Breastfeeding the Medically Complex October 6, 2008 Infant Healthy Infant Medically Complex • Rewarding Birth • Disappointment, Sense of Breastfeeding the Medically Failure, Guilt Experience , Proud • May be shocked by • Baby is beautiful!! Complex Infant appearance of infant • Little fear of danger to their • Great fear of danger to infant, infant Anxiety • Growing confidence in their • Mother is uncertain what her ability to care for and role is - other mothers are breastfeed their new baby, different. Lacks confidence in Identifies with peers • Kimberly H. Barbas, BSN, RN, IBCLC care-taking role • Feels pleasure and satisfaction • May be told she cannot • Boston Children’s Hospital when the baby latches on and breastfeed - Frustration and feeds at her breast disappointment if infant cannot feed at her breast Disclosure Breastmilk is Best! • NOT an issue of making mothers feel I have no conflicts of interest or financial GUILTY! relationships with commercial entities. • Family Centered Care – share the decision making Mention of specific products does not • Informed decision making represent endorsement of those products. (Miracle DJ - JOGNN, 2004 Nov-Dec; 33(6):692-703) Paula P. Meier, RN, DNSc, FAAN Learning Objectives Rush Presbyterian Hospital • Identify three potential barriers to “Human Milk is an Evidenced Based breastfeeding in the hospitalized infant Health Issue” • Identify three techniques to facilitate -It is not a “gift” breastfeeding in a medically complex infant -It is not an “art” • Describe creative feeding plans for the medically complex infant (Rodriquez N, Miracle D, Meier P. Sharing the Science on Human Milk Feedings with Mother of VLBW Infants. JOGNN 34: 109-119, 2005) Kimberly H. Barbas, BSN, RN,IBCLC - Children's Hospital Boston 1 Breastfeeding the Medically Complex October 6, 2008 Infant Benefits of human milk for Benefits of Breastmilk hospitalized neonates: . Immune properties . Decreased Obesity reduced sepsis (Secretory IgA) and Overweight . Late onset sepsis . Decreased . Decreased . >7 days of life Diabetes infection . Nosocomially acquired . Gastrointestinal . Decreased Leukemia and . Incidence ~60% lower for human milk vs. Respiratory lymphoma formula fed infants . Decreased Otitis . Neuro- . Intake >50 ml/kg/day may be needed Media developmental and . Decreased Asthma cognitive benefits and Allergy (Atopy) . Maternal Benefits Schanler et al. Pediatrics 1999, Furman et al. Arch Pediatr Adolesc Med 2003 AAP Policy Statement, Pediatrics 2012 – www.aap.org Benefits of human milk for Benefits of Breastmilk hospitalized neonates: reduced sepsis . 64% reduction in GI infections . Dose related response! . 72% reduction in URIs . First 14 days – no fortification . Improved neurodevelopment . 14 days of Human Milk increases chance of survival .Visual acuity (LCPUFAs) and discharge .Cognition . Decreases risk of late sepsis, NEC, death . Dose and exposure period: How much over what period of time? Ip et al. AHRQ meta-analysis 2007 . Each 100ml/kg HM decreases risk by 0.93 for sepsis (Multiple sources: Meinzen-Derr ~ Patel A~ Sisk P) Benefits of human milk for Benefits of human milk for hospitalized hospitalized neonates: NEC neonates: better feeding tolerance . Necrotizing enterocolitis (NEC) . Serious, acquired GI disorder . Achieve full enteral feeds with human milk . Preterm, CHD infants 2-7 days sooner than with formula . Cause unclear . Fewer days on parenteral nutrition . Human milk highly protective . Shorter length of stay . Incidence ~60% lower for infants fed human milk vs. formula . Intake >50 ml/kg/day may be needed for protective Schanler et al. Pediatrics 1999 effects . Exclusive human milk provides maximum benefit Ip et al. AHRQ meta-analysis 2007 Kimberly H. Barbas, BSN, RN,IBCLC - Children's Hospital Boston 2 Breastfeeding the Medically Complex October 6, 2008 Infant Benefits of human milk for hospitalized neonates: cost savings Human Milk Benefits . NEC (vlbw) • Sensory Stimulation . Medical $144,497 per case • skin to skin contact . Surgical $265,945 per case • olfactory (smell) input . Sepsis • neurological development . $10,440 per case . Parenteral nutrition . $500 to $1000/day Bartick, M - 2010 Human Milk Benefits Maternal Health Benefits • Increased Lifetime lactation duration decreases risk of Tolerance of enteral feedings Type II Diabetes • ease of digestion • Never Breastfeeding increases risk of Type II DM by 40% (even 1-6 months showed benefit) • high incidence of GERD • Women with Gestational Diabetes – Breastfeeding provided 86% decrease risk of progressing to metabolic • breastmilk is less irritating –complex syndrome infants are at increased risk for • Longer lactation decreased risk factors for Cardiovascular aspiration and intolerance to formulas diseases – difference equivalent to 30 minutes of vigorous activity in the Gym per day! (Dr. Alison Steube. MD, MSc – University of North Carolina) Human Milk Benefits Maternal Health Benefits • Maternal Attachment • Women’s Health Initiative • this is ONE thing only mom can do for http://www.nhlbi.nih.gov/whi/ baby • Nurses Health Study I and II • long separations from infant, often can’t http://www.nurseshealthstudy.org/ even hold baby Schwarz EB, Brown JS, Creasman JM, et al. Lactation and Maternal Risk • enhanced bonding, psychological of Type 2 Diabetes: A Population-based Study. The American journal of benefits medicine. 