INTEGRATING NCP TO SUPPORT

LACTATION

Amanda M Reyes, BS IBCLC

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Public Service Announcement

• WHO recommends that mothers with suspected or confirmed COVID-19 should be encouraged to initiate or continue to breastfeed. Mothers should be counselled that the benefits of breastfeeding substantially outweigh the potential risks for transmission.

• Mother and infant should be enabled to remain together while rooming-in throughout the day and night and to practice skin-to-skin contact, including kangaroo mother care, especially immediately after birth and during establishment of breastfeeding, whether they or their infants have suspected or confirmed COVID-19.

Heat Inactivation of the Virus

• Studies have documented complete heat inactivation of genetically similar viruses such as SARS and MERS, specifically heat treatment of 60°C for 30 minutes.

• All donor milk dispensed by HMBANA banks undergoes heat treatment using the Holder pasteurization method of 62.5°C for 30 minutes.

Screening Milk Donors

• Donors are rigorously screened by HMBANA member banks verbally, through a written questionnaire and blood testing.

• Screenings include detailed inquiries regarding international travel as well as recent illness history including family members in the home.

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Pasteurized Donor Human Milk

I have no actual or potential conflict of interest in relations to the program/presentation.

Gratitude to L. Hope Wills, MA, RD, CSP, IBCLC for help and contribution to the development of the presentation’s

concepts.

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Disclosure

At the conclusion of the presentation the listener will…

• Integrate the Nutrition Care Process model in assessing and protecting the hospitalized breastfeeding dyad.

• Be able to identify common tools and assessments to evaluate the breastfeeding dyad.

• Practice application of Nutrition Care Process model in a breastfeeding case study.

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Objectives

POSITION PAPER

The Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding

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“that exclusive breastfeeding provides optimal nutrition

and health protection for the first 6 months of life and

that breastfeeding with complementary foods from 6

months until at least 12 months of age is the ideal feeding

pattern for infants.”

(Academy of Nutrition and Dietetics, 2015)

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It is the position of the Academy of

Nutrition and Dietetics…

“Registered dietitian nutritionists and nutrition and

dietetics technicians, registered, should continue efforts

to shift the norm of infant feeding away from use of

human milk substitutes and toward human milk feeds.”

(Academy of Nutrition and Dietetics, 2015)

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What does that mean for my

practice?

• EBM: Expressed Breastmilk

• NCP: Nutrition Care Process

• NCPM: Nutrition Care Process

Model

• NCPT: Nutrition Care Process

Terminology

• OMM: Own Mother’s Milk

• PDHM: Pasteurized Donor

Human Milk

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Abbreviations and Definitions

Breastfeeding approach

• Exclusive breastfeeding —defined as nourishment, all nutrients and fluid, provided via breastfeeding for the first 6 months of life; permits oral vitamin and mineral supplements and medicines

• Predominant breastfeeding —defined as nourishment primarily from breastmilk, including expressed mother’s or donor breastmilk; permits infant formula and other liquids, oral vitamin and mineral supplements and medicines

• Partial breastfeeding —defined as nourishment partially from breastmilk, including expressed mother’s or donor breastmilk, with nourishment from infant formula and other sources

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Abbreviations and Definitions

(cont.)

• Adopted in 2003 for use in the United States

• A systematic method that dietetics and nutrition

professionals use to provide nutrition care

• Provides a framework for professionals to customize care,

taking into account the client's needs and values

• Distinguishes clinical dietetics’ unique body of knowledge.(Swan, Vivanti, Hael-Smithm, N.A., Hotson, Orrevall, Trostler, Howarter, Popoutsakis,2017)

(Hakel-Smith and Lewis, 2004)10

Nutrition Care Process

• Roadmap consists of 4 separate and interconnected

steps:

Step 1: Nutrition Assessment and Reassessment

Step 2: Nutrition Diagnosis

Step 3: Nutrition Intervention

Step 4: Nutrition Monitoring and Evaluation

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NCP

12(Swan, Vivanti, Hael-Smithm, N.A., Hotson, Orrevall, Trostler, Howarter,

Popoutsakis,2017)

