Newborn Nutrition and Lactation Problem Solving at the Bedside

Topics and Goals

• Identify three aspects of breast anatomy recently redefined by ultrasound

• Discuss the benefits of breastfeeding to moms and infants and review basic frequency and duration guidelines for all new moms

• Describe two positioning tips for the new breastfeeding mom

• Discuss techniques to use with the “noncompliant” infant

• Identify which moms should be referred for early follow up after discharge.

Why are lactation consultants our friends

• Provide prenatal information and breastfeeding assessment

• Assist with appropriate breastfeeding technique

• Assist breastfeeding mothers or babies who are ill or have anatomical challenges.

• Give information on maintaining or building milk supply

SUPPLLY=DEMAND=SUPPLY

• Reinforce the need to establish adequate milk production by effective “emptying” of the breasts at each feeding

• Newborns need “complete” meals, foremilk, and the rich in long chain fatty acids, hind-milk

• Baby and mother are both learning how to feed and when to feed

• USE IT OR LOSE IT !!!!!!

Early Follow-up

• Early follow-up is vital to preserve the breastfeeding relationship

• In most cases, interventions can be minor, and problems easily fixed

• Use of feeding logs can help parents make safe decisions in providing optimal infant nutrition by breastfeeding

• Infant “constipation” is a big red flag

Nutritional Comparison: Breast Milk

• 90% water• Same weight gain or

greater during first 3-4 months

• Fat is variable• Primary carbohydrate

is lactose, trace amounts of other carbohydrates

Nutritional Comparison: Formula

• 90% water• Greater weight gain

after 3-4 months• Lactose is only

carbohydrate

Summary of the Latest Anatomincal Findings by the University of Western

Australia

• Ducts branch closer to the nipple• Lactiferous sinuses do not exist• Glandular tissue is found closer to the nipple• Subcutaneous fat is minimal at nipple base• Range of mild ducts exiting the nipple is 4-18

(Average 9)• Complex ductal network neither arranged

symmetrically nor in a radial pattern

Reasons to Breastfeed

• Biological norm for human infants

• Optimal nutrition for infants

• Health advantages that last far beyond infancy

• Health benefits for mothers

Advantages of Breastfeeding

• Species specific

• Cholesterol in breast milk plays a role in myelination and neurologic development

• More efficient metabolism of cholesterol

• Composition varies according to gestational age

• Iron is more readily absorbed

Infant Benefits

Reduced risk ofType I or type II diabetes mellitus

Lymphoma, leukemia, & Hodgkin’s disease

Obesity

Hypercholesterolemia

Asthma

Infant Benefits: Immunologic

• Protection from– Respiratory tract and gastrointestinal tract

infections– Necrotizing enterocolitis– Urinary tract infections– Otitis media– Bacterial meningitis

Infant Benefits: Immunologic (continued)

• Protection from– Bacteremia– Allergies

The Statistics are Staggering

• 1.5 million infants die each year because they are not breastfed.

• In areas where water is not safe, bottle feeding children are 25 times more likely than breastfed children to die from diarrhea

• Even in developed countries, breastfeeding saves babies’ lives and reduces life-long illness.

Why the Fuss?

• Providing hospital formula discharge bags reduces the numbers of women exclusively breastfeeding

Donnelly A. Snowden HM, Renfrew MJ, Woolridge, MW. Hospital bags for breastfeeding women. Cochrane Data Base System Review 20002

Oxygenation changes during infant feedings

• Hypoxemia during bottle-feeding has been documented since the 1970’s. This occurs in both the full-term and preterm infants. Research suggests that the alteration in blood oxygen is a result of decreased ventilation.

One Formula Feed

• The protective benefits of human milk are dose dependent

• After I exposure to formula, it takes 14-21 days for the gut to re-establish its protection against enteritis

AAP Policy Statement

• “Human milk is the preferred feeding for all infants, including premature and sick newborns with rare exceptions.”

