Lactation management centres : A step forward in successful breast feeding

Breast milk (BM) is a unique product given to the human being by nature to fulfill all requirements of the offspring until it is mature enough to take adult food. Its uniqueness lies in the ability of the mother to produce milk which will vary in quantity, quality and consistency depending on the age of the baby, maturity and timing of the feed 1 . It has not been possible to achieve this with any other type of milk, even with state-of-the-art modifications using the most advanced technology. BM not only provides easily digestible and specifically needed amounts of nutrients, water, minerals and vitamins but also several other benefits to both mother and baby 1 .


S C Wickramasinghe 1
Sri Lanka Journal of Child Health, 2012; 41(2): 82-90 (Key words: Lactation management centre; breast feeding) Breast milk (BM) is a unique product given to the human being by nature to fulfill all requirements of the offspring until it is mature enough to take adult food.Its uniqueness lies in the ability of the mother to produce milk which will vary in quantity, quality and consistency depending on the age of the baby, maturity and timing of the feed 1 .It has not been possible to achieve this with any other type of milk, even with state-of-the-art modifications using the most advanced technology.BM not only provides easily digestible and specifically needed amounts of nutrients, water, minerals and vitamins but also several other benefits to both mother and baby 1 .
Benefits to the baby 1. Reduces infections through "priming" of the baby's immune system.
• Specifically diarrhoea due to E coli, rotavirus, Shigella, campylobacter etc. • Reduces incidence of respiratory tract infections • Reduces late onset sepsis in low birth weight (LBW) babies 2. Effect on better neurodevelopment 3. Reduces risk of sudden infant death syndrome 4. Provides analgesia to the baby during painful procedures. 5. Long-term diseases like type I diabetes mellitus, hypercholesterolaemia, hypertension, obesity and asthma have been found to be less in babies who were exclusively breast fed during the first 6 months.
Benefits to the mother 1. Reduces postpartum bleeding 2. Reduces menstrual blood loss 3. Helps with child spacing attributable to lactational amenorrhoea 4. Reduces obesity 5. Reduces risk of breast cancer and ovarian cancer 6. Promotes bonding between mother and baby 7. Convenience of feeding the baby on demand irrespective of the time or place 8. Economical _______________________________________ 1 Consultant Paediatrician, Teaching Hospital, Kandy Lactation reflexes 2 are shown in Figure 1.If a baby with a feeding problem is admitted to a Special Care Baby Unit (SCBU) it may lead to many problems.However, this was the routine practice earlier.Some problems are: • Mother and baby are separated.The basic and essential concepts of "rooming-in" and "bedding-in" cannot be implemented.• Mother cannot perform demand feeding.Instead it will be interval feeding.• It will have an impact on mother-baby bonding • Practices like Kangaroo Mother Care (KMC), cannot be done.• There is a significant risk of cross infections • Cost per cot per day in SCBU is much more than that in a normal ward.
A satisfactory solution to these problems will be to have a separate area and dedicated staff to deal exclusively with the problems of BF.
Lactation management centre (LMC) is the brainchild of Dr. Anoma Jayathilake, then a Consultant Community Physician at the Family Health Bureau (FHB) and currently the National Professional Officer, World Health Organisation (WHO).However, the idea of having a separate area adjacent to SCBU, to keep both baby and mother together has been in the mind of a senior paediatrician, who was in charge of the SCBU at Castle Street Hospital for Women (CSHW), Dr.(Mrs) Devakanthi Gunarathne even though it became a reality long after her retirement due to the untiring efforts of Dr. A. Jayathilake.The concept of mother-baby units and LMCs was planned and received Health Ministry approval in 2007.Building, staff guidelines and equipment were all designed by a consultative committee of which the author of this article was a member.This was an important policy decision in a country like Sri Lanka where free health service is a significant burden on the economy.Few countries in the world have paid attention to this aspect and identified the need for a separate facility for mothers and babies who need special support for BF 7 .Although different terms have been used the basic functions of these units have been the same.Some examples in other countries are: Lactation Management Education Centre in Kenya and National Lactation Management Centre in Iran.
By definition, LMC is a part of the mother-baby unit and addresses mainly problems of BF 8 .It functions as a day-care centre whereas babies who need overnight stay are admitted to mother-baby units.In Sri Lanka, the first LMC was started at CSHW, Colombo in the year 2000 and is running successfully to date.The second LMC was opened at General Hospital, Kandy (GHK) and thereafter many hospitals have installed such facilities.

Guidelines on construction of LMCs have been laid down by the FHB jointly with the Perinatal Society of Sri Lanka in collaboration with Central Engineering Consultancy Bureau (CECB) in 2007.
This gives all details of facilities needed if a LMC is planned in a hospital.These standards are for a hospital with average monthly deliveries of 500-1000.According to this document building and other instructions are given as follows: • Space 20 m 2 • Should be separated from duty station by a half wall up to a metre from the floor and a glass panel.
• Should be separated from counselling room by a door, half wall up to a metre from the floor with a glass panel.Maturation of oral feeding skills 9 is shown in Figure 3. Common Procedures performed at LMC 12 1.Weighing the babies and monitoring growth after correcting the feeding techniques 2. Correcting positioning and attachment 3. Helping/Teaching mothers how to express and spoon or cup feed the baby.4. Back massage/Let down relax 5. Hot and cold compresses to breasts when engorged.
6. Using "Syringe Method" for mothers with inverted/flat nipples.7. General counselling/reassuring and encouraging the mother Allowing them to share experiences with each other, clearing their doubts, myths etc.
When a mother has inverted or flat nipples "Syringe Method" 3 is a useful technique just before a breast feed (Figure 4).

