Transcript Supplementation of Breastfeeding Term and Near Term Healthy

Supplementation of
Breastfeeding Term and Near
Term Healthy Newborns
INDICATIONS & CONSIDERATIONS
Developed by:
Michelle Gnagey MSN, RNC-OB, C-EFM, C-BF, IBCLC, RLC
Lorrie Makofka MSN, RNC-OB, C-EFM
Why This Competency?
Our goal is to increase “exclusive breastfeeding at
discharge” rates!!
This takes teamwork from every staff person in the
obstetrics department starting in labor and delivery
and extending through their entire stay until
discharge from Mother-Baby
How Do We Do This?
Make sure we as nurses understand best practices
related to breastfeeding and supplementation
practices
Make sure we are united in giving patients
consistent messages
Do all we can to support early breastfeeding and
avoid non-medical formula supplementation
Objectives
List characteristics of exclusively breastfed
neonates
Discuss common non-medical reasons breastfed
newborns are given formula
List maternal and newborn indications for
supplementation
Describe the elements of best practice
supplementation
Characteristics of Exclusively
Breastfed Neonates
Baby will be wide awake and will feed several
times, if left skin-to-skin with mother over the first
two hours
Following the first 1-2 hours baby will fall into a
deep sleep and will sleep up to 24 hours
Baby will feed more often if he is kept skin-to-skin
with mother, perhaps 4-6 times
Often cluster feed
Characteristics of mothers
who exclusively breastfeed
Enjoy having baby skin-to-skin
The chest area in lactating women is 2-4 degrees warmer to
help keep baby warm
Have a bolus of colostrum in the first couple of hours
postpartum that if not removed is reabsorbed by the body
Get sleepy during and after the feeding
Will have uterine cramping with the feedings for about 2448 hours postpartum
Skin-to-skin (STS), why all the
fuss?
It is important for all babies to transition from
intrauterine to extrauterine life
Benefits baby, mother and significant other
Should be done appropriately
Should be offered and encouraged to everyone
regardless of feeding choice
STS-Benefits for Baby
Helps to regulate vital signs and stabilize
temperature
Helps to regulate blood glucose
Assists with neurodevelopment of the brain and
the hardwiring needed for later in life
Helps baby to feel secure and calms a fussy baby
Many more
STS- Benefits for Mom &
Significant Other (SO)
Builds confidence in her ability to mother and care for baby
Increases number of times baby will feed
Helps to increase her milk production
Bonding, especially for the SO who is not able to breastfeed
but can help to calm a fussy baby…
or give mother much needed breaks
How To Perform STS
Baby needs to be undressed down to the diaper and
mother/ SO need to have shirt and bra off
Baby is placed upright, chest to chest with mother/SObaby’s head is under the chin of the adult
Baby’s head should be turned to the side with arms up
Knees are on the upper abdomen of the adult they are STS
with
Cover the back with a blanket (warmed if baby is cold) and
place a cap on his head
Skin-to-skin care
Photo used with permission of Michelle Gnagey
Before we look at the medical
indications for supplementation, we
need to look at some inappropriate
reasons for supplementation
We have all seen this look!
This is amazing and
and terrifying!
I’m excited and exhausted!
DID YOU KNOW?
“Well meaning healthcare professionals
often offer supplementation as a means of
protecting mothers from tiredness or
distress, although this at times conflicts with
their role in promoting breastfeeding.”
Liebert, M.A., (2009). ABM clinical protocol#3: Hospital Guidelines for the use of supplementary
feedings in the healthy term breastfed neonate, revised 2009. Breastfeeding Medicine, 4 (3).
Reflect on your nursing practice and consider if you have ever
been one of those healthcare providers who leans toward
supplementation
◦ Do you feel “nervous” when a baby hasn’t eaten for more than 4 hours?
◦ Do you feel bad for a new mom who cannot get her baby to latch, or is
exhausted and needs to sleep?
