Strengthening Nurses’ Knowledge and Newborns’ Health

December 2011 • Volume 5, Issue 6

® NurseCurrents

Headline Parent Education Prior to Discharge of By Author the Late Preterm or Term Newborn By Sandra L. Gardner, RN, MS, CNS, PNP

ewborn babies do not come with instruction manuals. Professional ma- Nternal and neonatal nurses must teach parents how to care for their newborn prior to discharge. In the days when new moth- ers had longer hospital stays, there were 3-4 days in which to teach parents how to care for their babies. Today, with 48-hour hospitalization for normal vaginal births and 96 hours for C-sec- tions, we no longer have that luxury. If families opt for early discharge and meet the American Academy of (AAP) and American College of Obstetrics and Gynecology (ACOG) criteria1 we may only have 24 hours to teach par- ents how to care for the newborn at home. Parental expectations and the reality of caring for a newborn rarely match. Parent- ing is not an instinct, it is a learned behavior. Parenting a new baby can be overwhelming. Usually it is the hardest—if most rewarding— job an adult will ever have. Learning Objectives So what can professionals do to make this transition to parenting successful? Maternal- newborn nursing professionals are not the pri- mary caretakers for the newborn; our role is to care for the parents, so that they are able to care • for their baby. First and foremost we empower parents with knowledge and information. Every encounter with the family is a teaching opportu- nity.2 It is best to teach both parents, or a parent

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and supportive/significant others, together. The nurse and under a radiant warmer. Others were Content of Parent Education crisis of parenting a newborn occurs in the first given their first bath by the parents in the moth- Box 1 lists major content areas for parent 3 weeks after birth, so that seeing the family er’s room, with a nurse teaching and supervis- education of the late preterm or term newborn. within days of discharge and in the first 2 weeks ing. In both scenarios, the full-term infant’s The nutrition article in this issue discusses nu- are opportunities to guide and counsel parents. temperature dropped one degree after the bath. trition education about both breast and bottle Both professionals and parents may have The researchers concluded that with supervi- feeding that should be taught to parents prior unrealistic expectations of the childbearing ex- sion and teaching by a nurse, parents can safely to discharge. perience and the role of the maternal-newborn give their newborns the first bath. One might nurse. Some parents choose a hospital expect- expect that parents would be reluctant to give Box 1: Content of ing a two-day stay in a luxury hotel, with nurses permission for their newborns to be studied. available as glorified maids and babysitters. These researchers were surprised at how easily Parent Education Prior Even other health professionals see the mater- they were able to recruit newborns and parents to Discharge of the Late nal-newborn nurse as someone who sits, rocks, for their study because parents actually wanted Preterm/Term Newborn and feeds babies all day! Indeed, what philoso- to give their babies the first bath. phy is implied in our own maternal-newborn There is no need for nursery nurses to give • nursing departments? Are we more concerned baths or change . Parents not only need • about “patient satisfaction scores” (i.e., meeting to learn and practice bathing, diapering, and • parental expectations of a pleasant experience) caring for their babies—they want to do so. • rather than preparing parents to safely care for Yet many neonatal nurses persist in deliver- • their newborn baby? ing care “the way we’ve always done it.” Some • Maternal-newborn nurses should be first and believe that parents prefer that nurses care for • foremost teachers, coaches and supporters of their baby so that parents can rest. Many feel • new parents. As “Partners in Care” we model that caring for the infant is faster and more • and role model for new parents in how to care efficient than teaching the parents how to do • for their infant—and themselves. As profes- so. Nurses drawn to this specialty sometimes sional nurses we are patient advocates and we prefer to interact with babies more than with can empower parents to become advocates for adults. Nevertheless, we need to offer parents Elimination their and children. We collaborate with more opportunities to care for their infants in After feeding, one of the most important topics parents in making decisions for both inpatient the hospital. As the studies show, they not only of interest to new parents is elimination—“pees” and outpatient care for the neonate. We ensure need to, but actually want to participate. and “poops.” Term neonates produce 1-3 cc/kg/ that parents understand and are able to comply hour of very dilute urine with a specific grav- with those plans. Because parenting is not a ity of 1.002-1.012. Well-hydrated newborns “spectator sport,” we facilitate, encourage and have 8-10 wet diapers/ day and moist mucus assist parents in becoming the primary care- membranes. The frequency of normal neonatal taker for their newborn. bowel movements ranges from one every time the baby feeds to one stool/week. Newborn Challenges to Parent Education infants have a gastrocolic reflex that results in Numerous barriers and challenges to parent a stool every time the stomach is stimulated education, originating from parents as well as with food, but as the GI tract matures this professionals, exist. These include time, lan- frequency of stools decreases. The consistency guage, literacy, work design, expectations and of neonatal stools changes in the first days of ability to form a therapeutic relationship. Table life from: (a) thick, dark green meconium, to 1 lists some challenges and potential solutions. (b) seedy, transitional stools when milk has A cogent example of fostering parent educa- completely traversed the intestinal track, to (c) tion through participation in the newborn’s breastfed (liquid yellow stools) or formula fed care is illustrated in the research by Medves (soft-formed yellow to light brown) stools.4 and O’Brien3 on the baby’s first bath. These researchers wanted to examine the temperature Crying stability of term, normal newborns given their Babies are astute at nonverbal communica- first bath by either a nurse or the baby’s parents. tion. Research has identified types of crying Some newborns were given their first baths in that reflect the infant’s state and needs: birth the traditional way—in the nursery, by a nursery cry, distress call, hunger, pain, spontaneous

2 | December 2011 Nurse Currents Table 1: Challenges and Potential Remedies for Parent Education

Challenges Potential Remedies

What do professionals contribute?

• Amount of content–review discharge teaching sheets. When and with whom will the parents have their first follow-up visit? What basic information do parents need till the first visit, at which time the outpatient care provider continues par- ent teaching. Multimedia.

• Time: Do more with less.“It is faster if I do it myself Parents learn by doing, so have more than one set of parents perform “first baths” while a than if I teach the parent to do it?” single RN supervises and teaches.

• Work redesign.“We’ve always done it this way!” Is “What we have always done evidence-based and efficient?” Group learning, like group prenatal care such as Centering Pregnancy, may be just as, or more effective and efficient.

• Difficulty with change Mother-baby care and primary nursing are both more consistent and patient-centered, but may be considered unnecessary to some care providers. ` • Burnout. “If I’ve said this once, I’ve said this a Small group learning experiences, use of media and self-paced learning as options. million times…”

• Ability to form a therapeutic relationship…or not The crisis of parenting requires a minimal number of care providers for both parents and neonates. Use of mother-baby care and primary nursing ensures consistency and continuity.

• Lack of consistency—different patient assignments daily. Use of peer support, peer teaching, multimedia and modeling/role modeling and mentor- ing from older nurses to younger mothers. • Ageism—older nursing workforce and young childbearing women.

What do parents contribute?

• Culture/ethnicity Culturally competent care and communication, understanding by care providers of the val- ues, beliefs, customs, and behaviors of the cultural and ethnic groups using maternal-new- born services. Use resources such as: Shah M: Transcultural aspects of perinatal health care: A resource guide, Washington, DC: National Perinatal Association, 2004.

• Language A qualified, acceptable, bilingual and bicultural interpreter provided by the facility or the fam- ily. Do not use strangers, untrained hospital staff or children as interpreters.46 Telephone inter- preter services.

