Academy of Breastfeeding Medicine 임상프로토콜 #7 모유수유지원모성정책모델 Maria-Teresa Herna'ndez-Aguilar, 1,2 Melissa Bartick, 3,4 Paula Schreck, 5 Cadey Harrel, 6 과모유수유아카데미 모유수유아카데미중심목표는상업적인이득이나영향을받지않고, 모유수유성공에영향을미칠수있는흔한의학문제에대처할임상프로토콜을개발하는것이다. 이프로토콜은모유수유모와아기의관리를위한지침역할을할뿐이며배타적치료나표준의학관리방법을의미하지는않는다. 치료에있어서는개별환자의필요에따라변용함이타당할것이다. 배경 모유수유는생물학적규범이며젖을일찍끊으면엄마와 1-5 (1) 6 아기의 2.7-14 (1) 건강상위험이증가되고, 전세계적으로사회적비용이상당히높아진다 2,15 (1). 6,16 엄마와아기의산욕기돌봄은장차이들의모유수유성공 17 (2) 18,19, 건강및생명 15 (1) 16 에영향을미칠것이다. 이러한보살핌을세계적으로향상시키기위해, 세계보건기구와유니세프는 1991년아기에게친근한병원운동 (Baby-Friendly Hospital Initiative) 을출범시켰고, 그후 2차례개정하였다. 20,21 27년이경과하면서, 이운동은세계적으로시행되었고 22 ; 영아건강을상당히개선하였으며 23-25 (1); 모유수유시작, 기간및완전모유수유율을증가시켰다 1,24-27 (1). 아기에게친근한병원운동은다양한국제기구가승인한, 분만시설 28 을위한근거기반정책의대표적표준으로간주된다. 28-30 그러나, 건강의사회, 구조적결정요인과관련하여모유수유불균형은여전히만연해있다 8,15,31,32 (1). 33 이로인해여성과소아의불공평한이환율및사망률 33,34 과건강불평등이초래된다 7,35,36 (1). 33 그러나, 그무엇보다도, 아기에게친근한병원운동 2 (1), 진통과분만중지속적인일대일지원, 문화적으로민감한보살핌 37 (M) 또는동료지원 38 (1) 등모유수유를돕는, 근거에입각한모성관행을시행함으로써불평등이감소될수있을것이다. 목적 주산기관리관행은분만방법에영향을미치고, 모유수유및엄마와아기의건강에도영향을주며 40-44 (1) 45 (2) 46 (H) 47,48, 엄마의만족도에영향을미친다 49 (H). 그러므로, 모유수유정책은모성관리정책전반으로부터분리될수없다. 이프로토콜의목적은 영아섭식정책 을포함하여 모유수유지원모성정책모델 을제공하는것이다. 모유수유를표준으로인식하기위한일보로서 '' 모유수유정책 보다는 영아섭식정책 이라는용어를대신사용한다. 이것이포괄적이다 ( 완전히모유대체품만으로, 혹은유축젖으로만보충하거나, 성전환후가슴수유로보충하는부모들을위해적절한지원을보장하므로 ). 이는또한개정된 2018년세계보건기구 10단계 21 ( 표 1) 에서사용되는용어이기도하다. 우리는양질의주산기관리를시행할시설의모델이라는목적에맞게, 이문서에는근거에입각하거나 국제적으로권고되는사항을기반으로한내용만포함시켰다. 이는예를들어, 기관명과개정일등을각특정 기관에맞추어적용할필요가있을것이며, 승인과시행을위해각시설의제도적절차를따라야한다. 1 Breastfeeding Clinical Unit Dr. Peset, University Hospital Dr. Peset, National Health Service, Valencia, Spain. 2 National Coordinator of Spain Baby-Friendly Initiative (IHAN-España Iniciativa para la Humanización de la Asistencia al Nacimiento y la Lactancia), Madrid, Spain. 3 Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts. 4 Harvard Medical School, Boston, Massachusetts. 5 Department of Pediatrics, Ascension St. John, Detroit, Michigan. 6 Department of Family Medicine, University of Arizona, Tucson, Arizona. 1
우리는여기에기술된권장사항중일부는각국의특정상황에맞게조정해야할수있음을알고있다 ( 예 : 조산사가없는국가는다른유형의의료인이정상분만에참여할수있다 ). 아기에게친근한병원운동이현재입증된효과를보이는최상의모델이기때문에, 이프로토콜은아기에게친근한병원운동의 " 국제기준 " 21 에들어있는모든요소를포함한다. 일부국가에서는아기에게친근한인준기준은국제기준이나여기에설명된기준보다다소엄격할수있다. 따라서, 특정국가의필요조건을충족시키려면이모델정책에소소한변경이필요할수있다. 신생아집중치료실을위한철저한권고사항이이미출판되었기에, 본프로토콜은그와관련된몇몇특정요건은다루지않는다. 50,51 표 1. 성공적인모유수유를위한 10 단계 (2018 년개정 ) 주요관리절차 1단계. 정책 I a. 모유대체품판촉에관한국제규약과관련세계보건총회결의문을온전히준수한다. I b. 직원과부모들을위해일상적으로소통되는문서화된영아수유정책을마련한다. I c. 지속적감시와자료관리체계를구축한다. 2단계. 모유수유를지원할충분한지식, 능력, 기술을직원들이확실히갖추도록한다. 주요임상관행 3단계. 임산부와가족들과함께모유수유의중요성과관리에대해논의한다. 4단계. 출산후되도록빨리즉각적이고지속적인모자간피부접촉을용이하게하고, 모유수유를시작하도록엄마를지원한다. 5단계. 엄마가모유수유를시작하고유지하며흔한문제들에대처할수있도록지원한다. 6단계. 의학적적응증이없다면, 모유수유중인신생아에게모유외에어떤음식이나음료도먹이지않는다. 7단계. 엄마와아기가함께지내면서하루 24시간내내모자동실을실천할수있게한다. 8단계. 엄마가아기의수유신호를알아차려반응할수있도록돕는다. 9단계. 