◦ Do you think it is better to supplement so that you and/or the mom won’t
have to worry about jaundice, hypoglycemia, or weight loss?
◦ Do you allow your feelings to trump best practice because you just feel
relieved for yourself or the patient when the baby takes 30 cc of formula?
Conflicting advice is so frustrating to the patient and can contribute to
the choices made surrounding supplementation
Instead of hearing that they will get rest many hear the message that
they do not have enough and their confidence is sabotaged
Let’s get on the same page
On the next several slides are common concerns and the evidenced
based responses we should give:
“Messages”
Nurse/patient Concerns
Nurse Responses
Risk of Supplementation
Weight loss/dehydration
Certain amount of weight loss is
normal in the first week of life
(diuresis of extracellular fluid)
Supplementation interferes
with the normal frequency of
breast feedings
Jaundice
More frequent
breastfeeding=lower bilirubin
level
Supplementation interferes
with the normal frequency of
breast feedings
Colostrum acts as a natural
laxative to eliminate retained
pool of bilirubin contained in
meconium
Hypoglycemia
Healthy full term infants do not
develop symptomatic
hypoglycemia simply as a result
of suboptimal breastfeeding
Supplementation interferes
with the normal frequency of
breast feedings
Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the
healthy term breastfed neonate. Breastfeeding Medicine, 4 (3).
Additionally….
Nurse /Patient Concerns
Nurse Responses
Risk of Supplementation
“Not enough milk or colostrum”
Small amounts of colostrum are normal,
physiologic, and appropriate for term
newborn
Formula can alter bowel flora, increase
risk of diarrhea and infections
The term newborn’s stomach capacity is
approximately:
First 24 hours 2-10 ml/feed
24-48 hours 5-15 ml/feed
48-72 hours 15-30 ml/feed
72-96 hours 30-60 ml/feed
Potentially disrupts “supply-demand
cycle” leading to inadequate milk supply
Many reasons for a baby to be “fussy”
Filling or overfilling infant’s stomach with
formula may make infant sleep longer,
missing important breastfeeding
opportunities
Baby fussy, not “getting anything”
Infant may be wishing to cluster feed
May need to use other soothing
techniques:
Swaddling, swaying, father or relatives
assistance
Mom needs to sleep
Postpartum mothers actually
demonstrate restlessness when
separated from infant
Maternal engorgement due to
decreased frequency of breastfeeding in
immediate postpartum period
Risk of decreasing breastfeeding
duration or exclusivity
Mothers lose the opportunity to learn
infant’s feeding cues
The highest time of day for an infant to
receive supplementation is between 7
p.m. and 9 a.m.
Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the
healthy term breastfed neonate. Breastfeeding Medicine, 4 (3).
Finally…
Nurse/Patient Concerns
Nurse Responses
Risk of Supplementation
Mom (or well meaning family)
requests supplementation
Mothers may benefit from
education about how formula
adversely affects subsequent
breast feedings
Formula is slow to empty from the
stomach and often fed in larger
amounts, the infant will breastfeed
less frequently
Nurse spending time in passive
interactions such as listening to
and talking to mothers can be of
critical importance [when it comes
to avoiding supplementation]
Depending on frequency and
method of supplementation, the
infant may have difficulty returning
to the breast
Medications contraindicated with
breastfeeding
Consult references (Intranet,
lactation, books) to verify
contraindications
Risk of decreasing breastfeeding
duration or exclusivity
Sore nipples
Sore nipples are a function of
latch, positioning, and sometimes
individual anatomic variations, not
length of time nursing
There is no evidence that limiting
time at the breast will prevent sore
nipples
Risk of shortening breastfeeding
duration or cessation of
breastfeeding
Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the
healthy term breastfed neonate. Breastfeeding Medicine, 4 (3).
Prepare Yourself
Know how to respond to each of the common
concerns that come up nearly everyday
Demonstrate empathy but be committed to best
practice
Often, your presence can have a calming affect
that will relieve the stress and anxiety
surrounding breastfeeding issues
Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary feedings in the
healthy term breastfed neonate. Breastfeeding Medicine, 4 (3).
