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

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

BBC 10: Special Situations
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 Overview In the earlier sessions, we have been focusing on the process of establishing breastfeeding for normal mother-baby dyads This module addresses the management of breastfeeding in those special situations when either mother, baby or both have medical issues that complicate normal breastfeeding 2 Rev. March 2009 2

Special Babies and Mothers Need Special Nurse-Attachers!
BBC 10: Special Situations 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 Photograph: mother holding late preterm baby shin-to-skin Note to Trainer: Ask: What can the nurse do to support attachment when special circumstances arise? When special circumstances arise – expected or not – the mother and family is at great risk to being lost in the “system” and “routines” which are NOT routine at all for the family! Consequences of NOT supporting attachment at this time can include a delay or avoidance of bonding with the baby – which can delay healing in the baby and impair mother-baby connections. A nurse who is an “attacher” will: Advocate for the mother-baby (still to be considered a single entity) to be in as close contact as is possible - this may include questioning standard procedures when less intrusive ones can be safely used Include parents in infant feeding and care whenever possible - if baby is not breastfeeding at the breast then encourage participation in feeding NEAR the breast, diaper changing, bath, etc. Interpret information - ask questions of the family to ensure that they understand what is happening despite the stress they are experiencing Provide information about “next steps” Perform regular “emotional assessment” of the parents and assist them in dealing with the stress - refer parents to social workers and others who can provide emotional and spiritual support when appropriate 3 Rev. March 2009 3

Which Babies are at Risk of Breastfeeding Problems?
BBC 10: Special Situations Which Babies are at Risk of Breastfeeding Problems? Preterm babies Late preterm babies Babies with hypoglycemia Babies with hyperbilirubinemia (jaundice) Babies at risk for breastfeeding problems include: Preterm babies range from the very immature, tiny babies often seen in the NICU to the late preterm babies usually seen in the newborn nursery and in the mother/baby unit and who are often treated as full term babies. Late Preterm Babies - Highlight the issues related to the “late preterm” babies, which are increasing in number - They appear to be “normal-sized” babies but have “premature” skills, behaviors and state regulation Babies with Hypoglycemia or Hyperbilirubinemia may be found - in the newborn nursery for observation if the jaundice is mild - admitted into the NICU Breast feeding Challenges: latch difficulties & poor milk transfer Feeding Strategies: Mother will need help positioning baby for ease of attachment Encourage pumping following feedings until milk supply is established and/or anytime alternate feeding method is used Watson Genna, Supporting Sucking Skills in Breastfeeding Infants, 2008 If we can identify the baby who is most likely to have problems, we can offer anticipatory guidance and special help All of these babies are at high risk for supplementation with formula 4 Rev. March 2009 4

Additional Risk Factors
BBC 10: Special Situations Additional Risk Factors Size issues: SGA/LGA Low birth weight Multiples Babies with infections Womb position and birth trauma Torticollis, facial asymmetry Photograph 53: baby with obvious risk factor ie. Torticollis Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Babies at risk for breastfeeding problems include: Small for Gestational Age (SGA) / Large for Gestational Age (LGA) - increased risk for hypoglycemia and latch problems Walker, Breastfeeding Management for the Clinician: Using the Evidence, 2006 Multiples have an increased risk of: - preterm labor and birth - intrauterine growth restriction (IUGR)/ fetal growth restriction - low birth weight - congenital or pregnancy related anomalies - infant morbidity Gromada, Core Curriculum for Lactation Consultant Practice, 2008 Babies with infections have an increased risk of: - hypoglycemia & pathologic jaundice - often very lethargic and are not energetic at the breast - often NPO during septic workup Other risk factors listed on this slide: Womb position and birth trauma- Structural Issues: torticollis and facial asymmetry - probable causes include: - Intrauterine positioning (often seen with multiples) - Vascular injury to Sternocleidomastoid Muscle (SCM) Feedings: Once oral feedings are initiated breastfeeding is preferred offer expressed breast milk if mother not available or baby unable to complete feeding at breast Walker, Breastfeeding management for the Clinician: Using the Evidence, 2006 5 Rev. March 2009 5

