Successfully Breastfeeding
Babies Born Prematurely and/or
Affected by Neonatal Abstinence
Syndrome (NAS)
Ruth Munday, BSN, RN-BC, IBCLC, RLC
Lactation Consultant
Le Bonheur Children’s Hospital
General Breastfeeding
Overview

Have basic knowledge of
breastfeeding to be able to better
support the special needs of the
Premature/Neonatal Abstinence
Syndrome Infant
AAP Recommendations
Human milk is uniquely superior for
infant feeding and is species specific;
all substitute feeding options differ
markedly from it.
Human milk is the preferred feeding
for all infants, with rare exceptions.
Breastfeed as soon as possible after
birth, usually within the first hour. If
mother and baby are separated
mother should begin pumping within
six hours after delivery.
AAP Recommendations
(cont.)
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Newborns should be nursed whenever they
show signs of hunger and have 8-12
breastfeedings a day. Teach mom to wake a
sleepy baby to prevent hypoglycemia, jaundice,
etc.
No supplements, artificial nipples, and pacifiers
unless medically indicated.
Begin daily Vit D drops (400IU) at hospital
discharge for exclusively breastfed infants
Babies ideally should be exclusively breastfed for
six months, then add complementary foods such
as iron rich cereal, meats, fruits and vegetables.
Continue for 12 months, thereafter as long as
mom/baby mutually desires
AAP Contraindications to
Breastfeeding

Infant with galactosemia
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Mother has active herpes lesions on breast
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Mother has untreated active TB
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Mother is + fpr human T-cell lymphotrophic virus type I
or II or untreated brucellosis,
In the US, infant of mother who is + HIV
Although most prescribed and over-the- counter
medications are safe, there are a few medications that
make it necessary to interrupt breastfeeding temporarily.
These include:
–
Radioactive isotopes
–
Anti-metabolites
–
Chemotherapy agents
–
Small number of other medications
Caution in CMV + mothers of premature infants esp
<1500 grams
*Note: maternal
substance abuse is not
a categorical
contraindication to
breastfeedingadequately nourished
narcotic dependent
mothers can be
encouraged to
breastfeed if they are
enrolled in a
supervised methadone
maintenance program
and have negative
screening for HIV and
illicit drugs
Medication Considerations
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Risk vs Benefit for mother/baby
Effects of Drug on milk supply
Amount of drug excreted in the milk
Extent of oral absorption/effect on
infant
Age/weight of infant
In utero exposure vs a new drug
Medication Resources
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Thomas Hale Infant Risk Center
806-352-2519
Medications and Mother’s Milk-updated
every 2 years
LactMed http://toxnet.nlm.nih.gov
Breastfeeding Benefits for
Baby

Protects against/ lessens
the severity of many
illnesses such as:
1.
2.
3.
4.
5.
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Ear infections
RSV, respiratory infections
Diarrhea
Sepsis
NEC
Higher IQ
Easy to digest
Less likely to be
overweight or obese
Lower incidence of heart
disease as adults
Breastfeeding Benefits for
Mom
•Promotes skin to skin bonding
with baby
•Decrease risk of PP depression
•Uterus returns to normal size
quicker
•Helps reduce blood loss
•Lose weight faster
•Lowers risk of female organ
cancers and osteoporosis
What Dads can do to help:

