Promoting Breastfeeding Success in the Intensive Care Neonate

1. Promoting Breastfeeding Success in the Intensive Care Neonate Katie Compton School of Nursing, Pacific Lutheran University, Tacoma, WA Introduction Case Study Nursing Diagnosis • Provide mothers with privacy, time for skin-to-skin and holding their baby. (Nyquvist et al, 1993) • Involve fathers or mother’s support person in teaching sessions. Although a father’s role in decision-making may be secondary to a mother’s when it comes to infant feeding, the practical and emotional support he can provide may be essential to breastfeeding success. (Datta et al, 2012) • Refer parents to a IBCLC if one is available in-house. (Nyquvist et al, 1993) • Allow parents to talk and vent feelings by asking them how they are feeling and connecting them with available support groups. (Nyquvist et al, 1993) • Ineffective breastfeeding related to maternal knowledge deficit, infant’s poor sucking reflex as evidenced by a LATCH score of 4/10, mother’s verbalization of frustration and infant’s need for supplementation of 75% of ordered feeds after breastfeeding attempts. • Interrupted breastfeeding related to inadvisability of putting infant to breast for all feeds due to weight loss of over 10% since birth and maternal frustration as evidenced by statement of “I don’t know if I am doing this right or if my baby is getting enough to eat.” • A.D is a 34 week old female neonate admitted to the NICU for respiratory distress post caesarian delivery. Apgar scores were 5 & 6. Her mother- L.D- is a 30 y.o. G2P1 who states she is interested in breastfeeding her infant but has not initiated pumping when she visits the NICU 8 hours post delivery. She appears exhausted and tells the nurse she was in too much pain to sleep or eat. Per neonatologist’s orders, A.D was given 5 ml formula via OG gavage on her second day of life. L.D wants to begin breastfeeding her infant and asks the NICU nurse for assistance. • Mothers of infants admitted to the Neonatal Intensive Care Unit (NICU) often breastfeed at significantly lower rates than mothers of infants not admitted to the NICU. (Castrucci et al, 2007) • Healthy People 2020 includes goals to “increase the proportion of infants who are breastfed” (ever, at 3 months, at 6 months, exclusively through 3 and 6 months) (MICH-21.1-5). (Healthy People 2020, 2012) • The American Academy of Pediatrics recommends exclusive breastfeeding for all infants in the first 6 months of life. Breast milk is the best possible nutrition for neonates. Ill neonates especially need the unique qualities of breast milk with its ideal amounts of proteins, fats and vitamins, more easily digested components, and growth and immune factors. (Weddig et al, 2011) • Breastfeeding has been associated with neurodevelopmental advantages, lower rates of obesity and lower incidence of atopic disorders. Evidence also supports long-term cardiovascular benefits attributable to breastfeeding, including lower blood cholesterol levels in young adulthood and lower blood pressure. In the preterm hospitalized infant, breastfeeding decreases rates of life-threatening necrotizing enterocolitis and infections, and shortens hospital stays. (Colaizy et al, 2008). • Fragile, vulnerable, medically compromised infants often cannot eat by mouth initially. Some may not transition from tube to oral feedings until a few months old. Developmental limitations can result in inefficient feeds and inaccurate feeding cues. There are many challenges related to maintaining the milk supply until efficient direct breast feedings can be accomplished. (Pineda, 2011) • NICU nurses play an essential role in breastfeeding support by assessing the neonate and mother, identifying barriers to effective feeds, providing breastfeeding education and emotional support, encouraging practices that result in improved milk supply, more effective neonatal breastfeeding sessions, parental confidence and involvement, and the overall provision of best possible nutrition for the neonate. (Nyquvist et al, 1993) Assessment Planning Assess neonate’s physiological status and readiness to take breast milk. Direct breastfeeding practice can usually begin when the infant is able to coordinate breathing, sucking and swallowing together without drops in heart rate or decreases in temperature to below 36.5 C. This is normally around 34 weeks. Kangaroo Care (KC) with or without “dry” practice feeds allows the nurse to assess physiological readiness for direct breast feeds. Neonates may also also display feeding cues such as waking around normal feeding times, crying, putting hands to mouth or rooting. (Kuzma et al, 2003) Assess mother’s knowledge and experience with breastfeeding as a basis for education. Include age, lifestyle, other children and desire to breastfeed. Parents’ attitudes towards breastfeeding and personal factors can greatly influence the success of breastfeeding. (CDC, 2012) Assess access to pump/pump room as well as initiation and frequency of pumping. (Hadsell, 2010) Assess parent’s proximity and willingness to participate in care and feeds in terms of number and time of day. Pumping should begin within 6 hours after delivery and should be performed every 2-3 hours for 8-12 sessions/day to obtain breast milk for the neonate and to stimulate sustained lactation. Parents should participate in care as much as possible as this will help empower them. (Gregson et al, 2011) Assess neonate’s ability to participate in kangaroo care (temperature and cardiopulmonary stability) as well as parent’s