Rajiv Gandhi University of Health Sciences s22

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BENGALURU, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

NAME OF THE MS. SHANY JOSE 1. CANDIDATE K. R. COLLEGE OF NURSING 6. NAME OF THE #47, KATHA NO.12/1, 2. INSTITUTION AND UTTARAHALLI MAIN ROAD, ADDRESS UTTARAHALLI, BENGALURU-560061. COURSE STUDY AND 1ST YEAR M.SC NURSING 3. SUBJECT CHILD HEALTH NURSING. DATE OF ADMISSION 15.05.2010 4. TO COLLEGE “AN EXPLORATIVE STUDY TO ASSESS THE KNOWLEDGE AND ATTITUDE OF STAFF NURSES REGARDING THE STORAGE OF BREAST MILK FOR THE 5. TITLE OF THE TOPIC INFANTS OF WORKING MOTHERS IN SELECTED HOSPITALS OF BANGALORE, WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET.” BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

Breastfeeding is the best natural feeding. Women have been doing it in every corner of the world for thousands of years. Breastfeeding is an easy and inexpensive way for a mother to feed her child. Mother's milk is precious to both mother and her baby. It is the ideal and uniquely superior food for infants which represents commitment on mother’s part and ideal nourishment for her baby.1

The American Academy of Paediatrics states that breastfed premature babies have shown significant growth and progress beyond that of formula-fed counterparts. Studies have proven that breastfeeding lowers the risk of many illnesses in babies and mothers, like asthma, childhood leukaemia, and emotional disturbance in children and breast cancer among mothers. Breast milk provides the right balance of nutrients to help an infant grow into a strong and healthy toddler. Breastfed infants, and those who are fed expressed breast milk, have fewer deaths during the first year and experience fewer illnesses than babies fed with formula. 2

A few years ago, formula feeding was encouraged as a replacement for breastfeeding.

Formula feeding was prescribed by physicians as an alternative, only when the mother is medically unfit to breastfeed. But people started taking it for granted and used formula feeding in place of breastfeeding but encountered with lot of problem to the infants. The thought of providing a healthier and more natural feeding has moved breast feeding forefront again. Even if more number of mothers is choosing to go to work, they take up all hurdles and hard work to meet the health standards of their children. Mothers understand that breast milk is the best food for their babies, but returning to work greatly deters a mother’s ability to continue breast feeding. This was how the idea of storing breast milk came up. Breast milk storage is gaining popularity depending on its use and ease. Storing milk and using it for later use is helping working mothers to a great extent.3

2 The breast milk can be expressed either manually or by using breast pumps. After expression the mother can store the milk in the container. There are a variety of containers for breast milk storage. Glass is usually considered as the best choice for freezing milk because the components of milk are better preserved in glass. Second choice would be hard and clear plastic containers. Most mothers find plastic is more convenient and some day-care centers will not accept glass because of the risk of breakage. All containers should have a tight sealing, like one piece lid. . For most healthy, term babies, who get the bulk of their nutrition from direct breastfeeding, the storage container is not as important as it might be for a baby who is getting only expressed milk.4

Freshly expressed breast milk can be stored at room temperature, of 790 F, if the baby is to be fed within 4 hours and if the feeding is within 10 hours the room temperature should be between 660 F to 720 F. If the milk is refrigerated at 320 to 390 F it can be stored for up to eight days. Frozen breast milk can be stored three to six months, depending on the temperature of the freezer and frequency of freezer door openings. Deep freezers, or chest freezers afford the longest freezing time because of they usually have lower and more consistent temperatures. Do not store breast milk on a freezer or refrigerator door, since that is where the widest temperature variations occur.5

Human milk bank is a service which collects, screens, processes, and dispenses the human milk donated by nursing mothers who are not biologically related to the recipient infant. They are usually housed in hospitals, although sometimes they are free standing. Asia's first human milk bank was set up at the Lokmanya Tilak Municipal General Hospital in Mumbai in the year 1989. Since then, 25 human milk banks across India stared functioning and most of them

