Special Situations

1. Special Situations Birth & Beyond California: Breastfeeding Training & QI Project With funding from the federal Title V Block Grant

2. 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 2

3. 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 3

4. Which Babies are at Risk of Breastfeeding Problems? Preterm babies Late preterm babies Babies with hypoglycemia Babies with hyperbilirubinemia (jaundice) 4

5. Additional Risk Factors • Size issues: • SGA/LGA • Low birth weight • Multiples • Babies with infections  • Womb position and birth trauma • Torticollis, facial asymmetry 5

6. Additional Risk Factors • Congenital problems and defects:  • Heart conditions • Ankyloglossia (tongue tie) • Cleft lip & Cleft palate  6

7. Support & Intervention: Skin-to-Skin Skin-to-skin maintains the natural habitat for the infant 7

8. Benefits of the Skin-to-Skin for All At-Risk Babies Martinez, NeoReviews, 2007 • Reduces stress hormones in infant • Stabilizes respiration • Reduces risk of hypothermia • Reduces risk of hypoglycemia • Helps baby function optimally 8

9. Feeding Options • Breastfeed • Whenever possible • Breast milk • Using alternate feeding methods • Banked donor human milk • Artificial baby milk 9

10. Four Steps to Breastfeeding Success in Difficult Situations • Feed the baby • Establish & maintain the milk supply • Be sensitive to mother’s needs • Promote exclusive breastfeeding 10

11. Preparation for Discharge • Parent education and support • Hospital grade breast pump • Referral to • WIC • Community lactation consultant • Support services 11

12. Prematurity Anderson, Cochrane Database, 2003 • Skin-to-skin & human milk feeding are preventive medicine for premature babies 12

13. 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 13

14. 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 14

15. 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 Guidelines 15

16. 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 16

17. 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 Breastfeeding Nyqvist, Acta Pediatrica, 2008 17

18. A Premie Needs His Mother Video by Jane Morton, MD 18

19. The process of teaching a preemie to breastfeed is not a straight line… Based on the work of Berlith Person, Helsingborg Hospital, Sweden

20. 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 20

21. 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 21

22. 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 22

23. 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 23

24. 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 24

25. Breastfeeding Frequency During the First 24 Hours After Birth and Incidence of Hyperbilirubinemia on Day 6 Study 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 25

26. 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 26

27. 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 27

28. Which Mothers are at Risk of Breastfeeding Difficulties? Social/educational factors Lack of knowledge Lack of support • Anatomy and physiology • Inverted/flat nipple • Too large/meaty nipples • Breast surgery • Hormone problems • Health conditions 28

29. 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 29

30. 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 30

31. 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

32. “It is well known that most medications have few side effects in breastfeeding infants because the dose transferred via milk is almost always too low to be clinically relevant, or it is poorly bioavailable to the infant.” Hale, Medications and Mother’s Milk, 2008 32

33. 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 33

34. Every baby and mother deserves the best possible start even if they have special circumstances We can help 34