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Issue no. 17 - May 1984
pdf
version of this Issue
There is much information in this issue that is valuable
and useful. Online readers are reminded, however, that treatment guidelines and health
care practices change over time. If you are in doubt, please refer to
WHO's up-to-date Dehydration Treatment
Plans.
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Pages 1-8 Diarrhoea Dialogue Online Issue 17 -
May 1984
DDOnline
Diarrhoea Dialogue Online Issue 17 May
1984
Page 1 2
Breastfeeding: best start for all babies
Babies fed on human milk seem to get less diarrhoea than those fed on breastmilk
substitutes. If they do become infected, they are much less likely to die. Breastfeeding
should always be continued throughout oral rehydration therapy. Scientific evidence is fast accumulating to justify the belief that breastmilk is not
only the ideal food for all newborns and infants up to six months, but also contains
special substances which help protect them against dangerous organisms in the environment
(see="#page4">pages 4 and 5). From its first issue four
years ago, Diarrhoea Dialogue has continually stressed both the nutritional and the
protective significance of breastmilk. Breastfeeding is especially important where
diarrhoeal and other infections are common, water supplies are unsafe and supplementary
foods suitable for small children are both costly and scarce. More local groups needed
Breastfeeding partnership
This issue of Diarrhoea Dialogue describes the many benefits of the
breastfeeding partnership to both mother and baby. It includes a special pull-out poster
based on the materials used by a group in Kenya to promote breastfeeding among local
mothers. We hope this will encourage other readers to start their own groups and there is
a list on the poster of information sources to help you to do this.
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Value of colostrum Breastfeeding should start on delivery. Colostrum (the special fluid present in the
breasts at birth) is particularly rich in protective substances. Newborns should be
suckled straightaway, and then as frequently as possible to help establish and maintain
the breastmilk supply. The suckling of the baby helps the mother's womb to contract which
reduces any danger of maternal bleeding. It helps later on with family spacing. There is
therefore an extra contraceptive benefit for the breastfeeding mother (see="#page3">page 3). Very small, feeble or sick infants have a special need for human milk. Even where
babies cannot suck effectively, breastmilk can be expressed and, if necessary stored for
their feeding (see="#page6">pages 6 and 7). The mother
is, however, the best and safest milk bank! Reversing the trend
It is a sad comment on perceived social priorities that the custom of breastfeeding
seems to be on the decline, most noticeably among Third World urban populations, just when
well-educated Western women are busy rediscovering its advantages both for their infants
and for themselves (see="#page2">page 2). This trend away from breastfeeding
in developing countries needs to be stopped. First, however, it has to be understood. Only
then will breastfeeding be marketed as successfully as breastmilk substitutes were being
marketed before the introduction of the International Code (see="#page3">page 3). Rethinking priorities
Many more women in almost all countries now both wish and need to work outside the
home. Social and industrial adjustments must be made to permit them to combine
breastfeeding with employment. Extensive family and community support for breastfeeding
mothers is essential. Human milk must continue to play its invaluable part in reducing
diarrhoea mortality, morbidity and severity and the associated malnutrition among the
world's children. It is everyone's responsibility to see that babies everywhere receive
their natural and best start in life. KME and WAMC
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In this issue . . .
- The role of breastfeeding in child survival
- Breast milk banking in the U.K. and India
- News and reviews
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Diarrhoea Dialogue Online Issue 17 May
1984 1 Page 2 3
ORT in East Germany By law, all cases of diarrhoea in the German Democratic Republic (GDR) must be
reported. This system, operating since 1966, has revealed high attack rates due to
diarrhoea, although without the high mortality found in developing countries. This is
because patients are generally much healthier and, in particular, are much better
nourished. They can also be treated quickly. Until 1979 standard treatment for diarrhoea
in the GDR was by rehydration with drinks of tea or glucose-free solutions. Severe cases
were given intravenous drips in clinics. Antibiotics were used where necessary. Since 1979 the Institute of Childhood Infectious Diseases in Berlin-Buch has been using
Oral Rehydration Salts (ORS) in the treatment of dehydration as follows:
- Children who have already been given drinks such as tea are then given ORS (known as
Oralyt in the GDR).
- Almost all the children who would previously have been rehydrated intravenously, are now
given ORS by mouth. Intravenous drips are very rarely used.
- No side effects, either metabolic or other, have been found with use of
Oralyt.