엄마에게수유병, 인공젖꼭지, 노리개젖꼭지사용과위험에대해상담해준다. 10단계. 부모와아기가시기에맞게지속적으로지원과보살핌을받을수있도록퇴원을조율한다. 세계보건기구-유니세프의 10 단계에서발췌. 21 2018 년정책프로토콜에관하여 이포괄적프로토콜은다음과같은여러모유수유아카데미프로토콜내용을포함하고있다 : #1 ( 저혈당지침 ), 52 #2 "( 퇴원 ), 53 #3 ( 만삭신생아보충수유 ), 54 #5 ( 주산기모유수유관리 ) 48 #8 ( 만삭신생아를위한가정에서의모유저장정보 ), 55 #10 ( 후기조산아와조기만삭아의모유수유 ), 56 #14 ( 모유수유에친근한외래진료실 ), 57 #19 ( 산전단계에서모유수유증진 ) 59 #21 ( 모유수유와약물중독및약물사용장애에대한지침 ) 59 #26 ( 모유수유중지속적통증 ), 60 및 #28 ( 모유수유모를위한산욕기통증완화 ). 61 PubMed와 LILACS를이용하여과학문헌검토 ( 최근의성명서 / 지침 21,50,51,62-66 포함 ) 를철저하게시행하였다. 검색에는 2011년부터 2018년까지영어, 스페인어, 프랑스어및포르투갈어로된문서가포함되었다. 1,000개이상의초록을검토하여, 그중질이낮은것은제외하였고, 최종적으로논문총 302개를모두분석하였다. 정량적근거로는 2011년옥스포드센터의근거기반의학기준 (OCEBM) 에따라평가하였다. 즉근거수준을기준에따라 (1) 부터 (5) 까지점수화하였다. 67 정성적근거는 GRADECERQual에따라 H( 높음 HIGHER), M( 중등도 MODERATE), L( 낮음 LOW), VL( 매우낮음 VERY LOW) 으로분류하였다. 68 주어진근거수준앞의모든인용문헌은그근거수준에해당된다. ABM 프로토콜등전문가지침이나국제지침에는근거수준을붙이지않았으며, 특정연구는근거범주수준에해당되지않는다. 2
우리는분만한사람의파트너가남녀모두가능하다고인정한다. 또한, 대부분여성이출산을하지만, 성전환남성과제3젠더인사람도출산할수있으며많은사람들이모유수유나가슴에서먹이고 ( 가슴수유 ) 싶어하는것을인정한다. 흉벽을편평하게하기위해유방실질전체또는부분제거수술을받은, 남성으로성전환한일부여성들이다양한젖생산경험을보고하기도한다. 그들은보충수유도구나모유수유를통해가슴에서수유를하고싶어하기도하고, 반대로, 일부성전환부모들은모유수유나가슴수유 69 (M) 70 (VL) 라는개념을불편해할수있다. 본문서전반에걸쳐, 우리는 " 엄마 ", " 출산한사람 " 또는 " 부모 " 를통용하여언급한다. 우리는입양된신생아와그입양부모 71 (5), 대리모가낳은아기와그대리모 / 대리부모 72 (5) 도동일하게애착을 형성하고영아수유 ( 선택한경우라면모유수유도 ) 에도움을받을권리가있으며, 따라서이들을 엄마, 부모, 아기 라는용어에포함시켰다. 아래의 분유 라는용어는성장기분유나모든 특수분유 를포함하며모든종류의영아용조제분유와 모유대체품을지칭한다. 권장사항 모유수유를지지하는모성정책모델 정책 1. 모유수유는인간엄마와아기를위한생물학적표준이며인공수유와조기이유가엄마와아기의건강에 유의한해를미치므로, 본기관은모유수유를증진한다. 1-5,7-14 (1). 6 2. 아기에게친근한병원운동이모유수유율및모유수유기간과 24-27 (1) 아기의건강 23 (1) 62 에유의한긍정적 영향을주므로, 본기관은기관의분만관리를증진시키는가장효과적인최선의중재로인식한다. 3. 이문서는본기관의모성정책을구성하며모유수유를지원하는영아섭식정책 ( 또는헌신적인모유수유 정책 ) 으로이루어진다. 이정책은전직원의의무사항이며이를지키지않을경우는상당한이유가있어야 하며그이유를엄마및 / 또는아기임상기록에기록해야한다. 21 이정책은 : A. 모유수유보호, 증진및지원과그시행감시를위해, 직원들의임상적역량과기술을보장하는모유대체품판촉에관한국제규약및관련된세계보건총회결의문 ( 국제규약 ) 65,66 준수에관한제도적책임을다룬다. B. 최상의모성및영아보호를보장하고최선의영아수유관행을적절히지원하기위한직원의책임 ( 주요임상관행의시행 ) 을다룬다. C. 분만시설에이용되는모유수유및영아수유와관련된모든프로토콜과기준이세계보건기구권고 ( 즉, 아기에게친근한병원운동기준 ) 와현재의근거중심지침및프로토콜에부합해야함을언급한다. 21,63 D. 진통및분만중필수적인질관리와분만질관리전달의일환으로, 출산직후모자간피부접촉 (SSC) 및적극적인모유수유지원을증진한다. 73 E. 입양아를포함하여모든신생아와부모들을위해, 문화적으로겸허하며, 정중하고차별없는보살핌을보장한다. 21,63,73 F. 엄마와가족을돌보고지원함에있어시기적절하고, 적합하며, 그들의필요에민감하고 21,62,63 사생활및정보에근거한의사결정 57,63 을존중하며, 의료진간의협조를확보한다. 3
4. 이정책시행을보장하려면 : A. 이정책의시행을감시, 감독할목적으로주된관심사가모유수유인, 영아섭식 / 모유수유위원회를수립한다 75 (1). 이위원회는기타병원질향상위원회및임상관행에준한다. B. 정책은다학제적이면서문화적으로적절해야하며엄마와신생아건강, 질보증및관리분야의결정권자, 의료기관 / 의사, 간호사, 조산사, 수유전문가, 기타적절한직원및부모대표로구성되어야한다. 선출된모유수유조정자와비서가이사회를주재하고답변한다. 21 C. 위원회위원들은적어도 6개월마다감시목적으로만나게된다. 위원들이정책시행을평가하고기관의정책준수평가빈도를결정한다. 위원회위원들은정책을준수하기위해필요한행동을정의한다. 21 D. 모유수유및모자관리지표와정책시행을통상적으로추적할자료수집장치가마련되어주산기관리의질을지속적으로감시하고향상시키게된다. 21 필수적으로모유수유지표를시설질향상감시체계에통합해야한다. ㆍ조기모유수유시작및완전모유수유는감시지표 (sentinel indicators) 로간주되므로일률적으로추적해야한다. 21,63 ㆍ영아섭식 / 모유수유위원회가필요하다고판단하면다른지표를추가할수있다. E. 