Indian Pediatrics 2003; 40:343-347 

Initiation of Lactation and Establishing Relactation in Outpatients

Shobha Banapurmath, C.R. Banapurmath, Nirmala Kesaree

From the Bapuji Child Health Institute and Research Center, Davangere-577 004, India.
Correspondence to: Dr. Shobha Banapurmath, # 390, 8th Main, P.J. Extension, Davangere 577 002, India.
E-mail: [email protected]

Manuscript received: May 7, 2002; Initial review completed: June 11, 2002;
Revision accepted: December 11, 2002.

The present study was conducted to evaluate whether mothers with babies less than 6 weeks of age can be helped to initiate or establish lactation in outpatient department. One thousand mothers with babies less than 6 weeks of age who completed 10 days of follow-up in outpatient have been analyzed. Mothers who had either stopped breastfeeding or were not able to initiate breastfeeding were helped with establishing lactation at outpatient clinic. Sick babies and mothers having breast problem and systemic illness were excluded. 91.6% of mothers succeeded in establishing lactation within 10 days. 83.4% mothers achieved complete lactation and 8.2% of mothers achieved partial lactation in 10 days. However, 8.4% of mothers could not be helped in this study. They had to be hospitalized because of various reasons. It is possible to help majority of mothers with lactation difficulties at the outpatient when the baby is less than 6 weeks of age. Helping mothers with proper attachement at the breast appears to be crucial for success.

Key words: Breastfeeding, Relactation.

Many mothers are unable to breastfeed after delivery, as a result babies are at increased risk of illness, malnutrition and death. Every encounter of a mother and infant with a health worker throughout at least in the first year, whether for immunization, growth monitoring, treatment of an illness or family planning should include a basic assessment of breastfeeding. If there is any difficulty, help should be offered. Babies who were unable to initiate breastfeeding and mothers who had stopped breastfeeding were helped to re-establish breastfeeding in the initial 6 weeks of life in a pediatric out patient.

Subjects and Methods

One thousand mothers with babies less than 6 weeks of age who had either not initiated breastfeeding or stopped breast-feeding were taken for study from pediatric out patients between March 94 to March 2002 at Davangere. Care was taken not to include babies weighing less than 1.5 kg, sick babies, preterm babies, babies who had suffered from birth trauma, or had major congenital anomalies. Mothers with serious systemic illness and problems like inverted nipples, mastitis and breast abscess were not included in the study.

When the lactation gap was less than 15 days, the process was called as establishing lactation(1) and when the lactation gap was more than 15 days the process was called as relactation(2). Lactation and relactation were termed complete when no top milk was supplemented(3). It was termed partial when top milk requirement was reduced by more than half(3).

Mothers were followed up regularly for 10 days. Doctors and nurses well-trained in human lactation management helped the mothers. A room was provided with hand washing facility. Some mothers stayed in out patient for 3 to 4 hours. Mothers were informed about the benefits of breastfeeding. They were also informed how lactation works and how long it may take to establish lactation. Flip charts were used to educate mothers and her family members. Mothers were taught the technique of manual expression of breast milk. Drop and drip method(4) was taught to the mother and her relatives. Mothers were shown how she should attach the baby to the breast, with aiming the baby’s lower lip well below the nipple. Babies who were refusing to attach at the breast were induced with "Drop and Drip" method(4). If attachement was not satis-factory, mothers were helped to procure good attachment. If baby was sleeping or irritable or mother was exhausted, they were advised to try breastfeeding as demonstrated after some time. Once mother and baby were receptive, breastfeeding was tried again. They were told to try at home every 2nd hour for 10 to 15 minutes on each breast.

Mothers were supported and helped with confidence building and positive reinforce-ment. Family members were advised to extend practical help to mother, so that she gets more time with the baby. Mothers were advised to give plenty of skin to skin contact and continue to offer breast at any time that the infant showed any interest. They were encouraged to sleep with baby at night to allow an easy access to the breast and extra contact to increase the babies willingness to suckle(5).

Mothers were advised to feed the babies with cup and spoon. As breast milk production increased, the amount of supplement consumed was reduced. No drugs were used to induce lactation. Baby’s weight was monitored. Mothers were asked to follow the urine out put of babies in 24 hours. If baby was passing clear, colorless urine of good quantity, more than 6 time during day time and more than 2 times at night time, mothers were assured that her baby was getting enough milk, when baby was receiving only mother’s milk.

On subsequent days, babies were again assessed with breastfeeding. Some mothers succeeded with good position early and other mothers were able to get attachment at the breast after repeated attempts. However, some babies were crying and were doing only nipple suckling with cheeks getting puckered with each feed, such mothers were helped again with positioning until the positioning was found to be satisfactory.

Telephone services were given to mother and her family to clear doubts and allay their anxiety. Parents were instructed to bring the infant if he became dull or unwell. Constant growth monitoring was done. Top feeds were reduced gradually. Demand feeding was advised once lactation was established.

