Breastfeeding the NICU Infant - Mother

Breastfeeding
the
NICU Infant
Microsoft Office Clipart
Developed by Lisa Fikac, MSN, RNC-NIC
Expiration Date - 12/10/17
This continuing education activity is provided by Cape Fear Valley Health System,
Training and Development Department, which is an approved provider of Continuing
Nursing Education by the North Carolina Nurses Association, an accredited approver by
the American Nurses Credentialing Center’s Commission on Accreditation.
0.8 Contact hours will be awarded upon completion of the following criteria:
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Completion of the entire activity
Submission of a completed evaluation form
Completion a post-test with a grade of at least 85%.
The planning committee members and content experts have declared no financial
relationships which would influence the planning of this activity.
Microsoft Office Clip Art and Creative Memories are the sources for all graphics unless
otherwise noted.
The author would like to thank Stacey Cashwell for her work as original author.
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Identify the benefits and challenges of breastfeeding the preterm infant.
Discuss nursing interventions to promote successful breastfeeding for the
preterm infant and family.
Breastfeeding for the term, healthy infant has been well
documented and supported by the American Academy
of Pediatrics (AAP).
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The AAP recommends that infants be exclusively
breastfed for the first 6 months of life and
continue breastfeeding the remainder of the
first year while introducing foods.
Breastfeeding past the first year is recommended
if it is mutually desired by the mother and infant.
The World Health Organization and the UN
International Children’s Emergency Fund also strongly support the value of
breastfeeding and human milk.
The Department of Health and Human Services, Office of Women’s Health has
published their strategic plan for the United States to increase the initiation and
duration of breastfeeding.
While literature tells us breastfeeding among mothers of premature infants and/or sick
compromised infants is continuing to increase, it also tells us that many mothers of
premature infants are not breastfeeding at the time their infant is discharged from the
hospital.
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Breastfeeding the premature infant is a greater challenge than feeding a term
infant who goes to breast shortly after birth.
However, breastfeeding offers some GREAT benefits for both mom and infant.
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The maternal benefits are of such significance that even mothers who do not wish
to breastfeed or whose infant has a poor prognosis should be encouraged and
supported to pump and provide breastmilk for their infant.
The maternal benefits of breastfeeding are well established.....
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Breastfeeding increases levels of oxytocin, a hormone that stimulates uterine
contractions, which helps to o Expel the placenta.
o Minimize postpartum maternal blood loss.
o Induce a more rapid uterine involution.
In most women, breastfeeding, particularly exclusive breastfeeding, delays the
resumption of normal ovarian cycles and the return of
fertility.
Mothers who breastfeed their infants may also experience
psychological benefits, such as o Increased self-confidence
o Facilitated bonding with their infants
o Enhanced emotional and psychological outcomes
during and after the infant’s discharge
o Alternative focus for stress and anxiety of having a
premature infant
o Help with weight loss and a return to pre-pregnancy
weight
o Decreased incidence of breast and uterine cancer
But what are the benefits to the premature infant.....
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Is it too stressful for the premature infant to breastfeed as it has been "assumed"?
Should we offer only oro-or nasogastric feedings until the premature infant is
physiologically ready to bottle feed?
Should we delay breastfeeding until the premature infant can "successfully"
bottle feed?
OR.....
o Is breastfeeding the premature infant beneficial?
o Are there alternatives?
So, what are the benefits for the infant who breastfeeds?
Human milk contains a balance of nutrients that is specially
produced for the preterm infant. It is more easily tolerated and
digested.
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Human milk has been shown to have properties that protect
the gut mucosa and stimulate rapid growth in the intestinal
mucosal surface area.
Human milk provides protection from infection. Infants who are
fed human milk experience fewer or less severe cases of •
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Diarrhea
Respiratory tract infections
Otitis media
Pneumonia
Urinary tract infections
Necrotizing enterocolitis (NEC)
Human milk contains anti-inflammatory factors that regulate the immune response to
infection. This promotes an enhanced immune response to the following immunizations
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Polio
Tetanus
Diphtheria
Haemophilus influenzae
Respiratory syncytial virus (RSV)
Infants who are fed human milk have lower rates of the following illnesses •
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Sudden infant death syndrome (SIDS)
Type 1 and 2 diabetes
Obesity
Celiac disease
Inflammatory bowel disease
Childhood leukemia and lymphoma
Allergies and asthma
Visual, neurological, and cognitive development are improved.
