homework

42Karbandi et al

Evidence Based Care Journal http://ebcj.mums.ac.ir/

Effect of Breast Milk Expression

during Kangaroo Mother Care on

Milk Volume in Mothers with

Premature Infants Admitted to

Neonatal Intensive Care Unit

Mahdiye Mansoori, Naiire Salmani

The online version of this article can be found at

http://ebcj.mums.ac.ir/article_15453.html

Evidence Based Care Journal 2020 10:44 originally published

online 01 April 2020

DOI: 10.22038/ebcj.2020.45519.2238

Online ISSN: 2008-370X

Address: Mashhad Nursing and Midwifery School, Ebn-e-Sina St., Mashhad, Iran P.O.Box: 9137913199 Tel.: (098 51) 38591511-294 Fax: (098 51) 38539775 Email: [email protected]

Mansoori and Salmani . Breast Milk Expression during Kangaroo Mother Care and Volume of Milk 44

Downloaded from http://ebcj.mums.ac.ir/ at Mashhad University of Medical Sciences on April 01, 2020

Original Article

Effect of Breast Milk Expression during Kangaroo

Mother Care on Milk Volume in Mothers with Premature

Infants Admitted to Neonatal Intensive Care Unit

Mahdiye Mansoori1, Naiire Salmani2*

Received: 19/01/2020

Accepted: 14/04/2020

Abstract

Background: Breastfeeding is a two-way interaction between mother and infant, the sustainability of

which requires the presence of both parts given their complementary roles.

Aim: The present study was conducted to investigate the effect of breast milk expression during

kangaroo mother care (KMC) on milk volume in mothers with premature neonates.

Method: This quasi-experimental study was performed on 40 mothers with premature newborns

admitted to a neonatal intensive care unit in a city in the west of Iran in 2019. The participants were

randomly assigned into two groups of intervention and control. Breast milk in both groups was

expressed 8 times a day from day 4 to day 6 after birth using a 20-cc syringe and recorded in a

checklist. In the intervention group, two milking sessions were performed during the KMC. However,

in the control group, milking was conducted according to the ward routine. Data were analyzed in

SPSS software (version 23) using repeated-measures ANOVA.

Results: The mean ages of the participants in the intervention and control groups were 29.05±4.09

and 27.85±3.58 years, respectively. There was a statistically significant difference between the milk

volume of the intervention and control groups on days 4 (P=0.04), 5 (P=0.02), and 6 (P=0.007) and

between the total volume of milk during the three days (P=0.01).

Implications for Practice: Breast milk expression during KMC could have a positive effect on

increasing milk volume. Therefore, can be recommended as an intervention to support mothers with

insufficient milk.

Keywords: Breast milk expression, Kangaroo mother care, Neonatal intensive care unit, Premature

infant

1. MSc Student, School of Nursing and Midwifery, Shahid Sadoughi University of Medical Sciences, Yazd, Iran 2. Assistant Professor, Meybod Nursing School, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

* Corresponding author, Email: [email protected]

Evidence Based Care Journal, 10 (1): 44-50

45 Evidence Based Care Journal, 10 (1): 44-50

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Introduction

Annually, about 20 million neonates with low birth weight are born worldwide, mostly in developing

countries (1). Despite all the efforts made to prevent preterm delivery and the birth of premature and

low birth weight neonates, the birth rate of such newborns remains high. Every year, the United States

witnesses the birth of 250,000 premature and low birth weight neonates, constituting about 8.5% of

births (2).

Premature neonates are not able to get enough milk volume for various reasons. This is a major

concern for mothers (3) since premature newborns require breastfeeding in their infancy more than

ever to achieve optimal growth (4). The best nutrition for premature neonates is breast milk.

Breastfeeding has positive psychoemotional effects on mothers. However, the lack of enough milk is

a common problem for many mothers with premature newborns (5), while the separation of the

premature neonates is inevitable (6). Such conditions lead to the disruption of lactation initiation and

force the family and medical team to feed the newborn with formula. Moreover, failure to breastfeed

undermines maternal confidence, thereby impairing the evolution of the relationship between mothers

and infants. Finally, breastfeeding cessation is the main result of insufficient milk production and the

resultant anxiety (7, 8).

