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Supplementation of Breastfeeding Term and Near Term Healthy Newborns INDICATIONS & CONSIDERATIONS Developed by: Michelle Gnagey MSN, RNC-OB, C-EFM, C-BF, IBCLC, RLC Lorrie Makofka MSN, RNC-OB, C-EFM Why This Competency? Our goal is to increase “exclusive breastfeeding at discharge” rates!! This takes teamwork from every staff person in the obstetrics department starting in labor and delivery and extending through their entire stay until discharge from Mother-Baby How Do We Do This? Make sure we as nurses understand best practices related to breastfeeding and supplementation practices Make sure we are united in giving patients consistent messages Do all we can to support early breastfeeding and avoid non-medical formula supplementation Objectives List characteristics of exclusively breastfed neonates Discuss common non-medical reasons breastfed newborns are given formula List maternal and newborn indications for supplementation Describe the elements of best practice supplementation Characteristics of Exclusively Breastfed Neonates Baby will be wide awake and will feed several times, if left skin-to-skin with mother over the first two hours Following the first 1-2 hours baby will fall into a deep sleep and will sleep up to 24 hours Baby will feed more often if he is kept skin-to-skin with mother, perhaps 4-6 times Often cluster feed Characteristics of mothers who exclusively breastfeed Enjoy having baby skin-to-skin The chest area in lactating women is 2-4 degrees warmer to help keep baby warm Have a bolus of colostrum in the first couple of hours postpartum that if not removed is reabsorbed by the body Get sleepy during and after the feeding Will have uterine cramping with the feedings for about 2448 hours postpartum Skin-to-skin (STS), why all the fuss? It is important for all babies to transition from intrauterine to extrauterine life Benefits baby, mother and significant other Should be done appropriately Should be offered and encouraged to everyone regardless of feeding choice STS-Benefits for Baby Helps to regulate vital signs and stabilize temperature Helps to regulate blood glucose Assists with neurodevelopment of the brain and the hardwiring needed for later in life Helps baby to feel secure and calms a fussy baby Many more STS- Benefits for Mom & Significant Other (SO) Builds confidence in her ability to mother and care for baby Increases number of times baby will feed Helps to increase her milk production Bonding, especially for the SO who is not able to breastfeed but can help to calm a fussy baby… or give mother much needed breaks How To Perform STS Baby needs to be undressed down to the diaper and mother/ SO need to have shirt and bra off Baby is placed upright, chest to chest with mother/SObaby’s head is under the chin of the adult Baby’s head should be turned to the side with arms up Knees are on the upper abdomen of the adult they are STS with Cover the back with a blanket (warmed if baby is cold) and place a cap on his head Skin-to-skin care Photo used with permission of Michelle Gnagey Before we look at the medical indications for supplementation, we need to look at some inappropriate reasons for supplementation We have all seen this look! This is amazing and and terrifying! I’m excited and exhausted! DID YOU KNOW? “Well meaning healthcare professionals often offer supplementation as a means of protecting mothers from tiredness or distress, although this at times conflicts with their role in promoting breastfeeding.” Liebert, M.A., (2009). ABM clinical protocol#3: Hospital Guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeeding Medicine, 4 (3). Reflect on your nursing practice and consider if you have ever been one of those healthcare providers who leans toward supplementation ◦ Do you feel “nervous” when a baby hasn’t eaten for more than 4 hours? ◦ Do you feel bad for a new mom who cannot get her baby to latch, or is exhausted and needs to sleep? ◦ Do you think it is better to supplement so that you and/or the mom won’t have to worry about jaundice, hypoglycemia, or weight loss? ◦ Do you allow your feelings to trump best practice because you just feel relieved for yourself or the patient when the baby takes 30 cc of formula? Conflicting advice is so frustrating to the patient and can contribute to the choices made surrounding supplementation Instead of hearing that they will get rest many hear the message that they do not have enough and their confidence is sabotaged Let’s get on the same page On the next several slides are common concerns and the evidenced based responses we should give: “Messages” Nurse/patient Concerns Nurse Responses Risk of Supplementation Weight loss/dehydration Certain amount of weight loss is normal in