Development of the Newborn & Care of the mother in the First 72 Hours Kittie Frantz, RN, CPNP-PC...

Development of the Newborn & Care of the mother in the First 72

HoursKittie Frantz, RN, CPNP-PC

Clinical Instructor in PediatricsKeck School of Medicine at

The University of Southern CaliforniaLos Angeles, California

frantz@usc.edu 1

American Academy of Pediatrics/American College of Obstetrics & Gynecology Perinatal

Guidelines says…

“Healthy infants should be placed & remain in direct skin-to-skin contact with their mothers

immediately after delivery until the 1ST feeding is accomplished.”

2American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.

Attachment Right at Delivery

Delivery Room Attachment• Place baby on mom’s body• Dry baby while skin-to-skin• Apgars done while skin-to-skin• Baby will rest for 20 minutes• Crawls to attach by 50 minutes• Process disturbed if removed for weight,

measuring, etc. Righard, L, Alade, M. (1990) Effect of delivery room routines on success of first breast-feed, LANCET 336: 1105-07

• American Academy of Pediatrics says tasks to be done after the complete first breast feed

Brimdyr, K. SKIN TO SKIN THE FIRST HOUR AFTER BIRTH; PRACTICAL ADVICE FOR STAFF AFTER VAGINAL OR CESAREAN BIRTH. [DVD]The Healthy Children Project, Inc., 2010, www.healthychildren.cc

Watch Baby do it

Several Studies Looked at This

• Dr. Lennart Righard in The Lancet Righard, L, Alade, M: (1990) Effect of delivery room routines on success of first breast-feed. THE LANCET; 336:1105-1107

• Ann Marie Widstrom in Sweden Widstrom, A.

et al (2011) Newborn behavior to locate the breast when skin to skin: a possible method for enabling early self regulation. ACTA PAEDIATRICA Jan;100(1):79-85

• Varendi in England Varendi, H., Porter, R.; Breast odour as the only maternal stimulus elicits crawling towards the odour source, ACTA PAEDIATRICA, 2001, 90:372-5.

The first two hours baby is very alert to do this

Baby gets A LOT of colostrum this first long feed! (Sometimes 1 hour)

Many Baby Procedures can be done while on Mom

Formula feeding moms can do skin-to-skin too!

Gift from Family

Best to do the bath and measurements before he goes into his transition sleep

BUT AFTER THE 1ST BREAST

FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Villiage, IL 2007.

Then baby goes into a deep sleep for four to six hours because he is in transition

This is the best place to sleep while in transition! Skin-to-skin on mom

Mom and baby are then transported together to their post partum room

Rooming-in means baby with mom 23 out of 24 hours

World Health Organization, UNICEF Baby Friendly Hospital Initiative

Transition is the baby’s first 12 hours.

What occurs in transition?

Skin-to-skin is the best place to spend transition even when awake

Where would you want to be in this transitional

period?

45 degree reclining position with baby prone is comfortable for them both

19© LAC+USC Medical Center

Do we need to worry that he is not eating?

• No, he is in transition & may not feels like eating if awakened

• Remember we are discussing full term normal newborns

• Explain to family that he will eat when he awakens

When baby wakes after this deep sleep, he will go to the breast again

He may falter a bit but it is normal for him to lick, try and learn

The baby who was skin-to-skin at delivery does better

23© LAC+USC Medical Center

Baby-led latch works best here

Baby will reach with his tongue and draw the breast in

Baby will place his mouth in an asymmetrical latch

What does baby need this first day?

American Academy of Pediatrics and The Joint Commission says 8-12 feedings per

each 24 hours

Can he do it thisfirst day?

American Academy of Pediatrics, American College of Obstetrics & Gynecology: GUIDELINES FOR PERINATAL CARE, 6th ed. AAP & ACOG, Elk Grove Village, IL 2007.

The first 24 hours• He breastfed at delivery once

• If he doesn’t feed during the transition sleep (8 hrs) then…,

• The next 16 hours he will need to do 7 feedings

• That is about every 2.25 hours until he is 24 hours old. It works!

The problem with saying “every 2-3 hours”…

• Parents choose the 3 hours

• Smaller babies need 10-12 feeds

• Parents try to schedule the baby and ignore baby’s feeding cues

• Parents try to get the baby to sleep longer with swaddling and pacifiers

Best to say feed as often or as long as baby wants to or when baby shows feeding cues

Brazelton infant states

• Deep sleep (nothing moves)• Rem sleep (eyes closed but move)• Quiet/semi-awake (eyes, mouth, hands move)• Alert awake (eye contact, quiet)• Active alert (moving a lot, arm cycling)• Crying

Brazelton, TB, Nugent, JK (2011) Neonatal Behavioral Assessment Scale, 4 th ed. CLINICS IN DEVELOPEMENTAL MEDICINE, #190, Wiley, Hoboken New Jersey

Which infant state is best for feeding?