Other clinics in the GDR are now using Oralyt - particularly for treating children in
out-patient departments. As a result, the Institute for Drugs and Drug Control has put
Oralyt on the official medicines list. This has provided a standard for all pharmacies
regarding the manufacture, storage and dispensing of Oralyt. The successful use of Oralyt in the GDR highlights how a practical treatment, developed
to solve a problem in the Third world, can also be used very effectively elsewhere. Professor Dr H. W. Ocklitz, Institute of Childhood Infectious Diseases,
Wilthergstrasse 50, Berlin-Buch, GDR 1115.
Arabic DD An Arabic edition of Diarrhoea Dialogue, containing material from issues 1-15,
will be available in June. Readers who would like to receive this should write to AHRTAG,
85 Marylebone High Street, London, W1M 3DE, U.K. Portugal: rediscovering breastfeeding
Women in many countries are rediscovering the benefits of breastfeeding for both
themselves and their babies. This trend is clear in Portugal which has characteristics of
both developed and developing countries. The increase in breastfeeding here is due largely
to the promotional effort being made by paediatric associations, paediatric and teaching
hospitals, maternity units, health centres and educators. The implementation and
monitoring of the International Code of Marketing of Breastmilk Substitutes has been in
operation since 1981 in Portugal. Several clinical surveys have been carried out to
evaluate the success of these interventions in promoting breastfeeding. From our own experience three main facts have emerged:
- In the children's hospital at Coimbra, no child was admitted with severe dehydration who
had been exclusively breastfed. Of 4,213 children admitted during a year in the short-stay
hospitalisation unit, 422 needed rehydration for diarrhoea. All these children were being
bottle-fed.
- Mothers staying close to their babies in the hospital are able to breastfeed them.
Babies stay close to their mothers, not in a separate nursery and this is important for
all, but particularly so if the infant has a low birthweight and/or is sick. Maternity and
paediatric departments are ideal places to reinforce teaching which has been given at
health centres. This dialogue between hospitals and health centres is essential to achieve
the goal of increasing breastfeeding and reducing diarrhoea morbidity and mortality.
- A recent study in our district to assess breastfeeding prevalence in relation to illness
showed that the number of infants with diarrhoea was significantly less among those
receiving only breastmilk, compared with those receiving breastmilk substitutes.
Dr A. Torrado, Hospital Pediatrico de Coimbra, Centro Hospitalar de Coimbra, 3001
Coimbra Codex, Portugal.
Urban priority A study was carried out recently in Sri Lanka on the link between infant feeding
practices and the incidence of diarrhoeal disease. In Colombo, over 90 per cent of small
babies admitted to hospital with diarrhoea were found to have been bottle-fed. In a larger community-based study, cluster samples were identified from 70 per cent of
the total population. Weekly inquiries were made about the feeding practices and
diarrhoeal illnesses of 2,700 infants. City children who were breastfed were shown to have
a significant degree of protection against diarrhoea. In cases where breastfeeding had
been stopped 25 per cent of the parents reported diarrhoea. Only 13 per cent of breastfed
children had suffered from diarrhoea. This difference was particularly apparent during the
first four to six months of life. The Sri Lankan study underlines the particular importance of promoting breastfeeding in
urban areas, where poor environmental conditions result in a high incidence of diarrhoea. Professor Priyani Soysa and Dr Dulitha Fernando, Department of Paediatrics, Faculty
of Medicine, University of Colombo, Sri Lanka.
Tropical Diseases Bulletin Echoing the WHO day theme 'Children's Health -Tomorrow's Wealth', the April issue of
the Tropical Diseases Bulletin contains abstracts of 250 selected papers
relating to children's health, available at £5/$12.50 from the Bureau of Hygiene and
Tropical Medicine, Keppel Street, Gower Street, London, WC1, U.K.