the first week of life (diuresis of extracellular fluid) Supplementation interferes with the normal frequency of breast feedings Jaundice More frequent breastfeeding=lower bilirubin level Supplementation interferes with the normal frequency of breast feedings Colostrum acts as a natural laxative to eliminate retained pool of bilirubin contained in meconium Hypoglycemia Healthy full term infants do not develop symptomatic hypoglycemia simply as a result of suboptimal breastfeeding Supplementation interferes with the normal frequency of breast feedings Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeeding Medicine, 4 (3). Additionally…. Nurse /Patient Concerns Nurse Responses Risk of Supplementation “Not enough milk or colostrum” Small amounts of colostrum are normal, physiologic, and appropriate for term newborn Formula can alter bowel flora, increase risk of diarrhea and infections The term newborn’s stomach capacity is approximately: First 24 hours 2-10 ml/feed 24-48 hours 5-15 ml/feed 48-72 hours 15-30 ml/feed 72-96 hours 30-60 ml/feed Potentially disrupts “supply-demand cycle” leading to inadequate milk supply Many reasons for a baby to be “fussy” Filling or overfilling infant’s stomach with formula may make infant sleep longer, missing important breastfeeding opportunities Baby fussy, not “getting anything” Infant may be wishing to cluster feed May need to use other soothing techniques: Swaddling, swaying, father or relatives assistance Mom needs to sleep Postpartum mothers actually demonstrate restlessness when separated from infant Maternal engorgement due to decreased frequency of breastfeeding in immediate postpartum period Risk of decreasing breastfeeding duration or exclusivity Mothers lose the opportunity to learn infant’s feeding cues The highest time of day for an infant to receive supplementation is between 7 p.m. and 9 a.m. Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeeding Medicine, 4 (3). Finally… Nurse/Patient Concerns Nurse Responses Risk of Supplementation Mom (or well meaning family) requests supplementation Mothers may benefit from education about how formula adversely affects subsequent breast feedings Formula is slow to empty from the stomach and often fed in larger amounts, the infant will breastfeed less frequently Nurse spending time in passive interactions such as listening to and talking to mothers can be of critical importance [when it comes to avoiding supplementation] Depending on frequency and method of supplementation, the infant may have difficulty returning to the breast Medications contraindicated with breastfeeding Consult references (Intranet, lactation, books) to verify contraindications Risk of decreasing breastfeeding duration or exclusivity Sore nipples Sore nipples are a function of latch, positioning, and sometimes individual anatomic variations, not length of time nursing There is no evidence that limiting time at the breast will prevent sore nipples Risk of shortening breastfeeding duration or cessation of breastfeeding Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeeding Medicine, 4 (3). Prepare Yourself Know how to respond to each of the common concerns that come up nearly everyday Demonstrate empathy but be committed to best practice Often, your presence can have a calming affect that will relieve the stress and anxiety surrounding breastfeeding issues Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeeding Medicine, 4 (3). Teamwork “Now that you know better, do better…” Maya D’Angelo Knowledge Check It is 9 hours after delivery and the baby hasn’t eaten in the last 7 hours. She is full term with no risk factors, nursed for 15 minutes right after delivery, had one urine but no meconium. Mom cannot get baby awake to eat. Which statement best reflects your thinking? 1. I would not be very concerned and would recommend placing the baby skin to skin for an hour, review feeding cues and normal breastfeeding mother behavior, then re-assess. 2. I would be very concerned. Infants need to eat at least every 3-4 hours. I would try vigorously to wake this infant up for a feeding and recommend supplementing if she will not eat soon. I would explain weight loss and risk for jaundice. 