• Dynamic and multidirectional to support critical

thinking and timely care

• Incorporates scientific evidence moving professionals

from experience-based to evidence-based practice

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NCPM

(Swan, Vivanti, Hael-Smithm, N.A., Hotson, Orrevall, Trostler, Howarter,

Popoutsakis,2017)

• Admitted overnight through the ED on 8/07/2020

• Anticipated Discharge:8/10/2020

• Lactating parent at the bedside

Age: 12 days old

Sex: Female

Birth Weight: 2.61 kg (5.75lb)

Birth Length:46.99cm (18.5in)

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Luna

“Nutrition Assessment is a systematic approach to collect, classify, and synthesize

important and relevant data from clients (where “client” refers to individual and

population). This step also includes Reassessment, which additionally includes collection of new data, and comparing and

re-evaluating data from the previous interaction to the next. Nutrition

Assessment is an ongoing, dynamic process that involves initial data collection as well as continual reassessment and analysis of

the client’s status compared with accepted standards, recommendations, and/or goals”

(Swan, Vivanti, Hael-Smithm, N.A., Hotson, Orrevall, Trostler, Howarter, Popoutsakis,2017)

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Step 1: Nutrition Assessment and

Reassessment

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Case Study: Luna

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Anthropometric Data

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Anthropometric Data

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Labs

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What are some questions you ask?

What affirmations would you say?

What visual inspections do you make of the dyad?

What education would you provide?

What tools would you utilize?

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Meeting the Lactating Parent

“I am giving formula because I am not making anything.”

“I tried to pumping, but nothing is coming out.”

“I tried to breastfeed her but she cannot latch so I am using formula.”

“Nah, I am not that patient to wait that long for her to get breastfeeding that is why I wanted to pump.”

“No, I do not have a pump at home.”

“I have insurance and I am part of that Welcome Baby.”

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What the parent says:

• How will you acquire, analyzes, and interpret the important and relevant data contributing to the potential nutrition-related problem or problems?– Determining important and relevant data to collect

– Determining the need for additional information

– Selecting assessment tools and procedures that match the situation

– Applying assessment tools in valid and reliable ways

– Validating the data

• What will you communicate to the multidisciplinary team?– Would you involve other disciplines in the care?

• Can the problem be modified by further nutrition care?

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Determination of Continuation of

care

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Tools

“Nutrition Diagnosis is a

nutrition and dietetics

professional’s identification and

labeling of an existing nutrition

problem that the nutrition and

dietetics professional is

responsible for treating”(Swan, Vivanti, Hael-Smithm, N.A., Hotson, Orrevall, Trostler, Howarter,

Popoutsakis,2017)

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Step 2: Nutrition Diagnosis

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Breastfeeding Difficulty (NC-1.3)

Definition

Inability to sustain infant nutrition through breastfeeding.

Etiology (Cause/Contributing Risk Factors)

Factors gathered during the nutrition assessment process that contribute to the existence or the maintenance of

pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:

Infant:

• Difficulty latching on

• Poor sucking ability

• Oral pain

• Malnutrition/ malabsorption

• Lethargy, sleepiness

• Irritability

• Introduction of feeding via bottle or other

route that may affect breastfeeding

• Swallowing difficulty

Mother:

• Painful breasts, nipples

• Breast or nipple abnormality

• Mastitis

• Perception of or actual inadequate breastmilk*

supply

• Lack of social or environmental support

• Cultural practices that affect the ability to

breastfeed

• Introduction of feeding via bottle or other

route that may affect breastfeeding

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Examples of the measurement methods or data sources for these outcome indicators: Client report,

practitioner observation of breastfeeding, self-monitoring records, infant weight trends

Typically used with the following domains of nutrition interventions: Nutrition education, nutrition

counseling, coordination of nutrition care by nutrition professional, population based nutrition action

Typically used to determine and monitor and evaluate change in the following nutrition

diagnoses: Breastfeeding difficulty, predicted breastfeeding difficulty, food and nutrition related knowledge

deficit, unsupported beliefs/attitudes about food or nutrition related topics, unintended weight loss, inadequate

fluid intake

Judgment must be used to select indicators and determine the appropriate measurement techniques and

reference standards for a given client population and setting. Once identified, these indicators, measurement techniques, and reference standards should be identified in policies and procedures or other documents for use

in client records, quality or performance improvement, or in formal research projects.