• Literacy/ Illiteracy—inability to read the language Do not assume that parents are able to read written materials, even if written in their spoken one speaks. US reading level is 12th grade, but language. Illiterate adults will not disclose this fact because of shame. But illiterate does not comprehension level is only 6th grade. mean unintelligent. Use other forms of teaching besides the written word: pictures, diagrams, videos, verbal instructions.

• Expectations—of hospitalization, of the birth When the birth experience deviates from parental expectations, perinatal grief is experi- experience, of parenting enced and needs to be facilitated by care providers. Mothers also need to be assisted in resolving their “missing pieces”47 about labor/birth. These activities enable parents to be emotionally available to begin parenting their newborn. Parenting is “the working out of the discrepancy between the wished for and the actual child”.48

• Ability to enter into a therapeutic relationship…or not Maternal cognitive dissonance within the first 24 hours after birth.48 Comfort measure and pharmacologic interventions for maternal pain control.

Nurse Currents December 2011 | 3 Feature: Parent Education Prior to Discharge

and pleasure cries.5-9 The loud, lusty cry of the day than at night. As babies become older and and sufficiently mature circadian rhythms to healthy term newborn is a sign of wellness and more mature their crying decreases. Persistent sleep through the night. robustness, as well as a way of communicating crying (>3 hours a day) is more common in the Parents need to be shown how to position needs.6,8 Environmental stressors such as noise, breast-fed infant, while early evening crying is the baby for sleep and told the reason why the cold, light, overstimulation, multiple caregivers, more likely in the formula-fed infant.12 Crying supine—on the back—is the proper position. or lack of synchrony may precipitate crying.8 increases in the first 3 months of life, peaking at The AAP position paper on infant sleep recom- Tension in the environment or caregiver may about 6-8 weeks of age, then decreasing signifi- mends that all healthy infants be placed only potentiate or contribute to an infant’s crying. cantly at around 3–4 months of age.13 supine for sleep with a pacifier in the mouth.19 Development of a sense of trust occurs as Colic is irritable crying without an obvious Sleeping in the same room, but not in the same the infant’s cries are responded to by parents reason. It occurs in 10-20% of all infants, de- bed with parents is also recommended.19 Side- who are able to meet the infant’s needs. More veloping at about 2 weeks of age, and persisting lying for term infants is not recommended responsiveness by parents to an infant’s cries has for 4–5 months. Although the cause of colic is because they may spontaneously roll from side- been shown to result in diminished crying be- unknown, historically it has been attributed to lying to prone. Adoption of the “Back-to-Sleep” haviors—the infant associates comfort with the GI or CNS disturbances, allergies or parental program has resulted in a 40% to 50% decrease parent.9,10 Prompt parental responses prevent stress. Newer research attributes colic to nor- in the rate of sudden infant death syndrome escalation to out-of-control crying and quickly mal neurodevelopmental changes in newborn (SIDS).19,20 All care providers (including grand- attended babies are easier to soothe. Consistent, infants.13 How parents interpret and respond parents, childcare providers and babysitters) prompt response does not “spoil” babies. Term to the infant’s crying is influenced by their un- should sleep babies supine. infants have the ability to self-quiet during a derstanding of the reason for crying and their In healthy term infants, overheating, use fussy state by hand-to-mouth behaviors, sucking knowledge of strategies to soothe their infant. of soft sleeping surfaces/bedding, stuffed on tongue/fists, and using visual and auditory toys, and positioning devices should also be stimuli in the environment.11 Parent behaviors Sleeping avoided.19 Smoking is a risk factor for SIDS, to help quiet a crying baby are listed in Box 2. It Circadian rhythms in infants are influenced by as well as increasing the infant’s susceptibility should be pointed out, however, that sometimes genetic factors, brain maturation, and the envi- to respiratory infections.21 Parents should be nothing helps soothe a crying baby. ronment.14-17 Following birth and for the first encouraged to stop smoking. If they continue several weeks after birth, term infants distribute to smoke, they should do so only outside of Box 2: Graduated Parental sleep over a 24-hour period, sleeping from 16- the house and car. (See Gardner SL: Sud- Interventions to Quiet a 19 hours/day. As term infants go to sleep they den infant death syndrome (SIDS) and the 8 enter active, rather than quiet sleep and spend sleep environment Nurse Currents 2009; 3:1. Crying Infant more time in active sleep than adults.18 Active (Available at www.anhi.org). • sleep cycles vary from 10-45 minutes and quiet sleep cycles last about 20 minutes.18 While adult Skin Care22 sleep cycles are 90–100 minutes in duration, an Babies only need to be bathed 2–3 times/week, • infant’s sleep cycle lasts 50–60 minutes. in water that is 100 degrees Fahrenheit, with a At birth, infants have their own internal mild soap. Between tub baths, sponge bathing clock for sleep-wake, hunger, feeding and fussy with water on face, folds and bottoms is ad- times. The clock is often a continuation of in- equate. Products to be used on the newborn’s • trauterine rhythms. Family disruption and con- skin should contain no/few additives such flict may result when the infant interferes with as fragrances, to reduce the incidence of con- the family’s schedule of wakefulness and sleep. tact sensitization. Minimal use of lotions and • Maturation of sleep-wake cycles to coincide creams on newborn skin is best. Powders should with the family’s rhythm occurs as a result of not be used because of the risk of inhalation of brain maturation and environmental influenc- talc into the baby’s lungs. Frequent changes of • es. As the infant’s brain matures and the infant wet/soiled diapers, cleansing the area and • is exposed to patterned caregiving by parents, using diapers that wick the moisture away from • organization and stabilization of sleep-wake the skin are usually sufficient to prevent diaper cycles occurs. For example, at 6 weeks postnatal rash. If the infant’s skin becomes red and irritat- • age, infants are awake more during the daytime ed with the use of disposable diapers, a change than at night; by 12 weeks more sleep occurs of diaper brands often solves the problem. during the night than during daytime hours.8 When diaper rash does occur, the use of Term infants develop a diurnal pattern of By 4–6 months of age term newborns have the protective barrier products such as zinc oxide crying after birth—they cry more during the brain maturation, adequate stomach capacity will prevent further injury and allow skin to