Accurate measurement of weight
• Is an essential procedure at the LMC • Electronic scale that is accurate to the nearest 2-3gm is essential • Weigh before and after a feed under exactly same circumstances (e.g.Do not change the diaper in between weighing) • Baby does not need to be nude during weighing • 1gm of weight gain equals 1ml of milk intake • If the baby in connected to a monitor, disconnect the wires and lay them on top of the baby rather than allowing them to hang over the side of the scale.
Monitoring adequacy of breast feeding 13 is shown in Figure 5.   Mother sits, leaning forward, arms folded on a table, head resting on arms.Breasts must hang loose, unclothed.Helper rubs on either side of her spine using her fists, thumbs pointing forward, with small circular movements.Massaging should be done from the neck to the tip of the shoulder blade, up and down for few minutes.

Figure 9: Expression of breast milk
Advice on storage of BM A container with a lid which has been boiled to sterilize for 10 minutes is suitable to store the EBM.
• Can be kept safely for 6 hours at room temperature • In the fridge -24 hours • In the freezer compartment -3 months Milk which has been refrigerated must be kept in a warm water bath and adequately warmed for a few minutes before feeding,

Experience at LMC, GHK
GHK is the second biggest hospital in the country.It has 78 wards and 13 special units with total bed strength of 2291.There are 3 obstetric units (270 beds), 3 labour rooms and 4 Consultant Obstetricians.There are over 15,000 deliveries per year.GHK was declared a Baby Friendly Hospital in 1993.LMC was started in June 2006 (second in the country) (Figure 10) There is open access to all mothers (no referral letters needed).There are referrals from OPD/ clinics/SCBU/postnatal wards/paediatric medical and surgical wards.After the first visit reviews are arranged by nurses.There is no age limit for babies (usually under 1 year) Monthly feed-back is expected to be sent from all the LMC's around the country to FHB in a standard form which is shown in figure 16.This has been started since 2008 and is in the process of being regularized gradually.

Final remarks
The concept of starting LMCs must be introduced to every health facility in the country and the paediatricians have a key role to play in the maintenance of services and standards 15 .

Figure 1 :
Figure 1: Lactation reflexes 2 Factors affecting the oxytocin reflex 3 are shown in Figure 2.

Figure 2 :
Figure 2: Helping and hindering oxytocin reflex 3 Following are some current statistics related to neonates and breast feeding (BF) in Sri Lanka 4,5,6 : • Neonatal mortality rate: 5.9/1000 live births • Infant mortality rate: 7.4 /1000 live births • Percentage contribution of neonatal mortality rate to infant mortality rate :72% • Infection is one of the three common causes of morbidity and mortality in neonates.• Percentage of babies breast fed within the 1st hour of age : 85%

Figure 3 :
Figure 3: Maturation of oral feeding skills Common problems encountered at LMC 10,11 Maternal Problems 1. Flat/inverted nipples -antenatal diagnosis and attempts to correct is not often helpful.Instead, • Build confidence • Educate on the 'Syringe Method' to be used just before the feed • Provide extra support • Explain that baby suckles the breast not the nipple.Sucking helps to elongate the nipple • Encourage frequent Skin To Skin (STS) contact • Try different positions to hold the baby 2. Difficult breast -e.g.large breast • Needs extra support • Loosely tying up a rolled up nappy around the breast will help to improve the shape

Figure 5 :
Figure 5: Monitoring adequacy of breast feeding Back massage to stimulate the oxytocin reflex 3 (Figures 6 & 7) • Helps the mother psychologically • Builds her confidence • Tries to reduce pain or anxiety • Helps her to have good thoughts about her baby

Figure 7 :
Figure 7: Back rub in practice Wash hands • Place the infant upright on mother's lap • Napkin around the neck • Fill the cup/paladai a little short of the rim • Place it at the lips and gently tilt to the top of the lip • Let the baby actively swallow • Gentle stimulation will help if the baby is sleepy • Calculate the volume needed for the age and weight and volume taken by the baby • Wash the cup with soap and water, boil for 20 minutes to sterilize before the next feed

Figure 10 :
Figure 10: LMC at Teaching Hospital, KandyThere is a day area (a small partition from a corridor) which is open 7 days a week from 7 a.m. to 5 p.m.The Staff consists of the Consultant Paediatrician in charge of SCBU, 4 staff nurses (all trained in BFHI course), 2 minor staff and a medical officer cover from SCBU staff.

Figure 16 :
Figure 16: Monthly returns form from LMC to FHB Best service coverage can be given if the number of nurses is as follows: One nurse/ maternity unit + one extra nurse.•1-2minorstaff workers or orderlies depending on the hospital size and work load at LMC. • Opening times must be 7/7 days 7 am -5 pm • There must be a telephone hotline for communication • Mothers with problems in BF should be free to come without referral letter or appointments.Brief health messages to mothers in antenatal /postnatal wards during the routine rounds.•Adviseby telephone.•Attending to the mothers who come to LMC, some of whom may be in-patients, some out-patients • Contribution by means of talks on BF for antenatal health educational classes.
• Visiting mothers who are at ICU's on request and help with expressing milk.•