Improving practical skills for breastfeeding vulnerable infants in low-resource settings: training material development and a case study from Rwanda

Background

Establishing and maintaining successful breastfeeding continues to be a global challenge, despite strong evidence to suggest its importance in infant survival. Breastfeeding vulnerable infants in special care and neonatal units in low-resource settings poses further difficulties due to infants’ prematurity and intrapartum-related illnesses. A review of relevant training materials available for frontline staff on breastfeeding high-risk infants revealed a significant gap in targeted training for these care groups, particularly with regard to how to support the infant-mother dyad in these circumstances (Box 1). 

Another fundamental omission in existing training is addressing the risk of aspiration (i.e., inhaling milk into the lungs during feeding) in these infants (Jadcherla, 2016). Among the group of premature infants and infants with birth asphyxia and congenital anomalies who may appear to be able to feed using generic intervention strategies, there is a significant proportion who are unable to coordinate sucking, swallowing and breathing required for safe feeding. Without specific intervention strategies to minimise this risk, these infants will go on to develop lower respiratory tract infections from aspirated material. 

Additionally, these infants face long-term nutritional and growth challenges with higher rates of chronic and acute malnutrition (Christian et al, 2013; Kakooz-Mwesige et al, 2015). The heterogeneous nature of these infants poses a challenge when developing a robust training package that meets the needs of at least the majority of high-risk infants. It is essential that training addresses assessment of an infant’s feeding behaviours and skills prior to feeding, especially prior to directing them to cup-feed or feeding with a spoon, syringe or dropper where the feeder is advised to pour the milk directly into the baby’s mouth (WHO, 2003). There is a significant gap in current training materials on identification of specific feeding difficulties and, as such, the interventions offered do not support the feeding development of this group of high-risk infants.

Given this, our aim was to develop a training package to fill these gaps as a complement to currently available training for frontline staff, which could stand alone or be used as an adjunct to other courses, such as the courses identified by the authors in Box 1. This article describes the training approach developed, rollout to date and experiences of implementation in Rwanda in collaboration with Partners in Health (PIH). PIH is an international non-governmental organisation (NGO) that partners with the Rwandan Ministry of Health to develop paediatric development clinics (PDCs) in response to a need for outpatient, long-term clinical, nutritional and developmental follow-up of infants born preterm, with low birth-weight (LBW), or other birth or perinatal complications. While the PDCs were found to address a critical gap in care for vulnerable infants, challenges remained, particularly around early identification and management of breastfeeding difficulties and nutritional outcomes (Beck et al, 2018).