Kangaroo Mother Care Method

Feeding strategies for preterm and Low birth infants

Module 3

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Table of contents

1. Introduction and goal of the KMC feeding strategy2. Suction in newborns 3. Breastfeeding preterm infants4. Adaptation to the KMC feeding strategy5. Feeding modes in preterm infants 6. Feeding preterm infants from the breast 7. Alternative feeding methods8. Stimulation of feeding in preterm infants 9. Milk extraction 10. Maternal difficulties to breastfeed11. Problems with insufficient milk production 12. Transition from hospital to home after discharge 13. Preterm infant formula

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KMC Components

• 1st : Kangaroo position– The infant is placed almost naked in strict upright ventral position

between the mother´s breast, in direct contact with her skin, as long as possible

• 2nd : Kangaroo Feeding and Nutrition strategy− Ideally exclusive breastfeeding to have a weight gain similar to the

growth during the intra uterine life ( 15 g/Kg/day )until full term

• 3rd : Early Discharge and strict ambulatory follow up − Discharge in kangaroo position regardless of weight and gestational

age when the child is able to coordinate sucking, swallowing and breathing , gaining weight for 3 days and have parents informed , trained and ready to come to follow up visits

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Introduction

• The kangaroo nutrition strategy is intended for children who are in the “stable growth period”, after the transition period until the infant reaches full term– This period is considered similar to the period of intra uterine growth

which may have occurred if the infant was not born prematurely

• Children during this period face a double challenge: having to grow at the rate they would have grown while still “in utero”, and to recover from the deficits accumulated during the transition period

• KMC feeding strategy focusses on successful breastfeeding

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Breast milk is the “must” • “Human milk is species-specific ,and all substitute feeding

preparations differ markedly from it, making human milk uniquely superior from infant feeding.

• Exclusive breastfeeding is the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health , development , and all short and –and long terms outcomes.

• In addition, human milk-fed preterm infants receive significant benefits with respect to protection and improved development outcomes compared with formula fed preterm infants “

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Goals for the KMC Nutrition • Obtain adequate growth and short term nutrient retention, which allow

the preterm infant to come close to the intra uterine growth charts and to the fetal composition of reference

• Decrease neonatal morbidity by improving food tolerance; reduce the incidence of necrotizing enterocolitis (NEC) and minimize nosocomial infection

• Achieve a nutrition that contributes to optimal short and long term neurological development

• Reduce atopy and allergy index• Decrease the potential risk of hypertension, cardiovascular disease and

hypercholesterolemia in adulthood• For the preterm infant, milk from the infant’s own mother is the “must”

and will be used whenever possible; the mother’s milk is always supplemented with A, D, E and K vitamins up to term. Mother milk may be also fortified and supplemented whenever it may be necessary

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Nutrition goal to the KMC method

• Obtain adequate growth and short term nutrient retention, which allow the preterm infant to come close to the intra uterine growth charts and to the fetal composition of reference

• The goal is to reach a weight gain similar to the usual growth during the intra uterine life 15 g/kg/ day until full term – If this goal is not reached through exclusive breast feeding it is

necessary to identify and to correct conditions which may explain inadequate weight gain

– Once the abnormal condition is corrected, growth must improve. If not, or if there was no any secondary cause for inadequate growth, breast milk should be fortified or supplemented with special preterm formula

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Nutritional Supplements

• ‘Kangaroo’ children who are not getting weight being fed by breast milk with or without hind milk and who do not present any pathologies, may receive a supplement, for a limited period of time in order to avoid losing the initial growth potential and preventing them to become malnourished

Supplement starts with 25 to 30% of the daily quantity, based on 180 to 200 ml /kg/day

• The mother must give the supplement using a syringe, a cup or a dropper but not a baby bottle and always before nursing the infant, so that the baby only takes what he needs from the breast

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Suction in Newborns• The tongue fills the oral cavity and protrudes outside the mouth in

response to the rooting reflex, it goes beyond the limit of the gums, envelops the nipple-areola complex, compressing it against the hard palate and making an undulating back and forth movement: “tongue slither” which generates positive pressure– Lips have a sealing function generating negative pressure during

suction; by being everted and well adapted to the mother’s breast, they provide a hermetic seal

