Lactation and Breastfeeding in the NICU Considerations and challenges

1. Lactation and Breastfeeding in the NICUConsiderations and challenges Natalie Mendenhall BSN, RN, IBCLC Steve Van Scoy, M.D.

2. “The Expectation”

3. “The Reality”

4. Parents--shared issues • Unprepared for early birth emotionally/educationally/home planning/ work, etc. • Loss of dream • Fragile infant • Stresses Money/work/other kids/separation/family S

5. Parents--shared issues • Parent-child separation • Sick child • Choices: Donor milk, formula, IV fluids • Pressure to prove good parents to hospital staff, etc • Fear of being judged S

6. Mother • Hormonally prepped/physically unprepared • Guilt • Sick during pregnancy • Pressure to perform-time at bedside, care, pumping N

7. Mother • Unrealistic goals with breastfeeding – • Baby should be breastfeeding, • baby is sleepy at breast, • baby is not latching on or able to sustain attachment • Why is baby is needing to be “topped” off after breastfeeding? • Defeated – • Infant receiving larger volumes than what mom would “normally” be producing at pp day or can produce at this time. N

8. Father • Less physically (emotionally) invested • Unable to ‘protect’ family • May blame mother • Pressure to prove good parent—may overcompensate, withdraw, or control S

9. Father • Unsure of his role as a father and how that fits in with the this new environment • Guilt – Has to return back to work. Can not be present as much as he would like. • Wants to bond with baby but is unsure how - Does not want to take away from mom’s time with baby S

10. Baby • Something is not “average” • Premature or sick or both • Recovering from or undergoing some stress • Congenital anomalies S

11. Premature Baby • Neurologically immature • Poor state control • Suck-swallow-breathe coordination/control is developing , NOT being taught. • Vagal predominance S

12. Premature Baby • Have “opinions” • Modified reaction to feeds due to previous experience • Anxiety of being touched/manipulated • Oral aversion from care • High arched palate from ETT • Pressure to nipple by parents, staff more oral aversion • At risk for prolonged feeding dysfunction S N

13. Near-Term Baby • Need initial sugar intake higher than term infants • low glycogen stores • Cold stress • Unanticipated or stressed delivery • Acute illness-infection, etc • Recovering from failed trial of couplet care S

14. Term Baby • Recovering from illness/insult • Neurologic dysfunction • Sepsis and inflammation • Birth stress • Ongoing insult • Maternal medicine/drug use • Congenital anomalies • Maternal Diabetes S

15. Baby • Delayed breastfeeding • mother not able to be present • “easier” for baby to feed from bottle • mother may prefer bottle feeding to facilitate discharge • Forces LOTs of pumping • fatigue, stress, lack of nipple stim, • hormonal causes – low prolactin levels, Hyper/Hypo Thyroid, high androgens, PCOS/Infertility issues, Insulin –Diabetesdeclining supply • May require additional measures to increase supply N

16. NICU Environment • Cold/clinical • Noisy • Not familiar • Busy • Separation/poor bonding • Interruptions • Time pressure • Feeding schedules N

17. Challenges, what challenges? S

19. Transforming parental outlook S

20. Supporting the parents • We don’t do average in the NICU • Challenges are a normal part of the process • If they weren’t, we wouldn’t be needed • Embrace them • Let parents know perceived challenges: • Are normal and expected • Do not mean “sick” • We know how to navigate them S

21. Supporting the parents • Manage expectations • Colostrumdelay to mature milk • Variations in milk volumes • Importance of regular pumping • Baby will need to bottle feed • Communicate • Prepare and strategize with parents • Welcome questions and explain the why • Make them part of the team • Honor their preferences when possible N

22. Supporting the parents • Phrasing is important: • Positive spin • Do not demonize partial feeds, decreasing volumes • Validate that mother has been sick &/or under stress • Reassure that mother can be successful • “Millions of good particles in each ml milk” • “10ml/feed is great” • “It’s not you, it’s everything else” S

23. Teaching Parents the “Breast Steps” • Step 1: Skin to skin time • move to step 2 when showing feeding cues or looking for the breast • Step 2: Nuzzling at the breast • Pump before • If too sleepy place back skin to skin N

24. Teaching Parents the “Breast Steps” • Step 3: Learning to breastfeeding • Nipple shield may be used if indicated • Start with one breast per feeding • Let feed until tired, about 10-15 minutes • Step 4: Breastfeeding • AC/PC weights to assess milk transfer N

25. Supplemental devices N

26. SNS (Supplemental Nursing System)Advantages: • A baby can get the additional milk at the breast without introducing other feeding methods or techniques • Increases the flow of milk to the baby and helps to eliminate frustration. • Breast are stimulated to make more breast milk by additional suckling • Baby can get more practice at breastfeeding properly • The mother is able to enjoy the full experience of breastfeeding • Baby associates feeling full at the breast and this helps to reinforce his/her desire to breastfeed. N

27. SNS (Supplemental Nursing System)Disadvantages: • May affect baby’s latch • Some babies become aware of the tube and prefer the straw to the nipple • Controlling the rate of flow of milk • Too fast may cause choking, bradycardia, oral aversion • Too slow may underfeed an underweight, preterm or near term baby with insufficient stamina. • Cleaning may be time consuming and difficult for a stressed NICU mother N

28. Cup FeedingAdvantages • Cup feeding can begin from as early as 29 weeks gestational age. • A baby can feed at his/her own pace • Cup feeding is thought to be a positive oral experience for baby • Open cups are very easy to clean • Cup feeding can prepare a baby for breastfeeding by encouraging the tongue to come forward for feeding. N

29. Cup FeedingDisadvantages • There is a risk for aspiration or choking • Feeds can take longer • There can be a lot of spilled and wasted milk • Long term cup feeding can dampen the sucking reflex or create a preference for the cup N

30. Finger Feeding with syringe or tubeAdvantages • More like a breastfeed than cup feeding or bottle feeding • Helps a baby use the correct sucking technique for breastfeeding • Keeps a baby fed • Maintains skin to skin contact • Can be used as suck training to improve breastfeeding technique N

31. Finger Feeding with syringe or tubeDisadvantages • Not appropriate for all babies • Can be time consuming • May be awkward to finger feed until parents get the hang of it • Milk can be lost if flow rate is too high N

32. Nipple Shield Advantages • Assists with getting the baby onto the breast when the baby has had a lot of bottles. • Decreases the intra-oral space and increases the strength of the baby’s suck = Increase milk transfer • Assists an infant with a weak or disorganized suck at the breast until an effective suck is achieved. N

33. Nipple Shield Disadvantages • Decrease the amount of milk transferred which can lead to a reduced milk supply. • Increases the risk for getting clogged ducts or mastitis • Weaning off the shield can be difficult. N

34. Our expectation