3. My concern would be moderated by knowledge of one good feeding and urine output in a healthy term infant. Answer I would not be very concerned and would recommend placing the baby skin to skin for an hour, review feeding cues and normal breastfeeding mother behavior, then re-assess. Use critical thinking Look at the whole picture and know your couplets’ risks ◦ Is the infant full term or near term? ◦ Does the infant have pre-existing risk factors for jaundice, hypoglycemia, weight loss, infection? ◦ Is the infant voiding and stooling adequately? ◦ Was delivery complicated? Elements of the whole picture regarding weight loss and dehydration How many voids and stools has baby had over the course of their stay? ◦ What is the normal number you should expect? ◦ Has the baby superseded that amount? In your assessment did you find baby is dehydrated? ◦ Mucus membranes moist? ◦ Fontanels soft and flat? ◦ Uric acid crystals are normal through the 4th day of life Is the baby jaundice and sleepy? How many feedings has baby had? Has anyone assessed this baby feeding at the breast? Can mother hand express colostrum/milk? If mom chooses to supplement in the absence of a medical indication… Educate the mother on the risks of non-medically indicated supplementation ◦ Decreased frequency of feedings=decreased removal of breast milk=lower milk supply ◦ Inappropriate stretching of baby’s stomach due to overfeeding=increased risk of childhood obesity ◦ Decreased prolactin to fill the receptor sites, which determines how much milk a mom will produce and this is most critical over the first couple of days Document that she was provided with education Baby’s Belly Size 2-10 ml 5-1520ml Expected Output for the Exclusively Breastfed Newborn Day 1- 1 Wet/1 Meconium Stool Day 2- 1-2 Wet/1-2 Meconium Stools Day 3- 3 Wet/ 1-3 Stools, may be transitional Day 4- 4-5 Wet/Transitional stools changing to loose, yellow, and seedy Day 5- 6-8 wet diapers/ Several loose, yellow, seedy bowel movements Neonatal Medical Indications for Supplementation Newborn ◦ Hypoglycemia ◦ Weight Loss ◦ Hyperbilirubinemia “Before any supplementary feedings are begun, it is important that a formal evaluation of the mother – baby dyad, including direct observation of breast feeding, is completed” ABM Protocol, 2009 If you cannot do this yourself page the lactation consultant for help Review of Hypoglycemia Transient hypoglycemia in the immediate newborn period is common Healthy full term infants do not develop hypoglycemia as a consequence to underfeeding Routine monitoring in asymptomatic neonates is unnecessary AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579. Hypoglycemia in the exclusively breastfed neonate Breastfed term infants have lower concentrations of blood glucose but higher concentrations of ketone bodies than formula fed infants These infants tolerate lower glucose levels without any significant clinical manifestations or sequelae possibly due to the high ketone concentration (Keener, 2014) Hypoglycemia can be minimized by early initiation of breastfeeding, 30-60 minutes after delivery The best way to combat hypoglycemia is to keep mother and baby skin-to-skin Kenner, C. & Lott, J.W. eds(2014). Comprehensive neonatal nursing care 5th ed. New York: Springer. AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579. Signs and Symptoms of Hypoglycemia in the Infant Jitteriness Tachypnea Apnea Poor feeding Hypotonia Seizures Irritability Lethargy AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579. So, which babies need blood glucose screening? 1. Babies born to mothers with diabetes 2. Large and small for gestational age babies 3. Late Preterm Infants 4. Symptomatic infants Timing and intervals for screening should be according to your policy and based on the risk factors and assessment of the individual infant. AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579. Why the Timing? It takes breastfed babies time to recover from the birth process and to latch and feed They go through 9 instinctive stages following delivery, each stage requires time They must be left skin-to-skin undisturbed to accomplish this process It takes 30 minutes after a feeding for the breast milk protein to begin digestion and to be absorbed by the gut Other babies that need screening Intrauterine growth restricted infant (IUGR), small for gestational age (SGA) (<10th percentile for weight), all infants 35 0/7-36 6/7 weeks These infants should be fed every 2-3 hours Bedside glucose monitoring should be performed before every feed for at least 24 hours unless discontinued by a physician. AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579. Other indications for blood glucose screening… Perinatal distress, eg, 5 min Apgar < 5 Polycythemia (venous hematocrit > 65%) Presence of microcephaly or midline defect Discordant twins (> 20% weight difference) Respiratory distress Anytime there is concern about possible hypoglycemia (clinical signs, poor feeding, etc.) All infants admitted to SCN or NICU AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. Pediatrics, 127, 575-579. Feeding and Glucose Monitoring Unless otherwise ordered, these infants should be fed within the first hour of life and have their initial glucose screen 30 minutes following the first feed. If not otherwise specified, a minimum of 2 glucose