SPECIAL BABY SPECIAL CARE a Guide to Caring for Your Baby in the NICU

SPECIAL BABY SPECIAL CARE A guide to caring for your baby in the NICU

SAMPLE parenthood Joy baby skin-to-skin birth Mother family journey Love communication Mother family baby skin-to-skin breastfeedingSAMPLE SPECIAL BABY SPECIAL CARE A guide to caring for your baby in the NICU

Dedication This book is dedicated with love to parents and all who support them. We hope that this book, along with help and guidance from your baby’s caregivers, will help answer many of the questions you have about your baby’s care in the NICU or SCN. Thank you to the many people and organizations that participated in the production of this publication. We are very grateful for their willingness to share their personal experiences with us. SAMPLE CCI Scan + Play App

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• Parent Emotions 5 • Breastfeeding Benefits . . . .36 • NICU Hygiene ...... 9 • Breast Physiology ...... 37 • NICU Equipment ...... 11 • Milk Production ...... 38 • Baby Care 14 • Hand Expression ...... 40 • Kangaroo Care 16 • Pumping in the NICU 41 • NICU Therapies ...... 17

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Visit us at: www.customizedinc.com • Email us at: [email protected] Table of Contents

Part 1: Part 2: When Your Baby Needs Special Care Breast Milk in the NICU

What You May Be Feeling ...... 5 The Benefits of Breast Milk ...... 36 Your Baby’s Health Care Team ...... 6 How Breast Milk is Made ...... 37 Communicating with the Care Team 8 Stages of Milk Production ...... 38 Being with Your Baby 9 Milk Supply 39 Who Can Visit 10 Hand Expression ...... 40 Monitors and Equipment 11 Pumping Your Milk ...... 41 Pain ...... 13 Cleaning Your Breast Pump Parts 43 Using a Pacifier ...... 13 Storing Breast Milk for Use in the NICU 44 Parenting in the NICU ...... 14 Choosing a Home Breast Pump 44 Kangaroo Care 16 Increasing Your Milk Supply 45 Comforting Your Baby ...... 17 Breastfeeding 101 ...... 46 The Importance of Positioning ...... 18 Positions for Breastfeeding ...... 48 Baby Behavior ...... 19 Latch Guidelines 50 Sleep Development 20 Nipple Shields ...... 51 Developing Senses in a Premature Baby 21 Fortifying Breast Milk 51 Communicating with Your Baby . . . . . 22 Donor Human Milk ...... 52 Preemie Development ...... 23 Challenges ...... 54 Adjusted / Corrected Age ...... 24 Safe and Healthy Breast Milk Facts 59 Screenings / Procedures ...... 25 Nutrition and Fitness ...... 60 Safe Sleep ...... 27 Pumping Log ...... 62 Shaken Baby Syndrome ...... 28 Glossary ...... 63 Child Safety Seats 29 Bibliography ...... 64 Look Before You Lock 30 Infant CPR (Under 1 Year of Age) 31 Infant Choking (Under 1 Year of Age) . . . . . 32 Warning Signs of Sickness 33 GoingSAMPLE Home ...... 34 PART 1: When Your Baby Needs Special Care

Introduction

The birth of your baby is one of the most exciting and memorable events of your lifetime. It is a deeply moving experience that can be shared forever with friends and family. Some babies will be born prematurely. Others may have a critical illness or condition that requires highly specialized care. If your baby needs to be in the Neonatal Intensive Care Unit (NICU) or Special Care Nursery (SCN), you may be experiencing a wide range of emotions right now. It is normal for the excitement you feel about the birth of your new baby to quickly change to worry or fear about what lies ahead. It is also true that the more you know about what to expect when your baby is in the NICU, the easier it can be for you and your family to manage these feelings and move forward. We want to help. How to use this book You are your baby’s most important caregiver. To help you understand the people and procedures in the NICU and how we work with you to care for your baby, this book has been divided into two parts:

Part 1: When Your Baby Needs Special Care • Introduces the doctors, nurses and therapists on the care team • Offers an overview of the NICU equipment and procedures • Provides insight into your baby’s experience while in the NICU

Part 2: Breast Milk in the NICU • Explains how vital your breast milk is to your new baby’s health • Provides key insights into breast milk production and nutritional value • Includes illustrated guides on how to breastfeed, pump and store your milk

See a word in blue text? You’ll find it defined in the Glossary section at the back of the book. We hope this information is helpful and answers many of your questions. But the book is just the beginning. Every person on your care team is here to help you and your baby get the best possible start in life. Remember: • If you have a question, just ask • If you feel afraid or uncertain, reach out to us • If youSAMPLE need anything, please let us know 4 Part 1: When Your Baby Needs Special Care What You May Be Feeling Some parents describe the early days of having their baby in the NICU as “fuzzy.” You are recovering from the birth, you may feel exhausted, and your baby is in the nursery instead of in the room with you. How you feel can also depend on whether you were expecting your baby to need NICU care after birth, your baby’s condition, your own condition, and if you have had experience with the NICU before. You are your baby’s most important caregiver. Take care In addition to excitement and love for of yourself so you can actively your new baby, it is normal for parents take care of your new baby. to experience a wide range of other emotions, including: • Fear • Anger • Guilt • Worry • Loss • Helplessness

Taking Care of Yourself In order to be strong for your baby, you need to take care of yourself—emotionally and physically. Remember that you are not going through this experience alone. Reach out to a trusted member of the care team, your partner, friends and/or family members and talk about what you are feeling. Ask for help if you need it. Also take care of yourself physically. You’ll need to be healthy so you can spend time with your baby in the NICU. Get as much sleep as possible, eat healthy foods, drink lots of water, and exercise when you can to lower your stress levels.

Looking Forward It is going to take time for you, your baby, your friends, and your family to recover from this experience. But you will get through it. Accept that what you may be feeling is normal. Take care of your emotional and physical health. Reach outSAMPLE for support if you need it. Part 1: When Your Baby Needs Special Care 5 Your Baby’s Health Care Team Your baby’s care team includes specially- trained professionals who are dedicated, experienced, and deeply committed to providing the highest levels of medical care. You can count on them to work closely with you to develop a plan of care for your baby.

MEDICAL TEAM NURSING TEAM

• Neonatologist: Physician with specialized • Registered Nurse (RN): Works closely with training in caring for premature babies and you and the neonatologist to plan your baby’s infants who need extra attention at birth care. Monitors your baby closely, directs and beyond. Oversees your baby’s care and feedings, and gives medications. Members of examines them daily. the care team that you will see the most.

• Resident: Physician who is receiving • Neonatal Nurse Practitioner (NNP): Registered additional specialized medical training in a nurse with specialized training in caring for hospital setting. babies who require extra attention at birth and beyond. Works closely with neonatologists to • Pediatrician: Physician specializing in the diagnose and treat illness. health care of infants and children. You’ll choose a pediatrician to be your baby’s • Charge Nurse: Oversees the daily care and doctor after you go home from the hospital. operations of the unit during each shift. Answers questions and helps with any • Consulting Physician: Specialist in a specific concerns when you visit your baby. area of medicine: heart, lungs, bowels, eyes, brain or infection. May be brought in to help • Nurse Manager: Oversees nursing operations with your baby’s care. and unit processes. Spends time in the unit speaking with staff, physicians and parents. • Physician Assistant (PA): Medical professional who works with the doctors on • Clinical Educator: Works with staff to make the medical team. Nationally-certified and sure that all patients receive the best quality state-licensed to practice medicine under the care. Also handles patient care standards, supervision of a physician. new staff orientation, and continuing staff SAMPLEeducation. 6 Part 1: When Your Baby Needs Special Care SUPPORT TEAM

• Developmental Specialists: Team includes • Unit Secretary: Handles administrative duties a physical therapist, occupational therapist to keep the unit running smoothly. Welcomes and/or speech therapist. Works with the and helps you, answers questions about hand medical team to help babies with specific washing, cell phone cleaning, where to secure developmental and medical needs. your belongings, and breast milk storage.

• Dietitian: Specializes in the nutritional • Lactation Specialist: International Board well-being of preterm and term infants. Certified Lactation Consultant (IBCLC) Works closely with the neonatologist to professional with knowledge, clinical provide optimal nutrition to help babies experience and skills to support breastfeeding. grow and develop. • Respiratory Therapist (RT): Licensed health • Case Worker: Helps with discharge care practitioner trained to care for babies planning, dealing with insurance with breathing difficulties. Works closely with companies, and addressing any financial the neonatologist to monitor equipment and concerns or individual needs. manage a baby’s respiratory needs.

• Pharmacist: Experienced in neonatal • Social Worker: Provides information about medicine. Reviews, monitors and available community programs, guidance dispenses medications ordered by your and support. Can also help with financial, baby’s providers. emotional, and/or family concerns. SAMPLE Part 1: When Your Baby Needs Special Care 7 Communicating with the Care Team Tips for Smooth Communication • Give the care team a phone number A provider or nurse practitioner will stay in they can use to reach you every day touch with you by phone. Your baby’s nurse can also update you in the nursery or over the • Give the team permission to leave phone. To help you make informed decisions a message on your voicemail if you about your baby’s care, the health care can’t take a call team will answer any questions and provide • Create a voice mail greeting that updated information. Information about your includes your name and number. baby’s health is only shared with parents. For example, “Hello, you have reached ______at ______. Please leave a message.” This helps the UNDERSTANDING care team know that they can YOUR BABY’S CARE leave a confidential message at this number. Medical terms can be hard to understand or remember. And it’s easy to forget important • Clear your voicemail messages details if you are tired or worried. Here regularly so there is room for are some practical ways to keep track of the care team to leave you a information and improve communications detailed message with your baby’s care team: • You can call us any time to check on your baby, although there may • Write down any questions or keep be times when the nurse has to a journal call you back • If you don’t understand a word or subject they are talking about, ask to have it explained in simpler terms • Taking an active part in the care and decision making for your baby can help reduce anxiety and help you feel more connected • Ask when and how you can help with your baby’s care • Learn as much as you can about your baby’s health and condition

Photo Credit: EvaDiana Photography SAMPLE 8 Part 1: When Your Baby Needs Special Care Being with Your Baby You are always welcome to spend time at your baby’s bedside. Your little one already knows your voice and will need the love and support only you can provide. To protect the safety, health and privacy of you and your baby in the NICU or nursery, you will need to follow certain guidelines. Each hospital may have its own specific rules that you’ll need to follow.

SAFETY To keep your baby safe, the nursery is a limited-access area. Only authorized persons can be there. After the birth, you, your baby and a support person were given identification bracelets that are unique to you. The bracelets must stay on the designated person’s wrist, not taken off or shared. You will need your bracelet (and another piece of identification) to visit the nursery, and when your baby is discharged to go home.

