As I am also a trained and experienced lactation manager counsellor when I need to move babies from mix feeding to exclusive breastfeeding this is what I advise mothers

If there is definite low supply of BM by mother : 

1. Always put baby to breast first  atleast 30-40 mins on each side - if she found to be fussy then only top feed with just 30cc and if still fussy then baby to go back on breast and continue the same process till baby is satisfied. 

2. encourage mother to  pump or hand express as many times she has top feed baby e.g. 3 times topfeed then 3 times pump +1 

3. try and replace the top feed with ebm 

4. Keepa watch on pee count and weekly growth monitoring 

5, Motivational counselling , nutrition for mother and if required domperidone for increasing milk supply

If mother has good milk supply:

1. Motivational counselling 

2. Explain cluster feeding may required to establish EBF , allow her to practise it before discharge or at home  ( also known as nursing vacation)

3. Let her watch pee count ( 6+ in 24 hours) and weekly growth monitoring

4. ask her to pump once and stock it up in case pee count drops so she may use it for top up 

Hope these tips help and help you formulating your discharge protocol. You may connect with me if you need any more resources and support. 

Dear Neha Arora,

thanks a lot for your reply, actually at inpatient level we have a protocol to follow which is based on the same points you listed (this to confirm even more its appropriateness). The big concern then is not really during inpatient period, where we can advocate and practice safe relactation, the issue is when you have to discharge those patients before you manage to re-establish lactation and thus before the infant is exclusively breastfeed.

Thus at this point, as those infants are not EBF, but still need a certain quantity of BMS to integrate their diet, how much of BMS should we provide at home?

As previously mentioned, we could give full BMS ration but that could discourage breastfeeding, and it's not needed at those high amounts, considering maybe they need a minimal quantity only. We also thought of supplying with the same amount of BMS used in last days, + x% for spillage (which could be 20% for example). [this is only an idea at the moment that we are still discussing].

what is everyone experience about it?

thanks again

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.

Dear Fabrizio. Having consulted with other members of the MAMI Global Network - we've discussed your specific question reading > In MAMI care pathway we know what to do if EBF and what are the suggested quantities of BMS if the patient is not breastfed, but what about if the patient is on "mixed feeding" at discharge? - Should we stay in the "safe side" and give the dosage of BMS as per non-breastfed at all infants, or we should give the amount of BMS as per last days of hospitalization, as integration/top-up of breastfeeding?

Response: Obviously we would aim to have EBF re-established upon discharge (you have already noted this), however, we recognise that sometimes mother/carer-infant pairs cannot/do not stay for the requisite time to achieve this. In this instance, we would advise that at the point of discharge, the same amount of BMS be given for outpatient care, as last day in hospital/inpatient care. We do not want to risk giving increased amounts and displacing breastfeeding either intentionally or unintentionally. However, we would also recommend that follow-up through outpatient care happens more regularly than would usually be done i.e. daily or every 2-3 days (rather than weekly), in order to monitor BF status, weight gain and general well-being. In this way the BF status can also be assessed and quantity of BMS gradually pulled back in line with weight gain, as this means breastfeeding is improving. If however, BM production reportedly reduces, weight gain starts to faulter, or general well-being of infant/mother is noted to have deteriorated, this would warrant a re-referral to inpatient care.

With regards to quantities of BMS. It is advised that you calculate dosages according to patient weight rather than age, as weight does not correspond to age appropriately when a child is malnourished. Note that if preterm, or otherwise vulnerable, you might consider a specialist formula.

For ref’. Please check out the MAMI Care pathway (released in May 2021). Esp’ the “support actions book” https://www.ennonline.net/mamicarepathway

https://www.ennonline.net/attachments/3905/MAMI-Counselling-Cards-(standard-version-horizontal).pdf