newborn nutrition and lactation problem solving at the bedside
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Newborn Nutrition and Lactation Problem Solving at the Bedside. Topics and Goals. Identify three aspects of breast anatomy recently redefined by ultrasound Discuss the benefits of breastfeeding to moms and infants and review basic frequency and duration guidelines for all new moms - PowerPoint PPT PresentationTRANSCRIPT
Topics and Goals
• Identify three aspects of breast anatomy recently redefined by ultrasound
• Discuss the benefits of breastfeeding to moms and infants and review basic frequency and duration guidelines for all new moms
• Describe two positioning tips for the new breastfeeding mom
• Discuss techniques to use with the “noncompliant” infant
• Identify which moms should be referred for early follow up after discharge.
Why are lactation consultants our friends
• Provide prenatal information and breastfeeding assessment
• Assist with appropriate breastfeeding technique
• Assist breastfeeding mothers or babies who are ill or have anatomical challenges.
• Give information on maintaining or building milk supply
SUPPLLY=DEMAND=SUPPLY
• Reinforce the need to establish adequate milk production by effective “emptying” of the breasts at each feeding
• Newborns need “complete” meals, foremilk, and the rich in long chain fatty acids, hind-milk
• Baby and mother are both learning how to feed and when to feed
• USE IT OR LOSE IT !!!!!!
Early Follow-up
• Early follow-up is vital to preserve the breastfeeding relationship
• In most cases, interventions can be minor, and problems easily fixed
• Use of feeding logs can help parents make safe decisions in providing optimal infant nutrition by breastfeeding
• Infant “constipation” is a big red flag
Nutritional Comparison: Breast Milk
• 90% water• Same weight gain or
greater during first 3-4 months
• Fat is variable• Primary carbohydrate
is lactose, trace amounts of other carbohydrates
Nutritional Comparison: Formula
• 90% water• Greater weight gain
after 3-4 months• Lactose is only
carbohydrate
Summary of the Latest Anatomincal Findings by the University of Western
Australia
• Ducts branch closer to the nipple• Lactiferous sinuses do not exist• Glandular tissue is found closer to the nipple• Subcutaneous fat is minimal at nipple base• Range of mild ducts exiting the nipple is 4-18
(Average 9)• Complex ductal network neither arranged
symmetrically nor in a radial pattern
Reasons to Breastfeed
• Biological norm for human infants
• Optimal nutrition for infants
• Health advantages that last far beyond infancy
• Health benefits for mothers
Advantages of Breastfeeding
• Species specific
• Cholesterol in breast milk plays a role in myelination and neurologic development
• More efficient metabolism of cholesterol
• Composition varies according to gestational age
• Iron is more readily absorbed
Infant Benefits
Reduced risk ofType I or type II diabetes mellitus
Lymphoma, leukemia, & Hodgkin’s disease
Obesity
Hypercholesterolemia
Asthma
Infant Benefits: Immunologic
• Protection from– Respiratory tract and gastrointestinal tract
infections– Necrotizing enterocolitis– Urinary tract infections– Otitis media– Bacterial meningitis
The Statistics are Staggering
• 1.5 million infants die each year because they are not breastfed.
• In areas where water is not safe, bottle feeding children are 25 times more likely than breastfed children to die from diarrhea
• Even in developed countries, breastfeeding saves babies’ lives and reduces life-long illness.
Why the Fuss?
• Providing hospital formula discharge bags reduces the numbers of women exclusively breastfeeding
Donnelly A. Snowden HM, Renfrew MJ, Woolridge, MW. Hospital bags for breastfeeding women. Cochrane Data Base System Review 20002
Oxygenation changes during infant feedings
• Hypoxemia during bottle-feeding has been documented since the 1970’s. This occurs in both the full-term and preterm infants. Research suggests that the alteration in blood oxygen is a result of decreased ventilation.
One Formula Feed
• The protective benefits of human milk are dose dependent
• After I exposure to formula, it takes 14-21 days for the gut to re-establish its protection against enteritis
AAP Policy Statement
• “Human milk is the preferred feeding for all infants, including premature and sick newborns with rare exceptions.”