PREVENTING INFECTION Hand hygiene is very important in the nursery to prevent infection. Every time you visit your baby you must “scrub in.” The nursery staff will show you how to wash your hands. You’ll also find detailed instructions near the sinks. If you have any questions or need help, just ask. Some nurseries may also ask you to place your cell phone or electronic device in a sealed plastic bag to lower the risk of infection. Parents need to think carefully before allowing someone who is sick to visit your baby. If you or someone else has a cold, cough, skin infection, fever blister, diarrhea or other contagious disease, please don’t visit the nursery until you are completely recovered. Any visitor who shows signs of illness or appears impaired or disruptive will not be allowed to visit.

SAMPLEKeep your hands clean No sick visitors allowed Seal your phone in a bag Part 1: When Your Baby Needs Special Care 9 Who Can Visit Here are some general guidelines about who can visit your baby in the NICU or Special Care Nursery. Some hospitals may have additional rules, so please ask if you’re not sure.

SIBLINGS Your baby’s brothers and sisters are welcome to visit as long as they are old enough, healthy and accompanied by an ID band wearer. You will be asked about the health of any children coming to visit your baby and they may have their temperature taken. This is to prevent your baby from exposure to an infection. Some hospitals don’t allow children to visit during cold and flu season. If you have questions about children visiting your baby, please ask.

SPECIAL VISITORS You can designate adults who are important to you as “special visitors.” For the safety of all the babies, your special visitors may be asked to present a photo ID before entering the nursery. Due to the size of the rooms and the need to maintain a quiet environment, we may limit the number of visitors allowed in at the same time. Visitors need to stay in your baby’s room, at their bedside, or in the family waiting area. Please teach your visitors how to wash their hands and use hand sanitizer before touching your baby. Visitors may be asked to wear a gown over their clothing.

CONFIDENTIALITY The care team wants you to have full access to your baby in the nursery. But there may be times when you are asked to wait in the family waiting area. If this happens, please understand and comply. The care team needs to do everything possible to ensure that every baby is receiving the best possible care. The health care team will make every effort to keep you updated on your baby’s condition. By law, we can only share medical information with parents. Ask the staff how to get information by phone.

PRIVACY Privacy is very important. Although the care unit tries to keep all information private, there may be times when conversations are overheard in open areas. Please do not ask about other babies in the nursery.SAMPLE Stay with your baby and ask your visitors to do the same. 10 Part 1: When Your Baby Needs Special Care Monitors and Equipment Based on the level of care your baby needs, there may be several different types of specialized medical equipment connected to the baby by wires or patches. The care team will be happy to explain how each piece of equipment works.

BEDS RESPIRATORY CARE • Incubator: A clear box-like bed with an • Oxygen Hood: Provides babies with extra oxygen internal heat source. Provides a womb-like if they can breathe on their own. Looks like a clear environment. Common incubator brands are plastic box over the baby’s head. Giraffe® and Isolette®. • CPAP (Continuous Positive Airway Pressure): • Radiant Warmer: An overhead heater to Uses a special mask or prongs to cover the nose keep your baby warm. Allows easy access to and send a continuous flow of oxygen and air into the baby and to other equipment. the lungs. Gently keeps the air sacs open and helps your baby breathe better. • Open Crib: When babies can regulate their own body temperature, they will be moved to • Endotracheal Tube: Goes from a baby’s mouth or an open crib. nose to the windpipe. Used with a ventilator to get air and oxygen into your baby’s lungs.

MONITORS • Mechanical Ventilator: Helps babies breathe or breathes for them when they can’t breathe • Cardiopulmonary Monitor: Connects to your on their own. Works by pushing warm air and baby with sticky pads (leads) on their chest. oxygen through the breathing tube into the Measures your baby’s heart and breathing rates. baby’s lungs.

• Blood Pressure Monitor: A cuff wrapped • High-Frequency Ventilator: Oscillating or jet around your baby’s arm or leg to measure ventilators give a baby small breaths at a faster blood pressure. rate than regular ventilators.

• Pulse Oximeter: A small bandage-like sensor • Extracorporeal Membrane that shines a red light through a baby’s hand, Oxygenation (ECMO): wrist, or foot. Measures how much oxygen is in Filters a baby’s blood to add their blood, and if they need more or less oxygen. extra oxygen to it. SensorSAMPLE does not cause pain and is not hot. Part 1: When Your Baby Needs Special Care 11 Photo Credit: EvaDiana Photography

LINES OTHER • Central Line: A thin tube placed into a blood • Syringe Pump: Computerized pump vessel. Can be used to give your baby medicine that delivers feedings, medicine and and fluids, and to draw blood. Also called a PICC blood products. line (Peripherally Inserted Central Catheter). • Phototherapy: Phototherapy is a special blue • Umbilical Catheter: A thin tube placed in light used to treat jaundice. Your baby’s eyes a baby’s umbilical cord to give them fluids, are safely covered during the treatment. medicine and blood. Also used to draw blood to measure the baby’s blood gases (acid, oxygen • Cooling Cap or Blanket: Used to lower a and carbon dioxide in the blood). baby’s brain and body temperatures. After 3 days, babies can be gradually warmed in • Intravenous (IV): Intravenous is a small plastic the incubator to a normal body temperature. tube inserted into your baby’s blood vein. Connected to an IV pump to give your baby ALARMS measured fluids and medications. • Why is that alarm going off? Is my baby OK? FEEDING TUBES Alarms on monitors alert the care team to many different things. They can be triggered • Nasogastric Tube (NG Tube): The Nasogastric by loose equipment, a hiccup, or a baby’s Tube goes through a baby’s nose to deliver movement. It is normal to worry when you feedings or medications into their stomach. Also hear one, but your baby’s nurse will check called gavage feeding. each alarm. Monitors do not pick up on your baby’s feelings or behavior. If you think your • Orogastric Tube (OG Tube): Goes through baby’s condition is changing for the worse, a baby’s mouth (instead of nose) to deliver notify the nurse. Please feel free to share feedings or medication into their stomach. your concerns or ask questions any time. Another type of gavage feeding.

• Gastrostomy Tube (G-tube or Gastric Feeding Tube): Inserted through a baby’s abdomen to directly deliver liquid nutrition to their stomach. UsedSAMPLE when babies need long-term feeding help. 12 Part 1: When Your Baby Needs Special Care Pain It can be hard to tell if a baby is feeling pain. Sometimes babies, especially preterm babies, can’t let us know what they are feeling. Your baby may have some painful experiences while in the NICU. Know that it is very important to the care team that they minimize any pain and do everything they possibly can to keep your baby comfortable.

Signs that your baby might be in pain include: • Crying, a worried face or a frown • Tightly fisted hands or feet • A higher than normal heart rate and blood pressure • A change in oxygen levels when touched or handled

The health care team uses a method called the Premature Infant Pain Profile (PIPP) to assess a baby’s pain. Please feel free to talk to the nurse if you have any questions or concerns about pain.

MEDICATIONS TO PREVENT AND TREAT PAIN Procedures that may cause pain include heel sticks and IV or chest tube placement. Infants placed on a ventilator can be uncomfortable and may need pain medication. Treatments and procedures known to cause pain can be treated with narcotics given through an IV tube. The medication can either be given slowly and continuously through the IV or only when the Using a Pacifier baby shows signs of needing comfort. Non-nutritive sucking (sucking without Some babies will need to receive narcotic taking milk), has many benefits for medications for a short period of time. When preterm/ill infants, especially during no longer needed, medication will be gradually gavage feedings through a feeding tube. reduced to prevent symptoms of withdrawal. This A pacifier or an emptied breast (called does not mean that your baby is addicted to the nuzzling) can give your baby these benefits. medicine, just that their body has gotten used to it. Although pacifier use soon after birth has been linked with breastfeeding problems in healthy term infants, no similar adverse NON-MEDICAL WAYS effects have been reported for preterm/ TO HANDLE PAIN ill babies. Talk with your baby’s nurse or Sucrose is a sugar used to provide short term health care provider about when you can pain prevention and management for procedures begin nuzzling during gavage feedings. like heel sticks, feeding tube placement, vein Pacifiers and bottle nipples help babies learn sticks, and shots. to suck. Using a pacifier can also provide Placing a few drops of sucrose on the baby’s comfort during painful procedures. You can tongue with a dropper or pacifier can help expect to see your baby using bottles and control pain before, during and after a procedure. pacifiers while in the NICU. If you have any Swaddling, nesting, hand hugs, and verbal questions about this, please ask your baby’s reassurance can also help calm an uncomfortable nurse or health care provider. or fussySAMPLE baby. Part 1: When Your Baby Needs Special Care 13 Parenting in the NICU Did you know that parents are also very important members of your baby’s health care team? Some of the ways you can help include communicating with staff members, feeding, bonding, touching, and spending skin-to-skin (kangaroo care) time with your baby.

VISIT BATHING Visit your baby when you can and take photos At first your baby will get a small sponge bath to share with others. When your baby is ready with warm water. As your baby grows they will for stimulation, you can softly read, sing or talk become ready for a swaddle bath, which can be to them. both cleansing and therapeutic.

TAKING A TEMPERATURE DRESSING Premature babies may not have enough fat to When your baby is able to wear clothes, you keep themselves warm. Take their temperature can begin dressing them. Before you bring any before you take them out of the incubator or bed garments into the NICU, be sure to wash them and again when you put them back. This tells you in unscented detergent. Write their first and last if they can maintain their own body temperature. name on all clothing and hats.

CHANGING DIAPERS MOUTH CARE If you are changing diapers You can begin mouth care right away. Using while your baby is in the your breast milk for oral care helps prevent incubator, you may feel a little infection. Your baby can absorb immune cells uncoordinated. Their bodies and nutrients from your colostrum. It only takes may be a little floppy and a few drops, so save a small amount of milk for difficult to lift if they were mouth care when you pump or hand express. born prematurely. SAMPLE 14 Part 1: When Your Baby Needs Special Care SIBLINGS TOUCH AND HOLD Having their new baby brother or sister in the At first, a touch may be too stimulating for your NICU can also be a difficult experience for your new baby. Offer a finger to grasp or hold their other children. Spend time alone with them, hand in yours. You can also use containment even if it is just a few minutes each day. Read holding and kangaroo care. them books about babies in the hospital. If they are old enough, bring them in for short visits to bond with the baby. Making signs and CAMERAS IN THE NICU decorations for the crib is a great way to help Some hospitals have web-based cameras siblings feel involved. (webcams) that let parents watch over their baby in real time. Nursery webcams are routed PERSONALIZING YOUR BABY’S SPACE through a secure internet portal, which you will need to access with a password. One way to create an environment that is Only nursery staff and people with authorized meaningful for all of you is to bring in access (usually parents and any family members photographs of your baby’s entire family. you give access to) can watch the live feed. You can also place black-and-white patterned The video feed may be off at times for a variety designs near the crib for your baby to look at of reasons. If your webcam is offline for an when they are awake. extended period of time, contact the nursery. As your baby grows, ask about bringing in other developmentally appropriate items. SAMPLE Part 1: When Your Baby Needs Special Care 15 Kangaroo Care Kangaroo care involves holding your baby, who wears only a diaper, skin-to-skin on your bare chest. There are many positive benefits to providing kangaroo care.