Be a team player !
– Change infant diapers
– Bring infant to Mom
– Help with positioning and latch
– Wash pump parts
– Calm infant
– Rock and cuddle infant
– Support mom’s decision
– Skin to skin
Skin to Skin for all Babies
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Promotes bonding
Helps increase
mom’s milk supply
Calming for the
baby (recognizes
mom’s heartbeat)
Regulates baby’s
temperature and
stabilizes vital signs
Promotes healthy
brain development
Hunger/Feeding Cues
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Rooting
Mouth opening
Lip licking
Hands in mouth
Sucking on fingers
Flexion of arms
Last sign – crying
Cradle Position
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Have Mom sit up straight
with good back support
Use pillows to raise the
baby to breast level
Place the baby on his side
facing chest
Place his head on Mom’s
forearm, near her elbow
Your arm and hand support
the baby’s back, keeping
him hugged in close
Use free hand to support
the breast
Football Position
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Have Mom sit up straight
with good back support
Use pillows at her side to
raise baby to breast level
Turn baby slightly in toward
Mom
Support the base of the
baby’s neck and shoulders in
Mom’s hand
Hug baby’s body close
Use free hand to support the
breast
Cross Cradle Position
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Have Mom sit up straight with
good back support
Use pillows to raise baby to
breast level
Hold the base of baby’s neck
and shoulders in hand,
opposite the breast from which
he is feeding
Have Mom hold baby’s body in
forearm, with his bottom
hugged in near the crook of
arm
Use free hand to support the
breast
Side-Lying Position
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Mom and baby lie on sides,
facing each other
Place baby’s head on Mom’s
forearm near elbow or on the
mattress
Put pillows under Mom’s head
to help her see baby
Pull baby’s knees and bottom in
close to Mom
If needed, roll a blanket or
other support behind his back
Use free hand to support breast
Breast Support: C Hold
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Fingers underneath,
thumb on top
Index finger and thumb
well away from areola
May need to continue
breast support during
feeding in early weeks
Proper Latching
Technique
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Aim nipple toward
nose & upper lip
Brush upper lip with
nipple to encourage
baby to open WIDE
Proper Latching
Technique (cont.)
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WAIT for baby to open
mouth wide , with
tongue down
Press on baby’s back
between shoulder
blades and quickly
bring baby to breast
Proper Latching
Technique (cont.)
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Baby’s chin and lower
lip touch breast FIRST
More of lower lip
covers areola than
upper lip
Chin buried in breast
Lips curled outward
Nose usually will not
touch the breast
Signs of Milk Transfer
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Sucks with pauses to
swallow
Watch the chin move up
and down
Listen for swallowing when
baby pauses (use breast
compression)
Longer pauses mean
swallowing more milk
Let baby nurse on first
breast until he stops
sucking and swallowing,
then offer 2nd breast if he is
still hungry
Cues that the Baby Has
Finished Feeding
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When he looks content,
he is usually finished
Some babies may let go
of the breast on their
own
Use breast compression
to see if the baby is
finished or just taking a
break.
Sometimes it is
necessary to break the
suction to take baby off
the breast when he is
finished
Always evaluate for
adequate milk transfer
Breastfeeding Should Not
Hurt!
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Proper position, latchon, head support and
removal from the
breast prevents
soreness and is the key
to breastfeeding
success
Blisters, cracks, scabs,
bleeding nipples are
NEVER normal and are
a sign something is not
right and mom needs
help ASAP!
Is the baby getting
enough milk?
 Can see and hear
baby swallowing
 8-12 feedings in 24
hours
 The baby meets the
number of feedings,
wet and dirty diapers
each 24 hours
 Have mother keep a
log sheet
 By day 4 or 5 baby’s
stools will change
color from dark tarry
to seedy yellow
 Baby should regain
birth weight by 2
weeks
 Then baby should
gain 4-7 ounces a
week or 1-2 pounds
a month until 4
months of age
B r e a s tfe e d in g L o g
C i rc le e v e r y h o u r w h e n y o u r b a b y s ta r ts a f e e d in g . ( E a c h 2 4 h o u r s b e g i n s w ith y o u r b a b y ’s tim e o f b ir th . M a r k
th e h o u r y o u r b a b y w a s b o r n to s ta r t th e c o u n t.)
C i rc le W w h e n y o u r b a b y h a s a w e t d ia p e r.
C i rc le D w h e n y o u r b a b y h a s a d i r t y d ia p e r .
B ir th D a t e :
T im e :
2 4-h o u r
p eriod
1 st
AM
or
PM
T im e lin e
G o a ls
M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1
8 - 1 2 f e e d in g s
1 o r m o re w e t
1 o r m o r e d i rt y
W e t d ia p e r
B r o w n , ta rr y s to o l
W
D
M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1
2 nd
W e t d ia p e r s
B r o w n , ta rr y s to o l
W
D
M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1
3 rd
W e t d ia p e r s
G r e e n s to o l
W W W
D D D
M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1
4 th
W e t d ia p e r s
Y e ll o w s to o l
W W W W
D D D
M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1
5 th
W e t d ia p e r s
Y e ll o w s to o l
W W W W W
D D D
M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1
6 th
W e t d ia p e r s
Y e ll o w s to o l
W W W W W
D D D
M id n ig h t 1 2 3 4 5 6 7 8 9 1 0 1 1 N o o n 1 2 3 4 5 6 7 8 9 1 0 1 1
7 th
W e t d ia p e r s
Y e ll o w s to o l
W W W W W
D D D
8 - 1 2 f e e d in g s
1 o r m o re w e t
1 o r m o r e d i rt y
8 - 1 2 f e e d in g s
3 o r m o re w e t
3 o r m o r e d i rt y
8 - 1 2 f e e d in g s
4 o r m o re w e t
3 o r m o r e d i rt y
8 -1 2 fee d in g s
5 o r m o re w e t
3 o r m o r e d i rt y
8 - 1 2 f e e d in g s
5 o r m o re w e t
3 o r m o r e d i rt y
8 - 1 2 f e e d in g s
5 o r m o re w e t
3 o r m o r e d i rt y
I t is o k a y f o r y o u r b a b y t o f e e d m o r e t h a n 1 2 t im e s e a c h d a y a n d t o h a v e m o r e w e t a n d d ir t y d i a p e r s .
Y o u c a n n o t f e e d h im to o o f t e n . Y o u c a n f e e d h im t o o lit tl e . L e t y o u r b a b y f in is h t h e f ir s t b r e a s t b e f o r e
o f f e r in g h im t h e s e c o n d b r e a s t. Y o u r b a b y m a y n o t a lw a y s ta k e b o th b r e a s ts a t e a c h f e e d i n g . R e m e m b e r
to w a tc h y o u r b a b y a n d n o t th e c l o c k . I f y o u r b a b y is n o t m e e t in g t h e g o a ls , p le a s e c a ll a b r e a s tf e e d in g
s p e c ia li s t o r y o u r b a b y ’ s d o c to r .
When Mom should call for help:
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baby is not meeting
the feeding and
wet/dirty diaper goals
baby is not latching
on well
baby looks jaundiced
Mom has sore or
damaged nipples
Mom has painful
breast engorgement
 Mom has
engorgement and
develops a high fever
 baby is below birth
weight at two weeks
of age
 after two weeks,
baby gains less than
4 ounces per week
 Mom has any
questions or
concerns
Nutrition Tips
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Well balanced
Helpful foods:
 Oatmeal
No dietary
 Almonds
restrictions