AAP/2005

• Postneonatal infant mortality rates in the US are reduced by 21% in breastfed infants

• …benefits include the potential for decreased annual health care cost of $3.6 billion in the US

• Skin to skin contact and direct breastfeeding should be encouraged as early as feasible

• Banked human milk may be a suitable feeding alternative for infants whose mothers are unable or unwilling to provide their own milk

Colostrum Production

• Mothers produce 30-100 ml of colostrum in the first 24 hours, 2-10 ml per feeding on day 1 and 5-15 ml per feeding on day 2

• Newborn stomach does not stretch

• Time of transition to mature milk varies based on parity of mother:

31-96 hours in the primiparous mothers

24-80 hours in the multiparous mothers

Redefining Normal Breastfeeding Frequency and Expected Duration

• Average physiologic capacity of the stomach in the first 10 days of life is 7-81 mls or 2-24 ml/kg

• The range of gastric half-emptying time for breast milk is 16-86 minutes

• Average breast milk volume per feed on day one is just 7 mls

• By day of life 4 the average volume per feed is only 58 ml

Frequency and Duration

• Feed frequently and follow infant feeding cues closely:

• Sucking movements• Sucking sounds• Hand-to-mouth movements• Rapid eye movements• Soft cooing or sighing sounds • Restlessness

Frequency and Duration

• Watch the baby not the clock

• Use the log on the back side of handout to monitor feeds and output

• 4 by day 4• AAP/AAFP and WHO

recommendations

When to Wean

• “…if humans weaned their offspring according to the primate pattern, without regard to cultural beliefs and customs, most children would be weaned somewhere between 2.5 and 7.0 years of age.”

• “Extended breastfeeding…is healthy, physiologically normal and evolutionarily adaptive.”

-WHO

Human Cultural Norms

• “…for all our time as hunters and gatherers, more than 99.9% of our existence on earth, all human infants were breastfed.”

• “…this has been the method of feeding to which human infants have adapted, and on which human infants have survived, for millions of years.”

Sri Lankan widower breastfeeds his babies

Milk Men?

• http://images.google.com/imgres?imgurl=http://1.bp.blogspot.com/_Di1HzTLtBlM/RreOBPvv4VI/AAAAAAAABds/g3sJdIFl4i8/s400/breastfeeding%2Bman.jpg&imgrefurl=http://www.thethinkingblog.com/2007/08/fact-men-can-breastfeed.html&usg=__E4wr4Co6FzFjvtteg_pt6WWxqhQ=&h=308&w=400&sz=28&hl=en&start=9&um=1&itbs=1&tbnid=unPmmp8BJkrkoM:&tbnh=95&tbnw=124&prev=/images%3Fq%3Dpictures%2Bof%2Bbabies%2527%2Bbreastfeeding%26hl%3Den%26rlz%3D1T4ADFA_enUS346US346%26sa%3DX%26um%3D1

Top Three Reasons New Mothers Stop Breastfeeding

• 47% of mothers felt they were not producing enough milk

• 33% of mothers said they had trouble getting the baby to nurse

• 29% quit because of work-related issues

Factors Related to Early Termination

• Low income women• Perception of insufficient milk• Plan to work outside the home• No previous breastfeeding experience• Formula supplementation while in the hosptial• Younger women who are less educated• Initiation of breastfeeding after 16 hours of age• More positive bottle-feeding attitude and less

positive breastfeeding attitude.

Information Given to New Mothers

• Must explain the benefits of breastfeeding

• Must give the health risks and costs associated with artificial feeding

Information Given to Health Workers

Must be based on scientific and factual research

Skin-to-Skin Contact, Breastfeeding and Perinatal Neuroscience

• Dr. Nils Bergman, MD, DCH, MPH

• Capetown Sputh Africa

• www.kangaroomothercare.com

• Implementing Best Practice in US Hosptials

Fetal Brain Development

90% of what we know about human brain function we have learned in the past 15 years.

Cells that fire together, wire together

For a baby the environment is the mother

Critical period: “Early interpersonal events positively and negatively impact the structural organization of the brain

Milk product=10% of the benefits of the product

Infant Brain Development

• Early brain development is

INTERACTIVE

RAPID

DRAMATIC

• Quality sensory stimulation makes brain able to think and regulate

• Negative experiences (both the absence of good…and the presence of bad) have long lasting effects

• Could attention deficit disorder, obesity, depression be effected by early wiring?

Separation if Harmful

• The separated baby that has “settled” is in DESPAIR, dissociation

• The primary violation, the very worst thing to any newborn according to biologists is separation

• Separation violates the innate agenda of mother and newborn

Maternal-infant separation = ABUSE

How the Nurse can Promote Attachment

• Facilitate breastfeeding within the first hour after birth and provide for continuous skin-to-skin contact between the mother and infant until after the first feeding

Avoid routine procedures until after the first breastfeeding

Strategies

• Keep the mother and infant together during the entire postpartum stay

• Conduct examinations and routine tests of the infant while the infant is in the mother's room, in the mother’s arms, or on the breast. Babies at breast are less receptive to pain.