Client Example

Example(s) of one (or more) of the Nutrition Care Indicators (includes sample initial and reassessment

documentation for one of the indicators)

Indicator(s) Selected

Exclusive breastfeeding (yes/no)

Criteria for Evaluation

Comparison to Reference Standard, Recommendation, or Goal:

1. Reference Standard: Not applicable.

2. Recommendation: Not applicable.

3. Goal: Client fears breastfeeding will be difficult upon return to work. Client goal is exclusive

breastfeeding until returning to work when client will add supplemental infant formula to

breastfeeding.

Sample Nutrition Assessment and Monitoring and Evaluation Documentation

Initial encounter

Postpartum client states goal of exclusive breastfeeding and then a combination

of formula and breastfeeding upon return to work. Will provide nutrition

education, promotion of exclusive breastfeeding and discussing with employer

accommodation for pumping breastmilk at work, and refer to lactation support

group.

Reassessment after nutrition

intervention

Client reports exclusive breastfeeding for three months. Promotion of exclusive

breastfeeding and nutrition education. Continue to monitor.

*If a synonym for the term “breastmilk” is helpful or needed, an approved alternate is “human milk.”

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Predicted Breastfeeding Difficulty (NC-1.5)

Definition

Future hindrance to breastfeeding, or lactation, is anticipated, based on observation, experience, or scientific

reason.

Etiology (Cause/Contributing Risk Factors)

Factors gathered during the nutrition assessment process that contribute to the existence or the maintenance of

pathophysiological, psychosocial, situational, developmental, cultural, and/or environmental problems:

• Scheduled or planned procedure, therapy or medication (mother[s] or infant[s])

• Condition (mother[s] or infant[s]) that may hinder breastfeeding

• Cultural or religious norms or practices that may hinder breastfeeding

• Presence or absence of organizational, community, and/or societal procedure or policy that may hinder

breastfeeding

• Anticipated increased psychological/life stress

• Food and nutrition knowledge deficit

• Unsupported beliefs/attitudes about food, nutrition, and nutrition-related information

• Lack of social support for breastfeeding

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Signs/Symptoms (Defining Characteristics)

A typical cluster of subjective and objective signs and symptoms gathered during the nutrition assessment

process that provide evidence that a problem exists; quantify the problem and describe its severity.

severity.

Nutrition Assessment

Category

Potential Indicators of This Nutrition Diagnosis (one or more must be

present)

Biochemical Data, Medical

Tests and Procedures

• Population-based biochemical data that may hinder breastfeeding

Anthropometric Measurements

• Population-based anthropometric data that may hinder breastfeeding

Nutrition Focused Physical

Findings

• Population-based data anticipated physical exam finding that may

hinder breastfeeding

Food/Nutrition-Related

History

Reports or observations of:

• History of impediment to breastfeeding or breastfeeding difficulty

• Medications that may hinder breastfeeding

• Inaccurate or incomplete food and nutrition knowledge

• Unsupported food and nutrition beliefs and attitudes

Client History

• Anticipated procedure or therapy for which research shows a hindrance

to breastfeeding

• History or presence of a condition for which research shows a

hindrance to breastfeeding

• Presence or absence of a policy that may hinder breastfeeding

• Cultural or religious norms or practices

• Absent or limited family and/or social breastfeeding support

• Anticipated life stress or change

• Social or personal considerations of the mother

• Breastfeeding Difficulty (NC-1.3)

Breastfeeding difficulty related to infant’s difficulty latching on as evidenced by parent’s self report and decision to formula feed because “[they] do not have any patience”.

