Nurturing the Late Preterm Baby and Mother:

Promoting Successful Breastfeeding

Part 1

Objectives

• Describe why breastmilk is so important for the preterm baby.

• Describe characteristics of the late preterm which may influence breastfeeding.

• Describe interventions which will contribute to successful breastfeeding for the late preterm baby and mother.

• Describe interventions which will support mother’s milk supply.

What Gestational Age is the late preterm?

• Preterm: <37weeks• Near term: 34 to 38 weeks• Term: 37 to 41 and 6/7

Breastfeeding Management for the Clinician, Marsha Walker

• Late Preterm: 34 to 36 and 6/7 March of Dimes Perinatology Data Center, 2005

• Near-term: 35 to 36 and6/7Many of the near-term problems can be found in the larger 34 to 35 week preterms and the borderline term infants of 37 weeks gestationAcademy of Breastfeeding Medicine

Premature Birth Rate

• The premature birth rate (prior to 37 weeks) rose to 12.7% of live births in 2002. This was a 31% rise since 1981.

Martin et al, Births :Final Data for 2005, National Vital Statistics Reports, CDC

• Late preterm newborns account for 74% of all premature births and about 8% of all births.Davidoff et al, Seminars in Perinatology, 2006

• Infants with low birth weight (less than 5lb 5oz or less than 2500gms) increased to 7.8%

Why More Late Preterm Births?

• The late preterm birthrate has risen 25% since 1990.

• Induction of labor occurs in 22.3% of all births.

• Rates of cesarean births in the United States is 30.3% an increase from 14.6% in 1996. YNHH rate for 2007 was 36.4%.

Martin et al, Births :Final Data for 2005, National Vital Statistics Reports, CDCCheryl Raab, YNHH, 2007

Mother’s Milk:

Especially Important

for Premature Babies

Gestationally Dependent Differences in Milk Composition

Mothers of premies make milk containing higher amounts of most of the nutrients that premies need and in greater amounts than when they deliver full term babies:

• calories, fat, proteins • iron, calcium, zinc, chloride, phosporus • white blood cells, immunoglobulins

The Premature Baby Book, Sear et al.

Breastfeeding management for the Clinician, Marsha Walker

Premies Mother’s milk

• Slow growth

• Susceptibility to infection

• Constipation

• Immature digestion

• Intestinal inflammation

• Visual problems

• Weaker bones

• Anemia

• Dry, flaky skin

The Premature Baby Book, Sears et al.

• Extra protein, fat, calories

• High doses of immune boosters, infection fighters

• Exerts laxative effect

• Easier to digest

• Protects against NEC, severe inflammatory bowel syndrome

• Improves visual acuity

• Builds strong bones

• Builds better blood

• Smoother healthier skin, less eczema

Maturational Readiness

• 24 weeks: sucking movements, turns head toward oral stimulation.

• 26 weeks: gag reflex• 28 weeks: phasic bite (rhythmical opening/closing of the

jaw with gum stimulation) • 28 weeks: transverse tongue reflexes (tongue gravitates

toward stimulus) • 32 weeks: burst-pause pattern of sucking emerges, rooting• 34 weeks: regular rhythm of suck-swallow–breathe, moro • 37 weeks: rhythm and rate of sucking similar to a full term

infant.

The Management of Breastfeeding, Module 4; Black, Jarman, Simpson

Problems of the Late Preterm

• Neuromuscular immaturity

• Low birth weight

• Neurological immaturity: State organization versus disorganization

Neuromuscular Immaturity

Hypotonia• Poor seal of lips on breast or bottle• Inefficient cupping of tongue on nipple• Altered efficiency of tongue peristalsis in stripping of

nipple for milk bolus• Coordination of suck:swallow:breathe 1:1:1 rhythm may

be altered• Increase in non-nutritive(flutter) sucking versus nutritive

(deep movement of entire jaw in smooth movement)• Less stamina at breast resulting in shorter suck bursts

and early fatigue/stress

Milk transfer is affected by hypotonia.

Low facial toneWilson-Clay, The Breastfeeding Atlas

Low tone - tongue tip elevation, 4 day oldWilson-Clay, The breastfeeding Atlas

Poor seal on bottle teatWilson-Clay, The Breastfeeding Atlas

Low Birth Weight

Small muscles:• Early fatigue• Shorter feedings

Less developed buccal fat pads:• Stabilizes ability to suck and sustain bursts

Less nutritional stores: • Increased loss of weight

The Breastfeeding Atlas video, Chapter 3 37 weeker Facial assessment (2-3minutes)

Neurological Maturity

• The brain of a 34 to 35 week fetus is only two thirds the weight of the brain of a term infant.Kinney, H., Seminars in Perinatolgy, 2006

• The volume of white matter increases fivefold between 35 and 41 weeks’ gestation.Kinney, H., Seminars in Perinatolgy, 2006

Neurological States Organization vs. Disorganization

Organization• Demonstrates alertness• Stamina• Self-regulation in response to stimulation…i.e. from cry to self

calming with vocal stimulation• Shows cues for feeding • Active and quiet alert states

Disorganization• Rapid change of state from alert to sleep• Yawning• Arching• Facial grimaces• Riordan, Breastfeeding and Human Lactation 3rd Edition