모든직원이입사후 1주일이내와그후정기적으로이정책에대해적절한오리엔테이션을받게된다. 21 F. 부모들이손쉽게이용할수있도록사용하기편한정책요약본을제공한다. 정책시행과관련하여논평, 칭찬, 혹은불만을시정할명확한서면책임체계가있으며, 그내용을정기적으로개정할수있도록엄마와가족들이쉽게접근할수있는의견제시기제를마련한다. 63 5. 본기관은직원들이어려움없이모유수유를할수있게하며, 수유휴식시간을허용하고, 직원들이 ( 전공의를포함하여 ) 76 (3) 적절한조건하에모유수유를하고, 젖을짜고, 저장할적합한공간을마련한다. 77 (1) 78 (3) 6. 국제규약및관련된세계보건총회결의문 21,66 을지키지않는것이모유수유의주된방해요인이므로, 본 기관은이를준수한다 79-82 (1) 83 (M) 84 (3). A. 본기관은조제분유뿐아니라국제규약에포함된관련제품들을판촉하지않는다. 이들제품 ( 업계 ) 의직원, 제조사및보급사가본시설내부에서일반인들과직접적으로접촉하는것을허용하지않는다. 79 (1) 83 (M) 21,63,66 B. 모든종류의선물 ( 직원들을대상으로한비과학적문헌, 자료, 장비또는엄마 / 가족을대상으로한사은품패키지를포함하여 ), 모든진열 ( 포스터나플래카드포함 ) 이나브랜드로고가들어있는교육자료, " 업계 " 가지원하거나지불하고직원, 임산부, 엄마또는가족을대상으로하는모든종류의행사가금지된다 63,84 (3). 66 C. 본기관이필요로하는, 국제규약상모든제품은 ( 조제분유, 인공젖꼭지, 수유병, 혹은노리개젖꼭지등 ) 공정한시가로구입한다 80 (1). 66 D. 의료인이이해상충을피하고엄마들에게상충되는조언을하지않도록국제규약에관한교육을받는다 81,85 (1) 83 (M). E. 제조사의식품이나제품을홍보하는메시지는엄마나가족을대상으로한교육자료에허용되지않는다. F. 본기관은영아용조제분유의안전한준비와수유및수유병과인공젖꼭지의안전한취급을, 그것이필요하거나 ( 임상적보충수유적응증이있거나, 모유수유가금기이거나 ( 표2), 혹은불가능한경우 ), 부모가정보에근거한선택을한경우 ( 모유대체품의위험성을충분히설명한후 ) 에한해반드시출산한사람과배우자에게시연해보여준다. 21,63 본기관은조제분유사용에대해단체교육을하지않으며, 젖을먹이지않기로한엄마들에게모유수유하지않을경우의위험을충분히설명한다. 21 4
표 2. 모유수유금기 엄마상태에볼라바이러스 (Ebola) 헤르페스바이러스 (Herpes) 엄마가에볼라바이러스로의심되거나, ( 이경우는배제될때까지 ) 확진된경우유방에활동성포진병변이있는엄마는그쪽으로젖을먹이지말아야하며, 감염되지않은유방으로는모유수유를할수있다. 모유자체를통한혈역학적전파우려가없기때문에, 병변쪽유방에서젖을짜도된다. 그러나, 유축기를통해젖이오염될수있으므로, 유축기일부라도헤르페스병변에닿는다면그젖은버려야한다. 이경우, 모유수유가재개될때까지유축으로젖양을유지하도록격려해야한다. 인간면역결핍바이러스 (HIV) 인간T림프친화성바이러스 1형과 2형 (HTLV I/II) 인공수유가수용가능하고, 실현가능하며, 저렴하고, 지속가능하고, 안전한지역에서는, 인간면역결핍바이러스나 HTLV I/II 에감염된엄마는모유수유금기에해당된다. 각국권고사항이다를수있으므로현지당국에확인한다. ( 예, 미국정부는 2018 년현재, 미국내 HIV 감염여성에게모유수유를권장하지않는것으로선언하였지만, 모유수유를원하는사람들을위한지침및상담은제공한다.) 수두 산전 5 일 ~ 산후 48 시간이내에수두가발병하는경우, 엄마가전염성이없어질때까지엄마와아기를격리하고, 짠젖을먹이고, 가능한빨리아기에게수두면역글로불린 (Varicella-Zoster Immune Globulin) 을투여한다. 피부병변과의긴밀한접촉을피한다. ( 연장아라면, 엄마의피부병변이나타나기전에전염성이있어아기가이미노출되었으므로격리를권장하지않는다.) 전문가의자문이필요하다. 브루셀라 (Brucella) 치료받지않은엄마의브루셀라증 결핵 치료받지않은활동성폐결핵에걸린엄마는더이상전염성이없어질때, 즉치료 15 일째까지, 직접모유수유를하지말아야하며, 단, 유축해서먹일수는있다. 그러나, 분만 15 일이전에진단된경우가아니라면, 엄마의진단시점에아기는이미결핵에노출되었을것이고, 따라서예방적아이나 (INH) 를먹여야한다. 아기가벌써치료를받고있는중이라면, 엄마와아기를격리할이유는없다. 전문가의자문이필요하다. 약물 항암화학요법과같은치료중에는일시적또는영구적으로모유수유중단을 권고할수있다. LactMed, InfantRisk.com, e-lactancia, Lactation Study, 및기타각 지역사회내에서구할수있는정확한자료를확인한다. 불법약물아기의의료진이각각의사례별로결정한바, 불법약물 ( 예 : 코카인, 헤로인, 펜사이클리딘 (phencyclidine) 을현재사용중인경우. 아기상태선천성대사이상갈락토스혈증 (Duarte 변형으로부분모유수유가가능한경우는예외 ). 선천성유당분해효소결핍. 일부선천성대사이상에서는보충수유가필요할수있다. ( 페닐케톤뇨증, 메이플시럽병 ). 출처 : (ABM Protocols), 59,60 ( 공식권고사항들 ), 172,180 ( 웹페이지 ), 169-171 그리고 (5). 181-184 괄호의숫자는 OCEBM 67 ( 본문의다른곳과마찬가지로 ) 에따른, 근거수준 (LOE) 을나타낸다. 5