It helps your baby: • Stay warm • Gain weight • Sleep better • Learn your smell • Stabilize their heart and breathing rates

It also helps with: • Breastfeeding by increasing your milk production • Increasing the length of time (in months) your baby will breastfeed • Lowering stress hormones in you and your baby • Growth and development of brain function You build immunities to germs Preparing for kangaroo care: in the NICU and pass them on • Use the bathroom before you begin to your baby. • Wear clothing that will make it easy (no bra, a button-down shirt) • Remove all jewelry • Do not wear perfume • Dress your baby in only a diaper • Plan on 1 to 3 hours—the longer the better

How to safely hold your baby skin-to-skin: • Sit up elevated, not lying flat • Support your arms with pillows • Lay your baby chest-to-chest with you • Cover your baby with a blanket • Make sure your baby has their: ¬¬ Head under your chin (kiss the head) ¬¬ Head turned to one side ¬¬ Chin up, not on their chest ¬¬ Face visible and not covered by a blanket ¬¬ Body tucked with a blanket or approved wrap ¬¬ Legs bent or flexed

Hold your baby skin-to-skin every day. It is easy to become sleepy when you are holding your baby, SAMPLEso it may be helpful to have someone with you. If you feel sleepy, return your baby to the crib. 16 Part 1: When Your Baby Needs Special Care Comforting Your Baby Having you close can be very comforting to your baby. But every baby is unique and special. Some babies like to be held, talked to, massaged, or given a pacifier. Some babies like to be wrapped snugly or nested between your hands. Some babies prefer to be left alone. Your baby’s nurse will help you decide what works best for your newborn. Keeping the area quiet and lowering the lights can also be helpful.

Ways to help calm and comfort your baby include: • Holding your baby quietly skin-to-skin (kangaroo care) • Hugging your baby with your hands • Swaddling your baby in a blanket • Placing your baby in a position that cradles them • Providing boundaries with blankets and position aids • Offering your baby a pacifier • Letting your baby hold your finger • Shielding their eyes from bright lights • Decreasing the noise around your baby’s bed • Speaking or singing softly to your baby • Offering a cloth that smells like you or your breast milk • Giving your baby some quiet time alone To give a hand hug: Place one hand around the baby’s head and your other hand supporting their feet. Hand hugs help your baby curl up and relax. “Containment” means moving your baby into a curled position with their legs flexed and helping them bring their hands up to their mouth. Placing your warm hands gently on your baby is soothing and calming. But please note that premature infants prefer not to be stroked, tickled or rubbed. This is because their neurological system isn’tSAMPLE ready yet for this type of touch. Part 1: When Your Baby Needs Special Care 17 The Importance of Positioning In the womb, babies curl into a snug little ball (fetal position) and can feel their “home” on all sides. A baby who is correctly curled Your baby may have to stay on their tummy or (“flexed”) will have: back immediately after birth. But in time they will benefit from a variety of positions that help their • Chin tucked into chest muscles develop and give them a sense of security. • Rounded trunk These containment positions mimic the womb by • Forward and rounded limiting movement and giving babies something to shoulders push against to help develop their muscles. • Legs bent at the knees and hips Babies who don’t have the energy to keep • Thighs resting on or near themselves in a healthy position can be positioned the tummy by building a nest around them using rolled • Arms bent and tucked in close blankets and bendable bumpers. Your baby will to their sides be placed in a variety of positions to encourage • Hands near chest, head or face growth and development.

SAMPLE 18 Part 1: When Your Baby Needs Special Care Baby Behavior Premature babies have six different states of activity that help explain their different behaviors: alert, drowsy, fussy, crying, light and deep sleep states. The more premature your baby is, the less their activity state will change. The predominant state for premature babies is sleep—either light or deep. As your baby grows, you will observe more of the other states.

ALERT STATE LIGHT SLEEP Your baby is bright and awake, breathing Also called REM (Rapid Eye Movement) sleep, regularly, and not moving around very much. this is the most common sleep state for a They can focus their attention on a face, an premature baby and crucial for learning and object, the sound of your voice, or music. This is memory. You can see your baby’s eyes flutter the best time to interact with your baby. Try only beneath closed lids. Your baby may be restless, one stimulation at a time—speak quietly or just make little noises, or breathe unevenly. Their eyes smile at your baby without talking. may be slightly open, and they will likely react to noises and light changes.

CRYING STATE FUSSY STATE Your baby is actively moving, crying intensely, and hard to calm. This state is very difficult for you as Babies may be thrusting their arms or legs, a parent who wants to comfort your baby. If your breathing irregularly, appear irritable with raised baby is able, skin-to-skin contact can be soothing. eyebrows and a wrinkled forehead. Instead of You can also try other comfort measures, like looking worried, your baby may have a glassy-eyed swaddling, hand containment, positional aids, and look. This state is very tiring for the baby. lowering noise and light. Comforting measures can help them calm down.

DROWSY STATE DEEP SLEEP Drowsy babies have a dazed look, somewhere Your baby is breathing evenly and lying very still. between awake and asleep. Their eyes are dull They might startle or sigh during this type of with droopy eyelids and it is harder to focus on sleep. If your baby is very premature you may not you. They may increase their movements or see this state of sleep often. As they get older the be startled by sounds. You may see a delayed deep sleep state will be very important for growth reactionSAMPLE to voices or other noises. and brain development. Part 1: When Your Baby Needs Special Care 19 Sleep Development

23 TO 27 WEEKS GESTATION 30 TO 33 WEEKS GESTATION In these early weeks your baby sleeps most of the Your baby’s sleep is now cycling regularly time. They may only have brief moments when between active and quieter stages. They are still they are in a drowsy or partially awake state. An unable to reach a deep sleep, but they do enter immature nervous system causes their movements a quieter stage, which helps them grow and to be jerky and trembling, even during sleep. Your develop. Your baby still needs approximately baby should be sleeping 23 to 24 hours per day. 21 to 22 hours of sleep per day.

28 TO 29 WEEKS GESTATION 34 TO 36 WEEKS GESTATION At this age, premature babies will begin to have Babies at this age still sleep 18 to 20 hours periods of REM sleep and only brief moments per day—only a few more hours than full-term of wakefulness. They are still not ready to focus infants who need 16 to 17 hours of sleep per day. on your face. During this light sleep you will see At about 35 to 36 weeks your baby will begin irregular breathing, sucking movements, and to experience very deep, quiet sleep, which is occasional brief eye openings. Your baby may essential for growth and development of the body respond to voices and other noises and should be and brain. sleeping 22 to 23 hours per day.

SAMPLE 20 Part 1: When Your Baby Needs Special Care Developing Senses in a Premature Baby If your baby is in the nursery because they were premature, you need to understand when and how their bodies will grow and develop. Premature babies need time and special care to mature, which is different from full-term babies whose senses are well-developed at birth. Outside of the womb, your baby will be challenged to develop these senses: hearing, seeing, taste, smell and touch. The goal during your baby’s stay in the nursery is to mimic the womb environment as much as possible to promote the “natural” development of these senses. Because your baby’s neurological system is immature, you’ll need to understand the difference between what will help their development and what will overwhelm their fragile state.

VISION

• Their eyes are very sensitive to light • Sight takes longer to mature than hearing and touch • Too many images at one time can be overwhelming

SMELL

• Can recognize your scent from the womb • Helps them adjust to the environment • Soothing smells help with comfort from pain • Don’t use scented soaps or wear perfume

TASTE

• Begins in utero with amniotic fluid • Taste buds well-developed by 21 weeks gestation • Prefers sweet tastes like breast milk

TOUCH

• The first sense to mature • Baby’s skin is fragile and sensitive • Prefers supportive touch with boundaries like in the womb • Light touch may be too stimulating or even painful

HEARING

• Important for language development • Can hear a variety of sounds • Can pick out their parent’s voice • Soft voice is best SAMPLE• Shows more interest in voices than other sounds Part 1: When Your Baby Needs Special Care 21 Communicating with Your Baby Even though your baby can’t speak to you yet, they can definitely communicate. Your baby’s cues, or signs, can tell you what they can tolerate and what mood they are in. These signs will be more subtle than in a full-term baby. Your baby will also have skills to soothe and comfort themselves. As your baby grows and matures, their skills will change.

Here’s a quick look at what your baby’s cues are telling you:

I’m ready to interact I’m soothing myself • Alert, eyes are open • Clasping their hands • Can focus on your face • Sucking on their hands or fingers • Regular breathing pattern • Tucking their arms and legs close to the body • Relaxed face, arms, or legs • Resting their feet on something for support • Cooing • Going into a light sleep state

I’m feeling stressed • Changes in breathing pattern or an increased need for oxygen • Changes in vital signs, like an increase or decrease in heart rate, oxygen saturation or blood pressure • Hiccups, fussing or crying • Yawning, looking exhausted • Frowning or grimacing, won’t look at you • Arms or legs stretched out stiff, hand up as if to say “stop” • Arched back and neck

When you see one of these signs of stress, it means that your baby needs either a change in activity or rest. Limit the stimulation your baby is receiving and use some comfort measures. Premature babies are very sensitive and can only handle one kind of stimulation at a time. For example, either talk to your baby or hold them. Doing both at the same time may cause your baby to feel stress. As a baby grows, they will develop more socialization skills. Following the cues will help you learn the best ways to communicate SAMPLEwith your baby now. 22 Part 1: When Your Baby Needs Special Care Preemie Development

Less than Size Characteristics 26 weeks • 8 to 9 inches long • No fat • 1 to 2 pounds • Tiny fingernails • Finger and footprints still developing • Lanugo — coating of fine hair to keep them warm • Thin skin and visible veins • Eyelids may be fused shut • Hearing is very sensitive • Twitchy, jerky movements • Startles easily

27 to 28 Size Characteristics weeks • Around 16 inches long • Skin is fragile 1 • About 2 /2 pounds • Eyes may open briefly, but do not focus • Hearing is very sensitive • Twitchy, jerky movements • Startles easily • May be ready for kangaroo care (skin-to-skin)

29 to 30 Size Characteristics weeks • Around 17 inches long • Skin appears more normal • About 3 pounds • More body fat • Eyes open for short periods of time • Sensitive to bright lights • Loud noises are uncomfortable • Jerky movements, but with more intention • Stretches arms and legs • Benefits from kangaroo care • Begins to suck on pacifier

31 to 32 Size Characteristics weeks • 18 to 19 inches long • Opens eyes 1 • 3 /2 to 4 pounds • Briefly looks at faces • Hearing is sensitive, prefers soft voices • All 5 senses are developed, but are easily overstimulated • Can be held for feedings • Sucks on pacifier

33 to 34 Size Characteristics weeks • Almost 20 inches long • Lungs still developing • 4 to 5 pounds • Immune health still immature • Sucking, swallowing and breathing not coordinated • Movement is smoother • Begins to show cues for feeding • Needs to sleep between nipple feedings

35 to 37 Size Characteristics weeks • 20 inches long • Looks full-term • 5 1/ to 6 pounds • Has fat, but not enough to stay warm 2 • Gets tired during feedings • May have low blood sugar • Slow weight gain SAMPLE• Burning calories to stay warm Part 1: When Your Baby Needs Special Care 23 Adjusted / Corrected Age In order to evaluate a premature baby’s growth and development over the first couple of years, you need to know the baby’s “corrected age.” A corrected age is the difference between the day the baby was born and the baby’s actual due date.