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Diarrhoea Dialogue Online Issue 17 May
1984 2 Page 3 4
Journal of Diarrhoeal Diseases Research
International Centre for Diarrhoeal Disease Research, GPD Box 128, Dhaka 2,
Bangladesh In 1978 the World Health Organization set up a control programme for diarrhoeal
diseases, and the International Centre for Diarrhoeal Disease Research was established in
Bangladesh (ICDDR, B). The Centre is the home of this new journal, and it naturally lays
special emphasis on work in Asia. However, anyone in the world interested in advances in
the field would be well advised to examine this periodical since so much research in
recent years has come from this part of the world. There are to be four issues each year. The first half of each is devoted to original
articles and short communications. In the first two issues these have come from countries
as far apart as China and the USA, and have covered a range of subjects from developments
in oral rehydration and drug therapy to the mechanisms of a variety of diarrhoeal agents,
but especially cholera. The second half is devoted to an annotated bibliography. About one third of the articles are merely mentioned by title and summarized in one or
two paragraphs. These reviews might be more valuable if they concluded with a few
sentences of critical comment, preferably signed by an authority on the subject. This
would indicate the novelty and strength of the papers presented. However, the journal is
off to an excellent start, has set itself a high standard to maintain, and is a valuable
source for all those interested in research and for the many concerned with the management
of diarrhoeal diseases. Readers in the Asian region may like to know that the Centre also publishes a
newsletter, Glimpse, which covers items of local popular interest relating to
diarrhoeal disease prevention and control. WHO study
WHO has carried out a collaborative study on prevalence and duration of breastfeeding
in nine countries. Findings indicate that while there are signs of a decline in
breastfeeding among certain groups in developing countries, there is also a marked
increase in the prevalence and duration of breastfeeding elsewhere. In Sweden and Hungary,
the two most industrialized of the nine countries, only 7 per cent and 3 per cent
respectively of the mothers studied had never breastfed their youngest child, a marked
improvement from 25 years ago. In the Philippines and Guatemala the situation among
middle-income mothers was significantly different: 32 per cent and 23 per cent
respectively had never attempted to breastfeed their last child. A more recent review of 200 studies suggests that a process is emerging in which higher
income groups and industrialized countries set the trend, and are then followed gradually
by the urban lower income, rural groups and less industrialized countries. Later, there is
a resurgence of interest in breastfeeding among middle-income families and this, in turn,
is gradually followed by other urban and rural groups. Clear lessons The information offers clear lessons for health planners and educators. A crucial fact
is that breastfeeding is declining in urban areas of developing countries. At the same
time, the data show that breastfeeding is quite compatible with an urban industrial
environment and that appropriate breastfeeding promotion can succeed anywhere. It would
therefore be ironic if, while breastfeeding rates were to increase in countries with low
infant mortality and morbidity, they were allowed to diminish in countries where
breastfeeding is still critical to sound infant and young child health. Good infant health also depends on the capacity of mothers to care for their children.
The mother of a large family of small children has little time or energy to attend to the
needs of any one child. Child spacing is therefore an important aspect of the infant and
young child morbidity and mortality equation. The WHO study showed that where the use of
contraception was low, patterns of child spacing were closely related to the length and
frequency of breastfeeding. Promotion and support If breastfeeding is to be effectively promoted, comprehensive programmes will need to
be developed. These must involve measures to improve the social conditions in which women
live and work and strengthen informal social support systems to help at-risk mother-child
groups. The health care system in general needs to make a more concerted effort to promote
appropriate infant and young child feeding and provide adequate educational support for
mothers. In many situations this will require the revision of health care practices and
attitudes. The development of appropriate interventions also calls for the regular monitoring of
trends in feeding practices. A simplified methodology has been developed by WHO for use in
preparing national surveys of infant and young child feeding. This is available from the
Maternal and Child Health Unit at WHO. Manuel Carballo, Scientist, Maternal and Child Health, WHO, 1211 Geneva,
Switzerland. The Code: country evaluation
WHO has recently published a report(1) evaluating progress round the world in the
implementation of the International Code of Marketing of Breastmilk Substitutes. Judging
by the amount of information sent to WHO by Ministries of Health, it appears that many
governments are taking the code seriously and ensuring that health staff are aware of its
contents. Legislation has been altered in some countries to accommodate the provisions of
the code.
James Akré, Technical Officer, Division of Family Health, WHO, 1211 Geneva,
Switzerland 27. In the next issue...
Recent studies have underlined the key role of personal hygiene - especially
handwashing - in preventing diarrhoea. DD18 will look
at these issues and includes a practical advice page on making soap.
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Breastfeeding: helping to reduce the severity of diarrhoea |
Protection, energy and nutrients
Leonardo Mata considers the unique role of breastfeeding
in child health and survival, and possible interventions to promote it in areas where
bottle-feeding is common. The exceptional properties of human milk are the:
- numerous powerful substances in human colostrum and milk which protect against
infectious diseases;
- unique biochemical properties which assure the best combination of energy and nutrients
for the growing child;
- remarkable behavioural interactions of mother and child which arise from breastfeeding;
- significantly lower cost when compared to any other form of infant substitute feeding.
