Successfully Breastfeeding Babies Born Prematurely and/or Affected by Neonatal Abstinence Syndrome...

Successfully Breastfeeding Successfully Breastfeeding Babies Born Prematurely Babies Born Prematurely

and/or Affected by Neonatal and/or Affected by Neonatal Abstinence Syndrome (NAS)Abstinence Syndrome (NAS)

Ruth Munday, BSN, RN-BC, IBCLC, RLCRuth Munday, BSN, RN-BC, IBCLC, RLC

Lactation ConsultantLactation Consultant

Le Bonheur Children’s HospitalLe Bonheur Children’s Hospital

General Breastfeeding General Breastfeeding OverviewOverview

Have basic knowledge of Have basic knowledge of breastfeeding to be able to better breastfeeding to be able to better support the special needs of the support the special needs of the Premature/Neonatal Abstinence Premature/Neonatal Abstinence Syndrome InfantSyndrome Infant

AAP AAP RecommendationsRecommendations

Human milk is uniquely superior for infant feeding and is species specific; all substitute feeding options differ markedly from it.

Human milk is the preferred feeding for all infants, with rare exceptions.

Breastfeed as soon as possible after birth, usually within the first hour. If mother and baby are separated mother should begin pumping within six hours after delivery.

AAP Recommendations AAP Recommendations (cont.)(cont.) Newborns should be nursed whenever they

show signs of hunger and have 8-12 breastfeedings a day. Teach mom to wake a sleepy baby to prevent hypoglycemia, jaundice, etc.

No supplements, artificial nipples, and pacifiers unless medically indicated.

Begin daily Vit D drops (400IU) at hospital discharge for exclusively breastfed infants

Babies ideally should be exclusively breastfed for six months, then add complementary foods such as iron rich cereal, meats, fruits and vegetables.

Continue for 12 months, thereafter as long as mom/baby mutually desires

AAP Contraindications to AAP Contraindications to BreastfeedingBreastfeeding Infant with galactosemiaInfant with galactosemia

Mother has active herpes lesions on breastMother has active herpes lesions on breast

Mother has Mother has untreated activeuntreated active TB TB

Mother is + fpr human T-cell lymphotrophic virus type Mother is + fpr human T-cell lymphotrophic virus type I or II or untreated brucellosis,I or II or untreated brucellosis,

In the US, infant of mother who is + HIVIn the US, infant of mother who is + HIV

Although most prescribed and over-the- counter Although most prescribed and over-the- counter medications are safe, there are a few medications that medications are safe, there are a few medications that make it necessary to interrupt breastfeeding make it necessary to interrupt breastfeeding temporarily. These include:temporarily. These include:

– Radioactive isotopesRadioactive isotopes

– Anti-metabolitesAnti-metabolites

– Chemotherapy agentsChemotherapy agents

– Small number of other medicationsSmall number of other medications

Caution in CMV + mothers of premature infants esp Caution in CMV + mothers of premature infants esp <1500 grams<1500 grams

*Note: maternal substance abuse is not a categorical contraindication to breastfeeding-adequately nourished narcotic dependent mothers can be encouraged to breastfeed if they are enrolled in a supervised methadone maintenance program and have negative screening for HIV and illicit drugs

Medication Medication ConsiderationsConsiderations

Risk vs Benefit for mother/babyRisk vs Benefit for mother/baby Effects of Drug on milk supplyEffects of Drug on milk supply Amount of drug excreted in the milkAmount of drug excreted in the milk Extent of oral absorption/effect on Extent of oral absorption/effect on

infantinfant Age/weight of infantAge/weight of infant In utero exposure vs a new drugIn utero exposure vs a new drug

Medication ResourcesMedication Resources

Thomas Hale Infant Risk CenterThomas Hale Infant Risk Center

806-352-2519806-352-2519 Medications and Mother’s Milk-Medications and Mother’s Milk-

updated every 2 yearsupdated every 2 years LactMed http://toxnet.nlm.nih.govLactMed http://toxnet.nlm.nih.gov

Breastfeeding Benefits Breastfeeding Benefits for Babyfor Baby Protects against/ Protects against/

lessens the severity of lessens the severity of many illnesses such as:many illnesses such as:

1.1. Ear infectionsEar infections2.2. RSV, respiratory RSV, respiratory

infectionsinfections3.3. DiarrheaDiarrhea4.4. SepsisSepsis5.5. NECNEC

Higher IQHigher IQ Easy to digestEasy to digest Less likely to be Less likely to be

overweight or obeseoverweight or obese Lower incidence of Lower incidence of

heart disease as adultsheart disease as adults

Breastfeeding Benefits Breastfeeding Benefits for Momfor Mom

•Promotes skin to skin bonding with baby•Decrease risk of PP depression•Uterus returns to normal size quicker•Helps reduce blood loss•Lose weight faster•Lowers risk of female organ cancers and osteoporosis

What Dads can do to What Dads can do to help:help: Be a team player ! Be a team player !

– Change infant diapersChange infant diapers

– Bring infant to MomBring infant to Mom

– Help with positioning and latchHelp with positioning and latch

– Wash pump partsWash pump parts

– Calm infantCalm infant

– Rock and cuddle infantRock and cuddle infant

– Support mom’s decisionSupport mom’s decision

– Skin to skinSkin to skin

Skin to Skin for all Skin to Skin for all BabiesBabies Promotes bondingPromotes bonding Helps increase Helps increase

mom’s milk supplymom’s milk supply Calming for the Calming for the

baby (recognizes baby (recognizes mom’s heartbeat)mom’s heartbeat)

Regulates baby’s Regulates baby’s temperature and temperature and stabilizes vital stabilizes vital signssigns

Promotes healthy Promotes healthy brain developmentbrain development

Hunger/Feeding CuesHunger/Feeding Cues

RootingRooting Mouth openingMouth opening Lip lickingLip licking Hands in mouthHands in mouth Sucking on fingersSucking on fingers Flexion of armsFlexion of arms Last sign – cryingLast sign – crying

Cradle PositionCradle Position

Have Mom sit up straight with good back support

Use pillows to raise the baby to breast level

Place the baby on his side facing chest

Place his head on Mom’s forearm, near her elbow

Your arm and hand support the baby’s back, keeping him hugged in close

Use free hand to support the breast

Football PositionFootball Position


Use pillows at her side to raise baby to breast level

Turn baby slightly in toward Mom

Support the base of the baby’s neck and shoulders in Mom’s hand

Hug baby’s body close Use free hand to support

the breast

Cross Cradle PositionCross Cradle Position


Use pillows to raise baby to breast level

Hold the base of baby’s neck and shoulders in hand, opposite the breast from which he is feeding

Have Mom hold baby’s body in forearm, with his bottom hugged in near the crook of arm

Use free hand to support the breast

Side-Lying PositionSide-Lying Position

Mom and baby lie on sides, facing each other

Place baby’s head on Mom’s forearm near elbow or on the mattress

Put pillows under Mom’s head to help her see baby

Pull baby’s knees and bottom in close to Mom

If needed, roll a blanket or other support behind his back

Use free hand to support breast

Breast Support: C HoldBreast Support: C Hold

Fingers underneath, thumb on top

Index finger and thumb well away from areola

May need to continue breast support during feeding in early weeks

Proper Latching Proper Latching TechniqueTechnique

Aim nipple Aim nipple toward nose & toward nose & upper lipupper lip

Brush upper lip Brush upper lip with nipple to with nipple to encourage baby encourage baby to open WIDEto open WIDE

Proper Latching Proper Latching Technique (cont.)Technique (cont.)