직원교육. 7. 본기관은엄마와아기를담당하는모든직원이모자를적절하게보살피고모유수유관리에필요한지식과기술을갖추도록보장한다 86, 87 (1) 17 (2)( 표 3) 21. 특정직원이전직원들의교육활동을조정하고교육을기록한다 75 (1). A. 모유수유관리 88,89 (1), 엄마와아기관리, 대인소통, 상담 (2) 63 에대한의료진의지식과기술을채용시와이후주기적으로평가한다. B. 아기에게친근한병원운동모유수유교육및기술표준은모든직원에대한최소요구사항이다. 21 이전교육이요구사항에못미치면언제나추가교육이필요하며, 모유수유와수유관리, 그리고역량을고용후 6 개월이내에, 이상적으로는 2 개월안에검증한다. C. 아기에게친근한병원운동안내서 87,93 (1) 와본정책을반드시준수하기위해적절한내용과기간이명시된보수교육과주기적인업데이트 (1) 62 를필요에따라제공한다. 21 D. 지지적인감독 94 (2) 을통해, 본정책에따라관리를하고모든부모들에게정확하고일관된최신정보가제공되도록보장한다. 63 표 3. 분만기관내엄마와아기담당직원에서평가할능력목록 1. 엄마를상담하기위한청취및학습기술과, 자신감을확립하고지지하기위한기술사용방법. 2. 임신부에게모유수유에관해조언하는방법. 3. 최적의모유수유양상에대해엄마에게설명하는방법. 4. 엄마에게본인자신의건강에대한모유수유의이점에관해조언하는방법 5. 분만후 1시간이내에모유수유를시작하도록엄마를돕는방법. 6. 모유수유를적절하게평가하는방법. 7. 엄마가모유수유를위해자신과아기의자세를잡고젖을올바르게물릴수있도록효과적으로도울수있는방법. 8. 엄마가젖을짜서컵으로아기에게먹이도록돕는방법. 9. 가장흔한모유수유문제에대해엄마를돕는방법 a. 젖양이부족하다고생각하는엄마 ; b. 자주우는아기의엄마 ; c. 모유수유를거부하는아기의엄마 ; d. 편평유두나함몰유두인엄마 ; e. 유방이울혈된엄마 ; f. 유두가아프거나갈라진엄마 ; g. 유선염이있는엄마 ; h. 저체중아나아픈아기때문에, 필요시유방에부착한보충수유관이나다른도구를사용중인엄마 ; 10. 보건시설에서국제규약을시행하는방법. 출처 : 세계보건기구-유니세프. 21 산전 8. 엄마는모유수유에가장도움이될출산경험을하게된다. 원하는모유수유목표등, 상세한모유수유과거력을산전병력의일부로임상차트에기록한다 95 (1). 58 9. 본시설은이곳에서산전관리를받는모든임산부가자신의우려와필요에맞게개별화된산전모유수유지원및교육 75,87,96 (1) 41 (2) 을받도록보장한다. 엄마들이모두필요한정보를받을수있도록산전관리를제공하는관련시설과협업한다. A. 조기에출산할지모를여성에게정보가부족해지지않도록교육은첫번째또는두번째방문때일찍시작된다. 21 B. 일대일또는소그룹교육이진행되며 97 (1) 파트너및가족의참석이권장된다 98,99 (1). 58 C. 산전교육을제공하는이로는조산사 100 (1) 101 (1) 와모유수유전문가등기타의료인 102 이선호된다. 6
10. 매방문시제공되는교육은산모의임상차트에기록되며, 앞으로제공될정보와일정을모든산모에게알려준다 ( 표 4). 21 임산부에게가르칠교육과정에는모유수유에필요한필수정보가포함되며이는지역사회에서가족들에게산전교육을하는인근단체들과공유된다. 11. 자존감 103 (3) 과성평등을포함하여자율권부여기술을높이기위해특별히행동학적, 심리교육학적접근 58 이고려된다. 12. 교육은엄마의개인적요인 ( 배경, 민족, 문화, 사회경제적 ) 58 과모유수유율이낮은위험군엄마들 ( 즉, 청소년 104 (1), 비만 105 (1), 불법체류자 102 (1), 106 (M) 또는사회적혜택을받지못하는군 87,96 (1), 107 (2), 108 (M)) 의특수요구사항에맞게조정된다 : 기관방문이어려운가정에게는, 필요하다고판단되면 mhealth( 의료서비스에대한이동식무선장비사용 ) 교육이제공된다 109 (1). 21 표 4. 산전교육에서다루어야할주제, 일정모델방문날짜 ( 임신주수 ) 주제 의료진서명 임신주수 : 방문 # 1. 존중받는분만관리를받을권리-이는모든여성이진통과출산 동안자신의품위를유지하고, 사생활과비밀을존중받으며, 유해하거나잘못된치료를절대로받지않고, 정보에입각한 선택을하고지속적인지지를받을수있는방식으로체계화된 관리를제공받음을의미한다. 임신주수 : 방문 # 2. 진통중비약물적통증완화방법과분만방법이모유수유 성공에미치는영향 임신주수 : 방문 # 3. 모유수유의국제적권장및중요성, 첫 6 개월간완전모유수유의 중요성, 모유대체품제공의위험성, 6 개월부터적절한이유식을 하면서 1 년혹은 2 년이상모유수유를지속하는것의중요성 임신주수 : 방문 # 4. 출산후즉각적이고지속적인모자간피부접촉의중요성 임신주수 : 방문 # 5. 모유수유조기시작과 24 시간내내모자동실의중요성 임신주수 : 방문 # 6. 아기의적절한영양을위한젖공급과수요의기본 임신주수 : 방문 # 7. 올바른자세와젖물림, 그리고배고픈신호인식의기본 임신주수 : 방문 # 8. 통증, 몰아서먹기, 졸린아기, 젖물림문제, 울혈, 그리고안전한 수면관행등가장흔한초기문제관리 각기관그리고 / 또는국가별아기에게친근한병원운동의요구사항에따라, 주제와산전정보를특정 시점에다루어야할수도있다 ( 예를들어미국의아기에게친근한병원운동에서는 28 주이전에주제를 다루도록요구됨 ). 출처 : ( 괄호안의숫자는 OCEBM 67 에따라부여된증거수준을나타냄 : (1), 40,44,186-187 (2), 43,107,188 189-190 (5), 189-190 ( 지침또는프로토콜은평가되지않음 ). 21,28,62,63,73 방문 #, 방문차수 ; 임신주수 : 방문해야할임신주수. 진통과분만관리 13. 생리적진통과분만이권장되며 49 (H) 유해한관행과불필요한옛방식의중재는피한다. 63,73 A. 본기관에서진통, 출산및초기산욕기에일어나는모든행위와중재는제왕절개분만이나도구를사용하는질식분만위험을최소화하는문서화된최신지침을따른다. 73 이둘모두엄마와아기의건강상해로운결과 44,96,110 (1) 42 (2) 및불량한모유수유결과 111,112 (1) 43 (2) 와관련이있다. B. 환자중심 47 의세심하고지지적인관리가제공된다. 63,73 통증조절방법, 마약성진통제주입경로와유형, 계획된제왕절개분만과유도분만등중재의이점, 위험성, 잠재적합병증이논의된다. 73 출산하는개인의정보에입각한선택이존중된다 40,43,44 (1) 49 (H). C. 엄마가분만중본인이원하는동반자를선택하도록권장된다. 48,63,73 D. 정상질식분만이기대되는저위험산모에게는가능할때마다일대일지원을제공하면서조산사가주도하는지속적관리모델서비스 113 방식을제공한다 38,114,115 (1) 49 (H). ( 이권장사항은조산사프로그램이잘작동되는환경에만적용된다 ). 63 7
