Supporting Breastfeeding

in theNeonatal Unit

Emma Sasaru

Breastmilk important for the preterm infant• Preterm babies are at risk of

infection.• Unlikely to have had skin to

skin at birth.• Decreases the incident and

severity of NEC.• Supports growth and

development.• Only breastmilk can be given

to very preterm babies.• Helps with bonding.

Hand expressingThe early days

• It is important that a mother is supported to hand express as soon after birth as possible to simulate milk production.

• Colostrum should be collected by syringe, dated and labelled.

• Explain how there maybe a delay in milk production, but to keep going.

• Help to have a good routine of expressing is important to building and maintaining supply later on.

• Hand express for a few days then add hand or electric pump.

The importance of Skin to Skin

• Stimulates hormones needed for breastmilk production.

• Helps regulate heart rate, temperature, breathing, and sugar levels.

• Pain relief, reduces cortisol and raises oxytocin.

• Babies enter a deeper sleep, thus aiding brain development and growth.

• Enhances, mother - baby bonding.• Encourages ‘feeding cues’ such as

rooting, sucking, searching for the breast.

Expressing with a Pump

• Correct use of pump equipment should be shown.• Discuss how often to pump and for how long.• Hand expressing after expressing can help fully empty breasts, build

supply.• Pumping near baby, or with baby’s photo or item of baby’s clothing

etc, helps milk production and flow.• Support for correct storage, labelling, and transporting of milk to

unit.• An expressing assessment can help staff and parents know how

expressing is going.• There should be no pressure for specific amounts expressed, rather

support and encouragement. However a general target is around 750ml by 14 days.

Things that can impact supply• Baby born very early. (before 30

weeks)• Traumatic birth, PPH, C-Section.• Lack of stimulation of breasts in first

few days after birth.• Incorrect use of pump/ wrong fitting

funnel.• Expressing less than 8 times in 24

hours.• Long Gaps between expressing.• Not expressing at least once in the

night.• Emotional distress.• Health issues in mother.

Low milk supply?• Complete expressing assessment/ check pump and use.• Encourage more skin to skin.• Pump for a few minutes longer after flow stops, or hand

express.• Power or cluster pump.• Is mother struggling emotionally? Needs more support?• Has mother started a new medication?• Encourage, commend and support.

Ways baby may be fed in Neonatal

• Syringe feeding. Often in the early days with colostrum.

• Nasal gastric tube. If baby is very small, very sick, struggling to latch at the breast or bottle feed.

• Cup feeding. To support baby to develop feeding skills.

• Bottles. Parental choice, baby unable to breastfeed.

• Breastfeed. Parental choice.• Often fortifier and protein

supplements are added to breastmilk as prem babies have high protein needs.

Cup feeding • When baby is ready feeds may be given

by a special cup.• Baby laps milk which helps support

development of suck, swallow and breathing.

• Avoids possible nipple confusion. • Can begin as early as 30 weeks.• Baby paces feed which helps with

oxygen saturation. • Helps with positive oral stimulation.• Feeds can be given by parents. • Studies show babies that are cup feed at

greater chance of leaving neonatal unit exclusively breastfeeding.

Non-nutritive suckingDummies may be used within the neonatal setting where clinically indicated,as part of a non-nutritive sucking programme, where baby is struggling to develop sucking skills. It is important that an individual approach is adopted to prevent routine use of dummies in neonatal. That babies are assessed as to sucking abilities. It is recommended that dummy use is discontinued when the baby begins to attempt to breastfeed. It is important a full discussion takes place with the parents thus enabling them to make an informed choice.

Emotional support • Emotional support empathy,

encouragement and commendation are very important in neonatal.

• Trauma may have accompanied a preterm birth.

• Parents maybe worried about the health of baby.

• Mother may not of planned to breastfeed/express.

• Expressing for a preterm baby is very demanding, physically and emotionally.

• Balancing act of expressing, traveling to unit, caring for other children, recovering from birth.

• Keeping parents regularly updated about their baby’s progress help alleviate anxiety.

• Parents must feel like partners in their baby’s care.

