Hello friends 👋

In this episode of the Global Neonatal Podcast, the hosts interview Dr. Emily Njuguna  and Kimberly Mansen MSPH RDN  from PATH to discuss the importance of human milk in low and middle-income countries (LMICs) and the strategies used to support lactation. The guests highlight the challenges faced by mothers in LMICs and  emphasize the importance of early lactation support for mothers of the most vulnerable newborns. Emily and Kimberly  discuss the three-pronged approach of kangaroo mother care, lactation support, and human milk banks in providing human milk for babies in LMICs. They also share examples of successful initiatives, such as the establishment of a human milk bank in Kenya, and discussed plans for scaling up these programs in other countries.

PATH is a global organization dedicated to improving public health through innovation. They work in over 70 countries to accelerate health by bringing together public institutions, communities, social enterprises, and investors.

Resources mentioned in episode:

PATH Newborn Nutrition page: https://www.path.org/who-we-are/programs/maternal-newborn-child-health-and-nutrition/newborn-nutrition/

Article on potential effectiveness of human milk banking and lactation support on neonatal outcomes at the Pumwani Maternity Hospital in Kenya

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10750015/

Contact:   

Kimberly Mansen https://www.linkedin.com/in/kimberly-mansen/

kamundson@path.org

Emily Njuguna MD https://www.linkedin.com/in/emily-m-njuguna-062b7724/?originalSubdomain=ke

enjuguna@path.org

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Bios:

Emily Njuguna MD

Dr. Njuguna is a pediatrician and global health practitioner. She is the Africa Lead for Maternal and Newborn Health at PATH and the elected nutrition lead for the Africa Neonatal Association. As an advocate for improved nutrition policies, she has worked tirelessly to influence policy reforms prioritizing the nutritional needs of infants and young children, particularly small and vulnerable newborns in resource-limited settings.

As the previous Head of Pediatrics at Pumwani Maternity Hospital, she was part of the team that established and sustained the first human milk bank in East and Central Africa in Nairobi, Kenya. This milestone has significantly improved the nutritional outcomes for vulnerable infants in the region. Her expertise extends to research, publications, and presentations at international conferences and global expert consultations, contributing to the global discourse on systems strengthening for neonatal nutrition.

Dr. Njuguna has forged strategic partnerships with governments and key stakeholders in Kenya, Ethiopia, Tanzania, Malawi, Nigeria, and Uganda. Her work also spans quality improvement, strategic planning, healthcare leadership, and management. She continues to be a leading voice in the field, dedicated to advancing neonatal nutrition and health for vulnerable newborn populations across Africa and beyond.

Kimberly Mansen, MSPH, RDN

Kimberly Mansen is a Maternal and Newborn Nutrition Advisor with PATH’s Integrated Maternal and Child Health and Development Program. She is trained as a Registered Dietitian Nutritionist, having experience both clinically and in the global health field. She currently focuses on improving maternal, infant, and young child nutrition, particularly in strengthening systems to improve maternal lactation support and ensure all infants receive human milk, including small and sick newborns. She helps to lead PATH’s Newborn Nutrition portfolio, consisting of implementation, research, advocacy, and technology development. Her work at PATH has spread across multiple settings, including India, Kenya, Malawi, South Africa, Tanzania, and Vietnam, among others. Kimberly previously practiced as a Clinical Pediatric Dietitian at Seattle Children’s Hospital. Prior to PATH, she served as an Operations Research Field Coordinator for Johns Hopkins Bloomberg School of Public Health in the Democratic Republic of Congo, investigating interventions to improve food security. She received a Masters of Science in Public Health in International Nutrition from Johns Hopkins Bloomberg School of Public Health, and a Bachelor of Science in Human Nutrition from Pepperdine University.

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The transcript of today's episode can be found below 👇

Shelly-Ann Dakarai (00:00.818)

Well, hello everyone. Welcome back to another episode of the Global Neonatal Podcast. We are so happy to be back with another interview and we're here a week early. I don't know if you guys have noticed, but our episodes tend to come out the second Wednesday of the month, but we're bringing this one on the first week to highlight World Breastfeeding Week. And so we're excited to have some experts in the field as it relates to the global context. And Bozu, how are you today?

Mbozu Sipalo (00:26.013)

I'm doing good, Shalianne, how are

Shelly-Ann Dakarai (00:29.478)

I'm doing great, doing great. As I said, just kind of excited to have this conversation and learn a little bit more. And so just happy to be here.

Mbozu Sipalo (00:38.997)

Yes, happy to be here. Happy summer. Happy we're talking to some new people from PATH team. So it's going to be a very, very interesting conversation.

Shelly-Ann Dakarai (00:49.52)

Yes, I agree.

Shelly-Ann Dakarai (00:54.672)

All right, in the interest of time, we're gonna introduce our guests with a shortened version of their bio, but we'll have the full bio on our episode webpage. Maybe I'll have Embo Zu go ahead and introduce our first guest, and then I can round it out and introduce our second guest.

Mbozu Sipalo (01:11.785)

All right. Thank you, Shealyan. Okay, so we have two amazing ladies from PATH. So we have Dr. Yuguna, who is a pediatrician and global health expert serving as African lead for maternal and newborn health at PATH and the elected nutrition lead for the African Neonatal Association. She champions improved nutrition policies for infants and young children.

particularly in resource -limited settings. Welcome to the podcast, Emily.

Emily Njuguna (01:47.386)

Thank you so much, Mbozu. I'm really excited to be here. Thank you, Shalya, as well. Thanks.

Shelly-Ann Dakarai (01:53.586)

Yes, excited to have you guys. And we also have with us Kimberly Manson, who is a maternal and newborn nutrition advisor with PATH's Integrated Maternal and Child Health and Development Program. She's a trained registered dietitian nutritionist, and she has clinical and global health experience focusing on improving maternal, infant, and young child nutrition. She leads PATH's Newborn Nutrition portfolio, covering implementation, research, advocacy, and technology development.

working in India, Kenya, Malawi, South Africa, Tanzania, and Vietnam. Kimberly, welcome to the podcast.