4 | December 2011 Nurse Currents sheets and detergents with fragrances should be avoided; exposure of sensitive skin to chemicals Overdressing and overheating are the most common problems for may cause contact sensitization. newborn infants. Parents should be instructed to maintain the How to Recognize a Sick Baby23 baby’s temperature between 36.5 and 37 degrees Centigrade… Preventing infection is a vital part of parent education. Parents, siblings and all visitors must heal. With each diaper change, waste should be overdressing and overheating is also associated wash their hands prior to handling the baby. cleaned from the skin, but the barrier product with decreased risk of SIDS. A recent study Contact with the infant should be restricted— should not be removed, as this may disturb showed that the presence of an oscillating fan no one with a “cold” or any infection should healing skin. Diaper dermatitis caused by yeast in the room of a sleeping infant decreased the be around the baby. Crowds—large numbers infection requires antifungal medication. Care incidence of SIDS.19 of people with potential infections—should of the circumcised male infant includes keep- Late preterm infants (34 0/7 to 36 6/7 weeks be avoided. Newly born babies should not go ing the penis clean and observing for redness, of GA) present a special challenge both in the to shopping areas, children’s parties, childcare foul odor or drainage. The uncircumcised penis hospital and after discharge. Because of their centers or church nurseries. For parents resum- should be kept clean and the foreskin should biologic and physiologic immaturity these pre- ing work, child care settings with 1-2 children not be retracted. term infants may have difficulty maintaining rather than many children will decrease expo- The umbilical cord needs to be kept clean. normal axillary temperature. After discharge sure to illness. The diaper should be turned back away from the parents may need to use more and Vaccination against influenza is recommend- the intact umbilical cord until it separates, dries blankets to assist these preterms in maintain- ed for all infants at 6 months of age, as well as and falls off (within 7–10 days after birth). As ing thermal neutrality. Failure to keep these their contacts.24 For infants at-risk for respira- the cord separates there may be some spots of infants sufficiently warm, if they are unable to tory syncytial virus, the first dose of prophy- blood on the baby’s diaper; this is normal and regulate their own temperatures, results in their laxis should be given prior to discharge, then is similar to the slight bleeding that occurs as a using calories for warmth instead of for growth. monthly, according to published recommenda- scab separates from skin. If the umbilical cord However, both professionals and parents must tions. (See Bolyard D: Respiratory syncytial vi- becomes soiled with urine/stool it should be remember that there are other reasons why rus: A seasonal occurrence requiring year-round wiped with water. However, if a warm, red area these infants may not be warm enough­—in- planning Nurse Currents 2011; 5:2. (Available at of skin is seen around the base of the umbilical cluding hypothermia due to sepsis. (See below) www.anhi.org). Exposure to secondhand smoke cord, or there is a foul odor or drainage from The infant’s clothing, bedding and blankets must be avoided. the cord, the baby’s healthcare provider needs should be washed in a mild detergent and Recognizing an infected/septic newborn is to be called immediately. rinsed twice to remove all soap residue. Dryer difficult for professionals and even more difficult

Clothing and Dressing Overdressing and overheating are the most common problems for newborn infants. Parents should be instructed to maintain the baby’s temperature between 36.5 and 37 de- grees Centigrade (97.7–98.6 degrees Fahren- heit) with clothes, blankets and adequate en- vironmental temperature.1,7 Prior to discharge, parents should be taught how to take an axil- lary (never a rectal) temperature. It should be explained to parents that when newborns go home, it is not necessary to raise the ambient temperature in the house because of the pres- ence of an infant. A comfortable temperature for the family should be maintained, and the infant dressed accordingly. For instance, if the house is cool enough for adults and older children to wear sweaters, then the infant will also need more clothes to maintain his/her temperature in the normal range. Avoidance of

Nurse Currents December 2011 | 5 Feature: Parent Education Prior to Discharge

Box 3: Signs and Symptoms Predictive of Serious Illness and Parent Education Materials the Need for Hospitalization in Infants from 0-6 days and 7-59 and Resources days of age27 • • • • • • • • for parents. Early recognition and treatment of illness in their infant. (See Parent Education septic infants is critical in improving morbidity Materials and Resources on the right.) and mortality rates. Prior to discharge, parents Box 4 lists common symptoms of infection must be taught verbally and given written mate- in the neonate. Infected neonates have tem- rials on how to recognize a sick newborn. Signs peratures that are either too low or too high. and symptoms of illness, how the infant acts Most often, the septic newborn becomes cold and who to notify are important for all parents (hypothermic), rather than febrile (hyperther- discharged with a newborn infant. This is es- mic). Hyperthermia in the neonate can be due pecially critical for newborns with risk factors, to sepsis—serious infection—or environmental such as late preterms, who are at increased risk causes such as overdressing and overheating. for infections.25,26 Changes in behavior, especially feeding behav- The World Health Organization conducted iors, may be caused by infection. a large multi-site study of the clinical features and causes of bacterial disease in 0- to 6-day- old newborns and in 7- to-59-day-old infants.27 Box 4: Signs and Symptoms From an initial list of 20 signs and symptoms of Neonatal Infection25,50,51 of neonatal illness, 7 were found to be indepen- dent clinical predictors of severe illness requir- • ing hospital admission. The presence of any one sign listed in Box 3 indicates high sensitivity and • specificity for severe illness.How Will I Know My Baby is Sick? is a useful tool that can be given • to families at discharge to help them recognize

• •

•

• Mothers, especially mothers of older chil- • dren, should be instructed not to give a neo- nate any medication without calling the baby’s healthcare provider first. Mothers of toddlers who are familiar with giving sick older children

6 | December 2011 Nurse Currents anti-inflammatory medications may believe this how to properly position their infant safely in baby sleeps. Cribs should have no more than 2 practice is also advisable for a newborn. It must the car seat. Instruct them to limit the infant’s 3/8 inches between slats, have firm, tight-fitting be emphasized that if a neonate is sick enough duration of travel, to closely observe the infant mattresses, no missing or improperly installed to be medicated, he/she is sick enough to be while traveling and to avoid using the car seat hardware, no corner posts >1/16th inches high, seen by a healthcare provider. for infant sleeping.35,36 (see Gardner SL: Sudden and no cutouts on the head/footboard.39 Ac- Bilirubin levels of late preterm infants peak infant death syndrome (SIDS) and the sleep en- cording to the Consumer Protection Agency, later (at 5–7 days of life) and higher than those vironment Nurse Currents 2009; 3:1. Available drop-sided cribs have been associated with >30 of term neonates.28 Late preterms are at higher at www.anhi.org) infant deaths since 2000.39 As of June 28, 2011, risk for developing significant hyperbilirubine- Standard car seats are designed for 7–8 drop-sided infant cribs are no longer manufac- mia and 2-3 times more likely to be readmit- pound term babies. When placed in a standard tured, and the sale or donation of drop-sided ted for treatment of their jaundice than more car seat infants <37 weeks GA may experience cribs made prior to July 23, 2010 is prohibited. mature infants.29,30 Since hyperbilirubinemia apnea, bradycradia, and oxygen desaturation Babies should never be left unattended in a may be a symptom of neonatal sepsis, both due to head slouching and airway obstruction.32 car seat, baby seat or swing. They should not AWHONN discharge teaching guidelines31 and Therefore, a car seat challenge is recommended sleep or spend excessive time in these devices. the AAP late preterm discharge criteria32 require for all infants born <37 weeks’ gestation, in- The seat can fall over, the infant can fall out of professionals to assess for developing jaundice cluding late preterm infants.34,35 There is no the seat and the baby’s breathing can be com- and screen every infant with age-appropriate standardized procedure for a car seat challenge, promised because of slumping in the seats.35 nomogram prior to discharge.29 A follow-up although certain components are common. Infants should never be left unattended on a appointment within 24-48 hours after dis- 1. Use the infant’s car seat, purchased flat surface without protective rails, or while charge should be made and the importance of by parents; bathing. Before changing, dressing or bathing compliance should be stressed to the parents. 2. Position the infant in the car seat while the baby, all necessities should be immediately They should also be taught the way to assess he/she is attached to cardiorespiratory and at hand. The unbreakable rule of infant care jaundice at home: evaluate in daylight, progress pulse oximetry monitors; is: always have one hand on the baby. If what is from head-to-toe, blanch skin, and, after the 3. Monitor the infant for 30-90 minutes; and needed cannot be reached while keeping one skin is blanched, note how far down the body 4. Record heart/respiratory rates, oxygen sat- hand on the infant, the infant must be picked the yellow coloring is visible. urations, apnea/bradycardia episodes and up and taken with the parent. Making the rule positioning devices used. a habit prevents parents from walking away Safety to retrieve a forgotten object or to answer the Box 5 lists safety measures all parents of new- Shaken Baby Syndrome doorbell or phone. borns must be taught prior to discharge. It cannot be overemphasized to parents: never Every parent needs to know how to use a suc- shake a baby! Frustrated parents who have no tion bulb to prevent choking and aspiration. At strategies to comfort a crying baby may shake the hospital they can see, as well as practice its Box 5: Safety Measures for the baby to stop the crying.13,37 The fragile brain use. Most of all they should be taught when to Care of Newborn Infants of a baby bounces back and forth inside the skull use it, such as when the baby finishes feeding • causing bruising, swelling and bleeding. Of the and suddenly vomits. If vomit is coming out of infants who are shaken 80% suffer blindness, both nose and mouth demonstrate suctioning • brain damage, developmental delays, seizures the baby’s mouth first, then the nose, explaining 38 • and/or paralysis; 25% of them die. The Na- that the mouth holds a large amount of vomited tional Center on Shaken Baby Syndrome38 milk. If the nose is cleared first, then newborns, • advocates three actions to prevent shaken baby who are nasal breathers, will take a breath im- • syndrome: (1) Increase contact. Carry, walk and mediately after their nose is cleared and aspirate • talk to the baby to reduce crying. (2) If crying all the vomit that was in their mouth. becomes too frustrating, put the baby down in Vaporizers used in the nursery for babies with • a safe place, walk away and calm down. (3) No congestion should emit cool, not warm, mist to matter what, never shake a baby. prevent thermal burns. The microwave should not be used to warm Nursery Equipment either or formula. Microwave warm- Car Seats Newborns and infants depend on their parents ing results in hot pockets within the liquid that All states require infants to be restrained in car and caregivers to provide them with a safe en- can result in oral burns. Slow room-temperature seats while riding in motor vehicles. Newborns vironment. Pillows, soft bedding such as quilts, warming of formula or breast milk is advised.43 may be discharged home only in a properly in- comforters, sheepskins or bumper pads and soft Using room-temperature or tepid water to mix stalled infant car seat. Demonstrate to parents objects like stuffed toys do not belong where the powdered formula avoids potential burns.43 An

