Session 10 Infants With Special Needs
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Transcript of Session 10 Infants With Special Needs
SESSION 10 INFANTS WITH SPECIAL NEEDS
Breastfeeding Promotion and Support A Training Course for Health Professionals
Adapted from the Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care (Section 3)
WHO/UNICEF 2009
1
INTRODUCTION
• Human milk has been recognized as the gold standard for human feeding for centuries.
• Milk of other species that is fed to human infants have been known to contribute to increase in infant mortality.
2
Which Baby Require Special Attention?
• Prematurity• Twin babies• Hypoglycemia• Neonatal jaundice• Dehydration• Cardiac problem• Babies with breathing difficulties• Cleft palate• Down Syndrome• Medical problems
– neurological condition– ill babies 3
Importance of Breastmilk for Preterm/LBW/Ill Infants
Breastmilk contains:
1. Protective immune factors Help to prevent infection
1. Growth factorsHelps baby’s gut and other systems to develop as well as to heal after diarrhoea
1. EnzymesMake it easier to digest and absorb milk
1. Special Essential Fatty Acids
Help brain development
5
Other Benefits
5. Calms the baby
6. Reduces pain from venipuncture etc
7. Gives mother important role in caring for baby
8.Comforts the baby & strengthen bonding
6
Babies With Special Needs need breast milk as much as well babies
Feeding depends on each baby’s condition:•Not able to take oral feed•Able to take oral feeds but not able to suckle•Able to suckle but not for full feeds•Can suckle well•Not able to receive any breastmilk
7
Composition of Preterm Human Milk (26-36wks)
Comparison to mature term human milkProtein 50-100% higher during first 4-7 wks
Sodium 30-150% higher first 4-6 wks
Chloride 30-80% higher during 3-4 wks
Potassium 30-75% higher during first 3-4 wks
IgA Higher during first 2-3 months
Medium chain FA 40-80% higher during first 3 months
Polyunsat FA 40-70% higher in colostrum and transitional milk
Enzymes and growth factors
Equal to mature human milk
9
Milk from mother giving birth preterm contains more protein,sodium and calcium than full term milk.
Benefits of Breastfeeding for Preterm Infants
Benefits References
Greater enteral feeding tolerance and more rapid achievement of full enteral feeding
Armand et al,1996Gross,1983Simmer et al,1997Uraizee &Gross,1989
Reduced risk and severity of infection (short and long term)
El-Mohandes et al,93,97Narayanan et al,81,82,84Uraizee & Gross,89
Reduced risk and severity of necrotizing enterocolitis
Albanese & Rowe,95Buescher,94Neu,96
Reduced risk of atopic disease for infants with family risk histories
Chandra,97Lucas et al,90
Enhanced retinal maturation and visual acuity Carlson et al,86Faldella et al, 96de Andreca & Uauy, 95
Enhanced developmental and neurocognitive outcome
Carlson et al,86Faldella et al, 96de Andreca & Uauy, 95Morley, 96
10
Issues on Breastfeeding in Premature Infants
• Expressed Breast Milk (EBM) -if the infant cannot suck directly at the breast
• Hindmilk – has higher calories than foremilk for better
weight gain.• Human milk fortifier.• Non nutritive sucking
11
Human Milk Fortifier (HMF)
• HMF provides additional nutrients to breast milk.(protein and minerals).
• Usu use in hospital setting for baby< 1.8 kg. • Fortification is usually started when feeds reach
100 ml/kg by adding 1 sachet (2 grams) to 50 ml of Expressed Breast Milk (EBM).
12
Non Nutritive Sucking/ Comfort Sucking
• Used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants.
• Facilitates development of sucking behaviour in premature babies.
• Help to Improves
digestion of enteral feeds• Calming effect on infants
13
Method of Feeding in Premature Infants
• Oro/Nasogastric tube feeding
• Cup feeding
– when suck-swallow coordination has been
achieved
• Supplementer Nursing System
Session 10: Infants With Special Needs Ministry of Health Malaysia 14
Supplementer Nursing System(SNS)
17
Supplemental Nursing System (SNS) is a feeding tube device to provide babies supplemental feedings at the breast. When a baby is at breast over a period of days or weeks, a hormonal mechanism is triggered that causes milk to be produced. Used for :Induce and maintain lactation
1.Arrange Contact Between Mother And Baby, Day and Night
• Encourage mother to visit, touch and care for baby as much as possible
Mother’s exposure to pathogen in NICU will stimulate antibody production which is passed to babies via breastmilk
• Kangaroo Mother Care (KMC)/Skin-to skin contact– Encourage mother to hold baby closed to breast– Baby can go to breast whenever he wants.– Helps regulate baby’s temperature and breathing,assists
in development and increases production of milk.
19
2.Take Care Of The Mother
• Help mother to rooming in.• Provide place for mum to rest • Provide meals for mother.• Be parents friendly
– Answer parents’ questions and explain patiently • Let parents know breastfeeding is important
21
3.Help To Establish Breastfeeding
• Assist mother to express her milk within 6 hours of birth ( > /= 6 x in 24 hours)
• Baby can go to breast while receiving a tube feed to associate the feeling of fullness with being at breast.
