Part II Chapter 10 Flashcards
Engrossment
Parents interacting with their infants
Lactational amenorrhea method
Pregnancy protection during exclusive breastfeedingg for the first six months postpartum
Parent infant attachment
A commitment by parents to love and care for their infant
Reciprocity
The capacity to engage in social exchange
Transition
A life event that creates a need for an individual or family to redefined themselves and their situation
Four stages identified for becoming a parent
Commitment and preparation (pregnancy).
Acquaintance, practice, and physical restoration (first two weeks).
Approaching normalization (two weeks to four months).
Integration of maternal identity (four minutes)
Parental role acquisition
Anticipatory: during pregnancy parents learn about their new parental role by reading, talking with her own parents and asking questions of other family members and parents and attending classes.
Formal: after birth parents want to master practical childcare skills but made like self-confidence and become overwhelmed. Develop confidence in their ability to meet their babies basic needs when provided with concrete demonstration and suggestions.
Informal: parents begin interacting with peers and others in informal interactions and begin to relax the more rigid rules.
Personal: parents modify their practices and evolve their own unique parenting skills
House defined 4 categgories of social suport behavious
INformational suport, Instrumental support, Emotional support and esteem support
Informational Includes Support behavior including offering information, suggestions, directives, or advice. Should encourage exclusive breast-feeding. What realistic, accurate and sufficiently detailed information. Not enough also need instrumental for practical advice.
Instrumental suport - practical and Intangible assistance can include offering time modifying the environment, or helping with physical test.
Emotional support
Breast-feeding parents appreciate informational and instrumental support that is offered with empathy, trust, and concern.
Adolescents need these types of support from nurses, their mothers and fathers of their babies to successfully breast-feed. They need realistic information, accurate and sufficiently detailed along with encouragement for breast-feeding
Esteem support behaviors
Offering affirmation and encouragement and feedback.
Breast-feeding confidence is central to a parents experience of breast-feeding. Experience the diminished confidence include:
feeling unprepared, difficulties initiating breast-feeding, infant who cries inconsolably, unexpected infant breast-feeding patterns, perceived inability to produce enough milk during growth spurts, and supportive comments from family, friends and healthcare professionals, feeling overwhelmed by too many different opinions
Grandmothers tea project
Http://www.illinoisbreastffeding.org/21401/21464.html
Lactational amenorrhea
Menses have not yet returned.
Baby is breast-fed around the clock and receives no other food or pacifiers (minimum of 8 to 12 Breastfeeding sessions per 24 hours, and no more than six hours between feedings, even at night).
The baby is younger than six months
Intimate partner violence during perinatal period. One year before conception
Abused women often exhibit health related behaviors such as missing prenatal appointments, delaying prenatal care until the third trimester, experiencing corn attrition or insufficient weight gain, smoking, or using drugs. These are all associated with adverse event birth outcomes.
Issues from stress during pregnancy
May alter of women’s hypothalamic- pituitary-adrenal axis resulting in higher levels of corticotropin releasing hormone, which could initiate labor leading to preterm birth, restrict utero-placental perfusion leading to low birthweight and small for gestational age and delayed lactogenesis I I.
Past childhood sexual abuse can affect a woman’s health during pregnancy and in the first part
Survivors of childhood sexual abuse initiate and continue breast-feeding at rates similar to those with no history of abuse. \
Some may find put an infant to breast is too traumatic.
May choose to pump and feed milk through a bottle.
50% or more of adolescent mothers experience childhood sexual abuse.
Childhood sexual abuse and intimate partner violence place women at increased risk for depression and PTSD
Adolescent parents
Particularly vulnerable to early introduction of formula and decreased breast-feeding duration. Can influence through social support. Providing social support can build adolescence breastfeeding confidence and can influence their decisions to continue breast-feeding.
Delay childbearing and increased age
Higher rate of scheduled cesarean birth related to the rate of multiple gestation period use of assisted reproductive technology and cesarean birth increase the likelihood of introducing infant formula before discharge from hospital and early weaning in the first four months postpartum.
Facilitative style
Combines consistent information, practical help, and encouragement is an effective way to build breast-feeding confidence.
Business case for breast-feeding
A US program designed to educate employers about the value of supporting breast-feeding employees in the workplace
Exclusive breastfeedingg
Receiving only human milk and no solid food, water, or other liquids
Full-time employment
Working a minimum number of hours (usually 35 to 45). Usually with benefits not offered to part-time, temporary, or flexible workers.
International labor organization (ILO)
United Nations agency dealing with international labor standards, social protection, and work opportunities for all
Lactation support program
Accommodations available in the workplace Medassist new mothers transition back to work. May include physical space, resources, breaks, and breast-feeding support it may be part of employee benefits.
Maternity leave
A period of absence from work for an expectant or new mother, which may last from several days, weeks, or months. Maybe paid or unpaid depending on policies
Occupational hazards
Hazard counter in the workplace that they include chemical, biological, psychosocial, and physical hazards and it’s a risk excepted as a consequence of an occupation
Part time employment
Working less than what is considered full-time, usually fewer than 35 hours a week and a half it without the benefits offered to full-time workers
Paternity leave
Appeared of absence from work taken by a parent. Like the time in monetary reimbursement depending on location and job
Work force
Individuals in the country, area, or business who are engaged and paid employment who are actively seeking paid employment.
Working poor
Individuals who income fall below the poverty level
Workplace environment
Place of employment including physical geographical location as well as immediate surroundings and psychosocial feelings of safety and respect.
When when win for employers, employees, and babies with breast-feeding
Employees: optimal outcomes for the babies health, growth, and development. Significant reduction in numerous acute infections and chronic diseases.
Continued emotional bonding with baby.
Fewer missed days of work because the baby is healthier.
Lower healthcare costs.
Saving energy, time, and cost to purchase, store and prepare infant formula.
Oxytocin released during breast-feeding and milk expression ways to increase feelings of relaxation and a sense of well-being.
Strong sense of reconnection with mother and child when reunited find separation at work.
Employers: fewer employee absence to care for sick baby and shorter absences.
Lower classroom employers who provide healthcare.
Reduce turnover rates and improved employee loyalty to company.
Higher job satisfaction.
Community recognition as a family friendly business.
Community: workplace support for breast-feeding results in longer Breastfeeding duration, with Help and economic benefits
Barriers to Sustaining Lactation after returning to work
Employees: real or perceived low milk production.
Lack of accommodations in workplace.
Time and scheduling issues.
Fatigue, stress and exhaustion.
Feeling overwhelmed with demands of job requirements and meeting child’s needs. Child care concerns and reliance on family for help.
Discomfort in discussing breast-feeding needs with a male supervisor.
Personal concerns such as medical issues, health complications and early breast-feeding challenges
Employers: lack of knowledge about the health benefits of breast-feeding and differences between human milk and artificial milk.
Lack of awareness about breast-feeding laws, numbers of employees breastfeedin, away is breast-feeding can decrease employee absenteeism and lower healthcare cost of the company.
Infrequent request for breast-feeding accommodations.
Believe the breastfeeding will be too fatigued and less productive.
Believe that breast-feeding expression in the workplace will interfere with poor productivity.
Lack of space to accommodate a lactation room and little time for employees to expressed milk.
Liability concerns.
Believe breastfeeding is a personal decision and not the employer’s responsibility Concern that other employers will complain or resent.
Lack of knowledge about how to set up a lactation support program.
Prioritizing other employee health programs ahead of lactation support.
Components of a successful lactation support
A space to express milk that is clean and private and comfortable.
Should be accessible and easy to get to.
Requirements for room include central area that it’s easy to access, private, nearby access to running water, electrical outlet, comfortable chair, table or flat surface, well lit, ventilated and heated or air condition.
Optional features include multi user breast pump, telephone, parenting literature, soft lighting, storage space, footstool and breast-feeding artwork.
A secure place to store milk as necessary.
Employees need time to express milk.
Education with standard information about the company lactation program is important. Support is critical.
Atrophy
Wasting away of a body organ
Cholestasis
Itching of the palms of the hands and soles of the feet is bile salts build up in the body
Clonus
Series of involuntary, rhythmic, muscular contraction and relaxation
Gestational
Of pregnancy
Morbidity
Negative and long-term health consequences following a pregnancy complicated by conditions such as hypertension
Pancytopenia
Deficiency of all three cellular components of the blood (red cells, white cells, and platelets)
Placenta increta
Condition in which the placenta is deeply in bedded into the endometrium and uterine muscle
Placental abruption
Sudden separation of a placenta
Pronuturance
Combination of skin to skin contact and breast-feeding within 30 minutes of birth
Thrombophilia
Abnormality of the blood coloring mechanism in the body (coagulation cascade)
Thromboprophylaxis
Profession of the formation of thrombi (client)
Thrombus
Clot formed inside a blood vessel that obstructs the blood flow through the circulatory system
Hypertensive disorder is a pregnancy
Defined as systolic blood pressure greater than 140 mmHg, diastolic blood pressure greater than 90 mm of Mercury or both based on at least two measurements taken 15 minutes apart using the same arm.