Nurse Currents December 2011 | 7 Feature: Parent Education Prior to Discharge

sequence of development is the same in all significant other. “It is your responsibility to children, the rate of development is individual. make sure that Mom, baby and you are getting Therefore, within the range of normal devel- enough rest and sleep. You may need to tell opment, differences between babies should be friends or family that they cannot visit because expected as an individual baby develops at his/ you are too exhausted.” her individual pace. At birth neonates are able Since newborns and infants do not sleep to see within 8-10 inches of their face, recognize through the night for the first 4-6 months, par- mother’s face and are able to follow an inter- ents now have a 24 hour/day job. Exhausted, esting face/ object horizontally and sometimes sleep-deprived parents are unable to be emo- vertically. During the last trimester of preg- tionally present for their infant. (Even adults in nancy, the fetus is able to hear parental voices intensive care units can develop psychosis as a and prefers these voices after birth. In 2012, an result of sleep deprivation.) Sleep deprivation issue of Nurse Currents will discuss the sensory may also result in depression and inadequate capabilities of the newborn. breast-milk supply. With both parents present affirm: “You have a 24 hour/day job. The num- Follow-up Care ber of hours of sleep that you missed during the additional danger of microwaving breast milk Parents need to understand the importance of night when you were awake with the baby must is the destruction of heat-sensitive anti-infective follow-up care after hospital discharge, whether be recovered. So if you were up for 3 hours dur- agents such as lysozyme and secretory IgA, at a clinic, physician’s office, or a home visit.4,7 ing the night, you need to get 3 hours of sleep which can result in overgrowth of bacteria in Follow-up care within 24-48 hours after dis- sometime during the day.” This is especially the milk.40-42 charge is especially important for late-preterms important if the mother is breast feeding, and and newborns discharged within 12-24 hours the father may not realize how much sleep she Siblings of life.1,25,33,32 is missing. Siblings, especially young siblings, do not un- Resumption of sexual relations after birth derstand that babies are fragile. They need pa- Parental Needs is now based on the woman’s comfort level rental help to interact safely with the new baby. In order to care for an infant, parents need to and her emotional and physical readiness for Parents can teach the concept of “gentle” by care for themselves. Their needs for rest, sleep, intercourse. The gravid uterus involutes to a using the word and showing the sibling how to privacy and resumption of sexual relationship normal size by 6 weeks postpartum, so 6 weeks touch and stroke the baby. Infants should never is necessary to help with the transition from a of abstinence was the traditional advice given to be left unattended with a young sibling. Parents couple to a family. new mothers. However, this advice was never should expect sibling rivalry and prepare for it. Ask if anyone will be coming to help in the evidence-based and the latest edition of Wil- first weeks after delivery. Take note of not only liams Obstetrics states that “following an un- Medications and Cardiopulmonary the name of the person and the relationship to complicated birth, a six-week abstinence from Resuscitation (CPR) the family but the tone of voice in which this in- intercourse makes little sense. It can be safely Generally, late-preterm and term neonates are formation is given. Ground rules should be set resumed in as little as three weeks or when com- not discharged from the hospital with medica- for the “helper.” These should include cooking, fort can be maintained.44 tions. However, in the event that an infant is cleaning and shopping while the new mother does not provide contraception sent home with meds, the parents must be fully rests and cares for herself and the baby. Help- after birth. Even though monthly periods may informed, verbally and in writing, about each ers should not care for the baby while the new not occur with breastfeeding, ovulation does medication, including name, action, dose, route, mother cooks, cleans, shops and plays hostess. occur. Without contraception a breastfeeding side effects and schedule for administering. Because everyone wants to see the new baby, woman can become pregnant.45 Because of time constraints parents of many new families have too much company. healthy term babies are not taught CPR as part They are so busy with an endless stream of Conclusion of discharge teaching. However parents should visitors that the new parents do not get enough Preparing parents to care for their newborn be encouraged to take a CPR class offered by sleep or privacy and soon become exhausted. is the responsibility of maternal and neonatal the American Red Cross, the hospital or a Authorize families to tell those wanting to visit nurses. Given the short period of time that healthcare provider.4 that the hospital nurse ordered all potential visi- most parents spend in the hospital after giving tors to: (a) be certain they are well, not ill, (b) birth, adequately covering all the information Developmental Needs be prepared to wash dishes, do laundry, or run that parents needs is a challenge. Using creative Development occurs in an orderly sequence errands, (c) bring a covered dish that can be strategies such as care-by-parents, small group influenced by readiness, maturation, genetics frozen, and, (d) stay a maximum of 30 minutes. classes, multimedia, written materials, and re- and environmental influences. Although the Assign the task of “enforcer” to the father or turn demonstrations, may expedite the teaching

