1. 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

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

3. 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

4. How do we make health programmes work at Implementation Level?

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

9. 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

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

12. 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

13. 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

14. A focus on Neonatal care in Tshwane

15. Where do women deliver?
MOU
MOU
MOU
MOU
MOU
MOU
MOU
MOU
MOU
MOU

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

17. 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

18. Lodger ward & policy

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

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

21. KMC wards as standard of care

22. Components of KMC

23. 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

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

25. 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)

26. 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

27. Stages of implementation
Slide: Courtesy Dr AM Bergh

28. 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

29. 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

30. Training & Job Aids: neonatal care

31. Empowering staff

32. 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

33. 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

34. Monitoring childhood growth

35. PMTCT & Breastfeeding
Antenatal HIV prevalence, South Africa

36. 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

38. The unique RTHB identifier
Tshwane District:
The unique RTHB identifier

39. 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!

40. Reducing stigma

41. 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’

42. 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