WAIT for baby to WAIT for baby to open mouth wide , open mouth wide , with tongue downwith tongue down

Press on baby’s back Press on baby’s back between shoulder between shoulder blades and blades and quicklyquickly bring baby to brebring baby to breastast

Proper Latching Proper Latching Technique (cont.)Technique (cont.) Baby’s chin and lower Baby’s chin and lower

lip touch breast lip touch breast FIRSTFIRST More of lower lip More of lower lip

covers areola than covers areola than upper lipupper lip

Chin buried in breastChin buried in breast Lips curled outwardLips curled outward Nose Nose usually usually will not will not

touch the breast touch the breast

Signs of Milk TransferSigns of Milk Transfer

Sucks with pauses to Sucks with pauses to swallowswallow

Watch the chin move up Watch the chin move up and downand down

Listen for swallowing Listen for swallowing when baby pauses (use when baby pauses (use breast compression)breast compression)

Longer pauses mean Longer pauses mean swallowing more milkswallowing more milk

Let baby nurse on first Let baby nurse on first breast until he stops breast until he stops sucking and swallowing, sucking and swallowing, then offer 2then offer 2ndnd breast if breast if he is still hungryhe is still hungry

Cues that the Baby Cues that the Baby Has Finished FeedingHas Finished Feeding

When he looks content, When he looks content, he is usually finished he is usually finished

Some babies may let go Some babies may let go of the breast on their of the breast on their own own

Use breast compression Use breast compression to see if the baby is to see if the baby is finished or just taking a finished or just taking a break.break.

Sometimes it is Sometimes it is necessary to break the necessary to break the suction to take baby off suction to take baby off the breast when he is the breast when he is finished finished

Always evaluate for Always evaluate for adequate milk transferadequate milk transfer

Breastfeeding Should Breastfeeding Should Not Hurt!Not Hurt! Proper position, latch-Proper position, latch-

on, head support and on, head support and removal from the breast removal from the breast prevents soreness and prevents soreness and is the key to is the key to breastfeeding successbreastfeeding success

Blisters, cracks, scabs, Blisters, cracks, scabs, bleeding nipples are bleeding nipples are NEVER normal and are a NEVER normal and are a sign something is not sign something is not right and mom needs right and mom needs help ASAP!help ASAP!

Is the baby getting Is the baby getting enough milk?enough milk?

Can see and hear baby swallowing

8-12 feedings in 24 hours

The baby meets the number of feedings, wet and dirty diapers each 24 hours

Have mother keep a log sheet

By day 4 or 5 baby’s stools will change color from dark tarry to seedy yellow

Baby should regain birth weight by 2 weeks

Then baby should gain 4-7 ounces a week or 1-2 pounds a month until 4 months of age

B r e a s t fe e d in g L o g C i rc le e v e ry h o u r w h en y o u r b a b y s ta r ts a fee d in g . (E a c h 2 4 h o u rs b e g in s w ith yo u r b a b y ’s t im e o f b ir th . M a rk th e h o u r yo u r b a b y w a s b o rn to s ta r t th e c o u n t.) C i rc le W w h en y o u r b a b y h a s a w e t d ia p e r. C i rc le D w h en y o u r b ab y h a s a d i r ty d ia p e r . B ir th D a te : T im e : A M o r P M

2 4 -h o u r p er io d

T im e lin e G o a ls

M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1

W e t d ia p er W 1 s t

B ro w n , ta rr y s to o l D

8 -1 2 fee d in g s 1 o r m o re w e t

1 o r m o re d i rty

M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1

W e t d ia p ers W 2 n d

B ro w n , ta rr y s to o l D



M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1

W e t d ia p ers W W W 3 rd

G re e n s to o l D D D



M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1

W e t d ia p ers W W W W 4 th

Y e llo w s to o l D D D



M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1

W e t d ia p ers W W W W W 5 th




M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1





M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1





I t is o k a y fo r y o u r b a b y to fe e d m o r e th a n 1 2 t im e s e a ch d a y a n d to h a v e m o r e w et a n d d ir ty d ia p e r s . Y o u ca n n o t fe e d h im to o o f te n . Y o u c a n fe e d h im to o lit tl e . L e t y o u r b a b y f in is h th e f ir s t b r e a s t b e fo r e o f fe r in g h im th e se c o n d b r ea s t. Y o u r b a b y m a y n o t a lw a y s ta k e b o th b r ea s ts a t ea ch fe e d in g . R e m e m b e r to w a tc h y o u r b a b y a n d n o t th e c lo c k . I f y o u r b a b y is n o t m ee t in g th e g o a ls , p le a se c a ll a b r ea s tfe e d in g sp ec ia li s t o r y o u r b a b y ’s d o c to r .

When Mom should call for help:When Mom should call for help:

baby is not meeting baby is not meeting the feeding and the feeding and wet/dirty diaper goals wet/dirty diaper goals

baby is not latching baby is not latching on wellon well

baby looks jaundicedbaby looks jaundiced Mom has sore or Mom has sore or

damaged nipplesdamaged nipples Mom has painful Mom has painful

breast engorgementbreast engorgement

Mom has engorgement and develops a high fever

baby is below birth weight at two weeks of age

after two weeks, baby gains less than 4 ounces per week

Mom has any questions or concerns

Nutrition TipsNutrition Tips

Well balanced Well balanced No dietary No dietary

restrictionsrestrictions Drink until thirst is Drink until thirst is

satisfiedsatisfied Limit caffeine to 2 or Limit caffeine to 2 or

less servings per dayless servings per day Continue taking Continue taking

prenatal vitaminsprenatal vitamins

Helpful foods:OatmealAlmondsProtein3 meals, 2 snacks

Latching DifficultiesLatching Difficulties

Can happen in full term healthy infant, Can happen in full term healthy infant, Premature and the NAS InfantPremature and the NAS Infant

Possible Causes:Possible Causes:Maternal nipple shapeMaternal nipple shape

Low Milk SupplyLow Milk Supply

Bottle Nipple and Flow preferenceBottle Nipple and Flow preference

Tongue Tie or short upper frenulumTongue Tie or short upper frenulum

Cleft Lip/PalateCleft Lip/Palate

Receseed Chin (Pierre Robin)Receseed Chin (Pierre Robin)

Low Tone /difficulty maintaining latchLow Tone /difficulty maintaining latch

Types of NipplesTypes of Nipples

Compress nipple where baby will latch on to breast

Lactation Aid – Nipple Lactation Aid – Nipple ShieldsShields UsesUses

– Flat or inverted nipplesFlat or inverted nipples– Latch-on difficultiesLatch-on difficulties– Overactive let-downOveractive let-down

Helpful to transition baby Helpful to transition baby from bottle to breastfrom bottle to breast

16mm, 20mm or 24 mm16mm, 20mm or 24 mm Washable and reusableWashable and reusable

Lactation Aid - SNSLactation Aid - SNS

SupplementationSupplementation Help infant’s with Help infant’s with

poor suck-swallow poor suck-swallow coordinationcoordination

Can be used:Can be used:– At breastAt breast– FingerfeedFingerfeed

Starter SNS is only Starter SNS is only for 24 hour use per for 24 hour use per manufactures manufactures guidelinesguidelines

Wash between uses.Wash between uses.

Test Weights

Weighing a baby before and after breastfeeding to determine intake.

Weigh baby in exact same manner before and after nursing.

