Breastfeeding for Preterm Infants

DR. Varsha Atul Shah

Breastfeeding for Preterm Infants

• Mother’s feelings• Advantages of breastfeeding a premature baby• Building a relationship between mother and baby• LBW Premie (BW >1500g)• VLBW Premie (BW <1500g)• Determining baby’s readiness to breastfeed• The first nursings• Use of nipple shield

THE MOTHER’S FEELINGS

The Mother’s FeelingsMother’s Feelings

• May be in shock, making it difficult for her to remember information.

• May doubt her ability to breastfeed.

What we can do• Patience is needed. Give a written

information to which she can refer.• Reassurance and encouragement. • Explain what she needs to know at

this stage – importance of beginning frequent milk expression.

• Keep information brief and to the point.

• Be available to talk on a regular basis as circumstances change and she begins to come to terms with her situation.

The Mother’s Feelings

Mother’s feelings• May pass through the stages of grief,

including shock, denial, anger, bargaining, depression and finally acceptance.– She may feel overwhelmed.– She may feel as though her body has failed

her and her baby.– She may feel anger, guilt and depression.– Her questions may center around finding

reasons for the baby’s problems.– She and her husband may blame themselves

or each other while searching for a reason why the birth occurred early.

– Their anger may be directed at the hospital staff or the doctor.

– May have feelings of helplessness, loss of control and isolation.

– She may have crying bouts and develop physical symptoms eg, insomnia, eating problems or fatigue.

What we can do• Recognize that strong feelings are

normal, if the mother feels so overwhelmed, encourage her to seek the help of a psychiatrist.

• The mother and father may be in different stages of grief at the same time, impairing their ability to communicate with and comfort each other.

• Give mother positive reinforcement and suggest specific ways she can keep in touch with her baby.

• Suggest a support group – may benefit from spending time with others going through the same experiences.

What can influence mother’s breastfeeding choices?

Mothers who choose to breastfeed• Deciding to breastfeed is a

healthy reaction to feelings of guilt and helplessness.

• Breastfeeding increases her feelings of being in control and gives her tangible way to “make it up to her baby” and lessen her feelings of guilt.

Mothers who choose not to breastfeed• The emotional commitment to

their baby makes them feel more vulnerable.

• May be afraid to become too attached to their baby in case he dies.

• May decide not to breastfeed or postpone expressing her milk until her baby’s condition stabilizes.

If a mother has mixed or negative feelings about breastfeeding?

• Baby receives the greatest benefit from his mother’s milk during his 1st few weeks and that the mother could approach it as a temporary commitment.

• Assure her that if decides to quit after a week or two, her milk will already have given her baby valuable protection from infection.

• It is much easier to stop expressing milk after two weeks than it is to start expressing them.

“Say this in a caring way with respect that the decision rests with the mother.”

ADVANTAGES OF BREASTFEEDING A PREMATURE BABY

Breastfeeding advantages over formula• Easier to digest and better tolerated by the premature baby.

– Proteins in human milk are more completely broken down and better absorbed.– Tube feeding tends to be established earlier and with fewer problems.

• Contains lipase – helps baby digest milk fat more efficiently.• Anti-infective and anti-inflammatory agents to protect from potentially

serious bacterial infections.– Premature baby’s immune system is immature, he is at greater risk of

developing a variety of infections and is less able to cope with them should they occur.

• Better vision in premies – due to the types and ratios of fatty acids in human milk that are absent in formula.

• Higher intelligence and improved motor development.– Breastfed premies scored an ave of 8.3 points higher on IQ tests than formula-

fed premies– Dose-related

• An array of hormones and enzymes in human milk including various growth factors have been found to be important to the maturation of the baby’s brainstem.

• Breastfeeding brings the mother and her baby closer.

Preterm milk vs Donor human milk

Preterm milk• Mother’s own preterm

milk can be given fresh to her baby.

• Contains more antibodies than term milk.

• Higher in certain nutrients eg, protein, sodium, iron and chloride.

Donor milk• Donor milk must be

pasteurized, which kills the live cells that fight infection.

“All preterm infants should receive human milk, with pasteurized donor milk rather then premature formula, the preferred alternative if a mother is unable to provide adequate volume.”