The Late Preterm May Show Us All of These

• Sleepier: does not fuss or wake to show hunger• Latch difficulties: weak seal, dimpled cheeks with suck• Poor milk transfer• Suck:swallow:breathing uncoordinated• Greater delay in excretion of bilirubin• Respiratory instability• May falsely appear vigorous at first glance

ABM Protocol # 10

Potential Outcomes for The First Week

• Excessive weight loss• Dehydration• Hypoglycemia• Hypothermia• Hyperbilirubinemia• Delayed onset of Lactogenesis II• Low milk supply• Shorter duration of breastfeeding • Breastfeeding failures…..Mothers feel inadequate

having “failed”

Management

• Assessment prior to feeding• Early and frequent skin-to-skin (Intervention)

• Alerting techniques (Intervention)

• Understanding subtle behavior (Intervention)

• Providing incentives at breast (Intervention)

• Assessing the breastfeeding session• Intervention for specific problems• Supplementation (Intervention)

• Supporting milk supply (Intervention)

• Supporting mother (Intervention)

Assessment Prior to Breastfeeding

Assessment Prior to Breastfeeding

• Mother’s medical history for conditions of pregnancy such as PIH, HTN, anemias.

• Mother’s breastfeeding history• Mother’s goal for breastfeeding• Baby’s delivery: The late preterm baby is even more

affected by delivery factors such as prolonged labor, difficult birth needing resuscitation, use of forceps, vacuum use…leads to fatigue and delayed interest in readiness to feed.

Early and Frequent

Skin-to-Skin

Skin-to-Skin

• “Changing habitat…..womb, mother’s body, family…world…..keeping baby in his natural “habitat” so that fragile natural behaviors and responses are triggered.”

The Breastfeeding Answer Book, 3rd Ed, LLI

• Mothers more inclined to breastfeed• Mothers breastfeed longerThe Management of Breastfeeding, Module 4; Black, Jarman, Simpson

Skin-to-SkinThe Benefits Are Even More Important

• Adequate oxygenation (increased oxygenation)• Body temperature regulation via thermal synchrony• Respiratory stabilization, decreased periodic breathing

and apnea• Energy conservation• Fathers receive equal responsiveness when involved• Promotes optimal behavioral states (alert inactivity)• Increases parental confidenceThe Management of Breastfeeding, Module 4; Black, Jarman, Simpson

Helps Immune System

• “ The newborn needs to have contact with and be colonized by a normal flora. It is safest when these bacteria come mainly from the mother because she provides defenses against them.”

• “Early skin to skin provides for contact with normal microbial flora from mother’s skin and mucous membranes, leading to colonization which protects baby from more dangerous bacteria. Normal flora competes against dangerous bacteria for nutrients and space.”

Lars A Hanson, M.D., Ph.D. “Immunobiology of Human Milk”

Skin-to-Skin: Between the breasts, baby’s face turned to side,

cover with blanket(s).

Alerting Techniques

Alerting Techniques

Sensory stimulation of the 5th cranial nerve (trigeminal) leads to rooting and sucking. The 5th cranial nerve inputs into the reticular activating system which is the alarm clock of the brain:

• Skin-to-skin• Talking to baby with variable pitch• Sit baby upright• Providing the smell of colostrum • Moving baby in any direction with uneven rhythm• Tickle/stroke palms or soles of feet

Other alerting techniques

Understanding Subtle Behaviors

Understanding Subtle Behaviors

• Early hunger signs may be subtle: REM, facial grimaces, licking, furrowing of eyebrows, light sucking motions.

Respond to these subtle signs by putting baby skin-to-skin.

• Instinctive behaviors for feeding when skin-to-skin: minor movements of head and tongue show interest.

Assistance needed to move baby to nipple.

Subtle Responses Showing Distress or Stress

• White knuckled clenched fist• Widely splayed fingers• Sagging chin• Furrowed brow• Arm bent at elbow with a raised hand (stop sign)• Legs up as if in leg lift• Arching away• Averting their gaze• Turning head away• Hiccups or yawnsThe Breastfeeding Answer Book, 3rd Ed. LLI

Motoric stress cues:finger splaying, stiffening, crying

The Breastfeeding Atlas, Wilson-Clay

37 weeker demonstrating stressWilson-Clay, The Breastfeeding Atlas

Stress cue while bottle feedingWilson-Clay, The Breastfeeding Atlas

Interventions for Distress

• Calming atmosphere

• Skin-to-skin

• Re-swaddle

• Rest periods

• Pacing any bottle feedings

Providing Incentives At Breast

Providing Incentives at Breast to Initiate and Sustain Sucking

• Massage of breast and hand expression will assist let-down bringing drops of milk to nipple when latching.

• Hand express colostrum into med cup or spoon for cup, spoon or syringe feeding.

• Deep breast compression of breast by mother while feeding moves more milk into baby’s mouth.

• Use of tube/syringe to deliver small boluses at breast.(5 Fr. tube)

Deep breast compressionWilson-Clay, The Breastfeeding Atlas

Spoon feedingWilson-Clay, The Breastfeeding Atlas

SNS with both tubes on the same breastWilson-Clay, The Breastfeeding Atlas