BREASTFEEDING THE PRETERM AND LATE PRETERM INFANT: CHALLENGES AND STRATEGIES FOR POST DISCHARGE MANAGEMENT
Emily Pease, RN, BSN, IBCLC Madeline Smith, RN, BSN, IBCLC Swedish Medical Center Pediatric Specialty Care Conference 1/25/19 1 OBJECTIVES
Review definitions of preterm and late preterm infants List risk factors associated with poor feeding outcomes Describe strategies to initiate and maintain milk production Discuss care plans to help late preterm and preterm infants transition to direct breastfeeding CDC DATA ON PRETERM DELIVERIES 2017
9.93% of all babies born were preterm in 2017 7.17 % of all live births were late preterm in 2017 72 % of all preterm births in 2017 were late preterm
CDC https://www.cdc.gov/nchs/data/databriefs/db318.pdf
3 CONSENSUS ON TERMINOLOGY NEWER DEFINITIONS
PRE-TERM:< 37 completed weeks • Late preterm: 34-36 6/7 week • Early term: 37-38 6/7 weeks FULL-TERM: 39-41 6/7 weeks POST-TERM: > 42 completed weeks
ACOG
https://www.acog.org/-/media/Departments/Patient-Safety-and-Quality-Improvement/2014reVITALizeObstetricDataDefinitionsV10.pdf
4 PRETERM STATS AT SWEDISH 10/1/17-9/30/18
Total number of live births across 4 campuses: 11418
Total preterm (< 37 weeks): 1016=8.9% of all births
Total LATE preterm births (34-36 6/7 w): 736=6.4% of all births and 72% of all preterm births
5 LATE PRETERM BIRTHS AT SWEDISH 10/1/17-9/30/18
116 were 34-35 weeks (96% were in NICU)
207 were 35-36 weeks (49% were in NICU with average LOS of 8+ days)
413 were 36-37 weeks (25% were in NICU with average LOS of 4+ days)
6 RISK FACTORS FOR THE LATE PRETERM INFANT
Hypoglycemia Hypothermia Respiratory problems Jaundice Sepsis Feeding problems Higher rates of re- hospitalization Increased morbidity and mortality
7 Near-Term Infant Breastfeeding Cascade
Less stamina Less Coordinated S/S/B Less effective sucking Less alert, awake periods
Insufficient breast stimulation Insufficient milk transfer Incomplete emptying
Hypoglycemia Insufficient milk supply Jaundice Poor weight gain
Readmission Supplementation Separation from mother
Source: Nancy E. Wright, MD, FAAP, IBCLC
8
LACTATION RISK FACTORS IN THE MOTHER OF THE PRETERM/LATE PRETERM INFANT
Delayed Lactogenesis and low milk supply Maternal stress during labor and delivery, birth trauma Infection Chorioamnionitis Maternal obesity Diabetes Mellitus Medications to treat PIH/PTL Hemorrhage Prolonged Bed rest Multiple births Delay in initiation of colostrum expression
9 BASIC GUIDELINES FOR IN AND OUT OF HOSPITAL MANAGEMENT
Feed the Baby: usually requires supplementation with expressed colostrum (ideally) or formula initially in addition to breastfeeding Swedish protocol for management of the late preterm in postpartum • 2-10 ml per feed first 24 hours • 5-15 ml per feed 24-48 hours • 15-30 ml per feed 48-72 hours • 30-60 ml per feed 72-96 hours Establish and preserve maternal milk volume
10 ESTABLISH MILK SUPPLY
Timing is important. Provide support for mothers immediately after birth. Hand expression: start within 1 hour after birth Hand expression: q 2-3 h or 8x/24h Hand expression: before or after pumping Pump starting after the first 6 h if mom/baby are separated or anytime flow increases Studies: mothers of preterms who initiated hand expression within 1 h of birth made more milk, breastfed/breast milk fed longer and with higher rates of exclusivity than those who waited more than 6 hours. Mothers of preterm infants are less likely to initiate milk expression early and to make sufficient milk than mothers of term infants. (Parker et al, 2012, Morton et al, 2009)
11 ESTABLISH MILK SUPPLY
Gems from Dr. Jane Morton: Milk production is strongest determinant of duration and exclusivity Insufficient milk production – Most common reason for stopping ~ 3 times greater risk of early cessation of lactation in preterm mothers compared to term mothers High production correlates with transition from bottle or tube feeding to breastfeeding. Hormones set the stage: ↓ progesterone (placenta) precedes lactogenesis. Oxytocin release (let-down) enables episodic milk removal Yet the early, frequent and effective removal of colostrum determines future production potential Production within first 4 days predictive – Low production correlates with early termination! http://idahobreastfeeding.com/breastfeeding-handouts/Jane%20Morton%20Boise%201%20handout(NoPics).pdf
HAND EXPRESSION!!!