Evidence: Decreased rates of late-onset sepsis, NEC, ROP. Fewer re-hospitalizations in the first year of life. Improved neurodevelopmental outcomes. Lower rates of metabolic syndrome, lower blood pressure, lower LDL levels,

less insulin and leptin resistance when they reach adolescence. Decreased NEC – most compelling evidence

Dose response effect of human milk feeding (for each 10ml/kg/d increase in human milk in the diet there is a 5% reduction in hospital readmission rate).

Changes in milk composition over time

BUILDING A RELATIONSHIP BETWEEN MOTHER AND HER PREMATURE BABY

“It is more challenging for the mother of a premie to form an emotional bond with her baby”

Reasons..• Mothers feel more vulnerable

to even greater trauma if her baby should die.

• Mother may find her baby’s appearance upsetting.

• Mother’s inability to touch or hold her baby will affect her feelings towards him.

• A premature baby may not be able to respond.

Ways to help mother feel closer to her baby..

• Encourage mother to help with her baby’s care.• Watch her baby’s cues so that he doesn’t become

overstimulated.• Spend as much time as she can with her baby.• Other suggestions..

– Name the baby and use the name when talking to him and about him.

– Change and feed baby whenever possible.– Ask questions and let staff know what she thinks and how she feels.– Leave a photo of the family in the baby’s incubator.– Take pictures of the baby to keep a record of his progress.– Keep a record of the baby’s changes to make small improvements

more obvious.

Kangaroo Care• Gives premies warmth, physiological

stability, good sleep and comfort through skin-to-skin contact.

• Provides opportunities for early breastfeeding.

• Mothers who give kangaroo care tends to breastfeed longer and more frequently.

• Mothers feels more confident about caring for their babies in the hospital and about bringing their babies home than mothers whose babies received conventional care.

• Increases mothers’ milk volume

LOW BIRTH WEIGHT PREEMIE

BW >1500g

Low Birth Weight Premie (BW >1500g)

• Usually born at >30 weeks gestation• If healthy – the larger premature baby may be able to

breastfeed within the 1st hour or 2 of birth.– May have a weak suck– Watch for feeding cues

• If ill or not yet ready – many considerations will be the same as for the tiny premie.– Extended hospitalization– Long-term milk expression– When to begin breastfeeding

• Larger premature babies tend to grow well on their mother’s milk without the need for vitamins or mineral supplements.

VERY LOW BIRTH WEIGHT PREEMIE

BW <1500g

Feeding Methods and Options At first, the baby may be fed thru IV or by NG/OG tube.

– Place the baby skin-to-skin at the mother’s breast during feeding.• Colostrum and mature milk are better tolerated than formula

– Contains growth modulators – help premie’s digestive system adjust to oral feeding.

• Mother’s own fresh milk is better than frozen or donor milk– Higher anti-infective properties and nutrients (eg, nitrogen, protein

nitrogen, Na, Cl, Fe, fatty acid)– Changes over time in keeping with baby’s needs which changes as he

grows.• When human milk is in short supply or unavailable, special preemie

formula can be used.• May need to be fortified to meet all the baby’s nutritional needs.

– Calcium, phosphorus, protein, Na and vitamins.

Human milk fortification

1. Lacto-engineering Ideal Human milk is processed and specific components added to

EBM eg, Human milk protein culled from banked human milk Add extra high-fat hind milk to EBM

2. Human milk fortifiers Derived from cow’s milk.

Powdered fortifiers – used when there is enough human milk to provide necessary volume.

Liquid fortifiers – can be used to increase the volume of human milk feeding if in short supply.

Foremilk and Hindmilk

Feeding Methods and Options

• If weight gain is a concern, assess milk production.– Give more high-fat hindmilk – express at least 10-15 minutes per

breast, longer if the flow continues at a steady rate.– Continuous feeding system – greater milk fat losses.– Intermittent feeding – orienting the syringe in an upright position

decrease fat losses from 48% to 8%.• A mother who thinks her milk may not be meeting her baby’s

needs may be depressed.– Needs reassurance and support.