attitudes and willingness to perform kangaroo care. Kangaroo care has been shown to aid in milk production, temperature regulation and comfort for the neonate and to improve breastfeeding outcomes. (Wedding, 2011) Assess mother’s breast qualities, comfort & hold when initiating breastfeeding using the LATCH scale. Assess need for nipple shield. Mothers usually require a nipple shield to aid the neonate in latching and to allow to infant to preserve energy for sucking rather than maintaining latch. The cross-cradle, football and dancer holds are generally most effective in terms of comfort and control of the neonate’s head and the breast. Mother and baby’s comfort are important in terms of duration and quality of feeds. (Spatz, 2004) When beginning direct breast feedings, assess infant’s oral muscular tone, latch, audible swallowing, degree of satiety after feeds and neonate’s tolerance to feeds. Assess infant’s weight trends and need for MBM supplementation with HMF or BP (Spatz, 2004) • Mother will be able to verbalize basic breastfeeding knowledge, will report no pain with breastfeeding, and will express reduced stress and frustration. • Infant will receive only fortified MBM with supplemental feeds, will take at least 1 feed/ day at breast, will display satiety and no signs of feeding intolerance with feeds, will show trend of weight gain and will breastfeed exclusively by discharge. Evaluation • A quasi-experimental study involving 2132 infants admitted to the NICU found that rates of breastfeeding prior to hospital discharge were 27.3% higher among women delivering at hospitals with an IBCLC. (Castrucci, 2007) • A cohort study of 214 NICU neonates found that kangaroo care is a simple but effective intervention in improving breastfeeding rates on discharge. (Gregson et al, 2011) • A retrospective cohort study of 66 very low birth weight neonates in the NICU found that direct breastfeeding (as opposed to breast milk feedings via tube gavage or bottle) resulted in better success and duration of breastfeeding. (Pineda, 2011) Implementation • Encourage direct, on-demand breast feeding as soon as medically possible. Educate mothers to increase their breastfeeding knowledge and skills and to influence their attitudes toward breastfeeding. Pick one or two benefits of breastfeeding specific to their neonate’s condition to teach them. (CDC, 2012) • Teach parents to practice kangaroo care with stable neonates. Plan for sessions, provide privacy, position the infant (dressed only in a diaper) upright on mom or dad’s bare chest and cover with a blanket. Monitor neonate’s temperature after 15 minutes and one hour. Monitor vital signs and check on parents periodically. Kangaroo care has been shown to improve rates of breastfeeding success in preterm neonates. (Gregson et al, 2011) • Provide teaching relating to maintaining the milk supply. Inform parents that initiation and adequate frequency (every 2-3 hours) of pumping is essential for stimulating lactation and allows mothers to give their babies the best nutrition possible. Show mothers how to use pump and give tour of pump room. Teach mothers that hand-expression, warm compresses, thinking about their baby, looking at their picture and smelling the neonate’s clothing can aid with lactation. Keep mother’s updated on stored milk supply so that more can be brought in with visits. (Hadsell, 2010) • Encourage mother to maintain proper nutrition, pain control, rest and stress-reduction. Ask mother how she is doing, allow her to express feelings, provide water during visits, and give hand out on foods that aid lactation. Nutrients and fluids are required to form breast milk and pain and stress interfere with lactation. (Nyquvist et al, 1993) Case Study Outcome • The NICU nurse allows L.D to view and touch her infant in the isolette and then encourages her to go back to her room for pain medication, rest and a meal. The nurse also encourages her to pump as soon as she can and to continue doing so every 2-3 hours. L.D returns to the NICU that evening rested with 4 ml colostrum. After ensuring A.D’s vital signs are stable, the nurse explains kangaroo care and with LD’s approval, positions A.D for skin-to-skin time and gives the feed vis gavage while A.D sucks at the breast. L.D’s milk supply improves with continued pumping and skin-to-skin time. A.D’s respiratory status is resolved and she continues to gain weight and is discharged in satisfactory condition 2 weeks later. Barriers Premature and ill neonates may have conditions that may delay or complicate direct breastfeeding including significant episodes of apnea and bradycardia; severe feeding intolerance evidenced by blood in stool, frequent emesis, gastric residuals >50% of feed; and being NPO for necrotizing enterocolitis (NEC) or surgery. Only in very rare cases should a neonate receive formula over MBM (mother’s breast milk) or donor milk, such as when a mother is currently using certain prescription or illegal drugs or has certain diseases such as HIV. (Kuzma, et al, 2003) Mothers may have difficultly with milk production due to fear, anxiety, lack of knowledge, stress, lack of sleep, pain, inadequate hydration and nutrition, lack of privacy and lack of time (having to care for other children or work). Certain medications, conditions (hypertension) and foods may also hinder lactation. (Nyquvist et al, 1993) Acknowledgements • Special thanks to my clinical advisor Dana Zaichkin MSN, RN; my preceptor Sarah Newport RN, IBCLC; and the Tacoma General NICU staff for their support and guidance.