http://newborns.stanford.edu/ Breastfeeding/HandExpression. html
http://newborns.stanford.edu/ Breastfeeding/ABCs.html
Attributed to Dr. Jane Morton, Stanford University School of Medicine
13 Hand Expression: Issaquah
We use the Stanford University demo (patient & staff education) by Jane Morton. We are seeing 20 to 40 ml of colostrum on day two when this is implemented in L&D. It has been truly impressive! First pump at 12 hours, with hand expression This is the result on day 2 when you hand express Hand expression the first in labor and Hand couple delivery. Day 2 expression in hours. pumping the OR for a baby in NICU 15 ml!!!! ESTABLISH AND MAINTAIN MATERNAL MILK SUPPLY
Milk volume at week 2 Ideal = 750-1000 ml/24 hours Adequate= 500 ml/24 hours Borderline= 350 ml/24 hours Many at-risk moms take longer to establish a full milk supply. No good data on this, but in clinic we see it take anywhere from 4-8 weeks. Reassure mothers that milk supply may continue to increase over time with regular milk removal. What they see at week 2 is infrequently not the full volume they will reach as long as they have the support to continue to pump frequently.
15 TIME AND GROWTH IS ON THEIR SIDE
Until baby is able to breastfeed effectively: PRESERVE THE MATERNAL MILK VOLUME Effectiveness of milk removal affects the milk volume overall Hands-on pumping; frequency of milk removal and degree of emptiness of breasts. Ideal: 8 times per 24 h, pump past 2 let downs Give baby opportunities to practice at the breast without high expectations.
16 WHOSE PROBLEM IS IT ANYWAY?
Preterm Infant Suck may be weak, disorganized, dysrhythmic Inability to latch, or maintain latch: • muscle weakness, poor coordination, low vacuum pressures; vacuum is essential to milk removal from the breast (Meier et al. 2007, Hurst et al. 2004, Sakalidis and Geddes 2016) • tongue tie, releases seal, bites • habituation to bottle feeding/faster flow • severe reflux Sleepy/poor stamina due to preterm status or jaundice Determine if Pediatric Therapy Services would be helpful
17 WHOSE PROBLEM IS IT ANYWAY?
Maternal Low supply due to inadequate breast stimulation, infrequent or ineffective pumping Flat/Inverted nipples Breast/Nipple pain, trauma Medical complications Separation Lack of support from family or staff
18 FEEDING STRATEGIES: OUTPATIENT CLINIC
Evaluate infant’s suck/strength/coordination/stamina Pre/post feed weight, observe for rhythm, teach swallowing, difference between nutritive and non-nutritive sucking Evaluate mother’s milk supply and flow Frequency of milk removal; support for mother to maintain pumping post discharge
19 FEEDING STRATEGIES: OUTPATIENT CLINIC
Babies need to practice breastfeeding in order to learn to breastfeed. Practice in NICU helps increase duration (Pineda 2011, Briere et al. 2016)
Most common: Triple Feeding (Breast/bottle/pump)
BF x 5-10 min per side for all daytime feeds. Limit time on the breast INITIALLY, finish with bottle, pump after.
Milk flows fastest when breasts are more full. Mother may need to hand express or massage breasts to initiate flow to help baby attach and stay attached
20 FEEDING STRATEGIES: OUTPATIENT
Feeding tube/SNS at breast: adds flow to keep baby active at breast, pump after to finish emptying breast. Nipple shield may compensate for weak suction pressures. (Meier et al. 2000, Chertok et al. 2006) Size shield to fit mom’s nipple (priority) and baby’s mouth. Monitor intake at breast and mother’s milk supply with nipple shield. “Oroboobular disproportion!” Small mouth/large nipple-baby needs to grow into mom’s nipple! Do some short practice feeds until baby’s mouth grows.