Kimberly (02:28.935)

Thank you. Thank you for having both Emily and myself. We're looking forward to being

Mbozu Sipalo (02:36.417)

All right, okay, so just so our listeners learn more about your backgrounds and where you're from, could you please tell us a little bit about PATH? I'll give this one to Emily.

Emily Njuguna (02:51.278)

Yeah, thank you so much.

So PATH is a global organization that's dedicated to improving public health through innovation and we have been around since 1977. So that's close to 45 years now. And this organization was started by a group of engineers who really wanted to advance, to develop and advance health technologies for low middle income countries. But we've really evolved over the past 45 years and currently our work spans over 70 countries to accelerate health

by bringing together public institutions, communities, social enterprises, and investors to solve the world's most pressing health challenges. So our work spans multiple health areas, including infectious diseases, reproductive health, maternal and child health, including early childhood development, nutrition, pharmaceuticals, vaccines, and many other health disciplines. But really our main goal is to advance health equity for communities.

Mbozu Sipalo (03:55.678)

Thank you so much for that introduction, Emily, and it's great to hear about the amazing work that you're doing at PATH. The next question I have, I think I'll give it to Kimberly, which is, could you please tell us about the newborn nutrition program at

Kimberly (04:12.273)

Yeah, happy to. And both Emily and I helped to co -lead along with another colleague of ours, Kirsten Israel Ballard. We're thrilled to get to explore a little bit more about the program that we help run with PATH. But really, this is about all the partners that we work with and strengthening and ensuring that really a hidden issue or a gap that we've seen in the field is addressed.

So our goal for newborn nutrition is ensuring that all infants receive human milk. Ideally, mothers on milk wherever possible. But for the most vulnerable of populations from the first hours of birth, re -understanding what it means to support the mom and the baby when they're born too soon, when they're born too small, what can we do to strengthen systems?

to ensure that all women receive the lactation support that they need and all newborns receive from the first few days the most optimal nutrition to grow and thrive, both for long -term feeding success and health. So that for us, we sit under our integrated maternal and child health and development team at PATH, which is under our primary health care program. So we continue to have a lens

what does it mean to meet people where they need it, when they need it most to receive optimal care. And in the case that we're working, we primarily are focusing on the directly at birth with facilities that are providing inpatient newborn care. That extends into the community and beyond because those babies go on to live and need additional programmatic support or health system support

Survive and Thrive as well. But much of our work, historically, is focused in the facility. So we are doing global advocacy work, research, programmatic support, ensuring KMC, Kangaroo Mother Care, early lactation, specialized lactation support for the mom of the small, vulnerable newborn, and advancing

Kimberly (06:28.179)

nutrition as well, and when that's not possible, integrating human milk banking programs to provide access to donor human milk in a safe and effective way that does not undermine breastfeeding but supports it. So happy to explore that further, but that's a brief overview.

Mbozu Sipalo (06:48.617)

All right. Thank you so much for that overview. And can hear that you're doing a lot of impactful work and it spans across many sectors of health, which is amazing. And particularly nutrition, which is really important for newborn babies. Sounds really, really amazing, like really, really amazing work. The next question would just be to both of you. So our listeners can learn more about who you are and your roles at PATH. What led you to PATH?

and what is your role within the program of the neonatal nutrition. So I'll start with Emily, then Kimberly, you can follow.

Emily Njuguna (07:29.658)

Yeah, thank you so much. So as I had mentioned,

I work for PATH and Kimberly had mentioned that Kimberly, myself and a few other colleagues helped to co -lead our Newborn Nutrition team. But my role at PATH is as the African lead for maternal and newborn health. So I help to lead all our programs for the African division. But more to that, I also help to support the African Unitary Association as the elected lead for nutrition. So really tying in some of the work that we're doing at

with one of the biggest advocacy groups on the continent really advocating for newborn nutrition. So beyond that, I am a board certified pediatrician based in Nairobi, Kenya, and I have been a doctor for many, many years. And prior to joining PATH, I served as the head of pediatrics at Pumwani Maternity Hospital, where I was part of the team that helped to establish and sustain the first human milk bank in Eastern Central Africa.

But really, you know, that work evolved and I found myself joining a wonderful organization that was really spearheading some of the, you know, my aspirations around really supporting the small and sick newborn to survive and thrive.

So my work includes, know, program leadership, particularly thinking through how we can develop key partnerships with governments, non -governmental organizations, and key organizations such as the African Neonatal Association, as I had mentioned. But then our work also involves a lot of research and development, a lot of policy advocacy and community engagement. So that's in a nutshell what I do at PATH. And I'll hand it over to my colleague, Kimberly.

Kimberly (09:13.723)

Yeah, we're so thankful that Emily joined our team after we had collaborated with her at Pumani. It was so fantastic and seeing her expertise and hands -on experience really working with the Milk Bank introduction and continuity really led to strengthening this program. So the question is, what led us to PATH or what is our role? Remind me where the focus is on both of those. OK.

Mbozu Sipalo (09:41.695)

Yes.

Kimberly (09:43.539)

Yeah, so my background just having I've always been interested in nutrition and maternal health. That is vast and far between that there's so many ways to be addressing this this time of life. However, more and more what drew me to this and kept me going in this space. I've been with PATH for over 10 years. Specifically, what has kept me here is this body of

So PATH has been able to prioritize and continue to support that this is an essential, that newborn nutrition, maternal lactation, the small and sick newborn is an essential component of overall infant health and maternal health. And the ability to focus in this specific area where there is very little guidance and a lot of innovation that is possible has been what has kept me here. So my...

My role more broadly is across all nutrition work. So investigating other interventions during ANC, postpartum, early infant nutrition, far beyond this, but this is the continuous body of work that I've been most passionate and personally interested in and what has kept me going here.

