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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA. SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION Ms. ROSE K PLACID 1st YEAR M.Sc. NURSING CHILD HEALTH NURSING YEAR 2011 – 2012 SJB COLLEGE OF NURSING BENGALURU - 560060 1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BENGALURU, KARNATAKA ANNEXURE-I SYNOPSIS PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION 1 NAME OF THE Ms. ROSE K PLACID CANDIDATE SJB COLLEGE OF NURSING AND ADDRESS BGS HEALTH AND EDUCATION CITY KENGERI, BENGALURU 60 2 NAME OF THE SJB COLLEGE OF NURSING INSTITUTION BGS HEALTH AND EDUCATION CITY KENGERI, BENGALURU 60 COURSE OF STUDY & IYEAR M.Sc. NURSING SUBJECT CHILD HEALTH NURSING 4 DATE OF ADMISSION 4-07-2011 5 TITLE OF THE TOPIC “A STUDY TO ASSESS 3 KNOWLEDGE AND ATTITUDE REGARDING HUMAN MILK BANKINGAMONG LACTATING MOTHERS AT SELECTED HOSPITALS, BENGALURU” 2 6. BRIEF RESUME OF THE INTENDED WORK ˝Mother’s milk time tested for million years is the best nutrient for babies because it is nature’s perfect food˝ Robert S Mendelsohn 6.1 INTRODUCTION A child is an individual who always need special care to survive and thrive. They are the major consumers of health care. In India, about 35% of total population are children . They are not only large in number but also vulnerable to various health problems and considered as special risk group. 1 Breast feeding is the best natural feeding and the best.1 Breast milk is thought to be best form of nutrition for neonates and infants. It is the healthiest form of milk for babies. WHO recommends exclusive breast feeding for the first six months, supplemented breast feeding is recommended until at least two years and then as long as the mother and child wishes.2 Breast milk it is easily digestible by the newborns intestine, offers a variety of immunologic properties, effective in protecting the baby from respiratory tract infection gastrointestinal infections and numerous allergies. It has got bacteriostatic functions against gram positive bacteria and also act as a laxative agent in neonates. Human milk contains growth modulators that modify growth and maturation.3 The preferred food for newborn infant is the mother’s own milk irrespective of baby’s gestational age but sometimes particularly in the case of sick and immature infants, the mother is unable to maintain her lactation and an alternative food is required. In 1800 BC the infant have been directly breastfeed by wet nurse..A wet nurse is a lactatingwoman who breast feeds another baby. While this may seem to be ataboo in our culture wet nurse was actually popular until the invention of formulas.2 The practical alternative diet for baby who are unable to breast feed are banked human milk or commercially available formula. The term human milk banking refers to the collection, storage and processing of human milk donated by lactating mothers for infants other than their own.The term some times applied to the collection and storage of milk for a mothers own infant when the infant is temporarily unable to suckled.2 Banked human milk is used for the treatment of many conditions (mainly in Neonatal Intensive Care 3 Units: NICUs): prematurity, malabsorption, short-gut syndrome, intractable diarrhea, nephrotic syndrome, congenital anomalies, formula intolerance, failure to thrive, immune deficiencies.4 The world’s first human milk was established in 1909, in Vienna, Austria. Asia’s first human milk bank was set up at LokmanyaTilakMuncipal Hospital in 1989.The first human milk bank in Pune city was inaugurated in the DeenathMangehkar Hospital. Human milk are crucial for India because the practice of women donating milk on humanitarian grounds is common, since then some 25 human milk banks across India – most of were located in the western states of Maharashtra and Gujarat have been performing vital services for premature babies requiring temporary intervention in cases of delayed lactation abandonment or illness, these banks also been a life savers for infants.5 6.2 NEED FOR THE STUDY According to a joint statement by the World Health Organization and United Nations Children's Fund in 1980. The best food for any baby whose own mother's milk is not available is the breast milk of another healthy mother. 6 The recently released India Report of World Breast Feeding Trends Initiative 2008, highlights the role of breast feeding in ensuring child health and reducing infant and child mortality. India has an infant mortality rate of 55 per 1000 live births (SRS 2008) which accounts for 72 per cent of the country’s under-five mortality rate.7 In 2010 the infant mortality rate was 49.13% and in 2011 it is 47.57% per 1000 live birth in that males is 46.18% and females is 49.14%.8Breast feeding is the most important intervention to prevent newborn infections, diarrhea and pneumonia, which cause child deaths in the month after birth till the end of the first year of life. Initial breast feeding in the first hour after birth and exclusive breast feeding in the first six months after birth can go a long way in preventing most neonatal and infant deaths in India. 