E. 엄마의바램과국가 / 기관정책에따라, 훈련된출산동반자와둘라를허용한다 38 (1). 48 F. 합병증없는두위분만 (cephalic delivery) 에서는비약리적조치가선호된다. 엄마와아기의건강과모유수유에미칠위험을최소화하기위해, 마약성진통제약제, 투여시점, 및경로를주의깊게선택하고엄마 113 (1) 61 와상의한다. 40 (1) 산후관리 14. 선택된수유방법과무관하게, 자연분만과제왕절개직후, 합병증없는모든엄마와신생아에게모자간 피부접촉을허용하고권장하며, 115,116 (1), 엄마와아기가안정되면언제나, 후기조산아 (LPT)( 재태연령 34~36 6/7 주 ) 56 와저출생체중아 (LBW) (1,200~2,500g) 117 도마찬가지로한다. 117,118 A. 출생직후건강하고의식이또렷한모든신생아는맨몸으로엄마가슴에엎드려놓는다 119 (2). 이후 완전히말리고 ( 손은제외 ), ( 산모가원할경우 ) 기저귀를채우고, 엄마의온기를품을따뜻한담요를 덮어주게된다 120 (5). 주의깊은관찰하에엄마와배우자, 그리고아기가서로애착을형성할수있도록 해준다. 아기는출생시모자간피부접촉을할때자연적으로일어나는 121 (2) 신생아행동 9 단계를 - 냄새맡기, 핥기, 휴식취하기, 젖물기전자연스럽게유두를향해기어가기등 - 경험하도록놓아두어야 한다 121 (2) 122 (4) 123 28, 117 (5). B. 정당한의학적이유가없으면, 모자간피부접촉은적어도 2 시간동안 115, 116, 124, 125 (1) 126 (2) 127 (5) ( 표 4) 또는첫모유수유전까지중단시키지말아야한다. 초기모자간피부접촉을미루거나중단할필요가 있는경우는, 엄마와아기가임상적으로가능해지자마자빨리의료진이반드시모자간피부접촉을할수 있도록한다 127 (5). 21,28,48,62,128 모자간피부접촉개시와종료시간을의료기록으로문서화한다. C. 분만실실내온도는 25 C(77 F) 이상으로설정하고외풍은없어야한다. 63 의료진은밝은빛과시끄러운 소음을차단하여아기가내재된반사작용을보일수있도록돕는다. 28,63 D. 제왕절개분만후이상적으로는수술실이나회복실에서즉시 ( 또는최대한빨리 ) 모자간피부접촉이 가능하도록필요한조치를한다 115,125 (1) 126 (2). 긍정적인경험을하고자하는엄마의바램에부응하여 투명한외과용포사용이선호된다. E. 예상치못한생후돌발허탈 (Sudden Unexpected Postnatal Collapse) 위험을최소화하기위해의료진과 산모의배우자가엄마와아기를감시하도록지시하는동시에지속적인감독과 ( 중재는필요한경우에만 ) 안전한수유자세잡기가모자간피부접촉프로토콜에포함된다. 의료진의관례는근거 127 (5) 에기반한 신생아시기안전한수면및모자간피부접촉에대한권고안이포함된프로토콜을따른다. F. 아프가점수는모자간피부접촉상태로평가된다 127 (5). 양수에태변이있는경우라도자발호흡을 시작한아기에게는경구, 비강또는기관흡입을하지않는다. 117 G. 제대결찰은산모와아기가불안정하거나 131 (1) 117 제대혈채취를원하는경우가아니면, 미숙아와만삭아 모두에서 129 (1) 117,130 늦춰진다. 132 H. 아기신체측정, 133 (3) 비타민 K 근주투여, 134,135 안과적예방조치 136 및 B 형간염백신접종 137 은 최소한엄마와아기가지속적으로접촉한지첫수시간후또는첫모유수유이후로연기된다. 48,63 I. 목욕은적어도 24 시간동안늦춰진다. 73 J. 아빠나배우자와의즉각적인피부접촉은엄마가할수없는경우에만이루어진다 126 (2). 50 K. 모든부모가병실에머무는동안 ( 되도록엄마와더오래 ) 아기와피부접촉을하도록독려한다 127 (5). 15. 모유수유가가능한모든엄마와신생아 ( 저출생체중아와미숙아포함 ) 는생후첫 1 시간이내에최대한빨리젖을먹이도록지원한다 125,138,139 (1). 56,62,118 A. 첫 1 시간내에아기스스로젖을물지않거나엄마가요청할경우, 아기가맨처음젖을물수있도록돕는다 115 (1). 48,118 B. 특히미숙아와조기만삭아는반드시젖물림과적절한젖이행을하도록도움을받게된다 140 (1). 56 모자간피부접촉, 캥거루케어, 141 (1) 모유수유및모자동실에있어, 첫 12-24시간동안미숙아와저출생체중아에게요구되는주의깊은관찰이이루어진다. 56,117 아기상태가허락하는즉시, 엄마가아기의요구에따라젖을먹이도록격려한다. 21 8
16. 모든엄마가모유수유에필요한정도의도움을받게된다. 의료진이확실히엄마가유방에아기를올려놓고젖을물릴수있도록해준다. 위험군산모 ( 합병증을동반한분만과제왕절개분만, 비만, 청소년, 흡연부모, 파트너의도움결여, 가까운파트너의폭력 ) 에게는추가로맞춤형도움을준다. 21,48 A. 숙련된의료진이첫번째모유수유를주의깊게관찰하고효과적인젖물림, 자세및효율적인수유징후를확인한다. 모든것이잘진행되면개입은하지않을것이다. 개선이필요한경우, 엄마스스로젖물림과자세를개선시킬방법을먼저보여주되, 의료진이엄마를대신해주지는않는다. 28 B. 숙련된의료진이퇴원전까지매교대시마다한번이상수유를관찰하고기록하고, 가능하면언제나모든의료진이엄마와접촉할때그렇게할것이다. 자세, 젖물림, 모유이행, 아기의대소변빈도및특징, 황달, 아기체중, 그리고모든수유문제를임상병력에기록한다. 48 C. 산후초기산모들에서반쯤뒤로누운자세 ( 생물학적양육 ) 가장려되지만, 122 (4) 각자가장편한자세를찾도록자율권을준다. D. 산모와파트너가젖빨기와삼킴, 모유이행을확인하고젖생산을최적화하기위해배고픈신호, 올바른자세와효과적인젖물림징후를확인할수있게된다. 21,48 E. 의료진이모든모유수유문제 ( 유두통증, 젖물림문제, 젖양부족 ) 를다루고 48 필요할때마다수유전문가에게의뢰한다. 