So my journey to PATH and what led me to PATH, I interestingly in grad school had been interning on the MCHIP program, a USAID funded, know, maternal and newborn program. PATH happened to be the lead for nutrition. So I was interning for MCHIP under the PATH umbrella. I was from the Seattle area and asked if I could do a few of those.

weeks of the internship back in Seattle over the holiday season. And sure enough, they found another project at Path Seattle for me to internet that was heating milk on a stove, measuring the time it took to heat it sufficiently to pasteurize the milk in a almost like a flash heat system. And this was all under Dr. Kirsten Israel Ballard's leadership that was innovating and working

Kimberly (12:00.723)

partnering with the Human Milk Banking Association of South Africa, an incredible human milk bank in KwaZulu -Natal, Atembaletu, that was focused on providing donor milk for orphans under six months. And we were looking at, without any temperature monitoring, what volumes take what amount of time to do something like a high temperature, short time treatment. And

Couple of weeks just focusing in the lab, seeing all of what PATH is doing in the engineering space and realizing this is incredible, both the newborn nutrition, the specific niche of an area, as well as all the other work that PATH was doing. It made me realize how unique this organization really was and that you could walk down the hall and talk to someone that's working in the lab or an engineer, very different than trying to form formal partnerships under

names and roofs. So I eventually after grad school worked for Hopkins in the Congo, doing more operations research, food security. But as I made my way back to Seattle, this work really drew me in and I pursued, there anything to keep doing in this space? And this is, it just grew over time. So a consulting role turned into focusing on this for a long time now. But it's

was those early experiences that just showed how impactful this can be and what has kept me here.

Emily Njuguna (13:35.544)

Yeah, and I realize I'm not sure I answered the question on how I found myself here. So I focused on my role. But thanks Kimberly for leading the way. So I'm happy to add on if that's OK, Shellyan and Bozu. Yeah, so as I mentioned, I had been working as a head of pediatrics at Pumwani Maternity Hospital in Nairobi, Kenya, which is the largest maternal and newborn health facility and really was part of the team that set up the first human milk bank.

Shelly-Ann Dakarai (13:35.592)

Thanks, it's always.

Emily Njuguna (14:04.474)

to sustainability. So to point where the Ministry of Health and the government of Nairobi were actually sustaining it through continuous funding. So that work really interested me and I was also working very closely with the research team at the county at then. And so, know, PATH, we were doing a lot of work, for example, really thinking through how to digitize our systems within the facility to ensure that we were able to generate data for action, that we were able

really be able to track how milk flows within the department, which is something that was really hard for us, mostly because our systems are largely manual. And so I had been working very closely with Parth on the milk banking work, on this other digital piece. And we were also working to really look and analyze the donor human milk that we had in our facility to see what

if there were geographical differences between milk that was donated in low -middle income countries vis -a -vis the high -income countries. So that work led to a consultancy as just like for Kimberly and that evolved into now this role that I am in and I'm very excited to be here. Yeah, thank

Shelly-Ann Dakarai (15:19.752)

Thanks so much for sharing that. It's always interesting to hear everybody's paths to where they are right now. You go to school for one thing and then you wake up and you're somewhere else. So it's always nice. And I know we do have some listeners who are still on their career path journey. So it's always interesting to hear how people end up where they are. I want to go back a little bit to something Kimblee had mentioned about supporting moms in that beginning stage and kind of talk a little bit about the importance of human milk.

Emily Njuguna (15:28.781)

Exactly.

Shelly-Ann Dakarai (15:50.046)

in the LMIC context specifically. So I know a lot of our listeners are neonatal providers and some are trainees and things like that. And some people who may not even be in the healthcare space but find this interesting. But in general, I think many people understand the importance of human milk now. But I'm not really sure if we're all familiar with the impact it is in a low and middle income context. So I don't know if any of you or both of you can potentially speak to why this is such an important issue.

globally.

Emily Njuguna (16:22.298)

Yeah, Kimberly, you can start.

Kimberly (16:23.773)

Would you take that one? Yeah, that sounds great. So specifically, so there's a few different facets to this. General breastfeeding is forever, not forever, but for a long time now been realized how one of the most cost effective, impactful interventions at large for all babies, not just the small and sick newborns. There are priorities looking

improving early initiation of breastfeeding, which is still less than half of babies are put to the breast within the first hour. And even exclusive breastfeeding through six months or until six months, excuse me, is where we've achieved major gains in the last 10 years. The last decade, we've seen over 10 % increase, but we're still less than half of infants that are reaching even that milestone.

So if you think about it, we've prioritized breastfeeding for a long time and knowing how important it is for not just growth development, but health. There are the health components to human milk that is, you know, some call a magical potion. I'm sure all of the mechanisms and the matrix of all of the immunoglobulins, all of your micronutrients.

macronutrients, everything in terms of the needs of the infant. It has much more than we even know it has to be providing for long -term health and growth and development. For this specific population, it's fascinating. This baby was born typically too early and their gut is not as mature as a term infant. Exposure to human milk and the human

protein versus a bovine milk protein found in other substitutes for mom's milk actually can cause necrotizing enter colitis, a reaction at the gut lining, inflammation that can lead to a deadly surgical need of that same newborn already so vulnerable, adding that onto their plate can really change the trajectory of their ability to survive and thrive. And

Kimberly (18:40.903)

What we know of as simple as being able to provide early diets with human milk, the gut tolerates that a lot better. It is jumpstarting the microbiome. is influencing so many different pathways at the gut lining and beyond within that vulnerable preterm newborn. There are questions around, we know that baby was supposed to be in utero. Is it really, you know, what are we actually supposed to be feeding this baby if

they're out in the world too soon. There are a lot of questions yet to be answered, but one that keeps coming back from a health perspective and seeing results is focusing on mom's own milk for that baby where possible as early as possible to the as high a volume as safe as possible. And getting that baby towards breastfeeding is still seen as the optimal goal.