Figuring a baby’s corrected age takes two steps: 1. Determine how many weeks or months early your baby was by subtracting the number of your baby’s gestational weeks from 40 weeks (full-term). Example: If your baby was born at 33 weeks, they were born 7 weeks (2 months) early. 40 weeks minus 33 weeks = 7 weeks (2 months).

2. To arrive at your baby’s corrected age, subtract those 7 weeks from the baby’s current age. Example: If your baby is now 15 weeks (4 months) old, their corrected age is 8 weeks (2 months) old. 15 weeks actual age minus 7 weeks preterm = 8 weeks (2 months).

Using your baby’s corrected age will help you realistically evaluate how well the baby is developing. While a full-term 4-month-old baby may be starting to roll over, if your baby’s corrected age is only 2 months old, they may just be starting to hold their head up and look around.

Actual age weeks Adjusted / in weeks preterm corrected age

SAMPLE 24 Part 1: When Your Baby Needs Special Care Screenings / Procedures Newborn screenings test infants shortly after birth for medical conditions that are treatable, but not seen, during the newborn period. Every U.S. state requires specific newborn screening tests on all babies.

METABOLIC SCREENING An essential preventive health measure, metabolic screening tests newborns for developmental, genetic and metabolic disorders that may not be immediately apparent after birth. If identified early, many of these rare conditions can be treated before they cause serious health problems.

How the test is performed A few drops of blood will be taken from your baby and sent to the lab for testing. You will be notified of the results by the hospital or your baby’s health care provider.

HEARING SCREENING Testing the hearing of babies before they leave the hospital is becoming a common practice. It is recommended that all newborns be screened. If hearing loss is not caught early on, there will be a lack of stimulation of the brain’s hearing center that can delay speech and other types of development.

How the test is performed This painless test is performed in the hospital using a tiny earphone, microphone or both. It takes about 10 minutes and is done while your baby is sleeping.

PULSE OXIMETRY SCREENING FOR CONGENITAL HEART DISEASE Pulse oximetry is a simple, painless test used to measure how much oxygen is in your baby’s blood. It can help identify certain heart diseases that are present at birth.

How the test is performed Sensors are placed on your baby’s hand and foot with a sticky strip and a small red light or probe. The sensors measure the baby’s oxygen level and pulse rate. The test takes a few minutes to perform when the baby is still, quietSAMPLE and warm. Part 1: When Your Baby Needs Special Care 25 BLOOD SUGAR JAUNDICE A baby’s blood sugar level may be either too Jaundice is common in newborn babies, giving low or too high. Low blood sugar is more their skin and the whites of their eyes a yellow common in both full-term and preterm babies. color. Most babies have physiologic jaundice, High blood sugar is more common in babies caused by a buildup of bilirubin in the blood and who are getting most or all of their nutrition skin. Bilirubin is released when red blood cells through an IV. break down. Because a newborn produces extra red blood cells for the birth process, their liver How the test is performed has a lot of bilirubin to break down. A full-term Blood sugar can be checked by placing a drop of newborn has a fully-developed liver, even though blood onto a chemical strip. The strip goes into it is not 100% efficient. If your baby is premature, a machine that reads the sugar level. A blood their liver may not be developed enough to break sample may also be sent to the laboratory for a down the extra bilirubin, so it will stay stored in blood sugar determination. the baby’s skin.

Treatment for low blood sugar How the test is performed If your baby can take feedings by mouth, Transcutaneous bilirubin testing is painless you can breastfeed or express colostrum to and done by simply placing a light meter on feed them. If your baby is stable, hold them the baby’s skin. If the bilirubin level is high, a skin-to-skin after the feeding until their blood blood test can measure serum bilirubin levels. If sugar is checked again. If the level is still too needed, treatment will be ordered based on your low, your baby’s feedings may be supplemented baby’s age in hours and other risk factors. with donor human milk or infant formula. If your baby’s blood sugar level remains low, the Treatment health care team will start an IV. If your baby is Phototherapy is a painless treatment for jaundice. already on IV feeding, the amount of sugar in Your baby will be placed under a special light the intravenous fluids will be increased. wearing only a diaper and eye protection. Another treatment option is to place a fiberoptic Treatment for high blood sugar blanket under your baby. The light and blanket If your baby is being fed through an IV, the care are sometimes used together. A blood test can team can lower the amount of sugar in the IV confirm that the treatment is working. fluids or give the baby insulin to help their body use up more of the sugar. SAMPLE 26 Part 1: When Your Baby Needs Special Care Safe Sleep The Centers for Disease Control and Prevention (CDC) estimates that nearly 3,500 infants die suddenly and unexpectedly each year in the United States. These deaths are called Sudden Unexpected Infant Deaths, or SUIDs. About half of all SUID deaths are due to Sudden Infant Death Syndrome (SIDS), which are sudden deaths that cannot be explained. SIDS is the leading cause of SUID for infants under 1 year old, especially from birth to 4 months. One of the best ways to reduce the risk of SIDS is to put healthy infants on their backs when putting them down to sleep. Since the American Academy of Pediatrics (AAP) recommended in 1992 that all babies sleep on their backs, deaths from SIDS have declined dramatically. Sleep-related deaths from other causes, including suffocation, entrapment and asphyxia, have unfortunately gone up. The safest place for your baby to sleep is on a baby bed placed close to the parent’s bed. Parents and caregivers should always follow these recommendations from the AAP to help to protect your baby from SIDS and SUID:

Make sure Dress your baby in Always place Keep pillows, nothing covers sleep clothing like a your baby on their sheepskins, crib the baby’s head one-piece sleeper, and back to sleep, for bumpers, and toys out do not use a blanket naps and at night of your baby’s bed

Share this vital information with babysitters, grandparents and other caregivers. It is also important for parents and caregivers to take an infant CPR course.

Baby’s sleep area is next to Do not smoke or Use a firm sleep surface, such as where parents sleep. Do not let anyone smoke a mattress in a safety approved SAMPLEshare a bed with your baby. around your baby crib, covered by a fitted sheet Part 1: When Your Baby Needs Special Care 27 Shaken Baby Syndrome When you are a parent of a new baby, there may be times when you feel frustrated and even angry when your baby cries. You may have tried everything to comfort them, but If you or a caregiver has violently nothing seems to help. You are not getting any sleep. You shaken your baby for any are frustrated. No matter how you feel: reason, seek medical attention immediately. Do not let fear or NEVER, EVER SHAKE YOUR BABY! shame keep you from doing the When a baby is violently shaken, it’s called Shaken Baby right thing. Getting treatment right Syndrome (SBS) or Abusive Head Trauma (AHT). SBS is one away may save your baby’s life. of the leading forms of child abuse. Many shaken babies die or have irreversible brain damage. Those who survive may have visual disturbances or blindness, mental injury, paralysis, seizure disorders, learning and speech disabilities, or neck and back damage. When a baby is shaken, the back and forth movement of their head can cause bleeding and increased pressure on the brain. A baby’s neck muscles are not strong enough and their brain is too fragile to handle this “whiplash” motion. If you feel like you can’t deal with your baby’s crying and you have met the baby’s basic needs (clean diaper, fed, appropriate clothes, gently rocked, held, etc.) then stop, think, and reach out for help if you need it. There may be times when nothing you do will stop the crying. This is normal. DO NOT SHAKE YOUR BABY.

If you think your baby has been shaken, call 911 or take the baby to the emergency room immediately. Signs and symptoms of shaken baby syndrome include: • Irregular, difficult or stopped breathing • Very fussy, seizures or vomiting • Hard to feed or stay awake • No smiling or vocalization • Can’t focus or track movement with their eyes

What to do if you get frustrated:

Take a deep Put baby down in Give Ask a trusted friend, breath and their crib and leave yourself a neighbor or family member SAMPLEcount to 10 for a few minutes “timeout” to take over for a while 28 Part 1: When Your Baby Needs Special Care The American Academy of Pediatrics recommends infants and toddlers should ride in a rear-facing car safety seat as long as possible, until they reach the highest weight or height allowed by their seat. Most convertible seats have limits that will allow children to ride rear-facing for 2 years or more.

Child Safety Seats Your baby needs a car safety seat to go home from the hospital. Every state requires that infants and children ride buckled up. Using a car safety seat correctly can help prevent injuries to your infant. Read your car safety seat manual and your vehicle user guide ahead of time. Practice installing the seat before your baby goes home. When your baby is about to be discharged, you may be asked to bring in the car safety seat and seat base for a “challenge test.” This is to see if the baby can tolerate the ride home. During the test, your baby will be connected to heart rate and breathing monitors, then placed in the 1 car safety seat in riding position for about 1 /2 to 2 hours. The “best” car safety seat is the one that fits your baby and can be set up the right way for your car. It does not matter if it is the most expensive seat — if it is not installed properly, it may not protect your baby.

• Do not attach toys, wraps, etc. to the car seat. • Place rolled blankets at each side of head for positioning (if needed). Put a rolled cloth or blanket between baby and crotch strap (if needed). • Harness slots should be at or below baby’s shoulders. Harness straps must be snug. You should not be able to pinch any slack in the harness at baby’s shoulders. • Place harness retainer clip at armpit/nipple level. • Infant seat should recline according to manufacturer’s instructions. • Baby’s head must be 1 inch below the top of car seat shell. • Tightly install child seat in the car’s back seat, facing the rear. The infant seat should not move more than 1 inch side-to-side at the seatbelt pathway. • Avoid bulky clothing under the snug harness. Place a blanket over the child after they are securely in the car seat. • An infant in a rear-facing seat should not be placed in front of an active airbag. The safest place is SAMPLEin the middle of the back seat (depending on the car). Part 1: When Your Baby Needs Special Care 29 Look Before You Lock Your car heats up faster and gets hotter than you might think. Remember to “Look Before You Lock,” so you never forget that your baby is with you. Never leave your child alone in the car, not even for one minute. Children’s body temperatures heat up 3 to 5 times faster than adults.

Create a reminder Put something that you need in the back where the baby is. For example, your cell phone, your left shoe, your purse, or briefcase. Set a reminder alarm on your electronic device to make sure your child is dropped off. Make a plan with your child care provider and have them call you if your baby or child is a few minutes late.

Shopping tip Infants can fall from shopping carts or the cart can tip over from the weight of the baby sitting in the car seat. Use a stroller when you shop.

Please remember:

Never leave Children’s body Always look Create a Don’t put your a child alone temperature before you lock! reminder infant’s car seat on in a car rises fast a shopping cart

“ Call 911 if you see a child alone in a car. It is an emergency and your call could save a life. ”

For more information, visit:

• www.aap.org/en-us/about-the-aap/aap-press-room/pages/aap-updates-recommendation-on-car-seats.aspx • wwwSAMPLE.nhtsa.gov 30 Part 1: When Your Baby Needs Special Care Infant CPR (Under 1 Year of Age) The thought of having to do Cardio-Pulmonary Resuscitation (CPR) on your baby is very frightening. However, you need to know what to do in an emergency. It is strongly recommended that parents and other caregivers take an Infant CPR class. Call your local American Heart Association or American Red Cross, search online for classes in your area, or ask the care team to refer you while your baby is in the nursery.

