Session 10

1. Discuss breastfeeding of infants who are preterm, low birth weight or have special needs.

2. Describe how to assist mothers to breastfeed more than one baby.

3. Outline prevention and management of common clinical concerns neonatal hypoglycemia, jaundice and dehydration, with regard to breastfeeding.

4. Outline medical indications for use of foods/fluids other than breast milk.

Preterm milk is more suited to the preterm infant than mature milk

The composition of preterm milk is unique:levels of nitrogen, long-, medium- and short-

chain fatty acids, sodium, chloride and iron are higher in preterm milk

Rental grade electric pumps combined with hand expression is ideal

Double collecting kit is preferred Optimal stimulation comes from 8 or more

pumping sessions per 24 hours, with total pumping time of 120 minutes per day

Follow collection, storage and handling protocols carefully

Encourage mother to be as involved as possible in the care of her infant. Help her learn to identify infant states, and observe baby language.

Skin-to-skin contact (kangaroo care) stimulates organization and maturation in the infant.

Skin-to-skin also assists mother in maintaining her milk supply.

Gavage or tube feeding is used when infants are too small to coordinate suck-swallow-breathe. Gavage may also be used to supplement during or after breastfeeding.

Cup feeding is also used to supplement breastfeeding in infants with suck-swallow-breathe and gag reflex.

Breastfeeding may be initiated when the infant is stable and can gag. Offer opportunities for non-nutritive suckling before actual feeding.

Breastfeeding fosterslonger, more rhythmic sucklingmore stable oxygen saturationless bradycardiamore normal heart rate

Mother should have realistic expectations of feeding.

Practice will be required for proficient breastfeeding.

Skin-to-skin care has positive impact on breastfeeding, maturation and growth, parenting, digestion and immune system.

Establish a follow-up team to ensure adequate growth and development and continuation of breastfeeding post-discharge

Foster frequent communication to address issues as needed

Are at risk for infection, jaundice and hypoglycemia

Advantages of human milk feeding include:easier digestion and absorption of fats and

proteinsfat and amino acid profile closest to infant needsenzymes which enhance maturation of gutanti-infective properties

Positioning strategies for nursing twins simultaneously: feet to feet with one twin higher than the other head to head in the football hold

Feeding twins simultaneously helps to develop synchrony of feeding schedule and increased prolactin levels.

Feeding each twin separately takes more time, but is more individualized.

Individualized feeding plans need to be developed

Infants may require supplementation, especially if one is smaller and/or weaker than others. Weight gain should be closely observed. Ideal weight gain is 15 - 30 gms daily.

Hypoglycemia means a low blood glucose level. Babies who are born prematurely or small for gestational age, who are ill or whose mothers are ill may develop hypoglycemia.

There is no evidence to suggest that low blood glucose

concentrations in the absence of any signs of illness are

harmful to healthy, full term babies. Term, healthy babies do not develop hypoglycemia

simply through under-feeding. If a healthy full term baby develops signs of hypoglycemia, the baby should be investigated for another underlying problem.

Early jaundice is distinct from late jaundice Physiological jaundice occurs when fetal type red blood

cells break down. Feeding, especially with colostrum, ensures earlier

passage of meconium and subsequent lower bilirubin levels.

Lasts two to three days, then begins to recede. Generally intervention is not needed for physiological

jaundice.

Physiological jaundice (cont.)

increasing breastfeeding frequency and/or improving latch-on is most effective in resolving this type of jaundice

Benefits of breastfeeding for infants with cleft defects:fewer upper respiratory infectionsless otitis mediaspeech improvement through optimal use of oral-

facial musculature

If infant has unilateral cleft lip, angle breast so that it fills the cleft.

Mother may use thumb to cover alveolar ridge defect (if any). This may help create better suction.

Infants with cleft defects take longer to feed. Use pillows to help support infant position and make mother comfortable to avoid fatigue.

The impact of the cleft defect on breastfeeding depends on the severity of the defect.

Explore many different nursing positions to determine which work best.

With unilateral cleft, direct nipple toward intact side.

Assess growth frequently to ensure adequate intake and growth.

Timing of surgical repair of cleft defects varies Lip repair can occur as early as 2 days of life and as

late as 3 months. Palate repairs usually occur after 10 months of life. Breastfeeding after surgery is less stressful to the

repair than allowing the infant to cry in hunger Use of obturators have been reported to benefit

breastfeeding A randomized prospective study on early

postoperative breastfeeding after cleft lip repair has shown that infants who were allowed to breastfeed shortly after repair had greater weight gain 6 weeks after the surgery.

Can feed at the breast with proper physical and emotional support for the dyad

Physical conditions which can affect breastfeeding: absent or weak sucking reflex weak suck incoordination of suck low muscle tone

Conditions Associated with Depressed Sucking Reflexes Central Nervous System (CNS) Dysmaturity CNS Maldevelopment

Prematurity Trisomy 18Delayed maturation Trisomy 21

Prader-Willi's syndrome Prenatal CNS Insults Perinatal CNS Insults

Congenital infections AsphyxiaVascular accidents Meningitis

HypoglycemiaKernicterus

Systemic Problems in the Infant TraumaCongenital heart disease Drugs administered to the Sepsis mother in laborHypothyroidism Drugs administered to the

infantNeonatal narcotic abstinence

Conditions Causing Weakness of Sucking Mechanisms Central nervous system abnormalities associated with severe hypotonia

Trisomy 21Prader-Willi's syndrome

Medullary lesionsPseudobulbar palsy (congenital or after an insult)Bulbar atresiaMoebius' syndromeArnold-Chiari malformationMotoneuron disease: Werdnig-Hoffman's syndrome (usually not present at birth)

Abnormalities of the neuromuscular junctionNeonatal myasthenia gravis (affected mother)Congenital myasthenia gravisFamilial infantile myastheniaBotulism

Abnormalities of muscleCongenital myotonic dystrophyCongenital myopathies (nemaline and myotubular)Metabolic myopathies

Conditions Associated with Incoordination of Sucking Mechanisms

Central nervous system insults Central nervous system maldevelopment

Asphyxia Arnold-Chiari malformation

Kernicterus Oral-buccal apraxia

Hypoglycemia

Bilateral cerebral bleeds Miscellaneous

Neonatal narcotic abstinence Leigh's disease

Dysautonomia

Cornelia de Lange's syndrome

Use team approach with neonatologists, primary care nurses, occupational therapists, speech pathologists with neurodevelopmental treatment (NDT) training, lactation consultants....

Assess for presence of suck, swallow, and gag reflexes on an ongoing basis.

Offer non-nutritive suckling at the mother’s breasts (after milk is expressed).

Position infant to provide maximal support. Interventions should be tailored to infant needs.

It is important to distinguish betweenBabies who cannot be fed at the breast but for whom breast milk remains the food of choice.Babies who should not receive breast milk, or any other milk, including the usual breast-milk substitutes.Babies for whom breast milk is not available, for whatever reason.

A very few babies may have inborn errors of metabolism such as galactosemia, PKU, or

maple syrup urine disease. These infants may

require partial or complete feeding with a special breast-milk substitute, which is appropriate to their specific metabolic condition.

Babies with medical conditions that do not permit exclusive breastfeeding need to be seen and followed-up by a suitably trained health worker. These infants need individualized feeding plans and the mother and family needs to be clear how to feed their baby.