가장흔한모유수유문제관리에대해퇴원전에모든모유수유부모와논의한다 ( 표 3 과 5). 21 표 5. 모유수유중인모든새내기엄마 ( 와가족 ) 가알아야하고 / 또는시연해봐야할필수문제목록 ( 퇴원전에산모들에게서확인해야함 ) --------------------------------------------------------------------------------------------------------------------------- 1. 완전모유수유와수유시엄마 / 부모와아기의눈맞춤과신체접촉의중요성. 2. 배고픈신호와적절한젖물림과삼킴, 모유이행및아기가만족한신호및이모두를인지하는방법. 3. 평균수유횟수 (24 시간동안 8-12 회 ) 및더자주수유해야하는일부아기들. 4. 통증없이편안한자세로수유하는방법. 5. 아기가먹고싶어하는신호에반응하여, 수유시마다양쪽젖을모두, 만족해보일때까지먹여야한다. 6. 젖생산과사출을보장하고향상시키는방법. a. 초유 / 모유를손으로짜는이유와방법 b. 유축기사용이필요한엄마는유축기를제대로사용하고관리하는방법을알아야한다. 7. 노리개젖꼭지나인공젖꼭지가모유수유에미치는영향과이러한제품을수유가확립될때까지금하는이유. 8. 모든약물이나엄마의질병이모유수유금기는아니다. a. 정확한정보출처 : www.e-lactancia.org 및 www.mommymeds.com 은부모를위한사용자친화적인웹사이트이다. b. 모유수유모가담배, 술이나기타마약을피해야하는이유. 9. 안전한수면지침 ( 안전한동숙방법 ), 특히소파와흡연을피함. 10. 아기의영양부족이나탈수징후와의료전문가에게상의해야할경고징후를인지한다. a. 아기 : 보통 4 시간이상깨지않거나, 항상깨어있거나, 전혀만족스러워보이지않거나, 하루에 12 번넘게수유하거나, 적어도 3~4 번빨때마다삼키는징후가없거나, 1 일대소변기저귀가너무적거나, 열이난다. b. 엄마 : 지속적으로고통스러운젖물림또는, 유방멍울, 유방통증, 발열, 의심스러운젖양, 아기에대한반감, 깊은슬픔및자신의모유수유능력에대한모든의심. --------------------------------------------------------------------------------------------------------------------------- 세계보건기구-유니세프 21 에서발췌하고다음출처에서추가함 : ( 괄호안숫자는 OCEBM 67 에따른근거수준을나타냄 ): ( 웹페이지 ), 172,192 (5), 191 (1). 192 17. 모든엄마는병원에있는동안유방마사지와손유축방법을, 142 (1) 143 (2) 그리고원하면유축기사용법도 배우게된다. 엄마와가족들에게, 처음유축할때는흔히겨우수밀리리터만나오지만, 이것이젖생산량이 적음을뜻하는것은아니라고가르쳐준다. 9
A. 유방마사지와손유축은다음과같은경우언제나일찍교육한다. ㆍ신생아가젖을물리는것만으로는초유를먹지못한다. ㆍ미숙아, 조기만삭아나어떤아기이건첫 24 시간내에젖을효과적으로물지못한다 143 (2). ㆍ저혈당위험이있는신생아 ( 당뇨병산모, 영양부족상태의아기 ) 에게처음몇번의수유후초유를보충해준다. ㆍ아기가직접수유를할수없다 ( 예 : 미숙아나아픈아기 ). ㆍ모자분리가불가피하다. ㆍ엄마가모유생성 2 기지연위험이있다 ( 표 6). B. 모자분리가수일이상지속되는경우는언제나엄마에게양쪽형전동식유축기로, 하루에 8 번이상, 손유축을병행하여젖을짜도록 144 (3) ( 미숙아엄마에서유용한것으로입증됨 ) 조언하고, 유방마사지와손유축도조기에교육한다. C. 산전또는출산직후, 모유생성 2 기지연위험이있는것으로확인된엄마는 ( 표 6), 적절하다고판단되는특별한도움을받게된다. 아기의수유계획과면밀한후속조치가 ( 유축을돕는것뿐아니라적절한수분공급과영양섭취를위해 ) 제공될것이다. 퇴원시는, 수유계획과주의깊은후속조치로지속적인관리를보장한다. 48 D. 모든새내기엄마와아기에게적절한감독과도움이보장되도록의료진에게근무시간을충분히배정하게된다. 21,48 E. 모유수유가신생아통증을완화시키는가장좋은방법이므로, 예방접종, 비타민 K 투여, 발꿈치채혈등아픈처치는수유와동시에시행된다 145 (2). 표 6. 모유생성 2 기지연이나실패혹은젖양부족의위험요인 ---------------------------------------------------------------------------------------------------------------------------- 엄마요인 30 세넘는연령, 초산. 유방문제 : 유선조직부족, 편평또는함몰유두조직, 유방수술과거력. 분만문제 : 제왕절개 ( 특히미리계획되지않은 ), 합병증을동반한분만, 중증출혈, 지연분만, 조산 (37 주미만 ), 잔류태반. 산후우울증. 대사문제 : 당뇨병 ( 임신성, 1 형또는 2 형 ), 고혈압, 자간전증, 다낭성난소증후군, 비만 ( 임신전체질량지수 >30), 높은코티솔수치, 갑상선기능저하증, 극도의피곤, 피로또는스트레스. 젖양부족과거력. 흡연과일부마약및약물이젖양부족을초래할수있다. 아기요인 조기만삭아 (37-39 주 ). 아프가점수 <8. 고출생체중아 >3,600g. 저출생체중아 <2,500g. 젖을잘물지못하거나아프게물기 / 제한된수유. 젖돌기전보충수유. 미숙아 (37주미만 ). --------------------------------------------------------------------------------------------------------------------------- 모유생성 2 기지연은분만후 72 시간이되어도, 전혀혹은거의젖차는느낌이없거나젖이새지않는것으로정의된다. 출처 : 이표는참고문헌정보를근거로마련됨 ( 괄호안숫자는 OCEBM 67 근거수준을나타냄 ): (1), 141,193 (5). 194 10
