12: Burns Chapter 11 & Thureen Chapter 8 Flashcards
What are the breastfeeding recommendations
Exclusive breastfeeding for 6 mo, then combined with other nutrients for at least the first year.
Healthy people 2020 initiative: increase education and support
What is Hospital-Based Support?
The baby-friendly hospital initiative:
10 criteria every facility must meet to be baby-friendly.
Educate all staff on breastfeeding
What are the benefits of breastfeeding?
As the infant grows and develops the properties of the breastmilk changes to fit the needs of the infant
Provides the best nutrition possible for infants
Lowers risk of gastroenteritis, necrotizing enterocolitis, acute OM, severe lower respiratory tract infections, asthma, atopic dermatitis, DM Type 1 & 2, obesity, SIDS, and childhood leukemia, allergic diseases
Reduces fever after immunization
Lowers rates of atopic disease - asthma
Lower cholesterol in adult
Need to add complementary foods by 6 months to reduce risk of allergens
Enhances bonding
Enhances cognitive development
Contraindications to breastfeeding
Herpetic lesions on the mother’s nipples, areolas, or breast
Maternal diagnosis and treatment of cancer
Maternal HIV
Infant with Galactosemia
Significant maternal or infant illness affecting the ability to feed
Maternal illness, such as TB, chickenpox, or Hep B
Invasive breast surgery
Documented hx of milk supple problems
Colostrum: When does production begin? Composition? Benefits?
Production begins at 20 weeks gestation - Pregnancy woman may notice small amount of yellow discharge
Thick, rich, and yellow has fewer calories than mature milk
Immunoglobulins (IgA) and other antibodies
Higher in: Na, Cl, protein, fat-soluble vitamins, and cholesterol
Facilitates passage of meconium
Often referred to as the infants “first immunization”
Transitional Milk: When does production begin? Composition?
Appears several days after delivery
Has more lactose, calories, and fat and less total protein than colostrum
Mature milk: When does production begin?
Composition?
Replaces transition milk by week 2
Water
Lipids-fat content is higher at the end of feedings (hindmilk) than at the beginning (foremilk)
Various lipids
Cholesterol
Fatty acids (DHA) - may play a role in brain and retinal growth, beneficial effect on neurobehavior functioning
Protein
Carbohydrates - Primary carb is Lactoase
Vitamins and Minerals - except Vitamin D - must supplement about 400 IU/day or sun exposure
Anatomy and Physiology of Milk Production
By 20 weeks OB mammary glands are capable for milk production
Breast Milk production is signaled by the fall of progesterone. Suckling stimulates the hypothalamus to decrease prolactin-INHibiting factors to permit prolactin by the anterior pituitary which leads to a rise in the level of prolactin. Suckling by the infant is essential to establish and maintain lactation by increasing prolactin levels. The hypothalamus also stimulates the synthesis and release of oxytocin by the posterior pituitary to cause “letdown reflex”.
Amount of milk production depends on stimulation of the breast - “supply and demand”
Assessment of the Breastfeeding Dyad
Maternal History - breast feeding hx, culture, expectations, drug use
Infant History - Health status, congenital conditions, trauma, complications, medications, gestational age, how is feeding going?
Maternal Examinations -Type of nipples, Presence of surgical scars, nipple bruising or bleeding
Infant Examination - oral motor skills
Maternal History
Overall health previous breastfeeding experience cultural expectations, routine use of medications/etoh/drugs/ect, surgical interventions nutritional status family and community support pregnancy history L & D history
Infant History
Overall health Congenital conditions Trauma or complications during delivery medications received during labor activities or procedures (circumcision, bili lights, tube feedings) gestational age early responses to feeding attempts
Maternal Examinations
Types of nipples
Presence of surgical scars on the breast or thoracic area
Any nipple bruising or bleeding
Infant Examination
Evaluate oral-motor skills and structures
Principle of correct positioning
good body position
Audible “glug” or swallow from the infant
Positions for breastfeeding
Cradle position
Side-lying position
Football hold
How long should an infant breast feed on each nipple?
Encourage infant to go to each breast for 10-15 minutes up to 20-30 min
After the first 24 hours how often should the mother breastfeed
8-12 times or every 2-3 hours a day
*Be aware of the infant that goes 4 hours between feedings and falls asleep in 5 minutes at the breast, these infants need to be woken up to feed
Urine output Guidelines
In first 24 hours infant may only urinate 1-3 times
By day 3: 4 wet diapers
By day 4: 4-6 wet diapers
Eventually: 6-8 wet diapers
Stool Output Guidelines
First 24 hours: one meconium followed by another the second day.