AAP/2005
• Postneonatal infant mortality rates in the US are reduced by 21% in breastfed infants
• …benefits include the potential for decreased annual health care cost of $3.6 billion in the US
• Skin to skin contact and direct breastfeeding should be encouraged as early as feasible
• Banked human milk may be a suitable feeding alternative for infants whose mothers are unable or unwilling to provide their own milk
Colostrum Production
• Mothers produce 30-100 ml of colostrum in the first 24 hours, 2-10 ml per feeding on day 1 and 5-15 ml per feeding on day 2
• Newborn stomach does not stretch
• Time of transition to mature milk varies based on parity of mother:
31-96 hours in the primiparous mothers
24-80 hours in the multiparous mothers
Redefining Normal Breastfeeding Frequency and Expected Duration
• Average physiologic capacity of the stomach in the first 10 days of life is 7-81 mls or 2-24 ml/kg
• The range of gastric half-emptying time for breast milk is 16-86 minutes
• Average breast milk volume per feed on day one is just 7 mls
• By day of life 4 the average volume per feed is only 58 ml
Frequency and Duration
• Feed frequently and follow infant feeding cues closely:
• Sucking movements• Sucking sounds• Hand-to-mouth movements• Rapid eye movements• Soft cooing or sighing sounds • Restlessness
Frequency and Duration
• Watch the baby not the clock
• Use the log on the back side of handout to monitor feeds and output
• 4 by day 4• AAP/AAFP and WHO
recommendations
When to Wean
• “…if humans weaned their offspring according to the primate pattern, without regard to cultural beliefs and customs, most children would be weaned somewhere between 2.5 and 7.0 years of age.”
• “Extended breastfeeding…is healthy, physiologically normal and evolutionarily adaptive.”
-WHO
Human Cultural Norms
• “…for all our time as hunters and gatherers, more than 99.9% of our existence on earth, all human infants were breastfed.”
• “…this has been the method of feeding to which human infants have adapted, and on which human infants have survived, for millions of years.”
Milk Men?
• http://images.google.com/imgres?imgurl=http://1.bp.blogspot.com/_Di1HzTLtBlM/RreOBPvv4VI/AAAAAAAABds/g3sJdIFl4i8/s400/breastfeeding%2Bman.jpg&imgrefurl=http://www.thethinkingblog.com/2007/08/fact-men-can-breastfeed.html&usg=__E4wr4Co6FzFjvtteg_pt6WWxqhQ=&h=308&w=400&sz=28&hl=en&start=9&um=1&itbs=1&tbnid=unPmmp8BJkrkoM:&tbnh=95&tbnw=124&prev=/images%3Fq%3Dpictures%2Bof%2Bbabies%2527%2Bbreastfeeding%26hl%3Den%26rlz%3D1T4ADFA_enUS346US346%26sa%3DX%26um%3D1
Top Three Reasons New Mothers Stop Breastfeeding
• 47% of mothers felt they were not producing enough milk
• 33% of mothers said they had trouble getting the baby to nurse
• 29% quit because of work-related issues
Factors Related to Early Termination
• Low income women• Perception of insufficient milk• Plan to work outside the home• No previous breastfeeding experience• Formula supplementation while in the hosptial• Younger women who are less educated• Initiation of breastfeeding after 16 hours of age• More positive bottle-feeding attitude and less
positive breastfeeding attitude.
Information Given to New Mothers
• Must explain the benefits of breastfeeding
• Must give the health risks and costs associated with artificial feeding
Information Given to Health Workers
Must be based on scientific and factual research
Skin-to-Skin Contact, Breastfeeding and Perinatal Neuroscience
• Dr. Nils Bergman, MD, DCH, MPH
• Capetown Sputh Africa
• www.kangaroomothercare.com
• Implementing Best Practice in US Hosptials
Fetal Brain Development
90% of what we know about human brain function we have learned in the past 15 years.
Critical period: “Early interpersonal events positively and negatively impact the structural organization of the brain
• Quality sensory stimulation makes brain able to think and regulate
• Negative experiences (both the absence of good…and the presence of bad) have long lasting effects
• Could attention deficit disorder, obesity, depression be effected by early wiring?
