Special Situations

Birth & Beyond California: Breastfeeding Training & QI ProjectWith funding from the federal Title V Block Grant

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Objectives

• List three benefits of skin-to-skin care for preterm infants

• Identify three benefits of human milk for preterm infants

• Describe three nursing strategies to prevent hypoglycemia while supporting breastfeeding

• List three breastfeeding-friendly jaundice treatments• List at least three contraindications to breastfeeding• Identify a reliable source of information regarding the

compatibility of medications with breastfeeding

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Special Babies and Mothers Need Special Nurse-Attachers!

• Protect the mother-baby

• Support the family with information

• Provide anticipatory guidance

• Nurture their dream

• Believe in miracles

Which Babies are at Risk of Breastfeeding Problems?

• Preterm babies

• Late preterm babies

• Babies with hypoglycemia

• Babies with hyperbilirubinemia (jaundice)

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Additional Risk Factors

• Size issues:– SGA/LGA– Low birth weight – Multiples

• Babies with infections 

• Womb position and birth trauma– Torticollis, facial asymmetry

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Additional Risk Factors

• Congenital problems and defects: – Heart conditions – Ankyloglossia (tongue tie) – Cleft lip & Cleft palate 

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Support & Intervention: Skin-to-Skin

Skin-to-skin maintains the natural habitat for the infant

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Benefits of the Skin-to-Skin for All At-Risk Babies

• Reduces stress hormones in infant

• Stabilizes respiration

• Reduces risk of hypothermia

• Reduces risk of hypoglycemia

• Helps baby function optimally

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Martinez, NeoReviews, 2007

Feeding Options

• Breastfeed – Whenever possible

• Breast milk– Using alternate feeding methods

• Banked donor human milk

• Artificial baby milk

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Four Steps to Breastfeeding Success in Difficult Situations

1. Feed the baby

2. Establish & maintain the milk supply

3. Be sensitive to mother’s needs

4. Promote exclusive breastfeeding

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Preparation for Discharge

• Parent education and support

• Hospital grade breast pump

• Referral to – WIC – Community lactation consultant– Support services

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Prematurity

• Skin-to-skin & human milk

feeding are preventive medicine for premature babies

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Anderson, Cochrane Database, 2003

Benefits of Skin-to-Skin for Preterm Babies

• Promotes physiologic stability

• Promotes milk production & breastfeeding

• Increases antibodies in mother’s milk

• Increases parent confidence

Anderson, J Perinatol, 1991

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Benefits of Human Milk for Preterm Babies

• Improved feeding tolerance• Better growth & development • Improved cognitive outcome – higher

IQ• Reduced risk of:

– NEC– Sepsis & any infection– Allergy

Schanler,Acta Paediatr Suppl. 2005 Lucas, Lancet, 1992

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Helping Mothers to Initiate & Protect Milk Supply

Pumping• Provide resources for a hospital-grade electric

breast pump with double kit to use at home

• Recommend a pumping schedule: 8 sessions per 24 hours– option: plan one 4-5 hour interval between

sessions during any 24 hour period to allow her time to rest

• Follow NICU Guidelines15

Late Preterm Infants

• Gestational Age 34-36 6/7 weeks • The imposter in the nursery • Often experience separation from mother• At increased risk for medical complications• Need time and help to successfully

breastfeed CPQCC, Care and

Management of the Late Preterm Infant Toolkit, 2007 Engle,

Pediatrics, 2007

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Helping Mothers with Transitioning Into Breastfeeding

• Skin-to-skin (kangaroo mother care)• Nose and mouth to nipple• Breastfeeding positions that emphasize

neck/head stabilization• Practice Breastfeeding

– “dry breastfeeding” milk transfer– part time breastfeeding / exclusive breastmilk

• Exclusive BreastfeedingNyqvist, Acta Pediatrica, 2008

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A Premie Needs His Mother

Video by Jane Morton, MD

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The process of teaching a preemie to breastfeed is not a straight line…

Based on the work of Berlith Person,

Helsingborg Hospital, Sweden

Hypoglycemia

Risk Factors : – Preterm, Post term, LBW – SGA, LGA – Infant of Diabetic Mother (IDM)– Stress – Use of Glucose – Multiples

Academy of Breastfeeding Medicine, Protocol #1 Revised 2006 www.bfmed.org

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Hypoglycemia: Definition and Testing

• At this Hospital hypoglycemia = glucose < ?