Teamwork
“Now that you know better, do
better…”
Maya D’Angelo
Knowledge Check
It is 9 hours after delivery and the baby hasn’t eaten in the last 7 hours. She is full
term with no risk factors, nursed for 15 minutes right after delivery, had one urine
but no meconium. Mom cannot get baby awake to eat.
Which statement best reflects your thinking?
1. I would not be very concerned and would recommend placing the baby skin to skin
for an hour, review feeding cues and normal breastfeeding mother behavior, then
re-assess.
2. I would be very concerned. Infants need to eat at least every 3-4 hours. I would try
vigorously to wake this infant up for a feeding and recommend supplementing if
she will not eat soon. I would explain weight loss and risk for jaundice.
3. My concern would be moderated by knowledge of one good feeding and urine output
in a healthy term infant.
Answer
I would not be very concerned and would recommend
placing the baby skin to skin for an hour, review feeding cues
and normal breastfeeding mother behavior, then re-assess.
Use critical thinking
Look at the whole picture and know your couplets’
risks
◦ Is the infant full term or near term?
◦ Does the infant have pre-existing risk factors for
jaundice, hypoglycemia, weight loss, infection?
◦ Is the infant voiding and stooling adequately?
◦ Was delivery complicated?
Elements of the whole picture regarding weight
loss and dehydration
How many voids and stools has baby had over the course of their stay?
◦ What is the normal number you should expect?
◦ Has the baby superseded that amount?
In your assessment did you find baby is dehydrated?
◦ Mucus membranes moist?
◦ Fontanels soft and flat?
◦ Uric acid crystals are normal through the 4th day of life
Is the baby jaundice and sleepy?
How many feedings has baby had? Has anyone assessed this baby
feeding at the breast?
Can mother hand express colostrum/milk?
If mom chooses to supplement in the
absence of a medical indication…
Educate the mother on the risks of non-medically indicated
supplementation
◦ Decreased frequency of feedings=decreased removal of breast milk=lower
milk supply
◦ Inappropriate stretching of baby’s stomach due to overfeeding=increased
risk of childhood obesity
◦ Decreased prolactin to fill the receptor sites, which determines how much
milk a mom will produce and this is most critical over the first couple of
days
Document that she was provided with education
Baby’s Belly Size
2-10 ml
5-1520ml
Expected Output for the
Exclusively Breastfed Newborn
Day 1- 1 Wet/1 Meconium Stool
Day 2- 1-2 Wet/1-2 Meconium Stools
Day 3- 3 Wet/ 1-3 Stools, may be transitional
Day 4- 4-5 Wet/Transitional stools changing to
loose, yellow, and seedy
Day 5- 6-8 wet diapers/ Several loose, yellow, seedy
bowel movements
Neonatal Medical Indications
for Supplementation
Newborn
◦ Hypoglycemia
◦ Weight Loss
◦ Hyperbilirubinemia
“Before any supplementary feedings
are begun, it is important that a
formal evaluation of the mother –
baby dyad, including direct
observation of breast feeding, is
completed” ABM Protocol, 2009
If you cannot do this yourself page the
lactation consultant for help
Review of Hypoglycemia
Transient hypoglycemia in the immediate newborn period is
common
Healthy full term infants do not develop hypoglycemia as a
consequence to underfeeding
Routine monitoring in asymptomatic neonates is unnecessary
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579.
Hypoglycemia in the
exclusively breastfed neonate
Breastfed term infants have lower concentrations of blood
glucose but higher concentrations of ketone bodies than
formula fed infants
These infants tolerate lower glucose levels without any
significant clinical manifestations or sequelae possibly due
to the high ketone concentration (Keener, 2014)
Hypoglycemia can be minimized by early initiation of
breastfeeding, 30-60 minutes after delivery
The best way to combat hypoglycemia is to keep mother
and baby skin-to-skin
Kenner, C. & Lott, J.W. eds(2014). Comprehensive neonatal nursing care 5th ed. New York: Springer.