18. 미숙아나저출생체중아엄마개개인에대한개별화된적절한관리가제공되며, 이는가족중심관리와 관리의연속성뿐아니라아기의요구를따른다. A. 미숙아는 27 주부터젖을찾고, 물고빨기도하지만, 비효율적모유수유가되기쉽다. 21 미숙아와조기만삭아는적절한젖물림과모유이행을확실히하기위해특별한도움을받게된다. 140 (1). 56 B. 저출생체중아 ( 초저출생체중아포함 ) 에게는엄마자신의젖을먹이도록, 그리고그것이불가능한경우, 저온살균된기증모유를먹이기위해모든노력을다한다. 117,128 미숙아나저출생체중아엄마는최대한빨리, 바람직하게는분만후 1 시간이내에 146 (3), 21,63 ( 만일모자간피부접촉이불가능했다면 ) 147 (3) 유축하되, 적어도첫 6 시간이내에는 146 (3) 56 유축을시작하도록돕는다. C. 적절한젖공급을확보하기위해하루에 8 번을목표로, 최소 5 번이상, 24 시간중밤에도 1 번이상젖을짜도록독려한다. 신생아병동내아기옆에유축공간을마련하고, 요청시는스크린으로사생활을보호받게한다. 유방마사지, 손유축, 전동식유축기 ( 가능하면양쪽형 ) 사용에대한지침을제공한다 148 (2). 필요시언제든젖양을늘리기위해모자간피부접촉 149 (2) 직후에최소 8 번이상유축기와손으로젖을짜도록독려한다. 144 (3). D. 2,000g 미만인경우, 아기를위해엄마가분만후최대한빨리캥거루케어를시작하여가능한연속적으로시행하며, 63,117 아기가안정되면즉시모든엄마가할수있게한다 141,150 (1) 151 (5). 산모나파트너가신생아병동에제한없이출입하도록 141,152 (1) 보장한다. 이를위해, 엄마에게복장과반쯤뒤로젖혀앉을만한적절한공간을마련해주어, 유방사이에아기를알몸상태로엎드려놓도록한다. 아기가배고픈초기신호를보일때마다의료진이수유를돕는다. E. 퇴원시, 아기와떨어져지내야하는엄마들에게모두올바른모유보관과이름표부착에관해문서와구두로지침을제공한다. 55 엄마에게계속젖을짜도록독려하고, 가능하면언제나, 기관에서유축기공급편의를제공한다. 19. 의학적으로보충 ( 물, 포도당용액, 조제분유나기타액체 ) 이요구되지않는한모유수유모에게완전모유수유 ( 비타민 / 약물을제외한다른음료나음식을주지않고젖만먹이는것 ) 를권장한다 (ABM 프로토콜 #3). 54 의학적적응증이없거나정보에입각하여엄마가서면으로요청하지않는한신생아에게보충수유를제공하지않는다. 21,62 보충수유가필요한경우 : A. 우선순위는다음과같다 : 초유 / 엄마자신의젖, 저온살균된공여모유, 21,62 바로사용할수있게조유된분유, 깨끗한물에탄분말또는농축분유. 만삭아는생후 1-2일에 1회수유당 2~15mL 이상필요하지않다. 48 B. 엄마에게초유나모유를아기입으로직접먹이거나수유병 / 인공젖꼭지외다른방법 ( 컵, 손가락, 주사기, 팔라다이나숟가락이더낫다 ) 으로먹이도록권장한다. 54 유방에서관으로보충하면수유하는동안유방을자극하는데도움이될것이다. C. 엄마의요구나, 의사의처방없이는 21 보충수유를제공하지않는다. 의학적적응증에대한처방은매일검토하고다시내려져야한다. 보충수유에대한의학적적응증, 유형, 횟수, 양, 보충수유방법과보충수유와관련해엄마에게제공되는지시사항을엄마 / 아기의임상차트에기록한다. 21,54 D. 의학적적응증이없음에도보충수유를요구하는엄마는그이유를듣고알아본다. 모유수유에대해신중하게평가하고보충수유위험을엄마와친척들과논의한다. 54 E. 모유대체품의안전한준비, 수유, 취급및보관방법을모유수유를하지않거나보충수유가필요한가족에게퇴원시개별적으로가르치고, 21 해당되는경우서면지침을제공한다. 20. 본기관에서는, 부모가택한수유방식이나분만방법과무관하게모든엄마와건강한만삭아가상호웰빙을위해하루 24시간내내함께지내야 ( 모자동실 ) 함을인정하고촉진한다 154 (1). 63,117 법적의무가없는한, 본시설은건강한만삭신생아를위한전용신생아실을두지않는다 ( 아기에게친근한병원운동에서신생아실을없애는것이요구조건은아니지만 ). 이기관이신생아실을유지한다면, 지나다니는사람들에게그안에있는아기들이보이지않게하여, 관심을끌지않아, 엄마와떨어져지내는것을정상으로여기거나신생아실이용을지지하거나권장하는인상을주지않는다. 11
A. 후기조산아 140 (1) 56 나특정의학적안전기준을충족하는 1,750g이넘는저출생체중아를포함하여모든신생아 156 (2) 에대해모자동실을촉진한다 155 (2) 21. 원내에서손쉽게사용할산모용침대옆에부착된아기요람을마련한다 157,158 (2). B. 정당한임상적이유가있을때만엄마와아기를분리한다. 모자동실중단이유, 그기간에아기가머무는곳과시간변수등모자동실중단에관해직원이문서작성을해야한다 154 (1) 56. 그원인이해결되는즉시모자동실을다시시작한다. 엄마가아기와분리되어야할때마다, 의료진은최대한빨리, 그리고분리후적어도첫 6시간이내에젖을짜도록엄마를지원한다. 21 부모가아기를데려가달라고요청할때는언제나, 그이유를알아보고아기의건강과웰빙을위한모자동실의중요성을설명한다. 154 (1). 교육내용을문서로기록한다. 의학적이유나부모의선택으로아기와분리되는경우, 아기담당간호사는아기가젖을먹고싶어하면즉시엄마에게데려와완전모유수유를지원할책임을진다. C. 일상적인처치, 평가, 신생아선별검사, 심장검사, 예방접종, 청력검사, 일상적검사실채혈은모두엄마침대옆에서이루어져야한다. 48,63 건강한만삭아의일상적인혈당모니터링은불필요하다. 52,73 신생아목욕은대부분꼭필요하지는않지만, 원하는경우, 가능한언제나부모가직원의도움을받아수행한다. 48,73 D. 정맥내항생제나광선치료를받아야하는것외에건강하고안정된아기는엄마와함께지내게한다 125 (1). 56 E. 아기의낙상과질식사고예방을위한안전한모자동실방법교육을, 정기적으로가족들에게제공하며, 이에는고위험시간 ( 이른아침 ) 과위험요인 ( 기진맥진한부모 ) 에관한정보와, 특히밤이나피곤할때아기를소파나안락의자가아니라성인침대에서수유하도록조언하는것이포함된다. 