Anti-infectious role Many elements able to protect against pathogenic viruses, bacteria and parasites are
found only in human colostrum and milk. They are not present in either quality or quantity
in other animal milks, nor have they been synthesised or imitated by modem science.
Anti-infectious substances can be:
- specific - such as immunoglobulins (antibodies) and lymphocytes (white blood cells)
which affect humoral and cellular immune responses; or
- non-specific - like lactoferrin, lysozyme and bifidus factors which either make human
milk a poor medium for bacterial survival or make the intestine unsuitable for the growth
of pathogenic agents.
Furthermore, the electrolyte composition of human milk makes additional water
unnecessary for the child even under dry and hot climatic conditions, reducing the risk of
giving contaminated water. The many anti-infectious factors reduce the severity of
symptoms of illness particularly diarrhoeal diseases. Epidemiological studies in both
developed and developing countries reveal a lower incidence of diarrhoeal diseases, otitis
and acute respiratory infections in breastfed compared with bottle-fed infants. It has been argued by some that infant mortality declined in the industrialized
countries over the years during which bottle-feeding became popular. Any such direct
correlation is not valid because other factors which can affect bottle-feeding techniques
- education, availability of sanitation and safe water and improved standards of home
hygiene - changed also over the same period. When social class and these other variables
are taken into account, bottle-fed babies are seen to suffer more malnutrition, more
infections and to die more frequently than their breastfed counterparts in all countries. Nutritional factors
Human colostrum and milk have unique biochemical properties - for instance a high
content of energy from lactose and lipids. The protein composition of human milk is
perfectly constituted and so aminoacid imbalance is unlikely. Furthermore, human milk
contains substances that bind iron, zinc and other elements, allowing them to be easily
absorbed, whilst protecting them from use by bacteria. The unique biochemical composition
of human milk protects against nutritional deficiency and results in adequate growth, even
among rural and slum infants living in poverty. In fact, growth rates are comparable with
those of North American and European infants up to four to six months of age and even
longer in some infants. When growth slows down in a two to four month old breastfed baby,
the most common cause is deficient calorie consumption by the mother; food supplementation
of the mother usually leads to a prompt increase in milk output and a subsequent
improvement in growth of the baby. Behavioural factors
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The marvelous interaction between mother and baby.
Close contact and interaction between mother and infant immediately after birth
stimulate successful breastfeeding. Sucking is strongest during the first hour after
delivery and there is no difficulty in initiating breastfeeding even in mothers who had
not wanted to do so. Early suction of colostrum stimulates the production of prolactin and
synthesis of milk. It also indirectly strengthens the maternal self-confidence which is
necessary for the release of oxytocin and the flow of milk. Breastfeeding strengthens the
bonds of attachment and love between mother and child both during the critical
child-rearing period and probably later in life.
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Economic factors Breastfeeding simplifies child-rearing in poor communities as it does not require
refrigeration, bottles, fuel and money to purchase breastmilk substitutes. Cost-benefit
analysis shows that breastfeeding is less expensive than any other form of nourishment. To
this should be added savings in transport, medicines and hospitalisation due to more
illness in bottle-fed infants. It is impossible to calculate the value of human lives
saved.
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Breastfeeding: helping to reduce the severity of diarrhoea |
Decline in breastfeeding in developing countries
Children have survived through centuries because of breastfeeding. Non-human milk
became available for human infants when animals were domesticated about 15,000 years ago.
However, techniques to feed substantial amounts of non-human milk to infants and the mass
production and preservation of cow's milk formulae only developed in this century. The
most rapid changes in life styles have also occurred in the 20th century, contributing to
a marked decline in incidence and duration of breastfeeding in most developing countries.
At present, only traditional rural societies, for instance in Bangladesh, Peru and Zaire,
carry on universal breastfeeding. Populations in transition - in either cities or
countryside - are subjected to factors that interfere with breastfeeding. Among them are
urban migration, changes from extended to nuclear families, exposure to inadequate medical
practices and the promotion of milk formulae. Promotion of breastfeeding
Studies in the Philippines and Costa Rica showed clearly that much can be done to alter
the trend described above. It is relatively easy to increase the incidence and duration of
breastfeeding in transitional societies by encouraging early mother-infant interaction
through rooming-in and by providing maternal support in the postpartum period. More
than 95 per cent of infants in a large maternity unit in Costa Rica have successfully
started breastfeeding following interventions carried out after 1977, compared to the
situation before in which 20 per cent of infants were not breastfed at all. A follow-up
showed that more than 80 per cent were still at the breast at age three months,
contrasting with 66 per cent of infants artificially fed at age three months before the
interventions began. The increased incidence and duration of breastfeeding was attributed
to the new hospital interventions, and to contact between health workers and mothers
shortly after discharge and at monthly intervals.