21 COURSES: FROM APPETIZER THROUGH DESSERT
Transition to more breastfeeding is gradual Appetizer: Practice at breast for a few minutes each side Main course: when infant is able to sustain a longer suck/swallow pattern, maintain normal vacuum pressures Dessert: when infant is able to stay engaged on the breast, take a break and then trigger a second or third let down to “finish” the feeding. They do not need dessert at every feeding Switch nursing Flow is a big factor
MOVING AWAY FROM TRIPLE FEEDING: CHALLENGE OR INDEPENDENT FEEDS
Start once baby is able to transfer 40-60 Every few days: increase the length of ml over about 20-30 min time for challenge feeds 5-6 hour block of breastfeeding ad lib, no Goal to move to exclusive ad lib pump, no bottle. breastfeeding or occasional bottles depending on parent choice. Expect: more frequent feeds Goal is for baby to be able to Try: switch nursing breastfeed effectively, drive milk supply Consider use of baby weigh scale at and for parent to eliminate pump home dependency. For the rest of the day, go back to triple Check in with parent feeds OR pump/bottle. Time frame: suction pressures mature Weigh baby every 3-4 days to ensure anytime from 36-44 weeks. Variable. normal gain (25-30 g/day) Achieving full feeds at breast is dependent on mother’s milk production
23 MOVING TO FULL BREASTFEEDING: MATERNAL ISSUES
Chronic low milk supply: Goal is that baby is able to remove Maternal exhaustion enough milk so pumping after is not needed Nipple shield: need long term studies, BUT Lack of support: pumping is hard to in clinical experience long term use of maintain nipple shield frequently results in less milk transfer→lower milk supply. “Finish at the breast” method may be good alternative Post partum depression: 10-20% of all mothers have postpartum depression or Mom can still do challenge feeds even if anxiety she has low supply, and may not need to supplement until the end of the day https://www.postpartumdepression.org/resources/statistics/ https://www.cdc.gov/mmwr/volumes/66/wr/mm6606a1.htm?s_cid=mm Many babies help increase milk supply 6606a1_w#suggestedcitation once they start nursing more effectively.
24 FREQUENT RE-EVALUATION IS KEY
How long until full breastfeeding? Variable, range in our clinical experience is 4-8 weeks after discharge
Track intake at breast, weight gain
Track pumping volumes; reduce frequency once baby nurses more effectively and can drive supply
Weekly appointments or Breastfeeding Support Groups
25 CONCLUSION
Preterm babies can learn how to breastfeed and need practice, ideally the earlier the better. Feed the baby Establish and maintain milk supply Establish feeding goal Buy time and be patient Give support and consistent information; the plan needs to be doable for the parents. Close follow up results in more success
26 REFERENCES
Academy of Breastfeeding Medicine clinical protocols for late preterm and preterm infants https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/10-breastfeeding-the-late-pre-term-infant-protocol-english.pdf https://www.liebertpub.com/doi/pdf/10.1089/bfm.2018.29090.ljn
Parker LA, Sullivan S, Krueger C, Kelechi T, Muelle M. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. Journal of Perinatology (2012) 32: 205–209
Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics.2003 Sep;112(3 Pt 1):607-19.
Ludington-Hoe SM, Anderson GC, Simpson S, Hollingsead A, Argote LA, Rey H. Birth-related fatigue in 34-36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care. Journal of Obstetric, Gynecologic & Neonatal Nursing. 1999 Jan-Feb;28(1):94- 103.
Meier PP, Furman LM, Degenhardt M. Increased Lactation Risk for Late Preterm Infants and Mothers: evidence and management strategies to protect breastfeeding. J Midwifery Women's Health. 2007 Nov-Dec;52(6):579-87
Morton J., Hall J.Y., Wong R.J., Thairu L., Benitz W.E., & Rhine W.D. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology. 2009. 29, 757-764.
Wight, Nancy E. Breastfeeding the borderline (late preterm) preterm infant. Pediatric Annals; May 2003; 32 (5) pg. 329
Hurst NM, Meier PP, Engstrom JL, Myatt A. Mothers performing in-home measurement of milk intake during breastfeeding of their preterm infants: maternal reactions and feeding outcomes. J Hum Lact. 2004 May; 20(2):178-87.
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