Subtract the first (before) weight from the second (after) weight. The difference in grams is the “intake” in milliliters. (1gram=1ml)

Riordan, page 304

Separation from Infant at Separation from Infant at BirthBirth Establishment of lactation Establishment of lactation

even more importanteven more important Possible with hospital grade Possible with hospital grade

breast pumpbreast pump Mother should begin milk Mother should begin milk

expression w/in 6 hours of expression w/in 6 hours of delivery to maximize delivery to maximize chances for successchances for success

Skin-to-skin contact w/ baby Skin-to-skin contact w/ baby assists in milk productionassists in milk production

Family & hospital staff need Family & hospital staff need to be supportiveto be supportive

Breast PumpsBreast Pumps

Provide each mom with a sterile Provide each mom with a sterile breast pump kit breast pump kit

Instruct on assembling kit per Instruct on assembling kit per manufacturing guidelines manufacturing guidelines

Provide mom with breastmilk Provide mom with breastmilk collection and storage guidelines collection and storage guidelines and supplies and supplies

Pumping GuidelinesPumping Guidelines

Begin pumping if:Begin pumping if:– successful latch has not occurred successful latch has not occurred

within within 1212 hourshours– effective breastfeeding as indicated effective breastfeeding as indicated

by signs of effective milk transfer by signs of effective milk transfer has not occurred within has not occurred within 1212 hourshours

– within within 66 hours if mom and baby are hours if mom and baby are separated separated

Pumping InstructionsPumping Instructions– Mother should wash hands before expression Mother should wash hands before expression

of breast milkof breast milk– Instruct to pump at least 8 times a day:Instruct to pump at least 8 times a day:

pump every 2-3 hours during the day and at least pump every 2-3 hours during the day and at least once over night with only one 4-5 hour break from once over night with only one 4-5 hour break from pumpingpumping

double-pumping for 10-15 minutes is preferred to double-pumping for 10-15 minutes is preferred to increase milk supply increase milk supply

– Inform Mom that it is Inform Mom that it is normalnormal only to see a few only to see a few drops, or a small amount of milk in the first drops, or a small amount of milk in the first few days while the milk supply is increasing. few days while the milk supply is increasing.

Pumping Instructions Pumping Instructions (cont.)(cont.) While expressing only small amounts of While expressing only small amounts of

milk, store milk in syringes or colostrum milk, store milk in syringes or colostrum collection containers that are provided, collection containers that are provided, label and place in “ziplock” bag. Once label and place in “ziplock” bag. Once milk increases use sterile plastic bottles milk increases use sterile plastic bottles with caps that are provided.with caps that are provided.

Label should include patients name, Label should include patients name, room number, date and time expressed. room number, date and time expressed.

Cleaning Pump PartsCleaning Pump Parts

Instruct mom on cleaning pump parts Instruct mom on cleaning pump parts per manufacturing guidelines:per manufacturing guidelines:– Clean after each use with hot soapy Clean after each use with hot soapy

water and thoroughly rinse.water and thoroughly rinse.– Parts should be disinfected at least once Parts should be disinfected at least once

daily, especially for critically ill infants.daily, especially for critically ill infants.– Microwave steam bags could be Microwave steam bags could be

provided for disinfecting using the provided for disinfecting using the microwavemicrowave

Tips for when your Tips for when your patient is receiving patient is receiving

breastmilk:breastmilk:

Breastmilk is classified as a clear liquid.Breastmilk is classified as a clear liquid.

Mother should pump at least 8 times in a 24 Mother should pump at least 8 times in a 24 period-pump every 2-3 hours during the day and period-pump every 2-3 hours during the day and at least once over night.at least once over night.

Double pumping for 10-15 minutes at each pump Double pumping for 10-15 minutes at each pump session is preferred to increase milk supply.session is preferred to increase milk supply.

Two licensed personnel should verify that the Two licensed personnel should verify that the label on the bottle of expressed breastmilk is label on the bottle of expressed breastmilk is correct using 2 patient identifierscorrect using 2 patient identifiers


breastmilk:breastmilk:Expressed breastmilk storage guidelinesExpressed breastmilk storage guidelinesLabels: Label per hospital policy with patient sticker, date and Labels: Label per hospital policy with patient sticker, date and time milk was expressedtime milk was expressedPlace milk bottles in individual bins or a single zip-lock bag for Place milk bottles in individual bins or a single zip-lock bag for storage. Patient’s name/label must be clearly labeled on bin or storage. Patient’s name/label must be clearly labeled on bin or bag.bag.Refrigerate or freeze milk if it will not be used within 4 hours Refrigerate or freeze milk if it will not be used within 4 hours of expression.of expression.Refrigerated milk that will not be used by 48 hours after Refrigerated milk that will not be used by 48 hours after expression should be frozen.expression should be frozen.Warming breastmilk for feedingsWarming breastmilk for feedingsWaterless Warmer is preferred. If not available, place Waterless Warmer is preferred. If not available, place container of milk in bowl of warm water or under warm running container of milk in bowl of warm water or under warm running water. Only the amount of milk needed for a feeding should be water. Only the amount of milk needed for a feeding should be warmed. Milk that has been warmed, but not used, should be warmed. Milk that has been warmed, but not used, should be discarded. discarded. Do not place in hot or boiling water or microwave breastmilk.Do not place in hot or boiling water or microwave breastmilk.


breastmilk:breastmilk:Frozen BreastmilkFrozen BreastmilkWhen breastmilk is moved from freezer to refrigerator, When breastmilk is moved from freezer to refrigerator, the time it was taken out of the freezer should be written the time it was taken out of the freezer should be written on the bottle’s label.on the bottle’s label.Unwarmed, thawed milk should be stored in the Unwarmed, thawed milk should be stored in the refrigerator and used within 24 hours.refrigerator and used within 24 hours.Tube FeedingsTube FeedingsChange syringe and tubing at least every 4 hours for Change syringe and tubing at least every 4 hours for continuous feedings . If bolus feeding is given, the continuous feedings . If bolus feeding is given, the syringe should be changed with each feeding.syringe should be changed with each feeding.Orient syringe tip to vertical position for continuous Orient syringe tip to vertical position for continuous tube feedings to enhance fat delivery.tube feedings to enhance fat delivery.

Why breastmilk Why breastmilk for the premature for the premature

infant ?infant ? Preemies don’t need breastmilk any less than Preemies don’t need breastmilk any less than

full-term infants, they need it full-term infants, they need it more more !! Breastmilk provides:Breastmilk provides:

– Protection against infectionProtection against infection– Protection against NECProtection against NEC– Appropriate lipid profile (PUFA’s)Appropriate lipid profile (PUFA’s)– Better cognitive developmentBetter cognitive development– Better visual developmentBetter visual development– A role for the mother in the care of her baby A role for the mother in the care of her baby

which is which is veryvery important important

Breastmilk SpecificityBreastmilk Specificity

Enteromammary CirculationEnteromammary CirculationIgA, Immunoglobulin AIgA, Immunoglobulin A

Maternal mucosal surfaces encounter Maternal mucosal surfaces encounter microbes in her own and baby’s environment microbes in her own and baby’s environment

Maternal lymphocytes at mucosal surfaces Maternal lymphocytes at mucosal surfaces stimulated by microbes to produce specific stimulated by microbes to produce specific IgAIgA

Maternal lymphocytes migrate to breastMaternal lymphocytes migrate to breast

Maternal lymphocytes produce specific IgA Maternal lymphocytes produce specific IgA against microbes encountered which is then against microbes encountered which is then secreted into breastmilk !secreted into breastmilk !