• Encourage and educate mother to give EBM via tube or cup before BF is established. Avoid artificial teats.
• Advise mum to express breast before putting baby on breast
premature babies do not have good sucking
swallowing coodination.22
Positioning a Preterm Infant
• Support baby’s head with mother’s hand (not grip) .Mother’s arm support baby’s body.
• Mother support her breast with her other hand to help baby keep breast in mouth.
• To increase milk flow, massage and compress breast each time baby pauses between suckling bursts
23
Explain to mothers what to expect at feeds
• Longer feeding time Feed for a long time ( ~ 1 hour) and will pause frequently to rest during a feed.
• Gulping and choking Baby's low muscle tone and uncoordinated suckle.
• Stop trying to feed if baby seems too sleepy or fussy .
• Keep the feed as calm as possible. Avoid loud noises, bright lights, stroking or talking to
baby. 24
INFANTS WITH SPECIAL NEEDS
Approach to feeding will depend on baby’s condition.
1.Baby not able to take oral feeds. Encourage EBM and freeze it
2. Baby able to take oral feeds but is not able to suckle at breast. Give EBM by tube and by cup if baby is able.
3.Baby able to suckle but not for full feeds. Let baby suckle whenever baby is willing. Frequent short feeds .Give EBM by cup or tube in addition
4.Baby can suckle well. Encourage frequent feeds
5.Baby is not able to receive breast milk.
Discharge Plan For Premature Baby
• When to discharge?-baby able to feed effectively and gaining weight-Usual discharge weight is 1800 gram
• Encourage rooming in before discharge to build up mother confidence on care of baby at home.
• Counsel on feeding technique.
• Counsel on how to get assistance and arrange follow up care.
29
Issues in Feeding More than One Baby
• Mothers can make enough milk for 2 babies, even 3. - Volume of breastmilk produced by a mother depends on demand.
• Key factors :
Time ,support and encouragement from health care
providers and family
31
How To Encourage Mother To Breastfeed More Than One Baby
Encourage mother to :•Get help with caring for other children/ household duties•Breastfeed lying down to conserve energy•Eat a varied diet and take care of herself•Try to spend time alone with each of the babies so that she can get to know them individually.
32
Breastfeeding Twins• Nursing 1 twin in the cradle
hold, using the free hand to comfort the twin not nursing
• If 1 baby is a good feeder and 1 baby less active, make sure to alternate breasts so that milk production remains high in both breasts.
.
34
Twins Grow Well on
Breastmilk
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Session 10: Infants With Special Needs Ministry of Health Malaysia 35
Breastfeeding a Baby and Older Child(Tandem Nursing)
When a new baby arrives • No need to stop breastfeeding an older
baby • Mother will produce enough milk for
both if she cared for herself• Abrupt cessation of breastfeeding should
be avoided to prevent older child from risk of malnutrition
37
4. Prevention and Management of Common Clinical Concerns
39
Practises to avoid newborn’s problem :
Early skin to skin contactEarly and frequent BFRooming in Breast expressionCup feedingAvoid water supplements
Neonatal Hypoglycemia
• Babies at risk of hypoglycemia– premature, SGA, LGA, infant of diabetic mothers and
sepsis• Babies fed on breastmilk may be better able to
maintain their blood glucose levels than babies artificially fed on formulas.
• Term, healthy babies do not develop hypoglycemia simply through under-feeding.
• If a healthy full term baby develops signs of hypoglycemia, the baby should be investigated for any underlying problem eg IEM, sepsis.
40
Breastfeeding Jaundice
• Result from inadequate breast milk volume or insufficient milk intake– Lead to dehydration, low caloric intake
• May occur in 1st week of life in breastfed infants• May be reduced by:
– Encouraging early feeds– Increasing frequency of feeds– Avoiding use of water to replace breastmilk
42
Breastmilk Jaundice• Occurs in 1% to 2% of breastfed babies.• Causes prolonged indirect jaundice.• Can persist until 12 weeks• Etiology:
– Increased concentrations of nonesterified free fatty acids
(NEFA) that inhibit hepatic glucuronyl transferase. – Increased enterohepatic circulation of bilirubin due to
(1) increased content of beta glucuronidase activity in breast milk and, therefore, the intestines of the breastfed neonate
(2) delayed establishment of enteric flora in breastfed infants
44
Prevention of Severe Jaundice
• Early initiation of breastfeeding- Colostrum helps infants to pass meconium,
removes excess bilirubin from the body• Encourage demand feeding - 8 – 12 feeds a day• Effective suckling
– ensure effective milk transfer
• No supplementary fluid
• Cup feeding with EBM if baby refuse to suck
45
Treatment of Severe Jaundice
• Phototherapy.
• Very frequent breastfeeding to avoid dehydration.
• Give expressed milk if the baby is sleepy.
• Water or glucose water supplements do not help as they reduce the intake of breastmilk and do little to reduce the jaundice.