Pre-existing hypertension predates pregnancy or occurs before 20 weeks of pregnancy and is associated with preterm birth, abruption, neonatal unit admissions growth restricted infants and stillbirth.
Gestational hypertension occurs after 20 weeks of gestation, with preeclampsia current many weeks after the onset of gestational hypertension. Characterized by gestational hypertension and new proteinuria (greater than 1+ protein in urine on dipstick), eclampsia and hemolysis, elevated liver enzymes and low platelets, HELLP syndrome)
Maternal a neonatal mortality and morbidity with hypertensive disorder’s pregnancy are too high
Hypertensive disorders of pregnancy and clear preeclampsia claim some 50 to 80,000 lives annually and some 500,000 fetuses and newborns more than 99% of those lives are lost in less developed countries.
Need regular prenatal care with increasing frequency towards the end of pregnancy. Preterm birth is commonly associated with hypertensive disorders.
Preeclampsia or eclampsia can occur in pregnancy or present after the birth of the baby especially in the first 24 to 48 hours and up to two weeks postpartum.
Preeclampsia results in multi organ dysfunction and affects the liver, brain, kidneys, systemic blood vessels and fetus.
Preeclampsia associated with number of predisposing factors: first pregnancy first pregnancy with a particular partner, more than 10 years since the previous baby, previous history of preeclampsia, family history of preeclampsia, multiple pregnancy, and BMI greater than 35.
No known cause for preeclampsia but seems to be associated with abnormal development of placenta.
Symptoms of preeclampsia vary dramatically.
Classic presentation is high blood pressure, visual disturbances, headache, proteinuria, epigastric pain or vomiting, liver tenderness, or signs of clonus.
Blood test should include liver function, renal function, urea and electrolytes and complete blood count.
Raised ALT and AST are classic signs of liver dysfunction in the absence of other hepatic conditions.
Magnesium sulfate may be administered for about 24 to 48 hours to prevent or treat the seizures or eclampsia if the patient is hyper reflective or has signs of clonus and irritability.
Clinical tips for moms with hypertension disorders
Consider the applicable steps from the 10 steps to successful breast-feeding:
education,
only breastmilk unless supplemental‘s are medically indicated,
maintaining milk production if the mother and baby are separated,
rooming in,
support after hospital discharge.
Think about any antihypertensive drugs mothers taking an affects on lactation.
Assist with expressing and storing colostrum antenatally as well as postnataly if the mother is separated from the baby.
Have the mother spend as much skin to skin time as possible with the baby to help heal the trauma of being very unwell in pregnancy and coming to terms with anticipated pregnancy and birth and the reality of their experience.
Consider the impact on breast-feeding and how breast-feeding may help the parent focus positively on the baby.
Venus thrombo embolic conditions in pregnancy
Pregnancy at 5 to 10 times higher risk for a Venous thromboembolism then in general population.
Hormonal change during pregnancy affect venous stasis, the hypercoagulable state of pregnancy and the obstruction of venous flow by the gravid uterus make pregnancy high risk.
When blood flow is slow or disrupted places the individual at risk of a thromboembolic event. Such as long haul flights, especially a pregnant woman, dehydration following severe morning sickness, or slow mobilization find surgery or sedentary lifestyle.
Two main types of thrombus: venous (as in a deep vein thrombosis, or DVT) and arterial (as in the coronary arteries)
Virchow triad is a disruption in one or more of the following: alteration of blood cell caused by injury or infection in a blood vessel, injury of the vascular endothelium, or alterations of the constitution of the blood (hypercoagulability).
Thrombophilia increases the risk of thrombosis. Can be acquired or congenital.
DVT usually occurs in one of the deep veins of the lower limb but can develop in pelvic and upper veins as well.
Clinical diagnosis of thromboembolic conditions
Can be unreliable in pregnancy.
Suggestive signs include pain, especially on walking with localized tenderness, swelling of the affected area of the leg compared with the unaffected leg, and dyspnea (leg swelling and dyspnea could be related to the physiological changes of pregnancy).
Objective testing for DVT or pulmonary embolus includes ultrasound, MRI, or x-ray sonography.
D-dimer not useful because has increased levels during advanced gestation
Individuals who smoke, are obese with a BMI greater than 30 kg/m² or sedentary, had gross varicose bees, or become dehydrated or more at risk of a DVT during child beasring.
DVT may be asymptomatic and difficult to diagnose.
Recognize those at risk and start thrombo prophylaxis by use of compression stockings and anticoagulant therapy. Low molecular weight heparin (LMWH) recommended during pregnancy and breast-feeding because it does not cross the placenta or enter breastmilk.
Warfarin cannot be used in pregnancy but can be used in breast-feeding mothers.
Thromboprophylaxis should be continued for up to six weeks and those who are at high risk.
Induction of labor can be performed at term for those with DVT. LMWH or low molecular weight heparin should be stopped 24 to 48 hours before induction begins then commenced after birth or at least four hours after removal of the epidural catheter.
Those at risk of DVT should not be prescribed combined oral contraception during the first three months after birth.
Those with a history of thromboembolic event have an increased risk in a future pregnancy.
Postpartum hemorrhage
Postpartum hemorrhage (PPH) is blood loss of more than 500 mL and can be greater than 1500 to 2000 mL.
Effect of blood loss, whatever the volume, is suggested to be of more importance of PPH then volume itself.
Primary PPH occurs in the period from birth to 24 hours postpartum.
Secondary PPH occurs from 24 hours to six weeks postpartum.
PPH is unpredictable and unexpected.
Risk factors are antepartum hemorrhage increases susceptibility to PPH.
In developing countries those who have iron deficiency anemia at end of pregnancy are more at risk of PPH because the anemia magnifies the hemorrhage making recovery after birth take longer.
Causes can be related to four Ts:
tone, poor tone of the uterus.
Tissue, retain products.
Trauma, lacerations of the general tract
Thrombin, disorders of coagulation including disseminated intravascular coagulation or DIC.
DIC
DIC is life-threatening and arise a secondary to diseases and conditions that cause hypercoagulation and hemorrhage.
In pregnancy those who have a placental abruption (sudden separation of the placenta), severe preeclampsia or eclampsia, or amniotic fluid embolism are at risk for DIC in pregnancy.
Sheehan syndrome
Can occur affect her postpartum blood loss that affects blood flow to the pituitary gland. Atrophy of the pituitary gland can affect the production of prolactin and the sufficiency of milk production.
In rare cases pancytopenia can occur following Sheehan syndrome after a PPH.
It is suggested that in most cases of PPH the cause of insufficient milk production is due to separation of the dyad.
Early skin to skin contact and breast-feeding after birth reduces postpartum hemorrhage for those at any risk of PPH but especially for those at low risk.
Clinical tips after postpartum hemorrhage
Consider impact of ongoing surveillance of the mother by multiple different healthcare professionals particular in the first 24 hours and what that would do to breast-feeding. Consider blood loss and affect on mothers health including fatigue when learning to breast-feed.
Routinely recommend prenatal expression and storage of colostrum.
Early and frequent skin to skin contact with a baby is vital especially when the mother is in intensive care.
Ensure assistance with watching the baby when mother is in intensive care.
Promote stimulating and maintaining milk production by assisting with milk expression after birth.
Be alert for low milk production which might be due to Sheehan syndrome.
Consider best supplemental feeds for baby including options for human milk.
Recognize the PPH may increase susceptibility to postpartum depression and post traumatic stress disorder which could affect breast-feeding bonding with the baby.
Chapter 13 facilitated assessing Breastfeeding initiation
Asymmetrical latch
Infant latched onto the brass curry more of the underside of the areola with the bottom lip cover most of the areola and the top lip covering somewhat less of the areola
Breast crawl
An organized set of innate behaviors in which the if it moves towards the nipple with the intent to latch and begin breast-feeding
Chest feeding
An infant feeding at the breast of a transgender man
Meconium
Infant spurs store which is black and tarry
Milk transfer
Process of milk moving from the breast to the infant during a feeding session
Nipple confusion
Infant has difficulty latching effectively at the breast after being exposed to artificial nipple
Nipple shield
Nipple shaped thin silicon shield that is positioned over the nipple and areola prior to nursing
Nonnutritive suck
Movement of infant’s jaw with minimal transfer, an average of two sucks per second or several short rapid sucking burst
Rooting
Reflects that is seen in normal newborns who automatically turn the face towards the stimulus and make suck emotions with the mouth when the cheek or lip is touched.
