Alternative methods of feeding for small or sick neonates

Alternative feeding methods Objectives: To describe the options available for alternative methods of feeding Teach a mother how to use an alternative feeding method To explain how to express breast milk

Alternative feeding methods Indications: Baby Not breastfeeding effectively Not sucking effectively (e.g. preterm, ill, cleft lip/palate) Mother Is ill Has flat/inverted nipple or engorged breast Is HIV positive and decides not to breastfeed

Assessment Action No Yes No Yes Yes No Yes No Manage as per guidelines for sick neonates* Is the baby clinically stable? No Yes Is birth weight more than 1250 g? No Start intravenous fluids Yes Is the baby able to breastfeed effectively? When offered the breast, the baby roots, attaches well and suckles effectively Able to suckle long enough to satisfy needs Yes Initiate breast feeding No Is the baby able to accept feeds by alternative methods? Give oral feeds by cup/spoon/ paladai Yes When offered cup or spoon feeds, the baby opens the mouth, takes milk and swallows without coughing/ spluttering Able to take an adequate quantity to satisfy needs Start intra-gastric tube feeds No * Assess daily for clinical stability ; once stable, assess for initial feeding method 4

Alternative feeding methods Options available: Cup Paladai Spoon Irrespective of the method, only expressed breast milk has to be fed to the baby

Expressing breastmilk by hand

Hand expression of breastmilk Have a clean dry container Tell the mother to: Wash her hands thoroughly Make herself comfortable Hold a wide necked container under her nipple and areola Place her thumb and first finger behind the nipple (at least 4cm from the tip of the nipple)

Hand expression of breastmilk… Compress and release the breast between her finger and thumb Compress and release all the way around the breast, keeping her fingers the same distance from the nipple Express one breast until the milk just drips, then express the other breast until the milk just drips Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes Stop expressing when the milk no longer flows but drips from the start

Hand expression of breastmilk Different ways to massage the breast

Hand expression of breastmilk Back massage Mother sits down, leans forward, folds her arms on a table in front of her, rests her head on her arms Her breasts hang loose and unclothed The helper works down both sides of the spine at the same time from the neck to just below the shoulder blades She uses her closed fist with her thumbs pointing forwards She presses firmly making small slow circular movements with her thumbs and continues for 2-3 min

Hand expression of breastmilk Storing expressed breastmilk Room temperature : 6 hours Refrigerator : 24 hours Freezer : 2 weeks (-40C) to 3 months (-200C)

Alternative methods: Cup feeding Cup and spoon are easy to clean with soap and warm water

Cups for feeding newborn babies An ideal cup can hold 50 to 90 mL of milk It can be glass or plastic and easily washable Edge should be rounded and smooth A cup with a lid is useful for storing expressed breast milk

Cups with lips and spouts Variations of cups with lips and spouts can easily be found They should be used with extreme caution It is DANGEROUS to POUR milk into a baby’s mouth

Cup feeding

Cup feeding Advantages Simple equipment ; easy to clean Baby can take what it needs in its own time Mother can do it herself Good eye contact between mother and baby

Cup feeding Steps Put a measured amount of milk in the cup Infant should be awake and held sitting semi-upright on caregiver's lap; put a small cloth on his or her front to catch drips of milk Touch the edge of the cup to the outer parts of the upper lip Tip the cup so that the milk reaches the baby’s lips

Pouring the milk into baby’s mouth can cause aspiration Cup feeding Steps Do not pour the milk into the infant's mouth Allow the infant to take the milk himself (upon smelling the breastmilk, the baby becomes alert, opens its mouth, and puts its tongue into the milk to start the feed) Feed the infant slowly; some milk may spill from the infant's mouth When the infant has had enough, he or she will close his or her mouth and will not take any more. Do not force-feed the infant. Pouring the milk into baby’s mouth can cause aspiration

Case study: cup feeding Measuring the correct amount of milk To measure 30 mL Use a desert spoon which holds approx. 10 mL Take 3 spoonfuls of milk Put a mark on the outside of the cup to guide her how much milk is needed each time If the baby does not take the required amount: feed more often or for longer

Paladai feeding A paladai is a small bowl with a long pointed lip The advantages are that it is usually faster than spoon or even cup feeding and also that there is less spillage A disadvantage is the risk of pouring large amounts of milk into the infant’s mouth

Paladai feeding Steps Infant should be awake and held sitting semi-upright on caregiver's lap; put a small cloth on his or her front to catch drips of milk Put a measured amount of milk in the paladai Hold the paladai so that the pointed tip rests lightly on the infant’s lower lip

Paladai feeding Steps Tip the paladai to pour a small amount of milk into the infant’s mouth Feed the infant slowly Make sure that the infant has swallowed the milk already taken before giving any more When the infant has had enough, he or she will close his or her mouth and will not take any more. Do not force-feed the infant.

Spoon feeding Advantages Disadvantages Useful for collecting small amounts of colostrum in the first days of life Useful in a baby with cleft lip/palate Disadvantages Slow method of feeding Often difficult to manage a spoon and a milk container while holding the infant semi- upright

Feeding colostrum with a spoon A grandmother giving colostrum to her grandson 5 hours after delivery The mother was recovering from a Caesarean section A health worker helped the mother express

Ensuring adequacy of intake Weighing him/her once a day and assess weight gain Check that (s)he has several wet nappies every day Babies who are growing adequately are receiving enough milk

Summary Alternative methods - indicated in those who are NOT able to breastfeed effectively Methods available: Cup, spoon, Paladai ONLY expressed breast milk should be fed Ensure hygiene and adequacy of intake while giving feeds by alternative methods