Dear Loddo,
Glad that you are doing your best to support infants under six and their mothers to EBF amidst the challenges in practice. I work in an in-patient therapeutic (ITC) facility in Uganda and our recently (2020) revised IMAM guidelines have an elaborate chapter on management of U6 based on the old MAMI version V2.
The main objective of treatment of these patients is to return all infants to full exclusive breastfeeding. This is achieved by stimulating breastfeeding at the same time as supplementing the child during breastfeeding until the infant becomes stronger and breast milk production is sufficient to allow the child to grow adequately.
At first point of contact with the mother and infant, we establish if the mother has prospects of breastfeeding or not. This is because our management for both groups differ.
Mothers with prospects of breastfeeding include all lactating mothers or those who wish to re-establish breastfeeding. At the beginning of stabilization (when feasible), supplemental suckling technique (SST) is started. SST entails the infant suckling at the breast while also taking the therapeutic milk from a cup through a fine-tube that runs alongside the nipple. The infant is nourished by the milk supplement while suckling stimulates the breast to produce more milk.
SST is done in addition to counselling and support on positioning, attachment and any other identified breast conditions / BF problems (Observe a breastfeeding sessions and examine the mother to identify these issues).
From experience, I realised that providing therapeutic feeds would satisfy the infants and these little ones would sleep two to three hours after a feed. This greatly reduced the number of times mothers breastfed and in turn cut on the breast milk supply. This made re-establishing breastfeeding difficult especially at point of discharge. So we made SST mandatory for all mothers with prospects of breastfeeding ....of course with consent after explaining and going through the process with her.
SST makes it easy to gradually wean off the therapeutic feeds during rehabilitation to EBF. The Uganda IMAM treatment protocol provides guidance on tapering off the therapeutic milk. Usually by end of hospital rehabilitation, the infant is gaining weight on only breast milk and the mother's confidence in breastfeeding is built. She is armed with ‘know why’ and ‘how to’ information on breastfeeding. These infants are discharged and followed up every week in the breastfeeding clinic where growth and development is monitored and health and nutrition messages are shared. This has been very successful so far.
Then;
Nutrition rehabilitation of infants without prospects of being breastfed; these include orphaned or abandoned infants or infants whose mothers have made an informed (even after counselling) decision not to breastfeed for various reasons.
Basing on our protocol, therapeutic feeds are provided for stabilization, transition and rehabilitation phases of management. During rehabilitation, a discussion with the caregiver is started on choice of an Affordable, Feasible, Acceptable, Safe and Sustainable BMS. This BMS is initiated in the hospital as monitoring and mentorship of the caregiver on preparation, storage, and frequency of feeding is done. When the infant is started on the BMS, weight gain and any adverse events associated with the introduction of the BMS are monitored. These infants are discharged on the BMS and followed-up in the breastfeeding clinic to monitor growth and development.
Note that the BMS is not the therapeutic feed used in ITC.
ALWAYS remember to treat the mother and infant as a pair. Mothers are often forgotten. At the nutrition unit, we feed them and care for them physically and psychologically. The unit has a designated section for mothers and infants less than 6 months with adult beds to encourage bedding-in and peer-to-peer support. This helps restore their health, ability to produce breast milk and respond better to their babies.