159 위험도가보다높다고확인된모자에대해서는감시가강화된다 127 (5). 56 21. 병원직원은, 분만이나수유방법선택에관계없이, 모든엄마들이, 수유, 친밀감및편안함을요구하는아기의신호에대응하는방법을반드시알도록해준다. 안정된신생아에게시간맞춰수유하는것은권하지않는다. 21,30,73 A. 수유빈도나시간에제한을두지않는다 ( 울음은늦은수유신호이다 ). 21 B. 엄마에게다음과같이알려준다 : ㆍ아기는하루에 8번이상모유수유를해야하며, 많은경우더자주먹어야한다. ㆍ매수유시마다양쪽젖을모두먹이는것이중요하지만, 아기가한쪽젖만으로만족해하면반대쪽은다음번에먹인다. ㆍ첫 24-36시간동안은몰아서먹기 ( 연달아여러번수유 ) 가일반적이며이것이젖생산을자극할수있다. 젖양이부족하다는신호가아니며, 보충수유도불필요하다. 30 나중에는, 모유이행이부족하다는신호일수있다. 160 (5). C. 저출생체중아, 미숙아또는조기만삭아나체중이너무많이빠지는신생아의부모는, 모자동실을하는중에, 조기수유신호에젖을먹이고, 필요시아기를깨워, 24시간동안적어도 8번이상수유하도록알려준다. 56 모자분리시는언제나, 의료진이수유신호를인지할때마다, 젖을먹이기위해아기를엄마에게데려다준다. 21 22. 건강한만삭모유수유아에게노리개젖꼭지나인공젖꼭지를일상적으로사용하거나물리지않는다 161,162 (1) 155,163 (2) 164,165 (3). 54 A. 엄마가아기에게수유병이나인공젖꼭지를달라고요청하면, 의료진은요청사유를알아보고, 우려사항을해소하고, 빨기에미치는영향을강조하여그것을사용하는경우의위험성을교육한다. 모유수유문제를배제하기위해모유수유를평가한다 165 (3). 21 B. 의료진은일상적으로모유수유아에게노리개젖꼭지를물리지않는다. 엄마가노리개젖꼭지를요청하면, 직원이요청사유를알아보고, 우려사항을해소하고, 노리개젖꼭지사용과관련된잠재적문제를교육하고교육내용을기록한다. 인공젖꼭지나노리개젖꼭지사용에대해엄마가정보에근거하여내린결정을존중하고의료기록으로문서화한다. 54 C. 신생아집중치료실이나특수치료실에입원한미숙아나아픈아기는비영양적빨기를위해노리개젖꼭지를사용할수있다. 21,50,163 12
D. 유두보호기 ( 또는수유병꼭지 ) 는수유전문가가권할때만, 그리고문제를교정하기위해했던다른시도들이실패한후에한해서사용한다 166 (1) 167 (2). 50 E. 모유수유아가통증을유발하는처치를받을때는모유수유가바람직한진정방법일것이다 145 (2). 처치중통증완화를위해서라면, 노리개젖꼭지는모유수유가불가능할때만물리고, 처치후에는빼준다. 23. 본기관은 LactMed, 168 InfantRisk, 169 Lactation Study Center, 170 또는 APILAM 웹페이지나 www.elactancia.org 등수유모의안전한약물사용을위한근거기반자료를사용한다. 젖을끊기위해통상적으로약물로수유를억제하지는않는다. 72,173 불편감을줄이기위해얼음등비약물적조치와약한진통제, 편한정도의유축, 울혈예방을위한유방지지가권고된다 174 (1). 172 분만한사람에서, 의학적또는심리적이유로수유억제가필요하고, 출산한개인이정보에입각한결정을내린후에는 173 (5), 리슈리드 (lisurid) 나카버골린 (cabergoline) 을사용할수있다 175 (1). 돌봄의연속 / 퇴원. 24. 본기관은모든엄마와아기, 가족을위해관련된의료및사회관리전문가들과명확하고정확한정보교환을통해통합된관리를제공한다. A. 퇴원전에, 의료팀은수유모가효율적으로모유수유할수있게효과적인모유수유가되고있는지확인하고, 후속방문 ( 가정방문포함 ) 또는자격을갖춘일차의료인및 / 또는수유전문가방문및 / 또는지지단체나동료상담가와의연락을통해지속적인돌봄이이루어지도록한다 21,28,62,1,176 (1). B. 퇴원시아직아기가젖을잘물거나수유를잘하지못하면, 개별적인수유계획을마련하고, 모자의임상상황과자원에따라아기의퇴원을연기할수있다. 53,54 어떠한이유로든엄마가더오래입원해야할경우, 엄마와아기가함께지내는것이불가능하지않은한 ( 예를들어, 엄마가중환자실에입원 ), 건강한아기를엄마없이퇴원시키지않는다. C. 엄마와그파트너에게모유수유에관한서면교육자료편의를제공하며, 적절히상의하되, 이것으로인간중심의사전예방적개인지원 ( 178 (1) 46 (H)) 을대치하지는않는다. 교육활동에가족을포함시키는노력을한다. 퇴원전에, 의료진은분만한사람이구체적인지식과기술을갖추고있는지확인한다 ( 표 4). 25. 본기관은모유수유메시지를조절하고관리연속성을제공하기위해지역사회기반프로그램과협력한다. A. 퇴원전, 모든엄마와아기에게지역사회지원단체나기타모유수유지원지역사회자원연락처를제공한다 1 (1). B. 엄마와아기의일반적인웰빙, 수유상황, 황달의존재를생후 2~4일과그다음주에재평가할수있도록모든엄마와아기의의료진방문일정을잡아준다. 21 C. 필요하면언제나, 구체적으로수유문제추적을위한방문일정을잡아준다. 가정방문이모유수유기간연장에중요한것으로확인되었으므로이를계획하거나마련해준다 1 (1). 적용 : 분만하는모든사람기타관련 ABM 프로토콜 프로토콜 #1, #2, #3, #5, #8, #10, #14, #19, #21, #26, #28. 연구의필요성 이프로토콜집필을위해증거를조사하는중, 병원상황에서아기에게친근한병원운동실행을개선하기위한효과적인전략이나직원들의병원모유수유정책준수감시방법등, 근거가불충분하거나전혀없는특정문제들이대두하였다. 모유생성 2기지연위험이있는만삭아산모에서산전, 조기손유축에대한통제연구가필요하며, 이것이모유생성 2기시점, 젖양및모유수유기간에미치는영향을더면밀히확인해야한다. 요구에따른수유, 최상의모유수유자세, 아빠가아닌부모나다른친척 ( 엄마가없는경우 ) 의피부접촉, 필요시최선의수유억제치료법과성전환부모의가슴수유경험및이를지원하는방법은적절한연구가부족하거나전혀연구되지않은기타문제들이다. 13
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