This document discusses strategies for breastfeeding special needs infants, including those born preterm or with low birth weight. It outlines recommendations for pumping and storing breastmilk, as well as supporting skin-to-skin contact and breastfeeding. The document also describes managing common clinical issues like jaundice, hypoglycemia, and dehydration. Finally, it notes that while breastmilk is usually best, in rare cases of inborn errors of metabolism, special formulas may be needed.

1. Session 10

2.  1. Discuss breastfeeding of infants who are
preterm, low birth weight or have special
needs.
 2. Describe how to assist mothers to
breastfeed more than one baby.
 3. Outline prevention and management of
common clinical concerns neonatal
hypoglycemia, jaundice and dehydration, with
regard to breastfeeding.
 4. Outline medical indications for use of
foods/fluids other than breast milk.

3.  Preterm milk is more suited to the preterm
infant than mature milk
 The composition of preterm milk is unique:
levels of nitrogen, long-, medium- and short-
chain fatty acids, sodium, chloride and iron are
higher in preterm milk

4.  Rental grade electric pumps combined with hand
expression is ideal
 Double collecting kit is preferred
 Optimal stimulation comes from 8 or more
pumping sessions per 24 hours, with total
pumping time of 120 minutes per day
 Follow collection, storage and handling protocols
carefully

5.  Encourage mother to be as involved as possible
in the care of her infant. Help her learn to
identify infant states, and observe baby
language.
 Skin-to-skin contact (kangaroo care) stimulates
organization and maturation in the infant.
 Skin-to-skin also assists mother in maintaining
her milk supply.

6.  Gavage or tube feeding is used when infants are too small
to coordinate suck-swallow-breathe. Gavage may also be
used to supplement during or after breastfeeding.
 Cup feeding is also used to supplement breastfeeding in
infants with suck-swallow-breathe and gag reflex.
 Breastfeeding may be initiated when the infant is stable
and can gag. Offer opportunities for non-nutritive
suckling before actual feeding.

7.  Breastfeeding fosters
longer, more rhythmic suckling
more stable oxygen saturation
less bradycardia
more normal heart rate

8.  Mother should have realistic expectations of
feeding.
 Practice will be required for proficient
breastfeeding.
 Skin-to-skin care has positive impact on
breastfeeding, maturation and growth,
parenting, digestion and immune system.

9.  Establish a follow-up team to ensure
adequate growth and development and
continuation of breastfeeding post-discharge
 Foster frequent communication to address
issues as needed

10.  Are at risk for infection, jaundice and
hypoglycemia
 Advantages of human milk feeding include:
easier digestion and absorption of fats and
proteins
fat and amino acid profile closest to infant needs
enzymes which enhance maturation of gut
anti-infective properties

11.  Positioning strategies for nursing twins simultaneously:
 feet to feet with one twin higher than the other
 head to head in the football hold
 Feeding twins simultaneously helps to develop
synchrony of feeding schedule and increased prolactin
levels.
 Feeding each twin separately takes more time, but is
more individualized.

13.  Individualized feeding plans need to be
developed
 Infants may require supplementation,
especially if one is smaller and/or weaker than
others. Weight gain should be closely
observed. Ideal weight gain is 15 - 30 gms
daily.

14.  Hypoglycemia means a low blood glucose level. Babies
who are born prematurely or small for gestational age,
who are ill or whose mothers are ill may develop
hypoglycemia.
 There is no evidence to suggest that low blood glucose
concentrations in the absence of any signs of illness are
harmful to healthy, full term babies.
 Term, healthy babies do not develop hypoglycemia
simply through under-feeding. If a healthy full term baby
develops signs of hypoglycemia, the baby should be
investigated for another underlying problem.

15.  Early jaundice is distinct from late jaundice
 Physiological jaundice occurs when fetal type red blood
cells break down.
 Feeding, especially with colostrum, ensures earlier
passage of meconium and subsequent lower bilirubin
levels.
 Lasts two to three days, then begins to recede.
 Generally intervention is not needed for physiological
jaundice.