If you take those numbers I talked about at the beginning for where we're at just in general breastfeeding, we're measuring general breastfeeding for the general population. We have very little information around these vulnerable newborns, what they're being fed, how many of their mothers are receiving lactation support and care. We know so little globally for this population, and yet it's one of the biggest interventions

is being talked about as promoting breastfeeding and early support. So the fact that we have so little information for what is being fed to these admitted inpatient newborns that are the most vulnerable is for our team, just a tragedy and that we're looking to change, but because of the importance of this process. But Emily, please expand that just for also some of the barriers.

Emily Njuguna (20:34.082)

Yeah, thank you so much, Kimberly. And just to, you know, circle back to the question around,

how we can provide, ensure that human milk gets to the most vulnerable newborns in LMICs. I think we have to put into context some of the challenges that are faced by moms. You know, when you think about, for example, maternal malnutrition, it remains to be such a huge burden, particularly in LMICs. And it's something that can affect the quality and quantity of milk that is produced by the mom and influence her ability to breastfeed. you know, all these things have to be taken into context of those health issues.

things include the cultural beliefs, know, some communities, for example.

look down on colostrum as something that is to be frowned upon and is usually discarded due to many misconceptions around its value. And yet we know that, for example, colostrum is one of the most nutrient -dense feeds that a baby can receive in the first few days of their life. And then you think about, for example, workplace support. A lot of the moms who work in low -middle -income countries tend to have informal work, and that means that they are able

they're not able to stay home with their babies soon after delivery. And that means that they tend to return to work very early after childbirth. And that can have an impact on her ability to maintain her milk supply. And again, you think about the lack of information around the importance of supporting moms and actually the lactation support that is needed for these moms. So these moms actually don't have information to be able to produce enough milk.

Emily Njuguna (22:13.954)

for their babies. So, you know, around what they should eat, how often they should express their milk, for example, to build their milk supply, how often they should feed their babies, and what signs to look for to ensure that they're continuing on the right path in terms of providing milk for their babies. So I think all these things have to be taken into context. And when you're thinking about intervening and ensuring that LMICs have access to, you babies and LMICs have access to human

We have to take all these things into context and really think through how we can strengthen the health systems to ensure that milk is provided to these babies. And maybe Kimberly, you could talk about the global breastfeeding collective policy actions and then we can do that.

Kimberly (22:53.747)

Yeah. Yeah. So there are global initiatives that are seeking for breastfeeding at large, that governments take action in terms of ensuring mothers have sufficient and parents have sufficient parental leave to protect this, that hospitals are abiding by the Baby Friendly Hospital Initiative, that there are protections in place that prioritize

moms being able to breastfeed. So all of this is good. We're starting to create different enabling environments, putting more money towards early lactation support, towards breastfeeding support and cultural changes around ensuring that women feel supported and receive the right support early to be able, if they choose, to continue to breastfeed. All of this is really good. However, this gap that we're talking

For the mom of the baby that is born too soon or too small, there is this major gap in even understanding the lactation support and the facility support, the staffing at the facility that can provide additional support and then the ongoing needs for that mom and baby. Just to put that into perspective, if you start with the term baby.

the messages, put that baby to the breast, they will start suckling and drive in milk supply. If you put them to the breast within the first hour and frequently through proper attachment, through working with mom with any challenges that come up, breastfeeding is possible. It is hard, but it is possible. Now we're talking about just after birth, maybe mom and baby being separated. Maybe for good reasons, maybe not,

but a lot of times separation is happening. Mom has her own needs. Maybe there was postpartum hemorrhage. Maybe she's dealing with preeclampsia, eclampsia, other issues going on that is impacting her ability to be at her newborn's bedside. How are we attending to her postpartum lactation needs within those first few hours as if there was a term baby?

Kimberly (25:07.929)

suckling at the breast, driving in her milk supply so that long term she has the milk supply to be able to feed that baby. When the breast is not programmed to start early and to be supported to express milk fully, frequently and ongoing to build and maintain that supply.

we're seeing that she may be able to express, hours, days later when she is at the bedside of her newborn, she may be able to express enough milk to meet the very premature baby's needs, but she's not building her supply as if she has a term baby that is eventually going to grow. So come one month, two months, three months out, what needs will that baby have and being met by her milk supply?

we're now talking about this different population where we have all these breastfeeding initiatives, but it's losing the focus for the really important needs of this mom population just after birth, attending to all of her medical needs, but seeing her lactation and the system that it is as its own system that needs support to get to optimal production and supply.

Shelly-Ann Dakarai (26:25.202)

Thanks for providing that context. what I like about what you have on your website, when you go on the Pathwives and I look at your newborn nutrition program, specifically at the newborn nutrition, you kind of have this three pronged approach with what it means to provide human milk for babies. And it's this intersection between kangaroo mother care, lactation support for the mom, and then the human milk banks when that is not possible. We'll get to that in a second. But one of the things you talked about a lot is that early

and so that moms can have that supply. And you talked a little bit about the culture of some places don't really see that that is an important, the colostrum's important and all the things that kind of go into that. So I wonder if you could speak to what are some of the strategies that you're using to do that early lactation support and perhaps talk a little bit of maybe a couple stories from the field that might have been successful.

Because I know in some situations, I could speak in my experience in some other places that I've worked, you know that human milk is important. You want that. And they are, in some situations, some places doing that early hand expression, but then it only goes so far. And then there's not the rest of the support, like the pumping and all those other things. So I don't know if you could speak to what it takes to support that mom in those early days and maybe some success stories or challenges of trying to provide that support.

Kimberly (27:53.423)

Emily, you just gave a training on this last week with Facility Staff. So I'm wondering if you want to speak to some of the core components.

Emily Njuguna (27:59.587)

Yeah.