Additional Risk Factors
BBC 10: Special Situations Additional Risk Factors Congenital problems and defects: Heart conditions Ankyloglossia (tongue tie) Cleft lip & Cleft palate Photographs: ) soft palate cleft 404-2) cleft lip ) cleft lip post surgery Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Congenital Problems and Defects Not all congenital problems pose the same degree of challenge All can be managed so that the infant can be fed human milk even if they cannot feed directly at the breast Babies with Congenital Heart Defects Are at greater risk of morbidity and are in need of the protective properties of breast milk They may be able to feed fully or partially at the breast depending on the severity of the condition, their energy level, and any other co-morbid factors. Combs, Pediatr Nurs, 1993 Ankyloglossia is a condition in which the sub-lingual frenulum is either short, tight, or attached to the tongue close to or at the tongue tip It restricts the free movement of the tongue making it difficult for the infant to grasp and manipulate the maternal teat in a way that assures adequate milk transfer Often causes damage to the mother’s nipples If diagnosed soon after birth, recommend referral to a clinician (MD. DDS) for evaluation and treatment A Frenotomy is a surgical procedure that divides the lingual frenulum and releases the restriction of tongue movements - also known as a “tongue clip”. Usually avascular and preformed as an outpatient or office procedure - can quickly resolve breastfeeding difficulties Watson Genna, Supporting Sucking Skills in Breastfeeding Infants, 2008 Cleft lips and cleft palates Whether separate or in combination, do pose a challenge depending on the location and severity of the defect. Openings in the palate can make it difficult for the infant to seal the oral cavity create suction at the breast. This negatively effects milk production and infant growth Types of cleft palates 1. Unilateral /bilateral, partial/ complete 2. A soft palate cleft ( may be undiagnosed initially) 3. A hard palate cleft Breastmilk & breastfeeding considerations: Cleft lip only - breastfeeding may be possible depending on the size and shape of mother’s breast the breast may fill the gap in the lip allowing for an adequate seal - if mother is experiencing engorgement she should be instructed to hand express or pump to soften her breast before offering it to her baby If baby cannot create a vacuum then breastfeeding exclusively without interventions (compressions, breast pump, twin that can increase milk supply) is usually not possible Advantages of Breast Milk: Since these babies are at greater risk for ear infections, providing them with expressed breast milk is a goal that should be discussed with the mother. Lawrence, Breastfeeding: A Guide for the Medical Profession, 2005 6 Rev. March 2009 6

Support & Intervention: Skin-to-Skin
BBC 10: Special Situations Support & Intervention: Skin-to-Skin Skin-to-skin maintains the natural habitat for the infant Photograph: Mother and baby skin-to-skin Summary Slide: Babies with any risk factors should be observed for adequacy of breastfeeding Post discharge follow up is very important The ability to transfer milk consistently is a very important marker to observe and document The baby who is too immature to coordinate the suck-swallow-breathe sequence, or too weak to sustain the suckling effort long enough to transfer adequate milk for his needs is at risk for poor weight gain The mother may report that her baby is at the breast “all the time” and weight gain is minimal - observation of these extended feeds will allow the clinician to assess the suckle patterns (nutritive vs non-nutritive) and determine if the baby is transferring milk efficiently - mother’s milk supply is also at risk Wolfe, Feeding and Swallowing Disorders in Infancy: Assessment and Management, 1992 Skin-to-skin provides the optimum environment for her baby to grow and mature Even if a baby is not yet ready for direct breastfeeding, a mother and baby should spend as much time as is feasible skin-to-skin 7 Rev. March 2009 7

