While Sri Lanka continues to hold the rank of a country that has one of the highest rates of breast feeding in South East Asia, the persistent prevalence of pre term babies is however a matter of concern for our health authorities due to the serious health complications they are likely to face during their life time.
The Sunday Observer spoke to Consultant Neonatologist University Unit, De Soysa Hospital for Women, Colombo and Senior Lecturer, Dept of Paediatrics University of Colombo, Dr. Nishani Lucas to find out more about the health issues pre term babies face, how they could be reduced if not eliminated as well as fielding questions from mothers on how they should feed their pre term babies and how to ensure they get enough milk with every feed.
Excerpts
 Dr. Nishani Lucas |
Q: Many mothers are still ignorant of the terms preterm and full term babies. How do you define 1) A pre-term baby 2) A full-term baby? And how long does it take for a full term baby to be born as against preterm babies?
A. It takes around 40 weeks (ranging from 37-42 weeks) for a baby to become mature enough to be able to survive outside the womb. Therefore, babies who are born between 38-42 weeks are known as full term babies. In comparison, babies who are born prior to the completion of 37 weeks are known as preterm babies. This may range from 23 weeks (5 months) to 36 weeks (9 months) gestation.
Q: Are there different sub -categories of preterm birth?
A. Babies who are born before 28 weeks (below 7 months) are known as extreme preterm, 28-32 weeks (7-8 months) as very preterm, 32-34 weeks ( 8 – 8.5 months) as moderate preterm and 34-37 weeks (8.5-9 months) as late preterm.
Q: Are there a difference in the weight of a pre term baby and a full term baby?
A. Yes, there is. Most often the weight of preterm babies is much lower than that of babies born at term gestation. Babies born earlier than 28 weeks gestation most often weigh less than 1 kg and can be as light as 500g which is the cut off for viability (ability to survive independently outside the uterus).
Q: What are the health complications of babies born too early?
A. The main problem in preterm babies is that they are born before their organ systems have attained maturity; immaturity of lungs needing respiratory support, immature blood vessels in the brain increasing the risk of bleeding inside the brain, immature immune system, increasing the risk of infection, inability to feed directly from the breast, necessitating expression of breast milk and feeding via cup or tube, increased risk of aspiration due to poor suck-swallow-breathe co-ordination, increased risk of blindness due to retinopathy of prematurity and increased risk of bone fractures due to osteopenia of prematurity etc.
Q: What is the best and most effective way to prevent/ minimise these serious health risks?
A. The most effective way to prevent all these complications is to prevent preterm birth. Good quality neonatal care with regular follow up is very important to prevent and treat these complications
Q: What is the role of breast milk as a preventive tool to these complications? Can it help reduce risk infections and rise immunity levels of the pre term baby? If so how?
A. Yes indeed. Breast milk is vital to increase the immunity in the baby, thereby minimising the risk of infection. This is due to the multitude of immune factors transmitted through the breast milk from mother to baby as well as the ability to remove intravenous lines early and avoid formula feeds, thereby reducing the risk of deadly infection. Handwashing, kangaroo mother care, minimal handling, minimal visitors other than parents are other effective ways of reducing the risk of infection in these babies.
Q: Such being the case, how early should the mother initiate breast feeding for the preterm baby? From day one or later?
A. Breast milk should be given to the baby soon after birth (ideally within the first 6 hours after birth), as soon as the mother can express and send milk.
Q: If the baby is in the incubator is it still possible for a mother to breast feed it? If so,how?
A. Yes, it is. The incubator is used to keep the baby warm, as preterm babies are very small and tend to become very cold in room temperature. The Baby can be taken out of the incubator and given to mother to breastfeed if the baby is not on respiratory support or on non-invasive respiratory support (breathing support given through the nose). However, if the baby is having a tube inside the trachea for breathing support, direct breastfeeding is not possible. In which case we express the breast milk and give it through a tube, directly into the baby’s stomach. So, provision of breast milk can be done however preterm, however small and however sick the baby is.
Q: A question uppermost in the minds of most working mothers of pre term babies is how to store extracted milk to use when they return home after work. Should she refrigerate it? If so,for how long? If left on a table without refrigeration, can the extracted milk get spoilt?
A. She should express and empty her breast during work, every 3-4 hours, to reduce the feedback inhibitor and maintain milk secretion. If she has a clean place to express breast milk, with access to an AC room with temperature 25C or less (can be kept for 4 hours) or refrigerator (can be kept in the main compartment for 24 hours), she should express and store the milk in air-tight cups, labelled with date and time which she can take home, in a cold box / bag. If she doesn’t have access to the above mentioned she should express and discard the milk to maintain milk secretion.