7 Donor milk has a broad range of therapeutic uses Common reasons for prescribing donor milk are prematurity, allergies, feeding formula intolerance immunologic deficiencies post operative nutrition etc. Breastfeeding is not recommended for mothers who have certain health problems such as active herpes lesions on the breast, active untreated tuberculosis, human immunodeficiency virus infection, nephritis, serious illnesses, heart disease or cancer, severe malnutrition.9 4 In the absence of the infant’s own mother’s milk, donor milk offers the benefits of human milk for the infant including optimal nutrition, easy digestibility, immunological protection against many organisms and diseases infection-fighting components such as immunoglobulin. Human milk also contains growth factors that can protect immature tissue, promote maturation, particularly in the gastrointestinal tract, promote healing of tissue damaged by infection. 9 A study was conducted to determine the composition of donated milk from a large number of banked donor milk samples and compared it to the reported values for macronutrients in mature breast milk. During a 9-month sampling period (May 2006 through February 2007) from a nationwide milk bank network, 415 sequential samples from 273 unique donors were analyzed for fat, protein, and lactose content, as well as energy density. Descriptive statistics were computed, including mean, standard deviation, coefficient of variation, median, and range. A ninety-five percent confidence interval was computed using standard, large sample (Gaussian) methods. Banked donor milk mean values (in weight/volume) were found to be 1.16%+/-0.25% for protein, 3.22%+/-1.00% for fat, 7.80%+/-0.88% for lactose, and mean total energy was 65+/-11 kcal/dl. Banked donor milk macronutrient content was found to differ from the values reported in the literature for mature human milk formulated banked donor milk was found to be a better choice for preterm infants than bovine-based formulas when mother's milk is unavailable.10 Breast milk is a natural, easily digestible and cost effective food necessary for the child’s entire growth and development. Thus, with the above view, the investigator felt the need to assess the knowledge and attitude of the lactating mothers regarding human milk banking and develop an information booklet on it. This will help the mothers to enhance their knowledge regarding human milk banking and to develop a positive attitude toward it. 6.3REVIEW OF LITERATURE The related literatures are presented in the following subheadings 1. 2. 3. Literature related to knowledge regarding human milk banking Literature related to attitude regarding human milk banking Literature related to importance of human milk banking 5 Literature related to knowledge regarding human milk banking An descriptive study was conducted to assess the characteristics of donation behavior and identify reasons, beliefs and feelings to donation of breast milk with women donors at two breast-milk banks. Data was collected from 36 women, aged 14 to 33 years with different levels of schooling. 58.3% of subjects participated were first-time mothers. Data was collected thorough interviews carried out during home visits. The study concluded that , the most frequently reported reasons for donating breast milk were altruism and excess milk production. 11 Literature related to attitude regarding human milk banking A study was conducted to assess the attitude of giving breast milk , sharing of breastfeeding or expressed breast milk by Australian women in a recent thirty-year period, 1978-2008. The objective of this study was to explore the mothers' experiences of sharing breastfeeding or human milk. The study report shows that the reason for the sharing of breastfeeding or breast milk was the desire of mothers to provide human milk to their babies, exclusively, including while they were absent or temporarily unable to breastfeed. Most mothers were selective about those with whom they would share breastfeeding or breast milk.12 A study was conducted among breast feeding mothers to assesstheir attitudes regarding breast milk banks and offering stored breast milk to their babies. Data was collected from 680 breast-feeding mothers by using a structured pretested questionnaire. Study report shows that about 71 percent would not accept donated breast milk for their baby while the rest would consent only if the donor were a close family relative, owing to fear of transfer of diseases (28 percent), fear of transfer of genetic traits (22 percent), and religious and cultural taboos (14 percent). However, 60 percent were willing to donate breast milk 38 percent would accept milk from a breast milk bank.13 A study was conducted to assessthe attitudes towards donated breast milk among mothers, families and healthcare providers of potential recipient infants. The qualitative data was derived from eight focus group discussions which included four groups with mothers, male partners grandmothers, nurses and doctors about their attitudes towards donated breast milk.Each 6 group had between four and eleven participants, leading to a total of 48 participants. Although breast milk was important to child health there were concerns about undermining of breast milk because of concerns about HIV and marketing and promotion of formula milks. In addition there were concerns about the safety of donor breast milkand discomfort about using another mother's milk. Participants believed that education on the importance of breast milk and transparency on the processes involved in sourcing and preparing donor milk would improve the acceptability. 