Innovative approaches to optimal breastfeeding for small and sick newborn babies Ute Feucht Paediatrician, Tshwane District Clinical Specialist Team 2nd World Breastfeeding Conference: 13 December 2016 Plenary session

Breastfeeding in small & sick newborns In this high-risk group of neonates: Implementing in-hospital interventions Continuum of care

Breastfeeding support Within South African Health System In-facility care Nutrition services MBFHI Primary health care services (Nutrition services) IMCI Community organizations Community IMCI Primary Healthcare Re-engineering DCSTs WBOTs

How do we make health programmes work at Implementation Level?

How did South Africa reduce smoking? Advocacy Cost of cigarettes ↑↑↑↑↑ Advertising – deterrent Social acceptability → Social outcasts

Differences to smoking Formula is not a poison Milk is an integral part of a child’s nutrition Children’s nutritional needs change as they grow Mother-infant pair

What will it cost South Africa to reduce Bottle feeding? Advocacy Cost of formula ↑↑↑↑↑ - ??????? Advertising – Code of Marketing Social acceptability → Social outcasts - ??

The Woman-infant pair in the centre Pregnancy and child birth are life-changing events for women Discussion and choices about infant feeding (can) change over time

Empowering women to Breastfeed Within their social context Breastfeeding is not a medical condition It is a normal part of life Addressing barriers to BF Getting off to a good start Practical BF issues Social standing of women Lack of support Women’s ability to balance many different, often conflicting demands In sick & small infants this becomes even more challenging

A focus on Neonatal care in Tshwane

Where do women deliver? MOU MOU MOU MOU MOU MOU MOU MOU MOU MOU

Do you suffer from Neonatitis? Definition: The irrational fear of HCWs to care for neonates Ute’s dictionary

Zero separation Of mother-infant pairs Needs to include midwives Implementing BM-only policy in neonatal units Not without difficulties! Dividends not immediately visible Crucial components: Policies & guidelines Dedicated, knowledgeable and enthusiastic staff Involvement of management Lodger mother facilities Rooming in Human milk banking KMC Nutrition interventions, e.g. BM fortifier Early discharge with good follow-up

Lodger ward & policy

Rooming in Why is this so difficult to implement - ???

Human Milk banking Very dedicated staff Milk handlers Standard of care defined

KMC wards as standard of care

Components of KMC

Large hospital 1 Very busy labour ward (10,000 deliveries/ yr) Neonatal unit: 80 beds (12 ICU, 18 HCU, 25 SIC, 25 KMC) Neonatal † : Prematurity, asphyxia and sepsis Way forward: Addressing overcrowding, space constraints & patient flows

District Hospital 1 Labour ward: 2,900 deliveries/yr Neonatal beds: 15 (12 KMC) Neonatal † : Almost none Way forward: Expanding neonatal service package

District Hospital 2 Labour ward: 3,000 – 3,200 deliveries/yr Neonatal beds: 16 (4 HCU, 9 SIC, 3 KMC) Neonatal † : Birth asphyxia Way forward: Improve labour ward management; Expand neonatal services (especially KMC)

District Hospital 3 Busy labour ward (5,500 deliveries/yr) Neonatal unit: 48 beds (4 HCU & 12 KMC) Prematurity the most NB reason of † Way forward: Addressing structural, space and support services issues in neonatal unit Improved doctor-coverage in neonatal ward at all hours

Stages of implementation Slide: Courtesy Dr AM Bergh

Lessons from using district approach to neonatal care Benchmarking & healthy competition can do wonders Sharing of resources: No need to re-invent the wheel Staff understand themselves as part of a bigger system High-risk infants managed as subgroup of all neonates Making multi-disciplinary collaboration work in practice We used KMC as a ‘non-threatening’ entry point to improving neonatal care

MBFHI One tool in the toolkit Measurements at different levels of care Individualised patient care Pass   Fail Risk of window-dressing Balance with continuous positive support

Training & Job Aids: neonatal care

Empowering staff

Patient Follow-up Without structured follow-up safe early discharge is impossible High risk group of infants Individualised patient care Multidisciplinary team Continuum of care crucial Hospital   PHC & Community Involvement of managers

the pieces of the puzzle: Neonatal care as a district priority Putting together the pieces of the puzzle: Neonatal care as a district priority Maternal-Child-Health Programme integration Family planning PMTCT gaps (‘safe breastfeeding’) RTHB, Immunizations, vit A, etc BF support Linkages Health facilities: Levels of care WBOTs Community Monitoring & Evaluation

Monitoring childhood growth

PMTCT & Breastfeeding Antenatal HIV prevalence, South Africa

HIV-exposed but uninfected child PMTCT cascade Delivery Antenatal care Clinical care, including HIV tests ART Clinical care, including HIV test Maternal ART Infant birth PCR test Infant ART prophylaxis Clinical care, including Repeated HIV tests Growth Maternal HIV care HIV-infected child Clinical care, including Confirmatory HIV test Urgent ART Growth Maternal HIV care

The unique RTHB identifier Tshwane District: The unique RTHB identifier

The RTHB is a constant factor – and now it has a unique number in order to identify and trace children, even if the first name or surname changes over time!

Reducing stigma

WHO Infant Feeding Update 2016 BF for 2 years in HIV+ women Stigma reduction Need to guard against repeating the mistakes of the past Programme integration crucial Goal: HIV-free survival ‘Safe breastfeeding’

Thank You! Acknowledgements: Kalafong colleagues: Dr Elise van Rooyen, Ms Marlene Gilfillian, others MRC unit for Maternal and Infant Health Care Strategies: Dr AM Bergh Tshwane DCST Tshwane MCWH & Nutrition staff The many mothers and babies I have been privileged to work with over the years