Feeding and Nutrition in the Preterm Infant, page 6.Feeding and Nutrition in the Preterm Infant, page 6.

Providing Breastmilk to the Providing Breastmilk to the Premature BabyPremature Baby

All “premature” infants are not alike !All “premature” infants are not alike !

Nutrition issues facing the 26 week gestation Nutrition issues facing the 26 week gestation baby, weighing 600 grams who is being baby, weighing 600 grams who is being ventilated for weeks, are much different from ventilated for weeks, are much different from the 33 week gestation baby, weighing 1600 the 33 week gestation baby, weighing 1600 grams, who is otherwise well.grams, who is otherwise well.

– The latter has more in common with a full The latter has more in common with a full term baby than he does with that 26 week term baby than he does with that 26 week gestation premature baby.gestation premature baby.

They both need breastmilk !They both need breastmilk !

However, the methods of feeding the early vs. However, the methods of feeding the early vs. older preterm infant, the need for fortification, older preterm infant, the need for fortification,

and the approaches are very different.and the approaches are very different.

AAP Recommendations for AAP Recommendations for breastfeeding management for the breastfeeding management for the Premature infantPremature infant

All preterm infants should receive human milkAll preterm infants should receive human milk Human milk should be fortified with protein, minerals, Human milk should be fortified with protein, minerals,

and vitamins to ensure optimal nutrient intake for and vitamins to ensure optimal nutrient intake for infants weighing <1500 grams at birthinfants weighing <1500 grams at birth

Pasteurized donor human milk, appropriately fortified Pasteurized donor human milk, appropriately fortified should be used if mother’s own milk is unavailable or should be used if mother’s own milk is unavailable or contraindicated.contraindicated.

Evidence based protocols for collection, storage, and Evidence based protocols for collection, storage, and labeling of human milk labeling of human milk

Prevent the misadministration of human milkPrevent the misadministration of human milk No data to support routinely culturing human milk for No data to support routinely culturing human milk for

bacterial or other organismsbacterial or other organisms

Breast Milk Fortifiers for Breast Milk Fortifiers for Premature InfantsPremature Infants

Used to increase protein, calcium, & Used to increase protein, calcium, & phosphorusphosphorus

May decrease immune factorsMay decrease immune factors

Liquid fortifiers dilute breastmilkLiquid fortifiers dilute breastmilk Powder fortifiers increase osmolality Powder fortifiers increase osmolality

Always Always necessary ? No!necessary ? No!

Hind Milk Collection

Have containers ready, labeled “foremilk” and “hindmilk”

Pump for 2-3 minutes after the milk begins to flow into the “foremilk” bottles.

Stop pumping and save foremilk for later use.

Switch to “hindmilk” labeled bottles and continue pumping as usual.

Use only hindmilk for feedings until further notice.

Riordan, page 305

ColostrumColostrum Colostrum should be provided as soon as Colostrum should be provided as soon as

possible. possible. – Even drops may be beneficial, by “priming” Even drops may be beneficial, by “priming”

the baby’s gut and giving protective SIgA. the baby’s gut and giving protective SIgA. Drops can be tolerated even by the tiniest Drops can be tolerated even by the tiniest baby and even drops protect.baby and even drops protect.

Many premature babies receive IV fluids, so Many premature babies receive IV fluids, so quantity of colostrum is not an issue quantity of colostrum is not an issue

– Small amounts of colostrum are perfectly Small amounts of colostrum are perfectly acceptable, and safer than early introduction acceptable, and safer than early introduction of foreign proteinsof foreign proteins

– Giving the few drops to the baby sends a very Giving the few drops to the baby sends a very strong message even a few drops of strong message even a few drops of breastmilk are important and goodbreastmilk are important and good

Even a drop or two of colostrum can be used for Even a drop or two of colostrum can be used for mouth care of the ventilated babymouth care of the ventilated baby

Talk Points for families to Talk Points for families to promote use of human milk in promote use of human milk in

the NICUthe NICU Breastmilk is the best milk for your sick or Breastmilk is the best milk for your sick or

premature infant. Would you be willing to premature infant. Would you be willing to provide breastmilk for your baby, at least during provide breastmilk for your baby, at least during this hospitalization ?this hospitalization ?

As a mother, you are the only one who can As a mother, you are the only one who can provide your baby with your special first milk provide your baby with your special first milk called Colostrum.called Colostrum.

Colostrum contains special factors that may help Colostrum contains special factors that may help protect your baby from infection and your protect your baby from infection and your breastmilk is like medicine to help your baby breastmilk is like medicine to help your baby while in the hospital.while in the hospital.

Breastmilk is usually easy to digest and gentle on Breastmilk is usually easy to digest and gentle on your baby’s tummy.your baby’s tummy.

Talk Points for families to promote use of human milk in the NICU

continued…

Breastmilk may help prevent infections.Breastmilk may help prevent infections.

Breastmilk helps develop your baby’s eyes and Breastmilk helps develop your baby’s eyes and brain.brain.

It is important to begin pumping and collecting your It is important to begin pumping and collecting your milk right away.milk right away.

You need to pump every 2-3 hours, even if you only You need to pump every 2-3 hours, even if you only are getting a small amount of milk. Every drop is are getting a small amount of milk. Every drop is important and will be used.important and will be used.

If you have not planned on providing milk for your If you have not planned on providing milk for your baby, it is not too late !baby, it is not too late !

Characteristics of a Breastfeeding Friendly Hospital

Unit Written breastfeeding polices in place

Employs or trains staff capable of skilled breastfeeding assessment and breastfeeding interventions when needed

What are some benefits you can think of to discuss with parents?

Facilitates milk expression by mothers who wish to provide milk for infants who are unable to breastfeed

Provides parents with written and verbal benefits of breastfeeding and breastmilk

Ways to Support theWays to Support the

Lactating Mother Lactating Mother Encourage rest and good nutritionEncourage rest and good nutrition Support kangaroo care as a way for mother to Support kangaroo care as a way for mother to

restrest Do not necessarily discourage visitationDo not necessarily discourage visitation Allow & encourage holding/touching babyAllow & encourage holding/touching baby Recognize her efforts to provide milkRecognize her efforts to provide milk Praise any milk brought in for the babyPraise any milk brought in for the baby Always ask if she has needs/problems with milk Always ask if she has needs/problems with milk

supply or with her breasts supply or with her breasts

refer to Lactation Consultantrefer to Lactation Consultant

Lactation Support in the Lactation Support in the HospitalHospital

Reassurance is needed that breastfeeding or Reassurance is needed that breastfeeding or breastmilk feeding will be possible breastmilk feeding will be possible

Review benefits of providing milkReview benefits of providing milk Any breastmilk is good and will be usedAny breastmilk is good and will be used Assistance with securing pump & supplies (both Assistance with securing pump & supplies (both

physical & financial)physical & financial) Milk expression becomes more difficult the longer Milk expression becomes more difficult the longer

a baby is in the hospitala baby is in the hospital

Maternal Maternal Conditions and Low Conditions and Low

Milk SupplyMilk Supply PregnancyPregnancy Primary mammary glandular insufficiencyPrimary mammary glandular insufficiency Breast Surgery (Reduction or Augmentation)Breast Surgery (Reduction or Augmentation) High Blood PressureHigh Blood Pressure Retained placenta and/or Post Partum HemorrhageRetained placenta and/or Post Partum Hemorrhage StressStress Autoimmune DiseaseAutoimmune Disease Thyroid diseaseThyroid disease Poly Cystic Ovary Syndrome/ Infertility IssuesPoly Cystic Ovary Syndrome/ Infertility Issues

*Also smoking is a risk factor for low milk supply and poor weight gain in infant.*Also smoking is a risk factor for low milk supply and poor weight gain in infant.

