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

Breastfeeding the Infant with Special

Needs, 2nd Edition

Donna Dowling, PhD, RNGail C. McCain PhD, RN,

FAAN

Slides prepared by Margaret Comerford Freda, EdD, RN, CHES, FAAN

© 2006, March of Dimes

Breastfeeding• AAP and U.S. DHHS recommend

exclusive breastfeeding for 6 months for all infants, healthy or ill

• “Breastfeeding” does not necessarily mean suckling from the breast, but rather giving breastmilk by any means necessary (gavage, bottle or breast)

© 2006, March of Dimes

Breastfeeding the Preterm Infant • Milk supply may diminish 4 to 6

weeks after delivery

• Furman, Minich & Hack (1998) found only 48% of mothers of preterm infants were still expressing milk at NICU discharge

© 2006, March of Dimes

Rates of direct breastfeeding are lower for preterm infants than for full-term infants

Breastfeeding the Preterm Infant (Continued)

© 2006, March of Dimes

Breastfeeding the Preterm Infant (Continued)

Nursing Care– Determine the mother’s intention to

breastfeed– Ensure that mothers know the benefits

of breastmilk for preterm infants– Teach use of the pump and encourage

mothers to freeze milk if the infant cannot feed yet

© 2006, March of Dimes

Science of Human Milk for Preterm InfantsBenefits from the literature

– 6 to 10 times less NEC in breastfed infants

– Decreased respiratory and GI infections

– Decreased incidence of retrolental fibroplasia

– More stable SaO2 during breastfeeding

– Improved feeding tolerance with breastfeeding

© 2006, March of Dimes

Science of Human Milk for Preterm Infants (Continued)

Long-term benefits– Decreased incidence of asthma

– Decreased incidence of allergies

– Decreased otitis media and GI disorders

– Decreased risk of diabetes mellitus

© 2006, March of Dimes

Science of Human Milk for Preterm Infants (Continued)

Nutritional benefits– Composition facilitates digestion– Protein is primarily whey, which forms a

softer, more easily digested gastric curd– Contains 20 amino acids, nine that are

essential– Fat provides 50% of total caloric content,

and long chain polyunsaturated fatty acids (AA, DHA)

– Primary carbohydrate is lactose, which is easily digestible and produces soft stool consistency

© 2006, March of Dimes

Obstacles to Milk Production and Breastfeeding for PretermsDeciding to breastfeed involves social and cultural norms and depends on social support mechanisms

– Nurses can assist mothers in decision-making by providing accurate information

© 2006, March of Dimes

Obstacles to Milk Production and Breastfeeding for Preterms (Continued)

• Successful initiation of lactation– Milk expression should begin as soon

as possible after delivery– Most mothers require assistance

• Maintaining an adequate milk supply– Directly related to frequency of milk

expression, complete emptying and duration of pumping

© 2006, March of Dimes

Obstacles to Milk Production and Breastfeeding for Preterms (Continued)

Initiating direct breastfeeding– Traditionally dictated by NICU protocols– Nurses should question NICU guidelines

that state that successful bottle-feeding must occur before direct breastfeeding can start

© 2006, March of Dimes

Obstacles to Milk Production and Breastfeeding for Preterms (Continued)

Ensuring adequate milk intake– Can be assessed by infant’s sucking

behavior, mother’s milk ejection reflex and milk transfer

© 2006, March of Dimes

Obstacles to Direct Breastfeeding for Preterm InfantsAssessing infant behavior

– Preterm infants often need several sessions before they can latch well and sustain bursts of several sucks

– Behavior at the breast is dependent on PCA – Preterm infants can take 20 to 30 minutes

to achieve successful positioning and intake

– Explain to mother that no one is an immediate breastfeeding expert

– Help the mother

© 2006, March of Dimes

Supporting the Mother Who Wishes to Breastfeed Her Preemie

•Assess the needs of the mother and baby

•Involve a lactation consultant, if possible

•Teach the mother that preterm infants take

longer to transition to full, direct breastfeeding (may not breastfeed

well until around 40 weeks PCA)

© 2006, March of Dimes

Supporting the Mother who Wishes to Breastfeed her Preemie (Continued)• Encourage kangaroo care, which

helps increase duration of breastfeeding

• Teach about pumping and storing

© 2006, March of Dimes

Nursing Interventions to Restore and Maintain Milk SupplyEncourage the mother to:

– Communicate frequently with nurse and/or lactation consultant to discover milk supply problems early

– Use support systems to help her express milk frequently (4 to 5 x/day)

– Use relaxation techniques and get adequate sleep

© 2006, March of Dimes

Nursing Interventions to Restore and Maintain Milk Supply (Continued)• Review medications the mother

takes that may cause lower milk volume

• Allow her to discuss her concerns and anxieties about her infant

• Encourage her to continue her efforts to provide human milk if at all possible

© 2006, March of Dimes

Supplementation• Supplementation is usually

necessary―not all mothers can be with their infants for every feeding

• Bottle-feeding may create nipple confusion; use breastmilk when bottle-feeding

© 2006, March of Dimes

Supplementation (Continued)

• Cup-feeding is the only alternate feeding method that has demonstrated to be safe

• Research is necessary to evaluate supplementation methods

• Test-weighing before and after feeding may be helpful to mothers after discharge

© 2006, March of Dimes

Breastfeeding the Infant with Cleft Defects• Cleft lip and cleft palate (1 in 700