HOW TO DO CPR ON A BABY Infant CPR is a little different from adult CPR, but the concept is the same. Memorizing the letters C-A-B will help you remember what to do in an emergency.

Check for Consciousness • Tap or flick the bottom of your baby’s foot • If there is no response and your baby is not breathing, start chest compressions and have someone call 911

Chest Compressions • Place your baby on their back on a hard, flat surface • Place two fingers of one hand in the center of the chest just below the nipple line 1 • Gently compress the chest about 1 /2 inches downward • Do compressions at the rate of about 100-120 per minute

Airway • After 30 compressions, gently tilt the baby’s head back to open the airway • To tilt, lift the baby’s chin with one hand and push down on the forehead with the other hand

Breathing • Cover the baby’s mouth and nose with your mouth • Gently puff until you see their chest rise • As the air escapes, the chest will go back down • Then give one more breath • Give 2 breaths after every 30 chest compressions • Continue CPR for 5 cycles • If you are alone, call 911 after 2 minutes • Continue with 30 compressions and 2 breaths until help arrives or the baby begins to breathe

The information on this page is for quick reference only and not a substitute for training. Parents SAMPLEand caregivers should take an infant CPR/first aid class before or soon after the baby comes home. Part 1: When Your Baby Needs Special Care 31 Infant Choking (Under 1 Year of Age) Choking can be scary. Little ones will put almost anything small enough into their mouths. If a small object gets lodged in the windpipe and your baby cannot cough, breathe or cry, you need to know how to dislodge it as quickly as possible.

If your baby is awake (responsive) and choking • See if the baby can cry • If the baby can’t cry, shout for someone to call 911

HOW TO CLEAR A BABY’S AIRWAY Step 1: Give 5 back blows • Lay the baby face down along your forearm • Use your thigh or lap for support • Hold the baby’s chest in your hand • Support their head by holding their jaw • Their head should be lower than their body • With the heel of your hand, give 5 quick firm back blows between the shoulder blades

Step 2: Give 5 chest thrusts • If back blows didn’t dislodge the object, turn the baby face up • Use your thigh or lap for support • Support the head which should be lower than the body • Place 2 fingers on the middle of the chest just below the nipple line 1 • Give 5 quick thrusts down, compressing the chest about 1 /2 inches • Repeat back blows and chest thrust until the airway is cleared (baby cries/makes noise) • If baby becomes unconscious while giving choking aid, start infant CPR (see page 31) • Carefully check the airway for blockage each time before giving breaths • Only put your finger in their mouth if you can see the object

Is My Baby Sick? Parents know their baby’s normal behavior and can sense when the baby isn’t feeling well. If you think your baby is sick, do not hesitate to call their health care provider or take them to the emergency room if it seems serious. Take your baby’s temperature before you call, because the nurse will ask you for this information.

Contact your doctor’s office if your baby has any of these signs or symptoms: • Breathing difficulty and bluish around lips or mouth — Call 911 immediately! • Change in breathing pattern: breathing too fast or struggling for air • Eating poorly or refusing to eat • No stool for 48 hours and less than 6 wet diapers a day • Temperature of 100.4˚F or higher (in babies younger than 3 months) • When a fever rises above 104˚F repeatedly for a child of any age • Vomiting repeatedly and unable to keep fluids down • Listless or hard to wake up • Crying excessively with no known cause or an unusual or high-pitched cry • An unusual or severe rash (other than prickly heat) • Frequent or successive bowel movements with excess fluid, mucus or unusually foul odor • Bloody vomit or stool • Signs of dehydration include: –– Crying without tears –– Sunken eyes –– Soft spot on baby’s head is sunken –– Dry skin, dry or cracked lips –– No wet diapers in 6 to 8 hours SAMPLE–– Increased sleepiness or irritability Part 1: When Your Baby Needs Special Care 33 Many hospitals will let you “room in” with your baby in a room close to the nursery. Rooming in helps you build confidence as you learn to completely care for your baby.

Photo Credit: EvaDiana Photography Going Home The answer to the question “when can I take my baby home?” will be different for every baby. There are several things that need to happen before your baby can be discharged (released) from the hospital. You and your baby may have things to do for several weeks to prepare for that big day.

YOUR BABY’S CHECKLIST YOUR CHECKLIST 55 Breathing on their own (some babies Weeks before discharge may go home on oxygen therapy) 55 Learn what kind of car seat is best for your baby 55 No incidents of apnea and bradycardia 55 Schedule a CPR training class or changes in color (some babies have a home apnea monitor if the episodes 55 Baby-proof your house do not require intervention) 55 Learn about Safe Sleep 55 Maintaining a normal body 55 Choose a health care provider for your baby to temperature in an open crib see after they come home 55 Feeding well from the breast or bottle 55 Spend time taking care of your baby in the 55 Gaining weight steadily nursery so you feel prepared to do it at home 55 Passed the car seat challenge test Days before discharge (if your baby was born before 37 weeks gestation) 55 Bring in your baby’s car seat for the challenge test 55 Screened for hearing 55 If your baby is going home with medications, have the prescriptions filled 55 If your baby will need medical equipment, make arrangements with the company providing it 55 Schedule an appointment for follow-up with your baby’s doctor 55 Meet with your baby’s case manager to make SAMPLEsure everything is ready for your baby to go home 34 Part 1: When Your Baby Needs Special Care PART 2: Breast Milk in the NICU

Introduction

When you were pregnant, your baby took nutrition from swallowing amniotic fluid containing growth factors, stem cells, and immunoglobulins. These nutrients helped prepare your baby for life outside the womb. During the last trimester, babies also receive growth factors from the amniotic fluid to help their intestines.

Your colostrum, or first milk, contains many of the same nutrients as amniotic fluid. That’s why it is important to hand express or pump your breasts right away to collect it for your baby. Your milk will help your baby develop a healthy gastrointestinal and immune system.

SAMPLE The Benefits of Breast Milk One of the most important things you can do for your baby is to give them your breast milk. It contains the If you can’t provide breast milk for your nutrients your baby needs for proper growth and baby, pasteurized donor human milk development. In fact, breast milk is recommended for from a “milk bank” is a valuable option. every baby in the NICU. Studies have proven that breast milk provides optimal health benefits to your newborn for as long as you decide to give it to them. Breast milk may even prevent medical problems and infections. Your baby may go home sooner if they receive your milk because breast milk is more than food—it’s also medicine for the baby.

Why your milk is vital to your preterm baby: • Different than breast milk for full-term babies • Made specifically for your baby • Easier to digest than formula • Helps your baby’s brain grow • Provides antibodies to help your baby fight infection

A higher IQ and better development Better vision Lower risk for obesity in Medical childhood and research has later in life shown that Fewer infections and other chronic premature or life-threatening babies who illnesses receive their mother’s own Reduced risk of milk have: asthma, allergies, eczema and Better blood anemia pressure and lower risk of Lower risk for a heart problems when older serious bowel Reduced risk disease called for Sudden necrotizing Infant Death enterocolitis Syndrome SAMPLE(SIDS) 36 Part 2: Breast Milk in the NICU How Breast Milk is Made

ANATOMY PHYSIOLOGY Fatty Tissue Your breasts may After the placenta is delivered, Alveoli become fuller and the level of progesterone hormone feel tender as the Milk decreases. This sudden drop milk-making tissue Duct signals your body to make breast in your breasts Nipple milk. To continue making milk, grows and prepares your body needs to keep receiving to make milk. This Areola signals from other hormones. can happen before When the baby begins sucking, this tells your or after your baby is born. By week 16 of your brain to produce two other hormones, prolactin pregnancy, your breasts can produce milk. and oxytocin. A breast contains alveoli cells, glands, ducts and Prolactin tells the alveoli to make milk. Oxytocin fatty tissue. The nipple has about 7 to 11 tiny causes the cells around the milk glands to openings, each surrounded by muscular tissue. contract, squeeze the milk down the milk ducts, When stimulated, hormones that promote the and out the nipples. This is called let-down or flow of milk are triggered. milk ejection reflex. It may take several minutes of Around the nipple is an area of darker skin called sucking by the baby until the milk ejection reflex the areola. This area will become darker and larger occurs. Two ways to know if your milk has let during pregnancy due to hormonal changes. The down include seeing it in your baby’s mouth or if areola contains pimple-like structures near its your other breast is leaking. border called Montgomery glands. These glands secrete an oily substance that lubricates and cleanses the nipple area. BREAST SIZE Some people worry about their breast size, shape, or nipple type. Breast size is determined by how It’s important to much fatty tissue the breast contains. Because empty the milk from milk is made in the breast’s glandular tissue, not your breast regularly. fat tissue, the size of your breasts does not affect If you don’t, your body how much milk you can make. will decrease the amount and eventually If you are concerned about your breast size or stop producing milk. shape, talk with your health care provider or lactation consultant.

SUPPLY AND DEMAND Milk production is regulated by supply and demand. The more milk your baby takes or you pump from your breast, the more milk you will make. An emptier breast also makes milk faster than a full one. You can keep your milk production up by breastfeeding your baby or pumping as soon as possible after birth. Feed or pump 8 or more SAMPLEtimes in 24 hours, including at night. Part 2: Breast Milk in the NICU 37 Stages of Milk Production

COLOSTRUM Colostrum is the first stage of breast milk. It develops during pregnancy and lasts for a few days after the birth. Much thicker than the milk produced later in breastfeeding, colostrum is high in protein, fat-soluble vitamins, minerals and immunoglobulins. Immunoglobulins are antibodies passed from your milk to your baby to help protect the baby from many bacterial and viral illnesses. Colostrum will be replaced by transitional milk 2 to 4 days after birth. Facts Colostrum gives your baby about colostrum: essential nutrients and • Can be yellow to clear in color infection-fighting antibodies. • Easily digested • Works as a laxative to help clear the baby’s intestinal tract • Very high in protein • Contains antibodies that help the baby fight infection • Coats the stomach and intestines and protects against any invading organisms

TRANSITIONAL MILK The second stage is called transitional milk. It begins 2 to 4 days after birth, lasts about 2 weeks, and causes your breasts to become firm, fuller and sometimes painful. It is vital to keep this milk moving by breastfeeding or pumping so that it doesn’t clog your milk ducts. Transitional milk has high levels of fat, lactose and water-soluble vitamins. It has more calories than colostrum and is very high in protein.

MATURE MILK The third stage is called mature milk. This stage begins at 2 weeks and lasts until you wean your baby. Mature milk is made up of water, vitamins and minerals. There are two types of mature milk: foremilk and hindmilk.

Foremilk is found at the beginning of the Hindmilk comes after the first release of feeding and satisfies the baby’s thirst. It foremilk and contains more fat along with contains 90% water along with vitamins, vitamins, nutrients and proteins. Hindmilk helps nutrients and protein. your baby gain weight.