values should be obtained. One value within the first hour (after a feed if possible) and the second after 2 hours of age. The attending physician should be notified of the patient’s admission and determine the final time frame for screening. When to Treat Hypoglycemia Notify Physician/NNP and Send Stat Lab Glucose For: Glucose < 40 mg/dl in symptomatic infant Any glucose < 25 mg/dl Any glucose < 35 mg/dl after 4 hours of age Any glucose < 45 mg/dl after 24 hours of age AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. Pediatrics, 127, 575-579. ALGORITHM AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. Pediatrics, 127, 575-579. Knowledge Check Baby Jones was born at 1300 with 7/9 Apgars and weighing 10 lbs at 39 weeks. Following birth, the infant had no signs of hypoglycemia and was placed skin-to-skin with the parent for bonding. You determine that the infant is LGA using the Fenton curve. The time is now 1325 Which statement best describes your nursing care plan? 1. Leave baby skin-to-skin to breastfeed, then check blood glucose 30 minutes after feeding complete 2. Check the blood glucose immediately after birth. Place the infant skin to skin, monitor for signs of hypoglycemia and check blood glucose in 1 hour 3. Encourage feeding after complete assessment and bath Answer Leave baby skin-to-skin to breastfeed, then check blood glucose 30 minutes after feeding complete Weight Loss Most babies who remain with their mothers and breastfeed adequately lose less than 7% of their birth weight Weight loss in excess of 7% may indicate: ◦ Inadequate milk transfer ◦ Low milk production ◦ Delayed lactogenesis II ◦ Above normal output Request a lactation consultant to assess breast feeding prior to supplementing ABM Protocol, 2009 HyperbilirubinemiaJust the Basics Jaundice is a normal phenomenon with benefits for baby A small percentage of babies can become ill or injured if bilirubin gets very high (>25 mg/dL) Mother’s milk appears to increase bilirubin levels, and this is probably a good thing the majority of the time Preventing kernicterus by identifying high risk babies is very important Supplementation Practices Continuation of breastfeeding is indicated (4% or less incidence of pathological jaundice) Occasionally, expressed breast milk or formula supplementation is indicated Supplementation should be given following a nursing session, use breast milk when available Kenner Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks’ gestation .Breastfeed Med. 2010 Apr;5(2):87-93. [53 references] Key Points Because the parents may associate breastfeeding with the development of jaundice requiring special treatment or hospitalization, they may be reluctant to continue breastfeeding Healthcare providers should offer special assistance to these mothers to insure that they understand the importance of continuing breastfeeding and know how to maintain their milk supply if temporary interruption is necessary Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks’ gestation .Breastfeed Med. 2010 Apr;5(2):87-93. [53 references] Key Points It is critical to maintain maternal milk production by teaching the mother to frequently and effectively express milk manually or by pump. The infant needs to return to a good supply of milk when breastfeeding resumes, or poor milk supply may result in a return of higher serum bilirubin concentrations. Knowledge Check Baby Smith was born at 40 weeks and has no risk factors. The 24 hour bili level was 8 which is in the high risk zone. The doctor has ordered supplementation with expressed breast milk or formula. Choose the response that best describes your interventions: 1. Instruct the mom to breast feed infant and then give 2030mls of formula 2. Instruct mom that hyperbilirubinemia is very dangerous and the best way to eliminate bilirubin is to switch to formula 3. Instruct mom to increase skin-to-skin contact in an effort to increase frequency of breast feeding and to hand express or pump after each feeding. Use EBM to supplement. If no EBM obtained, give formula in small amounts Answer Instruct mom to increase skin-to-skin contact in an effort to increase frequency of breast feeding and to hand express or pump after each feeding. Use EBM to supplement. If no EBM obtained, give formula in small amounts Maternal Indications for Potential Supplementation ◦ Geographic separation in different hospitals ◦ Contraindicated medications ◦ Delayed lactogenesis II beyond 5 days ◦ Intolerable pain or extensive nipple damage ◦ Breast anomalies, surgery or insufficient glandular tissue Separation of Mom and Infant Start mom pumping early and often!!!!!!! ◦ Pump within the first 2 hours post partum if possible or initiate hand expression ◦ L&D Nurses should be able to assist the mother