• Deep sleep (nothing moves)• Rem sleep (eyes closed but move)• Quiet/semi-awake (eyes, mouth, hands move)• Alert awake (eye contact, quiet)• Active alert (moving a lot, arm cycling)• Crying

Teach mom the feeding cues and states

• Babies feed best in REM sleep or Quiet/semi-awake states

• Crying disorganizes the baby• Teach mom what to look for in cues

and states• Baby should be skin-to-skin, loose in

a blanket or in a sleep sack blanket

Swaddling prevents baby from waking – can’t arm cycle – and doesn’t fully awake

Franco, P, Seret, N, Van Hees, J, Scaillet, S, Groswasser, J, Kahn, A: Influence of Swaddling on Sleep and Arousal Characteristics of Healthy Infants. PEDIATRICS, 115(5):1307-1311, 2005.

Your responsibility is to be sure baby breastfeeds 8-12 times each 24 hours

This is an American Joint Commission Sentinel Alert

Joint Commission on Accreditation of Health Care Organizations. Revised Guidance to help Prevent Kernicterus, SENTINEL EVENT ALERT, Issue 18, April 2001.

Pacifiers not recommended by the American Academy of Pediatrics until

breastfeeding is well established Why?

What about the length of the breastfeed?

• Parents don’t like being told a different number of minutes per breast by different nurses or doctors

• 10-15 minutes per breast is too short for colostrum!

• The American Academy of Pediatrics says no time limits for each feed. Feed until the baby falls asleep and lets go of the nipple

• We found our babies take 45 to 60 minute feedings the first two days!

What about the length of the breastfeed?

• We told the moms let him feed on the first breast till he spits it out

• Then feed on the second breast till he comes off by himself asleep

• Be sure baby is in a nice asymmetrical latch to protect the nipples

Colostrum suckling takes a LONG time

Mom feels like doing this because we get her

comfortable in laid-back positioning !

41Gift from Family

But, doesn’t he need to eat during transition???

Term babies are born with a “backpack”

• Tissue edema• Subcutaneous fat stores• They use this fat & urinate out the edema

constitutes the weight loss:– 5.5 -6/6% Between day 2 & 3 – 7-8% IN 1ST Week– No more than 12% in the first week

But, doesn’t he need to eat???

• Stomach is marble (5-7cc) sized at birth and initially not very elastic

• Stomach can stretch to take 20 CCs on the 1st day

• Frequent slow drip of colostrum is kind

• Is colostrum so thick so it won’t come too fast?

But, doesn’t he need to eat???

• Nurses know that if you give more than 20ccs that first feed that it might come back up!

• We don’t do baby a favor by forcing the stomach expansion those first few days

We need to explain this to the parents

• Show them a visual

• Tell them that their baby’s stomach is about the size of his fist when full

• Stress frequent refills!

We need to explain this to parents• Formula in the first week alters baby’s immune

system Host,A 1991 Importance of first meal on the development of cow’s milk allergy & intolerance ALLERGY

PRAC. 12(4):227-32

• Overfeeding in the first week sets baby up for future obesity

Stetler, N 2005 Weight gain in the first week of life and overweight in adulthood. CIRCULATION,111:1897-1903

What to do when she insists on a bottle

• Nurse to solve any problems, educate her and chart the interaction

• If she still insists on a bottle, get a doctor’s order. Chart the reason for the formula

• Offer formula not in a bottle with nipple. We choose the feeding tube device (SNS) at the breast as that is breastfeeding

48World Health Organization, UNICEF The Baby Friendly Hospital Initiative

What to do when she insists on a bottle

• Take ONE bottle into the room

• Always OPEN that bottle

• Educate her that formula is only good for one hour after opened

• If she just breastfed, pour out all but 10-15 ml so he doesn’t spit it up!

Academy of Breastfeeding Medicine (2013) Protocol #5 Peripartum breastfeeding management for the healthy mother of a term infant, BREASTFEEDING MEDICINE 8(6):469-73

How much does the full term baby need?

20 mls the first post partum day30 mls the second post partum day30-40 mls the third post partum day90 mls the fourth postpartum day

According to Scammon and Doyle, the amount baby takes doesn’t reach

120K/cal per Kg until day four….if he feeds 12 times a day for the first four

Scammon, R., Doyle,L, Observations on the capacity of the stomach in the first ten days of postnatal life. AMERICAN JOURNAL OF DISEASES IN CHILDREN, 20:516-38, 1920.

FIRST 12 HOURS

• What if he sleeps too much this first 12 hours?

• Remember, baby is in transition

Baby has blunted feeding cues if he is swaddled all the

How long can baby go without food?

• At risk for hypoglycemia?

• Skin to skin reduces energy loss

• If can’t maintain temperature skin to skin, consider sepsis

No energy loss here

Gift from Family

Mom’s feelings of inadequacy

• “What I do doesn’t matter”

• “He is getting nothing from me”

• “He feeds again and again and again”

• Knowledge that baby is bringing in the milk could be helpful

Suggestions for managing her rest

• Close your eyes and sleep between feeds

• Manage your visitors wisely

• Turn off or turn down the TV volume

• Turn your cell phone ringer off

Gift from Family

Anticipatory Guidance

• Tell her baby will feed every 2 – 2½ hours this first night

• If she knows this is coming, she may not view it as a problem and panic

• Can Dad or Grandma stay to watch her so she can sleep while baby breastfeeds?