Benefits of the Skin-to-Skin for All At-Risk Babies
BBC 10: Special Situations Benefits of the Skin-to-Skin for All At-Risk Babies Reduces stress hormones in infant Stabilizes respiration Reduces risk of hypothermia Reduces risk of hypoglycemia Helps baby function optimally Babies who are separated from their mothers exhibit more stressful behavior Ongoing stress is debilitating for anyone Infant stress results in: Increased calorie consumption Irregular respiration Faster heart beat Skin to skin calms baby and mother and helps both to function optimally considering their circumstances Note to Trainer: read the benefits of skin-to-skin listed on this slide Martinez, NeoReviews, 2007 8 Rev. March 2009 8

Feeding Options Breastfeed Breast milk Banked donor human milk
BBC 10: Special Situations Feeding Options Breastfeed Whenever possible Breast milk Using alternate feeding methods Banked donor human milk Artificial baby milk Photograph: Preterm baby breastfeeding This is a list of feeding options ordered from best to least preferred Breastfeeding If at all possible, the baby should be put to breast directly for feedings Transitioning to the breast at the earliest appropriate time should be a goal Breast milk (own mothers milk/ OMM) Using an alternate feeding method (discussed in BBC session 9) Most mothers with special circumstances will also need to pump to support their milk supply and provide supplements Banked Pasteurized Donor Human Milk Many hospitals now provide donor milk when own mothers milk is not available Artificial baby milk (formula) Summary statement: Human milk is the optimal food for babies even if the baby is unable to transition to direct breastfeeding - Rare exceptions do occur, ie: Galactosemia 9 Rev. March 2009 9

Four Steps to Breastfeeding Success in Difficult Situations
BBC 10: Special Situations 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 Photograph 86: Preterm baby breastfeeding Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Even in difficult situations the first priority is to feed the baby by whatever means necessary to meet his/her nutritional needs Because the baby is not functioning normally, we cannot rely on his instinctual feeding behaviors Patient Education Information specific to this mother-baby dyad Skills on how to feed the baby will need to be taught Teach the mother to pump to initiate and maintain her milk supply until the baby can feed effectively at the breast Parental Concerns When parents give birth to a sick or abnormal baby they are usually devastated and need gentle, consistent support to move forward with a customized plan of care Fears include demise- afraid their baby will die - they may not want to name baby or initiate pumping until baby is stable Refer to a clinically skilled Lactation Consultant to follow them through this process Exclusive breast milk feedings may or may not be possible but it is a goal For as long as the baby is hospitalized, mothers who never planned to feed their baby at the breast may be willing to at least pump milk for their baby up to the time of discharge Nurses can help the mother (and family) deal with their grief by being supportive, understanding, approachable, and non-judgmental Many nurses also don’t want to address the grief – so they leave mothers “alone” - however, many mothers want to hear that there was SOMETHING they could do/busy themselves with – and they pumped It is important to approach the mother to allow HER to decide what she can handle rather than not inform/give them options 10 Rev. March 2009 10

Preparation for Discharge
BBC 10: Special Situations Preparation for Discharge Parent education and support Hospital grade breast pump Referral to WIC Community lactation consultant Support services Photograph 301: Mother breastfeeding twins Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Couplets should not be discharged without instructions for post discharge baby care and referral options to the necessary community providers and support services These should include: Hospital grade breast pump - if a pump was not provided at time of mother’s discharge then provide rental options before baby is discharged Community Lactation Consultant Outpatient services for special needs babies Community support group WIC if the patient qualifies - in some WIC service areas eligible clients may receive a pump loan during baby hospitalization and for special situations post discharge Note to Trainer: Know the providers and services available in your community 11 Rev. March 2009 11