Extracting milk with a breast pump
The swing to breastfeeding was accompanied by a marked reduction in the incidence of
diarrhoeal disease. Remaining limitations on lactation result from an excess of ceasarean
sections and other problems during childbirth. Feeding all pre-term and high-risk neonates
from a pool of fresh colostrum in one large maternity unit in Costa Rica resulted in the
virtual disappearance of diarrhoeal illness in neonates over the five years of the
programme. Sepsis, acute respiratory infection and meningitis have also been significantly
reduced.
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Early discontinuation of breastfeeding and the introduction of substitutes is
increasing in less developed countries. The rapid adoption of modern ways of life and of
inappropriate Western medical practices are the most negative factors affecting
breastfeeding. The negative role of some medical practices to which communities in less
developed countries are increasingly exposed can be counteracted by encouraging
mother-infant interaction after delivery through close contact and by promoting
breastfeeding in the community. Most mothers know that breastfeeding is best but society
often interferes with the process. It is time to reverse this trend. Leonardo Mata Instituto de Investigaciones en Salud (INISA) Universidad de Costa
Rica. Further reading Cunningham A S 1979. Morbidity in breastfed and artificially fed infants. Journal
of Paediatrics (95) Vol pp 685-689.
Elliott K and Fitzsimons D W 1976. Breastfeeding and the mother. Ciba Foundation
Symposium No.46 (new series), Amsterdam: Elsevier/Exoerpta.
Jelliffe D B and Jelliffe E F P 1978. Human milk in the modern world: psychosocial,
nutritional and economic significance. New York. Oxford University Press.
Klaus M H and Kennell J H 1976. Maternal-infant bonding. St. Louis: C V Mosby.
Mata L et al 1984. Promotion of breastfeeding, health, and survival of infants
through hospital and field interventions. Malnutrition: determinants and consequences.
Alan R Liss, Inc., N.Y.
Relucio-Clavano 1981. The results of a change in hospital practice. A
paediatrician's campaign for breastfeeding in the Philippines. Assignment Children 55/56
pp, 139-165.
Winikoff B and Baer E C 1980. The obstetrician's opportunity: translating
"breast is best" from theory to practice. American Journal of Obstetric
Gynaecology 138 pp 405-412.
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Collecting, processing and storing breastmilk in the U.K. and
India |
Perspectives on human milk banking
David Baum and Peter Rolfe
discuss how breastmilk banking is carried out in the U.K. All healthy, mature newborn infants are best fed with their own mother's milk. There
is, however, considerable uncertainty about the ideal way to feed low birthweight, preterm
(premature) and sick newborn infants. Recent studies suggest that human milk, and
particularly the infant's own mother's milk, may be the best food for all babies. Low birthweight and preterm infants spend many weeks in special care baby nurseries and
many mothers, even those most motivated to breastfeed, find it difficult to keep up their
milk supply. This is partly because of anxiety about their child; partly due to the
inability of the immature and sick baby to suck; and partly due to practical problems of
being able to stay near the baby. It follows that to feed most preterm, sick or low
birthweight infants with human milk, some system of human milk banking needs to be set up.