8 | December 2011 Nurse Currents and learning process. Written and/or recorded SL, Carter BS, Enzman-Hines M, Hernandez JA, dations of the Advisory Committee on Immuni- materials that parents take home also provide eds: Merenstein and Gardner’s Handbook of Neo- zation practices (ACIP). MMWR 2010; 59(RR08): a reference when they are in doubt about their natal Intensive Care. ed 7. St. Louis: Mosby, 2011. 1. Available at www.cdc.gov/flu. Accessed July 2, baby’s care. Discharge parents with the phone 9. Ludington-Hoe S, Cong X, Hashemi F: Infant cry- 2011. number of the nursery, and encourage them to ing: Nature, physiologic consequences, and se- 25. Gardner SL: Late-preterm (“near-term”) new- call at anytime “because there is always a nurse lect interventions Neonatal Netw 2002; 21:29. borns: A neonatal nursing challenge Nurse Cur- here, awake, and ready to assist you if you are 10. Bell SM, Ainsworth MD: and mater- rents 2007; 1:1. Available at www.anhi.org. worried or have questions about your baby.” nal responsiveness Child Dev 1972; 43:1171. 26. Pados B: Safe transition to home: Preparing the 11. Brazelton TB: Neonatal behavioral assessment near-term infant for discharge Neonatal and In- About the Author scale, ed 2, Philadelphia: Spastics International fant Nursing Reviews 2007; 7:106. Sandra Gardner, RN, MS, CNS, PNP has Medical Publishers/ Lippincott, 1984. 27. The Young Infants Clinical Signs Study Group: worked in perinatal, neonatal, and pediatric 12. Thomas K: Differential effects of breast-and- Clinical signs that predict severe illness in chil- care for the past 44 years as a clinician, prac- formula feeding on preterm infants’ sleep-wake dren under 2 months: A multi-center study Lan- titioner, educator, author and consultant. patterns J Obstet Gynecol Neonatal Nurs 2000; cet 2008; 371:135. She is the Director of Professional Outreach 29:145. 28. sarici S, Serder M, Korkman A, et al; Incidence Consultation, a national and international 13. Barr RG: What is all that crying about? Bulletin course and prediction of hyperbilirubinemia in consulting firm established in 1980. She is of the Center of Excellence for Early Childhood near-term and term newborns Pediatrics 2004; also senior editor of Merenstein and Gard- Development 2007; 6:1. 1134:775. ner’s Handbook of Neonatal Intensive Care, 14. Fielder A, Moseley M: Environmental light and 29. Bhutani V, Johnson L, Maisels J, et al: Kernicterus: ed 7, 2011. The author was compensated by the preterm infant Semin Perinatol 2000; 24:291. Epidemiological strategies for its prevention Abbott Nutrition. l 15. Rivkees S: Developing circadian rhythmicity in in- through systems-based approaches J Perinatol fants Pediatrics 2003; 112:373. 2004; 24:650. References: 16. Rivkees S: Emergence and influences of circadian 30. Bhutani V, Johnson L: Kernicterus in late preterm 1. American Academy of Pediatrics and American rhythmicity in infants Clin Perinatol 2004; 31:217. infants cared for as term healthy infants Semin College of Obstetricians and Gynecologists: 17. Rivkees S, Mays L, Jacobs H, et al: Rest-activity Perinatol 2006; 30:89. Guidelines for Perinatal Care, ed 6. Elk Grove Vil- patterns of premature infants are regulated by 31. Association of Women’s Health, Obstetrics, and lage, IL: AAP, 2007. cycled light Pediatrics 2004;113:833. Neonatal Nurses: Near-term initiative. Washing- 2. London F: How to prepare the family for discharge in 18. Dreyfus-Brisac C: Ontogenesis of brain bioelec- ton, DC : AWHONN, 2005. the limited time available Pediatr Nurs 2004; 30:212. tric activity and sleep organization in neonates 32. Engle W, Tomashek KM, Wallman C, and the 3. Medves J, O’Brien B: The effect of bather and lo- and infants. In Faulkner F, Tanner JM, eds: Hu- Committee on Fetus and Newborn: “Late-pre- cation of first bath on maintaining thermal stabil- man growth, vol 3. New York: Plenum Press, term” infants: A population at risk Pediatrics ity in newborns J Obstet Gynecol Neonatal Nurs 1979. 2007; 120:1390. 2004; 33:175. 19. American Academy of Pediatrics, Task Force 33. Pilley E, McGuire W: The car seat: A challenge 4. Deacon J: Parental preparation. In Thureen P, on Sudden Infant Death Syndrome: The chang- too far for preterm infants? Arch Dis Child Fetal Deacon J, O’Neill P, Hernandez J, eds: Assess- ing concept of sudden infant death syndrome: Neonatal Ed 2005; 90:F452. ment and care of the well newborn. Philadelphia: diagnostic coding shifts, controversies regarding 34. American Academy of Pediatrics, Committee on Saunders, 1999. sleeping environment, and new variables to con- Injury and Poison Prevention: Safe transportation 5. christensson K, Cabrera T, Christensson E, et al: sider in reducing risks Pediatrics 2005; 116:1245. of newborns after hospital discharge Pediatrics Separation distress call in the human neonate in 20. Mitchell EA, Hutchison L, Stewart AW: The con- 1999; 104:986. the absence of maternal contact Acta Paediatr tinuing decline in SIDS mortality Arch Dis Child 35. American Academy of Pediatrics, Committee on 1995; 84:468. 2007; 92:625. Injury and Poison Prevention and Committee on 6. christensson K, Stiles C, Moreno L, et al: Temper- 21. Gardner SL: Sudden infant death syndrome Fetus and Newborn: Safe transportation of pre- ature, metabolic adaptation and crying in healthy (SIDS) and the sleep environment Nurse Currents term and low-birth-weight infants at hospital dis- full-term newborns cared for skin-to-skin or in a 2009; 3:1. Available at www.anhi.org. charge Pediatrics 2009; 123:1424. cot Acta Paediatr 1992; 81:488. 22. Lund CH, Durand DJ: Skin and skin care. In Gardner 36. Greenberg JM: The challenge of car safety seats 7. Gardner SL, Hernandez JA: Initial nursery care. SL, Carter BS, Enzman-Hines M, Hernandez JA, eds: J Pediatr 2007; 150:215. In Gardner SL, Carter BS, Enzman-Hines M, Her- Merenstein and Gardner’s Handbook of Neonatal 37. Carbaugh S; Understanding shaken baby syn- nandez JA, eds: Merenstein and Gardner’s Hand- Intensive Care, ed 7. St. Louis: Mosby, 2011. drome Adv Neonatal Care 2004; 4:105. book of Neonatal Intensive Care, ed 7. St. Louis: 23. Gardner SL: How will I know my newborn is sick? 38. National Center on Shaken Baby Syndrome: Mosby, 2011. Nurse Currents 2008; 2:2. Available at www.anhi.org. www.dontshake.org. Accessed on 6/30/2011. 8. Gardner SL, Goldson E: The neonate and the en- 24. Centers for Disease Control and Prevention: 39. US Consumer Product Safety Commission vironment: Impact on development. In Gardner Prevention and control of influenza-recommen- (CPSC): Crib safety tips: Use your crib safely,