Skin to skin
Placing the naked infant pronoun the parents naked chest
Supplemental feedings
Feedings provided in place of breast-feeding using expressed milk, bank donor human milk, or breastmilk substitutes
Initiation of breastfeedingg
Parents benefit for anticipatory guidance prior to birth of baby.
Promote supportive breast-feeding practices after birth.
Stable infant should be dried and placed on mothers abdomen prior to cord cutting.
Place skin to skin immediately after birth and left undisturbed and unmedicated will self-latch within one hour after delivery.
Healthcare providers should be educated to delay, minimize, or eliminate neonatal and postpartum procedures that interfere with the first breast-feeding.
Minimize oral suctioning deep suctioning can trigger a vagal response in the infant causing injury to the oropharynx and physiologic changes.
Can affect infants desire to latch.
Any nasooropharyngeal suctioning administered at birth were six times less likely to latch effectively.
Wiping a healthy infants mouth and nose to clear the air airways and stimulate the initiation of respiration without the potential adverse effects associated with bulb suctioning.
Delay routine procedures including assessments that can take place later.
For a healthy newborn weight measurements eye prophylaxis and vitamin K injection can be delayed for up to six hours after birth to avoid interfering with infant self regulatory processes.
Early bathing increases risk for hypothermia, removes the mothers bacteria and may inhibit the crawling reflex.
Organized, predictable feeding behavior develops during the first hours of life and progresses through spontaneous cycling and routine, hand to mouth activity, more intense sucking and finally sucking of the breast.
When given the option to progress will go through nine behavioral phases: crying, relaxing, awakening, being active, crawling, resting, familiarizing, cycling, sleeping.
Exclusive Breastfeeding in the postpartum.
Mother in infant should remain together throughout the postpartum. Regardless of the delivery setting.
Educate parents about the benefits of 24 hour rooming and keeping babies with her mothers.
Encourage skin to skin contact. Appears to promote a search in response in the hungry quiet alert and fed.
Milk production is higher when compared to dyads who are separated.
Fostrr an environment that promotes the establishment of breastfeeding.
Provide privacy to facilitate a relaxed focus on the infant to observe and respond to feeding readiness.
Review pages 201 to 203 for breast-feeding positions
Dancer hold
May be needed for a preterm infant or for an infant who has poor child support or control. Grass breast from below with the hand in a U-shaped and the babies chin resting on the fleshy part of the thumb and index finger.
Facilitate an effective latch
Optimal infant behavioral state for large ranges from slightly drowsy to active alert. The quiet alert state is ideal. Several factors may influence a successful latch. Breast anatomy including size and shape of the nipple, breast tissue elasticity and size and shape of the breast. Labor experience. Knowledge about breast-feeding management. For the infant includes oral anatomy including palate, cheeks, lip, tongue and jaw. Gestational age. Labor and birth experiences including medication‘s, length of labor, and assisted labor techniques.
The chin pressing on the breast stimulates the baby to reach over the nipple and grass a mouthful of breast to initiate sucking response. Babies were four times more likely to suck the effectively when their chin may contact with the mother‘s breast as they approach the nipple.
Baby is drawn to the breast and into the mouth. An asymmetrical or slightly off-center latch seems to aid in achieving a deep latch. Lips are flinched out, mouth is wide open, chin is close to or touching the breast, tongue is underneath the breast and over the alveolar ridge.
Signs of an ineffective latch include: tight, pursed lips, lower lip pulled in, dimpling of the cheeks, reports of nipple pain, flattened or misshapen nipple following feeding.
Clicking or smacking sounds during sucking may or may not indicate a problem but was further assessment.
Signs of milk transfer: wide jaw excursions, audible swallowing producing a ca sound from the throat, deep jaw excursions with a pause proceeding each swallow, adequate infant elimination based on age
Assess infants suck
First 24 hours after birth healthy newborn exhibit less rhythmic suckling then older infants.
In first two days of life infant will suck with short rapid burst with each due to the relatively small volume of colostrum.
A regular feeding rhythm begins about the 3rd to 4th day of life with the onset of lactogenesis II.
Nutritive and nonnutritive suckling
Nutritive cycling exhibit deep, slow sucks, about one suck per second, with a brief pause to swallow when the milk starts flowing.
Nonnutritive sucking is more rapid, about two sucks per second, with little or no swallowing noted.
Nonnutritive suckingmay indicate low milk volume.
Pacifiers
Should be used with caution during the new board. Pacifier use may suppress normal infant feeding behaviors and lead to decrease feeding frequency.
The 2016 American Academy of pediatrics task force on sudden infant death syndrome continues to recommend against use of a pacifier until breast-feeding is well-established. The WHO continues to recommend avoiding all bottles, teats, and pacifiers to foster the establishment of exclusive breast-feeding. More study is needed
Monitor the frequency of feeding
Infants should be fed a minimum of eight times in 24 hours.
Watching for responding to early feeding cues is more likely to result in an effective latch. Crying is a late indicator of hunger and may make it harder to latch.
Breast-fed infant should be fed throughout the night.
Some infants may require more frequent feedings while others may cluster feeds close together and then rest for a stretch of four hours or more.
Frequent, unrestricted feedings in the first few days of life facilitate the development of robust milk production.
Skin to skin contact allows the opportunity to observe early feeding cues and rouse a sleepy baby.
Infant should be arouse for a feeding if more than four hours have elapsed since the beginning of the previous feed.
Monitor a sleepy baby
Infants may be sleepy in the first day or two of life.
Evaluation and breast-feeding management may be indicated for a sleepy infant who is not feeding 8 to 12 times in the first 24 to 48 hours of life, demonstrates less than a 7% weight loss, and shows no signs of illness.
Weight loss in excess of 7% may indicate inadequate milk transfer or milk production although weight loss from 8 to 10% maybe within normal limits if all else is going well and the physical exam is normal.
If supplementation is initiated support milk production by early, regular, and frequent milk removal.
In general newborn stools go through several changes in the first few days of life. From black, tarry stools (meconium) followed by transitional stools that are looser and lighter in color.
Poops that may need additional evaluation include: not passing transition or seedy yellow schools by four days of life, having fewer than six clear voids per day by four days of life, appearance of urate crystals in the diaper after three days of life.
Increased stools each day during the first few days of life are significantly associated with decreased weight loss and early return to birthweight.
A continuation of meconium stools on day five of life is considered a delayed stalling pattern.
Evaluate a feeding
A systematic evaluation of feeding session should take place every 8 to 12 hours during the early postpartum period.
Assess for effective position and latch and correct as needed.
Maternal discomfort with continued nipple pain throughout the feeding or increase nipple trauma indicates a need to improve the latch, even when the infant is swallowing and is satisfied after feeding .
Assess the infant for signs of milk transfer: sustain, rhythmic, nutritive suck swallow breath pattern with periodic pauses, audible swallowing which will change based on the age of the infant. Relaxed arms and hands
Evaluate the end of the feeding
The nipple should appear rounded with no evidence of trauma.
Note any abnormal nipple shape, blister, or blanching.
Mother should appear relaxed and report no shoulder, neck, or back pain.
The infant should appear calm, satiated, and relaxed.
Managing challenges in initiating breast-feeding
Reasons for failure to latch include
drowsy mother or infant as a result of labor medication, duration of labor, or labor complications.
Mechanical or physical results of labor and delivery.
Separation of the dyad.
Prematurely.
Infant illness or congenital anomalies, including oral anatomy.
Maternal physical or psychological health problems.
Challenging breast anatomy.
Not latched effectively in 24 hours
Can’t be established with the passage of time, appropriate evaluation and timely interventions
Encourage continuous skin to skin contact and attempt Dane to breast-feed whenever feeding cues are displayed
Benefits of skin to skin contact continue beyond immediate newborn. Dim lights to encourage sleepy infant open eyes go to hell, fussy, overstimulated infant. Avoid using a pacifier
Protect production of milk and colostrum
Effective colostom removal within the first hour of birth maximize benefit of expressing milk to protect milk production.
Teach hand expression within an hour of birth and expression of colostrum may entice baby to latch in feet.