• Her milk is better for her baby than any type of formula.• The need for supplementation is temporary.• Infant formula must be also supplemented with extra nutrients to meet a

premie’s special physical needs.

– Help her to communicate her feelings and goals to staff.

1. Before expressing milk, mothers wash their hands thoroughly, giving special attention to fingernails and nail beds.

2. An electric breast pump with automatic cycling be used. Hand expression, manual, battery, or small electric pumps are considered inadequate for most mothers to establish and maintain a good milk supply, esp when they must pump for a long time.

3. Each mother use her own collection kit.

4. All parts of the collection kit that touch the milk be cleaned after each use with hot soapy water, thoroughly rinsed, then placed on a clean towel, covered with another clean towel, and allowed to air dry. Washing is a dishwasher is also acceptable.

5. In areas where water is contaminated, boiled or bottled water be used for cleaning pump kits.

6. The expressed milk be labeled with the date, the baby’s name, the baby’s hospital ID, any illnesses in the family, and any medication(s) the mother is taking.

7. Milk is stor eight ounces should not be used.

8. Colostrum and early milk may be “layered” – a mother may chill and add milk to the same container from different pumpings in order to get a full feeding.

9. Storage containers be hard-sided and made of glass, polycarbonate (clear, hard plastic) or polypropylene (cloudy, hard plastic) with solid caps that provide an airtight seal.

The challenges of expressing milk..• Most mothers do not get much milk during the first few days.

– Use 1ml or 5ml syringe to measure the milk expressed may help mother feel better.

• Mother may become discouraged if not able to express large quantities of milk immediately.– Assure the mother that no amount is too small to save for the baby.

• If there is a concern about bacteria levels in the EBM.• The KEY to establishing and maintaining a full milk supply over time while

expressing is to express milk early and often, express long enough to drain the breast and stick to a daily routine.– Begin ASAP, ideally within 6 hours of birth.– 10-15min/breast at least 8-10x/day.– Pump at least once during her normal sleeping hours.– Pump long enough (2 minutes after the last drop of milk or for 30 minutes

whichever comes first).• Using an effective breast pump is critical to establishing good milk

production.– Double-pumping cuts the time spent in half and increases milk supply more

quickly.

How do you know if mother is expressing enough milk?

• By Day 10– Ideal:

>750ml/day or 90-120ml/pumping

– Borderline: 350 – 500ml/day

– Low: <350ml/day

Ways to keep milk supply

• Holding and touching her baby may help the mother express more milk.

• Mother-to-mother support groups and encouragement from health care providers can be critical in establishing good milk supply and in motivating a mother to continue in her effort to provide milk for her baby.

• Other strategies to boost milk supply:– Plan “frequency days” – at 2-3wks, 6wks & 3mo.– Express longer – pump until 2min after the last drop or for 30min

whichever comes first.– Consider medicinal herbals – eg, herbal teas, fenugreek with or

without blessed thistle.– Consider prescription medicines – eg, domperidone, metoclopramide

When baby is going through a crisis..

• It is normal for a mother’s milk supply to temporarily decrease.– Assure her that the decrease in supply is

temporary and will increase again as baby’s condition improves.

– Talk to another mother of a premature baby who has gone through a similar experience.

– If appropriate, arrange a more skin-to-skin contact with her baby before milk expression as this may enhance milk let-down.

DETERMINING A BABY’S READINESS TO BREASTFEED

“Breastfeeding is less stressful than bottlefeeding.”

When a premie is ready..

• If the baby is ready to be fed by mouth, breastfeeding is less stressful than bottle-feeding.– Common assumptions include:

• Breastfeeding is too stressful for babies weighing <1500g.• Babies cannot coordinate sucking and swallowing enough to

breastfeed until they reach 34-35 wks gestation.• Babies must be able to bottle-feed before they can breastfeed,

because breastfeeding is more “difficult”.– Premies’ ability to effectively breastfeed by gestation. (Nyqvist

1999)• 28 weeks – root and grasp• 30.6 weeks – some nutritive sucking• 36 weeks – exclusively breastfeed

When a premie is ready..

• Practice at completely or partially drained breast.– 30-32 week babies– Fluid-restricted babies due to other medical problems

When a premie is ready..

