Transcript Welcome to our NICU Uppsala, Sweden

Promoting breastfeeding in a modern NICU
Uwe Ewald, Uppsala, Sweden
Why breastfeeding?
• The physiological norm of infant
feeding
– Optimal nutrient composition
• Promotes attachment/bonding and
parenting skills
– The prefrontal cortex and orbitofrontal area of
the brain are interconnected in a more
powerful way if a baby is given love and
attention (Gerhardt, 2004).
Systematic reviews on effects
• Suboptimal breastfeeding results in
more than 800 000 child death annually
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11.6% of all infant death 2011
Black RE et al Lancet 2013;382:427-51
• Association with:
• an increase in IQ of about three points, even after
adjustment for several confounders
• 1mm reduction in blood pressure
• 12% reduction in overweight or obesity
• Reduced risk of SIDS
Horta BL et al Geneva; WHO 2013
Barriers of breastfeeding preterm infants
Infants
• Tied to devices
• Breathing support
• Diseases
Mothers
• Diseases/complications
• Stress
• Depression, guilt
• Stress/pain
• Subtle bf cues
Care culture
• Separation
• Late initiation of
breastfeeding
• Low muscular tone, fatigue
• Small mouth, weak intraoral vacuum
Strategy
• Reduce losses
– Thermoneutrality
– Insensible losses
– Minimal handling
• Limiting early weight loss
– Max 7% (1SD) initial weight loss
Earlier nutrient intake
 Human milk from 2 hours after birth
 Colostrum
 Gavage and/or cup feeding
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Increase 10-20 mL/kg/d up to 150-250 mL/kg/d
Goal – full enteral at <7d
Early partial parenteral nutrition (<1 h)
Amino acids instead of NaCl in lines
Human milk – volume
tailored for growth rate of
term infants
• Energy
– 130 kcal /kg requires 200mL/kg/d from day 0
• Protein
– 4.5 g/kg requires 450 ml/kg/d from day 0
• Fat
– 6,5g/kg requires 150 ml/kg/d from d 0
Targeted fortification
Polberger 1999
If growth failure:
Analysis of mothers or donated bank milk
(protein fat, carbohydrate)
Improve pumping technique
Calculating goal intake (GA/PMA)
Increase if possible volume to 200-250 mL/kg/d
If protein deficency:
Commercial bovine fortifiers
Problems of lactoengineering
• Lack of research evidence (growth, body
composition, side effects)
• Difficult to reach balanced nutrient intake
• Enteral intolerance (higher osmolarity)
• Costs
• Potentially negative for mothers
expression/breastfeeding efforts
..`my milk is not good enough`…
Breastfeeding – not only
nutrition and volumes
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Emotions affect everything!
Enable closeness
Empower the parents to be self-sufficient
Emphasize feeding as a relational interplay
(for comfort and pleasure)
This promotes breastfeeding
Kangaroo mother care
Non-separation
Family centered care
Developmental care
Support
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Adult bed adjacent to the infant
Presence possible 24/7
Involvement in care decisions
Early breastmilk expression
Pumping
Breastmilk bank
Encouraging staff and context
Facilitating breastfeeding of
preterm infants in the clinical setting
• Space - place, privacy, environment
• Support (parental leave, social network)
Thernstrom, Ewald Acta Paediatr 2012
• Dedicated and well trained staff
J Hum Lact. 1996;12:221
• Avoid separation – Rooming-in
J Perinat Neonatal Nurs. 2012;26:336
• Early breast milk expression
J Perinatol. 2012;32:205
• Skin-to skin contact, Kangaroo Mother Care
Cochrane Syst Rev. 2012:16;5
KMC policy for preterm infants
•KMC for infants born ≥32 wks
– KMC 24/7 the norm
•KMC for infants born 28-31 wks
– Early after stabilization within hours, ideally 24/7
•KMC for infants born ≤27 wks
– Within 3-5 d, dependant on
stability in temperature,
fluid and electrolyte balance,
Karlsson, J Pedatr. 2012
Skin to skin at birth also if <32w GA
And always staying at
mum´s breast
Breastfeeding at discharge, 2009-2013
Thesis: Breast feeding of preterm infants, Ragnhild Måstrup, Lund 2014
Thank you!
Routines for breast milk
– Encouraged early expression/pumping
– Pump 6-8 times (also nights)
– Use double pump technique
– Aim for 700 ml/d at 5-7d
– Colostrum within hours
– Fresh milk (kept at +4oC)
– Surplus frozen at -20oC
– Donor milk from preterm mothers
Transition to exclusive
breastfeeding
• Breastfeedning on semi-demand.
• Decreasing daily amounts by tube or cup
• Day 1 breastfeeding + 250 ml
• Day 2 breastfeeding + 200 ml etc
• Weight once daily
Or
• Test-weighing before and after
• Adjusting amounts given by tube or cup