There is usually better stabilization of oxygen, temperature and
respirations as compared to bottle feeding.
Research has shown that there are two critical human milk exposure
periods for the preterm infant.
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Colostrum during the introduction and advancement of enteral feedings in the
early post-birth period.
The first 14 to 28 days after birth, when there is a dose-response relationship
between the amount of human milk received by VLBW and ELBW infants and
reduction in o Enteral feeding intolerance
o Nosocomial infection
o Necrotizing enterocolitis (NEC)
o The total number of morbidities during the NICU stay
During the first period of exposure to colostrum, guidelines for its use includes •
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Use colostrum as the first feeding received by the infant.
Use colostrum for trophic feedings.
Feed colostrum in the order that it is produced, even if it has been frozen.
After the first 3-4 days of exclusive colostrum feedings, colostrum can be
alternated with fresh, mature milk.
o This provides the infant with protection from NICU pathogens via the
enteromammary pathway.
Store colostrum in small, sterile, food-grade containers.
o Commercial vials that are specifically made for the smaller volumes of
colostrum are available.
Number the colostrum containers in the order that they were collected.
Drops of colostrum can be diluted with 1-2 mL of sterile water to remove the
drops from the collection device and achieve the desired volume for feeding.
Colostrum should not be mixed with fortifier or commercial formula.
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Effective removal of colostrum from the
breast may require a combination of hand
expression and use of a hospital-grade pump.
Avoid formula during this time because it
may cause detrimental effects on the
intestinal mucosa.
Preterm breastmilk has increased levels of •
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Protein with an improved o Whey:casein ratio
o Balance of amino acids
Iron
Lipids
o More specific for the premature infant
 E.g. - Cholesterol, omega-3 fatty acids, long-chain polyunsaturated
fatty acids
Lactose
o This is the major carbohydrate in breastmilk.
o It is more readily absorbed by the premature infant.
Calcium:phosphorous ratio
Potassium
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Sodium*
Calcium*
Chloride*
Magnesium*
*Even greater than in term breast milk
Breastmilk also has increased levels of •
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Anti-infective properties such as o Immunoglobulins (especially IgA)
o Lactoferrin
o Leukocytes
Hormones and growth factors such as o Epidermal and nerve growth factors
o Erythropoietin
o Prolactin
o Calcitonin
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Steroids
Premature breastmilk offers •
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Mucosal membrane protection properties
Low solute load
Low osmolarity
Increased protein and fat absorption and digestion
Delivery of a premature or a sick infant of any gestation causes
anxiety for the parents. It may also make the mother reluctant to
breastfeed or even consider pumping to provide breastmilk for her
infant.
The mother's own health may be of concern.
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She may be too ill or too weak to express milk.
Maternal medications may suppress her milk supply.
Stress, worry, fatigue, or discomfort may negatively impact her milk supply
The baby's health and/or survival may also be uncertain.
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The ups and downs of the baby health may have a negative impact on the
mother's milk supply and/or her willingness to consistently pump.
If the baby does not immediately "latch on" she may question her own ability to
successfully breast feed.
Even when the mother's health is not an issue, continuing to provide milk or coming to
the NICU to nurse the baby is a challenge if •
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The baby is hospitalized for an extended period.
Mom has to return to work.
There are other siblings at home.
In addition to maternal issues, the premature infant has limitations such as •
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Poor suck-swallow-breathe coordination which is generally not effectively
coordinated until about 34-36 weeks gestation
Diminished ability to initiate suck mechanism due to low energy level
Immature oral-motor musculature
Poor neurobehavioral control
Sleepiness
Allow the infant to self-waken if possible, but awaken for feedings as
needed.
o As the infant matures, there is an increase in quiet alert states.
Oral stimuli that may result in oral aversion such as o Repeated and/or frequent endotracheal intubation and taping
o Oral and/or nasopharyngeal suctioning
o Orogastric tube insertions
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So, how do we go from good intentions to the mother and baby having a successful
breastfeeding experience?