Colostrum Transitional Mature

Thick, yellow-colored milk, high Thin and white in appearance. More watery appearance, in protein, antibodies and some Composition is approaching slight bluish to white in color. vitaminsSAMPLE and minerals. mature milk. 38 Part 2: Breast Milk in the NICU Milk Supply

BUILDING A GOOD MILK SUPPLY Over the first few days, you may be able to hand express or pump only a few drops—or nothing at all. Save every drop and take it to the NICU for your baby. The amount of • Day 1 to 14 is the most important time to build a good milk supply milk you pump • Pumping your breasts tells your body there is a need for more milk each time can vary. Don’t get • Regular pumping increases your supply of breast milk discouraged. Just • Your first goal is to get the clear or yellow drops of colostrum keep pumping on It will be hard to go home and leave your baby at the hospital. Remember, a regular schedule. your main job is to make milk for your baby. While you are pumping, you can call the nursery to check on your baby. If your hospital has a webcam, watch from home while you pump.

MILK SUPPLY GOALS • Day one: Get a few drops of colostrum • Each day get more than the day before • End of first week: 12-16 ounces (350-500 ml) in 24 hours • End of the second week: 25-30 ounces (750 ml or more) in 24 hours • If you have health issues that can delay your milk supply, keep pumping and talk with your nurse and lactation consultant

MAINTAIN YOUR MILK SUPPLY From day 14 and beyond it is important to maintain a well-established milk supply. Your goal is to pump at least 24 ounces (750 ml) every day.

What You Need to Know: • Continue to pump often—8 times in a 24-hour period • Do not suddenly change your pumping schedule • Continue to pump at night, although you may be able to stretch the time between pumping • Track your milk volumes daily and contact the lactation consultant if you notice a decrease • Use both hand expression and pumping to maintain and increase milk volume SAMPLE• Skin-to-skin holding can increase milk production (See section on kangaroo care) Part 2: Breast Milk in the NICU 39 Hand Expression

MASSAGE EXPRESSION • Wash your hands with soap and water • Begin within the first hour after birth • Take a few moments to relax and • Position your thumb and first two fingers 1 get comfortable about 1 to 1 /2 inches behind the nipple • Warm compresses may help the milk • Push straight back towards your chest wall let down • Roll your thumb and fingers forward to • Massage your breasts using the pads of express milk your fingers • Continue this same motion while moving • Move in a circular motion from chest to around the areola nipple, massaging the entire breast • You may need to repeat this process on • Finish the massage by bending forward— each breast a few times gravity helps eject milk

1 2 3 4 Wash your hands Have a clean container Gently massage each breast Place your hand in a with soap and water. (bowl or cup) ready to from the top toward the wide, C-shaped hold catch your milk. nipple to help the milk flow on your breast. more easily.

5 6 7 Press in toward Compress your breast to express Rotate your fingers to another chest wall. milk, then relax. Don’t rub or move position on the breast and repeat. your fingers on your skin.

Practice will help you feel more confident in your ability to hand express your breast milk. Be patient with yourself. Massaging your breast before you pump followed by hand expression after you pump really can help increase SAMPLEyour milk supply. 40 Part 2: Breast Milk in the NICU Pumping Your Milk

ELECTRIC BREAST PUMP • Use a double electric pump • Begin within 6 hours after the birth • Position the shields over your nipples • Begin with the suction on minimum • Adjust the suction to a comfortable level—you should feel a slight tugging sensation • Pump for 15-20 minutes • Pump at least 8 times in 24 hours, 10 times for multiple babies (twins, etc.) Pumping Tips: • Pump at least once at night • Relax with soft music and • Having the suction set at the highest level does slow breathing not remove more milk • Pump at the baby’s bedside or gaze at a photo of your baby It can be normal to pump only a few drops, or • Apply warmth to your breasts for nothing at all, in the first few days. Regularly 5 minutes before pumping pumping will increase the amount of milk • Massage your breasts before and you produce. Don’t throw away any pumped during pumping milk. Every drop should be saved. • Removing milk at regular intervals will help you make more milk • Setting an alarm can help you HANDS-ON PUMPING remember your pumping times Using your hands, along with pumping, can help you • Keep a log of how much milk you remove more milk and increase your milk supply pump every 24 hours by 48%. For some people, pumping alone may not remove all of the milk from their breasts. Nipple Care: • After pumping, gently rub your • While you pump, massage and compress your milk on your nipples breasts as much as you can • Let your nipples air dry completely • Keep pumping until milk flows to a trickle • If your nipples become tender or • Massage your breasts again, concentrating on you feel you need an ointment areas that feel full contact your lactation consultant • Finish by either hand expressing your milk into • If you see rubbing or skin the pump’s breast shield or use a single pump— breakdown around your nipple, whichever produces the most milk ask your nurse or lactation consultant if you need a Draining your breasts also lets you collect your hind different-sized breast shield milk, the milk that is released last. Hind milk is high in fat SAMPLEand contains the calories your baby needs to grow. Part 2: Breast Milk in the NICU 41 COLLECTING YOUR MILK • Use clean new bottles each time you pump • Do not combine milk from different pumping sessions • Do not fill the bottles more than two-thirds full

LABELING YOUR MILK • If your hospital does not use the bar code system, ask your nurse about how they want you to label your milk • Pay attention when you write the date and time of pumping on each label • Carefully review the label before you place it on your expressed milk and again before you feed your baby • Clearly mark the container to identify your early milk • Take your labeled milk to the nursery when you visit your baby • Before checking in your breast milk, ask your baby’s nurse if your milk will be stored in a freezer or refrigerator • Please arrive 10-15 minutes before your baby’s feeding time so the nurses do not warm up milk if you are bringing fresh milk with you • Log your milk in the tracking system including the date, time and amount

TRACKING YOUR MILK • Track your milk using the pumping log on page 62 • Set an alarm or reminder to help you remember when it’s time to pump • It is helpful to see the total amount you pumped in 24 hours • Contact the lactation consultant if your milk volume is low or drops

TRANSPORTING YOUR PUMPED MILK • Always transport your breast milk in an insulated cooler protected with frozen packs or ice • Keep your pumped milk cold or frozen • Check with your baby’s nurse before you store milk for SAMPLEyour baby 42 Part 2: Breast Milk in the NICU Cleaning Your Breast Pump Parts • Clean your breast pump parts immediately after using the pump • Do not clean the breast pump in the sink • Use a separate container that you only use for this purpose

WASHING BY HAND

1 2 3 4 Take apart all pumping Rinse the parts Scrub the items using Air-dry breast pump parts pieces that have contact with cool running a clean brush used thoroughly on a clean with milk (not the water to remove only for infant feeding towel or place them on tubing). Place the parts the remaining items. Then rinse paper towels in your plastic in the clean plastic tub milk. Add soap under running water, tub. Clean the container provided for you. and hot water to or by submerging and bottle brush. Rinse the container. in fresh water in a them well and allow them separate container. to air-dry after each use.

There will be a small instruction booklet included in your pumping kit. Refer to it as needed for specific instructions.

STORE SAFELY SANITIZING OPTIONS TUBING

• Make sure the clean parts • Put your pump parts • Let the pump run a few and cleaning supplies through a dishwasher minutes with tubing connected have completely air-dried cycle that uses the heat to prevent moisture buildup before you store them drying cycle • Wipe the outside of the tubing • Place all of your parts, • Bring water to a boil, with a sanitizing wipe container and bottle brush remove from heat, soak • If your tubing has milk in it, in a clean area away from parts in the water for at replace it with new tubing dirt and dust least 15 minutes • Use microwave steam bags designed for cleaning SAMPLEbreast pump pieces Part 2: Breast Milk in the NICU 43 Storing Breast Milk for Use in the NICU

Fresh Pumped Milk, Unrefrigerated Fresh Pumped Milk, Refrigerated Frozen Pumped Milk

Feed within 4 hours of pumping Feed within 96 hours of pumping Feed within 24 hours or refrigerate or freeze of thawing

Safety alert: When your nurse is preparing breast milk and/or medications for a baby, please do not interrupt the process. It is extremely important to let the nurse concentrate on completing all verification steps.

Choosing a Home Breast Pump There are many types and brands of breast pumps. Using the right type of breast pump from the start can have a substantial impact on your milk supply. An automatic double electric breast pump is recommended when you are separated from your baby. This type of pump is most effective in stimulating release of the milk-producing hormone prolactin, which results in the highest volume of milk. Call your insurance company or Medicaid provider to see if they can help you get a pump. The hospital may have pumps available for rent or can refer you to a rental supplier. If you are eligible for WIC (Women, Infants and Children) benefits, please call your local office as soon as possible; they may be able to help you locate a pump. Remember to take ALL the Some considerations: pump’s personal use parts • Can the pump parts be sanitized daily? and tubing home with you. If you leave any pieces • Is the pump compatible with the collection/storage system behind, you will have to the hospital uses? buy replacement parts. SAMPLE• Is the pump recommended for long-term exclusive pumping? 44 Part 2: Breast Milk in the NICU Increasing Your Milk Supply • Use a double electric pump • If you smoke, try to quit or cut down. Smoke • Pump regularly (every 2-3 hours) after your pumping session instead of before because nicotine may decrease the flow of • Increase to 9-12 pumping sessions in breast milk. 24 hours • Some medications may interfere with • Wake up at night to pump your milk supply. Check with your • Use more hands-on pumping and lactation consultant. hand expression • Avoid or limit caffeine and sodas • Discuss power pumping with your • Increase your protein intake lactation consultant • Let your nurse or lactation consultant know • Pump at the baby’s bedside if you are having problems • Lower stress, increase rest • Avoid rapid weight loss, it takes extra • Use caution with hormonal birth control calories to make milk

HOW CAN OTHERS HELP? Fathers, partners, family and friends are an important part of your support system. You are the only one who can pump, so anything others can do to make pumping easier for you is helpful. For example: • Remind you when it is time to pump • Set up the pump and wash the pump parts • Fill in the labels for the milk storage containers • Sanitize your breast pump parts daily • Keep the pumping log up-to-date • Take freshly pumped milk to the baby • Remind you to do skin-to-skin contact

HERBS, MEDICATIONS AND MILK SUPPLY Because herbal products are not regulated by the Food and Drug Administration (FDA) in the United States, they may differ from manufacturer to manufacturer. Taking prescription medicine and herbal products at the same time may put you at risk for a drug interaction. Talk to your baby’s doctor or nurse before you take any herbal supplements. Although herbal, over-the-counter, or prescribed medications may be helpful for some women with a low milk supply, they don’t work for everyone. Medicines or herbal products should onlySAMPLE be used as a last resort. Part 2: Breast Milk in the NICU 45 Breastfeeding 101

GETTING READY TO BREASTFEED Babies born prematurely may not be ready to fully breastfeed until they are 1-2 weeks past their due date. Signs that your baby is ready to breastfeed include: • Stable medical condition • Is awake more often • Shows feeding cues like moving hands to mouth, licking lips, turning head

There are several ways to help your baby learn how to breastfeed: • Skin-to-skin (kangaroo care) • Non-nutritive sucking • Nutritive breastfeeding

KANGAROO CARE (SKIN-TO-SKIN) Breastfeeding your baby starts with having skin-to-skin contact. Spending time with your baby doing kangaroo care helps them learn your smell and touch. See page 16 for instructions on kangaroo care.