Separation if Harmful
• The separated baby that has “settled” is in DESPAIR, dissociation
• The primary violation, the very worst thing to any newborn according to biologists is separation
• Separation violates the innate agenda of mother and newborn
How the Nurse can Promote Attachment
• Facilitate breastfeeding within the first hour after birth and provide for continuous skin-to-skin contact between the mother and infant until after the first feeding
Strategies
• Keep the mother and infant together during the entire postpartum stay
• Conduct examinations and routine tests of the infant while the infant is in the mother's room, in the mother’s arms, or on the breast. Babies at breast are less receptive to pain.
Strategies
• Watch the baby not the clock• Teach mothers to recognize and respond to
early infant feeding cues and confirm that the baby is being fed at least 8 times in each 24 hours
• REMEMBER: crying is a late feeding cue and may interfer with effective breastfeeding
• Pattern the skill of reading the infant cues, save baby energy for feedings
Strategies
• Confirm that mothers know how to wake a sleepy infant
• Strategies to wake the infant include:
remove any blankets
change the infant’s diaper
PLACE THE INFANT SKIN-TO-SKIN
massage the infant’s back, abdomen, arms, legs
Latch
• Stimulate rooting reflex
• Take sufficient areola into mouth
• Flange lips around breast-”fish lips”
• Have wide angle at corner of mouth
Feeding Interventions: Birthing Room
• Assess for signs of readiness to feed
• Place newborn on mother’s chest
• Breastfeeding may begin in birthing room
• Assess infant physiologic status during feeding
Feeding Interventions
• Monitor progress• Education• Anticipatory guidance• Evaluate the need for
follow-up after discharge
Latch
• Stimulate rooting reflex
• Take sufficient areola into mouth
• Flange lips around breast-”fish lips”
• Have wide angle at corner of mouth
LATCH: A breastfeeding charting and documentation tool. LATCH was created to provide a systematic method for breastfeeding assessment and charting. It
can be used to assist the new mother in establishing breastfeeding and to define areas of needed intervention. SOURCE: Used with permission from
AWHONN. (1994).
Infant Feeding Education
• “On Demand” feeding pattern
• Infant feeding cues• Normal
feeding/sleeping patterns
• Satiety behaviors• Growth patterns
Problems
1. Mom does not keep baby’s body close to hers and begins to fatigue. Thinks she needs pillows to hold infant
2. Mom tickles baby’s cheek to get baby to turn toward the breast rather than facing baby directly at the breast
3. Mom holds baby in crook of her arm and tickles baby’s lower lip or chin with the nipple to entice him to open
4. Mom does not keep baby’s chin pressed into mom’s breast
Using a Fist to Teach Latch
• Ask mom to make a fist with the knuckle of her middle finger sticking out
• Ask mom to center the knuckle in her mouth and try to get as much of the fist in her mouth as possible
• Ask mom to place the knuckle in front of her nostrils and lift her chin and see how much of the fist fits in her mouth
Explaining feeding pattern
• Adult eating patterns• When to switch
breasts• Drinking vs eating• Babies using mom as
a pacifier
Human milk
• Colostrum Present in small volume before delivery and in first days after delivery. High in host defense proteins and immunoglobulins
• Transitional milk• Mature breastmilk
Benefits of Breastfeeding
• Species specific• Optimal nutrition• Minimizes exposure to foreign proteins• Customized• Promotes appropriate growth pattern• Provides multiple hormones and growth
factors• Promotes mother-infant attachment
Health Risks to Infant if Not Breastfeed
Increased incidence of:• Type 1 diabetes mellitus• Type 2 diabetes mellitus• Inflammatory bowel disease• Childhood cancer• Sudden infant death syndrome• Obesity• Compromised oral-motor development• Less optimal development of the arch of the mouth• Increase in orthodontic problems
Health Risks if Not Breastfed
• Increased incidence or seversity of• Gastroenteritis and diarrhea• Otitis media• Pneumonia and lower respiratory infection• Respiratory syncytial virus (RSV) infection• Neonatal sepsis• Necrotizing enterocolitis• Haemophilus influenzae type b (Hib) meningitis• Urinary tract infection
Cognitive Benefits
Human milk • contains fatty acids, nucleosides,
oligosaccharides, and taurine to enhance neural and retinal development
• Enables child to reach full developmental and intellectual potential
Human milk fat• Provides essential fatty acids• long-chain polyunsaturated fatty acids, including
docosahexaenoic acid (DHA) and arachidonic acid (ARA)
Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience
• “Prematures and newborns have a nervous system which lacks the ability to dampen down sensory signals…Over stimulation of any of the senses will be experienced as PAIN by the newborn.”