Yes, I will, but I think I want us to backtrack a little and just talk about our work developing a model of care that includes, know, KMC maternal health, ETC. So our work, as Kimberly had mentioned, has spanned many years. And one of the things that we developed was the Mother Baby Friendly Hospital Initiative Plus model. And this model seeks to ensure that all the newborns have access to exclusive human milk diets.

for the optimal growth. And this is through provision of several interventions. So we have kangaroo mother care, we have support for maternal mental health, we have the inclusion of appropriate resources for health for supporting this model. We have breastfeeding promotion. We have many components within that, including the use of human milk banks where that is appropriate. But one of the key components there is provision of lactation support for moms and their families.

so that they can produce enough milk for their babies very early on and continue to build their milk supply. So what we have been doing is to really work very closely with global organizations, including UNICEF, USAID, WHO to develop and really disseminate one of the only lactation support curriculum that's available for free for use for all the healthcare workers. So we have been really

developing and piloting this lactation support curriculum in the various countries. And one of the things that we did last week, just last week I was in Tanzania, really training healthcare workers to provide appropriate lactation support to these moms, particularly those who have small and sick newborns, because as Kimberly had mentioned, they have very unique needs. And so we have been training healthcare workers across several countries, both in Africa and Asia.

Emily Njuguna (29:52.826)

so that they have the right skills to provide the appropriate support for these moms and so that they can set up the mom -baby diet for success even when they are in the community. And maybe Kimberly, you could add in some of the core components that are in that curriculum.

Kimberly (30:09.925)

Yeah, so similar to what I was speaking to before, for your general breastfeeding program, you're going to want to focus on within an hour after birth, getting baby to the breast, supporting with attachment as issues arise. So continuing to encourage breastfeeding every two to three hours at a minimum, but letting baby really drive their hunger will drive. When we are speaking with about a much more vulnerable situation to early

the baby may not even be neurologically ready or capable of suckling at the breast to achieve their full diet that they need. And so we need to then at that point, from our perspective, see these two systems as separate, not eventually back together, but supporting them with individual needs. They are interconnected, but the newborn nutrition and receiving

human milk, mom's own milk as a priority and donor milk if unavailable as a separate need to the mom's needs. And we're seeing a lot of attention for human milk and newborn nutrition at large. There's a growing interest in feeding the baby better, sooner with higher volumes, achieving weight gain. We're seeing a lot of attention to growth.

What we're not yet seeing is this attention towards the lactation system or supply, that separate need that does not have a baby providing suction that stimulates its own hormonal process to say to the lactation system, to the breast to make more milk, bring in the milk supply, make this milk. And so what

due to support intervening and with the curriculum that Emily mentioned. Some of those core components are, let's pretend as if there was a term infant, how can we substitute that action? So some of the core components are ensuring that at the maternity unit, not at the newborn unit, not waiting until mom reaches there, but directly after birth, some systems are even having nurses support moms

Kimberly (32:29.881)

express milk even if she is unable because they see this as a priority. It's getting mom to be aware of this is how your milk supply works. This is how it comes in. Express early, fully, frequently. The one controversial area is about breast pumps, the cleanliness, the hygiene, especially in these settings. But for this population where we have

we already have a facility setting that is focusing on other similar issues of providing clean supplies for health. There is the need to substitute what that suction would be for the term infant that would naturally being provide providing that. How do we ensure that mom gets suction and somehow promoting prolactin and driving in

secretory activation, which is basically when your milk supply around day three ish fully comes in. We want to drive that in in a similar way. So we're setting her up and programming her lactation within those first two weeks. So there is a huge body of work. Diane Spatz, Paula Meyer, really amazing researchers that have focused on programs to drive in facility based systems. There's others around the world. Those are just two examples.

but that are focusing on supporting mom to within the first hour if possible, sooner if it, or as soon as possible if not, to start expressing colostrum. Ideally that gets to the baby. There's a transportation mechanism within the facility to get it to their infant. But then with every two to three hours expressing milk fully as if that baby was feeding. So mimicking that baby's needs.

can include provision of a manual pump or a double electric hospital grade or a multi -user pump that is a closed system that prevents transfer of milk or contamination between users. Mom has her own kit, the phalange kit. It's possible to do it in that way as well. We are currently investigating with multiple partners and facilities.

Kimberly (34:51.409)

the challenges around this space. And so I wouldn't claim that there is a really good operational guide right now that someone could just go and download from really any global body that says, this is how many women that you're looking to serve. These are their needs. This is the lactation support system you need. So we're calling for all innovators in this space. If you're seeing successful, safe, hygienic milk expression systems within facilities.

and seeing that done in a way that is building mom's milk supply for optimal long -term feeding. We would love to hear about it from your say, cause we're facing our own challenges across different partners and projects and research. And then you asked about what that looks like. So back to the components. So we're expressing early, we're expressing often. Now we're getting mom and baby together as soon as possible.

That's your KMC component. If immediate KMC is possible and the facility setting is an enabling environment for that, that is your best bet. You get mom and baby together, those hormones are driving in that milk supply as well. But as soon as baby is neurologically able to start suckling at the breast, they are practicing. We are giving them multiple chances for mom and baby to be connected, start just, we call it tasting breast milk at the breast.

How can we get baby to just practice to getting there? Eventually, that baby will start to be, most likely that infant will be able to start suckling. That will start to drive in some of the milk supply. But one of the missing messages is people think they go from, baby can breastfeed now. It's not as quick as a couldn't breastfeed yesterday, can breastfeed today. So the onus is on a supportive system to allow mom to be able to continue to express.

have support for cleaning those supplies, have support for provision of a expression cup of a breast pump where appropriate, and support to maintain all of those supplies in a hygienic way so that she can both practice breastfeeding at the breast and then continue to express milk. The general rule of thumb is that two weeks past when that baby would have been

Kimberly (37:16.527)

is when that baby might be able to fully feed by that time that maybe may be able to fully feed at the breast, where mom may be able to stop expressing additional milk and where baby can drive her supply. That is a murky number. And I think there's a lot of research still needed for guiding that well as discharge happens, as moms move back into the community and are taking care.

of their infant outside, how does she feed and still express and maintain her supply? So there's a lot of research projects. WHO is leading research, Gates funded projects at the moment led by Ariadne Labs, Addis Ababa University, where PATH is a support partner in many of those.

And there are others that are investigating this as well. So I think we're going to have a lot of learnings from this, but there will be even more needs over time. So calling all researchers to get interested in this space, because we need a lot more implementation science research to understand what are the optimal models that ensure long -term success for this population for eventual breastfeeding. Thanks.