with this process Educate mom on milk storage Help arrange for transport of colostrum/milk to the infant’s location Contraindicated Medications Always consult lactation to confirm that the medication is truly contraindicated Check with the physician to see if there is an alternative medication that could be used to continue breastfeeding Assist mother to pump milk ahead and store for use while on the medication Infant will receive EBM or formula until mom is able to breast feed Mom will “pump and dump” only for a prescribed period of time Breast anomalies, surgery or insufficient glandular tissue • Never assume that these mothers will have trouble with milk production •Baby should have output and weight monitored regularly until mother’s milk supply is established •Have Lactation see these patients as soon as possible to evaluate for milk production •Lactation can recommend the plan of care for supplementation if needed Maternal Complications of Delivery/Illness Area of biggest opportunity to improve!!!! When a mom is exhausted or ill, or if the baby is in the NICU, it is easy to skip/delay breast feeding or pumping. Remember to assist the mom and encourage her to breast feed or pump within 6 hours-sooner if feasible-within 1-2 hours post partum is recommended per lactation Mom may not feel “up to it” initially but will thank you later when she can enjoy the breast feeding experience Knowledge Check 23 year old primip is in the ICU after a post partum hemorrhage following delivery of a full term infant. The Critical Care physician wrote orders that patient cannot breast feed. The ICU nurse tells the patient about the orders and the patient is very upset. The ICU nurse calls you to see what they can do. You first best response would be: 1. Have the ICU nurse tell the patient that she can start breastfeeding once she is transferred to Mother Baby Care 2. Take a pump to ICU and instruct the patient to pump and dump until the critical care doctor says it is OK to breast feed 3. Ask lactation to see the patient to determine why the doctor wrote the orders to not breast feed 4. Consult lactation to see patient for breast pump assistance Answer Ask lactation to see the patient to determine why the doctor wrote the orders to not breast feed Primary Care Providers (PCP) often will write orders to not breast feed when mom is on various medications. There are very few medications that are actually contraindicated in breast feeding. Lacatation can look up the medications, contact the PCP and develop the most appropriate plan for the patient. If lactation is not available, do not delay pumping and save the milk until told otherwise. As appropriate have the baby in the room for skin to skin contact. Anyone may contact the Infant Risk Center at Texas Tech University for medication safety. Supplementing with Expressed Breast milk- the preferred method for supplementation Colostrum versus mature milk Alternate Feeding Methods for Term Infant Hand expression Spoon/cup Dropper Finger Feeding with feeding tube Supplemental Nursing System (SNS) Bottle/Nipple Feeding Note Alternative feeding methods are most commonly used with the breastfed infant when the mother must supplement per Lactation Consultant’s recommendations or physician order A lactation consultant or educated staff nurse should provide patient education regarding the use of alternative feeding methods Hand Expression To view the video on Hand Expression, Right Click on the Hyperlink below and click on “Open Hyperlink” http://newborns.stanford.edu/Breastfeeding/HandExpression.html Dropper feeding ◦ Use a sterile “one time use” feeding dropper ◦ Dropper feeding is best done as encouragement at the breast with smaller volumes of supplementation ◦ If the mother is unavailable, a dropper may be used in place of a rubber nipple and bottle ◦ Hold the newborn securely in upright position and place the filled dropper on the baby’s lips to elicit a feeding response. Gently slide the eye dropper into the mouth and allow the newborn to suck out the milk ◦ Repeat until the milk (or prescribed amount of formula) is gone, or until the newborn shows signs that it is satisfied Cup-feeding technique This technique is used per Lactation Consultant recommendation or physician order ◦ Fill a small (i.e. medicine) cup with approximately 10-15 mL of mother’s expressed breast milk or formula ◦ While holding the newborn in a semi-sitting position or cradling in the curve of mother’s/father’s arm, rest cup on newborn’s lower lip so the rim of the cup also touches the corners of the mouth ◦ Allow to feel/taste milk on tongue, then baby should lap up milk and swallow—DO NOT POUR MILK INTO THE NEWBORN’S MOUTH ◦ Allow newborn to lead its feeding and to rest between swallows ◦ If newborn