16.  Physiological jaundice (cont.)
increasing breastfeeding frequency and/or
improving latch-on is most effective in resolving this
type of jaundice

17.  Benefits of breastfeeding for infants with
cleft defects:
fewer upper respiratory infections
less otitis media
speech improvement through optimal use of oral-
facial musculature

18.  If infant has unilateral cleft lip, angle breast so
that it fills the cleft.
 Mother may use thumb to cover alveolar ridge
defect (if any). This may help create better
suction.
 Infants with cleft defects take longer to feed.
Use pillows to help support infant position and
make mother comfortable to avoid fatigue.

19.  The impact of the cleft defect on breastfeeding
depends on the severity of the defect.
 Explore many different nursing positions to
determine which work best.
 With unilateral cleft, direct nipple toward
intact side.
 Assess growth frequently to ensure adequate
intake and growth.

20.  Timing of surgical repair of cleft defects varies
 Lip repair can occur as early as 2 days of life and as
late as 3 months.
 Palate repairs usually occur after 10 months of life.
 Breastfeeding after surgery is less stressful to the
repair than allowing the infant to cry in hunger
 Use of obturators have been reported to benefit
breastfeeding
 A randomized prospective study on early
postoperative breastfeeding after cleft lip repair has
shown that infants who were allowed to breastfeed
shortly after repair had greater weight gain 6 weeks
after the surgery.

21.  Can feed at the breast with proper physical and
emotional support for the dyad
 Physical conditions which can affect breastfeeding:
 absent or weak sucking reflex
 weak suck
 incoordination of suck
 low muscle tone

22. Conditions Associated with Depressed Sucking Reflexes
Central Nervous System (CNS) Dysmaturity CNS Maldevelopment
Prematurity Trisomy 18
Delayed maturation Trisomy 21
Prader-Willi's syndrome
Prenatal CNS Insults Perinatal CNS Insults
Congenital infections Asphyxia
Vascular accidents Meningitis
Hypoglycemia
Kernicterus
Systemic Problems in the Infant Trauma
Congenital heart disease Drugs administered to the
Sepsis mother in labor
Hypothyroidism Drugs administered to the
infant
Neonatal narcotic
abstinence

23. Conditions CausingWeakness of Sucking Mechanisms
Central nervous system abnormalities associated with severe hypotonia
Trisomy 21
Prader-Willi's syndrome
Medullary lesions
Pseudobulbar palsy (congenital or after an insult)
Bulbar atresia
Moebius' syndrome
Arnold-Chiari malformation
Motoneuron disease:Werdnig-Hoffman's syndrome (usually not present at birth)
Abnormalities of the neuromuscular junction
Neonatal myasthenia gravis (affected mother)
Congenital myasthenia gravis
Familial infantile myasthenia
Botulism
Abnormalities of muscle
Congenital myotonic dystrophy
Congenital myopathies (nemaline and myotubular)
Metabolic myopathies

24. Conditions Associated with Incoordination of Sucking Mechanisms
Central nervous system insults Central nervous system maldevelopment
Asphyxia Arnold-Chiari malformation
Kernicterus Oral-buccal apraxia
Hypoglycemia
Bilateral cerebral bleeds Miscellaneous
Neonatal narcotic abstinence Leigh's disease
Dysautonomia
Cornelia de Lange's syndrome

25.  Use team approach with neonatologists, primary care nurses,
occupational therapists, speech pathologists with
neurodevelopmental treatment (NDT) training, lactation
consultants....
 Assess for presence of suck, swallow, and gag reflexes on an
ongoing basis.
 Offer non-nutritive suckling at the mother’s breasts (after milk
is expressed).
 Position infant to provide maximal support.
 Interventions should be tailored to infant needs.

26. It is important to distinguish between
Babies who cannot be fed at the breast but for whom
breast milk remains the food of choice.
Babies who should not receive breast milk, or any
other milk, including the usual breast-milk substitutes.
Babies for whom breast milk is not available, for
whatever reason.

27.  A very few babies may have inborn errors of
metabolism such as galactosemia, PKU, or
maple syrup urine disease. These infants may
require partial or complete feeding with a
special breast-milk substitute, which is
appropriate to their specific metabolic
condition.

28. Babies with medical conditions that do not
permit exclusive breastfeeding need to be
seen and followed-up by a suitably trained
health worker. These infants need
individualized feeding plans and the
mother and family needs to be clear how
to feed their baby.