• Predicted Breastfeeding Difficulty (NC-1.5)

Predicted Breastfeeding difficulty related to COVID-19 diagnosis that may hinder breastfeeding as lactating parent and infant may have periods of separation.

Predicted Breastfeed difficulty related to suboptimal breastmilk removal that may hinder the establishment of a milk supply to meet the nutritional needs of infant.

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Which stem? Signs? Symptoms?

“A Nutrition Intervention is a

purposefully planned action(s)

designed with the intent of changing

a nutrition-related behavior, risk

factor, environmental condition, or

aspect of health status. Nutrition

Intervention consists of two

interrelated components: planning

and intervention. The Nutrition

Intervention is typically directed

toward resolving the nutrition

diagnosis or the nutrition etiology

Less often, it is directed at relieving

signs and symptoms”(Swan, Vivanti, Hael-Smithm, N.A., Hotson, Orrevall, Trostler, Howarter, Popoutsakis,2017) 34

Step 3: Nutrition Intervention

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Tools

“During the first interaction,

appropriate outcomes/indicators are

selected to be monitored and

evaluated at the next interaction.

During subsequent interactions, these

outcomes/indicators are used to

demonstrate the amount of progress

made and whether goals or expected

outcomes are being met. Nutrition

monitoring and evaluation identifies

outcomes/indicators relevant to the

nutrition diagnosis and intervention

plans and goals”(Swan, Vivanti, Hael-Smithm, N.A., Hotson, Orrevall, Trostler, Howarter, Popoutsakis,2017)

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Step 4: Nutrition Monitoring and Evaluation

• Lactation met with the dyad

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Follow up

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Open reflection and a few questions…

Academy of Nutrition and Dietetics. (2015). Position of the Academy of Nutrition and Dietetics: Promoting and Supporting Breastfeeding [Position Paper]. https://www.eatrightpro.org/-/media/eatrightpro-files/practice/position-and-practice-papers/position-papers/promotingbreastfeeding.pdf

Academy of Nutrition and Dietetics. (2015).Promoting and Supporting Breastfeeding [Practice Paper]. https://www.eatrightpro.org/-/media/eatrightpro-files/practice/position-and-practice-papers/practice-papers/practicepaperpromotingandsupportingbreastfeeding.pdf?la=en&hash=39B07DA0E25D1703828C1AAF3ADEC410A8E8141F

Hakel-Smith, N., Lewis, N.M..(2004). A Standardized Nutrition Care Process and Language Are Essential Components of Conceptual Model to Guide and Document Nutrition Care and Patient Outcomes. Journal of the Academy of Nutrition and Dietetics, 104(12), 1878-1884. doi: 10.1016/j.jada.2004.10.015.

Human Milk Banking Association of North America. (06 April 2020). Milk Banking and COVID-19. https://www.hmbana.org/file_download/inline/1a0ef462-6185-4f2c-9115-433a676b8548

Salvatore, C.M., Young Han, J., Acker, K.P., Tiwari, P., Jin, J., Brandler, M., Cangemi, C., Gordon, L., Parow, A., DiPace, J., DeLaMora, P. . (23 July 2020). Neonatal management and outcomes during the COVID-19 pandemic: an observation cohort study. The Lancet: Child & Adolescent Health. DOI:https://doi.org/10.1016/S2352-4642(20)30235-2

Swan, W.I., Pertel, D.G., Hotson, B., Lloyd, L., Orrevall, Y., Trostler, N., Vivanti, A., Howarter, KB., Popoutsakis, C.. 2019. Nutrition Care Process (NCP) Update Part 2: Developing and Using the NCP Terminology to demonstrate Efficacy of Nutrition Care and Related Outcome. Journal of the Academy of Nutrition and Dietetics, 117(12), 840-855. https://doi.org/10.1016/j.jand.2018.10.025.