Wet diaper minimum should be 1 for each day of the week

59One wet diaper is fine this first 24 hours

THE SECOND 24 HOURS

• American Academy of Pediatrics says baby is to feed 8 -12 times this next 24 hours

• But …… babies are night people!

Night people???• They sleep a lot in the

• They do most feeds between 6pm to 6am

• Prolactin is the highest from 1-5am

• This is the pattern for the first THREE weeks and is normal

We need to teach this or parents try to “fix it”

• Pacifier• Swaddled all the time• “Shushing” a crying baby• Waking baby in the day time• Parent finger in mouth to hold him off• Asks to send baby away at night• Grandma or dad asks to give baby a bottle

Too many visitors in the day tires mom so that she has no energy to care for the baby at

Gift from Family

What to do to ensure her rest in the day??

• Mornings are baby’s sleepy time and ideal for mom to sleep too

• No visitors until 11:00 am

• Classes or visits by ancillary staff suggested for the afternoon when dad can attend

The second night feeding frenzy!

• Baby will want to breastfeed A LOT this night

• We don’t really know why?

• We see it happen even with moms tandem nursing a toddler

• Doubt it is lack of milk but perhaps a rhythm in the baby

Get the mother comfortable

Gift from Family

Baby is perhaps bringing in the milk!

Passion grows with

knowledge

Gift from Family

Hand express to show her what is really there

Baby is preventing engorgement if he is allowed to nurse a lot this night!

• If you explain this process

• She will respect your tips because it worked!

UNICEF

Engorgement can be caused by:

• Giving bottles of formula

• Using a pacifier

• Keeping baby swaddled

• Scheduling the feedings by parents

• Taking the baby away at night

Parents need to know what will happen this second night so they don’t panic!

Two wet diapers are the minimum for this second day

THE THIRD 24 HOURS

Milk is in before 48 hours if baby got to feed 8 – 12 times/24 hours for long feedings in the first two

• She needs to see success!

• Show her and praise her!

If baby is not suckling well, then:

• The milk coming in may be delayed

• Or she might get engorged even if feeding 8 – 12 times/24 hours

The length of the feeding may change because the milk is in

• When the milk comes in, the feedings shorten

• Still feed the baby till he falls asleep

• Help her resist others who tell her how long baby should sleep

Cluster feedings: a few feedings really close together usually in the evening

• Well documented cluster feedings for the normal newborn Why?

• Baby was fed continuously in the womb

• Is this a gradual transition to more spaced out feedings?

Use feeding chart to teach

Simplify any charts they may use

Circle clusters to show they occur every day

78Gift from Family

Milk coming in means a faster flow and now baby has to coordinate his

suckle & swallow with breathing

This challenges some newborns and they may balk a bit!

• Baby-led latch really helps here

• Let him sleep with mouth near the nipple so he can wake to suckling

• Pump if engorged to slow the initial flow

Watch as baby dances at the nipple knowing a flow is coming!

www.geddesproduction.com

The flow of the milk organizes the suckle

The baby who did not suckle well, may now improve rapidly!

The faster flow may organize the suckle and sore nipples may vanish

Get mom excited to know her milk is in!

• Teach the new sound of consistent swallows

• Have her watch the wide jaw openings as baby swallows

It is an art to send the parents home confident in the breastfeeding!

How will I know my baby is getting enough?

Do wet diapers or stools gauge the milk intake the best?

Shrago says stools are a better indicator of milk intake

• More stools indicate more colostrum ingestion

• The magic number is 4 stools within the fourth 24 hours

Shrago,L. (2006) Pediatric Nursing;32(3):195-201

American Academy of Pediatrics says yellow stools should be seen by day 4-5

89What is he peeing out? 3 wet diapers for this 3rd day

The very best measure for parents is to listen for consistent swallowing

Turning her fears into proactive steps

• Feed often

• Feed long

• No bottles, pacifiers, swaddling so he does feed often and long

• Hand express to store as insurance

DISCHARGE SUPPORT

Many moms quit in the first week without these questions addressed

Family that she trusts tells her she has no milk and they want to feed the baby

a bottle!

We all know that formula at discharge can encourage that fear and families will use it

World Health Organization UNICEF Baby Friendly Hospital Initiative

Her family is an important information source

• Encourage the 30-40 days of rest but with the baby cuddled up and nursing

• Explain how this is the secret to milk making success

• Try to get grandma in on the conversation

She needs someone she can call if worried

Where to call?

And cheer for her when her baby gains weight and is at birth weight at the 2 week visit!

99Gift from Family

Questions?

Development of the Newborn & Care of the mother in the First 72 Hours Kittie Frantz, RN, CPNP-PC...

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