14 Literature related to importance of human milk banking A study was conducted to assess the growth and clinical evolution of very low birth weight infants fed during hospital stay with milk from a human milk bank according to the caloric-protein value. Forty very low birth weight infants were included: 10 were fed milk from their own mothers (GI), and 30 were fed human milk bank > 700 cal/L and 2 g/dl of protein. Growth curves were adjusted using nonlinear regression to the measured growth parameters. full enteral diet was reached in 6.3 days by GI and in 10.8 by GII; a weight of 2 kg was reached in 7.3 weeks for GI and in 7.8 for GII. In GI, 3/10 (33.3%) and in GII, 7/30 (23.3%) developed sepsis. Necrotizing enterocolitis did not occur in GI, but in 3/30 (10.0%) in GII. GI presented with urinary calcium > 4 mg/L in 1/10 (10.0%), urinary phosphorus (Pu) <1 mg/L in 10/10 (100%), and Ca/Cr >0.6 ratio in 1/10 (10.0%) of the cases; in GII, no children presented alterations of the urinary calcium or the Ca and Cr ratio, and Pu was <1 mg/L in 19/30 (63.3%). In terms of growth the 50th percentile for GI was a weight gain of 12.1 g/day (GI) vs. 15.8 g/day (GII), a length gain of 0.75 cm/week (GI) vs. 1.02 cm/week (GII), and a head circumference gain of 0.74 cm/week (GI) vs. 0.76 cm/week (GII). Human milk bank allowed a satisfactory growth and good clinical evolution for very low birth weight infants. 15 A observational longitudinal was conducted to assess the feasibility of providing donor breast milk to infants after pasteurization.191 low birth weight infants were selected for the study, out of them 96 infants received their own mother’s milk.. Other 95 infants who were potentially eligible to receive donor milk, only 40 did in fact receive donor milk. Above study reported that it is feasible to supply donor milk to and there was no evidence of bacterial contamination in the samples analyzed, and no adverse events from feeding with donor breast milk. 16 A study was conducted to assess the impact of opening a milk bank in the neonatal unit on the proportion of infants receiving exclusive breast milk at discharge.50 infants born before the opening of milk bank and 54 infants 7 born after the opening of a milk bank were selected as samples. The data was collected about the hospital stay, hours of stay, hours of life when feeding was started, hours of life when full enteral feeding was attained, type of milk received during admission and type of feeding on dicharge.The results shows that proportion of infants receiving exclusive breast milk in first group was 54% and second group was 56%The study concluded that opening of a donor milk banking in a neonatal unit did reduce the proportion of infants exclusively feed with breast milk at discharge but did reduce the proportion of infants that received infant formula during the first four weeks of life.17 STATEMENT OF THE PROBLEM “A study to assess knowledge and attitude regarding human milk banking among lactating mothers at selected hospitals Bengaluru, with a view to develop an information booklet. 6.4 OBJECTIVES OF THE STUDY 1. To assess knowledge regarding human milk banking among lactating mothers at selected hospitals Bengaluru. 2. To assess attitude regarding human milk banking among lactating mothers at selected hospitals Bengaluru. 3. To determine the association on knowledge score with selected demographic variables. 4. To determine the association on attitude score with selected demographic variables. 5. To find the co-relation between knowledge and attitude regarding human milk banking among lactating mothers at selected hospitals Bengaluru. 6.4.1 HYPOTHESIS H1: There will be significant association between the knowledge score of lactating mothers regarding human milk banking. H2 : There will be significant association between the lactating mothers regarding human milk banking 8 6.5 OPERATIONAL DEFINITIONS a) Assess: It refers to appraise value or evaluate or judge the quality of something. b) Knowledge :It refers to level of understanding or familiarity of lactating mothersregarding human milk banking. c) Attitude: It refers to way of opinion or view of lactating mothers regarding humanmilk banking. d) Human milk banking :It refers to collection, storage and processing of donatedhuman milk e)Lactating Mothers: It refers to mother who breast feed her baby. f) Information booklet: It refers to carefully prepared concise and comprehensiveinformation material regarding human milk banking. 