Breastfeeding in the RCNIC

Background Approximately 60% of newborns admitted to the RCNIC are receiving human milk. We as health care providers should educate mothers on the benefits of breastmilk and try to increase our breastfeeding rates. AWHONN* guidelines state that “nurses working with breastfeeding women should maintain current, evidence-based knowledge of breastfeeding practice”. The American Academy of Pediatrics supports exclusive breastfeeding for the first 6 months and breastfeeding through the first year of life. *AWHONN – Association of Women’s Health Obstetric and Neonatal Nurses

Purpose Statement Mothers who plan to breastfeed or provide milk for their hospitalized infant require information and support. This support should be available 24/7. Bedside RNs in the RCNIC should be able to perform a basic lactation assessment and provide lactation support to RCNIC families.

Goal All bedside RNs in the RCNIC will be able to perform a basic lactation assessment and provide lactation support to RCNIC families.

Overview This module will present: Current evidence-based knowledge of breastfeeding practice. Information regarding current policies and procedures. Information regarding the process for supporting breastfeeding families.

Objectives After completion of this module, the RCNIC RN will be able to: Identify the benefits of breastfeeding for infants Identify the responsibilities of each discipline regarding breastfeeding. Assess 5 Key components of a good latch to assist a mother who is nursing. List storage times for fresh milk and frozen milk.

Benefits of Breastmilk Benefits of Breast Milk for a Hospitalized Infant Breast milk can help develop a baby's immune system. Breast milk is easier to digest and will empty faster from the stomach. Breast milk can lead to optimal brain development. Breast milk can protect the baby from respiratory illnesses. Breast milk can protect the baby from intestinal illnesses.

Breastfeeding Process - PCF Notified of admission Ask if breast or bottle feeding when receiving report Notify bedside RN and PCA or Diet Tech of feeding status

Breastfeeding Process - RN Notified of admission Determine feeding choice – breastmilk or formula and document in ICIS. If breastfeeding or plans to pump – order supplies from ESI. Collaborate with PCA or Diet Tech to obtain labels. Assess Mom’s current knowledge Educate parents - Breastfeeding education is included in the nutrition section of the Parent Resource Book Obtain additional assistance – if needed

Breastfeeding Process – Diet Tech Notified of admission Collaborate with RN to provide written education Assemble supplies at bedside as requested Labels BF cooler and kit Assist mom with breastpump set-up

Breastfeeding Process - PCA Notified of admission Assemble supplies at bedside as requested Labels Pump kit Storage containers Assist mom with breastpump set-up

Feeding Choice is Breastmilk but Baby is Unable to go to Breast Obtain Needed Supplies Breast pump kit Storage Containers Labels Identify Breastpump locations Label a Breastmilk Bin and place in freezer. This can be delegated to a PCA or Diet Tech

Pumping Information Initially pump every 2-3 hours around the clock It is best to use a hospital grade electric breast pump like a Medela Classic, Lactina or Symphony and a double kit. Wipe off the pump and counter with a fresh Sani-wipe Pump both breasts at the same time. This helps with let down and ensures collection of all the milk that may leak from the breasts. Pump about 15 – 20 minutes each time or 2 minutes after milk stops flowing to stimulate milk production.

Breastpumping Information Pump directly into a clean breast milk storage bottle or the bottles that come with kit. Adjust pump to the most comfortable setting. Start on the lowest setting and increase the suction as tolerated. To help with let down, try using warm compresses, breast massage, and relaxation for a few minutes before pumping. Place the breast shields on the breasts and turn the pump on. If the breast shields are too small, the service center has larger ones to fit a larger diameter nipple. The bigger shields are called Personal Fit Comfort or large shields. Do not fill the bottle completely or it may break when it is frozen. Never add fresh milk to a bottle that has already been refrigerated or frozen.

Breastpumping Information After pumping, use a Sani-wipe to clean pump surfaces, counter and any spilled milk. Wash the parts of the kit which touch milk using dish soap and hot water. This includes the collection bottles, shields, yellow valve and white membrane. Then, air dry the kit on a clean paper towel in the baby’s room or by their bedside. If the tubing gets milk in it, rinse and allow the tubing to dry. If the plastic filter gets wet, allow it to dry. It is important to sterilize the kit every day. You can do this by boiling it for 15 minutes or by using the dishwasher.

Breast Pump Rental Determine need for pump rental. Involve social work and/or care manager in this process Need to pump > 3 – 5 days? Plans to go home where she has no pump? If unable to obtain pump, the mother may use the hand pump provided in the kit. There is a list of breast pump rental locations with breastfeeding education.

Breastmilk Storage and Labels Provide mom with breastmilk storage containers and labels. The baby’s medical record number should be recorded on each label Labels must have the date and time of milk collection as well as current medications, supplements or herbal remedies. Instruct mom to give labeled breastmilk to a nurse. Parents should never place breastmilk in the refrigerator or freezer. Nurses will check for completeness of information prior to putting breastmilk in the refrigerator or freezer. Breast milk placed in the freezer should be placed in a plastic storage bin with lid that is labeled with the baby’s name and MRN. Breastmilk placed in the refrigerator should be marked as fresh and placed in a plastic ziplok bag and then placed in a plastic bin in the refrigerator.