Prematurity Skin-to-skin & human milk feeding are preventive medicine
BBC 10: Special Situations Prematurity Skin-to-skin & human milk feeding are preventive medicine for premature babies Photograph: Mother and baby doing Kangaroo Mother Care Benefits for Very Low Birth Weight Infants (VLBW) As soon as baby born at weeks is medically stable he/she can be: - placed skin-to-skin - offered the breast - dry or practice breastfeeding is also an option pending oral-motor feeding status - Note to Trainer: this technique is discussed on slide 17 Because these babies did not complete their prenatal development, every effort needs to be made to replicate outside the womb what should have occurred within the womb Vital health care issue Skin-to-skin contact and human milk feedings can be life saving - it is not an issue of preference for breast vs. bottle - important concept for both the Neonatologist and NICU staff to support The act of breastfeeding is less stressful than bottle feeding - a baby has better control over milk flow - better oxygenation - if mother is experiencing a forceful letdown (MER) there are strategies available to help her manage the flow Meier, Pediatric Annuals, 2003 Note to Trainer: Benefits of skin-to-skin: discussed throughout previous sessions, reviewed on next slide 13 Benefits of breast milk: discussed throughout previous sessions, reviewed on next slide 14 Anderson, Cochrane Database, 2003 12 Rev. March 2009 12

Benefits of Skin-to-Skin for Preterm Babies
BBC 10: Special Situations 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 Benefits of skin-to-skin (review from previous BBC sessions) Improved physiological stability - stabilizes respirations, temperature, heart rate and blood sugar Enhances growth Stimulates in the mother milk production and promotes breastfeeding Proximity to breast increases antibodies in mother’s milk to micro-organisms baby is exposed to while in the NICU Improves parents confidence - parents are intimidated at the prospect of caring for their tiny, fragile baby - holding baby skin-to-skin promotes bonding and increases confidence in their ability to nurture - they are able to provide something unique and valuable to their baby 13 Rev. March 2009 13

Benefits of Human Milk for Preterm Babies
BBC 10: Special Situations 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 Lucas, Lancet, 1992 Note to Trainer: Benefits listed on this slide are a review and have been discussed in previous BBC sessions When a preterm baby stays healthy, they use calories to grow Breast Milk fed preterm babies are discharged earlier for gestational age shortened length of hospital stay Benefits of breast milk (review from previous sessions) - Increased resistance to infection - Reduced incidence of NEC - Improved brain growth and development - Improved lung & gut maturity. - Lower morbidity/mortality rates Breastmilk is preventative medicine and should be described to parents as medicine (Ip, ARHQ, 2007) The reduced risk rate range for Necrotizing Enterocolitis (NEC) is 4% - 82% - % varies based on both gestational age and birth weight - fortunately only a small number of babies are diagnosed with NEC - NEC is a catastrophic complication - Breast milk is protective for NEC Role of Staff: Promote Breast milk - if mother expresses no desire to feed her baby at breast, ask her to at least pump while baby is hospitalized - if she pumps just to relieve engorgement for a week or two, it will provide weeks of feeds for a very low birth weight (VLBW) baby - Breast Milk can be given by an alternate feeding method Promote skin-to-skin - both mother & father can hold their baby 14 Rev. March 2009 14

Helping Mothers to Initiate & Protect Milk Supply
BBC 10: Special Situations 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 Pumping can help a mother to initiate and protect her milk supply while her baby is hospitalized and until breastfeeding is established Encourage mother to use unit pump (if available) whenever she is visiting her baby Assist mother to obtain hospital grade pump for home use - community pump rental programs - insurance options - WIC clients may have option of home use pump during infant hospitalization and post discharge pending services provided in your area Recommend a pumping plan to establish breast milk supply - encourage 8 pumping per 24 hours. - goal is frequent stimulation with the option of considering hour interval within any 24 hour period to allow her time to rest - once breast milk supply is established mother may be able to modify her pumping schedule pending her breast storage capacity Reinforce the importance of following NICU guidelines for collection & storage during infant hospitalization 15 Rev. March 2009 15