It is necessary for the members of the medical team to consider parents as clients, in addition to

providing care for the neonates. Furthermore, it is required to provide appropriate interventions to

prevent stress due to inadequate lactation (9) since parental support is one of the main tasks of

nurses (10). The nurses can help mothers to increase their ability to cope with negative emotions

and problems, adapt to their maternal role, and improve their confidence by enhancing

breastfeeding (11).

Numerous studies have been conducted to identify the effective interventions facilitating the

enhancement of breast milk secretion. Some of the proposed interventions include the stimulation of

oxytocin secretion by various methods, such as back massage, foot reflexology (4), relaxation training

(5), use of galactopoietic foods (12), and use of music while expressing milk (13).

The majority of the studies have focused on mother-centered interventions. Meanwhile, breastfeeding

is a two-way interaction between mother and infant, who have complementary roles in the initiation

and sustainability of the feeding process. Therefore, it is emphasized to recommend interventions that

can be performed with the participation of mothers and infants. The interaction of infants with

mothers can lead to the display of intuitive behaviors in infants. These behaviors increase response to

the stimulation of maternal and neonatal bodies and develop nutritional behaviors through the

engagement of olfactory and tactile senses in the neonate and visual, olfactory, and tactile senses in

mothers (14).

One of the interventions that can be effective for mother-infant interaction is kangaroo mother care

(KMC) (15). This type of care provides an opportunity for the neonate to breastfeed and enhances the

bonding and attachment between mothers and infants (14). There are a number of studies addressing

the impact of KMC on maternal variables, such as mental health, satisfaction (16), and mother-infant

attachment (17). Some other studies have examined the impact of KMC on infant-related outcomes

(e.g., weight gain and length of hospital stay) (18) and physiological parameters (19). In addition,

there is a study examining the volume of milk obtained in relation to the location and circumstances

of expression (i.e., at home, next to the neonatal incubator, during KMC, and after KMC) (20).

The insufficient breast milk in mothers with premature newborns and the limitations of studies in the

field of KMC and milk expression during a specific time underscore the need for the implementation

of research addressing these factors. Regarding this, the present study was conducted to determine the

effect of breast milk expression during KMC on the volume of milk in mothers with premature

neonates admitted to the neonatal intensive care unit (NICU).

Methods

This quasi-experimental study was carried out on mothers with premature neonates admitted to the

NICU of Shahid Sadoughi Medical Training Hospital with 30 beds, located in the center of Iran in

2019. The sample size was calculated using the formula of "comparing two independent society". The

sample size was estimated at 25 participants in each group with 95% confidence level, 80% power,

3.5 standard deviations for the expressed milk volume and considering 5-unit difference in the mean

milk volume based on a study performed by Acuña-Muga et al. (20), as well as 10% dropout.

Mansoori and Salmani . Breast Milk Expression during Kangaroo Mother Care and Volume of Milk 46

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Therefore, a total of 50 participants with preterm newborns admitted to NICU were selected and

equally randomized into two groups of intervention and control using the random allocation software.

No blindness was considered during the implementation of the study.

The inclusion criteria for the mothers were: 1) 24-hour presence in the NICU and use of maternal

resting place, 2) desire to breastfeed the neonate, 3) desire to perform KMC, 4) no addiction, 5) lack

of physical and mental diseases (e.g., tuberculosis, AIDS, cancer, breast abscess, purulent secretion,

blood in breast milk, depression, and postpartum psychosis). On the other hand, the exclusion criteria

for others included: 1) hospitalization during the study period, 2) death during the study period, 3)

unwillingness to continue participating in the study, and 4) partial or complete breastfeeding of the

neonate as instructed by the treating physician.

With regard to the newborns, the inclusion criteria were: 1) physiological stability (i.e., pulse,

breathing, and temperature), 2) a minimum weight of 1,250 g, 3) gestational age of 33-28 weeks, 4)

maximum hospitalization time of 3 days after birth, 5) permission of physician to perform KMC, 6)

no congenital abnormalities (e.g., omphalocele, meningocele, and hydrocephalus), 7) lack of grades 3

and 4 cerebral hemorrhage, 8) no need for central venous catheter in the shoulder, umbilical catheter,

or chest tube. On the other hand, the exclusion criteria for the neonates included: 1) connection to

mechanical ventilation, 2) instability in clinical conditions, 3) death, and 4) transfer to another

hospital.