– Eminences in the inner side of the lips have an anti-slid function – Bichat’s fat pads in the cheeks, prevent them to collapse due to

negative pressure – The nipple is elongated to allow the ejected milk to flow laterally to

the air way on a zone called “comfort zone”, in the union of soft and hard palate

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Feeding Reflexes (1)

• Fetus in utero sucks and swallows amniotic fluid• The rooting reflex explored by rubbing, stroking or touching the corner of the mouth

– The infant turn his lips, head and open his mouth to follow and "root" in the direction of the stimulus

– This helps the infant to find the breast opening widely the mouth allowing a correct attachment

– It is present from week 32 of gestation.• The suction reflex is assessed by placing a finger inside the infant’s mouth

– The infant begins to suck placing his tongue under the finger and applying pressure against the palate

– The sucking reflex appears and develops in parallel with the rooting reflex. – The suckling reflex creates negative pressure which associated to the positive

pressure of the palate allows suction, swallowing and breathing.

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Feeding Reflexes (2)

• The swallowing reflex is visualized by the movements of the larynx– It refers to the set of actions allowing the passage of solid or

liquid from the mouth to the stomach – It appears from week 16 of gestation

• Non-nutritive suction (NNS) as stimulation is recommended to develop suction reflexes

• At 34 weeks of gestational age, the suction/breathing pattern approximates 1:1

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Suction Disorders in Preterm Infants Oral motor dysfunction (OMD) is the alteration of the infant' capacity to

attach himself to the breast it can be primary or secondary and may generate functional and anatomical distortions

• Primary OMD: due to transitory or permanent neurological problems or to anatomical abnormalities

• Hypertonicity: when suckling , the infant bites the nipple • massaging the baby’s gums before nursing, and straddling him on the mother’s lap

while breastfeeding are recommended • Hypotonicity: infants with low vitality falling asleep while nursing

• The ” dancer hand position” and milk extraction are recommended•Secondary OMD: occur when original sucking and swallowing reflexes are modified due to use of artificial teats or bottles

• This causes pain for the mother and inhibiting the let-down reflex making milk extraction difficult.

• It can be corrected by massaging the child’s mouth with the finger pad, applying pressure on his tongue and gradually withdrawing the finger

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Prerequisites to Adaptation to the KMC Nutrition

• The kangaroo adaptation to the nutrition of a preterm infant is “a process of social and physical adjustment for the mother and family to the Kangaroo Mother Care Method” – It is done through an education process with social and emotional support– It is vital for the success of the kangaroo nutrition

• Existing open door policy for parent to stay with their child • The mother should be recognized as the baby’s primary care provider• her stay next to her child should be done comfortable

• The health team is a central person to advocate and promote satisfactory breastfeeding

• The support given during the breastfeeding period should:– Develop the mother’s confidence ,paying attention to the mother’s problems,– Provide precise and practical information about the child’s needs– Offer options and allow the mother to make decisions– Give timely pertinent information on technical and scientific content

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Breastfeeding preterm infants • The American Academy of Pediatrics recommended officially since 2005 administering breast

milk from the babies’ own mothers, to preterm and other high-risk babies – Since then, breastfeeding has been the recommended mode of enteral nutrition for

preterm and LBW infants• Breast milk has digestive enzymes, direct immune protective, immunomodulation, antioxidant

and anti-inflammatory factors, hormones bioactive factors and multiple cellular elements– Breast milk allows a better cognitive ability development, better neurobehavioral organization and

decrease infection • Benefits of breast milk are recognized but it is still difficult to establish successful breastfeeding

in Neonatal Units due to:– the fragility of preterm babies and their illnesses– their different nutritional needs , the complexity of their care – Infant- mother separation and mother’ anxiety jeopardizing regular milk production– No open door policy allowing parents to stay with children – Fixed schedules for feeding

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Characteristics of preterm breast milk• The Colostrum is produced during the first 3 - 4 days of life

– It is a thick, yellowish liquid of high density– From birth to day 3, the volume is from 2 to 20 ml per feeding – It contains less lactose, fat and water soluble vitamins than mature milk but

more protein, E, A and K vitamins carotene and zinc• Preterm colostrum contains more immunoglobulin A, lysozyme, lactoferrin and cells • Mature milk The mature milk not only vary from woman to woman but also from

one breast to the other, from one nursing to the next and, varies also during the same feeding. The hind milk is richer in fat