Late Preterm Infants Gestational Age 34-36 6/7 weeks
BBC 10: Special Situations Late Preterm Infants Gestational Age /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, Engle, Pediatrics, 2007 Photograph 373: Mother and preterm baby doing Kangaroo Mother Care Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. The Late Preterm infant (previously known as the near-term infant) Gestational Age wks & 6 days Characteristics: The imposter in the nursery - may appear vigorous at first glance - physically large newborns are often mistaken for being more developmentally mature than their actual gestational age More likely to be separated from mother - the sleepiness and inability to suck vigorously is often misinterpreted as sepsis, leading to unnecessary separation and treatment - separation can occur as a result of baby becoming ill due to poor feeding Increased risks for medical complications including: hypothermia, excessive weight loss, dehydration, slow weight gain, failure to thrive, prolonged artificial milk supplementation, exaggerated jaundice, Kernicterus, fever secondary to dehydration, re-hospitalization, breastfeeding failure Transition to breastfeeding Many of the acute problems can be managed on the postpartum floor in the first few hours and days Most late preterm babies are not discharged exclusively breastfeeding at breast, but on a combination of breastfeeding and supplementary feeding by an alternate method Best Practice: key points Avoid unnecessary separation Provide timely lactation support Initiate pumping to assist mother with establishing her milk supply Supplement as indicated and with breast milk whenever available Post discharge referrals and follow up are essential to breastfeeding success Parent education: baby may not be able to exclusively breastfeed until 40+ weeks post conceptual age Note to Trainer: For more information refer to: CPQCC, Care and Management of the Late Preterm Infant Toolkit, 2007) AWHONN handout on Late Preterm babies – and what the parents need to know about their care - see “Patient links”: 16 Rev. March 2009 16

Helping Mothers with Transitioning Into Breastfeeding
BBC 10: Special Situations 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 Photograph: mother breastfeeding preterm baby Full breastfeeding is a complex set of skills - the goal in the NICU setting is “breastfeeding readiness” Some babies may not be able to accomplish full breastfeeding until closer to term and perhaps not until after discharged from the NICU Steps for Transitioning a baby to breastfeeding Step 1: Begin with kangaroo care once baby is medically stable and mother is ready Reinforce the advantages of skin-to-skin as previously discussed (slide 8) Step 2: Hold baby with his nose in proximity to the nipple Enable the baby to recognize the look and scent of the nipple Baby may even extend tongue and tentatively lick the nipple Step 3: Positioning for neck/ head stabilization- especially when tone is low Instruct mothers in those breastfeeding positions that best stabilize the head and neck Recommended holds: football / cross cradle Step 4: Practice breastfeeding (also known as “dry” breastfeeding) Offering an “empty” breast allows infant to practice grasping the nipple and suckling without the challenge of managing milk flow Can be quite comforting for mother and baby and further encourage milk production It may be necessary to instruct mother to pump before offering her breast to her baby Step 5: Milk transfer There may be little to no milk transfer initially- as baby’s skill improves, milk transfer should improve Use of nipple shield to assist with transfer (Meier, JHL, 2000) - an experienced LC or OT should supervise use for effectiveness - use of a nipple shield should be monitored for evidence of milk transfer and adequate weight gain ABM protocol #12, 2004 17 Rev. March 2009 17

A Premie Needs His Mother
BBC 10: Special Situations A Premie Needs His Mother Video by Jane Morton, MD Photograph: Mother breastfeeding her preterm infant Refer to Session Plan for DVD Instructions for Use DVD: A Premie Needs His Mother by Jane Morton, MD Click on Menu - Part 2 - Begin at 3:45 End at 7:20 “Every premie is different” Background This DVD clip chronicles the experience of a couple, patients of Jane Morton MD from Stanford, as they gradually transition their preterm babies to breastfeeding Debrief DVD Ask: What was important and interesting to you? 18 Rev. March 2009 18

