BREASTFEEDING THE PRETERM AND LATE PRETERM INFANT:

CHALLENGES AND STRATEGIES FOR POST DISCHARGE MANAGEMENT

Emily Pease, RN, BSN, IBCLC Madeline Smith, RN, BSN, IBCLC Swedish Medical Center Pediatric Specialty Care Conference 1/25/19

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OBJECTIVES

Review definitions of preterm and late preterm infants

List risk factors associated with poor feeding outcomes

Describe strategies to initiate and maintain milk production

Discuss care plans to help late preterm and preterm infants transition to direct breastfeeding

CDC DATA ON PRETERM DELIVERIES 2017

9.93% of all babies born were preterm in 2017

7.17 % of all live births were late preterm in 2017

72 % of all preterm births in 2017 were late preterm

CDC https://www.cdc.gov/nchs/data/databriefs/db318.pdf

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CONSENSUS ON TERMINOLOGY NEWER DEFINITIONS

PRE-TERM:< 37 completed weeks

• Late preterm: 34-36 6/7 week

• Early term: 37-38 6/7 weeks

FULL-TERM: 39-41 6/7 weeks

POST-TERM: > 42 completed weeks ACOG

https://www.acog.org/-/media/Departments/Patient-Safety-and-Quality-Improvement/2014reVITALizeObstetricDataDefinitionsV10.pdf

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PRETERM STATS AT SWEDISH 10/1/17-9/30/18

Total number of live births across 4 campuses: 11418 Total preterm (< 37 weeks): 1016=8.9% of all births Total LATE preterm births (34-36 6/7 w): 736=6.4% of all births and 72% of all preterm births

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LATE PRETERM BIRTHS AT SWEDISH 10/1/17-9/30/18

116 were 34-35 weeks (96% were in NICU)

207 were 35-36 weeks (49% were in NICU with average LOS of 8+ days)

413 were 36-37 weeks (25% were in NICU with average LOS of 4+ days)

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RISK FACTORS FOR THE LATE PRETERM INFANT

Hypoglycemia

Hypothermia Respiratory problems

Jaundice

Sepsis Feeding problems

Higher rates of re-hospitalization

Increased morbidity and mortality

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Less stamina Less Coordinated S/S/B Less effective sucking

Less alert, awake periods

Insufficient breast stimulation Incomplete emptying

Insufficient milk transfer

Hypoglycemia Jaundice

Poor weight gain Insufficient milk supply

Readmission Supplementation

Separation from mother

Source: Nancy E. Wright, MD, FAAP, IBCLC

Near-Term Infant Breastfeeding Cascade

LACTATION RISK FACTORS IN THE MOTHER OF THE PRETERM/LATE PRETERM INFANT Delayed Lactogenesis and low milk

supply Maternal stress during labor and delivery, birth trauma

Infection Chorioamnionitis Maternal obesity Diabetes Mellitus Medications to treat PIH/PTL Hemorrhage Prolonged Bed rest Multiple births Delay in initiation of colostrum expression

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BASIC GUIDELINES FOR IN AND OUT OF HOSPITAL MANAGEMENT

Feed the Baby: usually requires supplementation with expressed colostrum (ideally) or formula initially in addition to breastfeeding

Swedish protocol for management of the late preterm in postpartum

• 2-10 ml per feed first 24 hours

• 5-15 ml per feed 24-48 hours

• 15-30 ml per feed 48-72 hours

• 30-60 ml per feed 72-96 hours

Establish and preserve maternal milk volume

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ESTABLISH MILK SUPPLY

Timing is important. Provide support for mothers immediately after birth.

Hand expression: start within 1 hour after birth

Hand expression: q 2-3 h or 8x/24h

Hand expression: before or after pumping

Pump starting after the first 6 h if mom/baby are separated or anytime flow increases

Studies: mothers of preterms who initiated hand expression within 1 h of birth made more milk, breastfed/breast milk fed longer and with higher rates of exclusivity than those who waited more than 6 hours. Mothers of preterm infants are less likely to initiate milk expression early and to make sufficient milk than mothers of term infants. (Parker et al, 2012, Morton et al, 2009)

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ESTABLISH MILK SUPPLY

Gems from Dr. Jane Morton:

Milk production is strongest determinant of duration and exclusivity

Insufficient milk production – Most common reason for stopping

~ 3 times greater risk of early cessation of lactation in preterm mothers compared to term mothers

High production correlates with transition from bottle or tube feeding to breastfeeding.

Hormones set the stage: ↓ progesterone (placenta) precedes lactogenesis. Oxytocin release (let-down) enables episodic milk removal

Yet the early, frequent and effective removal of colostrum determines future production potential

Production within first 4 days predictive – Low production correlates with early termination!

http://idahobreastfeeding.com/breastfeeding-handouts/Jane%20Morton%20Boise%201%20handout(NoPics).pdf

HAND EXPRESSION!!!

http://newborns.stanford.edu/Breastfeeding/HandExpression.html

http://newborns.stanford.edu/Breastfeeding/ABCs.html

Attributed to Dr. Jane Morton, Stanford University School of

Medicine

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Hand expression in the OR for a baby in NICU

Hand Expression: Issaquah

First pump at 12 hours, with hand expression

Hand expression in labor and delivery. Day 2 pumping

This is the result on day 2 when you hand express the first couple hours. 15 ml!!!!

