9.1d Care Management Flashcards
Breastfeeding Support
- Key is education and guidance as early as possible (before pregnancy)
- Support groups to connect expectant mothers with similar backgrounds
- Most common cause of concern for mothers is insufficient milk supply, painful nipples, problems getting baby to feed,
- Lactation consultants at hospitals can help breastfeeding mothers
Nursing Interventions for Breastfeeding
- Knowledge/Skills
- Promote and support breastfeeding
- Assist in early initiation of breastfeeding
- Assess lactating breasts
- Preform infant feeding observations
- Recognize normal/abnormal infant feeding patterns
- Develop/communicate appropriate breastfeeding care plan
Baby-Friendly Initiative 10 Steps to Breastfeeding
1 - Have written feeding policies routinely communicated to staff and policies
2 - Establish ongoing monitoring and data management systems
3 - Discuss importance of breastfeeding with parents
4 - Facilitate immediate skin to skin after birth
5 - Support breastfeeding and manage complications
6 - Only provide newborns with breastmilk unless otherwise indicated
7 - Enable others to remain with their baby and practice rooming in for 24 hours a day
8 - Teach mother to recognize cues of feeding
9 - Counsel mothers on risks of feeding bottles and pacifiers
10 - Coordinate discharge so parents have ongoing care
Feeding-Readiness Cues
Signs of Hunger
- Sucking/Mouthing motions
- Hand to mouth and Hand to Hand motions
- Rooting Reflex (infant moves towards whatever touches their mouth and tries to suck)
Education for Mothers
- Latch and Position
- Signs of adequate feeding
- Self-care measures such as engorgement prevention
- Resources they can contact from birthing facility
Breastfeeding Positions
- Football (Clutch) Hold - Under the arm
- Cross-Cradle (Modified Cradle) - Across the lap
- Cradle
- Side lying
- Mother should empty bladder, be in privacy, have their support partner before breastfeeding
Latch
- Mother should first express a few drops of colostrum over nipple to entice baby to open their mouth
- Babies with rooting reflex will latch on easier
- Tickle babies lips with nipple to stimulate baby opening mouth
- Once babies mouth is open and tongue down, hug baby to breast bringing it to the nipple
- Painful breastfeeding could mean baby has not taken in enough breast into the mouth and the tongue is pinching the nipple
Asymmetric Latch Technique
- Once babies mouth is open, pull baby in towards breast where chine and lower mandible make contact first, and then top lip
- Once latched babies chin should be pressed into underside of breast and nose tilted slightly away
Signs feeding is going well
- Mother reports firm tugging on nipple but no pinching/pain
- Baby sucks with rounded cheeks (not dimpled)
- Babies jaw glides smoothly
- Swallowing is audible
- Baby has bursts of 15-20 sucks/swallows at a time
Potential Problem 1
- Lack of knowledge about breastfeeding
OUTCOME
- Mother verbalizes understanding and demonstrates proper technique
INTERVENTION
- Assess knowledge of breastfeeding
- Observe feeding session once every shift
OUTCOME
- Mother reports no nipple pain with infant suckling
INTERVENTION
- Instruct mother with positive feeding signs
Potential Problem 2
- Difficulty with latch and milk transfer due to sleepy baby evidenced by lack of output
OUTCOME
- Latch and effective suckling
INTERVENTION
- Observe for cues of readiness of feeding
OUTCOME
- Infant wakes up and breastfeeds every 2-3 hours for 15-20 minutes
INTERVENTION
- Assist with awakening techniques such as skin to skin, massage, diaper change
OUTCOME
- Infant voids at least 2-3 times and 1 bowel movement in the next 24 hours
Intervention
- Closely monitor and document infants I&O
Potential Problem 3-
- Anxiety about producing adequate milk supply
OUTCOME
- Mother states signs that infant is receiving enough breastmilk
INTERVENTION
- Teach mother signs of positive breastfeeding (urine/stool output, weight gain, behavior, breast softening after feeding)
OUTCOME
- Mother verbalizes factors that influence milk production
INTERVENTION
- Teach supply-meet-demand, importance of regular feedings, teach to hand-express milk
OUTCOME
- Identify resources to help with concerns related to milk supply post-discharge
INTERVENTIONS
- Refer to lactation consultant and provide resources available on internet and community
Milk Ejection (Let-down)
SIGNS OF IT OCCURING
- Tingling in nipple and breast
- Baby suck changes from quick and shallow to slow
- Audible swallowing is heard
- Uterine cramping and lochia can be seen
- Mother feels relaxed and drowsy during feedings
- Opposite breast may leak
Feeding Frequency
- 8-12 times a day
- Some babies feed every 2-3 hours
- Some babies cluster feed where they feed every hour for 3-5 feedings then sleep for 3-4 hours
- ## First 24-48 hours, parents must wakeup baby every 3 hours during the day and every 4 hours at night to feed
Demand Feeding
- Once infants gain weight properly demand feeding is appropriate where baby determines frequency of eating.