resists the feeding, stop, comfort the newborn and try again later or use another method. Finger feeding/syringe feeding/Supplemental Nursing System (SNS) with feeding tube ◦ Position newborn upright with head secured by feeder’s opposite hand ◦ Attach a graduated feeding bottle or syringe with expressed breast milk (or formula) to the feeding tube (SNS, Lactaid or #8 feeding tube) ◦ The end of tube may be secured with paper tape or held by parent ◦ Elicit feeding reflex by stroking newborn’s lips ◦ Gently slide the finger in mouth, pad side up and allow the newborn to pull the finger back, generally to the juncture of the hard and soft palate ◦ Allow the newborn to begin sucking at a normal rate and rhythm, avoid forcing milk into tube ◦ If a nipple shield is in use, the feeding tube may be placed under the shield with the feeding tube tip positioned well into the “shield nipple” prior to initiating feeding Bottle/Nipple Feeding Obtain expressed breast milk or type of formula as ordered by physician/requested by mother, and verify expiration date. NOTE: if mother requests a formula other than as ordered by the physician, this should be discussed with the newborn’s physician prior to the feeding. Formula should be room temperature For the mother who is using the bottle/nipple to feed her newborn breast milk, refer for the Breastfeeding policy for pumping and storing of breast milk. Mother should be instructed and encouraged to never prop the bottle during the feeding Encourage and instruct the mother as appropriate, to support the newborn’s head while burping, after every ½ to 1 ounce, and at the conclusion of the feeding After feeding is concluded and is infant is content, position newborn on his/her back to sleep If the infant has been fed a bottle of either breast milk or formula, it is to be discarded within one (1) hour of being opened Pacing Bottle Feeds It is estimated by one researcher that bottle fed babies will consume up to 30,000 calories more than their breastfed playmates by the age of 8 months. Now that’s a lot of extra calories! Why do they eat so much more than they actually need? No one really knows, but it is thought that perhaps there are several factors related to the act of bottle feeding itself. 1. The “clean bottle club”. Encouraging the baby to finish just the last little bit that is in the bottle which may be more than the baby needs. 2. Babies who gulp down the milk so fast that their brains don’t register “full” before their tummies are overfull. 3. Making the holes in the bottle bigger so the baby will eat a bit faster and get it over with. 4. Paying attention to the lines and ounces on the bottle, and not watching the baby’s cues. All of which brings us to “pacing” bottle feeds – a technique that is imperative to use for preterm and near term babies, and one that is very good to use in full term babies in the first few months. ©2012/Lactation Education Consultants/May be reproduced/May not be sold The Paced Bottle-feeding Technique 1. Snuggle the baby close to you in a semi-sitting position. 2. Hold the bottle with the tip of the nipple just under the baby’s nose. When she is ready for it, she’ll open her mouth and “ask” for it. 3. Count swallows (6-7 for a baby a week and under). Take the bottle out of her mouth and put the tip of the nipple just under her nose again. When she’s ready for the next bit, she’ll open her mouth again. 4. Watch her face – if you see that she breathes heavily and quickly for a few seconds, trying to catch her breath reduce the number of sucks that you let her have. As you give her this chance to breathe, the lines in her face will relax, and then she’ll be ready for more. 5. Continue pacing her feeds until she closes her mouth, purses her lips and “tells” you she doesn’t want any more. You will see her slowing down before this. 6. You may find that even 6 swallows is too much for the baby to handle all at once, and you may need to back up to 3 or 4 for a day or so while she is getting used to handling all that fluid at one time. 7. It’s tempting to put the baby in the car seat and prop the bottle, first of all, that is dangerous, secondly, meal time should be a social time for both you and the baby. Pacing the feeds helps you to accomplish this social activity and enjoy your little one. ©2012/Lactation Education Consultants/May be reproduced/May not be sold What About a Nipple Shield? •Really should not be used during the first 24 hours of life and they need to be size appropriate •Many babies will use them like a pacifier in the early days and never suckle hard enough to actually transfer milk •Instructions for application, use, and cleaning must be given to the patient •Mothers who use a nipple shield prior to the transition of her mature milk