Mother can express colostrum into a spoon and feed it to the baby.
Often a baby will latch and feed effectively at the breast after being fed express colostrum.
Mother is tired, ill, or otherwise unable to participate in milk expression, nursing staff or family member can do it.
Encourage expression eight times per 24 hours and feed milk to the baby until effective feeding is established.
If not latched and fed effectively after 24 hours facilitate use of an electric breast pump. Combining pumping with hand expression maximize milk production.
Systemic evaluation of feeding attempts
Direct observation is essential.
Teach how to soften and damages nipples with gentle pressure applied by the fingertips around the areola called reverse pressure softening.
Teach how to stimulate a nonerectile nipple with hand expression to draw the nipple out and make it easier for the baby to latch.
Pain during latch or throughout a feeding requires assistance and possible correction positioning of latch. If pain persists be on 24 hours or if nipple trauma and it is unresolved with a change in position or latch consider referral for an evaluation of infant oral anatomy.
Use of a silicone nipple shield can facilitate a sustain latch and some circumstances however it requires appropriate use and close monitoring.
Consult with healthcare providers and other disciplines regarding complications that are outside the scope of practice such as restriction on turn movement indicating possible ankyloglossia.
Support infants nutritional needs while determine cause of breast-feeding difficulty.
In first 24 hours of life, feed baby hand express colostrum by spoon or dropper after every breast-feeding attempt watching for early feeding cues.
If challenges continue beyond 24 to 48 hours consider supplementation at the breast using a supplemental device with expressed milk, pasteurized donor milk, or artificial breastmilk.
Volume of supplement to be given varies with age of infant however should always be determined by infants indication of said a fullness.
Healthy breast-fed infants average intake of colostrum is:
first 24 hours to 2 to 10 ML.
24 to 48 hours 5 to 15 ML.
48 to 72 hours 15 to 30 ML.
72 to 96 hours 30 to 60 ML.
Note 10 ml =.3 oz (divide by 30)
Assisting when diet is separated or when breast-feeding is temporarily contra indicated
Begin hand expression within the first hour after birth and continuing expression every 2 to 3 hours for 8 to 12 sessions per 24 hours.
Oxytocin level is highest in the first hour after delivery when colostrum is quite easy to expressed and this is an important window of time to maximize the benefits.
When expressing do for approximately 15 minutes or until milk stops flowing which ever is greater.
Express around the clock and during the night.
Assist family in obtaining a quality breast pump and instruct them on using the pump within six hours of birth or as soon as possible after delivery.
Combining electric pump with hand expression increases mill production and the caloric content of the milk.
Pump not available hand expression will work.
Encourage frequent unrestricted Breastfeeding as soon as conditions permit.
Offer encouragement and emotional support
Task prior to discharge
Develop appropriate plan of care.
Provide referral and contact information for follow up with a breast-feeding expert and other healthcare providers as appropriate.
Complete any needed documentation
Clinical tips for the first days of life
Watch for active sucking.
Listen for swallows.
Monitor stool output and color.
Monitor adequate urine output with at least one or two wet diapers daily on day is 1 to 3 and at least six wet diapers by day four.
Pacifiers should be used with caution because they may interfere with identifying and responding to infant feeding cues.
Request assistance for any nipple pain or trauma.
Place infant skin to scan immediately after delivery to facilitate breast-feeding.
Teach parents to respond to early feeding cues.
Encourage extended periods of skin to skin contact allowing for unrestricted feeding opportunities.
Encourage frequent breast-feeding session 8 to 12 times in 24 hours and monitor the infant for signs of adequate milk intake.
Provide support and assistance with position in latch.
Weight loss greater than 7% may indicate an inadequate milk transfer or low milk production.
Prior to supplementation of formal evaluation of breast-feeding sessions must take place.
If an infant is unable to initiate breast-feeding support the infants nutritional needs through appropriate supplementation and support the mothers milk production using evidence-based techniques for milk expression.
Birthweight
Weight at which an infant is born which comparatively may be qualified as the following: Extremely low birth weight is an infant weighs less than 1000 g at birth.
Very low birthweight infant weighs less than 1500 g (3.3 pounds) but more than 1000 g greater than (2.2 pounds) at birth.
Low birthweight infant weighs more than 2500 g at birth (5.5 pounds)
Early enteral feedings
Feedings of human milk or of human milk substitutes via an enteral tube directly into the infant stomach. Early has been defined as prior to 72 hours after birth in most cases.
Family
Include significant others and is defined by the parent or parents or guardian.
Gastric emptying
The emptying of food from the stomach
Gastric residual
Volume of fluid remaining in a preterm infant stomach at some point after a feeding
Gestational age
Age refer to during pregnancy to describe the time in weeks from from the first day of the last menstrual cycle to the current date.
Human milk feeding
Providing infants with human milk by feeding Methods other than directly at the breast.
Kangaroo mother care (KMC)
Early, prolonged, and continuous skin to skin contact between a birth parent or substitute and a newborn low birthweight infant, both in hospital and after early discharge, until at least about the 40th week of postmenstrual age, with ideally exclusive breast-feeding and proper follow up. May also be referred to as kangaroo care or skin to skin care.
Lactoengineering
Tailoring breastmilk to the specific needs of a baby. May include separation of hind milk for preterm infants for greater calorie and fat intake at a lower volume.
Luer taper
Used for making leak-free connections. Standardized system a small scale fluid fittings or mechanical and laboratory instruments to connect a male taper and its female counterpart. Including hypodermic, syringe tips and needles or stopcocks and needles.
Neonatal intensive care unit
Specialty unit or Ward were intensive care is provided to preterm and all newborn babies that are ill
Postmenstrual age
Corresponds to gestational age plus chronological age
Postnatal age
Corresponds to chronological age or time elapsed since birth
Preterm
Babies born before 37 weeks gestation have been completed, including the following. Extremely preterm is less than 28 weeks.
Very preterm 28 weeks to 31 weeks and six days.
Moderately preterm 32 weeks to 33 weeks +6 days.
Late preterm 34 weeks to 36 weeks +6 days.
Supplementation
Feeding by other means than at the breast. Can consist of human milk or human milk substitutes.
Breast-feeding pre-term infant benefits
Optimal feeding behavior for human infants whether born at term or preterm.
Mothers owm milk at the breast or expressed is the optimal milk for the preterm infant. Morbidity and mortality rates increase significantly when infant is not fed human milk. Preterm infants when fed human milk accrue immune system enhancements, gastrointestinal maturation, and nutrient availability.
Pasteurized donor human milk is gold standard when parent milk is not available. Human milk leads to achievement of greater enteral feeding tolerance and more rapid advancement of full enteral feeds. P
hysiological amino acids and fatty acid profiles enhance digestion and absorption of these nutrients.
Human milk results in a low renal solute load.
Gastric emptying time in a formula fed preterm infant can be up to twice the time of human milk in food (51 versus 25 minutes).
Human milk contains active enzymes (such as lipase, amylase, and lysozyme) that are lacking in the under developed intestine or intestinal system and provide tropic factors that hasten the maturation of the preterm intestinal system.
Human milk provides for optimal development of visual acuity and retinal health. Preterm infants show higher IQ values. Long chain poly unsaturated fatty acids that are present in human milk but not many formulas are considered to be closely linked to this outcome.
Human milk provides protection from environmental pathogens.
Breastfeeding offers positive effects for children’s health
Respiratory benefits.
Decreased diarrhea episodes.
Decreased acute ear infections.
Decrease sudden infant death syndrome.
Decreased necrotizing enterocolitis or NEC.
Increase cognitive development with breast-feeding is strongly associated with better intelligence even controlling for confounding variables such as maternal IQ.
Preterm human milk ideally suited for preterm infant
Optimally suited for the maturation of systems, immunological requirements, and growth of preterm infant.
Human milk is a medicine for both the infant and the mother.
Preterm milk is optimal for the preterm infant because of the infants limited renal concentrating and diluting capacities, a large surface area in relation to weight, and insensible water loss.
Preterm milk has higher concentration of calories, lipid lipids, high nitrogen proteins, sodium, chloride, potassium, iron, and magnesium.
Calcium and phosphorus are the most commonly lacking macrominerals in pre-term milk. Often extra nutrients, vitamins, minerals are added for very low birthweight and fat but the research isn’t clear on this yet.
Milk from mothers of preterm infants matures to the level of term milk at about 4 to 6 weeks.
Preterm infants have unique needs for nutrition and optimal growth
Have special nutritional needs because lack sufficient subcutaneous fat, brown fat, and glycogen which contributes to an increased risk of hypothermia and hypoglycemia. Optimal growth is typically based on the growth curve they would’ve followed it remained in uterus.