Day 3: transition stools - loose, yellow, seedy
How often should a mother pump?
Pump 6-8 times in 24 hours for 15 min on a double pump, or 10 min per breast on a single pump set up
What are collection and storage of breastmilk?
Clean pump parts after each use
Milk defrosted, but not used within 24 hours needs to be thrown away
Pump milk can be stored in the fridge for 8 days or a “blue ice” cooler for 24 hours
Refrigerator freezer - 3 months
Deep Freeze - 12 months
Infant Weight Gain:
What is an acceptable percentage weight loss in first few days?
Normal to lose 5-8% of BW in first few days
How much weight should an infant gain per day?
0.5-1 oz per day, or 4-7 oz per week
When should the infant’s weight be back to birth weight?
2 weeks
When is an infant considered Failure to Thrive?
3 Week
What should an infant’s weight be by 6 months and 1 year?
The infant’s weight should be double the infants birth weight by 6 months and triple the infant’s body weight by 1 year
What are the characteristics of a healthy breastfed infant:
active and alert state
Developmentally appropriate progress
Age appropriate height and head circumference
Good skin turgor and color
Sufficient output of at least 6 wet diapers a day
Content and satisfied behavior after feeding
How often do growth spurts occur?
Periods lasting 2-4 days where infant seems to be hungry all the time
Tend to occur every 3-4 weeks
When does weaning naturally occur?
When the infant participates with self-feeding
How many total calories should a breastfeeding mother eat or how many extra calories per day
Minimum 1800 calories per day or extra 500 calories more than nonpregnant diet
How much weight should a breastfeeding mother expect to lose per month?
1-2 LBS per month
What drugs should a breastfeeding mother avoid or receive?
Estrogen
antihistamine
ergot compounds
- may give breastfeeding mothers medications that infants can receive
What are some common breastfeeding problems?
Flat or inverted nipples Sore nipples Severe engorgement Mastitis Nipple confusion Breastfeeding jaundice Thrush Poor weight gain
How to determine if a mother has flat or inverted nipples?
Pinch test
What causes flat or inverted nipples?
Adhesions cause retraction or inversion.
Flat nipples more often found in women with larger breasts
How are flat or inverted nipples managed?
Prenatal: breast shields during 3rd trimester if woman is not at risk of preterm labor
Postpartum: Football hold Wear breast shells between feedings Use pump for 1-2 minute before feeding Avoid pacifiers or bottle nipples until infant is 4-6 weeks old
What are the complications of flat or inverted nipples?
Frustration Loss of self-confidence Inadequate infant nutrition and its sequelae Severe maternal engorgement Plugged ducts or mastitis Discontinued breastfeeding
What causes sore nipples?
Improper latch Prolonged negative pressure Inappropriate suction release Use of sensitivity to nipple creams Incorrect use of breastfeeding supplies Thrush Leaking nipples that are not properly air-dried
What are the typical clinical findings of sore nipples?
Nipples, areola, and breasts are tender are bruised, raw, cracked, bleeding, blistered, discolored, swollen or traumatized
How are sore nipples managed?
Rub a few drops of colostrum or hindmilk onto the nipple and areola after every feeding and let air-dry
Expose nipples to air for short periods of time during the day
Breast shields
Pump affected breast if pain is too severe to allow nursing
Mild analgesics
Lactation specialist
What is severe engorgement?
Extremely full, sore, and swollen breasts, beyond the normal fullness experienced as the milk comes in
What causes severe engorgement?
Milk stasis in the breast from inadequate emptying
What are the clinical findings of severe engorgement?
Painful, hard, lumpy, swollen breast
Warm to touch
nipples flattened by swelling
bruising or trauma to the nipples and areola
How is severe engorgement managed?
Hot showers
Wrap breasts in warm, wet compress for 5-10 min before nursing
Gentle massage
manual expression before feeding to soften the areola
Nurse frequently
What is mastitis?
Infection of the breast usually by S. Aureus
What are predisposing factors of mastitis?
Stress Fatigue Cracked nipples Plugged ducts Constricting, ill-fitting bra Inadequate emptying of the breast sudden weaning or a significant decrease in the number of feedings Use of manual pump
What are the clinical findings of mastitis?