• Go directly from tube feeding to the breast – without giving bottles.– Babies who were supplemented as needed by NGT

feeding were 4.5x more likely to be breastfeeding at hospital discharge and >9x likely to be exclusively breastfed than babies supplemented by bottle. (Kleithremes 1999)• If feeding went well, no supplement was given.• If breastfed only fairly (latch-on but didn’t keep up the sucking rhythm for

very long & few swallows were heard) – baby received half of the usual feeding via NGT.

• If rooted or licked the breast but did not latch on or suck – he received a full feeding via NGT.

When a premie is ready..• Cup-feeding rather than bottle feeding

– Breast-refusal from early use of artificial nipples is rare in most East African hospitals because bottles were never used. (Newman, 1990)

– Lang 1994• Babies could successfully feed by cup as young as 30 wks gestation.• More babies who received supplements by cup were fully breastfeeding

at hospital discharge than those who received supplements by bottle (81% vs 63%).

• During cup-feeding, premies maintain satisfactory HR, breathing and SpO2 levels.

• Gives baby more control over milk intake than bottle-feeding and involves tongue movements that are important for successful breastfeeding.

• “Lapping” involves extending the tongue over the lower gum, is important for effective breastfeeding, but babies who sip from the cup does not learn the same tongue movements.

When a premie is ready to breastfeed..• Cup-feeding

– Concerns: • Amount of milk taken and

amount of spillage (up to 38.5%).

• Risks of aspiration.

– Technique is critical.• Baby should be upright. • The liquid is just high

enough so that the baby can sip or lap it in, but not so high that it is poured into his mouth.

When a premie is ready..

• A variation on the cup, feeding vessel called a “paladai”.– Low bowl with a spout,

shaped like "Alladin’s Lamp”.

– Milk is poured into the baby’s mouth through its spout.

– No reported cases of aspiration.

– Less spillage than cup.

When a premie is ready..

• Evaluate individually for readiness to breastfeed.– Baby’s overall condition.– How well the baby tolerates milk fed by gavage.– Baby’s ability to coordinate sucking, swallowing and

breathing.– Whether the baby can maintain his body

temperature outside incubator.• In some hospitals, premature babies are

breastfed without the use of bottles.– US, parts of Africa and India, England

When a preemie is ready..

• If the mother choose to use a bottle, find ways to make the transition to breastfeeding easier.– Bottle with long nipple– Softer nipple– Baby should be well supported during feedings.

• Bottle feeding in a breastfeeding position.• Sitting baby in a supported upright position.

– Latch the baby onto the bottle as she would the breast.• Touching the baby’s lips with the nipple and waiting until he opens

wide.• Allow the baby to draw the bottle nipple well into his mouth rather

than pushing it in.• Avoid latching the baby onto the tip of the rubber nipple with a tightly

closed mouth.

When a preemie is ready..

• Feed on cues (on demand) rather than a fixed feeding schedule.– Saunders 1991

• Compared 2 groups of stable premies weighing ≥1550g (1 group cue-based feeding, 1 group fixed feeding schedule).

• Babies on cue-based feeding feed well, no problems with overfeeding, same weight gain as babies fed on schedule despite taking less milk and took longer rest periods.

• Cue-based fed babies were discharged earlier and it allowed parents to learn their babies’ hunger cues before discharge making the first weeks at home easier.

• Knowing how much milk baby receives while breastfeeding can be important – use of special electronic scale.– Olympic’s SMART scale, Medela’s Baby Weigh scale

THE FIRST NURSINGS

Setting the Scene..

• Depending on gestational age, early feedings may take time and patience.– May take several breastfeeding sessions before the baby nurses

well.– Baby may simply lick or mouth the nipple at first.– Many premies start by sucking in short burst and fall asleep

quickly.– Assure the mother that it is alright if baby does not receive much

milk in these early nursing.

• Support and realistic expectation help early

feedings to go more smoothly.– A lactation consultant can be with her the first time

she puts the baby to the breast.