In developed countries this can be achieved by systematically collecting, processing and
storing donated breastmilk. Is the same possible in developing countries? Collecting donated breastmilk
There are many different ways to collect breastmilk from donors. The system used in
Oxford depends on the collection of drip breastmilk -milk which drips spontaneously from
the non-feeding breast in about twenty per cent of lactating mothers.(1) Drip milk
donors contribute between 50-100 ml of milk per 24 hours and individual mothers may
contribute overall anything from 100 ml to 40 litres of drip breastmilk. Collecting milk
in this way avoids 'pumping' the breast which many mothers find unattractive and which
requires buying and sterilizing breast pumps. It also avoids asking mothers to produce
milk over and above the needs of their own babies - particularly inappropriate in
countries where the nutritional state of the population may be marginal. Practical constraints
However, the collection of donor milk, whether drip milk or expressed milk, in the
community depends on the availability of clean water for washing hands, breasts and
utensils, access to deep freeze storage facilities and some system for collecting and
transporting the donated frozen milk to the hospital special care baby nursery. For these
reasons, the development of a community-based donor breastmilk system might not be
considered universally appropriate. The alternative is the collection of donor breastmilk
within the maternity hospital. Under these circumstances it is easier to maintain
standards of hygiene and sterility of equipment. The limiting factor is the relatively
small proportion of mothers who stay in the maternity hospital after delivery long enough
to establish lactation to feed their own babies and donate milk, drip or expressed, to the
milk bank. Nevertheless, such a system exists and appears to work satisfactorily in at
least one maternity unit in India. Processing and storaging donated breastmilk
In developed countries there is debate as to whether donated human milk needs to be
routinely pasteurized or used in its untreated state, provided the system of collection,
transport and storage can be adequately controlled. We have argued in favour of routine
precision pasteurization. In this process the amount of bacteria is minimised without
damaging the majority of the heat sensitive proteins, and particularly the non-nutritional
proteins, present in human milk. It seems likely that the argument for precision
pasteurization would be greater in a developing country, although this poses the problem
of purchasing and maintaining the equipment together with the appropriate deep-freeze
storage facilities. Is the effort worthwhile?
While appreciating the difficulties which need to be overcome in establishing a human
milk bank in a developing country district hospital, there are considerations which
indicate that such a scheme should be piloted to assess all aspects of the issue. For
example:
- In the future larger numbers of smaller and less mature babies will be looked after and
survive in some developing countries.
- The use of artificial formula preparations for such infants would have undesirable
effects on the maternity hospital and the local community both in terms of the expense and
the negative influence on breastfeeding practice.
- There is an educational role in collecting donated breastmilk for high risk infants,
affecting attitudes of parents and health workers both in the hospital and in the
community at large about the importance of human milk and breastfeeding.
- Infection is significantly more common among low birthweight infants in developing
countries and the studies of Narayanan et al suggest that the use of donated human milk
may reduce the incidence and severity of infection among such high risk infants.
Meeting nutritional needs
Mothers should be enabled and encouraged to donate their own fresh milk to their own
babies whether they live in a developed or developing country. However, there will always
be large numbers of low birthweight, preterm and sick newborn infants whose mothers cannot
meet all their nutritional needs and for whom alternative milk is necessary. Formula milk
represents one solution to the problem but frequently has serious and undesirable economic
and social side-effects. The setting up of appropriate systems for banking human milk may
appear difficult but requires closer study particularly in view of the therapeutic and
communal advantages associated with it. David Baum and Peter Rolfe, Department of Paediatrics, University of Oxford, John
Radcliffe Hospital, Oxford OX3 9DU. (1) Baum J D 1980 Preterm milk. Early human development Vol. 4 (1).
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Collecting, processing and storing breastmilk in the U.K. and
India |
Passport to life
Is breastmilk banking possible everywhere? Indira Narayanan
describes a programme in New Delhi. In developing countries, setting up conventional milk banks(1) is frequently neither
feasible nor desirable. Climatic conditions, lack of resources, poor education,
difficulties in maintaining the 'cold chain,' electricity failures etc., preclude
collection at home, transport to the special baby units and prolonged frozen storage.
Collection of large volumes is also difficult as many mothers are hesitant to donate milk
to other babies for fear of their milk supply decreasing. At the same time it is the high risk infant in the third world who is likely to most
benefit from human milk. Here, the most important advantages are protection against
infection, and, where the infant's own mother supplies most of the milk, a continued flow
and ultimate success in direct breastfeeding. Where the mother's milk is inadequate, wet nursing may be practised in certain
communities, using a suitable relation or friend. For infants who cannot suck from the
breast, expressed breast milk (EBM) is necessary. Planned prospective studies have shown
the value of human milk (2) (3). Based on these studies, practical guidelines for the use
of EBM for high risk infants in a developing country have been drawn up for the first time
(4) (5). In neonatal clinics collection should ideally be supervised. This is more easily
done if the mother comes to the nursery itself. The practice of permitting mothers to stay
in the nursery kept for high risk infants, as is done in some units (6) (7), should be
more widely encouraged. Besides other advantages, this is by far the best way of supplying
human milk to the infants. Hand expression
In under-privileged centres, direct manual expression of milk into sterilised,
wide-mouthed feeding bottles or cups, after washing the hands and breasts with soap and
water, appears to be most suitable method. Contamination by this method is less than with
pumps, and involves no cost. We have observed that in some cases, the Kaneson's pump may
be acceptable and relatively easier to sterilise. The commonly available hand-operated
pumps with bulbs are not suitable as they are associated with excessive contamination.