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579.
Signs and Symptoms of
Hypoglycemia in the Infant
Jitteriness
Tachypnea
Apnea
Poor feeding
Hypotonia
Seizures
Irritability
Lethargy
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term
Infants.Pediatrics, 127, 575-579.
So, which babies need blood
glucose screening?
1. Babies born to mothers with diabetes
2. Large and small for gestational age babies
3. Late Preterm Infants
4. Symptomatic infants
Timing and intervals for screening should be
according to your policy and based on the risk
factors and assessment of the individual infant.
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants.Pediatrics, 127, 575-579.
Why the Timing?
It takes breastfed babies time to recover from the birth
process and to latch and feed
They go through 9 instinctive stages following delivery, each
stage requires time
They must be left skin-to-skin undisturbed to accomplish
this process
It takes 30 minutes after a feeding for the breast milk
protein to begin digestion and to be absorbed by the gut
Other babies that need
screening
Intrauterine growth restricted infant (IUGR), small
for gestational age (SGA) (<10th percentile for
weight), all infants 35 0/7-36 6/7 weeks
These infants should be fed every 2-3 hours
Bedside glucose monitoring should be performed before every
feed for at least 24 hours unless discontinued by a physician.
AAP (2011).Postnatal Glucose Homeostasis in
Late-Preterm and Term Infants.Pediatrics, 127,
575-579.
Other indications for blood
glucose screening…
Perinatal distress, eg, 5 min Apgar < 5
Polycythemia (venous hematocrit > 65%)
Presence of microcephaly or midline defect
Discordant twins (> 20% weight difference)
Respiratory distress
Anytime there is concern about possible hypoglycemia (clinical signs,
poor feeding, etc.)
All infants admitted to SCN or NICU
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm
and Term Infants. Pediatrics, 127, 575-579.
Feeding and Glucose
Monitoring
Unless otherwise ordered, these infants should be fed within the first
hour of life and have their initial glucose screen 30 minutes following
the first feed.
If not otherwise specified, a minimum of 2 glucose values should be
obtained. One value within the first hour (after a feed if possible) and
the second after 2 hours of age. The attending physician should be
notified of the patient’s admission and determine the final time frame
for screening.
When to Treat Hypoglycemia
Notify Physician/NNP and Send Stat Lab Glucose For:
Glucose < 40 mg/dl in symptomatic infant
Any glucose < 25 mg/dl
Any glucose < 35 mg/dl after 4 hours of age
Any glucose < 45 mg/dl after 24 hours of age
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm
and Term Infants. Pediatrics, 127, 575-579.
ALGORITHM
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. Pediatrics, 127, 575-579.
Knowledge Check
Baby Jones was born at 1300 with 7/9 Apgars and weighing 10 lbs at 39
weeks. Following birth, the infant had no signs of hypoglycemia and was
placed skin-to-skin with the parent for bonding. You determine that the
infant is LGA using the Fenton curve. The time is now 1325
Which statement best describes your nursing care plan?