NON-NUTRITIVE BREASTFEEDING Non-nutritive sucking is the next step in the transition to breastfeeding. You can introduce your baby to breastfeeding by letting them suckle at your breast after pumping. This helps your baby start learning without being overwhelmed by a lot of milk. Your baby can practice latching onto your breast without having to coordinate sucking, swallowing and breathing. You will learn how to practice positioning your baby. Your baby may lie quietly at your breast or may latch and suck a few times.

NUTRITIVE BREASTFEEDING As babies learn to coordinate sucking, swallowing and breathing, they will be able to breastfeed and stay alert for longer periods of time. Talk with your baby’s nurse or lactation consultant to see if your baby is ready for nutritive breastfeeding. • Babies will do better with some feedings than others SAMPLE• Be patient with yourself and your baby 46 Part 2: Breast Milk in the NICU SIGNS YOUR BABY IS RECEIVING MILK • You can see long jaw movements • You hear sounds of swallowing • After a larger volume of milk comes in, you will hear swallow sounds like “ca-ca” • Your breasts feel softer after the feeding • You pump less milk than usual after a feeding

GOING HOME • Breastfeed your baby often • Spend time skin-to-skin (kangaroo care) • Do test weight/weigh-feed-weigh • Room in with your baby • Meet with the lactation consultant as needed

HOME WITH YOUR BABY • Continue pumping 6 to 7 times a day during the first week home • Baby may fall asleep easily • Stop after 30 to 45 minutes if your baby is not feeding well • Skin-to-skin contact is still good • If baby gains weight in the first week, drop to 4 or 5 pumping sessions per day • Continue to reduce pumping sessions every 3 or 4 days • Baby may be 41 to 42 weeks before feeding without supplements

At 32 weeks, babies will typically have bursts of sucking, followed by a suck/swallow rhythm SAMPLEat around 34 weeks. Part 2: Breast Milk in the NICU 47 Positions for Breastfeeding When you begin feeding your baby at your breast, one of these first two positions will probably work best for you. You can try the others when your baby is a little older.

CROSS-CRADLE OR CLUTCH OR SIDE-LYING TRANSITIONAL HOLD FOOTBALL HOLD This position gives you the In this position, you hold your In this position you tuck the chance to stretch out and rest baby with the arm opposite baby under your arm. Place a while your baby nurses. the breast. For example, if pillow behind your back and • Lie on your side and place you are feeding from your left along the side you are going to pillows all around you to breast, you will use your right nurse on. This helps support make it comfortable—behind arm to hold your baby. your baby and bring their nose your back, between your • Hold your baby along the to the level of your nipple. legs, and under your head opposite arm from the • Your forearm supports • Pull your baby close, breast you are planning your baby’s upper back facing you to use while your hand cradles their head • You can support your baby’s • Turn their body so their back with your forearm or chest and tummy directly • Your baby’s body and feet place a rolled towel behind face you are tucked underneath your their back for extra support • Support the base of their arm on the same side that neck loosely with your your baby is nursing and fingers, with the palm of their legs are behind you your hand supporting the • This position makes it easy baby’s shoulder blades to use your other hand to and back help position your baby’s • Place a pillow on your lap to mouth on your breast help support the baby and • Your baby’s body should bring them to the level of be in a straight line with SAMPLEyour nipple their head 48 Part 2: Breast Milk in the NICU CRADLE OR “MADONNA” HOLD LAID BACK This is a classic position that many people This natural, semi-reclined position is comfortable find very comfortable. for both you and your baby. It encourages natural • Hold your baby in your lap at breast level instincts in both of you. With very few rules, this position helps your baby get a better latch on your • You can place your baby on top of a nipple while also relaxing your body. pillow and also put a pillow under your arm for better support and comfort • Sit where you can comfortably recline with good support of your head, shoulders and arms • Your baby’s nose should line up with your nipple • Let your baby snuggle into your chest as gravity helps them stay close • Extend your forearm and hand down the baby’s back to support their neck, spine • Place the front of your baby’s body to the front and buttocks of your body • Your baby’s ear, hip and knee should be • Let your baby’s cheek rest close to your breast, lined up facing toward you and you can even as they may start squirming and bobbing tuck their lower arm under your arm their head toward your nipple • Support your baby’s neck and shoulders with one hand and their hips with the other • Follow your baby’s lead. When you see their chin hit your breast you may see them open their mouth and latch on. • Stay calm and relaxed as your baby follows SAMPLEtheir instincts and seeks your nipple Part 2: Breast Milk in the NICU 49 Latch Guidelines • Before feeding, wash your hands, get comfortable, and choose a feeding position • Use skin-to-skin contact before and during feeding if your baby isn’t ready to latch on • Gently massage each breast and hand express until milk comes out • Line up baby’s chest with your chest and their nose with your nipple Support your breast • Support and gently lift your breast, with your fingers away from the areola • Lightly stroke your baby’s upper lip downward with your nipple, pausing on baby’s lower lip to help their mouth open wide • Be patient until your baby opens their mouth wide; let them take the lead • Baby’s head should be slightly tilted back Align baby’s nose with your nipple • Aim your nipple toward the roof of their mouth • Their chin should come to your breast first • When your baby opens wide, quickly and gently pull them toward your breast • Their mouth should cover the nipple and more of the lower portion of the areola; this is called an asymmetrical or “off-centered” latch Wait for baby to open their mouth wide; • Deep latch-on is a learned response, so be patient lower lip is further from nipple with yourself and your baby

Signs of a deep latch: • All of the nipple and as much of the areola as possible is in baby’s mouth • Lips are “flanged” or turned out • Tongue is over lower gum A secure position helps with a deep latch • Baby stays on your breast • There’s no biting or pinching pain • Watch for signs of swallowing (long jaw motions)

HOW TO TAKE THE BABY OFF YOUR BREAST Slide your finger between the corner of the baby’s mouth and your breast to break the suction. Don’t pull the baby off your breast as it may make your nipples sore. SAMPLEBreak suction before removing from breast 50 Part 2: Breast Milk in the NICU Nipple Shields Nipple shields are thin silicone devices that fit over your nipple. If your baby slips off the nipple or can’t maintain suction, a nipple shield can help them stay attached. Shields come in different sizes. A lactation consultant can help you choose the right size.

How to use a nipple shield: • Place it over your breast so your nipple fills the chamber of the shield • Position your baby so their nose is over the cut-out part of the shield • Guide the nipple over the baby’s tongue, keeping their lips turned out over the base of the shield • The tip of the shield should be in the back part of the baby’s mouth • The firmness of the shield may increase the sucking reflex

Nipple shields are intended for short-term use. Many people stop using them once their baby is home. The more awake your baby is, the less likely you will need to use the shield. Ask a lactation consultant if a nipple shield is a good option for you.

Fortifying Breast Milk Your own milk is the best source of nutrition for your baby. In some cases, nutrients like calcium, phosphorus, protein and fat may need to be added to your breast milk. In the NICU, it is common to add nutrients to breast milk for premature infants to help them grow and develop.

Breast milk supplements may include: • Protein: Beneprotein® is a powdered supplement made from whey protein. It is used to provide babies with more protein, help with healing, maintain their immune system function, and build lean muscle to help them grow and develop. • Human Milk Fortifier: A milk-based supplement containing protein, fat, carbohydrates, vitamins and minerals, including iron, calcium and phosphorus. Its primary purpose is to add calories. • Fat: Microlipids (MCT oil) are a good source of essential fatty acids. They may be used if your baby is not receiving enough fat for adequate growth. In premature infants, fat is the most important source of nutrients to help them grow and develop. • Prolacta®: A human milk fortifier made from concentrated 100% human milk and essential minerals. • Other Supplements: If your infant needs other types of supplements, they will be added at the SAMPLEdirection of your baby’s health care provider. Part 2: Breast Milk in the NICU 51 Donor Human Milk

WHY DONOR MILK? When a parent’s own milk is not available, the next best option for your baby is Donor Human Milk (DHM) from a milk bank. There are no commercially-available infant formulas that offer as many benefits as human milk. That’s why donor human milk is a great option for sick or premature infants.

Key facts: • Donor human milk is much easier for babies to tolerate and digest than formula • Breast milk provides nutrition and protection from infection • Human milk coats the intestines with protective properties and lowers the risk of severe bowel diseases

WHAT IS PASTEURIZED DONOR MILK? Breast milk is donated to the milk bank from screened donors. It is then tested and heat-treated to destroy potentially harmful bacteria and viruses. Milk banks take many steps to ensure safety and also preserve the beneficial properties of donated breast milk.

WHO ARE THE DONORS? Milk bank donors are special people—just like you! They are healthy, conscientious people who are nursing their own babies, have plenty of milk, and want to donate their extra milk. Donors are not paid or compensated for their generosity. But they do feel very good about helping to improve the health of other babies. All donors receive detailed instruction in how to collect and handle their milk. This includes hand washing, breast and nipple cleansing, sterilizing breast pumps and equipment. SAMPLE 52 Part 2: Breast Milk in the NICU DOES PASTEURIZATION CHANGE MILK QUALITY? The human donor milk your baby receives has been pasteurized to eliminate any bacteria or other infectious organisms. Although this process destroys a small percentage of the milk’s nutritional properties, it is still an excellent food for your baby.

ARE THERE RISKS TO USING DONOR MILK? In the decades of non-profit milk banking under the Human Milk Banking Association of North America, there have been no reports of disease transmission or harm to a baby from properly pasteurized donor human milk from a milk bank. However, like any food (including formula and infant food), the risk of adverse effects, even though very small, can never be stated as zero.

DONOR MILK AND AIDS There has never been a case of a milk bank’s milk infecting a baby with the AIDS virus or any other disease. Milk donors represent a very low-risk population for the AIDS virus. Donors go through a multi-step screening process that includes verbal, written (by both the donor and their physician), and serologic (blood) test. No one is accepted as a donor unless they have no risk factors for AIDS and have tested negative for the virus. As an extra precaution, all donated breast milk is pasteurized—which kills the AIDS virus. These procedures follow the standards established by the Human Milk Banking Association of North America, in conjunction with the Food and Drug Administration and the Centers for Disease Control.

HOW CAN I BECOME A DONOR? If you are producing more milk than your baby needs, consider becoming a milk donor. Your breast milk can be a precious, life-saving gift for fragile preemies. Talk to your nurse or lactation specialistSAMPLE to learn more about becoming a donor. Part 2: Breast Milk in the NICU 53 Challenges

ENGORGEMENT Your breasts may become engorged (heavier and swollen) 3 to 4 days after birth. Engorgement is caused by increased blood flow to your breasts, breast tissue swelling, and the increase of milk. Your breasts may be swollen and uncomfortable. You may feel a throbbing sensation and discomfort as the milk begins to flow. Other people will feel only a slight fullness. Just like labor, everyone’s experience will be different. Breast swelling usually goes down within 1 to 2 days.