• The preterm mother’s milk contains 2 time more proteins, more sodium , it provides important amounts of taurine, glycine, leucine and cysteine, more fat , more calories and more calcium and phosphorus

• Only during the first 4 weeks after birth , mothers of preterm babies produce milk with a special composition that adapts to the estimated nutritional requirements of their children

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Feeding modes for preterm infants

• Feeding based on maternal milk from his own mother plus vitamins A,D,E and K:– Exclusive, with no fortifiers or supplements– Fortified (fortifiers added to extracted milk)– Supplemented with artificial milk for preterm infants– Supplemented with fortified and pasteurized human milk from a

donor (preterm or full term)

• Feeding based on artificial formula for preterm infants– Exclusive or supplementary use of other forms or oral or enteral

nutrition; protein hydrolysats, element and semi-element preparations

• For infants less than 1500g or born before 32 weeks GA breastfeeding is probably not sufficient to cover the calcium, phosphorus and occasionally, protein requirements and milk must be fortified with these elements

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Feeding on schedule preterm infants• Preterm babies do not demand to be fed until they reach full term

nursing must be done on a schedule rather than on demand• Infants weighing less than 2000 g or less than 37 weeks of GA, need

short intervals between feedings in order to receive enough nutrients and to allow for adequate thermoregulation, growth and development – Feeding intervals must be approximately every 1 hour and ½

during the day and 2 hours during the night • Controlling the frequency of feedings is useful:

– Decrease energy loss by suction– Provide the needed nutrients in sufficient quantities– Create a routine for mother and child strengthening their bond – Give the mother a clear timeline.

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Breastfeeding a preterm infant (1)

The transfer of maternal milk to the infant depends of the interaction between the volume of breast milk, the let-down reflex and the preterm infant’s suction•Check signs of readiness for breastfeeding:

– Gestational age 32 weeks– Baby able to coordinate breathing, sucking and swallowing– Baby’s health is clinically stable (no serious breathing problems)– Baby can suckle with rare episodes of apnoea and bradycardia– Apparent signs of being alert/ready to attach

•Breastfeeding a small baby requires patience and dedication because he/she:

– Suckles for a short time then rests– Can fall asleep while breastfeeding– Can take frequent pauses making breastfeeding longer– Is not always awake for breastfeeding

WHO EURO, 2002WHO EURO, 2002

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Breastfeeding a preterm infant (2)

• Reassure the mother that she is able to feed her baby– Train the mother to watch the baby completes at least 6 suctions,

alternated with pauses to breathe– The weight test can be used to determine the volume of ingested breast

milk, but it may stress the mother, daily weight is enough• Actively counsel her to:

– Feed the baby every 1½ -2 hours– Wake the baby up for feeding– Keep the baby at the breast longer – Let the baby takes long pauses and breastfeed more slowly– Do not interrupt breastfeeding if the baby is still trying to suckle – Express some milk before the baby attaches if milk flow needs to

be reinforced – Breastfeed the baby with hind milk if the baby does not gain

weight

WHO, 2003WHO, 2003

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Oral breastfeeding through suction -1

• Skin-to-skin contact has a positive effect on milk production, even before suckling begins– Putting children to the breast for the non nutritive suction, increases the

rooting response and stimulates the suckling functions • Direct oral breastfeeding

– Promote the milk let-down reflex by a gentle massage of the breast– Awake the baby and placed him in a recommended nursing position – The mother must surround the base of her breast with 4 of the 5 fingers and

place the 5th finger on the edge of the areola forming the letter “C” – The mother must hold the child’s neck base to control it and to bring the baby

close to the breast, offering him a secure position and orient the nipple in the direction of the child’s nose , stimulating the rooting reflex

– When the baby naturally tilts his head back and opens his mouth wide, the mother must bring him to the breast in one single swift and gentle motion of her hand or arm

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Oral breastfeeding through suction -2

• The baby’s lower lip must be turned outward, the tip of his nose near the mother’s breast, his chin touching it. The child will be able to breathe effortlessly.

• Nursing must not cause pain• The newborn will begin suckling, according to his maturity, from 5

to 15 successive suctions, followed by a breathing pause as long as the suckling period, and then resuming the activity

• 10 minutes after beginning nursing, it is possible for the child to fall asleep or to slow down the suckling rate.