Extremely low birthweight infant has a high energy requirement but limited volume tolerance.
Early enteral feedings of human milk before infants really ready to be fed by mouth may prime the gut.
Can be called trickle feeds, trophic feeds, or gastrointestinal priming feeds. May facilitate protective gut Flora, improve bowel emptying of meconium, and decrease morbidity and mortality from NEC.
If using an an an infusion pump the syringe should be ~upward at a 25 to 45° angle so lipids rise to the Luer Taper of the syringe and infused first which gives him more calories.
Other needs a pre-term infant to facilitate Norma Grove and development
Respiration rate within normal range and stable.
Maintain blood sugar above 2,5 mM/L (40 mg/dL) because neonatal hyperglycemia could have serious ramifications.
Maintain body temperature within normal limits.
Adequate nutrition intake for each infant.
Metabolized energy requirement varies according to gestational age, weight, and wellness of the preterm infant. It can vary from 109 to 140 kcal per kilogram per day. Continuous or intermittent kangaroo mother care or skin to skin contact whenever possible and as long and as often as mothers are able to willing to provide us care
Preterm infants receive at times fortified human milk
Can be fortified with commercial fortifiers that include cows milk based protein, electrolytes and a number of vitamins and minerals.
Can be fortified with specific nutrients such as calcium and phosphorus.
Usually begun after feeding is established and discontinued before discharge.
Using hindmilk portion of Xpress milk provides high calorie low volume low osmolar, readily absorbable supplement.
Commercial fortifiers are used to supplement essential nutrients.
Hind milk provides a concentrated source of lipids and calorie and can be used to increase caloric intake.
Lactoengineering can further refine and tailor milk to a specific infants need.
Lipid and calorie content of the milk can be estimated by creamatocrit,
Issues with fortification of human milk
Significantly slower gastric emptying times.
Neutralizing effect of some of the anti-infective (lactoferin) properties of human milk. Possible increase risk of infection.
Higher osmolarity of fortified milk increases the morbidity from gastrointestinal disease. Some nutrient loss can occur through enteral feeding tubes including lipids adhering to the lumen of a feeding tube, greatest lipid loss occur with continuous slow infusion so bolus feedings are preferred.
May influence short term outcomes.
Powdered fortified are controversial and require surveillance as they may not be sterile. Liquid fortifiers are often used in a one:one ratio with human milk reduction resulting in a reduction of human milk intake.
Key issues for breast-feeding related to prematurity
Pre-term infant spend more time in a diffuse, drowsy state with frequent shifts between sleep and alertness.
Direct light is an obstacle to eye-opening. These responses indicate a limited ability to handle visual stimuli.
Voices in a normal conversational tone, activity in the visual field, and touch by stroking and tickling the skin can cause stress. Resulting in irregular respiration and movements. Instead gentle still touch and sounds of a soft voice are appropriate.
Habituation or the capacity to shut our common environmental stimuli does not occur until the infant matures to term age so are easily overloaded.
Strategies for introducing Breastfeeding to preterm infant
There are no tests that inform clinical practice.
No restrictions need to be applied.
Offer parents an opportunity observed while breast-feeding with guidance.
Studies show that breast-feeding can be safely introduced from 29 weeks postmenstrual age. The only criterion for introduction of breast-feeding was the absence of severe apnea, bradycardia and desaturations.
Transition from schedule 2-hour feeds to unregulated feeding can be introduced when the infant shows signs of milk intake such as audible swallowing.
As transitioning to unregulated feeds not necessary to have fixed volumes per feet or fixed intervals for supplementation.
The preferred method for oral supplementation is cup feeding not bottlefeeding
Conditions associated with prematurity that may affect breast-feeding
Respiratory distress syndrome. Necrotizing enterocolitis. Hyperbilirubinemia. Intracranial hemorrhage. Hypoglycemia. Bronchopulmonary dysplasia a chronic lung disease that develops in preterm infants after a period of positive pressure ventilation. Patent ductus arteriosus. Sepsis.
All result in significant treatment and more separation of mother from child
Perinatal acidosis
Preterm infant requires individualized developmental care
Can be incorporated in all intensive care units. Some of the benefits include greater parental involvement and nurturing care,
more time for adequate rest for the infant, this prevents promotes brain development, prevention of overstimulation, reduced heart rate, reduce need for oxygen, early removal from a ventilator earlier initiation of breast-feeding, better weight gain, reduction in rates of infection, shorter hospital stay, improve medical and Nuro developmental outcome.
Examples of an environmentally sensitive special care nursery
Lights below 60 foot candles, blanket covering isolate low enough to protect infant’s eyes from direct light, day and night rhythms, cluster care across disciplines allowing for longer sleep periods, controlled noise levels less than 50 dB, positioning the infant to promote feelings of security, and containment preferably done by the parent, gentle pressure on the infants back or chest with an open hand to help infants organize themselves, supporting infant with blankets and rolls while supine or prone, providing boundaries when infant is lying prone, wetting a fist with Express milk and positioning it near the infants nose and mouth, use of expressed milk for oral care to help the infant identify the parent smell and taste of milk.
Recognition of breast-feeding is a developmental skill that will happen when an infant is neurobehavioral ready.
Sucking pressures are lower in preterm infants increasing the difficulty in transferring milk so the goal of early feedings is to allow the infant to gradually increase breast-feeding skill and stamina.
Focusing on weight or milk transfer too early can undermine confidence and put breast-feeding at risk.
Encouraging infants skin to skin continuously or as long and often as parents are able and willing.
Appropriate pain management.
Massage therapy for infant who show benefit,
music therapy.
Management of the preterm family for breast-feeding success
Mothers have identified five positive outcomes or rewards from their preterm breastfeedingg including the health benefits of human milk, knowing that they gave their infants the best possible start in life, enjoyment of the physical closeness, knowing that they made a unique contribution to the infant care, belief and experience the breast-feeding was more convenient.
Parents of preterm infants have special needs
May require special medical consideration from a complicated Pregnancy
May lack Breastfeeding Knowledge,
parental socioeconomic characteristics and infants gestational age, weight, and morbidity may affect successful breast-feeding,
Parent should be provided with information to make an informed decision regarding breastfeedingg, facilitating parental infant care in the nursery will increase their confidence, will need help establishing and maintaining Lactation.
NICU should provide a supportive environment for breast-feeding including privacy and quiet, open unrestricted access for parents with their infants information should be consistent and correct, sufficient private space needs to be provided for skin to skin care, breast-feeding and milk expression.
Necessary equipment includes breast pumps and comfortable chairs are beds to ensure parents presence by their infant and for frequent skin to skin contact.
Parents require counseling regarding alternative oral feedin methods and other options to bottlefeeding.
The Neo-BFHI
Guideline developed by the Nordic and Québec working group based on recommendations by the WHO and UNICEF in the baby friendly hospital initiative. Hospitals may adopt the baby friendly hospital initiative 10 steps to successful breast-feeding to integrate guidelines for preterm and sick infants. These steps are expanded for neonatal care based on relevant evidence, expert opinion, and experience implementing baby friendly practices in NICUs
Kangaroo mother care
KMC was developed in a Nicu in Bogota Colombia. Developed in the 1970s to prevent overcrowding and parents abandonment of infants. Also referred to as skin to skin. Babies born at gestational age of 27 weeks or less can have intermittent kangaroo mother care.
Gestational age of 32 weeks or greater can be cared for with continuous skin to skin Contact essential that the infants place with most of the body including the head and direct skin to skin contact with a parent.
Infants born at gestational age of 28 to 31 weeks should have continuous skin to skin care directly after birth and an incubator should only be used when necessary. Professionals should assist parents when introducing kangaroo care with positioning, provide appropriate clothing so that all skin services are adequately covered including head to ensure there is no temperature leakage.
Transfer of sensitive infants should be monitored by staff.
Stable infants can be transferred by parents to skin to skin.
Must make sure parents are comfortable when hold skin to skin. Privacy should be insured as much as possible. Early breast-feeding can be a component of kangaroo care. Can begin when infant is stable and still intubated.
There is high-quality evidence that significant reduction in the risk of mortality nosocomial infection or sepsis and hypothermia when using skin to skin.
Also moderate evidence that’s demonstrated increased weight gain length gain,head circumference gain and positive exclusive breastfeedingg a discharge and at 1 to 3 months follow up.
There are also benefits for the parent including increase bonding, confidence more more in control, reduction in parental stress, increase milk production, earlier discharge from the hospital, and significantly reduced cost.
