pump milk, this is attributable to problems in milk production.
A possible link was identified between schooling and breastfeeding practice: in this study three-quarters of the mothers interviewed reported a middle or high school education level, in whom the best breastfeeding practice was observed, a similar result to other studies;14,15 the finding that a higher academic level found a greater commitment to the practice of breastfeeding, contrasts with the hypothesis that with a higher educational level, the mother’s occupations or activities increase, which is the main reason for abandoning breatfeeding.13,16 In the present study, the mothers had partners, similar to that reported by Camargo,17 in which the majority of mothers lived with the child's father; this may explain the fact that over 80% of mothers work in the home and had their partner as economic providers, allowing them to spend time with their child.
The mothers’ reports of lack of information on breastfeeding coincides with the study by Felix Valenzuela,18 in which about half of the mothers specifically mentioned information on the benefits of breastfeeding; while it may reflect recall bias, the mothers did report knowing that it was important to feed their child with breast milk.
It is relevant in this study that about one fifth of mothers reported not receiving information on breastfeeding, however in this study mothers still pumped milk, but they were expected to have more information due to having received prenatal and perinatal care; almost half of the mothers lacked knowledge of stimulation, and how to keep and transfer milk; the worrying thing was that a third of those who pumped milk threw it away, and those who kept it did it wrong, so there was no milk for when the newborn began enteral feeding. These results show the need to emphasize the theme during pregnancy and postpartum stay and the newborn’s hospitalization.17
In this study the fact that more than three quarters of the mothers had had caesarean section surgery and being primiparous were not limiting factors for milk extraction, in contrast to what Niño reports.16 It is possible that for some mothers unable to breastfeed the newborn in the early days due to fasting, the alternative was to extract and store milk, to later integrate it into visiting the newborn in the hospital.
This supports the fact that a previous successful breastfeeding experience is associated with exclusive breastfeeding; a possible answer is that the mother feels motivated knowing her child is sick, or supporting and comforting the other mothers of hospitalized newborns, or also the possibility that nursing staff support milk pumping.
There is scarce information at a national level on reasons for abandoning breastfeeding in tertiary care; the existing information is for hospitals where the newborn leaves with the mother. This study’s main contribution is having studied the newborn separated from its mother due to its health, who has a greater challenge to be breastfed.
The NB’s health status and hospital stay may be factors that limit breastfeeding because their mothers’ milk is not extracted, half of their children were admitted when eight or more days old, and the rest were more than 25 days. It is necessary to increase the sample size to analyze these results in detail.
Fatigue had not been reported as a reason for abandoning breastfeeding; the answers can be varied and have different approaches and focuses; some factors to consider, only as examples, are: the newborn’s health and age, time fasting, the mother’s exhaustion from administrative procedures, appointments at the NICU, the mother accompanying and waiting during the NB’s studies or surgical procedures, visits twice a day, household activities, diet, and mothers’ periods of sleep during this process.
This study identified some limitations to promoting and encouraging breastfeeding: first, those having to do with the newborn’s health conditions, and second, the culture of bottle feeding and feeding with breastmilk substitutes by health personnel. Significantly, this is an area of opportunity to intervene with educational strategies to facilitate a cultural change in health personnel and timely educational intervention for mothers of newborns admitted to the NICU.