1. Leave baby skin-to-skin to breastfeed, then check blood glucose
30 minutes after feeding complete
2. Check the blood glucose immediately after birth. Place the
infant skin to skin, monitor for signs of hypoglycemia and check
blood glucose in 1 hour
3. Encourage feeding after complete assessment and bath
Answer
Leave baby skin-to-skin to breastfeed, then check blood glucose 30 minutes
after feeding complete
Weight Loss
Most babies who remain with their mothers and breastfeed adequately lose
less than 7% of their birth weight
Weight loss in excess of 7% may indicate:
◦ Inadequate milk transfer
◦ Low milk production
◦ Delayed lactogenesis II
◦ Above normal output
Request a lactation consultant to assess breast feeding prior to supplementing
ABM Protocol, 2009
HyperbilirubinemiaJust the Basics
Jaundice is a normal phenomenon with benefits for baby
A small percentage of babies can become ill or injured if
bilirubin gets very high (>25 mg/dL)
Mother’s milk appears to increase bilirubin levels, and this is
probably a good thing the majority of the time
Preventing kernicterus by identifying high risk babies is very
important
Supplementation Practices
Continuation of breastfeeding is indicated (4% or less
incidence of pathological jaundice)
Occasionally, expressed breast milk or formula
supplementation is indicated
Supplementation should be given following a nursing
session, use breast milk when available
Kenner
Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35
weeks’ gestation .Breastfeed Med. 2010 Apr;5(2):87-93. [53 references]
Key Points
Because the parents may associate breastfeeding with the
development of jaundice requiring special treatment or
hospitalization, they may be reluctant to continue
breastfeeding
Healthcare providers should offer special assistance to
these mothers to insure that they understand the
importance of continuing breastfeeding and know how to
maintain their milk supply if temporary interruption is
necessary
Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35
weeks’ gestation .Breastfeed Med. 2010 Apr;5(2):87-93. [53 references]
Key Points
It is critical to maintain maternal milk production
by teaching the mother to frequently and
effectively express milk manually or by pump.
The infant needs to return to a good supply of milk
when breastfeeding resumes, or poor milk supply
may result in a return of higher serum bilirubin
concentrations.
Knowledge Check
Baby Smith was born at 40 weeks and has no risk factors. The 24
hour bili level was 8 which is in the high risk zone. The doctor has
ordered supplementation with expressed breast milk or formula.
Choose the response that best describes your interventions:
1. Instruct the mom to breast feed infant and then give 2030mls of formula
2. Instruct mom that hyperbilirubinemia is very dangerous and
the best way to eliminate bilirubin is to switch to formula
3. Instruct mom to increase skin-to-skin contact in an effort to
increase frequency of breast feeding and to hand express or
pump after each feeding. Use EBM to supplement. If no EBM
obtained, give formula in small amounts
Answer
Instruct mom to increase skin-to-skin contact in an effort to
increase frequency of breast feeding and to hand express or
pump after each feeding. Use EBM to supplement. If no EBM
obtained, give formula in small amounts
Maternal Indications for
Potential Supplementation
◦ Geographic separation in different hospitals
◦ Contraindicated medications
◦ Delayed lactogenesis II beyond 5 days
◦ Intolerable pain or extensive nipple damage
◦ Breast anomalies, surgery or insufficient
glandular tissue
Separation of Mom and Infant
Start mom pumping early and often!!!!!!!
◦ Pump within the first 2 hours post partum if
possible or initiate hand expression
◦ L&D Nurses should be able to assist the mother
with this process
Educate mom on milk storage
Help arrange for transport of colostrum/milk to the
infant’s location
Contraindicated Medications
Always consult lactation to confirm that the medication is
truly contraindicated
Check with the physician to see if there is an alternative
medication that could be used to continue breastfeeding
Assist mother to pump milk ahead and store for use while
on the medication
Infant will receive EBM or formula until mom is able to
breast feed
Mom will “pump and dump” only for a prescribed period of
time
Breast anomalies, surgery or
insufficient glandular tissue
• Never
assume that these mothers will have trouble
with milk production
•Baby should have output and weight monitored
regularly until mother’s milk supply is established
•Have Lactation see these patients as soon as
possible to evaluate for milk production
•Lactation can recommend the plan of care for
supplementation if needed
Maternal Complications of
Delivery/Illness
Area of biggest opportunity to improve!!!!
When a mom is exhausted or ill, or if the baby is in the
NICU, it is easy to skip/delay breast feeding or pumping.
