9.1d Care Management

Question 1

Breastfeeding Support

Answer 1

• 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

Question 2

Nursing Interventions for Breastfeeding

Answer 2

• 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

Question 3

Baby-Friendly Initiative 10 Steps to Breastfeeding

Answer 3

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

Question 4

Feeding-Readiness Cues

Answer 4

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)

Question 5

Education for Mothers

Answer 5

• Latch and Position
• Signs of adequate feeding
• Self-care measures such as engorgement prevention
• Resources they can contact from birthing facility

Question 6

Breastfeeding Positions

Answer 6

• 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

Question 7

Latch

Answer 7

• 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

Question 8

Asymmetric Latch Technique

Answer 8

• 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

Question 9

Signs feeding is going well

Answer 9

• 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

Question 10

Potential Problem 1

Answer 10

• 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

Question 11

Potential Problem 2

Answer 11

• 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

Question 12

Potential Problem 3-

Answer 12

• 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

Question 13

Milk Ejection (Let-down)

Answer 13

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

Question 14

Feeding Frequency

Answer 14

• 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

Question 15

Demand Feeding

Answer 15

• Once infants gain weight properly demand feeding is appropriate where baby determines frequency of eating.

Question 16

Cue-based feeding

Answer 16

• Infants are fed whenever they display cues

- Keep baby close to best observe cues

Question 17

Duration of Feedings

Answer 17

• 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)

Question 18

Indicators of Effective Breastfeeding

Answer 18

• 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

Question 19

Stool

Answer 19

• 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

Question 20

Breastfeeding Assessment

Answer 20

• 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)

Question 21

Supplement/Bottles/Pacifiers

Answer 21

• 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

Question 22

When Supplementary Feeding may be Needed

Answer 22

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

Question 23

Slow Weight Gain

Answer 23

• 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

Question 24

Jaundice

Answer 24

• 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

Question 25

Preterm Infants

Answer 25

- 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

Question 26

Early Term Infants

Answer 26

- 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

Question 27

Steps to Expressing Milk

Answer 27

- 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

Question 28

Weaning

Answer 28

- 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

Question 29

Milk Banking

Answer 29

- Donor milk is important for babies who cannot survive without human milk, but mother is incapable of breastfeeding

Question 30

Milk Sharing

Answer 30

- Another woman who is not the mother breastfeeds the baby because mother is either contraindicated for breastfeeding (HIV), or maternal death occurred.

Question 31

Nutrition for Mother

Answer 31

- Breastfeeding women need 450-500 extra calories a day

Question 32

Breast Care

Answer 32

- 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)

Question 33

Breastfeeding and Contraception

Answer 33

- 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

Question 34

Breastfeeding

Answer 34

- 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

Question 35

Medications and Breastfeeding

Answer 35

- 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

Question 36

Engorgement

Answer 36

- 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

Question 37

Engorgement Treatment

Answer 37

- 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)

Question 38

Sore Nipples

Answer 38

- Best way is to use proper breastfeeding techniques | - Limiting infant time on feedings does not prevent sore nipples

Question 39

Ankyloglossia

Answer 39

- Tongue tie that restricts tongue range of motion for baby. - Can be surgically treated

Question 40

Insufficient Milk Interventions

Answer 40

- Skin to skin contact - Increase feeding frequency - Express milk using electric pump - Rest as much as possible, proper nutrition, reduce stress

Question 41

Galactagogues

Answer 41

- Medications that can increase milk supply

Question 42

Plugged Milk Ducts

Answer 42

- 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

Question 43

Mastitis

Answer 43

- 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