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:

• 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.

• 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).

• 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.

• 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.

• 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.....

• 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.....

• 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.

• 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 -

• 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 -

• Polio • Tetanus • Diphtheria • Haemophilus influenzae • Respiratory syncytial virus (RSV)

Infants who are fed human milk have lower rates of the following illnesses -

• 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.

• 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 -

• 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.

• 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 -

• 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

• Sodium* • Calcium* • Chloride* • Magnesium*

*Even greater than in term breast milk

Breastmilk also has increased levels of -

• 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

o Steroids

Premature breastmilk offers -

• 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.

• 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.

• 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 -

• 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 -

• 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

o 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

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 -

• 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

Encourage parents to hold their infant skin-to-skin (S2S).

• 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 -

• 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.

• 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.

• 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 -

• 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

• 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.

• 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 -

• 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

• 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 -

• 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 -

• 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 behaviors -

• 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 -

• 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 -

• 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 -

• Educate the staff. • Use definitions consistently. • Explain to mom.

Once at home the preterm infant should -

• 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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