Indian Pediatrics 2002; 39:173-178
Initiating the Process of Relactation: An Institute based Study
WHO recommends exclusive breast-feeding for at least the first four and if possible the first six months of an infant’s life, and continued breastfeeding with adequate complementary food for up to two years of age or more. Yet many infants stop breast-feeding in the first few weeks or months and, as a result, are at increased risk of illness, malnutrition and death(1). Contrary to belief, exclusive breastfeeding is fast deteriorating in our country both in rural as well as urban areas(2-5). The consequences are devastating. But most often the malady is preventable. There are now sufficient reports to show that most women can relactate if they are motivated and have adequate information and support(1). Lactation management is an integral part and first step of nutrition management. Child In Need Institute (CINI) has been working on Nutrition Rehabilitation of malnourished children for many years. Therefore, we thought of sharing our experiences on this important phenomenon affecting infant mortality and morbidity. This study was taken up to demonstrate the effect of relactation intervention on mothers who had complete lactation failure and the infants had been suffering from illnesses inherent to to top feeding.
Subjects and Methods
The study included 139 mothers with their less than 6-month-old infants who were admitted to Lactation Management Unit (LMU) of our Nutrition Rehabilitation Center (NRC) with illness (Acute Respiratory Infection and Diarrhea) and malnutrition of varying degrees associated with lactation failure during January 1999 to June 2000. These mothers had stopped suckling their infants at the breast for at least 10 days prior to admission, as there was no milk secretion even on manual expression. These cases were defined as complete lactation failure. The infants were totally on top feeds.
On admission, detailed history was taken and examination of the infants and the mothers was done to assess their health and nutrition status and to identify the cause(s) for introducing top feeds and subsequent lactation failure. Age of the infant, duration of lactation gap, reasons for stopping breastmilk and type of feeds given were noted. Relevant informa-tion regarding socio-economic profile, their cultural background and family support were collected. All the infants and their mothers were given treatment for their physical ailments.
In actual relactation intervention all the mothers were encouraged to reinitiate breastfeeding by repeatedly suckling their infants at the breast 10-12 times a day for about 10 minutes on each breast. Skilled health workers helped the mother to see that the infant was attached to the breast properly. If an infant was reluctant to suck due to lack of milk in the breast, prepared milk was slowly poured over the areola through dropper or from a cup to encourage the infant in the suckling and prevent frustration to the infant as well as the mother. Top feeds properly prepared, were given by cup and spoon immediately after the suckling process. The mother was advised to sleep with her infant and keep him/her near to provide skin to skin contact as often as possible. Bottle, if used was immediately discarded. The parents were clearly explained the whole process and the outcome expected. The mother was provided with adequate food and rest along with constant counseling by motivated and skilled staff, who could help her by offering physical and psychological support. Initiation of relactation was said to occur when the infant started suckling at the breast spontaneously and milk could be expressed manually. Relactation was termed complete when no top feed was required and the infant was exclusively breastfed. It was termed partial, when top-feed requirement was reduced by more than half. All the infants were weighted daily while in lactation management unit (LMU). The growth of the infant was assessed as appropriate, if the weight gain was within normal range and the curve followed the normal channel.
If there was no sign of milk secretion even after 3 weeks, it was termed as failure. In such cases the mother was taught to feed the infant adequate amount of top feeds, prepared hygienically and early introduction of home-made complementary food was advised at 4-5 months of age. At the same time, frequency of top feeding was reduced gradually. All the mothers while in the LMU were given practical inputs regarding infant feeding and caring practices like hygiene, sanitation, immunization, family planning/spacing methods, preparation of complementary food and necessity of care/stimulation for proper growth and development of the infant. The infants were discharged after establishment of successful relactation or when in spite of 3 weeks efforts there was no sign of lactation. After discharge from the LMU all the infants were followed up for assessment of growth and development initially at weekly intervals for 3-4 weeks and every fortnightly till 6 months of age. Subsequently monthly visits were scheduled till 9 months of age. On each visit persistence of lactation was noted and necessary counseling was done regarding introduction of appropriate homemade complementary food around 6 months of age along with continued breastfeeding and other related issues.
There were 139 mothers with 140 infants (one mother had twins). One hundred thirty seven were biological mothers and 2 were surrogate mothers. Eighty-five (60.7%) infants were male and 55 (39.3%) were female. Bottle was used for feeding in 29 (20.7%) infants and the rest were fed through cups or bowl and spoon. Three fourth mothers were from remote and rural areas. Eighty five per cent of them belonged to socio-economically backward classes. Only about 20% went outside their home for work. The age of the mothers varied from 17 to 35 years. The youngest infant was 17 days and the oldest was 5 months at the time of relactation intervention. The lactation gap ranged from 11 to 45 days in case of biological mothers and in surrogate mothers it was 4 years in one and the other had never breast fed before. The youngest child of the former was 6 years old and the latter had delivered a stillborn six months prior to lactation effort. The time taken for appearance of milk at the breast including the surrogate mothers, after the relactation attempt, varied from 5-15 days. For complete relactation it took an average of 15-20 days, the maximum being 40 days for a mother with her one-month-old Low Birth Weight (LBW) baby. The average stay in LMU was 15 days, ranging from 10 to 45 days. About 90% mothers stated ‘inadequate breast milk’ to be the cause of starting supplementary feeds, the other causes being problems of nipple/breast and chronic ill health of mother/infant. Most mothers perceived ‘cry’ of the infant as hunger and thus erroneously started top feeding.