3. Position at breast / Mom expresses milk
1. Skin to Skin 2. Mouth/ nose to nipple 3. Position at breast / Mom expresses milk 4. Help infant to latch 5. Sucking and swallowing 6. Baby really breastfeeds at times 7. Discharge preparations 8. Breastfeed and supplementing at home 9. Breastfeeding better on cue at times 10. Exclusively breastfeeding The process of teaching a preemie to breastfeed is not a straight line… This pathway can be used to provide parents with a visual reminder of the sequential steps that a baby must go through before achieving exclusive feeding at the breast Discuss steps as they describe baby’s transition to fully breastfeeding Identify that improvement will not always follow a straight line Note to Trainer: Ask: any questions about this tool? Option: give group 60 seconds to discuss with each other - instruct to: turn to person sitting next to you and ask: What is new, what is interesting about this tool? Based on the work of Berlith Person, Helsingborg Hospital, Sweden

Hypoglycemia Risk Factors : Preterm, Post term, LBW SGA, LGA
BBC 10: Special Situations 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 Medical Complications- Hypoglycemia The term hypoglycemia refers to low blood sugar Transient hypoglycemia in the immediate newborn period is common and occurs in almost all mammals May be caused by any of factors (also listed on slide) - preterm (less than 38 weeks) - post maturity - LBW (low birth weight) - SGA (small for gestational age) - LGA ( large for gestational age) - Diabetic mother (especially if poorly controlled) - Stress: including perinatal stress (severe acidosis, hypoxia-ischemia), cold stress, prolonged or difficult delivery - Excess use of glucose: during labor in mother’s IV and/or infant glucose water feedings post birth - Multiples - Other medical complications: including suspected infection, inborn errors of metabolism, endocrine disorders Overview of Feeding Strategies Note to Trainer: Strategies may vary based on the current protocols at this hospital Refer to written policy and procedures for alternate feeding methods - first try to stabilize with colostrum feeds at breast - if not feeding at breast, instruct mother to hand express and use alternate feeding method - formula may need to be used if colostrum is not available. If baby is admitted nursery/ NICU encourage mother to go into unit to breastfeed and request skin-to-skin time with her baby 20 Rev. March 2009 20

Hypoglycemia: Definition and Testing
BBC 10: Special Situations 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 Note to Trainer: The blood value at which treatment for hypoglycemia is initiated varies from hospital to hospital Find out what the threshold value is at this hospital and include it in this slide discussion 21 Rev. March 2009 21

Breastfeeding-Friendly Hypoglycemia Prevention
BBC 10: Special Situations 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 Photograph: Mother and baby skin-to-skin Note to Trainer: This slide lists the steps for transitioning to breastfeeding which also can to reduce the incidence of hypoglycemia in healthy term newborns Initiate skin-to-skin immediately after birth and throughout the first day Breastfeed early - within the first hour Breastfeed often - at least every 2-3 hours Breastfeed long - unrestricted breastfeeding sessions - no time limits Breastfeed well - assess latch and quality of suck-swallow - observe for active milk transfer 22 Rev. March 2009 22

Breastfeeding – Friendly Hypoglycemia Treatment
BBC 10: Special Situations 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: Supplement with formula Note to Trainer: Routine glucose testing is not recommended (ABM, Protocol #1, 2006) This treatment plan is to be instituted only if the baby shows clear signs of hypoglycemia Breastfeeding Friendly Hypoglycemia Treatment Plan If baby is unable to breastfeed - feed all expressed colostrum to baby using alternate feeding method (refer to BBC session 9) If mother is unable to express more than a few drops - feed all expressed colostrum to baby using alternate feeding method - supplement with formula as needed - supplement volume is determined by facility policy for supplementation and/ or age & weight of baby 23 Rev. March 2009 23

