Breastfeeding the Infant with Special Needs, 2nd Edition

1. Breastfeeding the Infant with Special Needs,2nd Edition Donna Dowling, PhD, RN Gail C. McCain PhD, RN, FAAN Slides prepared by Margaret Comerford Freda, EdD, RN, CHES, FAAN

2. Breastfeeding • AAP and U.S. DHHS recommend exclusive breastfeeding for 6 months for all infants, healthy or ill • “Breastfeeding” does not necessarily mean suckling from the breast, but rather giving breastmilk by any means necessary (gavage, bottle or breast)

3. Breastfeeding the Preterm Infant • Milk supply may diminish 4 to 6 weeks after delivery • Furman, Minich & Hack (1998) found only 48% of mothers of preterm infants were still expressing milk at NICU discharge

4. Breastfeeding the Preterm Infant (Continued) • Rates of direct breastfeeding are lower for preterm infants than for full-term infants

5. Breastfeeding the Preterm Infant(Continued) • Nursing Care • Determine the mother’s intention to breastfeed • Ensure that mothers know the benefits of breastmilk for preterm infants • Teach use of the pump and encourage mothers to freeze milk if the infant cannot feed yet

6. Science of Human Milk for Preterm Infants • Benefits from the literature • 6 to 10 times less NEC in breastfed infants • Decreased respiratory and GI infections • Decreased incidence of retrolental fibroplasia • More stable SaO2 during breastfeeding • Improved feeding tolerance with breastfeeding

7. Science of Human Milk for Preterm Infants(Continued) • Long-term benefits • Decreased incidence of asthma • Decreased incidence of allergies • Decreased otitis media and GI disorders • Decreased risk of diabetes mellitus

8. Science of Human Milk for Preterm Infants(Continued) • Nutritional benefits • Composition facilitates digestion • Protein is primarily whey, which forms a softer, more easily digested gastric curd • Contains 20 amino acids, nine that are essential • Fat provides 50% of total caloric content, and long chain polyunsaturated fatty acids (AA, DHA) • Primary carbohydrate is lactose, which is easily digestible and produces soft stool consistency

9. Obstacles to Milk Production and Breastfeeding for Preterms • Deciding to breastfeed involves social and cultural norms and depends on social support mechanisms • Nurses can assist mothers in decision-making by providing accurate information

10. Obstacles to Milk Production and Breastfeeding for Preterms(Continued) • Successful initiation of lactation • Milk expression should begin as soon as possible after delivery • Most mothers require assistance • Maintaining an adequate milk supply • Directly related to frequency of milk expression, complete emptying and duration of pumping

11. Obstacles to Milk Production and Breastfeeding for Preterms(Continued) • Initiating direct breastfeeding • Traditionally dictated by NICU protocols • Nurses should question NICU guidelines that state that successful bottle-feeding must occur before direct breastfeeding can start

12. Obstacles to Milk Production and Breastfeeding for Preterms(Continued) • Ensuring adequate milk intake • Can be assessed by infant’s sucking behavior, mother’s milk ejection reflex and milk transfer

13. Obstacles to Direct Breastfeeding for Preterm Infants • Assessing infant behavior • Preterm infants often need several sessions before they can latch well and sustain bursts of several sucks • Behavior at the breast is dependent on PCA • Preterm infants can take 20 to 30 minutes to achieve successful positioning and intake • Explain to mother that no one is an immediate breastfeeding expert • Help the mother

14. Supporting the Mother Who Wishes to Breastfeed Her Preemie • Assess the needs of the mother and baby • Involve a lactation consultant, if possible • Teach the mother that preterm infants take • longer to transition to full, direct • breastfeeding (may not breastfeed well until • around 40 weeks PCA)

15. Supporting the Mother who Wishes to Breastfeed her Preemie(Continued) • Encourage kangaroo care, which helps increase duration of breastfeeding • Teach about pumping and storing

16. Nursing Interventions to Restore and Maintain Milk Supply • Encourage the mother to: • Communicate frequently with nurse and/or lactation consultant to discover milk supply problems early • Use support systems to help her express milk frequently (4 to 5 x/day) • Use relaxation techniques and get adequate sleep

17. Nursing Interventions to Restore and Maintain Milk Supply(Continued) • Review medications the mother takes that may cause lower milk volume • Allow her to discuss her concerns and anxieties about her infant • Encourage her to continue her efforts to provide human milk if at all possible

18. Supplementation • Supplementation is usually necessary―not all mothers can be with their infants for every feeding • Bottle-feeding may create nipple confusion; use breastmilk when bottle-feeding

19. Supplementation(Continued) • Cup-feeding is the only alternate feeding method that has demonstrated to be safe • Research is necessary to evaluate supplementation methods • Test-weighing before and after feeding may be helpful to mothers after discharge