Remember to assist the mom and encourage her to breast
feed or pump within 6 hours-sooner if feasible-within 1-2
hours post partum is recommended per lactation
Mom may not feel “up to it” initially but will thank you later
when she can enjoy the breast feeding experience
Knowledge Check
23 year old primip is in the ICU after a post partum hemorrhage
following delivery of a full term infant. The Critical Care physician wrote
orders that patient cannot breast feed. The ICU nurse tells the patient
about the orders and the patient is very upset. The ICU nurse calls you
to see what they can do. You first best response would be:
1. Have the ICU nurse tell the patient that she can start breastfeeding once she is
transferred to Mother Baby Care
2. Take a pump to ICU and instruct the patient to pump and dump until the critical
care doctor says it is OK to breast feed
3. Ask lactation to see the patient to determine why the doctor wrote the orders to
not breast feed
4. Consult lactation to see patient for breast pump assistance
Answer
Ask lactation to see the patient to determine
why the doctor wrote the orders to not breast
feed
Primary Care Providers (PCP) often will write orders to not breast
feed when mom is on various medications. There are very few
medications that are actually contraindicated in breast feeding.
Lacatation can look up the medications, contact the PCP and
develop the most appropriate plan for the patient. If lactation is
not available, do not delay pumping and save the milk until told
otherwise. As appropriate have the baby in the room for skin to
skin contact. Anyone may contact the Infant Risk Center at Texas
Tech University for medication safety.
Supplementing with Expressed
Breast milk- the preferred method
for supplementation
Colostrum versus mature milk
Alternate Feeding Methods for
Term Infant
Hand expression
Spoon/cup
Dropper
Finger Feeding with feeding tube
Supplemental Nursing System (SNS)
Bottle/Nipple Feeding
Note
Alternative feeding methods are most commonly
used with the breastfed infant when the mother
must supplement per Lactation Consultant’s
recommendations or physician order
A lactation consultant or educated staff nurse
should provide patient education regarding the use
of alternative feeding methods
Hand Expression
To view the video on Hand Expression, Right Click on the Hyperlink
below and click on “Open Hyperlink”
http://newborns.stanford.edu/Breastfeeding/HandExpression.html
Dropper feeding
◦ Use a sterile “one time use” feeding dropper
◦ Dropper feeding is best done as encouragement at the breast with
smaller volumes of supplementation
◦ If the mother is unavailable, a dropper may be used in place of a rubber
nipple and bottle
◦ Hold the newborn securely in upright position and place the filled
dropper on the baby’s lips to elicit a feeding response. Gently slide the
eye dropper into the mouth and allow the newborn to suck out the milk
◦ Repeat until the milk (or prescribed amount of formula) is gone, or until
the newborn shows signs that it is satisfied
Cup-feeding technique
This technique is used per Lactation Consultant recommendation or
physician order
◦ Fill a small (i.e. medicine) cup with approximately 10-15 mL of mother’s expressed breast
milk or formula
◦ While holding the newborn in a semi-sitting position or cradling in the curve of
mother’s/father’s arm, rest cup on newborn’s lower lip so the rim of the cup also touches
the corners of the mouth
◦ Allow to feel/taste milk on tongue, then baby should lap up milk and swallow—DO NOT
POUR MILK INTO THE NEWBORN’S MOUTH
◦ Allow newborn to lead its feeding and to rest between swallows
◦ If newborn resists the feeding, stop, comfort the newborn and try again later or use
another method.
Finger feeding/syringe feeding/Supplemental
Nursing System (SNS) with feeding tube
◦ Position newborn upright with head secured by feeder’s opposite hand
◦ Attach a graduated feeding bottle or syringe with expressed breast milk (or
formula) to the feeding tube (SNS, Lactaid or #8 feeding tube)
◦ The end of tube may be secured with paper tape or held by parent
◦ Elicit feeding reflex by stroking newborn’s lips
◦ Gently slide the finger in mouth, pad side up and allow the newborn to pull
the finger back, generally to the juncture of the hard and soft palate
◦ Allow the newborn to begin sucking at a normal rate and rhythm, avoid
forcing milk into tube
◦ If a nipple shield is in use, the feeding tube may be placed under the shield
with the feeding tube tip positioned well into the “shield nipple” prior to
initiating feeding
Bottle/Nipple Feeding
Obtain expressed breast milk or type of formula as ordered by physician/requested
by mother, and verify expiration date. NOTE: if mother requests a formula other than
as ordered by the physician, this should be discussed with the newborn’s physician
prior to the feeding.