Hyperbilirubinemia (Jaundice)
BBC 10: Special Situations 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 Photograph: baby under bili lights Note to trainer: The intent of this content is not to lecture on medical treatments Encourage participant dialog Ask : What are the procedures at this hospital? Facilitate a discussion on how to make them less non-breastfeeding friendly Types and Causes of Jaundice Pathologic Jaundice - blood incompatibility ie: ABO, Rh - illness including sepsis - inborn errors of metabolism - intestinal defect or obstruction - macrosomic infant of diabetic mother Physiologic Jaundice - common in healthy newborns - it is the result of normal adaptive processes - Red Blood Cell (RBC) breakdown - immaturity of bilirubin metabolism systems - generally peaks in severity between 3-5 days after birth and then resolves over the next 7-10 days Breastfeeding Associated Jaundice - starvation/ lack of breastfeeding jaundice - delayed stooling Walker, Breastfeeding Management for the Clinician: Using the Evidence, 2006 Cohen, MS Jaundice in the Full Term Newborn, Pediatr Nurs 2006 24 Rev. March 2009 24

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 % jaundice on day 6 Exaggerated physiologic jaundice may be an early sign of breastfeeding difficulties Yamauchi, Pediatrics, 1990 Study Findings: Feeding frequency reduced incidence of hyperbilirubinemia Prevention is key Study Conclusions: Stooling patterns- if a baby isn’t stooling, suspect a milk transfer problem Breastfeeding difficulties - Need to complete a thorough assessment to determine why baby isn’t feeding well Possible contributing factors - lethargic baby - scheduled feedings - poor positioning and/or latch - ineffective suckle - glucose water feeds Feeding Strategies: - if the baby is alert and will open his mouth then attempt to breastfeed - if the baby sleeps more than 3 hrs, wake - if the baby won’t feed, hand express/pump and supplement 25 Rev. March 2009 25

Breastfeeding - Friendly Jaundice Treatment
BBC 10: Special Situations 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 Breastfeeding Friendly Jaundice Treatment Plan Staff should Observe a breastfeeding and assess: - latch: is baby experiencing difficulties with initial latch and/ or maintaining latch? - quality of suck: is it rhythmic? - baby’s energy level: describe state of alertness Observe milk supply and milk transfer - milk supply: are breast full before feeding and softer/ less heavy after feeding? - audible swallowing: non-nutritive vs nutritive suckle patterns - generally, if a baby is swallowing rhythmically then milk is being transferred Instruct mother to hand express and/ or use a breast pump - early and frequent stimulation is important for establishing mother’s milk supply - “double electric breast pump” if mom is told to stop breastfeeding x 24 – 48 hours Supplement baby with expressed breast milk whenever available Provide a referral to community services for all moms dealing with jaundiced babies - education and follow up are key to breastfeeding success 26 Rev. March 2009 26

Triple Feeding Protocol
BBC 10: Special Situations 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 Triple Feeding Protocol is adapted from ABM Protocol #12, 2004 27 Rev. March 2009 27

Which Mothers are at Risk of Breastfeeding Difficulties?
BBC 10: Special Situations Which Mothers are at Risk of Breastfeeding Difficulties? Anatomy and physiology Inverted/flat nipple Too large/meaty nipples Breast surgery Hormone problems Health conditions Social/educational factors Lack of knowledge Lack of support Photographs: ) baby attempting latch onto large nipple 29 - 2) mother & baby with a lactation consultant Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Assessment and evaluation including patient history and physical exam can identify mother-baby couplets at risk Risk factors include Anatomy and physiology - inverted/ flat nipple - too large/meaty nipples “oro-boobular” disproportion - breast surgeries - hormone problems - health conditions Social/ educational factors - lack of knowledge - lack of support 28 Rev. March 2009 28

