Calculating and making SDTM from F100 for a premature

Does the premature baby have a mother (is it the mother you mentioned?) and if not, could a wetnurse be found? Artificial milks increase the risks, especially for premature babies.

If the mother you mentioned is the mother of the premature baby, then in the early days, she will produce only small amounts of colostrum. That is normal. She should be encouraged to express or pump milk to increase production. If the baby can nurse, it should be encouraged to nurse as much as possible - kangaroo care facilitates this. If the baby can't nurse, or can't nurse effectively, then the expressed breastmilk can be fed to the baby with a syringe if necessary. In the first few days, you could expect the baby to be having about 5-10mls every hour, so the small amount of milk/colostrum will be sufficient.
Good luck with this baby.

I agree with Bindi that very small amounts are required initially.
To reply to Q1:
How old is the baby? What was the weight of the baby at birth? Is the baby medically stable?
If he/she is stable and able to feed Kangaroo Mother Care is a great technique, as suggested by Bindi, which keeps mother and baby close and breastmilk on the tap!
Is the mother well enough to feed even if she is producing small amounts, which is normal initially, as Bindi mentioned. If the baby cannot feed because unwell then the mother will have to express regularly (every 3 hours) to ensure her milk supply is maintained and her breasts are stimulated. As soon as the baby is well and strong enough encourage skin to skin and suckling on the breast. Expression, as Bindi mentioned, can be done by hand or breast pump depending on the context. However, whatever the context a mother should always learn to express manually. The expressed breast milk will then be fed regularly to the baby. Small amounts initially but at regular intervals (every 3 hours) too. This can be done by sterilised syringe, spoon, small medicine cup or NGT (if baby unable to swallow and/or medically unstable).
If the mother cannot express milk because she is too weak, can someone help her do it? If not, then it is possible to use a wet nurse with known HIV status.

For info on this you can refer to the ENN's Infant Feeding in Emergencies Module 2, Version 1.1 for health and nutrition workers in emergency situations (see Part 5). Some of the techniques used in emergency situations can be used in non emergency too.

To respond to Q2:
Mothers usually produce the required milk for their baby in most cases, even malnourished mothers can. There are rare cases where the mother won't be able to provide sufficient milk and this will include severely malnourished mothers. If the mother eats a balanced and varied diet, was healthy before the birth and has had a straightforward birth, then she should be able to produce enough milk for her baby. To help produce milk, she needs to breastfeed regularly during the day and night. Prolactin production is higher at night. It is the hormone that regulates milk supply, so breastfeed or express regularly is the key. Lots of support and encouragement too.

All the best.

I completely agree with YOLAND,
I just want to add to the answer 2:
In order for the mother to produce enough milk, she must avoid stress, engorgement, and breastfeed frequently.
The supplementary suckling technique could also stimulate milk production and allow you to stop supplementation with artificial milk.

Amount and frequency:
• Generally there should be guidance from the institution you are working in as to the rate for giving fluids in a premature infant. Pre-set guidelines are useful to avoid mistakes due to the fragility of small neonates and the tiny amounts involved. The fluid requirements for a premie are higher than for term neonates. There are many different protocols to follow, and so this would be a suggestion:

e.g. a 1.1kg neonate should have 80ml/kg/d on day 1, which would be – (1.1kg x 80ml) divided by 12 (for 12 feeds per day if 2 hourly feeds, or divided by 8 if 3 hourly feeds) = 7 ml of milk every 2 hours
• You should monitor blood sugars (pre-feed) to ensure the neonate is getting what they need
• Also temperature should be monitored as these premies get very cold, which will cause their blood sugars to drop (which is why Kangaroo Mother is so vital!)
• Normally I would try to feed the small babies as often as possible. Ideally every 1-2 hours. 1 hour is not usually practical, so I aim for every 2 hours, which is much more practical. It can be disastrous if they miss feeds as will drop their blood sugars very quickly since they have so few fat reserves.
• There are very useful guidelines to follow in the WHO resource: http://apps.who.int/iris/bitstream/10665/43206/1/9241546700.pdf (see page 51 onwards).
• There is also some background research here: http://apps.who.int/iris/bitstream/10665/43602/1/9789241595094_eng.pdf

Recipe:
• In an ideal situation, breast milk / wet-nurse would be best; however this is not always possible.
• Next best would be premature formula milk (better outcomes than term formula).
• There is some information on En-Net regarding use of SDMT: http://www.ennonline.net/fex/37/diluted which is worth a look at.
• I have used SDMT previously, when we did not have formula available, and where there were no other alternatives. There will be a risk of NEC (necrotising enterocolitis) so feeds needs to be carefully introduced and the baby watched for any signs of NEC (distended tender abdomen, blood in the stool, vomiting, temperature instability, etc.).
• SDMT formula: there are couple of formulas for preparing SDTM, this one is taken from MSF guidelines that are available online http://files.ennonline.net/attachments/799/protocol-for-newborns-and-infants-2008-final-english.pdf (see page 14)
• There are also some useful guidelines on increasing milk production and feeding infants in emergencies here: http://www.unhcr.org/45f6cc4e2.pdf

Maternal Feeds:
• Previously when I’ve worked in programmes where the mothers themselves are very malnourished, I’ve supplemented their feeds with the standard SP 100, and encouraged them to eat a varied diet (as much as possible), as well as giving them multivitamins / checking they’re not anaemic (if at all possible)
• The most important thing is adequate fluid intake, especially in hot climates. (Be aware of the risks of hyponatraemia – low sodium – in a hot climate, which I have seen, so important to encourage them to not drink litres and litres of pure water due to the lack of electrolytes but have a varied diet and varied fluids)
• Some centres recommend supplementation with medications such as domperidone and metoclopramide to be given to the mother, to increase breast milk production. In some countries this is routinely prescribed to the mothers, in other countries not so. The evidence base is mixed.
• The importance of Kangaroo Mother as has been pointed out already cannot be underplayed in terms of increasing breastmilk production, helping the baby to learn to breastfeed, once they are stable and not sick.
If you would like some further background reading on premature / LBW babies, this is one of my favourites: http://apps.who.int/iris/bitstream/10665/44864/1/9789241503433_eng.pdf?ua=1. It outlines many useful strategies to get further resources and how to focus on the best outcomes for these small babies.

Thank you for all these edifying answers. Nevertheless I would like to say that it is important that all children be brought into skin-to-skin contact with their mother immediately after childbirth to promote immediate breast-feeding. It is also important to avoid cradles as much as possible in neonatology rooms. It is therefore important that we make our baby-friendly health centres of the past baby-friendly communities, guaranteeing a reduction in the death rate of children 0 to 24 months.