Cross-cradle (Transitional hold)• Position herself comfortably with enough support behind.• Hold baby with the arm opposite the breast at which he will feed. Support the baby at

breast height so that his head, neck and hips are supported in a straight line.• With the hand holding the baby’s head, suggest the mother position her palm on baby’s

upper back, supporting the baby’s head with thumb and fingers behind the ears.• Use same-side hand to support the breast and use the “U-hold” so that her elbow is in a

comfortable position.• Position the baby’s nose at the level of nipple and adjust the baby’s position just to the

right of the L breast with his head tilted slightly back, so that when he is pulled on by his shoulders, he latches on to the breast chin first.

• Move the baby gently toward and away from the breast, tapping his lips lightly with the breast and wait until he opens wide, like a yawn.

• As he open his mouth, pull him on the breast chin first. (Bring the baby to the breast, not the breast to the baby)

• Apply gentle pressure on the baby’s shoulders throughout the feeding using thumb and index finger to support his head and prevent him from turning away. This gentle pressure also helps the baby keep more of the areola in his mouth, which minimizes soreness and maximizes the amount of milk he will be able to get.

Football (Clutch hold)• Using her L hand, position her palm on baby’s upper back,

supporting the baby’s head with thumb and fingers behind the ears to avoid triggering the rooting reflex. Avoid putting hand or fingers on the back of baby’s head, as most babies react by arching back when their heads are pushed to the breast.

• Tuck the baby’s body under her L arm on her L side, so baby is far enough under the breast so that he doesn’t have to bend his neck to latch on. The baby should not have to stretch or turn his head to reach the mother’s nipple.

• Use a pillow or two under the baby and under her forearm to bring the baby up to the level of the nipple.

• Use her R hand to support the L breast using the “C-hold”.

Putting the baby to breast..

• Need practice and encouragement to open wide – like a yawn – and latch on well to the breast.

Putting the baby to breast..

• If the baby has trouble staying on the breast, he may need more support. The mother also may need to support her breast throughout the feeding.

Putting the baby to breast..

• Breast compression in combination with good latch-on may help keep a premie active at the breast.

Putting the baby to breast..• Switching back and forth from breast to breast

may be too tiring for a tiny premie.– Baby nurse well from only one breast.– Watch for baby’s cues to avoid overtiring or stressing

him.

• An overheated baby may suck less vigorously.• He may need extra time to get the milk flowing.

– Evaluate individually.– May take a little extra time at the breast to stimulate

his mother’s let-down reflex.

USE OF NIPPLE SHIELDS

Nipple shields• Helps to latch on and

take more milk.• Babies are able to suck

for longer bursts and stay awake longer.

• Compensates for the weak suction.– Maintains the position of

the breast in the optimal part of the baby’s mouth.

Thin silicone nipple shields

• Must have good fit– Length:

• Too long – cause baby to gag.• For most premies 2-2.5kg – shorter nipple shields will be the best fit.• <1.3kg – even a short nipple may be too big, baby’s mouth may need

to grow more before he is ready.• Ideal teat length:

– Measure baby’s mouth by letting baby suck on clean finger, pad side up.– Allow finger to go to baby’s palate where the soft and hard palate meet.– Mark with pen where the baby’s lips close.– Range 1.9 – 3.1cm– Nipple shield range in size 1.9 – 6.4cm

– Width: • Wide enough to accommodate mother’s nipple.

2 Styles of nipple shields

Circular nipple shield

• Complete circle of soft silicone with a firmer tip that protrudes like a nipple.

Contact nipple shield

• Has a soft brim with a cut-out area.

• Cut-out area – where the baby’s nose is placed during breastfeeding.

Latching on to the shield..

• Baby needs to open wide and latch on to the softer brim surrounding the firmer tip of the shield to extend back far enough.

• If baby latched on shallowly to the firm tip of the shield, it will not go into the back of his mouth and trigger effective sucking.

• If can see any part of the firmer tip of the shield while the baby nurses, the baby needs to be removed from the breast and latched on again.

Breastfeeding for Sick Term Infants

Breastfeeding for Sick Term Infants

• When baby is acutely ill– Neonatal hypoglycemia– Vomiting– Reflux– Diarrhea– Cold or ear infection

• When baby has chronic illness or physical limitations– Cardiac problems– Cleft lip &/or cleft palate– Down syndrome– The neurologically impaired baby

“When baby is ill..”