2010;123(9):863.e861-863.e866. Schwarz EB, Ray RM, Stuebe AM, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstetrics and gynecology. 2009;113(5). Kimberly H. Barbas, BSN, RN,IBCLC - Children's Hospital Boston 3 Breastfeeding the Medically Complex October 6, 2008 Infant Prenatal Support Potential Barriers to Breastfeeding • Advantages of breastmilk • Delayed first feeding at breast • Preliminary discussion of milk • reduced frequency of feeding expression with breast pump • Often made to bottle feed first • Arrange equipment • Increased use of supplemental feedings – Check Insurance Benefits with formula – Provide prescription • Provide written information Mother and infant dyad A presents – infant with hyperbilirubinemia/ dehydration/sepsis/weight loss Clinical Pathway to Protect Breastfeeding in the Hospitalized Infant Perinatal Support Obtain Infant History Obtain Maternal History · Gestational Age · Birth History Spatz, D and Goldschmidt, K. · Birth History · Lactation History · Feeding History · Risks for Lactation Failure MCN 2006 (31)1:45-51 · Void/Stool History • Initiate breastfeeding in delivery room if Assess Maternal infant stable – colostrum Assess and Lactogenesis Stabilize Infant Assess breasts, nipples, and milk supply D • Imprinting: Mom and Baby! Infant able Provide mother with No electric pump – instruct B to feed at breast? to double pump • If unable to feed, encourage skin to skin No Yes • Immediate separation: Take a photo Assess maternal milk Initiate test Has infant’s production weights with weight increased (>500 ml/24 hrs by day 5) C electronic scale for to demonstrate before tubes! each breastfeeding adequate milk E session transfer? Develop alternative feeding plan · Breastmilk ng/og until able to orally feed (formula if no Yes breastmilk available) Determine need for technology to · Skin to skin care facilitate breastfeeding Continue to support · Non-nutritive sucking breastfeeding SNS – if milk supply low Nipple shield if latch difficulties When infant able to oral feed go back to B Prenatal Support Hand Expression • Fetal Diagnosis by ultrasound • Increased stimulation to breast (milk comes in • Congenital Heart Disease (CHD) faster) • Gastroschesis • Increased later milk production • Omphalocele • More milk to the baby – • Congenital Diaphragmatic Hernia (CDH) colostrum averages a • Craniofacial Anomalies few drops to 1 teaspoon… • Congenital anomalies Frequency of HEx >5 times per day in first 3 days postpartum correlated with increased milk volume by 2 weeks J Morton et al 2009 Kimberly H. Barbas, BSN, RN,IBCLC - Children's Hospital Boston 4 Breastfeeding the Medically Complex October 6, 2008 Infant Jane A. Morton, M.D. FAAP RPS – Reverse Pressure Softening • http://newborns.stanford.edu/Breastfeed • Triggers Milk ing/ ejection • Reduces resistance • http://newborns.stanford.edu/Breastfeed of subareolar tissue ing/HandExpression.html • Shifts edema back into breast to soften • http://newborns.stanford.edu/Breastfeed areola and facilitate ing/MaxProduction.html latch or pumping Cotterman, KJ 2004 Stanford University School of Medicine, CA Lucille Packard Children’s Hospital Postpartum 24-48 hrs RPS – Reverse Pressure Softening Basic principles for applying RPS • Teach proper storage and handling of 1. Clean hands and fingernails. expressed breast milk 2. Choose one method described, depending on fingernail length. 3. Exert steady, gentle, but firm positive • Early frequent stimulation to encourage pressure, onset of milk production 4. Press on a 1- to 2-cm radius of the whole central areola, right at its junction with the base of the nipple. • Milk Onset Day 3-7, gradual increase in 5. Press inward perpendicular to the volume – prepare mothers for minimal mother’s chest wall, for 1 to 3 full minutes. 6. Repeat once (or more), depending on output day 1-3 to decrease frustration severity of swelling. 7. Perform immediately before each attempt to latch until engorgement has Cotterman, KJ. 2004. resolved well enough for easy latching. Week One Week One • Engorgement vs. Normal Fullness • Early, frequent, complete milk removal •