Infant causes of low Infant causes of low milk supplymilk supply

– Causes:Causes:

– Infrequent feedingInfrequent feeding– Ineffective suck and/ or latchIneffective suck and/ or latch– PrematurityPrematurity– Neuromotor problems (Down’s Neuromotor problems (Down’s

Syndrome)Syndrome)– Oral anatomic problems (cleft, etc.)Oral anatomic problems (cleft, etc.)

Early Skin to Skin CareEarly Skin to Skin Care

Has been shown to be an important Has been shown to be an important and valuable option for caring for and valuable option for caring for hospitalized infantshospitalized infants

Underdeveloped countries have used Underdeveloped countries have used this process as a way to keep infants this process as a way to keep infants warm w/o availability of incubators and warm w/o availability of incubators and to stabilize infant’s breathing patterns to stabilize infant’s breathing patterns w/o availability of respirators w/o availability of respirators

Kangaroo Mother CareKangaroo Mother Care

If medical condition If medical condition stabilized, infant is stabilized, infant is placed naked between placed naked between mother’s breasts for mother’s breasts for extended periods extended periods throughout the daythroughout the day– Facilitates Facilitates

breastfeedingbreastfeeding– Maintains baby’s Maintains baby’s

physiological physiological functions at least as functions at least as well as incubator well as incubator carecare

Kangaroo Mother CareKangaroo Mother Care

Fewer apneas and Fewer apneas and bradycardiasbradycardias

Less frequent and less Less frequent and less severe desaturationsevere desaturation

Oxygenation improvedOxygenation improved Body temperature Body temperature

maintainedmaintained Earlier discharge from Earlier discharge from

hospitalhospital Improved arousal Improved arousal

regulation and stress regulation and stress reactivityreactivity

Infants cry less and cry is Infants cry less and cry is not of distress typenot of distress type

Provides analgesic effects Provides analgesic effects during painful proceduresduring painful procedures

Less stress in baby (shown Less stress in baby (shown by decreased ß endorphin by decreased ß endorphin release, cortisol)release, cortisol)

Positive effects seem to be Positive effects seem to be maintained after contact maintained after contact endedended

Better parent-child Better parent-child relationshiprelationship

Greater likelihood of full Greater likelihood of full breastfeeding in hospital breastfeeding in hospital and at dischargeand at discharge

Starting at the BreastStarting at the Breast As soon as the baby is stableAs soon as the baby is stable

– babies can start nuzzling the breast very babies can start nuzzling the breast very early (kangaroo care allows for this)early (kangaroo care allows for this)

– let them let them learnlearn to take the breast to take the breast

– waiting for coordinated suck and swallow waiting for coordinated suck and swallow wastes valuable time; needed for bottle wastes valuable time; needed for bottle feeding--not breastfeedingfeeding--not breastfeeding

– ““empty breast” feeding allows practice empty breast” feeding allows practice even before infant is ready to take oral even before infant is ready to take oral feeds feeds

Kangaroo care (mother & baby or father & Kangaroo care (mother & baby or father & baby) will prepare infant for breastfeedingbaby) will prepare infant for breastfeeding

Pholosong Hospital - South AfricaPholosong Hospital - South Africa

Breastfeeding is physiologicBreastfeeding is physiologic

Many premature infants Many premature infants respond by rooting and respond by rooting and sucking on the first sucking on the first contact with the breastcontact with the breast

Efficient rooting, areolar Efficient rooting, areolar grasp, & latching can be grasp, & latching can be observed at 28 weeks observed at 28 weeks

Nutritive sucking Nutritive sucking appears from 30 weeksappears from 30 weeks

Full breastfeeding is Full breastfeeding is possible as early as possible as early as 33 weeks 33 weeks

28 weeks and 28 weeks and breastfeedingbreastfeeding

31 wk GA - 3 days old 31 wk GA - 3 days old BreastBreastfeedingfeeding

Encouraging proper latch & Encouraging proper latch & adequate milk intakeadequate milk intake

Early kangaroo care (skin-to-skin)Early kangaroo care (skin-to-skin) Prevent slow milk flow to keep infant Prevent slow milk flow to keep infant

awake and actively transferring milkawake and actively transferring milk– best latch possiblebest latch possible– have mother use compression when have mother use compression when

baby doesn’t actually drinkbaby doesn’t actually drink– switch sides as flow slowsswitch sides as flow slows– can use lactation aid to supplementcan use lactation aid to supplement

Observe the baby at the breast!Observe the baby at the breast!

Lactation AidLactation Aid Is the best way to Is the best way to

supplement because supplement because babies learn to babies learn to breastfeed by breastfeed by breastfeeding.breastfeeding.

Baby continues to get Baby continues to get milk from breastmilk from breast

There is more to There is more to breastfeeding than breastfeeding than breastmilkbreastmilk

Finger FeedingFinger Feeding

Used essentially to Used essentially to help a reluctant help a reluctant baby to take the baby to take the breast.breast.

It calms him, gets It calms him, gets him suckling him suckling properly.properly.

After a few seconds After a few seconds to a minute or two to a minute or two of finger feeding, of finger feeding, baby should be put baby should be put to the breast.to the breast.

Position of tube forfinger feeding

The key for milk The key for milk transfer: transfer: positioningpositioning

& & latchlatch Important for the NAS/premature baby as Important for the NAS/premature baby as

much as in the full term healthy babymuch as in the full term healthy baby A good latch allows the baby to get milk A good latch allows the baby to get milk

better from the breastbetter from the breast– teaches the baby to suckle properlyteaches the baby to suckle properly– prevents nipple sorenessprevents nipple soreness

Babies learn to breastfeed by Babies learn to breastfeed by breastbreastfeedingfeeding

34 weeks, well latched 34 weeks, well latched onon

Breastfeeding Considerations for Specific

Conditions

Altered Neurological Function:1.Assess ability for safe and effective feedings (consider Speech consult as well as Lactation)2.When at the breast, observe for signs of weak suck, lack of effective tongue movement and poor lip seal.3.Positioning, head support, maternal breast support and easy milk flow may assist these children.4.Consider use of nipple shield for a firmer texture for latching and maintaining seal.5.Dancer hand position for latching.

When babies are not When babies are not breastfedbreastfed……

Higher incidence of infections Higher incidence of infections (NEC, RTIs, otitis media, UTIs, (NEC, RTIs, otitis media, UTIs, bacterial meningitis, bacteremia, bacterial meningitis, bacteremia, diarrhea, late onset sepsis in diarrhea, late onset sepsis in preterm infants)preterm infants)

21% higher rate of post-neonatal 21% higher rate of post-neonatal infant mortality rate in the U.S.infant mortality rate in the U.S.

When older, these children score When older, these children score lower on cognitive tests lower on cognitive tests

Increased risk of over-feeding & Increased risk of over-feeding & becoming obesebecoming obese

Greater chance of developing Type Greater chance of developing Type 1 & 2 Diabetes, lymphoma, 1 & 2 Diabetes, lymphoma, leukemia, Hodgkin dz, leukemia, Hodgkin dz, hypercholesterolemia, asthma.)hypercholesterolemia, asthma.)