Results

One thousand mothers with babies less than 6 weeks were taken up for study. Of them, 84 (8.4%) mothers could not be helped and were advised hospitalization. They were excluded from analysis in this study. Out of the remaining 916 mothers, it was easy to establish lactation in 871 babies having lactation gap of less than 15 days and in the remaining 45 babies where lactation gap was more than 15 days, relactation was possible at outpatient department within 10 days.

Table I shows that of the two groups of babies, 834 babies in Group-I achieved complete lactation and 82 babies belonging to Group-II, took longer time to achieve partial lactation and could not achieve complete lactation during 10 days of study. Table I also depicts time taken for partial lactation, complete lactation and time to proper attachment in days in both groups with mean and standard deviation according to age of babies in days. All the 916 babies (91.6%) could attach at the breast within 3 days and all babies less than one week of age could attach well within 24 hours.
 

Table I 

Establishing Partial Lactation (PL) and Complete Lactation (CL) in 
                              Outputient among 916 Mothers.			

Age (days)	No. of babies		Time to proper attachment		Time to PL(days)		Time to CL(days)		Mean		SD
	Gr-I	Gr-II	Gr-I	Gr-II	Gr-I	Gr-II	Gr-I	Gr-II	Gr-I	Gr-II	Gr-I	Gr-II
<7	441	48	0-1	0-1	2-3	5-7	3- 5	---	4.59	6.23	0.61	0.81
8-15	254	21	1-2	1-2	2-3	5-7	3- 5	---	4.29	6.14	0.76	0.79
16-30	121	10	1-2	1-3	4-5	7-10	7-10	---	9.31	8.30	0.97	0.95
31-45	18	03	1-3	1-3	4-5	7-10	7-10	---	8.89	9.00	1.13	1.73

Gr-I: Group I; Gr-II: Group II.

 

In this study, 318 (31.8%) mothers were less than 18 years, 766 (76.6%) mothers were from rural area and 718 (71.8%) mothers were primie gravida. A total of 811 (81.1%) mothers had delivered at home, 781 (78.1%) mothers had given prelacteal feeds, 260 (26.0%) mothers were bottle-feeding and none of them were using pacifiers. Reasons for attending out patient included: routine check up, immunization visits, illness in baby, excessive crying, not taking breastfeeding and not enough breast-milk.

Discussion

The first few weeks post partum has been identified as a critical time for establishing lactation or for early termination of breastfeeding(6). A study on breastfeeding and mortality showed that compared to exclusively breastfed infants, infants who were partially breastfed had a relative risk of death of 4.2 and those who were not breastfed had a relative risk of death of 14.2. When this analysis was limited to deaths within the first 2 months of life, the risk of death of not breastfeeding compared to that of exclusive breastfeeding increased to 23.3(7) extended to first six months of life.

Relactation is more time consuming, needs intensive and continuing support so every effort must be made to support mother from the very beginning of her confinement, during delivery and later also. When mothers receive good support and guidance from doctors and paramedical staff regarding how to initiate, establish and sustain breastfeeding, relacta-tion should rarely be necessary.

In this study duration to achieve ‘Partial Lactation’ and ‘Complete Lactation’ was less as compared to another study(8). This may be due to younger age of baby and shorter lactation gap(2,9). De et al.(10) reported 91% relactation when lactation gap is between 10-15 days and 84% success when lactation gap is between 16-20 days and 60% success when lactation gap was more than 20 days unlike our experience where we report 91% success in babies less than 6 weeks. The lactation gap varied from 1 to 45 days but 92.5% of babies were less than one month in the present study.

Mothers need support and help with pro-per positioning to establish lactation(11,12). Relactation is possible even if breast is producing little milk(13). Lakhkar et al.(14) from Manipal managed 20 mothers and babies successfully on an outpatient basis where lactation gaps ranged from 2 weeks to 4 months.

Babies who are bottle-fed develop prefer-ence for artificial nipple. It was interesting to note that in young babies less than 6 weeks old it was possible to attach the baby within 3 days even if infant had never sucked before, or if he was used to bottle feeding. This may be due to younger age of the baby and shorter lactation gap among the study cases.

The fear of managing the baby on out patient basis has some risks. Mothers may not come for regular follow-up and baby can become suddenly sick. Hence admission for every case was advised but parents were not willing for admission to hospital due to various reasons. Reasons for refusal to get admitted for lactation management were recent admission to hospital either for delivery or admission to neonatal intensive care unit, financial constraints or needed time to gather family support on this matter. When out-patient follow up was offered more mothers readily accepted it. The present study shows that young mothers delivering at home need more help. A recent study has shown that breastfeeding problems are not uncommon even in a predominantly breastfeeding rural community(15). Hospital based strategies for breastfeeding promotion cannot reach women delivering at home. Home visits by well-trained breastfeeding counselors were highly effective in extending the duration of exclusive breastfeeding(16-17).

Contributors: SCB was involved in the planning, design and drafting of the manuscript. NK provided critical review. CRB will act as guarantor of the study.

Funding: None.

Competing interests: None stated.

 References