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Breastfeeding the infant with special needs

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Random thoughts on raising a child with a cleft, life, and a few killer recipes thrown in for good measure…

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  • 24 font or two pages
  • Bottom bullets – initial caps or not???
  • Font size is small – two pages???
  • Essential should be flush
  • 160 kcal - ???? 24 kcal???
  • Title is small to fit above line
  • Down syndrome in MS…. Margaret wrote Down’s syndrome throughout the slides
  • Same title as set of slides 31 and ff.
  • Transcript

    • 1. Breastfeeding the Infant with Special Needs, 2nd Edition Donna Dowling, PhD, RN Gail C. McCain PhD, RN, FAAN Slides prepared by Margaret Comerford Freda, EdD, RN, CHES, FAAN
    • 2. Breastfeeding
      • AAP and U.S. DHHS recommend exclusive breastfeeding for 6 months for all infants, healthy or ill
      • “Breastfeeding” does not necessarily mean suckling from the breast, but rather giving breastmilk by any means necessary (gavage, bottle or breast)
    • 3. Breastfeeding the Preterm Infant
      • Milk supply may diminish 4 to 6 weeks after delivery
      • Furman, Minich & Hack (1998) found only 48% of mothers of preterm infants were still expressing milk at NICU discharge
    • 4.
      • Rates of direct breastfeeding are lower for preterm infants than for full-term infants
      Breastfeeding the Preterm Infant (Continued)
    • 5. Breastfeeding the Preterm Infant (Continued)
      • Nursing Care
        • Determine the mother’s intention to breastfeed
        • Ensure that mothers know the benefits of breastmilk for preterm infants
        • Teach use of the pump and encourage mothers to freeze milk if the infant cannot feed yet
    • 6. Science of Human Milk for Preterm Infants
      • Benefits from the literature
        • 6 to 10 times less NEC in breastfed infants
        • Decreased respiratory and GI infections
        • Decreased incidence of retrolental fibroplasia
        • More stable SaO2 during breastfeeding
        • Improved feeding tolerance with breastfeeding
    • 7. Science of Human Milk for Preterm Infants (Continued)
      • Long-term benefits
        • Decreased incidence of asthma
        • Decreased incidence of allergies
        • Decreased otitis media and GI disorders
        • Decreased risk of diabetes mellitus
    • 8. Science of Human Milk for Preterm Infants (Continued)
      • Nutritional benefits
        • Composition facilitates digestion
        • Protein is primarily whey, which forms a softer, more easily digested gastric curd
        • Contains 20 amino acids, nine that are essential
        • Fat provides 50% of total caloric content,
        • and long chain polyunsaturated fatty acids
        • (AA, DHA)
        • Primary carbohydrate is lactose, which is easily digestible and produces soft stool consistency
    • 9. Obstacles to Milk Production and Breastfeeding for Preterms
      • Deciding to breastfeed involves social and cultural norms and depends on social support mechanisms
        • Nurses can assist mothers in decision-making by providing accurate information
    • 10. Obstacles to Milk Production and Breastfeeding for Preterms (Continued)
      • Successful initiation of lactation
        • Milk expression should begin as soon as possible after delivery
        • Most mothers require assistance
      • Maintaining an adequate milk supply
        • Directly related to frequency of milk expression, complete emptying and duration of pumping
    • 11. Obstacles to Milk Production and Breastfeeding for Preterms (Continued)
      • Initiating direct breastfeeding
        • Traditionally dictated by NICU protocols
        • Nurses should question NICU guidelines that state that successful bottle-feeding must occur before direct breastfeeding can start
    • 12. Obstacles to Milk Production and Breastfeeding for Preterms (Continued)
      • Ensuring adequate milk intake
        • Can be assessed by infant’s sucking behavior, mother’s milk ejection reflex and milk transfer
    • 13. Obstacles to Direct Breastfeeding for Preterm Infants
      • Assessing infant behavior
        • Preterm infants often need several sessions before they can latch well and sustain bursts of several sucks
        • Behavior at the breast is dependent on PCA
        • Preterm infants can take 20 to 30 minutes to achieve successful positioning and intake
        • Explain to mother that no one is an immediate breastfeeding expert
        • Help the mother
    • 14. Supporting the Mother Who Wishes to Breastfeed Her Preemie
      • Assess the needs of the mother and baby
      • Involve a lactation consultant, if possible
      • Teach the mother that preterm infants take
      • longer to transition to full, direct
      • breastfeeding (may not breastfeed well until
      • around 40 weeks PCA)
    • 15. Supporting the Mother who Wishes to Breastfeed her Preemie (Continued)
      • Encourage kangaroo care, which helps increase duration of breastfeeding
      • Teach about pumping and storing
    • 16. Nursing Interventions to Restore and Maintain Milk Supply
      • Encourage the mother to:
        • Communicate frequently with nurse and/or lactation consultant to discover milk supply problems early
        • Use support systems to help her express milk frequently (4 to 5 x/day)
        • Use relaxation techniques and get adequate sleep
    • 17. Nursing Interventions to Restore and Maintain Milk Supply (Continued)
      • Review medications the mother takes that may cause lower milk volume
      • Allow her to discuss her concerns and anxieties about her infant
      • Encourage her to continue her efforts to provide human milk if at all possible
    • 18. Supplementation
      • Supplementation is usually necessary―not all mothers can be with their infants for every feeding
      • Bottle-feeding may create nipple confusion; use breastmilk when bottle-feeding
    • 19. Supplementation (Continued)