Professional support for parents of preterm infants
All parents should be offered prenatal information about the importance of breast-feeding and human milk. Should establish a breast-feeding plan. Should have appropriate management in establishing and maintaining milk production. Breast-feeding the preterm infant requires a commitment of parental and family time and energy.
Establishing and maintaining Lactation with a preterm infant
Milk expression should begin between one and six hours after birth.
The hospital grade electric breast pump is recommended.
Breasts should be massaged prior to pumping.
Pump eight times in 24 hours along with hand expression during the first three days. Ensure appropriate enough storage for expressed milk.
Breast-feeding should begin as soon as the infant shows signs of rediness without any unjustified delay.
Help parents transition the baby to the breast including offering pillows for positioning and helping to achieve a comfortable position.
Preterm infants are more active at the breast when they are held with still hands they do not appreciate stroking and tickling.
Talking in a soft voice provides gentle stimulation.
Transition from tube to oral feeding and from scheduled to unregulated feeding demands that feeding should occur with semi demand feeding as an intermediate phase. The infant should be put to breast as soon as the parents notice that the infant is waking up and show signs of interest. There are no restrictions on the frequency or intervals between breast-feeding sessions or on duration of sessions.
Complementary feeding is given with a prescription of a total daily volume of supplementation based on infants weight gain.
Discharge planning
Parents require a detail plan to care for their pre-term impent after discharge.
Must watch for signs at infant is getting enough milk by using weight checks. Also count the number of wet diapers and bowel movements.
Feeding should be at least eight per 24 hours with only one prolong sleep of up to five hours.
Milk expression should continue until infant is fully established at the breast.
Best if milk production exceeds what the infant needs a discharge because the infant increase volume helps the milk flow freely in the presence of a weaker suck.
When appropriate ensure that parent knows how to feed using a cup, feeding tube at breast, supervision of the use of a nipple shield, close follow up to continue as progress has made towards full breast-feeding.
Indications for the use of a tube feeding device at the breast include an infant who latches but exerts low milk transfer, lack of sucking rhythm, parents request a supplement in the breast with a lactation aid, when there’s limited milk production, impaired milk ejection reflex.
There should be a post discharge telephone follow up.
Parents should be given information about the availability of support services after discharge.
Late preterm infant
May be particularly vulnerable because they might look full-term as infants born in term but are not fully developed.
They are at increased risk for hypoglycemia hypothermia, respiratory morbidity, apnea, severe hyperbilirubinemia, dehydration, feeding difficulties, prolong artificial milk supplementation, weight loss, and hospital readmission.
There is an increase in late preterm birth probably due to increase in maternal age, obesity and diabetes, poor nutrition, smoking, alcohol use, and assisted reproductive technology resulting in multiple births.
Also increased obstetrical surveillance may lead to induction of labor a C-section. Because there is a wide range from 34 to 36 weeks and six days they need an individualized plan.
A stable infant should be placed skin to skin with a parent immediately after birth.
Avoid or delayed disruptive procedures like excessive handling, necessary suctioning administer vitamin K etc.
Parents may need help positioning the infant for breast-feeding.
Cross cradle hold works well and the dancer hold for support at the breast and may help an infant with jaw stability.
A silicone nipple shield can also be considered if latch is difficult and it’s not sustained or there is evidence of ineffective milk transfer.
They may need to be awakened every 2 to 3 hours for feeding.
Important to do close observation assessment of the infant at the breast using a breastfeedingg assessment tool such as latch, audible swallowing type of nipple, comfort, maternal HELP (laTCH) or infant breast-feeding assessment tour (IBFAT).
Monitor urinary and stool patterns as important.
Also use milk expression if infant is not breast-feeding effectively.
Any supplementation should be small: 5 to 10 ML per feeding on day one and 10 to 30 ML per feeding there after.
Milk expression should continue until infant demonstrates ability to sustain breast-feeding at least eight times each 24 hours and shows appropriate weight gain over time.
Timing of discharge include breast-feeding is going well or in combination with appropriate supplementation, milk production is becoming established infant can maintain normal body temperature in an open crib, bilirubin is stable or decreasing. Discharge strategies include parents demonstrate comfort with any alternate feeding methods, comfort with breast-feeding, follow up visit within 24 to 48 hours of discharge then weekly, post discharge feeding plans develop with the family, lactation consultant and healthcare provider, feeding log is provided to document the number of feedings, urinary output and stool in, parent is given a referral for post discharge lactation support.
Breastfeeding Multiples
Artificial Infant Milk (AIM)
Nonhuman animal or plant derived infant milk marketed and used as a replacement for some, or all, human milk in an infant’s diet.
Assisted reproductive technology (ART)
Techniques inn which both ova and sperm are hadled, including in vitro vertilization (IVF) with or without intracytoplasmic sperm injection (ICSI)
Expressed Human Milk (EHM)
Human milk obtained via milk expression
Extremely low birth weight (ELBW)
Less than 1000 g (2.2 pounds.
Dichorioic-diamniotic plactatation (Di/Di or DCDA).
Pregnancy in which each multiple has its own placenta with an outer chorionic and an inner amniotic sac. Multiples are usually dizygotic but may be monozygotic.
Gestational
Number of completed weeks plus days, Measure beginning with the first day of the last menstrual period until the current point in pregnancy or the day of delivery. Two weeks is added to conceptual age when ART was used to achieve pregnancy.
Higher order multiples (HOM)
Three or more multiples from one pregnancy.
Human milk fed (HMF)
Feeding of expressed human milk
In vitro fertilization (IVF)
A type of MAR in which over are removed from a woman’s ovaries and fertilized by sperm and a laboratory procedure, followed by one or more of the fertilized over being returned to the woman’s uterus.
Intrauterine growth retardation (IUGR)
Fetal weight determined by ultrasound to be below the 10th percentile for gestational age
Low birthweight
Less than 2500 g (5.5 pounds)
Medically assisted reproduction (MAR)
Use of medical techniques to treat subfertility and achieve a pregnancy includes ovulatory induction medications, ART, or a combination of medical and surgical techniques.
Monochorionic-diamniotic plancentation (MO/DI or MCDA)
Share placenta and outer chorion, but each multiple is within its own inner amniotic sac.
Monochorionic monoamniotic plancentation (MO/MO or MCMA)
Share placenta outer chorion and inner amniotic sac
Monochorionic placentation (MC)
MC multiples who share a single placenta in an outer chorionic sac. The types include monocorionic diamnitic and monochorionic monoamniotic
Monozygotic
Twins developing from one of them that is fertilized by one sperm creating one psycho they completely divides to form to genetically identical zygotes. Also called identical twins
Mother of multiples (MOM)
A woman who carries and then gives birth to two or more infants from a single pregnancy. The parent whose gestational carrier gives birth to two or more infance from a signal pregnancy. A parent who adopts two or more infants born from a single pregnancy.
Mother of twins (MOT)
The woman who carries and then gives birth to two infants from a single pregnancy. Appearance who’s GC gives birth to two infants from a single pregnancy. Apparent who adopts to infants born from a single pregnancy.
Plcentation
Formation, type and structure, or arrangement of placenta or placentas including the following preterm (PT) less than 37 weeks gestation completed at birth including the following extremely preterm (EPT) less than 28 weeks very preterm (the PT) 28 to 31 weeks 0 to 7 days moderately preterm (MPT) 32 to 33 6/7 weeks late preterm (LPT) 34 to 36 6/7 weeks
Simultaneous feeding
Feeding to infants from a set of multiples at the same time, with one of each breast. Also called tandem feeding.
Small for gestational age (SGA)
Infant who is smaller in size (below 10th percentile) than the normal parameters for gestational age
Term
Weeks of gestational age at birth includes the following. Early term (ET) 37 to 38 6/7 weeks. Full term (FT) 39 to 40 6/7 weeks. Late term (LT) 41 to 41 6/7 weeks. Post term 42 weeks or more.
Twins
To infants from one pregnancy
Very low birthweight (VLBW)
Less than 1500 g (3.3 pounds) but more than 1000 g (2.2 pounds)
Zygosity
As a pertains to twinning the development of multiples from one or more fertilized ova (dizygotic or monozygotic)
Multiple birth rate
Ranges from seven per 1000 to 34 per 1000 worldwide.
Higher birth rate of twins in industrial nations where parents delay childbearing and there are fewer restrictions on the number of embryos that may be transferred during in vitro fertilization.
Monozygotic twins is approximately four per 1000
Triplets in industrialized nation is 1 to 2 per 1000.