Comfortable Positions

Strategies

• Watch the baby not the clock• Teach mothers to recognize and respond to

early infant feeding cues and confirm that the baby is being fed at least 8 times in each 24 hours

• REMEMBER: crying is a late feeding cue and may interfer with effective breastfeeding

• Pattern the skill of reading the infant cues, save baby energy for feedings

Twin Challenges

Strategies

• Confirm that mothers know how to wake a sleepy infant

• Strategies to wake the infant include:

remove any blankets

change the infant’s diaper

PLACE THE INFANT SKIN-TO-SKIN

massage the infant’s back, abdomen, arms, legs

Latch

• Stimulate rooting reflex

• Take sufficient areola into mouth

• Flange lips around breast-”fish lips”

• Have wide angle at corner of mouth

Feeding Interventions: Birthing Room

• Assess for signs of readiness to feed

• Place newborn on mother’s chest

• Breastfeeding may begin in birthing room

• Assess infant physiologic status during feeding

Feeding Interventions

• Monitor progress• Education• Anticipatory guidance• Evaluate the need for

follow-up after discharge

Latch

• Stimulate rooting reflex

• Take sufficient areola into mouth

• Flange lips around breast-”fish lips”

• Have wide angle at corner of mouth

LATCH: A breastfeeding charting and documentation tool. LATCH was created to provide a systematic method for breastfeeding assessment and charting. It

can be used to assist the new mother in establishing breastfeeding and to define areas of needed intervention. SOURCE: Used with permission from

AWHONN. (1994).

Infant Feeding Education

• “On Demand” feeding pattern

• Infant feeding cues• Normal

feeding/sleeping patterns

• Satiety behaviors• Growth patterns

Breastfeeding Education

PositioningLatchingBreast milk pumping and storage Supplementation

Hand expression

Manual breast pump.

Problems

1. Mom does not keep baby’s body close to hers and begins to fatigue. Thinks she needs pillows to hold infant

2. Mom tickles baby’s cheek to get baby to turn toward the breast rather than facing baby directly at the breast

3. Mom holds baby in crook of her arm and tickles baby’s lower lip or chin with the nipple to entice him to open

4. Mom does not keep baby’s chin pressed into mom’s breast

Using a Fist to Teach Latch

• Ask mom to make a fist with the knuckle of her middle finger sticking out

• Ask mom to center the knuckle in her mouth and try to get as much of the fist in her mouth as possible

• Ask mom to place the knuckle in front of her nostrils and lift her chin and see how much of the fist fits in her mouth

Explaining feeding pattern

• Adult eating patterns• When to switch

breasts• Drinking vs eating• Babies using mom as

a pacifier

Human milk

• Colostrum Present in small volume before delivery and in first days after delivery. High in host defense proteins and immunoglobulins

• Transitional milk• Mature breastmilk

Benefits of Breastfeeding

• Species specific• Optimal nutrition• Minimizes exposure to foreign proteins• Customized• Promotes appropriate growth pattern• Provides multiple hormones and growth

factors• Promotes mother-infant attachment

Health Risks to Infant if Not Breastfeed

Increased incidence of:• Type 1 diabetes mellitus• Type 2 diabetes mellitus• Inflammatory bowel disease• Childhood cancer• Sudden infant death syndrome• Obesity• Compromised oral-motor development• Less optimal development of the arch of the mouth• Increase in orthodontic problems

Health Risks if Not Breastfed

• Increased incidence or seversity of• Gastroenteritis and diarrhea• Otitis media• Pneumonia and lower respiratory infection• Respiratory syncytial virus (RSV) infection• Neonatal sepsis• Necrotizing enterocolitis• Haemophilus influenzae type b (Hib) meningitis• Urinary tract infection

Cognitive Benefits

Human milk • contains fatty acids, nucleosides,

oligosaccharides, and taurine to enhance neural and retinal development

• Enables child to reach full developmental and intellectual potential

Human milk fat• Provides essential fatty acids• long-chain polyunsaturated fatty acids, including

docosahexaenoic acid (DHA) and arachidonic acid (ARA)

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience

• “Prematures and newborns have a nervous system which lacks the ability to dampen down sensory signals…Over stimulation of any of the senses will be experienced as PAIN by the newborn.”