Q: I read somewhere that the breast milk given to a pre term baby is slightly different from the milk of a mother who has given birth full term. Is this true? If so what is / are the difference/s? What does the breast milk of a pre term baby contain that full term birthing mother’s lack?
A. Yes, it is true. Every mother makes breast milk that is uniquely suited to satisfy the nutritional requirements for her own baby. The composition of breast milk secreted by the mother varies according to the maturity of the baby. Breast milk of a mother of a preterm baby is very high in protein, minerals and immune factors to satisfy the higher requirements in the preterm baby.
Q: Is breast milk suitable for a sick baby?
A. Yes, it is essential for a sick baby. It provides a multitude of immune factors which will play a major role in increasing immunity, to help the baby to heal.
Q: What if the mother is sick and is on medications? Can she still breast feed a pre term baby? Won’t there be negative side effects on the baby from those medications?
A. Mothers on almost any medication can continue to breastfeed their babies, as the amount of medication that gets transferred to breast milk is too little to cause adverse effects. The benefit of breastfeeding far outweighs the risks. The exception to this would be a mother on radiotherapy and chemotherapy as treatment for cancer, where breastfeeding should be discontinued until 3 months after cessation of the treatment.
Q: As Covid-19 is still prevalent in the country along with other new and re-emerging infections should a mother infected with a contagious disease be encouraged to breast feed her pre-term new born? Why? And how can it be done without infecting the baby?
A. Yes, it is very advantageous for the babies of mothers with Covid to be breastfed, as breast milk transfers antibodies produced in the mother against Covid, that would is vital for protection of the baby against Covid. In a preterm baby this is even more important, as they have less immunity than their peers born at term. Wearing a mask during breastfeeding and washing hands prior to handling the baby will prevent infecting the baby, as Covid is transmitted mainly via droplets and nasal secretions.
Q: Does this require a hospital setting? If so, are there separate wards where infected mothers can breast feed their pre term babies? If not what are the chances of a pre term baby catching an infection in the hospital itself?
A. No, it does not require a hospital setting. The Mother and baby should not be separated, in mothers with Covid-19 infection, irrespective of whether mother is at home or in the hospital at the time of getting infected with Covis-19. While other family members can get infected by the mother, her baby is protected due to antibody transfer that occurs through breast milk.
Therefore, the mother staying in a separate room with the baby may prevent the other household members getting infected with Covid-19. In the hospital there are separate wards for mothers who get Covid-19, to prevent other mothers getting infected with Covid-19. In such cases both mother and her baby will be moved to the Covid-19 ward, where breastfeeding is continued. If baby is in the neonatal unit due to prematurity, mother can express milk and send to the neonatal unit, as she will not be able to visit the neonatal unit within the first 7 days of infection, due to the risk of infecting the other mothers and the neonatal unit staff.
Q: It has been said that a mother must never be separated from her new born and that a mother’s warm embrace goes long way in raising the baby’s immunity and prolonging its survival. Your comments?
A. Very nicely said. We should do not separate the baby from the mother unless baby or mother needs intensive care.
Rooming in with the mother helps the newborn to establish breastfeeding as well as adapt well to its new environment outside the uterus.
Q: Do you follow up on the progress of each child even after discharge?
A. Yes we do, at least until 2 years of age.
Q: Some mothers who are unable to cope emotionally and psychologically with the health issues of their pre term babies, need outside help. Do you have trained counsellors and psychiatrists to support them? Where can they obtain such services free of charge?
A. Needing support from the psychiatry team is a very common occurrence, as undergoing a preterm birth with a baby needing intensive care, is a very stressful event for almost all mothers. And to your question, yes, we refer these mothers to the psychiatry team, who deliver the specialised counselling, support and treatment to these mothers, free of charge, in the state hospitals.
Q: Myths about breast feeding a preterm baby are often misleading resulting in negative results. What are the common myths about breast feeding a preterm baby in Sri Lanka and how would you debunk them?
A. The commonest myth is that breast milk does not provide enough nutrients for the preterm baby. The preterm baby’s mother produces milk which is very high in nutrients to match the nutritional requirements of the preterm baby. However, healthcare workers must provide the necessary support to the mother to breastfeed her baby, as she herself maybe undergoing medical issues which may have led to the preterm delivery in the first place.
Q: Have you a message for parents of premature babies out there?
A. Breastfeed your preterm baby to ensure quality survival for your baby with better immunity, better brain growth and healthy body composition. Demand your health care providers to adequately support breastfeeding without taking the easy way out with formula feeding.