1. Practices Supporting Breastfeeding and Oral Development in the NICU: A Case Report
Elizabeth E. Nottingham, M.S., CCC-SLP, CLC
Doctoral Student (Ph.D.)
Cynthia O’Donoghue, PhD, CCC-SLP
Professor and Head, CSD C
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2. Relevant Financial Disclosures
Cindy is a full-time faculty member at JMU
Relevant Non-Financial Disclosures
Beth was co-investigator for this research as part of a directed research project C
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3. Outline Breastfeeding background Survey design Results/Case Report
Roadmap
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4. Background Healthy people 2020 objectives Target 81.9% 60.6% 34.1%
46.2%
25.5%
14.2%
MICH*-21: Increase the proportion of infants who are breastfed
MICH-21.1: Ever
MICH-21.2: At 6 months
MICH-21.3: At 1 year
MICH-21.4: Exclusively through 3 months
MICH-21.5: Exclusively through 6 months
MICH-23: Reduce the proportion of breastfed newborns who receive formula supplementation within the first 2 days of life.
Increasing emphasis on breastfeeding, which is also seen in the NICU
Goal to increase BF while decreasing reliance on formula.
MICH-Maternal Infant Child Health
(CDC Breastfeeding Report Card, 2014)
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5. Recipe for disaster?
We know that infants born pre-maturely are more prone to infection
Factors affecting gut health:
Mode of delivery (c-section vs vaginal)
Introduction of non-species specific milk
Sanitary conditions of hospital
Microflora of female genital tract
(Mountzouris et al, 2002)
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6. Similar findings in study of 17 Canadian NICUs- 50% c-section for 28-32 weeks, 31% for term infants
C-section: bad for baby, bad for mom (milk supply)
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7. Fecal samples finding reveal Ph level (that influences growth of good bacteria and limiting bad bacteria). Some notions that breast mild has components that promote GOOD bacteria growth
(Bullen et al, 1977)
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8. Incidence of Necrotizing Enterocolitis
RCT HM with significantly lower incidence of NEC. Two isolated cases of HM that required surgery were later found to have accidentally received human milk.
I think most people agree that the provision of human milk for human babies is important, and even more so for NICU babies (one response on our survey indicated that no babies in their NICU receive any formula)
Still some uncertainty about direct breast feeding?
(Sullivan et al, 2010)
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9. Bottle or Breast?
Review of 7 articles looking at direct breastfeeding vs. bottle feeding
No differences in days to full oral feedings or d/c
Should encourage direct breastfeeding in NICU
The controversy of HM via breast of bottle continues. This meta-analysis was more a review than a true meta-analysis (powered adequately).
(Briere, 2015)
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10. Factors to Consider Support BF Hinder BF Breastfeeding culture
Access to paid maternity leave and adequate insurance
Kangaroo Mother Care
Early, frequent breastmilk expression
Avoiding bottle feeding
Breastfeeding is 1st oral feeding method
Hinder BF
Restrictive guidelines such as GA criteria
Lack of knowledge of pre-term infants breastfeeding capacity
Limited availability of mother
BETH
(Nyqvist, 2005)
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11. The Survey
Guided and expanded from previous instruments in the published literature
1994 US survey (Siddell, & Froman)
2008 Australia (Dodrill, McMahon, Donovan, & Cleghorn)
Developed in Qualtrics
Introduction sent to medical directors of 98 US Neonatal-Perinatal Fellowship training programs (level III and IV)
WHY only these programs?
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12. 32% response rate
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13. Demographics Participants: Medical Director: N=16 Nurse: N=4
Doctor (division chief, etc): N=6
Therapist (SLP, OT, RD): N=5
90% employed 10+ years in NICU
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14. Factors Targeted in Survey
Support BF
Breastfeeding culture
Access to paid maternity leave and adequate insurance
Kangaroo Mother Care
Early, frequent breastmilk expression
Avoiding bottle feeding
Breastfeeding is 1st oral feeding method
Hinder BF
Restrictive guidelines such as GA criteria
Lack of knowledge of pre-term infants breastfeeding capacity
Limited availability of mother
(Nyqvist, 2005)
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15. Case Report Difficulty conceiving- infertility
Baby born at 33 weeks, 2 days via c-section
Pre-eclampsia
Spontaneous onset of labor
Birth weight: 3 lb 9 oz (1615 grams)
No medical complications- breathing OK
TPN for 24 hours, then NG tube
NICU stay of 17 days, then d/c home
We will use a CASE REPORT to exemplify the survey findings
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16. Breastfeeding Culture
26% Baby-Friendly
97% routinely educate mothers on benefits of breastfeeding
97% have IBCLC full or part-time staff in NICU
52% prevent use of formula
42% use human milk based fortifier
ASHER: Lisa pumped within one hour of birth, pumped around the clock every 2 hours
Never received any formula, or bovine-based products
UVA has a pump room in the NICU- moms can “bond” while they pump- provides privacy
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17. KMC
97% of our respondents reported use of KMC
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18. 1st oral feeding method
61% direct breastfeeding is 1st oral feeding method for mothers wishing to breastfeed
87% have a policy on donor milk use
84% frequent exposure/latching onto breast
ASHER: 1st oral feed was at 3 days old, directly on breast. Daily “lick and learn” sessions 2-3 times per day
NG tube removed and 1st bottle feed at 13 days old
Would not take a bottle at home, used a syringe to provide fortified mother’s milk
Started using a nipple shield at 5 days old, stopped use at 7 weeks
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19. Guidelines other than GA
Nutritive oral stimulation begun as early as 22 weeks, and “as early as tolerated” with colostrum on oral swabs (CHOP)
100% of respondents use behavioral cues in addition to GA and weight to determine readiness for oral feeds
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20. Availability of Mother
ASHER: mom was in hospital for 10 days, she pumped while dad took milk to NICU. Last 7 days, they traveled back and forth.
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21. Progress? Then (1994) Now (2015) 36% have formal process
14.3% breast is 1st oral feed
58.2% cue-based schedule
89.5% include behavioral cues in eval for oral feed
75% rely in GA or weight
GA range weeks
> 60% use 34 weeks
50% use 1500 grams
80% have formal process
61% breast is 1st oral feed
58% cue-based schedule
100% include behavioral cues
70% rely on GA or weight
GA range weeks
56% use weeks
50% use grams
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22. Asher NOW! Photos used with permission from Lisa Akers
Baby has never received formula, mom is still pumping, baby is directly breastfeeding
Asher NOW!
Photos used with permission from Lisa Akers
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23. Contact Dr. Rory DePaolis
Interested in a Ph.D.?
Let’s talk Or
Contact Dr. Rory DePaolis
Ph.D. Program Director
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