We use the Stanford University demo (patient & staff education) by Jane Morton. We are seeing 20 to 40 ml of colostrum on day two when this is implemented in L&D. It has been truly impressive!

ESTABLISH AND MAINTAIN MATERNAL MILK SUPPLY

Milk volume at week 2

Ideal = 750-1000 ml/24 hours

Adequate= 500 ml/24 hours

Borderline= 350 ml/24 hours

Many at-risk moms take longer to establish a full milk supply. No good data on this, but in clinic we see it take anywhere from 4-8 weeks. Reassure mothers that milk supply may continue to increase over time with regular milk removal. What they see at week 2 is infrequently not the full volume they will reach as long as they have the support to continue to pump frequently.

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TIME AND GROWTH IS ON THEIR SIDE

Until baby is able to breastfeed effectively:

PRESERVE THE MATERNAL MILK VOLUME

Effectiveness of milk removal affects the milk volume overall

Hands-on pumping; frequency of milk removal and degree of emptiness of breasts.

Ideal: 8 times per 24 h, pump past 2 let downs

Give baby opportunities to practice at the breast without high expectations.

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WHOSE PROBLEM IS IT ANYWAY?

Preterm Infant Suck may be weak, disorganized, dysrhythmic Inability to latch, or maintain latch: • muscle weakness, poor coordination, low vacuum pressures; vacuum is essential to milk removal from the breast (Meier et al. 2007, Hurst et al. 2004, Sakalidis and Geddes 2016)

• tongue tie, releases seal, bites • habituation to bottle feeding/faster flow • severe reflux Sleepy/poor stamina due to preterm status or jaundice Determine if Pediatric Therapy Services would be helpful

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WHOSE PROBLEM IS IT ANYWAY?

Maternal

Low supply due to inadequate breast stimulation, infrequent or ineffective pumping

Flat/Inverted nipples

Breast/Nipple pain, trauma

Medical complications

Separation

Lack of support from family or staff

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FEEDING STRATEGIES: OUTPATIENT CLINIC

Evaluate infant’s suck/strength/coordination/stamina

Pre/post feed weight, observe for rhythm, teach swallowing, difference between nutritive and non-nutritive sucking

Evaluate mother’s milk supply and flow

Frequency of milk removal; support for mother to maintain pumping post discharge

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FEEDING STRATEGIES: OUTPATIENT CLINIC Babies need to practice breastfeeding in order to learn to breastfeed. Practice in NICU helps increase duration (Pineda 2011, Briere et al. 2016)

Most common: Triple Feeding (Breast/bottle/pump)

BF x 5-10 min per side for all daytime feeds. Limit time on the breast INITIALLY, finish with bottle, pump after.

Milk flows fastest when breasts are more full. Mother may need to hand express or massage breasts to initiate flow to help baby attach and stay attached

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FEEDING STRATEGIES: OUTPATIENT

Feeding tube/SNS at breast: adds flow to keep baby active at breast, pump after to finish emptying breast.

Nipple shield may compensate for weak suction pressures. (Meier et al. 2000, Chertok et al. 2006)

Size shield to fit mom’s nipple (priority) and baby’s mouth. Monitor intake at breast and mother’s milk supply with nipple shield.

“Oroboobular disproportion!” Small mouth/large nipple-baby needs to grow into mom’s nipple! Do some short practice feeds until baby’s mouth grows.

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COURSES: FROM APPETIZER THROUGH DESSERT Transition to more breastfeeding is gradual

Appetizer: Practice at breast for a few minutes each side

Main course: when infant is able to sustain a longer suck/swallow pattern, maintain normal vacuum pressures

Dessert: when infant is able to stay engaged on the breast, take a break and then trigger a second or third let down to “finish” the feeding.

They do not need dessert at every feeding

Switch nursing

Flow is a big factor

MOVING AWAY FROM TRIPLE FEEDING: CHALLENGE OR INDEPENDENT FEEDS Start once baby is able to transfer 40-60

ml over about 20-30 min

5-6 hour block of breastfeeding ad lib, no pump, no bottle.

Expect: more frequent feeds

Try: switch nursing

Consider use of baby weigh scale at home

For the rest of the day, go back to triple feeds OR pump/bottle.

Weigh baby every 3-4 days to ensure normal gain (25-30 g/day)

Every few days: increase the length of time for challenge feeds

Goal to move to exclusive ad lib breastfeeding or occasional bottles depending on parent choice.

Goal is for baby to be able to breastfeed effectively, drive milk supply and for parent to eliminate pump dependency.

Check in with parent

Time frame: suction pressures mature anytime from 36-44 weeks. Variable.