• Once the baby is awake, he can settle again to resume nursing or to make sure he is satisfied

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Breastfeeding Techniques The breastfeeding technique is a procedure by which suckling is carried out•The mother’s position:

– The mother can nurse sitting or lying down– The mother should be in a comfortable and relaxed position able to hold the

baby close to her without undue effort, her feed be supported •Check the infant’s position:

– The baby’s head and body must be perfectly line up – The baby’s face must face the mother’s chest, with his nose in front of the

nipple – The baby’s body must be close to the mother’s , turned towards her– If the baby is newly born, the mother must cradle him with one arm and give

support to the buttocks, not just to the head and shoulders•Check the Infant attachment to the breast:

– The mouth is wide open – The chin touches the breast (or close to) – The lower lip turn outwards – More areola is visible above the infant’ top lip

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Nursing Positions for preterm infants -1The preterm baby must be nursed in a position supporting his head and neck to prevent the obstruction of airway causing apnea and bradycardia during breastfeeding

Football or watermelon positionThe baby faces the mother while his body is tucked under one of her arm. The baby’s upper back rests on the mother’s forearm, while she holds his neck with her hand. The baby’s hips rest against the back of the chair or bed.

Crossed or inverse cradling positionThe hand opposite the breast offered to the baby is placed behind the baby’s head, in order to support and guide it. The hand of the same side may support the breast.

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Nursing Positions for preterm infants -2

The “dancer hand “position. This is a technique that supports the child’s jaw in order to improve the up and down excursions during suckling, made difficult by hypotonia.

Modified football position. The baby sits facing the mother, by her side, on the sofa or a pillow, with his legs at his mother’s side and his feet at her back.

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Alternative Feeding Methods

1.Cup/spoon/syringe/dropper

•Does not interfere with breastfeeding•Cup is easy to wash•Safe•Small baby gets the quantity she/he

needs•Cup-feeding can complement

breastfeeding if the baby is weak or tired

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Alternative feeding techniques Cup-Feeding Technique

• Measure the quantity of milk needed into a cup

• Hold the baby in semi-upright position• Touch the baby’s lips with the cup• Do not pour the milk into the baby’s

mouth• Allow the baby to lap or sip the milk and

swallow at own rate• The baby stops feeding when his/her

mouth closes and doesn’t show further interest in feeding

WHO EURO, 2002WHO EURO, 2002

BMJ, 2004BMJ, 2004

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Gavage-Feeding Technique (1)Used to feed very low-weight or sick baby

• Tube insertion • Select a thin gastric tube• Measure the distance from the tip of nostril to the lower tip

of the ear and from the ear to the stomach • Mark this distance on the tube• Insert the tube gently into the stomach through the nose• Check the correct position of the tube by:

– Aspirating some stomach content, or – Blowing air (1-2 ml) in the stomach and listening with

stethoscope • Leave the tube in the stomach maximum 3 days

WHO, 2003WHO, 2003

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Gavage-Feeding Technique (2)

• Use colostrum or expressed breast milk • During gavage feeding: • Mother holds syringe 5-10 cm above baby; milk runs

down tube by gravity• Stimulate the baby’s suckling reflex and taste • Encourage mother-baby skin-to-skin contact• Feed slowly over 15-20 minutes • Intermittent feeding for at least 15-20 minutes is

considered to be similar to “physiological feeding”• When it is possible, start cup-feeding• Continuous enteral milk infusion method

requires constant monitoring of the baby’s tolerance

WHO, 2003WHO, 2003Premji SPremji S et al, 2004 et al, 2004

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Teach the Mother Colostrum/Milk Expression Techniques

WHO EURO, 2002WHO EURO, 2002BMJ , 2004BMJ , 2004

If the mother extracts manually her milk, it is recommended to extract it 8 to 10 times a day Mothers must extract their milk until it no longer flows, usually after 10 or 15 minThe last drops have a high lipid concentration and may significantly contribute to caloric intake

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Hygiene for milk extraction • Breast milk is not sterile since it has its own micro flora • The mother must follow strict hygienic measures:

– Hand washing with soap and water and brush under the fingernail– Wash the milk container, with hot soapy water and rinse it with boiled

water– The container must have a wide opening and a cap

• it must be made of glass or hard polycarbonate suitable for food preservation

• it must never be a polypropylene bag because of the risk of liberating toxic substances into the milk

– Previous cleansing of the nipples is not necessary– It is also unnecessary to discard the first drops of milk– Recommend the mother not to talk during extraction and only touch

the exterior of the containers and the breasts.