• “Routine monitoring of asymptomatic, not at-risk, term neonates is unnecessary.”

AAP, Pediatrics, 2005

Academy of Breastfeeding Medicine, Protocol #1, Rev. 2006

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Breastfeeding-Friendly Hypoglycemia Prevention

• Skin-to-skin: Immediately after birth and throughout the first day

• Breastfeed early: within the first hour

• Breastfeed often: at least every 3 hours

• Breastfeed long: without a time limit

• Breastfeed well: assess latch and quality of suck

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Breastfeeding – Friendly Hypoglycemia Treatment

• Keep skin-to-skin

• Breastfeed, then retest glucose level

• If unable to breastfeed well:– Hand express or pump colostrum– Feed colostrum to baby

• If unable to express more than a few drops:– Feed colostrum to baby– Supplement with formula

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Hyperbilirubinemia (Jaundice)

Types:• Pathologic

– Blood incompatibility- ABO, Rh– Illness

• Physiologic– Result of normal adaptive processes– Red Blood Cell (RBC) breakdown

• Breastfeeding Associated– Infrequent, ineffective feedings– “Lack of breastfeeding” jaundice

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Breastfeeding Frequency During the First 24 Hours After Birth and Incidence of

Hyperbilirubinemia on Day 6Study Conclusions• Early, frequent colostrum feeds accelerate meconium stooling

• Feeding frequency reduced the incidence of hyperbilrubinemia

9+ feedings 0% jaundice on day 6

• Exaggerated physiologic jaundice may be an early sign of breastfeeding difficulties Yamauchi, Pediatrics, 1990

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Breastfeeding - Friendly Jaundice Treatment

• Observe breastfeeding– Latch, quality of suck, energy level

• Observe milk supply and milk transfer– Breast fullness, audible swallowing

• Instruct mother to hand express and/or use breast pump– Supplement baby with expressed milk

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Triple Feeding Protocol

• Breastfeed at least every 3 hours– Switch sides often

• Supplement– With expressed milk if available– Use formula if necessary– Do not overfeed

• Express milk– Save milk at room temperature– Use at next feeding or refrigerate

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Which Mothers are at Risk of Breastfeeding Difficulties?

• Anatomy and physiology– Inverted/flat nipple– Too large/meaty

nipples– Breast surgery– Hormone problems – Health conditions

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• Social/educational factors– Lack of knowledge– Lack of support

Contraindications for Breastfeeding

• Galactosemia• HIV (in U.S.)• HTLV-I & II• Untreated Tuberculosis • Herpes simplex lesion on a breast• Street drugs • Small number of medications

- Radioactive diagnostic isotopes- Antimetabolites, chemotherapy

AAP, Pediatrics , 2005

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NOT a Contraindication

• Hepatitis A, B, C• Maternal fever• Low level environmental

contaminants• Maternal CMV carriers – term babies• Tobacco use• Occasional alcohol use

AAP, Pediatrics 2005

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Are These Drugs Safe to Take While Breastfeeding?

• Magnesium Sulfate

• Hydrocodone (Vicodin)

• Ortho-Novum (Birth control pills)

• Dicloxacillin or other antibiotic

• Alcohol

• Marijuana

• Nicotine

• Nitrofurantoin (Macrobid)Hale, Medications and Mothers’ Milk, 2008 31

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“It is well known that most medicationshave few side effects in breastfeeding

infants because the dose transferred viamilk is almost always too low to be

clinically relevant, or it is poorlybioavailable to the infant.”

Hale, Medications and Mother’s Milk, 2008

Medications in Mother’s Milk

• Reliable resources:– Briggs, Drugs in Pregnancy in Lactation, 2005– Hale, Medications in Mother's Milk, 2008– National Institute of Health: LactMed

• www.toxnet.nlm.nih.gov

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Every baby and mother deserves the best possible start even if they have

special circumstances

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