The participants completed the maternal and neonatal demographic questionnaire and the milking

record checklist, including data related to milking time, milk volume, and milking position, for 3 days

(i.e., from day 4 to day 6 after birth). Ten faculty members of the School of Nursing and Midwifery,

Yazd University of Medical Sciences, Yazd, Iran, explored and approved the content validity of the

given questionnaire and checklist.

The mothers in the control group performed the KMC twice a day according to the routine of the

ward. Milking was performed every 3 h to collect breast milk at different locations according to the

mother's desire (i.e., in the resting place, next to the neonate bed, and in the milking room). In doing

so, the mother pumped her milk from both breasts for 20 min with an electric pump 8 times a day, and

the volume of milk was recorded in the checklist.

In the intervention group, the mothers were milking according to the routine of the ward, like the

control group. However, in this group, two sessions of milking were performed during KMC. To

this end, 30 min after KMC, while the KMC was still going on, the ward nurse expressed breast

milk by means of an electric pump. In both groups, the mothers measured the volume of their

breast milk with a 20-cc syringe and recorded the data in a checklist for 3 days (i.e., from day 4 to

day 6 of birth).

It should be noted that five mothers were excluded from each of the control and intervention

groups. The reasons for exclusion in the control group included noncooperation (n=3) and neonatal

need for mechanical ventilation (n=2). Additionally, those in the intervention group were excluded

due to neonatal mortality, maternal hospitalization, neonatal transfer to another hospital, neonatal

need for mechanical ventilation, and maternal noncooperation. In line with the research ethics

principles, the researcher referred to the NICU and explained the research objectives and procedure

to the mothers. Subsequently, both written and oral informed consents were obtained from all

participants.

All data were presented as mean, standard deviation, and percentage. The statistical analysis was

performed using the descriptive statistics, Kolmogorov-Smirnov (to determine the normality of the

variables), Chi-square test, independent t-test, and repeated measures ANOVA. All analyses were

carried out in the SPSS software, version 23. A p-value less than 0.05 was considered statistically

significant.

Results

According to the results of the Kolmogorov-Smirnov test, the data had a normal distribution;

therefore, data analysis was performed using parametric tests. There was no significant difference

between the two groups in terms of maternal age, birth order, neonatal age, neonatal gender, and birth

weight (Table 1). Comparison of milk volume between the intervention (221.2±69.2) and control

47 Evidence Based Care Journal, 10 (1): 44-50

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Table 1. Comparison of quantitative variables between the study groups

Variable Mean±standard deviation P-value

(independent sample t-test) Intervention group Control group

Maternal age (years) 29.05±4.09 27.85±3.58 0.56

Neonatal age (weeks) 30.85±1.69 31.2±1.90 0.57

Neonatal weight (g) 1725.6±556.45 1556.66±733.66 0.43

n (%)

Neonatal gender

Female

Male

10 (50%)

10 (50%)

12 (60%)

8 (40%)

0.36

Being indigenous

Yes

No

13 (65%)

7 (35%)

12 (60%)

8 (40%)

0.27

Birth order *

First

Second

Third

11 (55%)

5 (25%)

4 (20%)

12 (60%)

3 (15%)

5 (25%)

0.38

Table 2. Comparison of the mean volume of milk between the study groups

Variable Mean±standard deviation P-value

(independent sample t-test) Intervention group Control group

Volume of milk on the 4th day 221.2±69.27 178.1±63.51 0.04

Volume of milk on the 5th day 239.3±69.62 181.3±63.83 0.02

Volume of milk on the 6th day 243.6±70.21 182.6±64.28 0.007

Volume of milk over 3 days 704.1±209.70 542.6±191.52 0.01

Figure 1. Trend of changes in the volume of milk obtained in the three stages of measurement

(178.1±63.5) groups on the 4th day after birth (i.e., first study day) by the independent sample t-test

showed a significant difference (P=0.04). Likewise, there was a significant difference between the

two groups in this regard on the 5th day after birth (i.e., the 2nd day of the study; P=0.02).

