By,
Lindsay Sims, BSN, RN, RNC-OB
The mother of a high risk infant
is confronted with numerous parenting challenges, not the least of which is the
decision about how to nourish her vulnerable newborn. Successful breastfeeding
depends on overcoming obstacles posed by infant condition, maternal health, and
the neonatal intensive care (NICU) environment. These obstacles include
preterm, very preterm infants, and even late preterm infants, hypoglycemia,
hyperbilirubinemia (jaundice), multiples (twins/triplets), drug addiction, size
issues (SGA or LGA), infections, womb position and birth trauma (torticollis,
facial asymmetry), congenital problems and defects (heart conditions, cleft
lip/palate, ankyloglossia/tong tie).
We will specifically be discussing
the challenges and support of breastfeeding the high risk infant during this
blog today. But know that there are many other issues related to breastfeeding
the high risk infant, such as maternal health, the NICU environment, and infant
contraindications (Galactosemia and amino acidurias such as
Phenylketonuria/PKU) that will not be discussed today. These are great topics
of research and knowledge if you wish to further educate yourself.
Support and interventions may vary
slightly depending on the situation at hand. After a careful assessment is
completed and the infant diagnosis is reviewed the healthcare worker can assist
the mother and baby to try to achieve a successful breastfeeding relationship. Things to take into consideration are upmost
the wishes of the mother in regards to breastfeeding, her physical and mental
condition, the infant’s physical and mental condition and
In recent years so much information and
research has surfaced regarding skin to skin directly after birth and the
Golden Hour. We have all seen it and
know the multiple benefits to not only to mother, but baby too. Now think of
your high risk baby and the array of things skin to skin could potentially help
during the first few hours, days, weeks or months of its life. Skin to skin supports the natural habitat for
the infant and draws many benefits to both mom and baby. Some important benefits to the high risk infant
is bonding, promoting milk production/breastfeeding (increased antibodies in
mothers milk), reduces stress hormones, regulates respirations, reduces risk of
hypothermia, reduces risk pf hypoglycemia, and helps the infant function
optimally/physiologically. Skin to skin
and breastfeeding go hand and hand and help each other per se in aiding a
successful first feed. Remember, they also work as preventative medication for
the high risk infant.
Breastfeeding promotes many
benefits to high risk infants including improved feeding tolerances, better
growth and development, improved cognitive outcome (higher IQ), reduced risk of
NE, sepsis or any infection, and allergies. During this difficult time the mother may not
be able to provide skin to skin nor breastfeeding directly due to their
infant’s condition, but we must support that with an alternative. Two of the
ten steps listed in Baby Friendly are to help mothers initiate breastfeeding
within one hour of birth and also show mothers how to breastfeed and how to
maintain lactation, even if they are separated from their infants (this
includes hand expression or pumping if needed). These steps are endorsed and promoted by the
major maternal and child health authorities in the United States, including
AWHONN, AAP, AAN, and WIC.
The most important thing to
consider when caring for the high risk infant is knowing that the baby must be
able to suck-swallow-breathe in a coordinated way to take food by mouth. Some
of the signs that a baby is getting ready to do this include:
Physical stability. A baby's condition should be stable so the baby
can physically handle being held and fed.
Non-nutritive sucking. A baby first displays rhythmic sucking on a
pacifier, feeding tube, etc., in brief bursts of more than one suck per second.
Gestational age. At about 32 weeks gestation, a baby will begin to
display bursts of sucking and around 34 weeks a rhythmic suck-swallow-breathe
pattern develops.
Wakeful state. A baby must remain awake – from drowsy to quiet
alert to active – for brief periods in order to feed by mouth.
Oral reflexes. A baby must be able to tolerate touch to the mouth
area and demonstrate the reflexes needed for oral feeding. This includes
rooting, sucking, cough and gag reflexes.
Breastfeeding is usually less
stressful for a high-risk infant because the baby sets the pace. A baby's heart and respiratory rates, oxygen
saturation level and body temperature tend to remain more stable and often
improve during breastfeeding. This stability of physical systems means
breastfeeding takes less energy and is less work for the high-risk baby. Of course, a baby must actually latch-on and
effectively suck to get milk during breastfeeding. This may take time for a
baby to learn. When bottle-feeding, milk drips in the baby's mouth and a baby
must swallow it, ready or not.
The stages listed below describe
a baby's progression to direct breastfeeding. They are meant only as a
guideline, as progress varies among high-risk babies. A baby might move quickly from one stage to another
or skip a stage altogether. On the other
hand, a baby may sometimes seem to get stuck at one stage for a few days or
weeks, this is all normal progression for a high risk infant. Encourage the mother to practice feedings during
the early stages of learning to breastfeed. The high-risk baby may not take in
much milk during each feeding as it is quite normal for baby to only be practicing
the motions. Neither mom nor baby should
ever feel any pressure to perform. As we talked before, during skin-to-skin
contact a baby is likely to begin rooting or nuzzling at the breast and may
latch-on when held directly near mom. "Empty breast" feeding is when
a mother may want to pump before skin-to-skin holding sessions once rooting and
nuzzling are noted. Then, the baby can latch-on and practice without being
overwhelmed by the let-down of lots of milk at once. Being overwhelmed can
affect a baby's physical state, and mom’s mental state. Progressive non-nutritive
sucking sessions are when a baby will advance at the breast from latching-on,
to sucking in bursts, to occasionally coordinating suck-swallow-breathe. As the baby shows more ability, you will want
to see what he or she can do with more milk in the breast. Encourage pumping until the let-down flow
slows and then offer the breast. This prevents large amounts of milk that often
come with let-down from overwhelming the baby, yet leaves plenty of milk in the
breast for a feeding.
 |
If these milestones or stages are
not met or if baby or mother are unable to do skin to skin and breastfeeding in
the first hour (as recommended) then the healthcare team must support her with
education. This will include hand expression and pumping. Hand Expression is simple to explain. First wake
up the breasts (shake, massage, move them), the use fingers on opposite sides
of your areola. Press back toward chest.
Compress fingers toward each other, drawing slightly toward nipple but
not sliding skin. Release pressure, relax hand, and repeat several times. Don’t
expect anything immediately, this process takes time. Shift hand to a different position to move
milk from other ducts. Collect colostrum on a plastic spoon, then tip into
baby’s mouth or collect with dropper. Collect expressed milk into pump funnel
or large bowl. These can be labeled and taken to NICU for the baby. If pumping is a better option or used as
alternative, encourage the mother to pump on a scheduled, making sure she gets
at minimum of eight pumping’s in a 24-hour period (possibly allowing one 4-5
interval of rest during this 24-hour period).
There is no "one size fits
all" method for achieving effective breastfeeding with a high-risk baby.
Every baby and situation is unique. Reinforce with the mother to give extra
time to learn to breastfeed and let the infant set the pace for learning.
Learning to breastfeed effectively is a process that may take days or weeks for
premature and many other high-risk babies. However, mom and baby can become a
breastfeeding team if they are patient, persistent and maintain a healthy
perspective. Every baby and mom deserves the best possible start even if they
have special circumstances.