Before MAR the incidence was approximately one per 7500 to 10,000 live births
Barriers to Breastfeeding multiple birth neonate
Have a higher risk for fetal, neonatal, and maternal complications.
Infant related barriers to breast-feeding initiation, duration and exclusivity are many times more likely to affect multiple birth neonate.
Incidence of preterm or very preterm birth is 9 to 10 times higher for twins than for single born infants.
Approximately 10% of preterm twins and 40% of preterm higher order multiples are born very preterm.
Likely to have low birthweight and very low birthweight.
May be small for gestational age or affected by intrauterine growth restriction.
There may be central nervous system or musculoskeletal consequences affecting an infants sucking.
American College of obstetricians and gynecologists currently recommend delivery between 34 and 376/7 weeks of gestation for an otherwise uncomplicated monochorionic diamniotic twins gestation and cesarean delivery between 32 and 34 weeks for an uncomplicated monochorionic monoamniotic gestational period
Multiple pregnancy associated with an increased risk of a congenital abnormality including nursing related to early fetal development and those associated with interuterine crowding in the last trimester of pregnancy.
Separation of a parent in one or more multipled in an neonatal intensive care unit as well as any immaturity or physical systems affecting breast-feeding or milk expression initiation may have short or long term affects on breast-feeding.
Maternal morbidity and mortality increase during multiple pregnancy and birth. These may delay breast-feeding initiation or milk expression if they interfere with self-care ability.
Complications that are more common include hypermesis gravidarium, hypertensive conditions including preeclampsia and HELLP syndrome, gestational diabetes antenatal and postnatal anemia, surgical delivery, postpartum hemorrhage, or placental anomalies such as previa or abruption and DVT.
Almost 75% of twins and 95% of higher order multiples in US now delivered via C-section. Certain medical conditions such as PCOS, thyroid related conditions for obesity which may contribute to subfertility may also result in lower milk production.
Perinatal mood disorders are more common among mothers who kept giving birth to multiples.
Right to breast-feeding relationship
Have the same right to a breast-feeding relationship with human milk as a single birth infant. Parents are discouraged from breast-feeding multiples by healthcare professionals for reasons based less on evidence and more in assumption, attitude, or anecdote.
Anticipatory guidance prenatal preparation for breast-feeding multiples
 preparation for breast-feeding multiples should include an assessment of Breastfeeding, lactation in any previous history of breast-feeding or milk expression. Discuss the advantages and disadvantages of breast-feeding two or more.
Advantages include immunological and anti-infective properties, parents experience an eventual time-saving when simultaneously feeding to implants, direct contact with each infant is increased, time is invested in the infants rather than formula feeding, after the parent is past the initial learning curve breast-feeding is easier, breast-feeding is less expensive, pregnancy weight may be loss more quickly.
Challenges include requires ongoing milk expression and use of hand pump, increase time required for learning curve, sufficient milk production for multiple instances of concern, others cannot help with feeding including night feedings, transitioning of a preterm newborn to direct breast-feeding feels overwhelming, hard to return to work. Reinforce research in case study evidence demonstrating that most parents can produce enough milk for two or more newborns through infancy and into toddler years.
Help parents develop realistic, individualized short and long-term breast-feeding goals. Provide anticipatory guidance including the development of a breast-feeding plan that may minimize the barriers commonly affecting the initiation and timing of lactogenesis II with multiple neonates.
Discussed parents pregnancy diet.
Provide evidence-based information about vaginal versus cesarean multiple birth delivery.
A trial of labor before cesarean may be possible when the infant presenting first is vertex.
Convey importance of early within one hour to an hour and a half for frequent breast-feeding her milk expression to maximize milk production.
Explore options for obtaining donor human milk in the event milk production is insufficient.
Initiating Breastfeeding in Lactation
Should mimic that for a singleborn infant.
Encourage separate rather than simultaneous feedings at least until each infant is assessed for and demonstrates effective breast-feeding behaviors and one infant consistently latches deeply and painlessly.
Simultaneous feeding varies from the first 24 hours to several weeks or months after birth.
Encourage mother to have an around the clock supportive assistance to help with the neonate care and provide breast-feeding help for positioning infants.
Assist with affective milk removal via breast-feeding or milk expression at least eight times in 24 hours or show caregiver how to help.
Provide appropriate discharge planning that includes coordinate breast-feeding at infant care, how to monitor breast-feeding outcomes, how to distinguish breast-feeding issues from issues related to having two or more infants.
Initiating breast-feeding with preterm or otherwise compromised neonate will almost always require milk expression to establish and maintain lactation.
Initiate manual milk expression within 60 minutes or at least within six hours of birth. Instruct the mother on the use of hands-on technique in combination with a multi user, double electric breast pump.
Encourage frequent skin to skin contact.
Direct Breastfeeding in NICU stay is associate with higher rates of continued milk expression upon discharge.
A thin silicone nipple shield has been found to improve the effectiveness of milk transfer at the breast for some preterm infants.
A key point in a discharge plan is the protection of adequate milk production for all infants should include a high-quality multi user electric pump.
Bilateral expression of milk at least eight times in 24 hours. Milk expression more often during the daytime hours to allow for one 4-5 hour period of uninterrupted sleep at night.
As needed use of some form of power pumping for several consecutive days to boost milk production such as alternating pumping with no pumping every 10 minutes for one hour or pumping for 5 to 10 minutes whenever possible.
May also include psychosocial factors that affect discharge with multiples.
Make sure breastfeedingg parent has a printed copy of community breast-feeding support.
Biopsychosocial issues affecting breast-feeding duration with multiples
Discontinuation of breast-feeding postpartum includes factors related both to the parent and the infants.
Postnatal mental emotional conditions are more common after a multiple pregnancy and appear to be unrelated to the type of conception.
Incidence of postpartum mood disorders are 2 to 3 times higher in parents of multiples. High risk pregnancy and birth and staying in a NICU have been associated with symptoms similar to PTSD.
Forming an individual attachment with each infant in a set of multiples is more complex and takes longer therefore it is a more vulnerable process.
One aspect of the attachment process is differentiation. This may include comparisons of multiples physical and behavioral traits with a desire to treat each infant separately but also equally or fairly. This can affect breast-feeding multiples. Trying to treat equally or dealing with multiples as a unit may result in ignoring individual behavioral cues that could affect weight gain and growth.
Concern for older children and meeting their physical and emotional needs can complicate the early intense period of breast-feeding.
Maintaining breast-feeding after all multiples breast-feed effectively
When all infants are breast-feeding effectively it is a reason for an IBCLC to follow up. Can benefit from help develop a plan for coordinating breast-feeding in a way that accommodates the individuals infants needs and feeding patterns, the parents physical and emotional needs and other family demands.
Should review the variations in the infants normal breast-feeding patterns associate infant for breast-feeding ability, effectiveness of milk transfer use of 24 hour and fill out individualized feeding logs should be used until adequate eating is established, revise milk expression and complementary or supplemental feeding plan based on parental breast-feeding goals,
direct breast-feeding if that is the goal a few days around the clock breast-feeding may help complete the transition, effective breast-feeding is assessed for each infant any feeding rotation option can work if it is based on the individual inference cues,
if all infants breast-feed effectively and both breast produce milk adequately the parent may consider assign each infant a particular breast: advantages include helping an ineffective nurser, certain position anomalies, minimize cross-contamination but disadvantages include may affect milk production if attempt to monitor feeding babies at the same time, effects one infants intake leading to reduced growth if one breast produces less milk, contributes to infant refusal to feed on the opposite breast if one breast cannot be used for some reason, results and significant but temporary difference in breast sizes.
Parents with triplets may rotate infants and breasts more often. Parents with triplets may rotate infants and breast more often.
Parents with quadruplets do not tend to follow rotation although rotation plans for twins may be adapted for an even number of multiples.
Parents with higher multiples often include alternate alternative feeding in the rotation plan.
Many parents struggle with whether to feed twins separately or simultaneously. Advantages include saves time, facilitates the development of daytime and nighttime routine, theoretically increases milk production, may improve the breast-feeding behavior of one infant who is less effective at the breast by feeding with an effective breast-feeding infant.
Disadvantages of simultaneous feeding include often reinforce an ineffective latching or sucking behavior, may be difficult to manage two newborns who have little head or body control, may be difficult to facilitate latch for discrete breast-feeding during the early months, may be associated with feelings of aversion for some particulary later inn infancy and toddlerhood.
Positions for simultaneous feeding
Cradle clutch combination. May also be called a layered or parallel hold.