Emily Njuguna (38:33.316)

Yeah, thanks Kimbebe. And I just wanted to add that what sets apart this curriculum that we have developed is that it not only focuses on providing nutrition for the small and sick baby, but also calls out the other key interventions that would help this baby to develop and thrive. So for example, there's a lot of information around KMC and ensuring that even as we're supporting the mom to produce her own milk for her baby and that she's feeding her baby continuously and building her milk supply, she's also continuing to

Kangaroo Mother Care, which is a proven intervention that has massive benefits for reduction of morbidity and mortality, particularly for the small and sick newborn. And then of course, this curriculum also has other components, including infection prevention, discharge planning, for example, how do we provide adequate information to these parents, to these caregivers, so that when they go home, they're able to detect that there's something wrong, there's something wrong with my baby.

Because for example, in LMICs, just knowledge on danger signs has been such a big issue. And so our curriculum also trains health care workers on how to properly prepare these families and moms for discharge and to develop an appropriate discharge plan. So that's how it's a little different from others. Yeah, thanks.

Mbozu Sipalo (39:51.293)

All right. Thank you so much for shedding a lot of light on the program, the importance of nutrition and the curriculum that has been developed. I have two questions. I'll start with the first one. This curriculum, the lactation curriculum, what is your scale of program to get other stakeholders involved and to implement similar?

programs in their settings and where have you started? I know, Emily, you're based in Kenya. Where else have you started implementing the lactation program and training other clinicians and healthcare workers?

Emily Njuguna (40:33.306)

Yeah, thanks for that question, Bozu. And I think Kimberly and I both can answer this question. So we're currently just testing the curriculum. We have not developed it to the point where it's ready for scalability, but we are hoping that we can develop this curriculum for it to be a global good for health care workers to have this resource available within their health facilities at whatever point. And so we have two versions. We have our larger document that's available for sort of like an accreditation.

where it's very intense and healthcare workers can actually get certified as lactation support specialists. But the other thing that we have done is to develop mini modules. just really honing down on the information that's most important for healthcare workers, developing it into or, you know, sort of grouping it into small modules that can be pulled apart. So you can pick module one and train it within the facility on job. You can then choose next Wednesday to do module 27.

based on the needs within the facility. And that's been really useful because now healthcare workers, instead of taking them off their duties within the clinical setting for a training, they're able to continue this continuous education within the health facility. So that's been really exciting. We have been working in Tanzania, Malawi and India. That's where we have started the first batch and that's with Ariadne Labs.

But we also have another project, as Kimberly had mentioned, with Addis Ababa University in Ethiopia. And so we are working in rural Ethiopia to also test this curriculum and continue to iterate on it to ensure that it's fit for purpose within the countries where we work. And we're hoping that sometime next year, this curriculum would be available for use by healthcare workers across the world as a global good. Kimberly, you want to

Kimberly (42:22.867)

Yeah, I think you covered it well. I think it's calling out in some of the research programs that we're doing, each of those have different implementation models, that the curriculum is one small component of a larger implementation system. The curriculum itself is the base curriculum is seen to be a global good. It's a USAID funded body of work in partnership also with MCGL.

been fantastic partners to think through how can we get this out there. And so there will be a piloting of the curriculum in Nepal. And then we're hoping to do piloting in Kenya and perhaps Nigeria as well. And then that version of the curriculum will be a global good in 2025. So put out freely accessible. We're looking for them to be in a form that can be modified for different facilities to use.

putting in their own SOPs and other facility -based specifics that are specific to their setting. And it calls out competencies that cross over with the Baby Friendly Hospital Initiative competencies, as well as the essential newborn care version two that recently was finally fully approved. So there's a lot of crossover between those two, but it gets into the depth of the lactation support side that we talked about that is

not quite complete in other trainings that are out there for this population, as well as speaking to donor human milk, use of donor human milk to aid breastfeeding and move towards breastfeeding rather than a substitute or undermining breastfeeding. So that, yeah, that's all I had to add to

Shelly-Ann Dakarai (44:11.208)

Thanks. I wanted to kind of see it from a different perspective, just to see what your thoughts are in terms of, I know we are far away from this where it's, you know, everybody's getting human milk, but it's something that we're working towards if that's what the mom so desires. But where do you see that balance between then getting to the point where moms feel pressured,

to do something they are not very comfortable with or the challenges that come with having been an exclusive pumper until your newborn can nurse and things like that. seeing it from the other perspective where in some NICUs that I've worked at, you can tell that the mothers and the families almost feel shame in a way if they are not able to provide human milk or if they make a choice not to do so.

for their mental health or because they have other things going on. Where is that balance and what are your thoughts on

Kimberly (45:16.827)

Yeah, that's such a good question. And especially, you know, as we're looking to a future where women have much more of a say for their bodies, for their own health. This is a really interesting topic that I feel personally having my own breastfeeding journey and a lot of challenges early on. know, of all things, I...

Yeah, my five -year -old just went to kindergarten for the first time today. And with her, my experience, you I knew everything you need to know about breastfeeding, supposedly, you know, all the knowledge you need. It was more challenges than I would ever want to get into. And the pressure on both sides, at least from my own experience of, something's not, you know, your baby's not growing right. Here's your formula bottle, you know, in both sides of directions of

of course you're going to breastfeed. Here's what you need to do. I wasn't even a mom that gave birth early or, you know, I, there wasn't those added complications and navigating that. that decision is extremely difficult. And so from our perspective, this it's what we're talking about is different than just any breastfeeding journey, especially for a term infant. think all

that comes with its own decision -making and is hard and it's hard in our current culture. It's hard with the pressures we have to be going back to work to so many different things that our lives don't always align with being able to quote unquote do it in the right way. For this population, when it is, we are seeing that there is a medical necessity and it is a life -saving intervention. There is a different

There's a different mindset for how we need to be supporting mom to, yes, of course it is her choice. But if we, we, you know, say, it's your choice or not, you can do this or not. And we know that what her body is able to produce for her infant is life saving. As healthcare workers, we are, we are not doing our job to make sure she understands what her body is able to produce to save this life, the exposure to this.