3 sited in the western states of Maharashtra and Gujarat. These banks have also been lifesavers for infants whose undernourished mothers may be too feeble to breast feed. In South India the concept of storage of breast milk has to be broadened, in both rural and urban areas.6

6.1. NEED FOR THE STUDY

Children are our future and most precious resource. After birth the health of the baby depends upon the nurturing practice adopted by the family. The ideal food for the young infant is human milk, which has the specific characteristics that match the growing infants' nutritional requirements. It has a diverse and compelling advantage to infants, mothers, families and society. These include health, nutritional, immunological, developmental, psychological, social, economic and environmental benefits.7

Breast Milk is the first food in life which ensures that infants and young children get a healthy and nutritious start in life. One of the joys of breastfeeding is the bonding that forms between mother and baby. But with limited maternity leave, many young mothers are increasingly opting for expressing and storing their milk so they can get back to work quickly; it ensures that the babies are not denied breast milk. The father, a close family member, or any other mindful and loving caregiver would be ideal for baby’s smooth transition from mother’s breast to expressed milk. 68 percent of mothers initiate breastfeeding immediately after birth and 46 percentages of them continue till 1 year, only 22 percentages of mothers working full time still breast-feed up to six months.8

The number of working mothers is ever increasing. In urban India women have impressive number in the workforce. As an example at software industry 30 percentage of the workforce

4 is female. In rural India, agriculture and allied industrial sectors employ as much as 89.5 percentage of the total female labour. In overall farm production, women's average contribution is estimated at 55 percentage to 66 percentage of the total labour. According to a

1991 World Bank report, women accounted for 94 percentage of total employment in dairy production in India. Women constitute 51 percentage of the total employed in forest-based small-scale enterprises.9

In India most of the mothers are unaware of expression and storage of breast milk, which leads to inadequate provision of mother’s milk to the baby resulting in decreased health status of the child as the mother returns to work. So it is very important to give education to the working mothers regarding storage and expression of breast milk.

Nurses are the back bone of the health care delivery system. They are committed to care for all persons across life cycle. Being a primary health care delivery personnel he/she can teach the mothers about breast feeding, its importance, benefits and so on. Nurses, working in

NICU, PICU and Newborn ward should know the concept of storing the breast milk. This education should be included in the discharge education package. But this concept is still not very familiar in Indian hospitals. It is the duty of nurses to give education to the working mothers about storage of breast milk. Therefore it is necessary for the nurses to have adequate knowledge regarding expression and storage of breast milk. But studies have proved that most of the nurses and other health care professionals lack in knowledge about breast milk storage and related practices. A study which was done on the staffs of the children’s hospital, has proven that 45 percentage of the respondents rated the knowledge of their breast milk storage as only mediocre or below, and 43 percentage of the respondents rated their program as inadequate or in need of improvement.Therefore the researcher felt that there is a need to

5 improve the nurse’s knowledge regarding expression and storage of breast milk in order to educate the mothers and thereby enhancing the healthier life of the babies.

6.2. REVIEW OF LITERATURE

Reviews related to storage of breast milk

A study was done to find out the breast milk collection and its storage practices among mothers of hospitalized neonates. Data about breast milk expression, collection, and storage practices were obtained by questionnaires from 51 mothers of hospitalized neonates. The majority of mothers collected breast milk in plastic containers: however, over 50 per cent stored frozen milk in glass--this is considered a less than optimal choice for storage. Over 50 per cent of the mothers identified the need for additional information about breast-feeding upon returning home from the hospital, particularly in relation to pumping and storage techniques. 10