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Manual milk extraction techniquea) Stimulating the let-down reflex : The mother may stimulate gently the breast

– She may roll it gently between thumb and index finger, or have a pleasant beverage , or might imagine herself as a “fountain of milk”

– With practice, the mother gets used to stimulate the let-down reflex b) Locating the milk ducts : The mother is asked to gently feel her breast, 3-4 cm behind the nipple to find the milk ducts similar to a cord with knots or a string of peas

– The mother must place her hand as to form the letter C, with her thumb over the milk ducts and the index in the opposite side

c) Compression over the breast ducts : The mother applies pressure on the milk ducts with her thumb and index finger. Then, she releases the nipple and repeats the motion of pressure and release until milk begins to drip

- When the milk flow diminishes, the thumb and index finger are moved around the areola towards another section and the pressure-release motion is repeated

- When the flow stops, the technique is repeated on the other breast

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Mechanical milk extraction technique

• A pump does not really pump, suction, or express milk from the breast • The negative pressure of the pump reduces the milk’s resistance to flow

and allow the breast internal pressure to push milk outward• The milk let-down reflex produces an initial rise of the pressure inside the

mammary gland, the periodic rise of the pressure in the ducts maintain a constant pressure gradient – Induce the let-down reflex before using the pump– Use only the necessary negative pressure to maintain the milk flow– Massage the breast’s quadrants before and during extraction to

increase the pressure inside the mammary gland– Take as long as necessary to avoid anxiety– Maintain an the pump adequately fixed to the breast– Avoid prolonged periods of continuous negative pressure– Suspend the extraction if the milk flow is minimal or if it stops

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Preserving the extracted milk (1)

Consider 2 basic principles when storing and handling breast milk 1.Breast milk is a live fluid it must be handled as if it was blood. • It must be packed in plastic or glass container to avoid

contamination and to preserve its qualities. • The container must be clearly labeled, milk without

proper labeling must never be administered 2. All the milk to be given o a baby must be kept in the hospital under control – it is not recommended to receive milk stored outside of

the hospital, as its quality is not guaranteed

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Preserving the extracted milk (2)

Fresh milk: •Colostrum: at room temperature 27- 32º C( 80-90 ºF) , 12 to 24 hours •Mature milk - At 15º C (59ºF): 24 hours ; at 19-22º C (66 -72 ºF): 10 hours; 25º C (77 º F), 4 to 8 hours At 27- 32º C (80-90 ºF): 4 to 6 hours; at 0º C and 4ºC (32-39 º F): 5 to 8 days•Frozen milk ( - 18 º C = 0 º F)-In a freezer inside of a refrigerator: 2 weeks; in refrigerator with a freezer with a separate door: 3 to 4 months ; in a separate freezer with a constant temperature of - 19ºC: 6 months

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Milk banksWhen there is not enough milk for an infant from his own mother, milk from

a donor is an excellent alternative •There are numerous milk banks in the world; the majority of them directly linked to Neonatal Units. • There are no international regulations but working guides edited by each different association of milk Banks• Safety and traceability systems have been established, just as strict as they are for blood banks

– The milk should be safe and insure the best nutritional conditions•Milk is classified according to acidity and calories content•Pasteurization is individual, no “pooling “ of different donors.

– Comprehensive microbiologic control is performed only sterile milk is suitable for consumption

•Selection criteria used for donors are similar to those used in blood banks – An extensive health survey and serology for HIV, hepatitis B and C and syphilis is

conducted

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Maternal difficulties to breastfeed-1

Nipple cracks •If the infant is not correctly attached to the breast, nipple cracks could occurs; they are extremely painful and bleeding when feeding•If the crack is small or recent, it may resolve in 24 hours

– By insuring an adequate attachment to the breast– By applying some breast milk on the areola and nipple, after each nursing,

drying it with air blow dryer or exposing it to sunlight, for a few minutes.• If the crack is extensive and deep, the mother must:

– Insure an adequate attachment trying different positions to find the less painful position and begin feeding from the least painful breast, a natural treatment based on calendula can be recommended

– if there is excessive pain or bleeding worsen, extract the milk every 3 to 4 hours and give it to the baby with a cup or syringe for 24 to 48 hours.