Kimberly (47:39.547)

And we're not even talking about long -term feeding challenges, just early feeding. When that baby is admitted in the newborn, what the possibility, and it's much better than donor milk that's stored, processed from another mom. Even that's better than the other alternatives. But what she has to give is what is currently, any science and product is unable to beat it. And so what are we doing

producing an enabling environment, ensuring that mom, whatever, is driving her choice to be able to provide her milk for her baby or not? Is she receiving all of the support and the equipment and it is easy to do and there's not all these other pressures. That is a very different world than what we generally live in and what we're talking about. And so I do think there's a balance of, course we're not shaming or,

not supporting the mom that chooses not to do that. She is choosing that because of a lot of other pressures. And if we are putting that decision on her, no, that is so hard that she had to make that decision. And so the blame is not on the mom, the blame is on our system. And if we can do everything that we can to be supporting that choice to be made in a very informative way.

moms will choose what is best for her and her baby. And it is our job to provide an environment that allows her to make a choice that lends herself to say, I am choosing what is best for me and my baby, no matter the circumstances. So we're up under a lot, we have a lot of ways, know, a long ways to go to get to a enabling environment where staff and family and culturally

We understand what it takes for that mom to be able to provide and the decisions and pressures she is under and still leaving the space to make sure she knows how lifesaving this can be. So it is complicated and I don't begin to, but I'm the last person to ever want to shame, even though this is my full passion to say, wait a minute.

Kimberly (50:00.359)

This is a hidden, hidden issue. People do not understand that this is not being supported as it could for the moms that do want to or, and just to add to that, we also are seeing that some women come in to the whole process of breastfeeding, not wanting to do it. Then they have a preterm baby, a low birth weight. For some reason, that baby ends up in the NICU. When they realize, my gosh, what I have to give

could save this baby's life. The whole decision around breastfeeding changes. It is a different decision than do I want to put baby to rest or not. And so it's just, it's new on, you know, it's breaking away remembering that this population, the decisions being made is very different than other populations as well. But Emily, anything to add there?

Emily Njuguna (50:51.312)

Yes. Yeah. And I just wanted to add that, again, we are really focusing and honing in on this subset of newborns, the small and sick newborns, for which, you know, mother's own milk is really a lifesaver. And one of the things that we have done is to really advocate for support for maternal mental health, because we know that's the biggest issue that comes with, you know, really giving mom stress and almost enabling

not enabling her to complete her breastfeeding journey successfully. So we're really focusing on supporting moms and through their mental health journey, even from early on after delivery all the way into the community. So that's, we feel that that's a core component that must be emphasized as well beyond just the lactation support. Yeah.

Mbozu Sipalo (51:43.645)

All right. Thank you so much, both of you, for just shaping the landscape for everything that you're doing and just the importance of nutrition. Just to now explore another side of PATH and the stuff PATH is involved in, the breast milk banking. Can you describe PATH's involvement in establishing human breast milk banks in developing countries?

And could you get tell us at least one successful story from that initiative, either Kimberly or Emily.

Emily Njuguna (52:25.168)

Thank you so much, OK.

Kimberly (52:25.179)

Emily, why don't you go for it? Do want me to do this? I loved

Emily Njuguna (52:31.11)

You can start and then I can share about Kenya.

Kimberly (52:34.363)

Okay, that sounds great. That sounds great. So PATH's model is always to be going in holistically in partnership. We partner with the Ministry of Health and wherever possible, there is typically local newborn and nutrition and or lactation champions that are already interested in improving these systems. So growing out with the Ministry of Health, holistic,

does it mean for this population at the primary highest level facilities in the region? What will it look like to expand integrated human milk banking program and specialized lactation support? So all at once. if there's typically most interested parties find us because of the milk bank work, it is the niche.

You know, people call it, it's the sexy thing. It's the thing that is interesting. They've heard about breastfeeding, but this, this sounds, this is golden. This sounds so cool. Our facilities will advance if we have it. And we go, you know, hold the breaks. want, or put on the breaks. We want to start with what is currently happening for feeding? What are you feeding newborns when their mom's milk supply has not come in

How can we be strengthening lactation support to ensure that we will never undermine mom's own milk and her ability to feed her baby? And so we take a transformative process to say, let's reassess the whole system here. And yes, the Donor Human Milk Bank has a minimal but important role to play in the first few days for moms where their milk supply has not come in and the newborn's needs in a critical state are high.

and there's a role to play, but in the long term, we wanna be ensuring that there's long -term success for breastfeeding and mom's own milk. So we're reassessing systems. So our future plans, so beyond just this work where there's a lot of interest in the Africa region that I'll ask Emily to expand on after her example in Kenya specifically. We're also working with the World Health Organization. We're coordinating support body

Kimberly (54:48.203)

For many years now, they've been investing in creating standards for human milk banking. There also is an effort and a new effort for the feeding of at -risk infants that we're playing a consulting role that is inclusive of all lactation support teams, all newborn work, programmatic work in infant nutrition at large. MAMI, for the at -risk mothers and infants and incredible, the MAMI Global Network is doing incredible work.

for the less than six month population. So really collating and bringing groups together to foster where do we need improved tools? UNICEF is leading quite a few efforts in this space. So we're participating in this huge growing body of interest in the less than six months, inclusive of the newborn period of improving nutrition and lactation and getting mom and baby back on track if for some reason that has fallen

So all of this is a growing body of interest. There's research happening for implementation research. Our vision is that this grows into its own integrated system for newborns. So whenever we're talking about the health and building up systems to provide inpatient or community support for the small and sick newborn, that the mom and her lactation needs is the connection for nutrition and that we're connecting and working with various groups in this space.