Swan, W.I., Vivanti, A.,Hael-Smithm, N.A., Hotson, B., Orrevall, Y., Trostler, N., Howarter, KB., Popoutsakis, C.. 2017. Nutrition Care Process and Model Update: Toward Realizing People-Centered Care and Outcomes Management. Journal of the Academy of Nutrition and Dietetics, 117(12), 2003-2014. http://dx.doi.org/10.1016/j.jand.2017.07.015.

World Health Organization. (23 June 2020). Breastfeeding and COVID-19 [Brief]. https://www.who.int/news-room/commentaries/detail/breastfeeding-and-covid-19

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References

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Breastfeeding Assessment (FH-7.1)

Definition

Evaluation of breastfeeding ability and capacity to support the nutritional and other needs of the infant and

mother

Nutrition Assessment and Monitoring and Evaluation

Indicators

Initiation of breastfeeding

• Start breastfeeding (date)—defined as the day breastfeeding was initiated

• Stop breastfeeding (date)—defined as the day breastfeeding ceased

Breastfeeding approach

• Exclusive breastfeeding (yes/no)—defined as nourishment, all nutrients and fluid, provided via

breastfeeding for the first 6 months of life; permits oral vitamin and mineral supplements and

medicines

• Predominant breastfeeding (yes/no)—defined as nourishment primarily from breastmilk,

including expressed mother’s or donor breastmilk; permits infant formula and other liquids,

oral vitamin and mineral supplements and medicines

• Partial breastfeeding (yes/no)—defined as nourishment partially from breastmilk, including

expressed mother’s or donor breastmilk, with nourishment from infant formula and other

sources

Breastfeeding Difficulties

• Infant able to latch on to breast for feeding (yes/no)

• Infant unable to latch on to breast for feeding (yes/no)

• Difficulty latching on to breast for feeding (yes/no)

• Abscess of breast associated with lactation (yes/no)

• Cracked nipple associated with lactation (yes/no)

• Infection of nipple associated with lactation (yes/no)

• Non purulent mastitis associated with lactation (yes/no)

• Retracted nipple associated with lactation (yes/no)

• Inversion of nipple associated with lactation (yes/no)

• Breast engorgement associated with lactation (yes/no)

• Previous breast surgery associated with lactation (yes/no)

• Breast abnormality associated with lactation (yes/no)

• Inadequate flow of breastmilk (yes/no)

Finding related to infant’s ability to suck

• Infant able to suck (yes/no)

• Infant unable to suck (yes/no)

• Difficulty sucking (yes/no)

Note: Infant/child growth can be found on the Body Composition/Growth/Weight History reference

sheet.

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Nutrition Assessment

Category

Potential Indicators of This Nutrition Diagnosis (one or more must be

present)

Biochemical Data, Medical Tests and Procedures

• Laboratory evidence of dehydration (infant)

• Fewer than reference standard, eg, six wet diapers in 24 hours (infant)

Anthropometric Measurements

• Any weight loss or limited weight gain (infant)

Nutrition Focused Physical

Findings

• Frenulum abnormality (infant)

• Vomiting or diarrhea (infant)

• Hunger, lack of satiety after feeding (infant)

Food/Nutrition-Related

History

Reports or observations of (infant):

• Coughing

• Crying, latching on and off, pounding on breasts

• Decreased feeding frequency/duration, early cessation of feeding,

and/or feeding resistance

• Lethargy

Reports or observations of (mother):

• Small amount of breastmilk* when pumping

• Limited confidence in ability to breastfeed

• Doesn’t hear infant swallowing

• Limited support of mother’s choice to breastfeed

• Limited knowledge of breastfeeding

• Limited knowledge of infant hunger/satiety signals

• Limited support for engaging employer in discussions about

breastfeeding facilities

• Limited facilities or accommodations at place of empoyment or in

community for breastfeeding

• Feeding via bottle or other route

Client History

• Conditions associated with a diagnosis or treatment (infant), eg, cleft

lip/palate, thrush, premature birth, malabsorption, infection

• Conditions associated with a diagnosis or treatment (mother), eg,

mastitis, candidiasis, engorgement, history of breast surgery

• Social or personal considerations of the mother

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Tools