Furthermore, on the 6th day after birth (i.e., 3rd day of the study), there was a significant difference

between the intervention (243.6±70.2) and control (182.6±64.2) groups in terms of the volume of

milk (P=0.02). Additionally, the comparison of the total volume of milk between the intervention

(704.1±209.7) and control (542.6±191.5) groups showed a significant difference (P=0.01; Table 2).

According to the results of the repeated measures ANOVA, it was revealed that the changes in the

milk volume were significant over time, regardless of the group type (P<0.05). Furthermore, the trend

of changes in the volume of milk from the 4th to 5th and 6th days (time and group interaction) was

significantly different between the two groups (P<0.05; Figure 1).

Mansoori and Salmani . Breast Milk Expression during Kangaroo Mother Care and Volume of Milk 48

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Discussion The results of this study showed that breast milk expression during KMC increased the volume of

milk. Consistent with this finding, Acuña-Muga et al., examining the rate of milk secretion during

and after KMC, showed that the milk volume was higher in mothers during KMC than that in

mothers without KMC (i.e., those being next to the neonate or at home during breast milk

expression) (20).

In another study, Hurst et al. investigated the effect of keeping the infant in contact with the mother

(i.e., skin-to-skin) on the volume of breast milk in mothers with premature infants. They observed a

significant increase in the amount of milk production in the mothers having skin contact with their

infants for 24 h, compared to those who had no skin contact with their infants (21). The results of the

mentioned study are consistent with those of the present study, which showed the positive effect of

KMC on the amount of milk volume.

Heon et al. examined the strategies for increasing milk production during the first 6 weeks

postpartum. To this end, they provided training, involving KMC as one of the recommended

interventions, to mothers. The evaluation of the milk volume over 6 weeks showed no significant

difference between the mothers using training support and those in the control group. However,

clinically, the mothers who received training support and performed the KMC had a higher milk

volume than other mothers (22).

Based on the results of this study and those of the literature, it can be concluded that KMC plays an

important role in lactation sustainability as it keeps the infant and mother in contact. Skin contact

between infant and mother during KMC leads to the enhancement of oxytocin secretion, which, in

turn, increases the volume of breast milk (23). Moreover, the infant and mother skin contact with each

other is accompanied by the display of intuitive behaviors, including verbal and tactical interactions.

This increases the maternal body's response to skin provocation and positively affects the neonatal

nutritional behaviors (24, 25). Olfactory and thermo- receptors, which are among the strongest vagal

neurotransmitters, stimulate the release of oxytocin during skin contact (26).

In a qualitative study reviewing the biological experiences of mothers with premature infants, Wilson

introduced this intervention as an effective strategy to increase the amount of maternal milk

production. In the mentioned study, mothers reported that during touching the infant, the touch was

considered to be a stimulation for milk production and had a significant impact on the milk transfer

process and milk excretion. Some mothers even reported that KMC increased the amount of milk in

their breasts (27).

The present study entails a number of limitations, including the possibility of forgetting to record

the milk volume in the relevant checklist by mothers, which was tried to be prevented through

reminder texting. Another limitation is the loss of samples in both groups, which reduced the

sample size. In addition, the use of the availability sampling technique prevents the generalization

of the results. Therefore, it is recommended to perform further studies using random sampling and a

larger sample size.

Implications for Practice

As the results of this study indicated, breast milk expression during KMC had a positive effect on

increasing the volume of milk. This outcome is of value in planning support for mothers at hospitals.

Therefore, nurses can recommend this intervention for mothers.

Acknowledgments This article was taken from a master’s thesis submitted to the Yazd Shahid Sadoughi University of

Medical Sciences with the ethics code of IR.SSu.MEDICIN.REC.1398.077. The researchers, hereby,

express their gratitude and appreciation to the Honorable Research Assistant of the University, all the

staff of Shahid Sadoughi Hospital in Yazd, and the mothers who participated in this study.

Conflicts of Interest

None declared.

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