Newborn Nutrition and Lactation Problem Solving at the Bedside

1. Newborn Nutrition and Lactation Problem Solving at the Bedside

2. Topics and Goals • Identify three aspects of breast anatomy recently redefined by ultrasound • Discuss the benefits of breastfeeding to moms and infants and review basic frequency and duration guidelines for all new moms • Describe two positioning tips for the new breastfeeding mom • Discuss techniques to use with the “noncompliant” infant • Identify which moms should be referred for early follow up after discharge.

3. Why are lactation consultants our friends • Provide prenatal information and breastfeeding assessment • Assist with appropriate breastfeeding technique • Assist breastfeeding mothers or babies who are ill or have anatomical challenges. • Give information on maintaining or building milk supply

4. SUPPLLY=DEMAND=SUPPLY • Reinforce the need to establish adequate milk production by effective “emptying” of the breasts at each feeding • Newborns need “complete” meals, foremilk, and the rich in long chain fatty acids, hind-milk • Baby and mother are both learning how to feed and when to feed • USE IT OR LOSE IT !!!!!!

5. Early Follow-up • Early follow-up is vital to preserve the breastfeeding relationship • In most cases, interventions can be minor, and problems easily fixed • Use of feeding logs can help parents make safe decisions in providing optimal infant nutrition by breastfeeding • Infant “constipation” is a big red flag

6. Nutritional Comparison: Breast Milk 90% water Same weight gain or greater during first 3-4 months Fat is variable Primary carbohydrate is lactose, trace amounts of other carbohydrates

7. Nutritional Comparison: Formula • 90% water • Greater weight gain after 3-4 months • Lactose is only carbohydrate

8. Summary of the Latest Anatomincal Findings by the University of Western Australia • Ducts branch closer to the nipple • Lactiferous sinuses do not exist • Glandular tissue is found closer to the nipple • Subcutaneous fat is minimal at nipple base • Range of mild ducts exiting the nipple is 4-18 (Average 9) • Complex ductal network neither arranged symmetrically nor in a radial pattern

10. Reasons to Breastfeed Biological norm for human infants Optimal nutrition for infants Health advantages that last far beyond infancy Health benefits for mothers

11. Advantages of Breastfeeding • Species specific • Cholesterol in breast milk plays a role in myelination and neurologic development • More efficient metabolism of cholesterol • Composition varies according to gestational age • Iron is more readily absorbed

12. Infant Benefits Reduced risk of Type I or type II diabetes mellitus Lymphoma, leukemia, & Hodgkin’s disease Obesity Hypercholesterolemia Asthma

13. Infant Benefits: Immunologic • Protection from • Respiratory tract and gastrointestinal tract infections • Necrotizing enterocolitis • Urinary tract infections • Otitis media • Bacterial meningitis

14. Infant Benefits: Immunologic (continued) • Protection from • Bacteremia • Allergies

15. The Statistics are Staggering • 1.5 million infants die each year because they are not breastfed. • In areas where water is not safe, bottle feeding children are 25 times more likely than breastfed children to die from diarrhea • Even in developed countries, breastfeeding saves babies’ lives and reduces life-long illness.

16. Why the Fuss? • Providing hospital formula discharge bags reduces the numbers of women exclusively breastfeeding Donnelly A. Snowden HM, Renfrew MJ, Woolridge, MW. Hospital bags for breastfeeding women. Cochrane Data Base System Review 20002

17. Oxygenation changes during infant feedings • Hypoxemia during bottle-feeding has been documented since the 1970’s. This occurs in both the full-term and preterm infants. Research suggests that the alteration in blood oxygen is a result of decreased ventilation.

18. One Formula Feed • The protective benefits of human milk are dose dependent • After I exposure to formula, it takes 14-21 days for the gut to re-establish its protection against enteritis

19. AAP Policy Statement • “Human milk is the preferred feeding for all infants, including premature and sick newborns with rare exceptions.”

20. AAP/2005 • Postneonatal infant mortality rates in the US are reduced by 21% in breastfed infants • …benefits include the potential for decreased annual health care cost of $3.6 billion in the US • Skin to skin contact and direct breastfeeding should be encouraged as early as feasible • Banked human milk may be a suitable feeding alternative for infants whose mothers are unable or unwilling to provide their own milk

21. Colostrum Production • Mothers produce 30-100 ml of colostrum in the first 24 hours, 2-10 ml per feeding on day 1 and 5-15 ml per feeding on day 2 • Newborn stomach does not stretch • Time of transition to mature milk varies based on parity of mother: 31-96 hours in the primiparous mothers 24-80 hours in the multiparous mothers

22. Redefining Normal Breastfeeding Frequency and Expected Duration • Average physiologic capacity of the stomach in the first 10 days of life is 7-81 mls or 2-24 ml/kg • The range of gastric half-emptying time for breast milk is 16-86 minutes • Average breast milk volume per feed on day one is just 7 mls • By day of life 4 the average volume per feed is only 58 ml