How to prevent and treat engorgement: • Pump or feed your baby frequently • Gently massage your breast during pumping or feeding to help the milk flow • Apply cold compresses after pumping or feeding ¬¬ An ice pack or cold cloth placed on your breast for 15 to 20 minutes helps constrict blood vessels, reduce swelling and draining, and soothe discomfort ¬¬ Do not place ice directly on your skin • If your bra is too tight, it could decrease your milk supply and block milk ducts • Use warm compresses 3 to 4 minutes before pumping or feeding to relax and stimulate milk let-down • Talk to your nurse or lactation consultant if you’ve tried these suggestions and engorgement has not improved after 24 hours

Don’t let your breasts become engorged beyond the initial breast swelling associated with milk surge. Engorgement sends signals to your brain to slow down milk production and can cause other problems. Remember, milk production is regulated by supply and demand. That means if you slow down your pumping or feeding, you will see a significant decrease in your milk production. If you need help or more information about expressing breast milk, call your health care provider or lactation consultant.

REVERSE PRESSURE SOFTENING Reverse pressure softening is a technique that may be useful when your breasts are engorged. It helps soften the area around your nipple, encourage the milk to come, and makes it easier for the baby to latch onto your nipple.

How to do reverse pressure softening: • Place your fingers on each side of your nipple • Push back towards your chest and hold for about 1 minute • Move your fingers around the nipple, press back and hold SAMPLE• Continue if there are still firm areas Reverse Pressure Softening 54 Part 2: Breast Milk in the NICU SORE NIPPLES Sore nipples can be due to latch, position or pump issues. Don’t ignore sore nipples! If breastfeeding or pumping is painful, you need to find out what is causing the pain. Then take steps to correct the problem and relieve soreness. If you can’t identify the problem, call your lactation consultant.

How to help sore nipples: • Gently massage your breasts to stimulate the let-down reflex before bringing your baby to your breast or using the pump • Check your nursing position and baby’s latch or the position of your breast shields • Begin nursing your baby on the side that is least sore first • Try relaxation techniques and slow breathing when your baby first begins sucking or when you turn on the pump, and continue for as long as it is helpful • Warm cloths or Hydrogel pads can feel soothing • Always break suction before removing your baby from your breast and turn off your pump before removing the breast shields • Rub any residual milk over your nipples and let them air dry completely • Only apply ointment if recommended by your lactation consultant • Call your health care provider or lactation consultant if soreness does not improve, or if you have cracked or bleeding nipples

SAMPLE Part 2: Breast Milk in the NICU 55 BLOCKED DUCTS If the milk flow gets clogged, you can get a plugged milk duct. These can feel like pea-sized lumps or an area of engorgement in your breast. They are often sore to the touch, like a bruise. The area may also be warm to the touch.

Causes of blocked ducts: • Engorgement from oversupply, limiting feeding or pumping time, or latching problems • Infrequent or skipped feedings or pumping sessions • Pressure on a duct from a tight or underwire bra or thumb/finger pressure • Stress or fatigue • Breast surgery

Helpful measures for blocked ducts: • Take a warm shower or place a warm pack on the affected area • Feed or pump more frequently • Try different feeding positions and vary them • Hand express or gently pump after feedings • Apply a cold pack if you feel pain after feeding/pumping • GET MORE REST! • Drink plenty of fluids and eat healthy Gently massage the affected area toward the nipple while • Take anti-inflammatory medications (like ibuprofen) feeding/pumping.

SAMPLE 56 Part 2: Breast Milk in the NICU MASTITIS If a blocked duct stays blocked, breast tissue surrounding the duct can become swollen. This condition is called mastitis. Call your health care provider Your breasts can also get infected if your nipples are cracked. or midwife if you have any of If an infection occurs, it is the tissue surrounding the blocked the following: duct that is infected, not your breast milk. • Fever over 100.4˚F What to do: • Chills, flu-like symptoms or • Go back one page and try the helpful measures body aches noted under blocked ducts. • Mastitis in both breasts If you are prescribed an antibiotic: • Red streaks on your breast • Take it as directed until all pills are gone • Breast pain or burning while • If symptoms are not better in 2 to 3 days, let your feeding or all the time health care provider know • Your baby is less than 2 weeks old • Tell your baby’s provider or nurse that you are being • You’ve had a recent hospital stay treated for mastitis

It is important to keep feeding and/or pumping if you have mastitis. The best thing to do is to continue removing milk from the breast.

BREAST SURGERY If you had breast or nipple surgery you can still provide breast milk to your baby. Colostrum (the first milk) is hormonally produced and available when your baby is born. This may be all of the milk you produce, or you may produce an abundant supply. Most people fall somewhere in between. The type of surgery you had will determine if your milk supply is affected. Other factors include the location, length and depth of the incision, and if it involved removing the nipple and areola. Because milk production (after the initial colostrum) is triggered by nipple and areola stimulation, any damage to your nerves, milk ducts or breast tissue may limit how much milk you produce. The more feeling you have in your nipples, the higher your chances of producing a full milk supply. Be sure to share your surgicalSAMPLE history with your baby’s care team. Part 2: Breast Milk in the NICU 57 FUNGAL INFECTIONS An overgrowth of the candida (yeast) organism can cause a fungal infection in your breast or nipple, or in the baby’s mouth. One sign of infection is when your nipples feel sore for more than a few days.

Symptoms: Causes: • Shooting pains deep in your breast during • You or your baby have recently taken or after a feeding antibiotics; commonly given for GB • Your breast skin may appear: strep and/or cesarean birth ¬¬ Pink • Steroids ¬¬ Flaky • Diabetes ¬¬ Shiny • Anemia ¬¬ Itchy • Wet or plastic-lined nursing pads ¬¬ Puffy • Cracked nipples that allow organisms to enter during or after a feeding ¬¬ Blistered

Hygiene: Treatment: • Change nursing pads often • Meticulous cleanliness and hygiene • Wash clothing and burp cloths often in • Rinse your nipples with 1 tablespoon of hot water vinegar mixed with water and let them • Wear a clean bra every day completely air dry • Wash your hands and your baby’s • Keep nipples as dry as possible because hands often yeast blooms where it is warm, moist and dark • Boil pacifiers and pump pieces daily, then throw them away after a week • Yeast thrives on sugar and dairy products, so you may want to eliminate them from your diet for a while

Ask your health care provider or lactation consultant about using anti-fungal creams SAMPLEor prescription medications. 58 Part 2: Breast Milk in the NICU Safe and Healthy Breast Milk Facts

ALCOHOL SMOKING MEDICATIONS • Passes through your breast • Causes nicotine to pass • Almost all medications milk to your baby into your breast milk pass into your milk in a • Peaks in breast milk 30 to 90 • Decreases your milk supply small amount minutes after you drink it • Increases your baby’s risk • Few medications need to be • Moves out of your breast of SIDS avoided, but antihistamines, some decongestants and milk like it does from your • The harmful chemicals are bloodstream hormonal birth control can lower one hour after you affect your milk supply finish smoking Experts recommend: • Talk to your lactation If you smoke, try to quit or consultant or health • Limit your intake of alcohol to cut down. Smoke after your no more than 1 drink per day care provider before pumping session rather than taking any medications, • Wait at least 2 hours or more before because nicotine may including over-the-counter after drinking alcohol to decrease the flow of your medications, vitamins and breastfeed a full-term baby breast milk. herbal supplements • Check with your baby’s health care provider before you consume any alcohol

Resources: • www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm • www.infantrisk.com/categories/breastfeeding

WARNING — Drugs/Marijuana:

Illegal and street drugs: Drugs like cocaine, heroin, amphetamines, and club drugs will pass through your breast milk and are harmful to your baby. Marijuana: Marijuana is legal in some states, but it is strongly recommended that you avoid it if you are breastfeeding or pumping. Marijuana passes into the breast milk and it is unknown how it can affect your baby. Research is currently being conducted to determine how marijuana is SAMPLEtransferred through breast milk and how much babies actually absorb. Part 2: Breast Milk in the NICU 59 Nutrition and Fitness Eating healthy foods can provide energy and help you lose your extra pregnancy weight. You’ll find detailed nutritional information online at www.ChooseMyPlate.gov.

Tips on eating right: • Eat a variety of protein, carbohydrates and fats to make sure you’re getting the key nutrients your body needs • Eat a diet high in fiber, including whole-grain breads and cereals, raw vegetables, raw and dried fruits, and beans • Drink plenty of fluids, especially water • Eat small snacks throughout the day to keep your energy steady

HEALTHY EATING WHILE BREASTFEEDING • There are no special foods to eat while you breastfeed • You can probably eat small amounts of any food without affecting your baby • If you notice a relationship between eating certain foods and your baby’s behavior (irritability or fussy sleep), stop eating those foods and see if it makes a difference • The FDA warns women who are breastfeeding to avoid eating fish that have a high mercury content, including swordfish, shark, king mackerel and tilefish • Albacore (white) tuna has more mercury than other light-colored tuna; limit the amount of white tuna you eat to 6 ounces per week • Make sure you know the source and preparation of the raw fish before you eat sushi; like any raw food, sushi can carry parasites or bacteria • It is more important to eat a balance of healthy foods to stay strong and healthy than to “starve” SAMPLEyourself to get back to your pre-pregnancy weight 60 Part 2: Breast Milk in the NICU ARTIFICIAL SWEETENERS Most artificial sweeteners are considered safe to use while breastfeeding, although you should avoid saccharin. People with known phenylketonuria (PKU) should avoid aspartame. Don’t use artificial sweeteners if you feel discomfort, headaches or dizziness.

WEIGHT LOSS You probably won’t get back to your pre-pregnancy weight for a while, but you will lose some weight after giving birth. Between the weight of the baby, placenta and amniotic fluid, most people are about 12 pounds lighter after having a full-term baby. You should lose more weight after the birth as your body’s fluid levels return to normal. If you need to lose more weight, talk to your health care provider about a healthy exercise and eating plan. Don’t make drastic changes to your diet over the first couple of months after giving birth. It’s more important to make sure your milk supply is well-established. The good news is that breastfeeding burns 200 to 500 calories per day. So even without a weight loss program, you are still burning extra calories.

EXERCISE Talk to your health care provider about how soon you can start exercising and which activities are safe. Start slowly and don’t push yourself too hard.

Taking the time to exercise will: • Give you more energy • Help you sleep better • Relieve stress • Help prevent postpartum depression • Help your body get back to its pre-pregnancy shape

Guidelines: • Walking is a great way to start • Stay active for 20 to 30 minutes a day • Do simple exercises to strengthen back and stomach muscles SAMPLE• Drink plenty of water! Part 2: Breast Milk in the NICU 61 Pumping Log Pumping Session Date: Total 1 2 3 4 5 6 7 8 9 10

Amount (ml)

Time