Formula should be room temperature
For the mother who is using the bottle/nipple to feed her newborn breast milk, refer
for the Breastfeeding policy for pumping and storing of breast milk.
Mother should be instructed and encouraged to never prop the bottle during the
feeding
Encourage and instruct the mother as appropriate, to support the newborn’s head
while burping, after every ½ to 1 ounce, and at the conclusion of the feeding
After feeding is concluded and is infant is content, position newborn on his/her back
to sleep
If the infant has been fed a bottle of either breast milk or formula, it is to be
discarded within one (1) hour of being opened
Pacing Bottle Feeds
It is estimated by one researcher that bottle fed babies will consume up to 30,000 calories more
than their breastfed playmates by the age of 8 months. Now that’s a lot of extra calories! Why do
they eat so much more than they actually need? No one really knows, but it is thought that perhaps
there are several factors related to the act of bottle feeding itself.
1. The “clean bottle club”. Encouraging the baby to finish just the last little bit that is in the bottle
which may be more than the baby needs.
2. Babies who gulp down the milk so fast that their brains don’t register “full” before their
tummies are overfull.
3. Making the holes in the bottle bigger so the baby will eat a bit faster and get it over with.
4. Paying attention to the lines and ounces on the bottle, and not watching the baby’s cues.
All of which brings us to “pacing” bottle feeds – a technique that is imperative to use for preterm
and near term babies, and one that is very good to use in full term babies in the first few months.
©2012/Lactation Education Consultants/May be reproduced/May not be sold
The Paced Bottle-feeding
Technique
1. Snuggle the baby close to you in a semi-sitting position.
2. Hold the bottle with the tip of the nipple just under the baby’s nose. When she is ready for it,
she’ll open her mouth and “ask” for it.
3. Count swallows (6-7 for a baby a week and under). Take the bottle out of her mouth and put the
tip of the nipple just under her nose again. When she’s ready for the next bit, she’ll open her mouth
again.
4. Watch her face – if you see that she breathes heavily and quickly for a few seconds, trying to
catch her breath reduce the number of sucks that you let her have. As you give her this chance to
breathe, the lines in her face will relax, and then she’ll be ready for more.
5. Continue pacing her feeds until she closes her mouth, purses her lips and “tells” you she doesn’t
want any more. You will see her slowing down before this.
6. You may find that even 6 swallows is too much for the baby to handle all at once, and you may
need to back up to 3 or 4 for a day or so while she is getting used to handling all that fluid at one
time.
7. It’s tempting to put the baby in the car seat and prop the bottle, first of all, that is dangerous,
secondly, meal time should be a social time for both you and the baby. Pacing the feeds helps you
to accomplish this social activity and enjoy your little one.
©2012/Lactation Education Consultants/May be reproduced/May not be sold
What About a Nipple Shield?