When baby is ill..

• Human milk offers important benefits.– It is easy to digest.– Provides immunities to help fight sickness.– Offers a familiar taste in unfamiliar surroundings.– The sucking and closeness will be a source of comfort.

• If baby loses interest in nursing.– The mother may need to express her milk for her own comfort,

to keep up her milk supply and to provide milk for her baby.

• A lethargic baby can be given his mother’s milk in other ways eg, tube feeding.

When baby is ill

Common Condition What to do

Neonatal hypoglycemia

• In most cases, frequent nursing is all that is needed.• Treatment of documented hypoglycemia should not

be withheld in the exclusively breastfeed baby.

Vomiting • For some babies, it is not unusual to spit up after nursing.

• Regular projectile vomiting could be a sign of pyloric stenosis.

• In rare cases, vomiting may be a symptom of metabolic disorder that precludes breastfeeding.

• If baby is ill and vomiting, he will benefit from continuing to breastfeed. Ice chips may help.

• The danger is dehydration, know the signs and how to prevent it.

• Temporary weaning is not beneficial.

Cold / Ear infection • If refuses to nurse, use cup/spoon/dropper.

When baby is ill

Common Condition What to do

Reflux (GER) • Simple strategies eg, feeding position at 30-40°angle, small frequent feedings.

• Rule out allergy or cow’s milk protein sensitivity.• Common advice to “thicken feeds”.• Switching from human milk to formula not advocated

– human milk empty from the stomach 2x as quickly as formula.

Diarrhea • Baby will almost always benefit by continuing to breastfeed.

• Maximize the amount of hind milk her baby receive at the breast.

• May indicate the baby is sensitive to a food or medication mother is passing into her milk.

• The danger is dehydration, know the signs and how to prevent it.

• Temporary weaning is not beneficial.

WHEN BABY HAS CHRONIC ILLNESS OR PHYSICAL LIMITATION..

“The parents may need to go through a grieving process of giving up the baby they imagined in order to accept the baby in their arms”

The Mother’s Feelings

Mother’s feelings• Parents of baby with special

needs may be coping with feelings of disappointment, anger, helplessness and guilt.

• If breastfeeding is not going well,– Mother may blame herself and

believe that the difficulties reflect on her inability to care for her special child.

– Blame her child’s physical disorder for normal infant behavior (eg, fussiness).

What we can do• When offering information and options,

it may need to be repeated several times before she can use it. Written information may be more helpful.

• Listen and acknowledge her feelings.• Encourage her to take it one day at a

time, pay close attention to her baby’s cues as she tries to find ways that work for them.

• Focus on the normal aspects of the baby.– Focusing on the normal can help the

mother see her child as a baby first and a baby with a physical problem second.

• Refer to an appropriate support group.

Congenital heart disease• Usually gain weight very slowly even if receiving enough

nourishment.• Breastfeeding is less stressful and more energy-efficient than

bottle feeding.– More energy-efficient heart rhythms, lower HR and expended less

energy. (Zeskind 1992)– Shorter hospital stay and gain more weight. (Combs and Marino 1993)

• Some babies can be breastfeed exclusively, others may need to be supplemented.– Additional hind milk can provide the baby with more calories.– Supplement by nursing supplementer or other methods (eg, cup, spoon,

bottle, eyedropper, feeding syringe).• If supplementing causes the mother to question the value of her

milk or her milk supply, assure her that these are not the problem.– Babies with weak or uncoordinated suck improves with medication.

Cleft Lip and/or Cleft Palate• One of the most common birth defects.• May occur together or separately.

– 1/3 cleft lip only– 1/3 cleft palate only– 1/3 both cleft lip & palate

• Cleft Palate– Cleft of soft palate– Cleft of both soft and hard palate– Cleft of hard palate only (rare)

• Muscle of soft palate are used for swallowing – a large cleft of soft palate can have major effect on the baby’s ability to feed.

• “Submucosal cleft” – an opening of muscle or bone beneath the intact skin.– May not affect feeding – unlike other types of cleft palate, the baby is able to

seal off the mouth and generate suction.

“Breastfeeding and human milk are important to the health of a baby with a cleft lip and/or palate..”