Double clutch may also be called a double football or double underneath arm hold. Double cradle variation is the V hold or double parallel hold with one baby along each side of the parent in a reclined position.
Double laid-back or double straddle most often when the parent is in a slightly reclined or semi semi reclined position.
Comfort breastfeeding
Breastfeeding used for comfort when a child is fearful, and pain, or negative emotional support.
Gastro esophageal reflux disease (GERD/GORD)
Infant symptoms of reflux with symptoms of coughing, weight loss, or excessive crying where the esophagus become irritated from stomach acid
Lactose overload
Ingestion of a large volume of high-lactose low fat milk, causing excess gas that leads to pain
Milk stasis
Stagnant milk in the breast related to milk flow issues from a variety of causes that may include poor large, and frequent feeding, and insufficient acting of the breast
Posetting
Bringing up milk during or after a Feeding
Self weaning
Infant initiated weaning. Sometimes this may occur before the baby is developmentally ready to wean and can usually be reversed with parental efforts.
Tandem breastfeedingg
Continuing to breast-feed an older child after the birth of a sibling
Weaning
The sensation of feeding at the breast. Referred to the introduction of solid foods as the beginning of weaning
Babies age and stomach size plays a role in determining both how much milk is taken in at each feeding and how many times per day baby needs to breast-feed
Newborns taken in:
2 to 10 ML per feeding on the first day of life (max 1/3 oz)
5 to 15 ML per feeding on day two (max 1/2 oz)
15 to 30 ML per feeding on day three, (max 1 oz)
and 30 to 60 ML per feeding on day four of life. (Max 2 oz)
Hospital feeding practice tend to exceed infants physiological needs. This is shown by the large amount of artificial milk provided in 60 and 120 ML bottles. Leads to over feeding of both breast-fed and formula fed infants.
In the first day the breast-fed baby consumes an average of about 30 ML per day. At one week the average intake increases to 300 to 450 ML per day peak milk production is established by about one month postpartum and remains relatively stable until complementary foods are added at about six months of age. By one month of age a thriving breast-fed infants intake ranges from 330 to 1220 ML per day with an average of about 750 to 800 ML.
Growth spurts
Intense breast-feeding to adjust milk production. Often occurs about 2 to 3 weeks, at six weeks, and again at three months.
Babies may become easily distracted while at the breast
Around three months babies may become easily distracted by activities going on around them.
Many babies breast-feed longer and drain the breast more fully at night.
Breast-feeding in a darkened room with fewer distractions may help.
As babies become more mobile they often become increasingly distracted. This does not mean an interest in weaning.
Babies may clamp down on the breast during feeding for a number of reasons. Includes eruption of teeth may cause biting during feedings. May be the result of holding the baby in an awkward position. Babies cannot suck and bite at the same time. Observing when the biting occurs may lead to resolution. Have a baby clamps down explore the cause then proceed with possible interventions.
Provide the baby with a cold or frozen TV room.
Pull the baby in close toward the breast so the baby can naturally release the breast to breathe.
Avoid startling the baby by crying out.
In the feeding calmly and firmly and put the baby down.
Avoid say no because most babies may not differentiate between no biting and no feeding.
Evaluate the babies latch to prevent nipple damage. Have a finger ready to slide into the babies mouth and brake suction.
Colic
Described as excessive crying in an otherwise healthy baby. The classic 3– 3–3 definition of crying of colic is crying for greater than three hours per day, for greater than three days per week, and for greater than three weeks.
Some theories include GERD, food intolerance, lactose overload and improper feeding, maternal smoking, disruption of Gastro intestinal flora, pediatric migraine headache
Interventions include probiotics, manipulation therapies such as chiropractic treatments, changes in the maternal diet, increase skin to skin contact and holding, position adjustments to help avoid or manage trapped gas.
May associate feeding with pain resulting in slow weight gain.
Infant may frequently go to the breast for comfort increasing milk production and resulting in over feeding which in turn causes more pain.
Continuing to breast-feed is encourage.
Position infant in an upright position in the clutch hold straddle across the parents lap or try laid back biological nursing position.
Feeding on one breast at each feeding may avoid distending the stomach.
Feed the infant frequently.
Keep iinfant up right after feedings.
GERD
Medical condition diagnosed and treated by the infants primary healthcare provider.
Reflux is normal in infants younger than one year and requires no intervention.
Reflux becomes Gerd when symptoms such as coughing, weight loss, excessive crying occur and the esophagus becomes irritated from stomach acid.
Feeding management alone sometimes can resolve GERD symptoms.
Interventions to manage GERD include small frequent feedings with the infant in an upright position, medication such as proton pump inhibitors, trial of removing common allergens from the maternal diet.
Lactose overload can Impact The Infant weight and cause confusion
Lactose overload occurs when a baby gets a large volume of high lactose, low fat milk causing excess gas. These babies often present as “chubby after the parents interpret cry as hunger and the baby seek the breast for comfort. Feeding the baby from the same breast for several feedings in a row may decrease the amount of milk and lactose the baby receives per feeding and lead to more comfortable feeds.
Lactose malabsorption or lactase deficiency can be confused with an allergy to cows milk. It can be beneficial to restrict maternal intake of cows milk products to help relieve the infant symptoms. Incubation of expressed milk with lactase drops may be affective if the symptoms are severe. Latose overload with lactose intolerance and milk allergy may need help understanding the difference.
Sudden refusal to breast-feed reasons
Mothers return of menses, parental stress, maternal dietary changes, and unpleasant taste in the milk, change in the parents odors or aromas, a cold restricted nasal airflow or earache in the baby, teething discomfort, episode of biting with a startle and pain reaction by the parent restricted feedings because of sleep training programs, period of separation of the parent and baby, babies increase distractibility, travel or changes in the home environment.
Interventions include breast-feeding a quiet dark location, increased contact between the parent and baby without actively putting the baby to the breast, attempt to feed when the baby is sleepy before waking up from a nap, hold the baby skin to skin in a warm bath tub, attempt to breast-feed while walking rocking or dancing with the child, avoid startling the infant if biting occurs, rule out isn’t it illness, oral cavity problems or dental conditions, offer the breast frequently but do not coax too much
Breast refusal that lasts more than a day or two might require milk expression on a regular basis to protect milk production and avoid clogged ducts.
Later stages of breast feeding
Physiological and biological human norm for weaning age is between 2.5 and seven years. Several factors can impact breast-feeding during pregnancy including during the second trimester of milk production rate usually declines as the mammary gland reverts back to the secretory differentiation stage with disassembly of tight junction between memory epithelial cells research indicates that 74% of breast-feeding women experience nipple pain while breast-feeding during subsequent pregnancies the process of the mammary gland becoming more prone to infiltration of plasma components including markedly increased sodium concentration gives the milk a salty flavor. There’s no evidence to support recommendation to Wayne during pregnancy or the uterine contractions during breast-feeding increase the risk of preterm labor. Tandem breast-feeding is an option for parents with an infant and an older child. This may help the child adjust to the change in the family. There will be sufficient milk for both children. The newborn should feed before the older child. With the birth of the new baby the milk will begin as colostrum and progressed to mature milk. This is not harmful to older children. Decision to win should be a joint decision between the parent and the child.
Weaning
The return of menses can impact breast-feeding. Diminished milk production and tender nipples or breasts may occur with the onset of menses each month. Baby may be reluctant to breast-feed or even refuse the breast right before or during the first day or two of masses.
A new pregnancy may cause nipple pain, diminish milk volume, change in the taste of the milk.
Employment and scheduling play a significant role for many parents in the decision to Wayne.
Cultural or religious expectation may impact the process. Some guidelines recommend breast-feeding until age 6 months. The Koran states that infants should be breast-fed until two years of age.
Optimally weaning occurs naturally based on the needs of the child. Baby led weaning it is usually between five and nine months with a medium age of six months.
Infant shows increase interest in exploring the environment and other foods.
Weaning to a cup is a natural transition if the infant is at least seven months old.
Parents who desire to continue breast-feeding should provide only water during cup training.
Immunological benefits from human milk are present for the child as long as breast-feeding continues.
Breast-feeding provides comfort when the child is fearful or need of emotional support this has been termed comfort breast-feeding.
Abrupt weaning is very difficult for a child and it carries significant health risk for the breast. When abrupt weaning is desired or necessary, nondrug therapies may allow more comfort and prevent breast problems including warm showers or baths to facilitate milk released, and expression or pumping can remove just enough milk for comfort, wearing a supportive comfortable bra, watch for pluged ducts or signs of mastitis.