•Really should not be used during the first 24 hours of life and they need
to be size appropriate
•Many babies will use them like a pacifier in the early days and never
suckle hard enough to actually transfer milk
•Instructions for application, use, and cleaning must be given to the
patient
•Mothers who use a nipple shield prior to the transition of her mature
milk need to be hand expressing and pumping to insure that their
breasts are stimulated for milk production
What To Do If You Are Going to
Give Nipple Shield to a Mother
• Be sure that the size is appropriate: They come in 24, 20, and 16 mm sizes
• Show the mother how to apply it- you turn it halfway inside out on itself like a Mexican sombrero, place your
nipple in the center and flip it back onto the breast, adhering slightly. May adhere better if run under warm
water
• The cutout goes where the baby’s nose is located not 12 o’clock
• It needs to be washed between uses so provide her with a basin and castile soap and air dry with the tip of the
shield upright
• Because the shield is clear, it is difficult to see/find so you may give her a denture cup to store it in
• Mother needs to initiate insurance pumping after each feeding for 5-10 minutes to stimulate milk production
What Baby Should Look Like
When Using a Nipple Shield
•Baby should have his mouth wide open, lips flanged outward so that
you can see the pink ridge of the lips
•He should have the shaft of the shield completely in his mouth
•It should not be pinching or painful when baby is sucking and mother’s
nipple should remain round
•There should be moisture in the shield initially and after production
increases there should be milk in the shield at the end of the feeding
Knowledge Check
Baby Jones was born 36 hours ago at 37.4 weeks gestation. In report you were told
that the baby last ate 2 hours ago. When you go to see mom, she says the baby has
been at the breast every 2-3 hours but has never really latched well. Lactation had
assessed mom’s nipples and the baby’s suck at 6 hours of age and there were no
issues. The baby is just not very vigorous and will not attempt to feed at this moment.
You know that he is near a 7% weight loss. His 24 hour bili was in the low
intermediate range but he looks jaundice now. You realize that this baby is more at
risk of needing supplementation because of the weight loss, gestation age, and
potential of increased bilirubin levels. You check the diaper to find a small amount of
dark urine.
Another concern is that the pediatrician who is “on” in the morning is quick to order
formula supplementation. If he rounds and the baby has not had some good feeds
and stabilization of his weight loss trend, you know what will happen…
You have used your critical thinking skills and know it is time to leap into action!
Still more
But… It is the beginning of the shift and you need to assess
all of your patients. Plus, someone just called for pain
medications (…that they refused 20 minutes ago when you
did bedside rounding )
And…lactation is not available till morning!
You realize that best practice includes having the baby
placed skin to skin early and often.
So, you tell mom to place the baby skin to skin and you will
be back in about 1 hour. Review feeding cues, and ask mom
to call you to assess the breast feeding.
Later on…
You are back at the bedside. The baby remains sleepy despite
interventions to promote “gentle waking”. Select the series of steps that
you would try first to assist this patient:
1. Tell mom that you know she is exhausted. The baby has lost weight
and was born early. He is at risk for jaundice and now dehydration. His
blood sugar may even be low. The doctor is going to tell you to bottle
feed formula in the morning anyway. If you want to go home with the
baby tomorrow, you better give formula now.
2. Demonstrate and assist mom with hand expression into a spoon or
cup. Cup or spoon feed baby.
3. Obtain the electric pump and have mom pump and dropper feed
infant.
4. Obtain the electric pump and have mom feed EBM per bottle
Answer
Demonstrate and assist mom with hand expression into a spoon or cup.
Cup or spoon feed baby.
References
AAP (2011).Postnatal Glucose Homeostasis in Late-Preterm and Term Infants. Pediatrics, 127, 575-579.
Bergman, N. (2013) Kangaroo care: The science of skin-to-skin contact-benefits and implementation.
Conference handouts
Guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35 weeks’
gestation .Breastfeed Med. 2010 Apr;5(2):87-93. [53 references]
Hale, T. W., & Rowe, H. E. (2014). Medications & mothers’ milk (16th ed.). Plano, TX: Hale Publishing.
Kenner, C. & Lott, J.W. eds(2014). Comprehensive neonatal nursing care 5th ed. New York: Springer.
Liebert, M.A., (2009). ABM clinical protocol#3: Hospital guidelines for the use of supplementary
feedings in the healthy term breastfed neonate. Breastfeeding Medicine, 4 (3).
Morton, J. (2008). Hand expression of breast milk [motion picture]. Retrieved from
http://newborns.stanford.edu/Breastfeeding/HandExpression.html
Riordan, J., & Wambach, K. (2010). Breastfeeding and Human Lactation (4th ed.) Sudbury, MA: Jones
and Bartlett.
Walker, M. (2011). Breastfeeding management for the clinician: Using the evidence (2nd ed.) Sudbury,
MA: Jones and Bartlett.