Malaise Breast tenderness or pain A reddened, warm lump in any quadrant Some times streaking Flu like symptoms Fever Chills Body aches
How is mastitis managed?
Empty the breast Nurse frequently Use analgesics as necessary ABX: PCN or Cephalosporin that covers S. Aureus - Dicloxacillin, Augmentin, Cefuroxime Probiotics Rest Increased fluids Warm showers Do NOT abruptly wean
What are the complications of mastitis?
abscess and sepsis
What is nipple confusion? What is the problem with switching between breastfeeding, bottle feeding, and pacifier use?
confusing a nipple with a bottle or pacifier
The problem is they use different oral-mouth skills are used in sucking from a breast and bottle
What are the clinical findings of nipple confusion?
Ineffective sucking, breast refusal, sore nipples
How is nipple confusion managed?
Nipple confusion is managed by:
Avoiding baby bottle nipples and pacifiers for 4-6 week
Consulting a lactational specialist
If supplements are needed give them with a dropper, spoon, syringe, 5 french feeding tube attached to breast
Nipple shield
What are the complications of nipple confusion?
FTT hyperbilirubinemia Colic and crying Prolonged feedings Sore and cracked nipples Plugged ducts Mastitis Frustration
What is breastmilk jaundice?
Late onset jaundice occurring 7-10 days of life in an infant drinking an adequate amount of breastmilk with no other signs of liver abnormality
What causes breastmilk jaundice?
It is possible due to an enzyme in mother’s breastmilk,
(glucuronyl transferase)
Siblings are often affected
What are the clinical findings of breastmilk jaundice?
Healthy and thriving infant with adequate stooling and voiding, appropriate weight gain with the appearance of elevated bili between days 7-10 days that persists into the third month of life
Diagnostic studies: Serum bili, urine and other cultures to r/o infection
How is breastmilk jaundice managed?
Continue to breast feed unless clinical signs of pathologic jaundice are observed
What is thrush?
Oral candidiasis on the nipple and/or in the infant’s mouth
What can cause poor weight gain?
Infrequent or inadequate feeding bc of poorly managed breastfeeding
Inadequate milk production
Genetic predisposition
Infection
Organic disease
Physical anomaly that prevents good sucking/swallowing
What are the clinical manifestations of poor weight gain?
Continued weight loss after 5-7 days
Failure to regain birthweight by 2-3 weeks old
Failure to maintain an ongoing weight gain of 0.5-1 oz /day
Weight below 3rd percentile for age
Lethargic/sleepy/inactive/unresponsive infant
Poor skin turgor
Dry mucous membranes
Newborn or young infant sleeping longer than 4 hours between feedings
What are technique factors can cause poor weight gain?
Ineffective latch/sucking
Short time at the breast
Infant kept on schedule despite cues from more feeding
Infant given water between feedings
Infant encouraged or allowed to slep through the night before 8-12 weeks old
Fewer than 8 feedings in 24 hours
Infant fed in a distracting environment
What maternal factors can lead to poor infant weight gain?
Mother does not respond to infant’s cues for feeding
Hectic schedule with limited time for feeding
Recent illness or significant weight loss
Uses oral contraceptives or other hormones
How is poor infant weight gain managed?
Assess breastfeeding
Lactation specialist
Use supplemental system if needed
What are complications of poor infant weight gain managed?
Developmental delay
Poor bonding
Severe dehydration
Hospitalization for rehydration
What are the maternal benefits of breastfeeding?
Uterine involution Decreases Post partum bleeding Earlier pregnancy weight loss Improved bone mineralization Decreased risk ovarian and breast cancer
Bottle Feeding
Feeding and Frequency:
0.5-1 oz every 2-4 hours for first 24-48 hours
Then increase to 12-24 oz/day for first month
Formulas:
Iron-fortified is only acceptable alternative to breastfeeding
Fluoride supplementation (0.25 mg/day) may be recommended at 6 months of age
Bottles can be safely stored in the fridge for up to 24 hours
Warm to room temp - NEVER MICROWAVE
When should an infant be burped?
Attempt every 0.5-1 oz and at end of feeding to help remove swallowed air
Regurgitation
“wet burp” containing small amounts of formula are physiologically normal in the first 6 weeks of life
Projectile vomiting is NOT normal