Contraindications for Breastfeeding
BBC 10: Special Situations 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 This slide lists the very few contra-indications to breastfeeding in the United States The only infant contraindication is galactosemia Galactosemia is an inborn error of metabolism in which the infant is missing the enzyme necessary to digest lactose symptoms typically start about the third day of life - Unfortunately this condition is usually not diagnosed until the result of the Newborn Screening Test is known Failure to diagnose this defect can result in liver disease, mental retardation and death Only lactose / galactose free formulas can be ingested safely This is a life long problem Walker, Breastfeeding Management for the Clinician: Using the Evidence, 2006 Maternal Contraindications Breastfeeding with HIV - Transmission occurs most often through sexual contact, via blood or blood products and via breast milk - is not recommended currently in the US and other developed countries - is recommended in developing nations where the infant is more likely to die of diarrheal disease due to contaminated water used to prepare substitute feedings - iIn undeveloped and developing nations strict exclusive breastfeeding is recommended - combination (combo) feedings should be avoided to maximize the protective properties of breastmilk HTLV- 1 & II: Human T-cell leukemia virus type I & II Same precautions and recommendations as HIV Lawrence, A Breastfeeding Guide for the Medical Professional, 2005: TB: can breastfeed after 2 weeks of treatment. Some moms opt to pump and discard x 2 weeks – Reinforce importance of initiating pumping to staff. Mothers under going treatment CAN breastfeed eventually Note to Trainer: When helping mothers through these difficult issues remember to respect the mother As one mother put it, don’t tell me what I CAN’T do – let me know what I CAN do – and I’ll decide if it’s too hard for me…respecting the mom is essential! 29 Rev. March 2009 29

NOT a Contraindication
BBC 10: Special Situations 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 Note to Trainer: The criteria listed on this slide are frequently mistakenly identified as contraindications The following are NOT contraindications for breastfeeding: Hepatitis A, B, C Maternal fever Low level environmental contaminants Maternal CMV carriers – term babies for preterm babies the current recommendation is to freeze all expressed breast milk prior to use Lawrence, Breastfeeding Med, 2006 Tobacco use - smoking can decrease milk volume and fat content as well as depress letdown (MER) immediately prior to breastfeeding Hopkinsons, Pediatr, 1992 - babies of smoking mothers are at increased risk for respiratory infection, however the risk of respiratory infection in breastfed babies in smoking environments is equivalent to that of breastfed babies in non smoking environments if the baby is breastfed at least 6 months. Nafsted, Eur Respir J.,1996 Occasional alcohol use - alcohol intake may impair letdown (MER) - the level of alcohol in the maternal milk supply matches the level in the maternal blood Anderson, JHL,1995 30 Rev. March 2009 30

Are These Drugs Safe to Take While Breastfeeding?
BBC 10: Special Situations 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 Activity 1: Looking Up Medications in Hale Refer to Session Plan for Activity materials, time and instructions Background Medications in Mothers Milk by Thomas Hale PhD is a user friendly drug reference resource for health care providers Only rarely does the amount of medication transferred into breastmilk produce clinical doses in the infant Debrief Activity After describing the rating system and assigning different medications to different students, ask the participants to report back to the group about their findings In addition to finding the drug rating, it is important to read text for additional recommendations, concerns and instructions for use - Ultimately it is the clinician or health care providers responsibility to review the research on the drugs and make a clear decision as to whether the mother should continue to breastfeed Note to Trainer: The participants may choose to report on one of the drugs listed on the slide, or look up any drug of interest to them 31 Rev. March 2009 31

“It is well known that most medications
BBC 10: Special Situations “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 Note to Trainer: Read quote on slide 32 Rev. March 2009 32

Medications in Mother’s Milk
BBC 10: Special Situations 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 This slide lists several professional level resources which can be used on their units and by medical staff 33 Rev. March 2009 33

Every baby and mother deserves the best possible start even if they have special circumstances We can help Photograph: Kangaroo Mother Care Note to Trainer: Ask: How do we foster attachment in these special situations? 34 Rev. March 2009 34

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

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

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Presentation on theme: "Special Situations Birth & Beyond California: Breastfeeding Training & QI Project With funding from the federal Title V Block Grant."— Presentation transcript:

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About project

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