Protein
Drink until thirst is

3
meals,
2
satisfied
snacks
Limit caffeine to 2 or
less servings per day
Continue taking
prenatal vitamins
Latching Difficulties
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Can happen in full term healthy infant,
Premature and the NAS Infant
Possible Causes:
Maternal nipple shape
Low Milk Supply
Bottle Nipple and Flow preference
Tongue Tie or short upper frenulum
Cleft Lip/Palate
Receseed Chin (Pierre Robin)
Low Tone /difficulty maintaining latch
Types of Nipples
Compress nipple where baby will latch on to breast
Lactation Aid – Nipple
Shields
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Uses
– Flat or inverted nipples
– Latch-on difficulties
– Overactive let-down
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Helpful to transition baby from
bottle to breast
16mm, 20mm or 24 mm
Washable and reusable
Lactation Aid - SNS
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Supplementation
Help infant’s with
poor suck-swallow
coordination
Can be used:
– At breast
– Fingerfeed
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Starter SNS is only
for 24 hour use per
manufactures
guidelines
Wash between uses.
Test Weights
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Weighing a baby before and after
breastfeeding to determine intake.
Weigh baby in exact same manner before
and after nursing.
Subtract the first (before) weight from the
second (after) weight. The difference in
grams is the “intake” in milliliters.
(1gram=1ml)
Riordan, page 304
Separation from Infant at Birth
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Establishment of lactation even
more important
Possible with hospital grade
breast pump
Mother should begin milk
expression w/in 6 hours of
delivery to maximize chances
for success
Skin-to-skin contact w/ baby
assists in milk production
Family & hospital staff need to
be supportive
Breast Pumps
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Provide each mom with a sterile breast
pump kit
Instruct on assembling kit per
manufacturing guidelines
Provide mom with breastmilk
collection and storage guidelines and
supplies
Pumping Guidelines
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Begin pumping if:
– successful latch has not occurred within
12 hours
– effective breastfeeding as indicated by
signs of effective milk transfer has not
occurred within 12 hours
– within 6 hours if mom and baby are
separated
Pumping Instructions
– Mother should wash hands before
expression of breast milk
– Instruct to pump at least 8 times a day:
pump every 2-3 hours during the day and at
least once over night with only one 4-5 hour
break from pumping
 double-pumping for 10-15 minutes is
preferred to increase milk supply
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– Inform Mom that it is normal only to see
a few drops, or a small amount of milk in
the first few days while the milk supply is
increasing.
Pumping Instructions
(cont.)
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While expressing only small amounts of
milk, store milk in syringes or colostrum
collection containers that are provided, label
and place in “ziplock” bag. Once milk
increases use sterile plastic bottles with caps
that are provided.
Label should include patients name, room
number, date and time expressed.
Cleaning Pump Parts