Supporting breastfeeding in

neonatalTransitioning baby to the breast

When is baby ready?• In order to breastfeed a baby needs to be able to co-ordinate not only the ability to suck and

swallow, but also the ability to co-ordinate sucking and swallowing with breathing. • A baby’s sucking ability may be present from around 28 weeks’ gestation, however sucks will

often be irregular and the baby can tire easily. • At first the baby may show a suck/swallow pattern but will only take breaths when pausing in

feeding. • As the baby becomes older and stronger sucks become more co-ordinated. It is this co-ordination

of suck, swallow, breathing that is essential for good milk transfer. • Most premature babies will start to co-ordinate well around 32–36 weeks gestation, so this is an

ideal time to try transitioning baby to the breast provided baby is tolerating NG tube feeds and is showing signs of swallowing and non-nutritive sucking.

• It is also important of course that baby is physically stable and stable respirations. • Continuous Positive Airway Pressure (CPAP) is not a problem for non-nutritive sucking or trying

baby to the breast• Skin to skin really benefits both mother and baby. Time doing skin to skin will enable baby to

develop instinctive reflexes such as rooting and mouthing. It gives a mother to gain confidence in handling her baby which will help greatly with breastfeeding.

• All babies will be ready at different times, need patience and time.

Position and attachment• It is important that a mother is supported to

position and attach her baby at the breast. • Positions such as biological nurturing are

beneficial as similar position to skin to skin. • It is important that a premature baby’s head

is supported due to weaker neck muscles. This should be done in a way that still enables movement of the head but provides stability.

• A cushion can be an aid but should not prevent movement of the baby’s head or bringing baby to breast.

• If a baby is struggling to latch it can be helpful to use nipple shields. Nipple shields are available for premature babies and the mother should be given support to use them correctly.

• It is important that a full feed is assessed to determine effective milk transfer.

Challenges• Often babies in NICU will be on a strict feeding plan of set hours and amounts of

milk. • Parents may worry about how much milk a baby is getting at the breast.• Premature babies can tire easily and may feed well at one feed but may

struggle the next time. This is normal and will take time and patience. • It can be easy for a mother to become discouraged and feel like her baby is not

transitioning well to breastfeeding.• A challenge for staff as feeding schedules will change and more time will need

to be spent with mother and baby offering help, support and reassurance, something that is difficult when there are so many babies requiring care.

• Careful assessment of feeds will be needed and staff may not feel adequately trained to do this.

• Trying to move to responsive feeding may also mean changes in care routines, expressing times and care plans.

Challenges• A premature baby may not exhibit feeding cues and so responsive breastfeeding

will take time to establish.• After being on a feeding plan the premature baby has never really been hungry.

Communicating for food so responsive feeding has not be necessary. • Trying to stir a baby to put to the breast can take some doing, especially if the

hours before have involved tests or cares that may have tired baby. • In order for responsive feeding to be successful a mother needs to be with her baby

as much as possible, offering as much time at the breast as possible. This may be hard especially if there are other children to care for or no support and practical help.

• One challenge can be issues with the mothers milk ejection, she may be use to hand expression or pumping, thus a delay in let down of milk when her baby is put to the breast.

• Another challenge for mothers is the logistics of the transition. She may wonder about how many times she should put baby to the breast, how many times she needs to express and if she should reduce expressions.

Going HomeSupporting Breastfeeding at discharge

Support at HomeSupport must be given to build confidence in a mothers ability to provide for her baby. Going home can be scary and so having information she can draw up on to help her feel more confident with feeding is important. Good support from qualified staff is important and should include:• Explaining signs to look for that her baby is latched

well to the breast.• Explaining signs of effective milk transfer and how

to know if her baby is accessing a full feed.• Nappies, urine and stools of appropriate amounts.• Number of feeds in 24 hours.• What to do if her baby becomes reluctant to feed.• How to combination feed.• How to use, make up formula and sterilise

equipment as well as store EBM safely and correctly at home.

• Signposting to local support groups with qualified support can help encourage and maintain her breastfeeding journey.

Remember• The journey of neonatal is hard emotionally and

physically.• Parents are often struggling and need lots of support

to cope.• Listening is invaluable and will help us build good

relationships with families.• Communication is key and helps reduce anxiety.• Above all parents should be at the centre of care for

their baby.• Support, do not demand.

Natalie and Millie

“my milk kept her strong enough to keep fighting”