So Emily, think explaining both the regional but also Kenya would be

Emily Njuguna (56:22.05)

Yes, so maybe let me start with Kenya and just give you a bit of background on our work. So we have worked in many countries, really advocating for newborn nutrition and we have worked

to help governments to set up human milk banks in India, a bit of work in South Africa, and then most recently in Kenya. And PATH really has served in all these countries as a technical lead for this work, because again of our back -end experience for over 15 years. So in Kenya specifically, we have always been pro breastfeeding and provision providing milk to two babies. In fact, our rates for early initiation of breastfeeding stand at 60%.

our rates of exclusive breastfeeding standards another 60 percent. So we have always been championing for feeding of the newborn. And so our government, hot on the heels of this movement, really took the lead in terms of advocating for provision of donor human milk within our context when mother's own milk is not available. so we had been having, PATH had been having conversations with the government since I think 2016

2012 were there about for many years, just to really think through how we can contextualize an intervention through milk banking that is suitable for our context. And so we did a lot of research, formative research to understand, know, were our moms ready for such an intervention? Did they want it? Was there stigma around it? What were the misconceptions around it? And we found, surprisingly, that most women were actually very happy.

to have their children received on a human milk, which was fairly exciting for us, I must say. And on this back end, we were able to really advocate now for the setting up of the milk bank at Pumani Maternity Hospital. So we did formative research. We did a lot of learning exchanges just to understand what people were doing out there. So we went to South Africa to understand their model. We went to Glasgow, our teams from the Ministry of Health as well as.

Emily Njuguna (58:25.902)

the teams from Nairobi County to understand what would work for our context. And then the culmination of that was the opening or the inauguration of the first human milk bank in Eastern, so in East Africa at Pumani Maternity Hospital. And I think just to emphasize that for PATH, what is most important for us is that whatever intervention or program that we lead, it always has to have government ownership. And so because we really advocated for that.

This project has remained fully sustainable and funded by the government of Kenya many years after donor funding was cut short, particularly because of the COVID pandemic. And so that has been a huge success story, so successful that many countries have been coming to Kenya to learn from us. We have had visitors from all over the world. Several African countries have come to Pomani to see what we're doing there. And I think what is more peculiar is that this intervention, the Human Milk Bank,

and set up within a public health facility. as you can imagine, with all the systems challenges, those were, they still exist even now, yet the Human Milk Bank has remained sustainable. So they come to learn from us. And so because of that, we are now really advocating as an organization for other countries to think about this intervention as being one that is sustainable. And so we've actually had interest from governments such as Ethiopia.

Tanzania, Uganda, we have had interest from Nigeria, Zimbabwe, Zambia, Malawi, so many countries across Africa. And so what we have done, because these governments are actually inviting us to support them with technical expertise to set up human milk plants in those countries, we are now thinking through a regional approach for implementation.

where we can do massive implementation of this intervention. And so we are thinking through partnerships, particularly as I mentioned, one of the key bodies that we are thinking can be a key and crucial partner is the African Unital Association. And the African Unital Association is an association that brings together healthcare leaders, pediatricians, neonatologists from across Africa, more than 45 countries now, and they advocate for enhanced newborn care.

Emily Njuguna (01:00:44.43)

And so we think that this organization will be a great partner when we think about a regional implementation. And so we're hoping that we can foster partnerships with others. So if there's anyone listening to this podcast and you're interested, please reach out to us. We're more than happy to have discussions on how we can do this. So we want to do in -country implementation, but through a more regional programmatic approach.

Shelly-Ann Dakarai (01:01:14.184)

Well, Kimberly and Emily, thank you so much for joining us today. We learned a bit and thank you for giving us that context and also highlighting the system -wide approach that is required for these efforts. So as we wrap up now, I know you kind of mentioned if folks are interested in learning more about setting up human -milled banks or like you said, it starts really at the beginning, providing that support, seeing what really

what is happening at your unit and then moving from there? Where's the best place for folks to either connect with you or connect with the newborn nutrition program if they need to get some more information, if they're trying to start improving their ability to provide human milk for their vulnerable infants?

Emily Njuguna (01:02:04.034)

Yeah, so they can reach out, they can look at our work through our website, which is www .path .org. And there you will find our program page, Newborn Nutrition, and that highlights all the work that we have done in this space. But they can also reach out to us on email. So my email would be ejugona at path .org. And Kimberly can also share hers as well.

Kimberly (01:02:28.273)

Yeah, do we share here? Do we share? Is there the ability to share by other links as well? Great. That sounds great.

Shelly-Ann Dakarai (01:02:34.524)

Yes, so we can put it in the show notes. So email is the best way to get to both of you is what it sounds like. Okay. Okay. Okay.

Kimberly (01:02:39.825)

I think so, that sounds good. Or LinkedIn, whatever people, yeah, that's fine as well.

Emily Njuguna (01:02:43.46)

Yes. Yeah, reach out to us on social media as well, LinkedIn as well. My name is Emily Joguna and you should find me there. Thank you.

Shelly-Ann Dakarai (01:02:51.142)

Okay. Perfect. We'll put all those in the show notes.

Kimberly (01:02:51.181)

and I'm Kimberly Manson. Thank you so much for the time. We just appreciate all of the interest, especially from this podcast as well, and the focus on the newborn and realizing all the linkages across different programmatic efforts happening. So just welcome other innovators in the field, researchers, others that might see a way to include this. We would love to connect with them as

Emily Njuguna (01:03:19.14)

Yeah, definitely. Thank you so much for providing us this opportunity. We're always happy to share our work. We definitely do feel that our work belongs to the world. And so we're happy to connect in any way. If you have any questions or if you have any innovative solutions that you want to share with us, please reach out to us. We're more than happy to have a conversation.

Shelly-Ann Dakarai (01:03:19.39)

Perfect.

Shelly-Ann Dakarai (01:03:40.49)

We will go ahead and put all those in the show notes as well as your website and any other resources that you think are important for folks to know. So again, thank you so much for taking the time. We certainly learned a lot. And to everyone out there listening, we will talk to again next month when we bring you another interview from folks who are changing the world of neonatal care globally. Thanks so much. Bye.