Human Milk BankingHuman Milk Banking

Allows human milk for Allows human milk for infants in the very first infants in the very first days whose mothers do days whose mothers do not yet have enough not yet have enough milk available milk available

Early feeding is now felt Early feeding is now felt to be best for most to be best for most premature babiespremature babies

Donor human milk Donor human milk recommended as first recommended as first alternative to mother’s alternative to mother’s own milk before own milk before artificial feedingartificial feeding

Common Diagnosis for Use Common Diagnosis for Use of Human Donor Breastmilkof Human Donor Breastmilk

PrematurityPrematurity Mal-absorptionMal-absorption Feeding /formula intoleranceFeeding /formula intolerance Necrotizing enterocolitisNecrotizing enterocolitis Congenital anomaliesCongenital anomalies Post-op feedingsPost-op feedings Failure to thriveFailure to thrive Short gut syndromeShort gut syndrome

Current State of Milk Current State of Milk BankingBanking

Now about a dozen donor milk banks Now about a dozen donor milk banks operating in North America---all are operating in North America---all are regulated by the FDA and abide by the regulated by the FDA and abide by the HMBANA guidelines:HMBANA guidelines:

1. Donors screened & approved1. Donors screened & approved

2. Stored @ -20°C until selected for 2. Stored @ -20°C until selected for pasteurizationpasteurization

3. Pasteurization eliminates potentially 3. Pasteurization eliminates potentially harmful bacteria, viruses, & harmful bacteria, viruses, & pathogens pathogens

4. Major food components as well as 4. Major food components as well as most immunoglobulins are preservedmost immunoglobulins are preserved

5. Holder pasteurization is used in 5. Holder pasteurization is used in HMBANA milk banks: donor milk HMBANA milk banks: donor milk submerged & heated in shaking water submerged & heated in shaking water bath & held at 62.5°C for 30 minutesbath & held at 62.5°C for 30 minutes

How is Donor Milk How is Donor Milk Packaged ?Packaged ?

Usually in 3-4 oz. bottles Usually in 3-4 oz. bottles

Available in term or preterm; Available in term or preterm; 20, 22, & 24 kcals/oz; some 20, 22, & 24 kcals/oz; some banks have non-dairy or fat-banks have non-dairy or fat-free milk also availablefree milk also available

Each bottle/syringe labeled Each bottle/syringe labeled with kcals/oz, grams protein, with kcals/oz, grams protein, and expiration dateand expiration date

Good frozen for 1 yearGood frozen for 1 year

Important choice in Important choice in “Family-Centered “Family-Centered

Care”Care” **Many families have become Many families have become

aware of problems associated aware of problems associated

with artificial feeding products &with artificial feeding products &

request donor milk, esp. when ill or request donor milk, esp. when ill or

premature infant is involved orpremature infant is involved or

maternal milk insufficient or N/Amaternal milk insufficient or N/A

*With increasing emphasis on informed choice, family- *With increasing emphasis on informed choice, family-

centered care and best practice, health professionals also centered care and best practice, health professionals also

seeking information on establishing banksseeking information on establishing banks

How is donor milk ordered?How is donor milk ordered?

Milk can be ordered by Rx for a specific patient, or in Milk can be ordered by Rx for a specific patient, or in bulk as a standing supply in case it is needed bulk as a standing supply in case it is needed (allows (allows milk to be readily available)milk to be readily available)

Milk ordered by calling closest milk bankMilk ordered by calling closest milk bank Usually sent out weekly, so weekly usage Usually sent out weekly, so weekly usage

should be estimated before orderingshould be estimated before ordering Amounts may be adjusted as neededAmounts may be adjusted as needed Milk banks send invoice just as formula Milk banks send invoice just as formula

companies do & can be paid the same way companies do & can be paid the same way Current cost of donor milk $4.13 per ounceCurrent cost of donor milk $4.13 per ounce

(cost of processing only---HMBANA donors are NOT (cost of processing only---HMBANA donors are NOT paid)paid)

Donor Milk and NECDonor Milk and NEC

NEC is such a NEC is such a devastating disease devastating disease common among VLBW common among VLBW premature infants, premature infants, human milk may be human milk may be used to prevent it, used to prevent it, and may be the only and may be the only feeding tolerated for feeding tolerated for those infants who those infants who develop it.develop it.

Neonatal Abstinence Neonatal Abstinence Syndrome (NAS)Syndrome (NAS)

NAS mainly describes neonatal NAS mainly describes neonatal symptoms occurring after in-utero symptoms occurring after in-utero exposure to opioids. exposure to opioids.

Other substances may produce Other substances may produce neurobehavioral dysfunction in the neurobehavioral dysfunction in the neonatal period consistent with an neonatal period consistent with an abstinence syndrome.abstinence syndrome.

NAS OverviewNAS Overview

Since the 1980’s NAS has Since the 1980’s NAS has increased by 300%increased by 300%

Symptoms and length of Symptoms and length of withdrawal depends on:withdrawal depends on:--Type of drug usedType of drug used

-Frequency of drug use-Frequency of drug use

-Trimester of drug use-Trimester of drug use

-Timing of withdrawal-Timing of withdrawal

-Genetic susceptibility of the fetus/neonate-Genetic susceptibility of the fetus/neonate

NAS OverviewNAS Overview

Medical management aimed at Medical management aimed at treating symptoms of withdrawaltreating symptoms of withdrawal

Standardization of treatment is Standardization of treatment is difficult symptoms of withdrawal difficult symptoms of withdrawal vary with each infantvary with each infant

Pharmacological and Pharmacological and Nonpharmacological interventionsNonpharmacological interventions

Intrauterine Drug Intrauterine Drug ExposureExposure

May cause:May cause:

-Congenital anomalies and/or fetal -Congenital anomalies and/or fetal growth restrictiongrowth restriction

-Increased risk of preterm birth-Increased risk of preterm birth

-Signs of withdrawal or toxicity-Signs of withdrawal or toxicity

-Impair normal neurodevelopment-Impair normal neurodevelopment

Red Flags to consider Red Flags to consider Drug ScreenDrug Screen Absent, late, or inadequate PNCAbsent, late, or inadequate PNC Documented history of drug abuse or admitted drug useDocumented history of drug abuse or admitted drug use Previous, unexplained late fetal demisePrevious, unexplained late fetal demise Precipitous laborPrecipitous labor Abruptio placentaAbruptio placenta Myocardial infarctionMyocardial infarction Severe mood swingsSevere mood swings Repeated spontaneous abortionsRepeated spontaneous abortions Cerebrovascular accidentsCerebrovascular accidents

**Legal implications of testing vary among states. Each **Legal implications of testing vary among states. Each hospital should have a policy on maternal and new born hospital should have a policy on maternal and new born screening to avoid discriminatory practices and comply screening to avoid discriminatory practices and comply with local lawswith local laws

Drug Screen TestingDrug Screen Testing

Maternal and neonatal urine analysis:Maternal and neonatal urine analysis:-collect from infant asap after birth because drugs are -collect from infant asap after birth because drugs are

rapidly metabolized/eliminatedrapidly metabolized/eliminated

-positive urine screen may only reflect recent drug use-positive urine screen may only reflect recent drug use

Meconium analysis:Meconium analysis:-useful when history and clinical presentation suggest neonatal withdrawal but -useful when history and clinical presentation suggest neonatal withdrawal but

maternal and neonatal urine screens are negativematernal and neonatal urine screens are negative