Mothers with infections and those on drugs should not donate milk for other infants. Use
for their own babies will depend on the nature of the infection and drugs, and the risk
category of the infant. Correct storage
Milk should be used immediately without processing. Portions for the night and early
morning feeds can be stored in the refrigerator just under the freezer compartment, for a
maximum of 24 hours. Longer storage, even after freezing, is inadvisable unless definite
safeguards exist against electricity failures. On the whole, in developing countries,
collection when required, or a 'walking milk bank' system is likely to be more suitable.
At present, we are evaluating the cost-effectiveness and feasibility of collecting extra
milk to supplement our needs from educated women who return from maternity leave to work
in offices and schools. This practice can also benefit the mothers as it relieves fullness
during working hours and helps promote milk flow for their own babies. For home deliveries and units such as ours which practise an early discharge programme,
EBM is of great benefit in the home care of low birthweight and preterm babies. The
freshly collected milk can be fed with a boiled spoon or bottle (with a soft nipple) until
the baby can accept direct breastfeeding. Allowing the baby to suck intermittently at the
breast will help stimulate milk flow. Non-nutritive sucking on a pacifier has been shown
to promote earlier development of sustained sucking in a preterm baby. Surely there can be
no better pacifier than the breast itself. Avoiding contamination
It could be argued that, with under-privileged mothers, contamination of the milk is
likely to occur. Our earlier studies have shown that some concentration of organisms
including enterobacteria is not necessarily harmful to the infant (2) (7). This, however,
does not mean that one can be careless about the handling of human milk. Mothers and
health personnel should always be carefully informed as to how to avoid contamination or
at least to keep it to a minimum. It is also important to consider that, in such families,
contamination of other animal milks and formulae can occur to a greater extent, and that
this will be without benefits of the unique protective factors present in human milk. Breastmilk is the birthright of every baby. For the high risk infant in the third world
it is a passport to life. Indira Narayanan, No. 7 Type V1 Quarters, M. A. M. A. Campus, New Delhi, 110002,
India. (1) Williamson et al 1978. Organisation of raw and pasteurised human milk for
neonatal intensive care. British Medical Journal 1 pp 393-396.
(2) Narayanan I et al 1980. Partial supplementation with expressed breast milk for
the prevention of infection in low birthweight infants. Lancet, II pp 561-563.
(3) Narayanan I et al 1982. A planned prospective evaluation of varying quantities
of human milk in the prevention of infection in high risk low birthweight infants. Acta
Paediatrica Scandinavia 1, pp 441-445.
(4) Narayanan I et al 1981. Management of expressed breastmilk in a developing
country. Journal of Tropical Paediatrics, 28, pp 2.5-28.
(5) Narayanan I 1982. Human milk in the developing world - to bank or not to bank?
Indian Paediatrics, pp 395-399.
(6) Liebhaker M et al 1981. Comparison of bacterial contamination with two methods
of human milk collection. Journal of Paedatrics, 67, pp 565-569.
(7) Narayan I et al 1983. Bacteriological analysis of expressed human milk and its
relation to the outcome of high risk low birthweight infants. Indian Paediatrics, 20, pp
915-920.
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DDOnline
Diarrhoea Dialogue Online Issue 17 May
1984 7 Page 8
Still set-backs
With the introduction of ORT, there has been fresh reason for hope in the management of
diarrhoea and dehydration. It is however disappointing to still find that not enough
emphasis is laid on ORT in the various teaching institutions and that little importance is
attached to refresher courses for those not familiar with the concept. It is still common
to find a health worker who will not correctly give ORT to a dehydrated child even when
UNICEF oral rehydration salts packages are available. In hospitals it seems a lot easier to set up an intravenous drip for an otherwise
moderately dehydrated child than to sit by the bedside and explain to the mother what to
do when the child is vomiting. 'Pinches' of salt and sugar seem easier to explain to a
mother in the clinic or on discharge from the ward than the correct 'measures' even where
spoons and other measures are readily available. This sort of experience with many medical workers accounts for our failures with ORT.