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Maternal difficulties to breastfeed-2 Flat or inverted nipples•The most effective intervention is to stimulate and form the nipple just before nursing

– Massage a flat nipple or apply a cold compress to help the nipple come out– If inverted nipple teach the mother to form her nipple by placing her thumb 4 -5 cm

behind her nipple and pushing backward, towards her chest– An extracting pump or a syringe with an inverted plunger might help “evert” the nipple

before nursing.

Breast congestion or engorgement: 3 elements are involved:1. congestion and increased vascularization 2. accumulation of milk3. edema secondary to swelling and obstruction of lymphatic drainage

•Primary congestion: The breasts are enlarged and hardened, but milk extraction is still possible. It is due to infrequent or insufficient nursing.•Secondary congestion: The breasts are hard, painful, hot; milk extraction is not possible.

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Maternal difficulties to breastfeed-3 Breast congestion or engorgement: Treatment •Apply clean, warm-water compresses to the breasts and gently massage in a circular movement, before nursing•Extract some milk before nursing to help the child to attach to the breast•Apply cold compresses or ice bag on the breasts, between feedings, to relieve pain•The mother needs to rest and must nurse more often from the congested breast.•Insure a correct breastfeeding technique•Use analgesics and relaxation techniques•A rather untraditional but effective approach is to use the warm blow hair dryer to soften the congested breasts at the beginning of nursing.

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Insufficient milk production

• Breast milk production is influenced by many factor including the frequency and intensity of infant’s suckling, especially during the immediate post-partum period

Causes of low milk productionMother Child

Insecurity and lack of confidence of the mother.Breast surgery

Additional milk formula in a bottle. Incorrect position of child at the breast.

The mother is using rubber nipples or nipple shields.

Nipple confusion in the child

Use of contraceptives Decrease in extracted volume.Nursing from only one side . Shortened feedings Presence of drowsiness Low frequency of feedings

Low weight gain. Strict feeding schedule (Every3 hours) as in many Neonatal Units.

Maternal tiredness or illness Total or partial absence of nursing. Discontinued night feedings

Decrease in the daily volume due to lack of stimulation.

Cracks and pain while nursing

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Difficulties at discharge from hospital• At discharge from the hospital , sometimes advantages of exclusive

breastfeeding may be misunderstood by parents or health staff

• The mother may show resistance to breastfeeding asking questions: “Why I must try to breastfeed my child as he was bottle fed in hospital?” ”Is my baby really getting all that he needs from my milk?” – When babies were bottle fed in hospitals– When where may be not enough time to help the mother to nurse

her baby

• Several factors may cause resistance to breastfeeding but in case of breastfeeding failure, especially for preterm infants, the responsibility lies usually on the health professionals and on the restrictive schedules used in Neonatal Units contributing to the mother’s inability or resistance to nurse

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Preterm infant milk formula (PBF)-1

• The right of every mother to breastfeed her baby and of every baby to receive breast milk is becoming widely recognized

• There are 2 main factors harming natural breastfeeding– The 1st one is the promotion of breast milk formula made

by manufacturers– The 2nd one has to do with the inability of the health

professionals to defend, protect, support and understand the benefits of breastfeeding

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Preterm infant milk formula (PBF) -2

• Preterm milk formulas are developed with modified cow’s milk or based on soy proteins – The proteins of the cow's milk are one of the nutrients

producing frequent food allergies when administered in the 1st year of life.

• There are some indications to the use of preterm baby formulas – The mother is ‘disabled’: oncological cases, active TB, HIV mother– The mother’s milk production is insufficient with poor gain weight. It is a

medical decision whether to supplement breastfeeding with a special PBF before 40 weeks, and later, with a milk formula for the 1stsemester.

– The mother does not want to nurse, regardless of all the advice given to her on the benefits of mother’s milk.

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Conclusion

• It is vital to point out that maternal breastfeeding represents a ‘dynamic feeding’, which responds to the constantly changing needs of the infant from his birth to the months following it, in contrast with formula feeding, which is a synonym of a ‘static feeding’

• It is impossible to match the ‘dynamism’ of mother’s milk in relation to variation, from one woman to another, within the same woman and throughout the day; nor the changes that take place between colostrum, transition milk and mature milk