-must be collected before it is contaminated by human milk or formula stools-must be collected before it is contaminated by human milk or formula stools

Maternal and neonatal hair analysisMaternal and neonatal hair analysis Testing of umbilical cord tissueTesting of umbilical cord tissue

Effects of Drug Withdrawal Effects of Drug Withdrawal on the Neonateon the Neonate

Opioids are the most common Opioids are the most common cause of NAScause of NAS

Among neonates exposed to Among neonates exposed to opioids in utero, withdrawal will opioids in utero, withdrawal will develop in 55%-94%develop in 55%-94%

Effects of Drug Effects of Drug Withdrawal on the Withdrawal on the NeonateNeonate

Opioids:Opioids:-Hyperirritability-Hyperirritability

-GI dysfunctions (excessive sucking, poor feeding, -GI dysfunctions (excessive sucking, poor feeding, regurgitation, diarrhea)regurgitation, diarrhea)

-Tremors-Tremors

-High pitched cry-High pitched cry

-Increased muscle tone-Increased muscle tone

-Seizures-Seizures

-Nasal congestion-Nasal congestion

-Hyperthermia-Hyperthermia

-Tachypnea-Tachypnea


Cocaine:Cocaine:

-No significant withdrawal symptoms-No significant withdrawal symptoms

Benzodiazapines:Benzodiazapines:

-Few infants have withdrawal -Few infants have withdrawal symptomssymptoms

Cannabis/marijuana:Cannabis/marijuana:

-Most commonly used illicit drug-Most commonly used illicit drug

-Jitteriness, tremors, impaired sleeping-Jitteriness, tremors, impaired sleeping


Selective Serotonin Reuptake Inhibitors:Selective Serotonin Reuptake Inhibitors:

((Paxil, Prozac, Zoloft, Celexa, Lexapro, Luvox)Paxil, Prozac, Zoloft, Celexa, Lexapro, Luvox)

-Most frequently used drugs to treat -Most frequently used drugs to treat depression in pregnant womendepression in pregnant women-Third trimester use may be linked with -Third trimester use may be linked with neonatal signs of:neonatal signs of: Continuous crying Continuous crying Shivering Shivering

FeverFever TremorsTremors

HypertoniaHypertonia HypoglycemiaHypoglycemia

Feeding difficulties Feeding difficulties JitterinessJitteriness

Respiratory distressRespiratory distress Sleep disturbanceSleep disturbance

Preterm Infants and Preterm Infants and NASNAS Lower risk of drug withdrawal and/or less Lower risk of drug withdrawal and/or less

severe symptomssevere symptoms Some studies have shown the lower Some studies have shown the lower

gestational age correlated with lower risk of gestational age correlated with lower risk of neonatal withdrawalneonatal withdrawal

May be related to immaturity of the CNS, May be related to immaturity of the CNS, differences in total drug exposure, or lower fat differences in total drug exposure, or lower fat deposits of drugdeposits of drug

Also, may be more difficult in preterm infants Also, may be more difficult in preterm infants because scoring tools are geared more toward because scoring tools are geared more toward term or late preterm infantsterm or late preterm infants

Evaluating NASEvaluating NAS

Finnegan’s Neonatal Abstinence Finnegan’s Neonatal Abstinence Scoring Tool:Scoring Tool:

-predominant tool use in US-predominant tool use in US

-comprehensive instrument-comprehensive instrument

-assumes cumulative score based -assumes cumulative score based on interval observation of on interval observation of

21 items 21 items relating to signs of relating to signs of neonatal neonatal withdrawalwithdrawal

Evaluating NASEvaluating NAS

Each nursery/NICU should have a Each nursery/NICU should have a protocol for evaluation and protocol for evaluation and management of NASmanagement of NAS

Staff should be trained on correct Staff should be trained on correct use of abstinence assessment use of abstinence assessment tooltool

AAP Committee on DrugsAAP Committee on DrugsGuidelines for Care of Guidelines for Care of NASNAS Utilize NAS scoring systemUtilize NAS scoring system Drug therapy if indicatedDrug therapy if indicated Supportive careSupportive care Breastfeeding if not Breastfeeding if not

contraindicatedcontraindicated-supervised methadone maintenance program-supervised methadone maintenance program

-negative HIV and illicit drug use-negative HIV and illicit drug use

Pharmacological Pharmacological InterventionsInterventions

Drug therapy is indicated to relieve moderate to Drug therapy is indicated to relieve moderate to severe NAS and to prevent complications such as severe NAS and to prevent complications such as fever, weight loss, and seizures when neonate does fever, weight loss, and seizures when neonate does not respond to nonpharmacologic supportnot respond to nonpharmacologic support

Morphine or Methadone usually drugs of first choiceMorphine or Methadone usually drugs of first choice

Methadone and Buprenorphine are synthetic opiatesMethadone and Buprenorphine are synthetic opiates Phenobarbital as second drugPhenobarbital as second drug New studies indicate Clonidine may also be a good New studies indicate Clonidine may also be a good

first line drugfirst line drug

Nonpharmacological Nonpharmacological InterventionsInterventions Decrease environmental stimuli Cluster care activities with gentle handling Use swaddling, supine or side-lying

positioning Apply gentle pressure over infant’s head and

body for calming effects Encourage breastfeeding and Kangaroo care Rooming in with mother if possible Encourage non-nutritive sucking Small, frequent feedings

Breastfeeding and NASBreastfeeding and NAS

Breastfeeding may decrease the severity of NAS Breastfeeding may delay onset of NAS Breastfeeding may decrease need for

pharmacologic treatment May be able to wean more aggressively from

methadone-Breastfeeding recommended in stable mothers on methadone and buprenorphine maintenance therapy who are not concurrently using illicit drugs-Transfer of methadone and buprenorphine into breastmilk is minimal and unrelated to maternal dose

Breastfeeding and NASBreastfeeding and NAS

Assists with bonding under difficult Assists with bonding under difficult circumstancescircumstances

Decrease stress response of the mother and Decrease stress response of the mother and lead to a calm interaction with the infantlead to a calm interaction with the infant

Decrease length of stayDecrease length of stay Need support for increased breastfeeding Need support for increased breastfeeding

durationduration

-24% of opioid dependent mothers -24% of opioid dependent mothers breastfeedbreastfeed

-60% stop on average after 5.9 days-60% stop on average after 5.9 days

Good Position, Good Good Position, Good LatchLatch

Nipple points to roof of Nipple points to roof of mouthmouth

Two Errors:Two Errors:

Nipple is pointing Nipple is pointing to the lower lip, not to the lower lip, not upper lip (or has upper lip (or has moved baby too moved baby too much to the side)much to the side)

Mother is Mother is squeezing nipple squeezing nipple to put it into the to put it into the baby’s mouthbaby’s mouth

BetterBetter

Well latched onWell latched on

Home Breastfeeding Plan Home Breastfeeding Plan for the Premature or NAS for the Premature or NAS

infantinfant Offer the breast _____ times each 24 hours when baby is awake and Offer the breast _____ times each 24 hours when baby is awake and

alert.alert. Have baby latch with top and bottom lip outHave baby latch with top and bottom lip out Let baby suck as long as baby shows signs of interest:Let baby suck as long as baby shows signs of interest:

– Focus on baby’s body language---Focus on baby’s body language---– Is baby doing sucking motions or sticking out his tongue?Is baby doing sucking motions or sticking out his tongue?– Is baby attempting to open his mouth?Is baby attempting to open his mouth?– Is baby trying to latch?Is baby trying to latch?