Out of 139 mothers, 117 (83%) were successful in relactation. Eighty-five (61%) including both the surrogate mothers and one with twins were successful in complete relactation, whereas 32 (23%) were partially successful. There was failure in 22 (16%) cases. Table I shows the relationship of age group of the infants and success rate in relactation effort. Younger the age at the time of intervention better was the relactation achievement. Correspondingly the failure rate was more with the increasing age of the infant. Relationship of lactation gap with relactation achievement is shown in Table II. Shorter the lactation gap, better was the relactation achievement. The mothers whose infants were used to feeding bottle took longer time for motivation and initiation of relactation. The weight gain of all the infants in complete as well as partially successful group was within normal range and followed their channel in growth curve. The episodes of illness also decreased in these infants.
The incidence of failure increased with increase in age of the infant as well as the increase in lactation gap. Possibly as the infant approached around six months of age, motivation for breastfeeding decreased as the infant can be initiated to semisolid/solid food. At the same time oxytocin-prolactin reflex mechanism in the mother becomes week. Six mothers started milk secretion initially on intervention, but it was small in quantity and it did not sustain. They were considered as failure. Both the surrogate mothers however, were successful in complete relactation/induced lactation in spite of longer lactation gap.
Table I__Age group of Infants and Success Rate of Relactation Effort
Table II__ Relationship of Lactation Group with Relactation Achievement
Relactation is possible in most mothers with motivation and support of the family and the health workers including doctors involved in the process. In our study out of 139 mothers with complete lactation failure, 117 (84%) were successful in relactation. Out of these, 85 (61%) had complete relactation and 32 (23%) were partially successful. Encouraging results have been reported by other workers also (6-10). Lakhkar et al.(6) in their study reported that all the 20 mothers having complete lactation failure with their infants aged between one month to one year were able to relactate irrespective of the age and lactation gap. The cases were managed as out patients. In the study of Banapurmath et al.(7) all the 15 mothers with infants under 4 months of age associated with complete lactation failure were able to successfully breastfeed after the relactation intervention. Ten mothers (66.6%) including two surrogate mothers could exclusively breastfeed, whereas 5 (33.3%) were successful in partial breastfeeding. The study was conducted in the out patient clinic. Alves et al.(8) had studied 163 mothers with infants aged between 30 to 90 days hospitalized due to pneumonia or diarrhea associated with complete lactation failure. Forty-five mothers (27%) were able to relactate even with their sick infants in a short-period. The mean duration of hospital stay was 6.9 days (SD = 1.7). The infants of mothers who could relactate, were spared from hospital induced malnutrition as compared to those infants whose mothers could not relactate. The results would have been much better, had these mothers under-gone the relactation intervention for a longer period. Mathur et al.(9) tried relacta-tion intervention in 75 mothers (71 mothers with partial and 4 with complete lactation failure) where, the infants under four months of age were admitted in hospital for treatment of illness. Forty-nine (69%) mothers in the partial failure group and 3 (75%) in the complete failure group had complete success in relactation. Chaturvedi(10) had hospitalized for relactation intervention 6 mothers with complete lactation failure and 2 with partial failure. In 4(50%) cases, relactation was complete and in 2 cases there was partial success.
In the relactation intervention process the key factor is to bring back the confidence of the mother and make her believe that she can successfully breastfeed her infant. Generally, the lack of confidence is aggravated by the lack of support from the family and also the medical personnel, who generally do not have sufficient time, knowledge and skill regarding breastfeeding counseling. Skilled help is necessary to encourage mother for frequent suckling and also help unwilling infants to attach to the breast and start suckling. Involvement of father in the counseling process appears to be more effective in bringing about crucial change in motivation required for correct infant feeding and caring practices. With appropriate counseling and support, the result of intervention is good, whether the mother is hospitalized or managed in the out patient clinic. However, in some cases where motivation and support at home is inadequate, admission in an LMU produces better result. Both the surrogate mothers were successful in complete relactation in our study. They were of great asset during their stay in the LMU in counseling and demonstration to the newly admitted mothers. Admitting the mother in the LMU has got advantage over carrying out intervention as outpatient. Apart from cons-tant encouragement and guidance by a skilled health worker, the mother is given support in the form of food, rest and treatment according to need. At the same time she is away from the anxiety and tension at home which might have precipitated/aggravated the lactation failure. Over and above, she has the access to the company of other women who have recently succeeded in relactation(11). The LMU also serves as a unit for learning and practical training for the health workers and doctors concerned with lactation management.
In conclusion, relactation is possible and practical for almost any woman if she is adequately motivated and supported. Age, parity, previous breastfeeding experience, and lactation gap, are less important factors(1). Attempt should be made to re-establish breastfeeding at every opportunity and in any situation, whether it is at home or in hospital. The health workers including doctors need to be more sensitive to the tragedy that lactation failure brings to the infant, family and the community.
Contributors: SNC conceptualized and initiated the study. He was also involved in critical revision and final approval of the manuscript. KP had assisted in designing and co-ordination of the study. NCD was associated with designing and carried out the systematic reviews, documented the whole process and wrote the final draft of the paper. He will act as the guarantor for the manuscript. BP collected data and analyzed it. SKM discussed the core ideas, contributed to the interpretations of the findings and edited the manuscript.
Competing interests: None stated.