Nurse Currents December 2011 | 9 Feature: Parent Education Prior to Discharge

Document #5030. Available at: www.cpsc.gov. We salute what you Accessed on 6/30/2011. 40. Academy of Breastfeeding Medicine: Protocol #10: Breastfeeding the near-term infant (35- do and built a nation 37 week’ gestation), 2004. Available at www. bfmed.org. Accessed July 3, 2011. 41. American Academy of Pediatrics, Section on just for you Breastfeeding: Breast Feeding and the use of human milk Pediatrics 2005; 115:496. 42. Quan R, Yang C, Rubenstein S, et al: Effects of microwave radiation on anti-infective factors in Join NightNurseNation.com today and get human milk Pediatrics 1992; 89:667. your monthly email newsletters packed with 43. Gardner SL, Lawrence RA: Breast feeding the special information just for you neonate with special needs. In Gardner SL, Carter BS, Enzman-Hines M, Hernandez JA, eds: Merenstein and Gardner’s Handbook of Neonatal Intensive Care, ed 7. St. Louis: Mosby, 2011. 44. cunningham F, Leveno K, Bloom S, Hauth J, eds: NightNurseNation.com is your resource for: Williams Obstetrics, ed 23. New York: McGraw- • Continuing education courses Hill Professional, 2009. • News and research on infant nutrition 45. Lawrence RA, Lawrence RM: Breast feeding: A Guide for the Medical Professional, ed 6. St. • Tips and advice for the night-nurse lifestyle and more Louis: Mosby, 2005. 46. Siegel RA, Gardner SL: Families in crisis: Theoret- ical and practical considerations. In Gardner SL, Carter BS, Enzman-Hines M, Hernandez JA, eds: Merenstein and Gardner’s Handbook of Neona- tal Intensive Care, ed 7. St. Louis: Mosby, 2011. 47. Affonso D: Missing pieces: A study of post-par- Connect. Learn. Grow. tum feelings Birth Fam 1977; 4:159. 48. solnit AJ, Stark MH: Mourning and the birth of a defective child Pschyoanal Study Child 1961; 16:523. 49. eidelman A, Hoffman N, Kaitz M: Cognitive de- fects in women after childbirth Obstet Gynecol 1993; 81:764. 50. Venkatesh M, Adams K, Weisman LE: Infection in the neonate. In Gardner SL, Carter BS, En- zman-Hines M, Hernandez JA, eds: Merenstein and Gardner’s Handbook of Neonatal Intensive Care, ed 7. St. Louis: Mosby, 2011. 51. American Academy of Pediatrics: Red Book: Re- port of the Committee on Infectious Diseases, ed 28. Elk Grove Village, IL: AAP, 2010.

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______Feature: Nutrition Education for Parents Prior to Discharge

Nutrition Education for Parents Prior to Discharge of the Late-Preterm and Term Newborn By Sandra L. Gardner, RN, MS, CNS, PNP

eeding competence is crucial prior to weight, a late-preterm and term infant needs discharge of the high-risk neonate,1 the to consume 110-120 kilocalories/kilogram/ late-preterm newborn,2,3 the newborn day. Daily nutritional requirements of carbo- F 1 discharged at less than 48 hours of life, and hydrates, fats and protein are listed in Table even for the well-term newborn.1 The ability 1. By the 8th day of life, neonates begin to to take in adequate fluids and calories is so gain weight at the rate of ½-1 ounce/day or important that many late-preterm and pre- 20–30 grams/day. Thriving neonates and in- term infants need prolonged (days to weeks) fants grow at a predictable rate. By 6 months lengths of stay until they master this skill. of age, they have doubled their , Meeting the neonate’s nutritional require- by 1 year they have tripled their birth weight, ments is vital to maintaining health and resist- and by 2 years of age they have quadrupled ing disease and for building new body tissue their birth weight. (i.e., growth) during a critical period of brain Healthy term newborns awaken themselves growth. Nutrition is so central to a newborn’s to feed while late-preterms may need to be life that a change in feeding behavior is one awakened to feed (discussed below). Breast- of the earliest signs of neonatal illness, such as fed babies awaken and eat more often than hypoglycemia or infection. formula-fed infants, but all infants need to Regardless of feeding method there are be fed every 1½–4 hours around the clock. some principles of neonatal nutrition that ap- Feeding young babies is the major reason that ply to all neonates. In order to grow and gain parenting is a 24-hour/day job.

Learning Objectives Table 1: Daily Nutritional Requirements for the Neonate

Percentage of Total Substrate Caloric Intake Grams/Kg/Day •  Carbohydrates 40%-50% 12-14 g/kg/day

Fat 40%-52% 4.4-5.7g/kg/day •  Protein: Term Neonate 2-2.5g/kg/day Preterm Neonate 3.5-4g/kg/day <30wkGA ELBW Average intake 3.5g/kg/day •  (<27 wks GA; <1000g) 4g/kg/day

Adapted from: Anderson MS, Wood LL, Keller JA, Hay WW: Enteral nutrition. In Gardner SL, Carter BS, Enzman-Hines M, Hernandez JA, eds: Merenstein and Gardner’s Handbook of Neonatal Intensive Care, ed 7. St. Louis: Mosby 2011.

Nurse Currents December 2011 | 11 Feature: Nutrition Education for Parents Prior to Discharge

Allowing an infant to awaken and signal supplemented with vitamin D or don’t have breastfeeding at 3 and 6 months, as well that he/she needs to eat is called “demand feed- adequate exposure to sunlight, are at risk for as any breastfeeding at 6 and 12 months ing,” and term, healthy newborns will demand rickets. For infants ingesting <1,000 ml/day of remain lower than the Healthy People 2010 to feed. An infant who has been demanding formula, supplementation of vitamin D is also goals of 50% breastfeeding at 6 months and to feed and changes his behavior—becomes necessary for prevention of rickets.5 25% breastfeeding at 1 year.11 sleepy, doesn’t demand to eat, needs to be Honey is contraindicated for infants in the Mothers are more successful with breastfeed- awakened to feed, is difficult to arouse to feed, first year of life.6 The gastrointestinal tract of ing when they have a positive attitude about falls asleep during feedings without having fed infants and young children cannot kill the live it, are confident in their ability, and have sup- well, or sleeps through the night needs to be Clostridium botulinum spores found in honey. port from significant others (both professional evaluated by a healthcare provider. Some par- When live spores infect infants and children, and personal).12-14 Overwhelmingly, maternal ents want to feed their babies by the clock, or infantile botulism characterized by muscle perception of “not enough milk” is the major on a schedule, which may or may not work, es- weakness, paralysis, respiratory arrest and reason mothers abandon breastfeeding for both pecially if the baby is breastfeeding and sleepy. death, occurs.7 Strongly advise parents that term and preterm infants.12,14 Therefore it is Generally, babies who demand their feedings honey should not be used on breast nipples, crucial to teach mothers simple ways to assess do so in a predictable fashion, eventually meet- pacifiers, in mixing formula or in any solid if their baby is getting enough breast milk (see ing parental needs for a schedule and the ability foods for the first two years of life. Box 1). Notice that none of the indicators in to anticipate feeding. Parenting is eminently Box 1 call for weighing the baby before/after easier if the baby leads and the parents follow. Breastfeeding feedings. This is work-intensive, requires equip- Swallowed air and the need for burping is The AAP,8 Institute of Medicine9 and the ment that is not usually available or convenient more common in bottle-fed than breastfed in- US Surgeon General’s Blueprint for Action on and may result in excessive and unnecessary fants. Breastfed infants can be burped between Breast Feeding10 state that (1) all infants in the worry in mothers of term, healthy babies. breasts, but no burping by the infant is not US should be breast fed, (2) “human milk is From 2001–2005 I consulted with the Ger- uncommon. Burping is necessary in bottle-fed uniquely superior for infant feeding,”9 (3) ber company about their new electric pump. babies at every ½ to 1 ounce, to remove swal- “infants should be exclusively breast fed for From the breastfeeding mothers in the research, lowed air that may cause distension, discomfort 5 to 6 months”8 and (4) “breast feeding is I learned how important having this knowledge and vomiting. the ideal method of feeding and nurturing is to breastfeeding success. For various reasons, Helping parents distinguish between wet infants.”10 Nationally, 75% of new mothers all mothers in the study used a burps, regurgitation, and vomiting is impor- are discharged from the hospital breastfeed- and after using the prototype I consistently tant because new parents are poor judges of the ing their babies.11 However, rates of exclusive inquired if there were any breastfeeding issues type and amounts that their baby brings up. Wet burps, bringing up some feeding with a burp, is common and normal within the first 6 Box 1: How to Determine if the Baby is Getting Enough Breast Milk weeks of life.4 Regurgitation—vomiting of part of a feeding—is most frequently due to over- feeding. Forceful projectile vomiting, vomiting an entire feeding, vomiting as a new finding, or • vomiting of blood or bile is abnormal. Parents should be instructed to call their baby’s health- care provider immediately if abnormal vomit- ing occurs. The infant should be examined to rule out gastric or intestinal obstruction, esophageal abnormality, newborn infection/ sepsis or gastroesophageal reflux. At discharge, or within the first several days of life, all newborns, both breast- and formula- fed, will be started on vitamin D supple- mentation. To prevent rickets, the American Academy of Pediatrics (AAP) recommends 400 international units of vitamin D/day beginning in the first few days of life.5 Because human milk contains <25 international units/liter of vitamin D, breastfed infants who are not