Cue-based feeding
- Infants are fed whenever they display cues
- Keep baby close to best observe cues
Duration of Feedings
- Average is 30-40 minutes total (15-20 minutes per breast)
- Length of feeding decreases as babies become more efficient at feeding
- Time spent breastfeeding is not reliable indicator of how much milk baby has gotten
- If baby is feeding effectively, I&O is normal, but weight gain is not enough, mom may be switching breasts too soon.
- Feed first breast until soft to ensure baby receives higher-fat hindmilk (weight gain milk)
Indicators of Effective Breastfeeding
- Food diary is helpful
- Output is good indicator of adequacy
- As volume of breastmilk increases, baby urine will become more dilute and lighter yellow. Dark yellow urine can indicate inadequate intake and dehydration
- 6-8 urine a day after day 4
Stool
- First 1-2 days will be meconium stool (green/black, thick and sticky)
- Day 2-3 stool is more green, thinner, and less sticky
- If meconium is still being passed by day 3-4 breastfeeding should be assessed
- Day 7 for breastfeeding stool will be yellow/soft and seedy
- 3 stools a day for the first month
- Breastfed babies may have more than 1 stool a day or 1 stool every 2-3 days
- As long as baby gains weight and appears healthy, decreased bowel movement is normal
Breastfeeding Assessment
- Breastfeeding should be assessed at least once every 8-12 hours for effectiveness
- There should be at least 1 assessment during the 8 hours prior to discharge
(Position, Latch, Milk Transfer) - Jaundice and daily weights should also be assessed
- Output should be assessed (voiding and stools, color, transition, uric acid crystals)
Supplement/Bottles/Pacifiers
- No supplements should be given with breastfeeding (unless indicated)
- When supplements are needed, expressed breastmilk is the best. If milk is not providable than pasteurized donor milk is the next best option
- Best to avoid bottle feeding until breastfeeding is well established (3-4 weeks) to avoid confusing the infant (they require different motor skills)
- Pacifier can be used at 3-4 weeks of age after breastfeeding is well established
- Pacifiers at naps or sleep has shown to decrease risk of SIDS
When Supplementary Feeding may be Needed
INFANT
- Hypoglycemia/Dehydration/Hyperbilirubinemia
- Weight loss more than 8% by day 5 (exceeding 75th percentile)
- Delayed passage of stool or still meconium by day 5
MOTHER
- Delayed lactogenesis
- Intolerable pain during feedings
- Temporary cessation due to medications
- Insufficient glandular tissue
- Previous breast surgery such as breast enlargement or reduction
Slow Weight Gain
- Babies lose 5-10% of weight after birth prior to gaining weight
- Weight loss more than 7% during first 3 days should be investigated
- Once baby is on mature milk, 110-200g should be gained per week (20-28g a day) for the first 3 months
- Solution to slow weight gain is increased feedings and improved feeding technique
Jaundice
- Newborns should be fed frequently 8-12 times a day to prevent breastfeeding-associated jaundice
- Treat early-onset jaundice by evaluating breastfeeding technique
- Late on-set jaundice or breast milk jaundice develops between 5-10 days of age
- Baby should be evaluated for weight loss greater than 7%, less than 3 stools a day, and less than 4-6 wet diapers a day
Preterm Infants
- Human milk is ideal
- Breastmilk enhances retinal maturation in preterm infants
- Improves neurocognitive outcomes
- Decreases risk of sepsis and necrotizing enterocolitis (GI issue)
- Mothers of pre-term babies who cannot breastfeed yet should begin pumping their breasts as soon as possible after birth
Early Term Infants
- 34 weeks - 36 6/7 weeks Late Preterm Infants
- 37 weeks - 38 6/7 weeks Early Term Infants
Both at risk for breastfeeding difficulties due to low energy stores and high energy demand
RISKS
- Hypothermia/Hypoglycemia/Hyperbilirubinemia
- Respiratory issues
- Sleepiness/Minimal Wakeful Periods/Tired After Feedings
- Weak suck and low tone
Steps to Expressing Milk
- Wash hands with soap before starting
- Containers for storing milk should be washed with hot soapy water or dishwasher. Specific plastic bags for storage of breastmilk lasts less than 72 hours
- Write date of expression on container before storing milk
- Store milk in 2-4 ounce servings
- Milk can be stored at room temperature for 4 hours and refrigerator for 4 days
- Milk can be stored in freezer from 6 months to a year
- Storing in fridge and freezer is the best (can be placed with other foods)
- You can combine milk from pumping on the same day but do not add warm milk to cold milk
- Place milk in the back of the fridge, not on the door
- Only fill storage to 3/4 if they will be frozen to allow expansion
- Thaw milk in refrigerator or under warm water (never microwave)
- Milk thawed in fridge is good for 24 hours
- Milk should never be refrozen
- Shake milk container before feeding and test temperature on inner wrist
- Discard un-used milk within 1-2 hours
Weaning
- Transferring dependence on breastmilk to other sources of nutrition
- Should be done gradually over weeks/months
- Abrupt stopping of breastfeeding can cause engorgement/mastitis and baby stress
Milk Banking
- Donor milk is important for babies who cannot survive without human milk, but mother is incapable of breastfeeding
Milk Sharing
- Another woman who is not the mother breastfeeds the baby because mother is either contraindicated for breastfeeding (HIV), or maternal death occurred.