A study was done by Wake Forest University Health Sciences, North Carolina, to identify patterns of factors that supported or hindered initiation of breast milk expression and maintenance of breast milk production after the birth of a very low birth weight infant in a sample of US women with varied prenatal infant feeding intentions. In-depth interviews were conducted 1 to 6 months after delivery in 32 women who initiated breast milk expression after encouragement from hospital staff. Pregnancy complications, anxiety regarding their infant's health, and lack of privacy interfered with initiation of milk expression. After hospital discharge, using manual or small electric breast pumps travel to the neonatal intensive care unit, return to work, and difficulty with time management interfered with maintenance of breast milk production. From these data emerge points of intervention where additional support could improve mothers' experiences and increase duration of breast milk feeding.11

6 A study was carried out to assess the effect of storage duration at varying temperature ranges, the pattern of microbial isolates and the quantity of colony-forming units on expressed breast milk. This cross sectional study found out that there was no growth of organisms in stored breast milk. The study revealed that storage duration for expressed breast milk should not exceed 24 hours in refrigerator temperature of 40 to 100 C, eight hours at room temperature of

150 to 270 C and four hours at high temperature of 300 to 380 C. Although freezing temperature of 00 to 40 C seemed safest for breast milk storage, short-term storage in a freezer is not recommended due to the hazards of the thawing process.12

Review Related to Staff Nurses Knowledge on Breast milk Storage

A descriptive Study was done in North Carolina to assess the nurse’s knowledge and attitude about storage of breast milk. The nursing staffs of 27 private pediatric practices were surveyed. The 42 item questionnaire included questions about who was responsible for breastfeeding support, what staff nurses knew and believed about breastfeeding and breast milk storage , and where their breastfeeding education was obtained. The response rate was

59 percentage. Only 46 percentage of respondents reported having received breastfeeding education in their training programs; 85 percentage had received on-the-job training. The nurses surveyed were involved in breastfeeding support, yet many had incorrect information and negative attitudes toward breastfeeding and storage of breast milk.13

A study was conducted among nurses and midwives working in a large pediatric hospital and three neonatal units in London, England, regarding support for mothers to provide breast milk. One hundred and twenty-two pediatric staff and 55 neonatal staff returned the questionnaires. Fifty-three percent of pediatric staff had received no training in breastfeeding

7 during or after nursing school. Twenty-two percent of neonatal staff had no relevant training, yet they frequently were asked to help mothers in providing breast milk for their infant. Some respondents demonstrated lack of relevant knowledge including the importance of breast milk, ideal frequencies for milk expression, and the potential to establish lactation at any time.14

A study was conducted in India to assess the attitudes of medical and nursing personnel to breast milk storage practices. 50 doctors and 50 nurses, was interviewed in an assessment of attitudes towards and knowledge of storage of breast milk. 98 percentage of the respondents believed that breast feeding was better than artificial feeding. All of the doctors and 94 percentage of the nurses agreed that the newborn should be given the opportunity for a breast feed within the 1st 12 hours following birth. While most of the doctors and nurses generally supported breast feeding, they also did not believe that the 1st feed should be breast milk.

Even though a general awareness and understanding of breast feeding existed among the medical personnel interviewed, there are still areas like expression and storage of breast milk, in which staff could be re-educated and re-directed.15

Review Related to Information Booklet

A study was conducted to examine the effect that a breastfeeding information booklet had on breastfeeding behavior. Feedback about breastfeeding information needs from a preliminary study of 58 Perth mothers at 3 months postpartum provided the basis for the development of an information booklet. The sample consisted of 150 mothers of full-term infants who were breastfeeding for the first time. Upon discharge from hospital, a random sample of 75 mothers was sent the booklet. These mothers and a control group were surveyed for 52 weeks to compare breastfeeding duration. Although the breastfeeding information booklet was

8 found to be useful by 97 percentage of the experimental group, there was no significant difference noted for breastfeeding duration between groups.16

STATEMENT OF THE PROBLEM

“ An explorative study to assess the knowledge and attitude of staff nurses regarding the storage of breast milk for the infants of working mothers in selected hospitals of Bangalore city, with a view to develop an information booklet.”