12 | December2011 Nurse Currents with which I could help them. Many mothers of collection. To the untrained eye, the change the first 4 minutes of sucking.16 A healthy stated that they did not know if their baby was in color and consistency looks like “weaker” and bottle-feeding baby is able to complete a feed- getting enough milk. Not just first-time moth- thinner milk. This perception may prompt the ing in 15–20 minutes; taking longer than this ers, but experienced breastfeeding women of mother, significant other, relatives or friends to expends more calories than will be obtained infants from 4 months to 10 months of age, suggest that the milk isn’t rich enough and that in the feeding. During the first month of life made this statement. The indicators in Box 1 formula feeding should be substituted. volume of feedings increases as do the intervals can reassure such mothers. Without even see- Another factor for successful breastfeeding between feedings. ing the baby, it is possible to reassure a mother is the comfort of the mother. Proper posi- Infants should always be held for feeding. that her baby is getting enough milk. tioning during nursing prevents sore nipples. Bottles should never be propped with the in- For instance, in counseling the mother of a Regularly changing positions encourages fant left alone to feed from the propped bottle. 4-month-old consider the following exchange. draining all breast lobes and prevents plugged The bottle nipple needs to be positioned so ducts and mastitis. that milk fills the nipple and the baby will not “What did your baby weigh at birth?” be swallowing air instead of milk. The baby “Eight lbs.” Formula Feeding should be burped every ½ to 1 ounce, and at At the first feeding, the stomach capacity of the end of the feeding. “What does your baby weigh now?” a term newborn is 2ml/kg, which gradually Human milk and/or formula provide “The last time she had her shots, she weighed increases with subsequent feedings. In the first complete nutrition for most term infants 20 lbs.” 24–48 hours, term newborns take between till they are 4–6 months of age. Too early 1–2 ounces/feeding and demand feeding ev- introduction of supplements/solids is not “Well since your baby weighed 8 lbs at birth, ery 2–4 hours. Term formula-fed infants are recommended. (See Gardner SL: Intro- she should weigh 16 lbs at 6 months. But she as efficient as their breastfeeding counterparts duction of solids into the diet of infants is only 4 months old and already weighs 20 lbs. because 86% of bottle feeding is obtained in Nurse Currents 2011; 5:11.) Your baby is getting plenty to grow on!”

Breastfeeding mothers who use a pump often Table 2: Stages of Lactation12 compare the amount of pumping time to the amount of time it takes their baby to nurse. From this comparison they decide that the baby could not possibly be getting enough milk. Stage/ Time Composition Comments There is no correlation between the amount Colostrum: (0-7 days) • Specific gravity: 1.040- • Amount in each breast at of breast milk expressed while pumping and 1.060 first feeding: 2-20 ml the amount of milk a mother actually lets • 67 Kcal/100 ml (20 cal/oz) • Yellow coloring because of down when her infant nurses at her breast.12 beta-carotene Even using a double-pump set-up, pumping • Contains antibodies to milk takes 15–20 minutes to drain full breasts, protect against infection, while a breastfeeding baby is able to drain a full cathartic, propensity of ben- breast in 5–15 minutes after let-down occurs. eficial gut flora Research shows that full-term breastfeeding ba- bies are very efficient; they obtain 50% of their Transitional milk: (7-10 days to • Fewer immunoglobulins • Less yellow and more white 2 weeks) and total protein in color feeding in the first 2 minutes, and 80%-90% • Higher in lactose, fat, total by 4 minutes. Minimal milk is obtained in the caloric content 15 last 5 minutes. In addition, the human breast • Higher in water-soluble knows the difference between a suckling baby, vitamins and lower in fat- who stimulates the breast physiologically, and soluble vitamins a breast pump, which doesn’t and is not as ef- ficient. A nursing baby is able to nurse faster Mature milk (2 weeks of age) • Water is largest component • Milk fat is almost completely and obtain more milk than any breast pump. • Lipids: 30-55% of kcal are digestible (small globules Human milk changes from colostrum to fats (3.5-4.5g/100ml) with a finer curd) transitional milk to mature milk by 2 weeks after • Fatty acids necessary for • Color is white-blue and looks thinner birth. (See Table 2) The composition of human myelinizations of the brain are 2-3 times higher in milk is dependent on the gestational age of the linoleic acid infant, time of day, sampling time and method

Nurse Currents December 2011 | 13 Feature: Nutrition Education for Parents Prior to Discharge