Nutrition for Mother
- Breastfeeding women need 450-500 extra calories a day
Breast Care
- Bathing is all that is necessary to keep breast clean
- Avoid washing nipple with soap as it may dry them out
- Breast cream can cause blockage of oils from Montgomery glands (use them sparingly)
Breastfeeding and Contraception
- Not effective contraceptive
- Oral contraceptives with progesterone/estrogen not recommended due to potential to reduce breast milk
- Progestin only contraceptives are better options but not recommended during first 6 weeks postpartum
Breastfeeding
- Can continue even if mother becomes pregnant again
- Any breast surgery can affect milk production, it is possible for breast cancer patients to breastfeed though they may have lower milk supply
- Nipple piercings do not affect breast feeding
- Obese mothers may have delayed lactogenesis stages and insufficient milk production. Those with bariatric surgery must monitor for nutrient deficiency
Medications and Breastfeeding
- Benefits of breastfeeding outweigh the risks of medications.
ADVERSE EFFECT MEDICATIONS - Antimetabolite and Cytotoxic medications
- Cocaine
- Heroin
- Amphetamines
- Phencyclidine
- Methadone and Buprenorphine are safe
- Antidepressants such as nortriptyline, sertraline, paroxetine are safe
- Alcohol and Cigarettes are contraindicated
- Moderate caffeine pose no risk
Engorgement
- Common due to significant increase in milk volume during lactogenesis stage 2
- Occurs during day 3-5 during milk transition
- Breast take increased glucose and oxygen consumption
- Alveoli may become distended causing capillary blood flow impairment. As the vessels become more congested, fluid leaks to surrounding tissue causing edema.
- Breasts may be firm, tender, hot and appear shiny/taut
- Nipples can flatten making latching difficult
- Engorgement usually resolves in 24 hours
- Feed 8-12 times a day
Engorgement Treatment
- Icepacks
- Warm packs/showers
- Cabbage
- Anti-inflammatory medications
- Breast massage
- Hand/Pump expression
- Ultrasound
- Acupressure/Acupuncture
- Reverse Pressure Softening (manually displace areolar fluid inward which softens the areola and makes latching easier for baby)
Sore Nipples
- Best way is to use proper breastfeeding techniques
- Limiting infant time on feedings does not prevent sore nipples
Ankyloglossia
- Tongue tie that restricts tongue range of motion for baby.
- Can be surgically treated
Insufficient Milk Interventions
- Skin to skin contact
- Increase feeding frequency
- Express milk using electric pump
- Rest as much as possible, proper nutrition, reduce stress
Galactagogues
- Medications that can increase milk supply
Plugged Milk Ducts
- Breast can become swollen and tender
- Caused by inadequate removal of milk from breast caused by tight clothing, poor fitting bra, or always feeding in same position.
- Warm compress before feedings can help
REQUINTO FEEDING
- Baby begins to feed on affected side to foster more complete emptying
INTERVENTIONS
- Massage breasts while pumping
- Use proper fitting clothes
- Change positions while feeding
- These blocks should be resolved as soon as possible due to risk of infection
Mastitis
- Infection of breasts
- Influenza like symptoms (fever, chills, malaise, body aches, headache, nausea, vomiting)
- Localized breast pain and tenderness with hot red area
- Most cases occur 2-4 weeks postpartum
- Antibiotics such as cephalexin and dicloxacillin for 10-14 days is used as treatment
- Can still breastfeed