6.6 ASSUMPTIONS 1. Lactating Mothers may not have knowledge regarding human milk banking. 2. Information booklet may improve the knowledge of lactating mothers regarding human milk banking. 7.MATERIALS AND METHODS 7.1 SOURCES OF DATA :Lactating mothers at selected hospitals,Bengaluru. 7.1.1 RESEARCH APPROACH :Descriptive Design. 7.1.2 RESEARCH DESIGN : Explorative approach 7.1.3 SETTING : Selected hospitals Bengaluru 7.1.4 SAMPLE SIZE :100 lactating mothers at selected hospitals Bengaluru. 9 7.1.5 INCLUSION CRITERIA Lactating mothers, who can read and write Kannada & English. who are present at the setting during the time of data collection. who is willing to participate in the study. 7.1.6 EXCLUSION CRITERIA Non lactating mothers 7.2 METHOD OF DATA COLLECTION 7.2.1 SAMPLING TECHNIQUE :Non probability purposive sampling technique 7.2.2 TOOLS OF RESEARCH : Structured questionnaire Structured questionnaire consist of three parts, Part I – The demographic variables Part II – Knowledge based questionnaire regarding human milk banking. Part III – Attitude based questionnaire regarding human milk banking. 7.2.3 COLLECTION OF DATA The investigator collects data from lactating mothers The written consent will be obtained from the authority prior to the data collection Investigator introduces herself to the subject and notifies about aims, objectives, steps of the study and takes written consent. Selection of samples. Assess the knowledge and attitude of lactating mothers regarding human milk banking using structured questionnaire. Duration of data collection will be four weeks. 10 7.2.4 METHOD OF DATA ANALYSIS AND PRESENTATION The investigator uses descriptive and inferential statistical techniques for data analysis. The analyzed data will be presented in the form of tables, diagrams, and graphs based on finding. 7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY? Yes, the study will be conducted on lactating mothers at selected hospitals regarding human milk banking. 7.4 HAS ETHICAL CLEARENCE HAS BEEN OBTAINED FROM YOUR INSTITUTION? Yes, Consent will be obtained from concerned subjects and authority of institution. Scientific objectivity of the study will be maintained with honesty and impartial. 11 8. LIST OF REFERENCES 1. DuttaParul, Paediatric Nursing. 2nd ed.NewDelhi, Jaypee Brothers Medical Publishers; 2009. p. 2,51. 2. Willams A.F, Fisher C, GreasleyV,TraylerH,Woofride MW, Human milk banking. Journal of tropical peadiatrics. 31(4). 185-190. 3. Hockenberry, Wilson, Winkelstein, Kline. Nursing care of infants and children. 7th ed. India, Elsevier; 2003. p. 273-4. 4. Dr Carolyn, Dr Lisa Amir, the Maternal and Child Health Subcommittee. [online] 2009 [cited 2011 Sep 14]. Available From: URL: http://www.breastfeedingindia.org. NeetaLal, Growing pain in India. [online] 2008 [cited 2011 Sep 20]Available from:URL: http:// www.breastfeedingindia.org Arnold LDW, Human milk banking in North America .Journal of Human Lactation. 1997 13(2) . 159–162. Alex George. To save the child’s life. The Hindu 2009 Jan 11; (col.4) Infant mortality rate demographics. [online] 2011 [cited Oct 22] Avaiable from:URL: http://www.indexmundi.com/ India/ infant mortality rate html. Marea Ryan, Why we need a mothers milk bank. [online] 2010 [cited Sep 5] Available from:URL: http://www.bendigobank.com. Wojick KY, Rechtman, Lee ML, Montova A, Medo ET. Macronutrtient analysis of donor breast milk. [online] 2002 [cited Sep 14] Available from:URL: http://www.ncbi.nlm.gov./pubmed. Alencar LC, Seidl EM. Breast milk donation. [online] [cited Sep 5] Available from: URL: http://www.ncbi.nlm.gov./pubmed. Thorley V, Mothers experience of sharing breast milk. [online] [cited Sep 5] Available from:URL: http://www.ncbi.nlm.gov./pubmed. IghobojaIS,Olarewaju RS, OdumoduCU,Okuonghre. Mothers attitude towards donors milk.[online] 1995 [cited Sep 6] Available From URL: http://www.ncbi.nlm.nib.gov/pubmed. 12 .AprileMda, Feterbaum R, AndreassaN,Leonac. Growth and clinical evaluation of low birth weight infants. [online] 2010 [cited Sep 14] Available from:URL: http://www.ncbi.nlm.nib.gov/pubmed. Coustodis, Adihikari, Nair N, Coustoudis A. feasibility and setting up of a donor milk bank. [online] 2011 [Sep 15] Available from: URL:http://www.ncbi.nlm.nib.gov/pubmed. Utrera Torres, Medina Lopez,Vazquez Roman, Alonso Diaz, Cruz Rojo,Fernandez Cooke. Beneficial effects of human milk. [online] 2010 [cited Sep 16]. Available from: URL:http://www.ncbi.nlm.nib.gov/pubmed. . 13 9 Signature of Candidate 10 Remarks of the Guide The study is feasible and of genuine interest of the student 11 Name & Designation Of 11.1 Guide Mr. Hanock Reuben, M.Sc (N). Professor/ Principal HOD, Child Health Nursing. SJB College of Nursing. Bengaluru-60. 11.2 Signature 11.3 Co-Guide MrsRoseline Reddy, M.Sc (N). Professor, SJB College Of Nursing Kengeri, Bengaluru-60. 11.4 Signature 11. Head of the Mr. Hanock Reuben, M.Sc (N). Department Professor/ Principal Department of Child Health Nursing. SJB College Of Nursing Kengeri, Bengaluru-60 11.6 12 Signature 12.1 Remarks of the The topic for the study is relevant and forwarded for needful action. Principal 12.2Signature 14