In the past it was assumed that breastfeeding was “too much work” for the premature
infant and, therefore, couldn’t or shouldn’t be attempted. We now know this to be
untrue.
Learning to breastfeed a premature baby takes time and patience, as with any
breastfeeding infant.
The role of the nurse is to •
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Begin parent education on the benefits of human
milk as soon as possible - before birth if possible!
Facilitate maternal hand expression of colostrum
as soon after birth as possible.
Encourage skin-to-skin (S2S) contact with the
mother and baby as soon and as often as possible.
Offer individualized consultation with a Lactation
Consultant or a Lactation Educator as needed.
Support expression of breastmilk.
o Begin ASAP and continue around-the-clock.
o Provide privacy for pumping when mom is
with the infant.
o Provide pumping equipment, supplies, and freezer storage for milk.
Support breastfeeding in the infant, beginning with naso/orogastric feedings.
Minimize stimuli that may result in oral aversion
o Use nasogastric tubes instead of orogastric tubes.
o Secure ET tubes to decrease the need for repeated re-intubation.
o Extubate the infant as soon as it is medically sound.
Offer positive oral stimuli such as o Gently stroking of the infant's cheek
o Encourage non-nutritive sucking at mom's breast
o Pacifier
Recognize the premature’s cues to begin "at-breast" feedings
o The age of readiness varies with each infant depending on the infant's
maturation and overall condition.
o Avoid over stimulation.
o Consider non-nutritive sucking during nasogastric feeding when the
infant's post conceptional age approximates 30-32 weeks gestation.
Have mom empty her breasts prior to initiating breastfeeding to
allow the infant a "taste" of breastmilk but minimize the risk of
choking due to incoordination of sucking and swallowing.
Post-hospitalization resources may include o Follow-up visits with the hospital Lactation Consultant
o Women's, Infants' and Children's Program (WIC) offered through the
Public Health Department
o La Leche League
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Encourage parents to hold their infant skin-to-skin (S2S).
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S2S can be initiated as soon as the infant is stable enough
to be weighed.
Encourage S2S whenever parents are with their baby.
Don't worry if the infant begins to nurse.
S2S enhances milk let-down and influences the duration
and frequency of breastfeeding.
Explain expectations regarding •
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Personal hygiene
The handling of milk
Home storage of milk
Labeling and bringing in the milk
Give mom as much autonomy as possible
Non-nutritive sucking allows the mom and baby to “practice” and experience
breastfeeding before actually initiating breastfeeding.
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The baby may sleep, nuzzle, or latch-on during this time
However, it is not essential that the baby latch-on. Remember - this is practice.
Encourage breast pumping at least 8-10 times a day for 10-15 minutes each time,
initially.
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Begin milk expression as soon as possible after delivery - just as if the baby were
going to breast.
Once the mom's milk supply is established, mom should continue pumping until
a couple of minutes after the milk flow stops.
It is the frequency of pumping rather than the duration of one single pumping
that increases mom’s milk supply.
Facilitate the pumping and collection of breastmilk by -
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Providing a hospital-grade electric pump for use when mom spends time with her
baby.
o This is the most efficient method to establish and maintain an adequate
milk supply.
o Provide sterile containers and caps for transportation of milk to the
nursery.
Providing information on obtaining a hospital-grade pump for home use.
Facilitating the use of a double pump collection kit to optimize milk yield.
o This increases the amount of milk pumped in the least amount of time.
o Encourage mom to pump for a couple of minutes after flow stops to
completely empty the breasts and to stimulate milk production for the
next feeding.
Maintaining an adequate milk supply
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Remember - it is a matter of supply and demand. So, encourage frequent,
consistent pumping.
In order to maintain an adequate milk supply, the goal is for mom to produce a
minimum of 350 mL per day.
o Ideally, milk production should be 500-1000 mL per day.
Facilitate early expression of milk.
Encourage mom to keep a pumping log.
Reassure and support mom.
The first oral feeding should be at the breast.
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Teach mom about the cues that indicate her baby’s readiness for the first breast
feeding.
Encourage her to be available for as many feedings as possible.
Develop a policy allowing a delay in first at-breast feeding.
Delay should be for a specified time.
o e.g. no more than 4 hours.
Gavage the baby while waiting for mom’s arrival.