46
Dehydration• Healthy exclusively breastfed infants do not
require additional fluids to prevent dehydration.
• Babies with diarrhoea should be breastfed more frequently.
– Frequent breastfeeding provides fluid, nutrients, and protective factors.
– Growth factors in breastmilk aid in the re-growth of the damaged intestine.
47
Babies who have Breathing Difficulties
• Should be fed small amounts frequently as they tire easily.
• Breastfeeding provides the infant with nutrients, immune bodies, calories, fluid and comforts the distressed baby and mother.
49
Babies with Cardiac Problems
• Babies may tire easily• Short frequent feeds are helpful.• Breastfeeding is less stressful and
less energy is used >> better weight gain
• Breastmilk provides protection from illness thus reducing hospitalization and helping growth and development.
50
Babies with Cleft Lip/Palate
• Babies with cleft lip only should be able to breastfeed - tissue of the breast can help the baby to create a seal more effectively
• Babies with cleft palate are less likely to breastfeed directly from their mother's breast.
• Cleft palate babies often have problem with sucking, and may choke or gag on food that gets into their nose.
52
Breastfeeding and Cleft Palate
• Cleft palate babies can be given EBM via special cleft palate bottle (Haberman feeder), spoon or cup.
53
Breastfeeding and Cleft Palate
• Encourage mom to put baby on breast for suckling and bonding
• Following surgery to repair the cleft, breastfeeding can resume as soon as the baby is alert.
54
Cleft Lip And Palate - How To Feed?• Hold baby so that his nose and throat are higher
than breast– prevent milk from leaking into the nasal cavity,
Breast tissue or the mother's finger can fill a cleft in the lip to help baby maintain suction.
55
Benefits of Breastmilk to Cleft Palate Babies
• Provides immunities against infection, especially ear infections
• Less irritating to mucous membranes of nose
and gastro-intestinal system than formula.
56
Benefits of Breastmilk to Cleft Palate Babies
• Encourages proper development of baby's mouth and face.
57
Babies with Down Syndrome/Other Neuro
• Hypotonia and poor sucking reflex
• Encourage early contact• Might need to wake baby• Stimulate during feed• Help mother to position
59
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Supporting the breast and baby’s chin to stabilize baby’s jaw and maintain good attachment
DANCER’S HAND HOLD FOR PRETERM/HYPOTONIA
Breast Feeding and Down Syndrome/Neuro Problems
• Feeding need longer time
• May need cup feeding
• Avoid teats
• Weight gain might be slow even with enough breast milk
61
Infants Requiring Surgery
• BF can usually commence as soon as baby is awake after surgery.
• BF soon after surgery helps with pain relief, comforts baby and provides fluid and energy.
• If baby is not able to take large amounts of breastmilk immediately, mother can express and let baby suck on ‘empty breast’ until baby is more stable.
62
Acceptable Medical Reasons For Use Of Breastmilk Substitute
Imp TO DISTINGUISH BETWEEN :
1.Babies who cannot be fed at breast but for whom breastmilk remains food of choice
2.Babies who should not receive breastmilk or any other milk
3.Babies for whom breastmilk is not available for whatever reason
64
1.Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period :
• Very low birth weight infants ( < 1500g )• Very preterm infants ( < 32 weeks gest age)
– These infants may be fed expressed milk by tube, cup or spoon.
• Newborn who are at risk of hypoglycaemia if the blood sugar fails to respond to optimal breastfeeding or breast-milk feeding.
65
2.Infants who should not receive breast milk or any other milk :
Baby with Inborn Error of Metabolism1. Galactosemia:
require special galactose-free formula
1. Maple syrup urine disease: require special formula free of leucine, isoleucine and valine
1. Phenylketonuria: –require special phenylalanine-free formula (some breastfeeding is possible, under careful monitoring).
66
3.Babies for whom breastmilk is not available for whatever reasonNeed replacement feeding
1.Mother away from baby
2 Severely ill
3.Medical condition eg HIV +•need to be seen and followed-up by trained health worker.• Need individualized feeding plans
67
SESSION 10 SUMMARY INFANTS WITH SPECIAL NEEDS
• BF is imp for infants who are preterm, LBW ,Ill or have special needs.
• It protects,provides food , and aids in growth and development.
• Breastfeeding more than one baby / Clefts/ Heart/Breathing difficulties/ Down syndrome
• Prevention and management of common clinical concerns
• Does the baby need breast-milk substitutes? Infants with metabolic conditions /HIV mother
Limited period – preterm, LBW. ill etc68
SESSION 10 SUMMARYINFANTS WITH SPECIAL NEEDS
Approach to feeding will depend on baby’s condition.
1.Baby not able to take oral feeds. Encourage EBM and freeze it
2. Baby able to take oral feeds but is not able to suckle at breast. Give EBM by tube and by cup if baby is able.
3.Baby able to suckle but not for full feeds. Let baby suckle whenever baby is willing. Frequent short feeds .Give EBM by cup or tube in addition
4.Baby can suckle well. Encourage frequent feeds
5.Baby is not able to receive breast milk.