Breastmilk Storage and Labels Milk expressed at the hospital or at home should be placed in the refrigerator immediately. Freeze the milk if the baby is not being fed or will not use all the milk within 48 hours. Mothers who express milk at home should transport milk packed in a cooler using freezer gel packs or just packed tightly with several bottles of frozen milk, not ice. Milk freezes at a lower temperature than water and may thaw if packed with ice. It is best to thaw milk in the refrigerator. Once thawed; milk must be used within 24 hours for hospitalized infants.

Storage Times Frozen milk thawed is good for 24 hours Fresh milk is good for 48 hours. Try to use milk in the order in which it was pumped New labels have numbers to help you with this

Nurse Responsibilities when Feeding Breastmilk Breastmilk must be double-checked by two persons by comparing the name and MRN on the label with the information on the baby’s ID band. This should be documented by both persons by initialing the flow sheet. When taking breastmilk from the freezer, always use the oldest date first. The label from the breastmilk container should be removed and placed on a progress notes sheet in the chart.

How to Assess Breastfeeding Mom Ensure good hydration - provide mom with water and water bottle. Does mother feel full before and empty after nursing? What is her most comfortable position? Would support such as a pillow or boppy be helpful? Does she want privacy with nursing? Would screens be helpful? Document any problems

How to Assess Breastfeeding? Infant Signs Frequency of feedings/duration Stool Number and Appearance Newborns often stool every diaper change Meconium – Transitional-Yellow Seedy Wet Diapers Urine should be dilute Hunger Cues State Drowsy? Awake and Alert? Audible swallows with nursing? Visible Milk in mouth? Test Weight?

Process for Support and Education If baby is able to go to breast the bedside nurse should observe mom and baby during feeding and document the latch score. Latch score should be documented in narrative section of flowsheet. More information/education for documentation of latch score coming.

Latch Scale 1 2 L – latch Too sleepy or reluctant. No latch achieved 1 2 L – latch Too sleepy or reluctant. No latch achieved Repeated attempts Hold nipple in mouth Stimulate to suck Grasps breast Tongue down Lips flanged Rhythmic sucking A – audible swallow or palpable swallow None A few with stimulation Spontaneous and frequent T – type of nipple Inverted nipple, try nipple shield Flat/Very short nipple Retracts Everted (after stimulation) C – Comfort (Breast/Nipple) Engorged, cracked, bleeding, large blisters, or bruises. Severe discomfort Filling Reddened/small blisters or bruises Mild/moderate discomfort Soft Non-tender or slight discomfort H – Hold (positioning) Full assist Staff hold infant to breast Minimal assist Teach one side, mom does other Staff holds and mom takes over No assist from staff Mom able to position and hold infant.

Assessing Latch Score Determine a score for each of the 5 sections of the latch scale (latch, audible swallow, type of nipple, comfort pain scale, and hold). The sum of scores for the 5 sections is the latch score. Direct observation is the best method to obtain this information. If this is not possible, you can ask the mom to help you assess using the LATCH scale. Document the latch score, actual suck time and any issues that require follow-up or intervention in the narrative of chart. If the total latch score is 7 or < or other concerns of mother or nurse please refer to lactation resource.

Helpful Hints for Moms Helpful Hints for Breastfeeding Moms To prevent nipple tenderness, start with correct positioning: Cradle position Football hold Lying down position Breastfeed frequently: Initially every 2 - 3 hours 8-12 feedings per 24 hours Release suction before removing the baby. Never use soap, alcohol or breast creams. If nipples become sore: Limit nursing time on sore nipple Use non-plastic lined bras or bra pads Apply lanolin for dry or cracked nipples

Nursing positions - Cradle

Nursing positions – Football/Clutch

Nursing positions – Cross Cradle

Nutrition Instruct moms to eat a well balanced diet with all foods in moderation. If there is a history of serious food allergies in the family, check with the doctor or dietitian to see if mom should follow a special diet. It is a good routine to try to eat or drink something when pumping. It is important to drink plenty of fluids to keep up the milk supply. Water and ice are available. Moms may have water in a covered container in the unit. Alcohol and caffeinated drinks are not recommended as a regular practice. Try to eat foods containing calcium such as broccoli, greens, cheese, yogurt, puddings or salmon.

Referrals and Follow-up This presentation provides you with the basic information that you will need to assess and educate breastfeeding moms. If you identify issues that require follow-up beyond the scope of the information presented here, please contact one of the RCNIC Dieticians or the PCF. The PCFs have a list of RCNIC staff who have additional training and education for breastfeeding support.

Questions 1. The benefits of breastmilk for the infant would include which of the following: Breastmilk is easier to digest Breastmilk can lead to optimal brain development Breastmilk can protect the baby from respiratory and intestinal illnesses. All of the above. 2. Who is responsible for identification of the mother’s feeding choice? A. PCA B. HUC C. PCF or RN D. Diet tech 3. Fresh breastmilk may be used for 48 hours True or False

Questions 4. A Latch Score of _____ or less requires a lactation consult. 5. Breastmilk labels must contain the following information Name and MRN Medications the mom has taken All of the above Date and time expressed 6. When transporting breast milk, pack tightly with ice to reduce thawing. true or false 7. All bedside RNs in the RCNIC will be able to perform a basic lactation assessment and provide lactation support to RCNIC families.