Achieving full feeds at breast is dependent on mother’s milk production

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MOVING TO FULL BREASTFEEDING: MATERNAL ISSUES

Chronic low milk supply:

Goal is that baby is able to remove enough milk so pumping after is not needed

Nipple shield: need long term studies, BUT in clinical experience long term use of nipple shield frequently results in less milk transfer→lower milk supply.

“Finish at the breast” method may be good alternative

Mom can still do challenge feeds even if she has low supply, and may not need to supplement until the end of the day

Many babies help increase milk supply once they start nursing more effectively.

Maternal exhaustion

Lack of support: pumping is hard to maintain

Post partum depression: 10-20% of all mothers have postpartum depression or anxiety

https://www.postpartumdepression.org/resources/statistics/

https://www.cdc.gov/mmwr/volumes/66/wr/mm6606a1.htm?s_cid=mm6606a1_w#suggestedcitation

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FREQUENT RE-EVALUATION IS KEY

How long until full breastfeeding? Variable, range in our clinical experience is 4-8 weeks after discharge

Track intake at breast, weight gain

Track pumping volumes; reduce frequency once baby nurses more effectively and can drive supply

Weekly appointments or Breastfeeding Support Groups

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CONCLUSION

Preterm babies can learn how to breastfeed and need practice, ideally the earlier the better.

Feed the baby

Establish and maintain milk supply

Establish feeding goal

Buy time and be patient

Give support and consistent information; the plan needs to be doable for the parents.

Close follow up results in more success

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REFERENCES

Academy of Breastfeeding Medicine clinical protocols for late preterm and preterm infants

https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/10-breastfeeding-the-late-pre-term-infant-protocol-english.pdf

https://www.liebertpub.com/doi/pdf/10.1089/bfm.2018.29090.ljn

Parker LA, Sullivan S, Krueger C, Kelechi T, Muelle M. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. Journal of Perinatology (2012) 32: 205–209

Dewey KG, Nommsen-Rivers LA, Heinig MJ, et al. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics.2003 Sep;112(3 Pt 1):607-19.

Ludington-Hoe SM, Anderson GC, Simpson S, Hollingsead A, Argote LA, Rey H. Birth-related fatigue in 34-36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care. Journal of Obstetric, Gynecologic & Neonatal Nursing. 1999 Jan-Feb;28(1):94-103.

Meier PP, Furman LM, Degenhardt M. Increased Lactation Risk for Late Preterm Infants and Mothers: evidence and management strategies to protect breastfeeding. J Midwifery Women's Health. 2007 Nov-Dec;52(6):579-87

Morton J., Hall J.Y., Wong R.J., Thairu L., Benitz W.E., & Rhine W.D. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology. 2009. 29, 757-764.

Wight, Nancy E. Breastfeeding the borderline (late preterm) preterm infant. Pediatric Annals; May 2003; 32 (5) pg. 329

Hurst NM, Meier PP, Engstrom JL, Myatt A. Mothers performing in-home measurement of milk intake during breastfeeding of their preterm infants: maternal reactions and feeding outcomes. J Hum Lact. 2004 May; 20(2):178-87.

REFERENCES

Meier PP, Brown LP, Hurst NM, Spatz DL, Engstrom JL, Borucki LC, et al. Nipple shields for preterm infants: Effect on milk transfer and duration of breastfeeding. J Hum Lact 2000;16:106–14.

Chertok IR, Schneider J, Blackburn S. A pilot study of maternal and term infant outcomes associated with ultrathin nipple shield use. J Obstet Gynecol Neonatal Nurs 2006;35:265–72.

Mizuno K and Ueda A. Changes in Sucking Performance from Nonnutritive Sucking to Nutritive Sucking during Breast- and Bottle-Feeding. Pediatric Research. 2006 59 (5) 728-731.

Lau C, Schanler RJ. Oral motor function in the neonate. Clin Perinatol 1996 23:161–178

Cannon AM, Sakalidis VS, Lai CT, Perella SL, Geddes DT. Vacuum characteristics of the sucking cycle and relationships with milk removal from the breast in term infants. Early Hum Dev. 2016 May;96:1-6. doi: 10.1016/j.earlhumdev.2016.02.003. Epub 2016 Mar 8.

Sakalidis VS, Geddes DT. Suck-Swallow-Breathe Dynamics in Breastfed Infants. J Human Lact 2016 May;32(2):201-11; quiz 393-5. doi: 10.1177/0890334415601093. Epub 2015 Aug 28.

Briere C, McGrath J, Cong X, Brownell E, Cusson R. Direct-breastfeeding in the neonatal intensive care unit and breastfeeding duration for premature infants. Applied Nursing Research. 2016 32 pp 47-51.

Lefkowitz, Debra & Baxt, Chiara & Evans, Jacquelyn. (2010). Prevalence and Correlates of Posttraumatic Stress and Postpartum Depression in Parents of Infants in the Neonatal Intensive Care Unit (NICU). Journal of clinical psychology in medical settings. 17. 230-7. 10.1007/s10880-010-9202-7.