      • Cup-feeding is the only alternate feeding method that has demonstrated to be safe
      • Research is necessary to evaluate supplementation methods
      • Test-weighing before and after feeding may be helpful to mothers after discharge
    • 20. Breastfeeding the Infant with Cleft Defects
      • Cleft lip and cleft palate (1 in 700 U.S. births)
      • Cleft lip defects are surgically repaired by 6 months of age
        • Infants with cleft lip can successfully breastfeed
        • Breast tissue molds around the cleft to form a seal, or mother can place her thumb in the cleft to form a seal
    • 21. Breastfeeding the Infant with Cleft Defects (Continued)
      • Cleft palate defects are surgically repaired by 12 to 18 months of age
        • Infants with palate defects usually cannot breastfeed
        • Aspiration is the major problem
    • 22. Techniques for Breastfeeding the Infant with Cleft Lip
      • For a unilateral cleft, point the nipple away from the cleft; position the infant in a cradle hold
      • For a bilateral cleft, position the infant upright and face-on at the breast
      • Encourage the mother to try different positions to obtain the best latch
    • 23. Techniques for Breastfeeding the Infant with Cleft Lip (Continued)
      • Swallowing too much air is a possibility, so encourage frequent burping
      • Feeding may take twice as long for these infants than for infants without cleft lip
    • 24. Breastfeeding the Infant with Cleft Lip
      • Assessing adequate weight gain is essential
        • If inadequate with direct breastfeeding, use expressed milk with special bottle for infants with cleft defects
        • Emotional support of the mother is key
    • 25. Breastfeeding the Infant with Cleft Palate
      • Some infants with cleft palate can use palatal obturators that cover the cleft and aid in breastfeeding
        • Can reduce feeding time and increase volume
      • Encourage mothers to inquire about palatal obturators
      • Encourage pumping and use of human milk for gavage-feeding
    • 26. Breastfeeding the Infant after Cleft Repair
      • In some infants, sucking is discouraged for a time postop
      • Postop feeding may be via spoon, syringe or a squeeze bottle
        • Several studies demonstrate the effectiveness of these methods to provide human milk to infants with cleft lip repair
    • 27. Breastfeeding the Infant with a Congenital Heart Defect (CHD)
      • 8 per 1,000 live births
      • Coarctation of the aorta
      • Tetralogy of Fallot
      • Transposition of the great vessels
      • High risk for congestive heart failure until surgical correction
      • Infants become easily fatigued during feedings due to tachypnea, tachycardia and hypoxemia
    • 28. Breastfeeding the Infant with a CHD (Continued)
      • Infants with CHD take in only 65% of needed calories
      • Require 160 kcal/kg/day
      • Breastmilk for these infants should be fortified to increase caloric density to 24 kcal/oz
    • 29. Breastfeeding the Infant with CHD (Continued)
      • Nutritional supplements with medium chain triglycerides or microlipid products and glucose polymers are necessary
      • Studies have shown the best weight gain is from 24-hour continuous gavage feedings, but oral-facial stimulation is diminished
    • 30. Reasons for Using Fortified Breast Milk for Infants with CHD
      • Breastmilk has anti-infective properties to prevent respiratory disease
      • Breastmilk promotes cognitive development, which is important due to chronic hypoxia with CHD
      • Oxygen saturations have been shown to be significantly higher with breastfeeding
    • 31. Breastfeeding Techniques for the Infant with CHD
      • Require more frequent feedings
      • Upright or semi-upright positioning is important
      • Mothers must be aware of signs of fatigue during feedings―increased respiratory efforts, sweating and falling asleep
    • 32. Breastfeeding Techniques for the Infant with CHD (Continued)
      • Mothers might need to pump after feedings if the infant cannot empty the breast
      • Test weighing may be necessary
      • Encourage mothers to use human milk, even if direct breastfeeding is not possible
    • 33. Breastfeeding the Infant with Down Syndrome and Hypotonia
      • Down syndrome occurs in 1 in 800 live births
      • Extra chromosome #21 (“trisomy 21”)
      • Breastfeeding the infant with Down syndrome can be successful
      • Hypotonia may result in slower abilities to breastfeed (weak suck, poor head control, tongue protrusion, poor lip closure)
    • 34. Breastfeeding the Infant with Down Syndrome and Hypotonia (Continued)
      • Congenital heart defects are common
      • Breastfeeding can facilitate the infant’s oral-facial development
      • Breastfeeding provides practice for normal tongue placement and strengthens jaw muscles used to coordinate sucking and swallowing
    • 35. Breastfeeding the Infant with Down Syndrome and Hypotonia (Continued)
      • Breastmilk protects from infection and promotes development of the immune system, making it ideal for babies with Down syndrome
    • 36. Breastfeeding Techniques for Infants with Down Syndrome and Hypotonia
      • Infants may not show hunger signs, so try breastfeeding every 2 hours
      • Have infant suck on mother’s finger to practice tongue placement
      • Have mother use awakening techniques like face washing or rubbing the legs
    • 37. Breastfeeding Techniques for Infants with Down Syndrome and Hypotonia (Continued)
      • Pump after feedings until the baby is feeding well
      • Use upright positioning with the dancer hold or football hold, or use a sling to help the infant maintain a flexed position
    • 38. Breastfeeding the Infant with Down Syndrome and Hypotonia
      • Emotional support for parents is essential― most are shocked and surprised at diagnosis
      • Breastfeeding can provide a positive mothering activity
      • If rehospitalization is necessary, encourage mother to insist on breastfeeding and encourage her to continue to pump

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