need to be hand expressing and pumping to insure that their breasts are stimulated for milk production What To Do If You Are Going to Give Nipple Shield to a Mother • Be sure that the size is appropriate: They come in 24, 20, and 16 mm sizes • Show the mother how to apply it- you turn it halfway inside out on itself like a Mexican sombrero, place your nipple in the center and flip it back onto the breast, adhering slightly. May adhere better if run under warm water • The cutout goes where the baby’s nose is located not 12 o’clock • It needs to be washed between uses so provide her with a basin and castile soap and air dry with the tip of the shield upright • Because the shield is clear, it is difficult to see/find so you may give her a denture cup to store it in • Mother needs to initiate insurance pumping after each feeding for 5-10 minutes to stimulate milk production What Baby Should Look Like When Using a Nipple Shield •Baby should have his mouth wide open, lips flanged outward so that you can see the pink ridge of the lips •He should have the shaft of the shield completely in his mouth •It should not be pinching or painful when baby is sucking and mother’s nipple should remain round •There should be moisture in the shield initially and after production increases there should be milk in the shield at the end of the feeding Knowledge Check Baby Jones was born 36 hours ago at 37.4 weeks gestation. In report you were told that the baby last ate 2 hours ago. When you go to see mom, she says the baby has been at the breast every 2-3 hours but has never really latched well. Lactation had assessed mom’s nipples and the baby’s suck at 6 hours of age and there were no issues. The baby is just not very vigorous and will not attempt to feed at this moment. You know that he is near a 7% weight loss. His 24 hour bili was in the low intermediate range but he looks jaundice now. You realize that this baby is more at risk of needing supplementation because of the weight loss, gestation age, and potential of increased bilirubin levels. You check the diaper to find a small amount of dark urine. Another concern is that the pediatrician who is “on” in the morning is quick to order formula supplementation. If he rounds and the baby has not had some good feeds and stabilization of his weight loss trend, you know what will happen… You have used your critical thinking skills and know it is time to leap into action! Still more But… It is the beginning of the shift and you need to assess all of your patients. Plus, someone just called for pain medications (…that they refused 20 minutes ago when you did bedside rounding ) And…lactation is not available till morning! You realize that best practice includes having the baby placed skin to skin early and often. So, you tell mom to place the baby skin to skin and you will be back in about 1 hour. Review feeding cues, and ask mom to call you to assess the breast feeding. Later on… You are back at the bedside. The baby remains sleepy despite interventions to promote “gentle waking”. Select the series of steps that you would try first to assist this patient: 1. Tell mom that you know she is exhausted. The baby has lost weight and was born early. He is at risk for jaundice and now dehydration. His blood sugar may even be low. The doctor is going to tell you to bottle feed formula in the morning anyway. If you want to go home with the baby tomorrow, you better give formula now. 2. Demonstrate and assist mom with hand expression into a spoon or cup. Cup or spoon feed baby. 3. Obtain the electric pump and have mom pump and dropper feed infant. 4. Obtain the electric pump and have mom feed EBM per bottle Answer Demonstrate and assist mom with hand expression into a spoon or cup. Cup or spoon feed baby. References AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. Pediatrics, 127, 575-579. Bergman, N. (2013) Kangaroo care: The science of skin-to-skin contact-benefits and implementation. Conference handouts Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks’ gestation .Breastfeed Med. 2010 Apr;5(2):87-93. [53 references] Hale, T. W., & Rowe, H. E. (2014). Medications & mothers’ milk (16th ed.). Plano, TX: Hale Publishing. Kenner, C. & Lott, J.W. eds(2014). Comprehensive neonatal nursing care 5th ed. New York: Springer. Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate. Breastfeeding Medicine, 4 (3). Morton, J. (2008). Hand expression of breast milk [motion picture]. Retrieved from http://newborns.stanford.edu/Breastfeeding/HandExpression.html Riordan, J., & Wambach, K. (2010). Breastfeeding and Human Lactation (4th ed.) Sudbury, MA: Jones and Bartlett. Walker, M. (2011). Breastfeeding management for the clinician: Using the evidence (2nd ed.) Sudbury, MA: Jones and Bartlett.