6.3. OBJECTIVES

1. To assess the knowledge of staff nurses regarding the storage of breast milk for the

infants of working mothers.

2. To find out the attitude of staff nurses regarding the storage of breast milk for the

3. To determine the association between the selected demographic variables and the

knowledge and attitude of staff nurses regarding the storage of breast milk for the

4. To develop information booklet for the staff nurses on storage of breast milk for the

6.4. OPERATIONAL DEFINITIONS

ASSESS: Refers to exploring the information from the staff nurses regarding storage of breast milk.

9 ATTITUDE: Refers to the opinions and feelings expressed by the staff nurses on storage of breast milk.

STORAGE: It refers to expressing and keeping the breast milk for the infants in the room temperature or in the Refrigerator.

BREAST MILK: The human milk that the mother is giving to her newborn immediately after delivery up to six months.

INFANTS: In my study it refers to the babies between 0 – 6 months of age.

WORKING MOTHERS: Refers to the ladies who are employed and at the period of 0 – 6 months of delivery with a living kid.

STAFF NURSES: It refers to the nursing personnel who has completed auxiliary nursing and midwifery, general nursing and midwifery, BSc nursing course and are working in NICU,

PICU and Newborn ward.

SELECTED HOSPITALS: Refers to Paediatric units of K.R. hospital and corporation hospitals, Banashankari, Bengaluru.

INFORMATION BOOKLET: It refers to the content which narrates about the methods of breast milk expression and how to store the expressed breast milk properly.

6.5. HYPOTHESIS

H1: There will be significant association between the knowledge and attitude of staff nurses and the promotion of expression and storage of breast milk by the working mothers for their infants.

H2: There is significant association between the knowledge of staff nurses regarding storage of breast milk and selected demographic variables.

6.6. VARIABLES OF THE STUDY

10 Independent variable: Storage of Breast Milk.

Dependent variable: knowledge and attitude of the staff nurses regarding storage of breast milk working in NICU/PICU/Newborn ward.

Selected demographic variables: age, sex, educational status and experience of the staff nurses.

7.1. MATERIALS AND METHODS

Source of data: staff nurses working in NICU, PICU and Newborn Ward

Research approach: Non- experimental research approach

Research design: explorative research design

Population: staff nurses of selected hospitals, Bangalore

Sample: staff nurses working in NICU, PICU and Newborn Ward

Research setting: selected hospitals of Bangalore city

Sampling technique: Non-probability purposive sampling

Sample size: 50 staff nurses working in NICU, PICU and Newborn Ward of selected

Hospitals, Bangalore

SAMPLING CRITERIA

Inclusion criteria

1. Staff nurses who are willing to participate in the study.

2. Staff nurses of NICU/PICU/Newborn ward posted for morning and evening

Shift.

Exclusion criteria

1. Night duty staff nurses.

2. Staff nurses who are not willing to participate.

TOOLS OF DATA COLLECTION

11 PART A: Socio demographic profile.

PART B: Questionnaire on expression and storage of breast milk.

7.2. METHODS OF DATA COLLECTION

The investigator will analyse the data by using descriptive and inferential statistics.

The plan of data analysis will be as follows.

Descriptive Statistics : frequency, percentage, mean, median, mode, standard

Deviation will be used to describe the data.

Inferential Statistics : ‘Chi’ square test to determine the association between

Knowledge and attitude of staff nurses regarding storage of breast milk and

demographic variables.

7.3. Does the study require any investigation or intervention to be conducted on patients or human or animals? If so please describe briefly.

No, it is a descriptive study to assess the knowledge and attitude of staff nurses regarding the storage of breast milk working in NICU/PICU/Newborn ward.

7.4. Has ethical clearance been obtained from your institution?

1. Permission will be taken from Research committee of K.R.college of Nursing.

2. Written permission will be obtained from concerned authority of K.R.

Hospitals and Corporation Hospitals, Banashankari, Bangalore.