Breastfeeding and Cleft Lip / Palate

• More normal ear, respiratory and overall health.– Babies with cleft palate tend to have more ear infection – eustachian tube and muscles of the palate are not

functioning – fluids can accumulate in the middle ear and may become infected.– Immunities in human milk provide protection against infection.

• Non-irritating fluid.– Leakage of human milk into a baby’s nose is less irritating to the baby’s mucous membranes than formula.

• Closeness between mother and baby.– Cuddling time with skin-to-skin contact is calming and comforting for both mother and baby.

• More normal development of the baby’s mouth and face.– Muscles becomes stronger and more developed with practice – more normal formation of the muscles of the

face.– Promotes speech and language development.

• Feeding advantages– Breast is more flexible than a rubber nipple, allowing it to mold itself to compensate for many abnormalities in

the lip and mouth.– Baby has more control over the flow of milk and position of the breast in his mouth.– By positioning the baby above or below the breast, the direction of the milk flow can be changed to

accommodate how fast the milk is flowing, the baby’s individual sucking pattern and the location of the baby’s defect.

– Allows the baby to suck for comfort as well as for food. When a baby is fed by bottle, there is less comfort sucking, and babies with cleft defects often find it difficult to use a pacifier.

When to start?

• Encourage the mother of a cleft-affected baby to begin breastfeeding ASAP after birth, trying different nursing position.– Start life with the protection from infection provided by

concentrated antibodies in the colostrum.– Easier for baby to latch on and learn to milk the breast while the

breast is still soft. • By 3rd-4th day, breast become firmer and fuller and may be more

difficult for her baby to grasp, suckle and stay latched on.

– Early practice will help baby to remember how to nurse if breastfeeding must be interrupted due to corrective surgery.

– Facilitates attachment between mother and baby.• Keeps the mother’s focus on an important and normal task that require

her to interact with her baby.

“Tell the mother to expect feedings to be time-consuming during the first few weeks, no matter how the baby is fed..”

Challenges..• Mother may need to spend most of her baby’s waking hours feeding him.

• Whether fed by breast or bottle, a baby with a cleft lip and/or palate may take up to 2-3x longer to feed than baby without cleft defect.

• Mother will need to try different strategies to help make feedings go smoothly for her and her baby.

Cleft lip with intact palate

• Can usually nurse at the breast even before surgery.

• May be difficult for the baby to form a seal on the breast.– Depending on the location and

extent of the cleft, one breastfeeding position may be more effective than another.

– Mother can help baby form a seal and maintain suction by positioning their nipple to one side and use their thumb to fill the space above baby’s upper lip.

– Mother’s thumb can also be used to fill the space in babies with alveolar ridge defect.

Cleft Palate• Usually has difficulty feeding at both breast and bottle. The amount of

difficulty will depend upon the severity and location of the cleft as well as other factors.– It is impossible for the baby to seal off his mouth and create suction typically

used to keep the breast (or bottle) in place and pull the milk to the back of his mouth.

– Any milk the baby receives can flow through the opening in the palate and into the baby’s nasal cavity, causing choking.

– A wide cleft of the palate may make it difficult to locate an area on the upper palate that the baby can press the breast or bottle against to express milk.

• Even with good technique and use of a device exclusive breastfeeding remain an elusive goal.– From birth, the mother needs to begin expressing her milk after feedings in

order to ensure adequate milk production.– Encourage mother to be patient, to experiment to find what works best for her

and her baby and to seek support.

"Well-supported, upright nursing position”

Modified football position

– With mother sitting on a bed, have her sit the baby upright facing her at her side, with his legs along her side and his feet at her back.

– His bottom should be on the bed or a pillow at breast level with pillow behind his back.

– Mother can support the baby’s back with her upper arm and the base of his head with her hand.

– Mother may need to support her breast with the C-hold (thumb on top, 4 fingers underneath well back from the nipple).

– Lean forward until baby latches on, lean back again once baby is nursing to avoid backache.

Straddle position

– Mother sit her baby in her lap facing her, with his legs straddling her abdomen.

– If baby is small, it may be necessary to raise him to breast level by putting pillows under him.