U.S. births) • Cleft lip defects are surgically

repaired by 6 months of age– Infants with cleft lip can successfully

breastfeed– Breast tissue molds around the cleft to

form a seal, or mother can place her thumb in the cleft to form a seal

© 2006, March of Dimes

Breastfeeding the Infant with Cleft Defects (Continued)Cleft palate defects are surgically repaired by 12 to 18 months of age

– Infants with palate defects usually cannot breastfeed

– Aspiration is the major problem

© 2006, March of Dimes

Techniques for Breastfeeding the Infant with Cleft Lip• For a unilateral cleft, point the nipple

away from the cleft; position the infant in a cradle hold

• For a bilateral cleft, position the infant upright and face-on at the breast

• Encourage the mother to try different positions to obtain the best latch

© 2006, March of Dimes

Techniques for Breastfeeding the Infant with Cleft Lip (Continued)• Swallowing too much air is a

possibility, so encourage frequent burping

• Feeding may take twice as long for these infants than for infants without cleft lip

© 2006, March of Dimes

Breastfeeding the Infant with Cleft LipAssessing adequate weight gain is essential

– If inadequate with direct breastfeeding, use expressed milk with special bottle for infants with cleft defects

– Emotional support of the mother is key

© 2006, March of Dimes

Breastfeeding the Infant with Cleft Palate

• Some infants with cleft palate can use palatal obturators that cover the cleft and aid in breastfeeding– Can reduce feeding time and increase

volume

• Encourage mothers to inquire about palatal obturators

• Encourage pumping and use of human milk for gavage-feeding

© 2006, March of Dimes

Breastfeeding the Infant after Cleft Repair

• In some infants, sucking is discouraged for a time postop

• Postop feeding may be via spoon, syringe or a squeeze bottle– Several studies demonstrate the

effectiveness of these methods to provide human milk to infants with cleft lip repair

© 2006, March of Dimes

Breastfeeding the Infant with a Congenital Heart Defect (CHD)• 8 per 1,000 live births• Coarctation of the aorta• Tetralogy of Fallot• Transposition of the great vessels• High risk for congestive heart

failure until surgical correction• Infants become easily fatigued

during feedings due to tachypnea, tachycardia and hypoxemia

© 2006, March of Dimes

Breastfeeding the Infant with a CHD (Continued)

• Infants with CHD take in only 65% of needed calories

• Require 160 kcal/kg/day• Breastmilk for these infants should

be fortified to increase caloric density to 24 kcal/oz

© 2006, March of Dimes

Breastfeeding the Infant with CHD (Continued)• Nutritional supplements with

medium chain triglycerides or microlipid products and glucose polymers are necessary

• Studies have shown the best weight gain is from 24-hour continuous gavage feedings, but oral-facial stimulation is diminished

© 2006, March of Dimes

Reasons for Using Fortified Breast Milk for Infants with CHD• Breastmilk has anti-infective

properties to prevent respiratory disease

• Breastmilk promotes cognitive development, which is important due to chronic hypoxia with CHD

• Oxygen saturations have been shown to be significantly higher with breastfeeding

© 2006, March of Dimes

Breastfeeding Techniques for the Infant with CHD• Require more frequent feedings• Upright or semi-upright positioning is

important• Mothers must be aware of signs of

fatigue during feedings―increased respiratory efforts, sweating and falling asleep

© 2006, March of Dimes

Breastfeeding Techniques for the Infant with CHD (Continued)• Mothers might need to pump after

feedings if the infant cannot empty the breast

• Test weighing may be necessary• Encourage mothers to use human

milk, even if direct breastfeeding is not possible

© 2006, March of Dimes

Breastfeeding the Infant with Down Syndrome and Hypotonia• Down syndrome occurs in 1 in 800

live births• Extra chromosome #21 (“trisomy

21”)• Breastfeeding the infant with Down

syndrome can be successful• Hypotonia may result in slower

abilities to breastfeed (weak suck, poor head control, tongue protrusion, poor lip closure)

© 2006, March of Dimes

Breastfeeding the Infant with Down Syndrome and Hypotonia (Continued)

• Congenital heart defects are common

• Breastfeeding can facilitate the infant’s oral-facial development

• Breastfeeding provides practice for normal tongue placement and strengthens jaw muscles used to coordinate sucking and swallowing

© 2006, March of Dimes

Breastfeeding the Infant with Down Syndrome and Hypotonia (Continued)

Breastmilk protects from infection and promotes development of the immune system, making it ideal for babies with Down syndrome

© 2006, March of Dimes

Breastfeeding Techniques for Infants with Down Syndrome and Hypotonia• Infants may not show hunger signs,

so try breastfeeding every 2 hours• Have infant suck on mother’s finger

to practice tongue placement• Have mother use awakening

techniques like face washing or rubbing the legs

© 2006, March of Dimes

Breastfeeding Techniques for Infantswith Down Syndrome and Hypotonia (Continued) • Pump after feedings until the baby

is feeding well• Use upright positioning with the

dancer hold or football hold, or use a sling to help the infant maintain a flexed position

© 2006, March of Dimes

Breastfeeding the Infant with Down Syndrome and Hypotonia• Emotional support for parents is

essential― most are shocked and surprised at diagnosis

• Breastfeeding can provide a positive mothering activity

• If rehospitalization is necessary, encourage mother to insist on breastfeeding and encourage her to continue to pump