• Maternal-infant separation is the single greatest barrier to breastfeeding. The solution: never separate mothers and newborns.
• “Kangaroo Mother Care is…pure science.”
Skin-to-Skin
• Breast feeding=brain wiring, it involves all senses at one time
• 2 hours of Kangaroo Care will increase brain growth
• Increased mental and psychomotor development in KC infants
• First feeds are for firing and wiring the brain-critical period is the first 60-90 minutes
Skin-to-Skin
• Hard crying opens the foramen ovale, causing left to right shunting which can lead to cyanosis, increased blood pressure and increases the risk of IVH
• Breastfeeding is the brain based behavior of the newborn not the mother
• Mother is the only appropriate ENVIRONMENT,mother’s milK is the only appropriate FOOD
Benefits of Breastfeeding for Women
• Promotes uterine involution and decreased risk of postpartum hemorrhage
• Lowers the risk of ovarian and breast cancer
• Facilitates earlier return to prepregnancy weight
• May decrease risk of osteoporosis in post-menopausal period
• Burns additional calories
Maternal Psychosocial Benefits
• Improved maternal-infant attachment
• Skin-to-skin contact
• Tactile communication
• Learn behavioral cues and needs
• Prolactin increases feelings of relaxation and euphoria
• Oxytocin heightens responsiveness and receptivity toward infant
Disadvantages to Breastfeeding
• Pain due to nipple tenderness
• Leaking milk when breasts are full
• Embarrassment about breastfeeding
• Feeling tied down to the demands of breastfeeding
• Unequal feeding responsibilities/fathers left out
• Perceptions about diet restrictions
Disadvantages to Breastfeeding (continued)
• Limited birth control options
• Vaginal dryness
• Concerns about the safety of medications and breastfeeding
The Guilt Issue “…doctors are afraid to make mothers feel guilty about choosing not
to breastfeed. Breastfeeding is viewed by many as a lifestyle choice rather than a public health issue. Instead of discussing the added benefits of breastfeeding, physician should be discussing the risks of not breastfeeding. Women should have freedom of choice between artificial feeding and breastfeeding, but this choice must be informed…Guilt is what a human being feels when he or she knowingly chooses a lesser option. Regret is felt when the choice and the consequences of those choices are not explained. Ethical, caring professionals owe patients accurate information, appropriate guidance and long-term breastfeeding support. Physicians can help to eliminate the regret but let the guilt fall where it may!”
Nancy E. Wright, MD
A Breastfeeding Friendly Facility
• Helps mothers access professional lactation help and mother-to-mother support
• Refers mothers with breastfeeding questions and concerns to an International Board Certified Lactation Consultant (IBCLC)
A Breastfeeding-Friendly Facility:
• Has trained staff who give accurate and consistent breastfeeding information
• Has evidence-based policies that support breastfeeding
• Provides positive messages about breastfeeding
Ten Steps to Successful Breastfeeding
1. A written breastfeeding policy
2. Train staff to implement this policy
3. Inform all pregnant women of the benefits of breastfeeding
4. Help mothers initiate breastfeeding within the first half hour
5. Help mothers maintain lactation if separated
Ten Steps to Successful Breastfeeding
6. Provide no food or drink other than breast milk unless medically indicated
7. Encourage rooming in
8. Encourage breastfeeding on demand
9. Promote no artificial teats or pacifiers
10. Promote follow-up breastfeeding services and support post-discharge
Promote Breastfeeding
• Give parents consistent, positive information about breastfeeding
• Remove barriers that keep women from breastfeeding
Summary
• Breastfeeding is preferred feeding for almost all infants
• Mothers should be informed of the benefits of breastfeeding
• Supplementation is rarely indicated and interfers wit successful lactation
• Breastfeeding should be actively supported and promoted in the medical community and society
• Women should feel comfortable continuing to breastfeed for as long as desired
Formula Feeding Education
• Intake and output expectations
• Preparation and storage of formula
• Feeding technique
• Equipment
• Safety precautions
Growth Rates
• Both breastfed and formula-fed infants experience growth spurts requiring increased feedings
• Breastfeeding mother should nurse more frequently
• Formula feeding mother should slightly increase amount of feeding