3. Informed consent will be obtained from staff nurses

REFERENCES

1. Ronald S. Illingworth, The normal child, 10 th ed., New Delhi, Elsevier publishers, 2005,

P 3-25.

12 2. American Academy of Pediatrics Policy Statement. Breastfeeding and the use of human

milk. Pediatrics Feb 2005 ;115(2): P 496-506.

3. Dr. Sapna Samant, Text book of breast feeding, 1st ed, New Delhi, Sterling publishers

private limited, 1998, P 1-72.

4. Garza C, Johnson CA, Harrist R Effects of methods of collection and storage on

nutrients in human milk. Early Human Development 1982: P 295-303.

5. Barger J. and Bull PA., Comparison of the bacterial composition of breast milk stored at

room temperature and stored in the refrigerator. Intl Journal of Childbirth. 2nd edition.1987

: P 29 – 30.

6. Fernandez A, Mondkar J, Nanavati R . The establishment of a human milk bank in India.

Journal of Human Lactation. 1993.Jan 19( 9): P 189-90.

7. Ahn CH, MacLean WC. Growth of the exclusively breast-fed infant. Am J Clin Nutr. Feb

1980 ;33(2):P 183-92.

8. Hamosh M, Ellis LA, Pollock DR, Henderson TR, Hamosh P. Breastfeeding and the

working mother: effect of time and temperature of short-term storage on proteolysis,

lipolysis, and bacterial growth in milk. Pediatrics Apr 1996 ;97(4): P 492-8

9. Pruthi, Raj Kumar; Rameshwari Devi and Romila Pruthi . Status and Position of Women:

In Ancient, Medieval and Modern India. Vedam books.2001: P 6 – 81.

Available from: https://www.vedamsbooks.com/no21831.htm.

10. Hands A . Safe storage of expressed breast milk in the home. MIDIRS Midwifery

Digest .Apr 2003,13(9): P 378-85.

11. Chambers JA, McInnes RJ, Hoddinot P, Alder EM. A systematic review of measures

assessing mothers’ knowledge, attitudes, confidence and satisfaction towards

breastfeeding. Breastfeed Rev. 2007; 15(3), P 17–25.

13 12. Adeola KF, Adunni OO. Effect of storage temperature on microbial quality of infant

milk. Journal of Tropical Pediatrics, Apr 1998, 44(10): P 54-5.

13. Bernaix LW., Schmidt CA., Arrizola M., Iovinelli D. and Medina Poelinez, Success of a

Lactation Education Program on NICU Nurses' Knowledge and Attitudes. Journal of

Obstetric, Gynaecologic, & Neonatal Nursing, Feb 2008, Vol 37(5): P 436–445.

14. Pantazi M., Jaeger M.C., & Lawson M., Staff support for mothers to provide breast

milk in paediatric hospitals and neonatal units. Journal of Human Lactation, Jun 1998,

14(4), P: 291-296.

15. Lawrence R and Lawrence R. Breastfeeding: A Guide for the Medical Profession, 5th ed.

Mosby publications, 1999, P : 159-195.

16. Hauck YL. and Dimmock JE. Evaluation of an information booklet on breastfeeding

duration: a clinical trial. Journal of Advanced Nursing, Sep 1994 20(5): P 836–843.

9 SIGNATURE OF THE

CANDIDATE

10 REMARK OF THE GUIDE

14 11 NAME OF THE DESIGNATION

A.GUIDE MRS.VINUTHA CHRISTABEL

PROFESSOR, DEPARTMENT OF CHILD HEALTH NURSING, K R COLLEGE OF NURSING, BANGALORE

B.SIGNATURE

C.CO- GUIDE

D. SIGNATURE

E. HEAD OF THE

DEPARTMENT MRS.VINUTHA CHRISTABEL

F. SIGNATURE 12. REMARKS OF THE PRINCIPAL

A.SIGNATURE