How to handle formula is another impor- production is delayed.24,25 The Association tant aspect of discharge teaching. Preparing of Women’s Health, Obstetrics and Neonatal bottles of formula from concentrate requires Nurses’ late-preterm initiative recommends that all bottles be stored in the refrigerator, that parent teaching for discharge include then warmed to room temperature by sit- the fact that these infants feed poorly and ting the bottle in a pan of hot water. The that they may sleep through feeds and need temperature of the formula should be tested to be awakened to eat.2 In their 18 minimum on the inside of the wrist prior to offering criteria for discharge of late preterm infants, it to the baby. Microwaving formula is the AAP also has several recommendations contraindicated because it results in uneven related to feeding ability, assessment and Correct formula preparation is critical and heating, creating hot spots that have burned follow-up care. must be taught. In the hospital, parents see infants’ mouths. Although late-preterm infants have nurses open a bottle of formula and may copy Reconstituted powdered formula and/or unique nutritional needs, there is no docu- this behavior at home. Consider the follow- mixed liquid formula should only be pre- ment that delineates what these needs are.26 ing true—and tragic—incident: pared in a batch for 24 hours. Once mixed, There is also a paucity of research to sup- An 18-year-old single mother finally took formula should be refrigerated immediately, port nutritional interventions for this at-risk her set of twins home from the hospital after if not fed. Any remainder of a feeding should group of infants. However, clinically we are several months of NICU care. One week af- be discarded because bacteria can grow in the still responsible for caring for the nutritional ter discharge she returned to the Emergency unused formula. Bottles, nipples and rings needs of this population. Specific strategies Department with two sick infants. For one should be washed after every use in hot, to manage breastfeeding difficulties for late week she had been feeding them concen- soapy water or sterilized in the dishwasher. preterm infants are published by Meier,24 trated, undiluted formula; she had opened When parents have a clean city water supply, and Wight25 and available from the Support- the can and poured the liquid into bottles, sterilizing water for formula preparation is ing Preterm Infants Nutrition (SPIN) pro- as the nurses had done. Because of the solute unnecessary. gram.27 Wessel’s article26 (available at www. load and lack of free water, both of the infants anhi.org) encourages the use of donor breast were in renal shut down and they both died. Late Preterm Infants milk or nutritionally-supplemented prema- A recent study of children with failure-to- Regardless of whether breast or bottle is ture formulas, supplemental breast pumping thrive found that most were not growing be- used for feeding late preterm infants, they and awakening late preterms to feed during cause they were not receiving adequate caloric are poor feeders.18-20 Wang’s retrospective the night.26 intake for growth.17 In the neonatal/ infant chart review found that 76% of late pre- population inadequate calories may be the term infants had poor feeding compared to Conclusion result of not feeding enough (amount), often 28.6% of full term infants.19 Late preterm Babies are ready for discharge when their enough (frequency), or not preparing formula infants are re-hospitalized more frequently parents are ready to care for them. Profes- properly. Some parents dilute liquid formula for jaundice, feeding difficulties and de- sional mother-newborn nurses are in a key with more water or mix powdered formula hydration.20 Developmental immaturity position to educate parents in the safe care of with fewer scoops per ounce to stretch for- of the late preterm infant contributes to their baby. Through education, demonstra- mula when money is tight. However, when poor feeding skills because of (a) inability tion and provision of hands-on care, nurses infants receive fewer calories per ounce they to coordinate suck/swallow/breathe, (b) in- empower parents to care for their newborns fail to thrive during a critical period of brain ability to awaken for and demand feeding, after discharge. growth. Teaching parents that formula prepa- and (c) inability to remain awake to feed ration must be done exactly according to the effectively. However, poor feeding skills in About the Author manufacturer’s instructions is important. this population of immature infants may Sandra Gardner, RN, MS, CNS, PNP has Powdered formula is not only cheaper per also be a sign of infection/sepsis rather than worked in perinatal, neonatal, and pediatric serving but more convenient than concen- developmental immaturity. care for the past 44 years as a clinician, prac- trate and ready-to-feed. It does not need re- A late preterm, breastfeeding infant is at titioner, educator, author and consultant. frigeration and can be mixed with tepid water particularly high risk for the development of She is the Director of Professional Outreach one bottle at a time. Demonstrations and/or dehydration due to poor feeding, the devel- Consultation, a national and international videos of how to prepare formula should aug- opment of significant hyperbilirubinemia, consulting firm established in 1980. She is ment verbal instruction. Do not assume that and the need for rehospitalization.21-23 Moth- also senior editor of Merenstein and Gardner’s parents are able to read and follow either the ers of late preterm infants suffer delayed Handbook of Neonatal Intensive Care, ed 7, English or Spanish written instructions for lactogenesis because their immature infant 2011. The author was compensated by Ab- formula preparation on the side of the can. stimulates the breast so poorly that milk bott Nutrition. l

14 | December2011 Nurse Currents References 13. Dennis C, Hodnett E, Gallop R, et al: A ran- 27. Supporting Preterm Infants Nutrition Program. 1. American Academy of Pediatrics and American domized controlled trial evaluating the effect Available at: www. [email protected]. Ac- College of Obstetricians and Gynecologists: of peer support on breast feeding duration cessed 6/10/2011. Guidelines for Perinatal Care, ed 6. Elk Grove among primiparous women Can Med Assoc Village, IL: AAP, 2007. 2002; 166:21. 2. Association of Women’s Health, Obstetrics, and 14. Lawrence RA, Lawrence RM: Breast feeding: Neonatal Nurses: Near-term initiative. Washing- A Guide for the Medical Professional, ed 6. St. ton, DC: AWHONN, 2005. Louis: Mosby, 2005. 3. Engle W, Tomashek KM, Wallman C, and the 15. Prieto CR, Cardenas H, Salvatierra AM, et al: Committee on Fetus and Newborn: “Late-pre- Sucking pressure and its relationship to milk term” infants: A population at risk Pediatrics transfer during breastfeeding in humans J Re- 2007; 120:1390. prod Fertility 1996; 108:69. 4. Deacon J: Parental preparation. In Thureen P, 16. Lac C, Alagugurusamy R, Schanler R, et al: Char- Deacon J, O’Neill P, Hernandez J, eds: Assess- acterization of the developmental stages of ment and care of the well newborn, Philadel- sucking in preterm infants during bottle feeding phia: Saunders, 1999. Acta Paediatr 2000; 89:846. 5. Wagner CL, Greer FR and the Section on Breast- 17. Cornfeld R, et al: First things first in failure to feeding and Infant Nutrition of the American thrive Lawson Wilkins Pediatric Endocrine Soci- Academy of Pediatrics: Prevention of rickets and ety 2011; Abstract 2904.49. vitamin D deficiency in infants, children and ado- 18. Barrington K, Vallerand D, Usher R: Frequency lescents Pediatrics 2008; 122:1142. of morbidities in near-term infants, Pediatr Res 6. American Academy of Pediatrics: Prevention 55:372A, 2004. of disease from potentially contaminated food 19. Wang M, Dorer D, Fleming M et al: Clinical out- products. In Pickering LK, ed: Red Book 2009: comes of near-term infants, Pediatrics 114:372, Report of the Committee on Infectious Diseases, 2004. ed 28. Elk Grove Village, IL: AAP, 2009. 20. Escobar G, Gonzales V, Armstrong M et al: 7. Koepke R, Sobel J, Arnon SS: Global occurrence Rehospitalization for neonatal dehydration: a of infant botulism, 1976-2006 Pediatrics 2008; nested case-control study, Arch Pediatr Adolesc 122:e73. Med 156:155, 2002. 8. American Academy of Pediatrics, Section on 21. Sarici S, Serder M, Korkman A, et al; Incidence, Breastfeeding: Breast feeding and the use of course and prediction of hyperbilirubinemia in human milk Pediatrics 2005; 115:496. near-term and term newborns Pediatrics 2004; 9. Institute of Medicine: Committee on Nutritional 1134:775. Status During Pregnancy and Lactation: Nutri- 22. Bhutani V, Johnson L, Maisels J, et al: Kernic- tion during pregnancy and lactation: an imple- terus: Epidemiological strategies for its pre- mentation guideline, Washington, DC: National vention through systems-based approaches J Academy Press, 1992. Perinatol 2004; 24:650. 10. U.S. Department of Health and Human Ser- 23. Bhutani V, Johnson L: Kernicterus in late preterm vices: HHS blueprint for action on breastfeed- infants cared for as term healthy infants Semin ing, Washington, DC: U.S. Department of Perinatol 2006; 30:89. Health and Human Services, Office of Women’s 24. Meier P, Furman LM, Degenhardt M: Increased Health, 2000. lactation risk for the late preterm infants and 11. Centers for Disease Control and Prevention: mothers: Evidence and management strategies Breastfeeding report card—United States, 2010. to protect breastfeeding J Midwife & Women’s Available at www.cdc.gov/breastfeeding/data/ Health 2007; 52:579. reportcard.htm. Accessed on July 6, 2011. 25. Wight NE: Breastfeeding the borderline 12. Gardner SL, Lawrence RA: Breast feeding the (near-term) preterm infant Pediatr Ann 2003; neonate with special needs. In Gardner SL, 32(5):329. Carter BS, Enzman-Hines M, Hernandez JA, eds: 26. Wessel JJ: Nutrition and the late preterm Merenstein and Gardner’s Handbook of Neona- infant NICU Currents 2011: 2:1. Available at tal Intensive Care, ed 7. St. Louis: Mosby, 2011. www.anhi.org.

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