• Maternal-infant separation is the single greatest barrier to breastfeeding. The solution: never separate mothers and newborns.

• “Kangaroo Mother Care is…pure science.”

Skin-to-Skin

• Breast feeding=brain wiring, it involves all senses at one time

• 2 hours of Kangaroo Care will increase brain growth

• Increased mental and psychomotor development in KC infants

• First feeds are for firing and wiring the brain-critical period is the first 60-90 minutes

Skin-to-Skin

• Hard crying opens the foramen ovale, causing left to right shunting which can lead to cyanosis, increased blood pressure and increases the risk of IVH

• Breastfeeding is the brain based behavior of the newborn not the mother

• Mother is the only appropriate ENVIRONMENT,mother’s milK is the only appropriate FOOD

Benefits of Breastfeeding for Women

• Promotes uterine involution and decreased risk of postpartum hemorrhage

• Lowers the risk of ovarian and breast cancer

• Facilitates earlier return to prepregnancy weight

• May decrease risk of osteoporosis in post-menopausal period

• Burns additional calories

Maternal Psychosocial Benefits

• Improved maternal-infant attachment

• Skin-to-skin contact

• Tactile communication

• Learn behavioral cues and needs

• Prolactin increases feelings of relaxation and euphoria

• Oxytocin heightens responsiveness and receptivity toward infant

Disadvantages to Breastfeeding

• Pain due to nipple tenderness

• Leaking milk when breasts are full

• Embarrassment about breastfeeding

• Feeling tied down to the demands of breastfeeding

• Unequal feeding responsibilities/fathers left out

• Perceptions about diet restrictions

Disadvantages to Breastfeeding (continued)

• Limited birth control options

• Vaginal dryness

• Concerns about the safety of medications and breastfeeding

The Guilt Issue “…doctors are afraid to make mothers feel guilty about choosing not

to breastfeed. Breastfeeding is viewed by many as a lifestyle choice rather than a public health issue. Instead of discussing the added benefits of breastfeeding, physician should be discussing the risks of not breastfeeding. Women should have freedom of choice between artificial feeding and breastfeeding, but this choice must be informed…Guilt is what a human being feels when he or she knowingly chooses a lesser option. Regret is felt when the choice and the consequences of those choices are not explained. Ethical, caring professionals owe patients accurate information, appropriate guidance and long-term breastfeeding support. Physicians can help to eliminate the regret but let the guilt fall where it may!”

Nancy E. Wright, MD

A Breastfeeding Friendly Facility

• Helps mothers access professional lactation help and mother-to-mother support

• Refers mothers with breastfeeding questions and concerns to an International Board Certified Lactation Consultant (IBCLC)

A Breastfeeding-Friendly Facility:

• Has trained staff who give accurate and consistent breastfeeding information

• Has evidence-based policies that support breastfeeding

• Provides positive messages about breastfeeding

Ten Steps to Successful Breastfeeding

1. A written breastfeeding policy

2. Train staff to implement this policy

3. Inform all pregnant women of the benefits of breastfeeding

4. Help mothers initiate breastfeeding within the first half hour

5. Help mothers maintain lactation if separated

Ten Steps to Successful Breastfeeding

6. Provide no food or drink other than breast milk unless medically indicated

7. Encourage rooming in

8. Encourage breastfeeding on demand

9. Promote no artificial teats or pacifiers

10. Promote follow-up breastfeeding services and support post-discharge

Promote Breastfeeding

• Give parents consistent, positive information about breastfeeding

• Remove barriers that keep women from breastfeeding

Summary

• Breastfeeding is preferred feeding for almost all infants

• Mothers should be informed of the benefits of breastfeeding

• Supplementation is rarely indicated and interfers wit successful lactation

• Breastfeeding should be actively supported and promoted in the medical community and society

• Women should feel comfortable continuing to breastfeed for as long as desired

REMEMBER

BABIES WERE BORN TO BE BREASTFED!

Formula Feeding Education

• Intake and output expectations

• Preparation and storage of formula

• Feeding technique

• Equipment

• Safety precautions

Growth Rates

• Both breastfed and formula-fed infants experience growth spurts requiring increased feedings

• Breastfeeding mother should nurse more frequently

• Formula feeding mother should slightly increase amount of feeding

Influence of Culture on Infant Feeding

• Perception of breasts as sexual organ

• Perceptions of colostrum

• Language