– Mother need to tip the baby’s head back as little as baby latches on so she can position him carefully.

Dancer Hand Position• When baby need jaw and chin

support to nurse well.– Support her breast with the C-hold

(thumb on top, 4 fingers underneath)– Slide the hand supporting the breast

forward, supporting the breast with 3 rather than 4 fingers. Her index finger and thumb should now be free in front of her nipple.

– Rotate her hand around the breast so thumb and index finger form a “U”.

– Bend her index finger slightly so it gently holds the baby’s cheek on one side while the thumb holds the other cheek. The baby’s chin rests on the bottom of the “U”.

Haberman Feeder (Special Needs Feeder)

• Feeding device designed for babies with feeding problems.

• Special nipple does not require suction, has a slit valve that allows milk flow to be controlled so that the baby is not overwhelmed with milk.

Palatal Obturator• A plastic plate that is placed over the

opening in the palate and shaped to cover it.

• Used before corrective surgery.– To keep the cleft in the baby’s hard

palate from closing in an improper way.– Although it doesn’t allow the baby to

create a vacuum inside his mouth, it provides a firm surface on which baby can press breast or bottle nipple with his tongue during feedings.

• May be fitted as early as 24hrs after birth or as late as several weeks after birth.

• Needs to be replaced as baby’s mouth grows.

• If breastfeeding, request a smooth rather than a rough plate so it will be less irritating to the nipples.

Palatal obturator + Haberman feeder

• Decreases feeding time to half.• Marked increase in milk consumption.• Crying and later speech sound more

normal.• Reduction in the size of defect.• Positive effect on the family.• More normal sucking assists growth and

helps with feeding.

Down Syndrome• Breastfeeding may take longer than usual – low muscle tone (“floppy”) and a weak

suck. Muscle tone and sucking will improve with time and practice

• Often placid and sleepy – mother may need to set the pace for feeding Frequent feedings throughout the day Fully awaken the baby before offering the breast and stimulate him to stay

interested throughout the nursing Give lots of touching and attention to stimulate him Kangaroo care to provide skin-to-skin contact

• When positioning, keep baby’s body horizontal using pillows as support• If gulping and choking are a problem, position the neck and throat higher than the

mother’s nipple.• Tongue may protrude causing difficulty latching on to the breast.

Try an exercise “pushing the tongue down and out" before putting baby to the breast.

• May need jaw and chin support Provide extra support during nursing by using the “Dancer Hand Position”

• If not nursing effectively and not gaining weight, mother may express her hind milk and offer it as a supplement

“Learning to take one day at a time and to focus on the baby as a unique individual will help parents cope in the short and

long run...”

The Neurologically Impaired BabyHypertonic babies Hypotonic babies

• Babies who clamp down and clench their jaws at feedings.

• Gentle rocking before feedings – to calm and relax baby and decrease muscle tone enough for the baby to feed more effectively.

• Side-lying position with baby’s body resting on a firm, stable surface rather than on the mother’s arm.

• For baby who is tongue thrusting or has his tongue retracted – mother to help him learn more effective tongue movements on her fingers before putting him to the breast.

• Use nipple shield with or without nursing supplementer.

• Weak suck and low muscle tone.• May breastfeed more effectively if

provided with some extra stimulation and/or flow at the breast.

Swaddling and flexing baby at the hips.

Feed when breast feels fuller or firmer.

Help stabilize his tongue – apply gentle pressure behind the bony part of the chin directly under the floor of the mouth.

Firmly patting the baby’s lips before feeding if milk is dribbling during feeding.

Apply downward and forward pressure on the tongue if baby has protruding tongue.

• Use of nipple shield – babies with problems latching on and sucking effectively.

• Nursing supplementer – provide faster flow.

Nursing supplementer

• Allows the baby to receive supplements through a tube taped to a mother’s breast.• Helps baby learn a more effective sucking pattern because extra milk baby gets from

the supplementer stimulates him to swallow and consequently suck more effectively.• As the baby begins to suck more effectively, he automatically takes more milk from the

breast and less from the supplementer.• Gauge baby’s progress by how much of the supplement is left after nursing.• Can be used with a nipple shield to provide both flow and a firmer feel.

Thank you!