Coordinate feeding times so that mom can feed when she arrives.
Maternal Medications
Ask mom to inform the staff when she takes any drugs.
Instruct her on how to label the breastmilk with the medication,
dose, date, and time taken.
If the mom is taking any drugs that are contraindicated in the preterm •
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Have her pump and freeze milk.
Save for a time when the baby is older and bigger since he may tolerate it better
at that time.
Check with physician before using the milk.
Pain medication
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Pain can interfere with release of oxytocin which helps with milk flow.
o Manage mom’s pain as much as possible.
Make mom aware pain medications may make baby sleepy.
As healthcare providers, we spend a lot of time educating and
preparing the mother and baby for breastfeeding. .......but what
about the dad?
When caring for the mother and baby you might explain to him •
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The benefits of breastfeeding.
Mom will need his support and encouragement.
Breastfeeding saves time and money.
o He won't have to help with making bottles.
o He won't have to buy formula.
Some of the things the dad can do to help with his new baby include •
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Providing hands-on baby care.
o This helps to establish closeness with the baby.
o It also gives mom a break from caring for the baby.
o Dad can change diapers, give the baby a bath.
Participating in feeding time with mom by o Giving support and encouragement
o Burping the baby
o Enjoying family time
o Hold the baby S2S after feedings
Helping with household chores.
o This saves time so that the work is done quicker.
o This helps free up time for mom and dad to talk, share, and be together.
Support mom’s decision to breastfeed if questioned by family and friends.
"Breastfeeding well"
"Breastfeeding fair"
"Breastfeeding poorly"
Defining how well the baby has fed is confusing for staff and can be very confusing for
the family.
Breastfeeding “WELL” might include the following
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The baby latches-on.
The baby is sucking rhythmically, and swallowing
is audible.
Mom needs minimal assistance with positioning
the infant.
Mom states that her breasts feel less full after feeding.
Breastfeeding “FAIR” might include the following behaviors •
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The baby occasionally latches-on.
The baby has short bursts of sucking, and swallowing is audible.
Mom needs assistance maintaining the infant's position.
Mom states that her breasts feel full after feeding.
Breastfeeding “POORLY” might include the following behaviors •
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The baby does not latch-on but roots or licks at the breast.
Mom needs assistance with getting the baby properly positioned.
Mom states that her breasts remain full after feeding.
To determine the amount of milk transfer from the mother to the baby, some
institutions may use pre- and post-weights in association with the monitoring of wet
diapers and weight gain.
Whatever criteria you use or however you define “well,” “fair,” or “poor” breastfeeding •
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Educate the staff.
Use definitions consistently.
Explain to mom.
Once at home the preterm infant should •
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Appear healthy
Have firm skin
Have good color
Be gaining weight
Breastfeed 8-12 times in 24 hrs
Have pale, yellow urine
Have 5-6 wet diapers per day
Have the following stool pattern o At 5-6 days of age stools are greenish yellow
o After 5-6 days of age, stools are soft and mustard colored
o By day 5 of life, 2-5 stools per day
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American Psychological Association. (2010). Publication manual of the American
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Hake-Brooks, S.J. & Anderson, G.C. (2008). Kangaroo care and breastfeeding of
mother-preterm infant dyads 0-18 months: A randomized, controlled trial. Neonatal
Network, 27(3), 151-159.
Hale, T.W. (2010). Medications and Mothers’ Milk: A Manual of Lactational
Pharmacology. Hale Publishing, L.P.
Jackson, P.C. (2010). Complementary and alternative methods of increasing breast
milk supply for lactating mothers of infants in the NICU. Neonatal Network, 29(4),
225-230.
Kent, J.C., Prime, D.K., and Garbin, C.P. (2012). Principles for maintaining or
increasing milk production. JOGNN, 41(1), 114-121.
Kim, J.H. and Froh, E.B. (2012). What nurses need to know regarding nutritional
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during and after the NICU stay. Clin Perinatol 37, 217-245.
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Neonatal Intensive Care, 7th Edition. St. Louis, MO: Mosby Elsevier.
Myers, D. and Rubarth, L.B. (2013). Facilitating breastfeeding in the neonatal
intensive care unit: identifying barriers. Neonatal Network, 32(3), 206-212.
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