If baby is falling asleep, use breast compression to stimulate more If baby is falling asleep, use breast compression to stimulate more sucking. If baby still seems too sleepy, stop nursing and try to re-sucking. If baby still seems too sleepy, stop nursing and try to re-wake baby and then try latching again.wake baby and then try latching again.

Use the following wake up techniques:Use the following wake up techniques: Undress your babyUndress your baby Change your baby’s diaperChange your baby’s diaper Hold your baby skin-to-skinHold your baby skin-to-skin Rub your baby’s hands, feet, legs, etc.Rub your baby’s hands, feet, legs, etc. Massage or stroke your baby’s cheeks, lips, and mouthMassage or stroke your baby’s cheeks, lips, and mouth Wipe your baby’s face with a warm washclothWipe your baby’s face with a warm washcloth

Home Breastfeeding Plan Home Breastfeeding Plan continuedcontinued

Call your baby’s name or sing to your babyCall your baby’s name or sing to your baby More breast compressionMore breast compression Use breast compression while baby nurses as long as neededUse breast compression while baby nurses as long as needed Use football position or cross cradle position Use football position or cross cradle position Use breast pump as needed to stimulate let-down reflex before Use breast pump as needed to stimulate let-down reflex before

putting baby to breastputting baby to breast At each breastfeeding session, breastfeed first. If instructed to At each breastfeeding session, breastfeed first. If instructed to

do so, offer the prescribed amount of your expressed breastmilk do so, offer the prescribed amount of your expressed breastmilk or substitute after the breastfeeding. (Always use your or substitute after the breastfeeding. (Always use your breastmilk when it is available. If not, use the breastmilk breastmilk when it is available. If not, use the breastmilk substitute the doctor has prescribed.) substitute the doctor has prescribed.)

What: _________________________________________________What: _________________________________________________ How much: _____________________________________________How much: _____________________________________________ Feeding method: _________________________________________Feeding method: _________________________________________ Your baby’s average intake at each feeding has Your baby’s average intake at each feeding has

been:____________been:____________

Home Breastfeeding Plan Home Breastfeeding Plan continuedcontinued

When baby is taking half the original amount from the bottle When baby is taking half the original amount from the bottle after breastfeeding, then the bottle should be given after every after breastfeeding, then the bottle should be given after every other feeding. When the amount again is decreased by half, the other feeding. When the amount again is decreased by half, the bottle should be offered every third feeding.bottle should be offered every third feeding.

Remember to pump any time your baby is supplemented at a Remember to pump any time your baby is supplemented at a feeding. This means to pump when your baby is not breastfed feeding. This means to pump when your baby is not breastfed at the feeding, or when he is supplemented following a at the feeding, or when he is supplemented following a breastfeeding.breastfeeding.

When your baby reaches 40 weeks corrected age (his due date) When your baby reaches 40 weeks corrected age (his due date) and/or his medical issues have been resolved, supplemental and/or his medical issues have been resolved, supplemental bottle feedings may no longer be needed. Your baby should be bottle feedings may no longer be needed. Your baby should be breastfed on cue. When your baby is gaining weight well, you breastfed on cue. When your baby is gaining weight well, you may no longer need to use your breast pump. may no longer need to use your breast pump.

Keep a record of the following for each 24 hours:Keep a record of the following for each 24 hours: When baby was fedWhen baby was fed How baby was fedHow baby was fed Wet and dirty diapers for each 24 hoursWet and dirty diapers for each 24 hours (minimum in 24 hours>>6-8 wet diapers; 2-4 dirty diapers)(minimum in 24 hours>>6-8 wet diapers; 2-4 dirty diapers)

Discharge education specific to Discharge education specific to breastfed NAS infantbreastfed NAS infant

Call your baby’s Dr if the baby is Call your baby’s Dr if the baby is irritable, not consolable, jittery, irritable, not consolable, jittery, does not settle down between feedsdoes not settle down between feeds

If you are ready to wean from If you are ready to wean from breastfeeding consult with the breastfeeding consult with the baby’s Dr and lactation consultant baby’s Dr and lactation consultant to gradually wean off breastmilkto gradually wean off breastmilk

Referring Mothers Referring Mothers for Breastfeeding Supportfor Breastfeeding Support

International Board Certified Lactation International Board Certified Lactation Consultant (IBCLC) in: physician’s office, Consultant (IBCLC) in: physician’s office, hospital, private practice, local WIC hospital, private practice, local WIC programprogram

Shelby County Breastfeeding CoalitionShelby County Breastfeeding Coalition

www.shelbycountybreastfeeding.orgwww.shelbycountybreastfeeding.org La Leche League (1-800-LaLeche)La Leche League (1-800-LaLeche) Mothers are influenced by partner, family, Mothers are influenced by partner, family,

friends, OB, their baby’s doctor and You !friends, OB, their baby’s doctor and You !

Sweet SuccessSweet Success

Babies Were Born to Be Breastfed!Babies Were Born to Be Breastfed!

ReferencesReferences Abdel-Latiff ME, Pinner J, Clews S, Cooke F, Lui K, Oei, J. Effects of Breastmilk on Abdel-Latiff ME, Pinner J, Clews S, Cooke F, Lui K, Oei, J. Effects of Breastmilk on

the Severity and Outcome of Neonatal Abstinence Syndrome Among Infants of the Severity and Outcome of Neonatal Abstinence Syndrome Among Infants of Drug-Dependent Mothers. Pediatrics. 2006;117;e1163Drug-Dependent Mothers. Pediatrics. 2006;117;e1163

American Academy of Pediatrics. (2012). Policy Statement: Breastfeeding and American Academy of Pediatrics. (2012). Policy Statement: Breastfeeding and the use of human milk. Pediatrics. 2012;129;e827.the use of human milk. Pediatrics. 2012;129;e827.

Hale TW. Medications and Mother’s Milk, Fifteenth Edition, 2012.Hale TW. Medications and Mother’s Milk, Fifteenth Edition, 2012. Hudak ML, Tan RC, The Committee on Drugs and the Committee of Fetus and Hudak ML, Tan RC, The Committee on Drugs and the Committee of Fetus and

Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129;e540. Available Newborn. Neonatal Drug Withdrawal. Pediatrics. 2012;129;e540. Available at: at: www.http://pediatrics.aappublications.org/content/129/2/e540.full.html

Jansson LM, Velez M. Neonatal Abstinence syndrome. Curr Opin Pediatr. 2012;24 MacMullen MJ, Dulski LA, Blobaum P. Evidence-based interventions for Neonatal

Abstinence Syndrome. Pediatric Nursing. 2014; 165-203. Riordan, J. Riordan, J. Breastfeeding and Human Lactation, 3Breastfeeding and Human Lactation, 3 rdrd Edition. Edition. Sudbury, MA: Jones Sudbury, MA: Jones

and Bartlett Publishers; 2005and Bartlett Publishers; 2005.. Rodriguez NA, Meier PP, Groer MW, Zeller JM. Oropharyngeal administration of

colostrum to extremely low birth weight infants: theoretical perspectives. Journal of Perinatology. 2009;29; 1-7.

Sachs HC and The Committee on Drugs. The Transfer of Drugs and Therapeutics Into Human Milk: An Update on Selected Topics. Pediatrics. 2013;132;e796. Available at : www.http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985

Sublet J. Neonatal Abstinence Syndrome: Therapeutic Interventions. MCN American Journal Maternal Child Nursing. 2013;38(2) 102-7.

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