23. Frequency and Duration • Feed frequently and follow infant feeding cues closely: • Sucking movements • Sucking sounds • Hand-to-mouth movements • Rapid eye movements • Soft cooing or sighing sounds • Restlessness

24. Frequency and Duration Watch the baby not the clock Use the log on the back side of handout to monitor feeds and output 4 by day 4 AAP/AAFP and WHO recommendations

25. When to Wean • “…if humans weaned their offspring according to the primate pattern, without regard to cultural beliefs and customs, most children would be weaned somewhere between 2.5 and 7.0 years of age.” • “Extended breastfeeding…is healthy, physiologically normal and evolutionarily adaptive.” -WHO

26. Human Cultural Norms • “…for all our time as hunters and gatherers, more than 99.9% of our existence on earth, all human infants were breastfed.” • “…this has been the method of feeding to which human infants have adapted, and on which human infants have survived, for millions of years.”

27. Sri Lankan widower breastfeeds his babies

28. Milk Men? • http://images.google.com/imgres?imgurl=http://1.bp.blogspot.com/_Di1HzTLtBlM/RreOBPvv4VI/AAAAAAAABds/g3sJdIFl4i8/s400/breastfeeding%2Bman.jpg&imgrefurl=http://www.thethinkingblog.com/2007/08/fact-men-can-breastfeed.html&usg=__E4wr4Co6FzFjvtteg_pt6WWxqhQ=&h=308&w=400&sz=28&hl=en&start=9&um=1&itbs=1&tbnid=unPmmp8BJkrkoM:&tbnh=95&tbnw=124&prev=/images%3Fq%3Dpictures%2Bof%2Bbabies%2527%2Bbreastfeeding%26hl%3Den%26rlz%3D1T4ADFA_enUS346US346%26sa%3DX%26um%3D1

29. Top Three Reasons New Mothers Stop Breastfeeding • 47% of mothers felt they were not producing enough milk • 33% of mothers said they had trouble getting the baby to nurse • 29% quit because of work-related issues

30. Factors Related to Early Termination • Low income women • Perception of insufficient milk • Plan to work outside the home • No previous breastfeeding experience • Formula supplementation while in the hosptial • Younger women who are less educated • Initiation of breastfeeding after 16 hours of age • More positive bottle-feeding attitude and less positive breastfeeding attitude.

31. Information Given to New Mothers • Must explain the benefits of breastfeeding • Must give the health risks and costs associated with artificial feeding

32. Information Given to Health Workers Must be based on scientific and factual research

33. Skin-to-Skin Contact, Breastfeeding and Perinatal Neuroscience • Dr. Nils Bergman, MD, DCH, MPH • Capetown Sputh Africa • www.kangaroomothercare.com • Implementing Best Practice in US Hosptials

34. Fetal Brain Development 90% of what we know about human brain function we have learned in the past 15 years.

35. Cells that fire together, wire together

36. For a baby the environment is the mother

37. Critical period: “Early interpersonal events positively and negatively impact the structural organization of the brain

38. Milk product=10% of the benefits of the product

39. Infant Brain Development Early brain development is INTERACTIVE RAPID DRAMATIC

40. Quality sensory stimulation makes brain able to think and regulate Negative experiences (both the absence of good…and the presence of bad) have long lasting effects Could attention deficit disorder, obesity, depression be effected by early wiring?

41. Separation if Harmful • The separated baby that has “settled” is in DESPAIR, dissociation • The primary violation, the very worst thing to any newborn according to biologists is separation • Separation violates the innate agenda of mother and newborn

42. Maternal-infant separation = ABUSE

43. How the Nurse can Promote Attachment • Facilitate breastfeeding within the first hour after birth and provide for continuous skin-to-skin contact between the mother and infant until after the first feeding

44. Avoid routine procedures until after the first breastfeeding

45. Strategies • Keep the mother and infant together during the entire postpartum stay • Conduct examinations and routine tests of the infant while the infant is in the mother's room, in the mother’s arms, or on the breast. Babies at breast are less receptive to pain.

46. Comfortable Positions

48. Strategies • Watch the baby not the clock • Teach mothers to recognize and respond to early infant feeding cues and confirm that the baby is being fed at least 8 times in each 24 hours • REMEMBER: crying is a late feeding cue and may interfer with effective breastfeeding • Pattern the skill of reading the infant cues, save baby energy for feedings

49. Twin Challenges

50. Strategies • Confirm that mothers know how to wake a sleepy infant • Strategies to wake the infant include: remove any blankets change the infant’s diaper PLACE THE INFANT SKIN-TO-SKIN massage the infant’s back, abdomen, arms, legs