It is my belief that the information in Diarrhoea Dialogue will help us to overcome
these setbacks. Dr Silver Bahendeka, Nyabondo Hospital, P. O. Box 75, Sondu, via Kisumu, Kenya. Technical and practical information We have been receiving your bulletin Diarrhoea Dialogue regularly. We find it
very useful as we are getting relevant information on various issues on diarrhoea, ORT,
infant food etc. We not only get technical knowledge from Diarrhoea Dialogue but
also practical problems in the field. We pass on useful information from Diarrhoea
Dialogue to all our members through our newsletter. Thank you very much for sending us 15 copies of Diarrhoea Dialogue. Many of our
member institutions are interested in receiving it. We have a membership of 69
institutions in Gujarat. The majority of them are working in remote tribal areas where we
try to provide such useful information, materials etc. I wonder if it would be possible
for you to send more copies of Diarrhoea Dialogue to us so that we can meet the
needs of our member institutions. I hope you will oblige us with the same. I would also be
very grateful if you could send 3 sets of all the issues of Diarrhoea Dialogue for
our office and reference purpose. Kirit Sha, Organising Secretary, Gujarat Voluntary Health Association, Newman
Hall, P. O. Box 4002, Ahmedabad 380009, India.
Rural health care in Turkey
I am a doctor working at a countryside health unit. I graduated in July 1983 and was
appointed as a GP as a result of a new law making this service obligatory for two years. This health unit is located near a very small and impoverished rural community. We are
responsible for a total population of 11,000, including remote village people around.
South-eastern Anatolia is perhaps the most undeveloped and superstitious part of the
country, thus we encounter (I, a health technician, a nurse, two midwives and other
assistant personnel) all of the health problems crystallized in a small area. Then we would be very happy to receive Diarrhoea Dialogue and it would add much
to our practice. Dr Yanki Yazgan, Merkez Saglik Ocagi, Oguzeli, Gaziantep, Turkey. Condensing research Thank you very much for the time and effort it takes to sift through the volumes of
material appearing on diarrhoea research, and condensing it into an easily readable form.
We use Diarrhoea Dialogue as a resource for in-service education programmes for
health workers. The staff, Christian Health Association of Liberia, P. O. Box 1046, Monrovia,
Liberia. Harmful beliefs Christine Ansell and Pauline Wright's article: Combining Science with Tradition (Diarrhoea Dialogue 15) filled me with interest. In many places in
Africa as well as Asia traditional beliefs are held very strongly. In my native Sierra
Leone some women do not breastfeed their babies in the belief that their breast milk is
"bad" i.e. the milk in their breast is infested with worms thus making it unfit
for their babies. The example above is only one in a complex heritage of traditions or
taboos. Perhaps the wonderful professional achievement made in Yemen can be applied with
similar success elsewhere. I strongly believe that some of the most serious challenges in the way of prevention
and/or control of diarrhoeal diseases in children and infants are false customary beliefs. Dr Thaim B. Kamara, P. O. Box 1181, Freetown, Sierra Leone. French DD in the Ivory Coast
Thank you for sending us your questionnaire and for publishing Diarrhoea Dialogue. As
I mentioned we receive the French edition. We have one African nurse who sees most of our
children in clinic and I always see that he receives a copy. Then I give the other copies
out as I have them to others of our nursing staff. Linda Sharp RN, B. P. 111 Ferkessedougou, Ivory Coast, West Africa.
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Scientific editors Dr Katherine Elliott and Dr William Cutting
Executive editor Denise Ayres
Editorial assistant Kathy Attawell
Editorial advisory group
Professor David Candy (UK)
Dr I Dogramaci (Turkey)
Professor Richard Feachem (UK)
Dr Michael Gracey (Australia)
Dr Norbert Hirschhorn (USA)
Professor Leonardo Mata (Costa Rica)
Dr Mujibur Rahaman (Bangladesh)
Dr Jon Rohde (USA)
Ms E O Sullesta (Philippines)
Professor Andrew Tomkins (UK)
Dr Paul Vesin (France)
Dr M K Were (Kenya) With support from WHO and UNICEF
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Issue no. 17 May 1984
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This edition of Dialogue on Diarrhoea Online is produced by Rehydration Project. Dialogue on Diarrhoea was published four times a year in English, Chinese, French, Portuguese, Spanish, Tamil,
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updated: 23 August, 2019
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