20. Breastfeeding the Infant with Cleft Defects • Cleft lip and cleft palate (1 in 700 U.S. births) • Cleft lip defects are surgically repaired by 6 months of age • Infants with cleft lip can successfully breastfeed • Breast tissue molds around the cleft to form a seal, or mother can place her thumb in the cleft to form a seal

21. Breastfeeding the Infant with Cleft Defects(Continued) • Cleft palate defects are surgically repaired by 12 to 18 months of age • Infants with palate defects usually cannot breastfeed • Aspiration is the major problem

22. Techniques for Breastfeeding the Infant with Cleft Lip • For a unilateral cleft, point the nipple away from the cleft; position the infant in a cradle hold • For a bilateral cleft, position the infant upright and face-on at the breast • Encourage the mother to try different positions to obtain the best latch

23. Techniques for Breastfeeding the Infant with Cleft Lip(Continued) • Swallowing too much air is a possibility, so encourage frequent burping • Feeding may take twice as long for these infants than for infants without cleft lip

24. Breastfeeding the Infant with Cleft Lip • Assessing adequate weight gain is essential • If inadequate with direct breastfeeding, use expressed milk with special bottle for infants with cleft defects • Emotional support of the mother is key

25. Breastfeeding the Infant with Cleft Palate • Some infants with cleft palate can use palatal obturators that cover the cleft and aid in breastfeeding • Can reduce feeding time and increase volume • Encourage mothers to inquire about palatal obturators • Encourage pumping and use of human milk for gavage-feeding

26. Breastfeeding the Infant after Cleft Repair • In some infants, sucking is discouraged for a time postop • Postop feeding may be via spoon, syringe or a squeeze bottle • Several studies demonstrate the effectiveness of these methods to provide human milk to infants with cleft lip repair

27. Breastfeeding the Infant with a Congenital Heart Defect (CHD) • 8 per 1,000 live births • Coarctation of the aorta • Tetralogy of Fallot • Transposition of the great vessels • High risk for congestive heart failure until surgical correction • Infants become easily fatigued during feedings due to tachypnea, tachycardia and hypoxemia

28. Breastfeeding the Infant with a CHD (Continued) • Infants with CHD take in only 65% of needed calories • Require 160 kcal/kg/day • Breastmilk for these infants should be fortified to increase caloric density to 24 kcal/oz

29. Breastfeeding the Infant with CHD (Continued) • Nutritional supplements with medium chain triglycerides or microlipid products and glucose polymers are necessary • Studies have shown the best weight gain is from 24-hour continuous gavage feedings, but oral-facial stimulation is diminished

30. Reasons for Using Fortified Breast Milk for Infants with CHD • Breastmilk has anti-infective properties to prevent respiratory disease • Breastmilk promotes cognitive development, which is important due to chronic hypoxia with CHD • Oxygen saturations have been shown to be significantly higher with breastfeeding

31. Breastfeeding Techniques for the Infant with CHD • Require more frequent feedings • Upright or semi-upright positioning is important • Mothers must be aware of signs of fatigue during feedings―increased respiratory efforts, sweating and falling asleep

32. Breastfeeding Techniques for the Infant with CHD(Continued) • Mothers might need to pump after feedings if the infant cannot empty the breast • Test weighing may be necessary • Encourage mothers to use human milk, even if direct breastfeeding is not possible

33. Breastfeeding the Infant with Down Syndrome and Hypotonia • Down syndrome occurs in 1 in 800 live births • Extra chromosome #21 (“trisomy 21”) • Breastfeeding the infant with Down syndrome can be successful • Hypotonia may result in slower abilities to breastfeed (weak suck, poor head control, tongue protrusion, poor lip closure)

34. Breastfeeding the Infant with Down Syndrome and Hypotonia (Continued) • Congenital heart defects are common • Breastfeeding can facilitate the infant’s oral-facial development • Breastfeeding provides practice for normal tongue placement and strengthens jaw muscles used to coordinate sucking and swallowing

35. Breastfeeding the Infant with Down Syndrome and Hypotonia (Continued) • Breastmilk protects from infection and promotes development of the immune system, making it ideal for babies with Down syndrome

36. Breastfeeding Techniques for Infants with Down Syndrome and Hypotonia • Infants may not show hunger signs, so try breastfeeding every 2 hours • Have infant suck on mother’s finger to practice tongue placement • Have mother use awakening techniques like face washing or rubbing the legs

37. Breastfeeding Techniques for Infantswith Down Syndrome and Hypotonia(Continued) • Pump after feedings until the baby is feeding well • Use upright positioning with the dancer hold or football hold, or use a sling to help the infant maintain a flexed position

38. Breastfeeding the Infant with Down Syndrome and Hypotonia • Emotional support for parents is essential― most are shocked and surprised at diagnosis • Breastfeeding can provide a positive mothering activity • If rehospitalization is necessary, encourage mother to insist on breastfeeding and encourage her to continue to pump