Instruct mom on cleaning pump parts
per manufacturing guidelines:
– Clean after each use with hot soapy
water and thoroughly rinse.
– Parts should be disinfected at least once
daily, especially for critically ill infants.
– Microwave steam bags could be provided
for disinfecting using the microwave
Tips for when your patient is
receiving breastmilk:
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Breastmilk is classified as a clear liquid.
Mother should pump at least 8 times in a 24 periodpump every 2-3 hours during the day and at least
once over night.
Double pumping for 10-15 minutes at each pump
session is preferred to increase milk supply.
Two licensed personnel should verify that the label
on the bottle of expressed breastmilk is correct
using 2 patient identifiers
Tips for when your patient is
receiving breastmilk:
Expressed breastmilk storage guidelines
 Labels: Label per hospital policy with patient sticker, date and
time milk was expressed
 Place milk bottles in individual bins or a single zip-lock bag for
storage. Patient’s name/label must be clearly labeled on bin
or bag.
 Refrigerate or freeze milk if it will not be used within 4 hours
of expression.
 Refrigerated milk that will not be used by 48 hours after
expression should be frozen.
Warming breastmilk for feedings
 Waterless Warmer is preferred. If not available, place
container of milk in bowl of warm water or under warm
running water. Only the amount of milk needed for a feeding
should be warmed. Milk that has been warmed, but not used,
should be discarded.
 Do not place in hot or boiling water or microwave breastmilk.
Tips for when your patient is
receiving breastmilk:
Frozen Breastmilk
 When breastmilk is moved from freezer to refrigerator, the
time it was taken out of the freezer should be written on the
bottle’s label.
 Unwarmed, thawed milk should be stored in the refrigerator
and used within 24 hours.
Tube Feedings
 Change syringe and tubing at least every 4 hours for
continuous feedings . If bolus feeding is given, the syringe
should be changed with each feeding.
 Orient syringe tip to vertical position for continuous tube
feedings to enhance fat delivery.
Why breastmilk
for the premature infant ?
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Preemies don’t need breastmilk any less than fullterm infants, they need it more !
Breastmilk provides:
– Protection against infection
– Protection against NEC
– Appropriate lipid profile (PUFA’s)
– Better cognitive development
– Better visual development
– A role for the mother in the care of her baby
which is very important
Breastmilk Specificity
Enteromammary Circulation
IgA, Immunoglobulin A
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Maternal mucosal surfaces encounter microbes in
her own and baby’s environment
Maternal lymphocytes at mucosal surfaces
stimulated by microbes to produce specific IgA
Maternal lymphocytes migrate to breast
Maternal lymphocytes produce specific IgA against
microbes encountered which is then secreted into
breastmilk !
Feeding and Nutrition in the Preterm Infant, page 6.
Providing Breastmilk to the
Premature Baby
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All “premature” infants are not alike !
Nutrition issues facing the 26 week gestation baby,
weighing 600 grams who is being ventilated for
weeks, are much different from the 33 week
gestation baby, weighing 1600 grams, who is
otherwise well.
– The latter has more in common with a full term
baby than he does with that 26 week gestation
premature baby.
They both need breastmilk !

However, the methods of feeding the early vs. older
preterm infant, the need for fortification, and the
approaches are very different.
AAP Recommendations for breastfeeding
management for the Premature infant
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All preterm infants should receive human milk
Human milk should be fortified with protein,
minerals, and vitamins to ensure optimal nutrient
intake for infants weighing <1500 grams at birth
Pasteurized donor human milk, appropriately
fortified should be used if mother’s own milk is
unavailable or contraindicated.
Evidence based protocols for collection, storage,
and labeling of human milk
Prevent the misadministration of human milk
No data to support routinely culturing human milk
for bacterial or other organisms
Breast Milk Fortifiers for
Premature Infants

Used to increase protein, calcium, & phosphorus

May decrease immune factors
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Liquid fortifiers dilute breastmilk
Powder fortifiers increase osmolality

Always necessary ? No!
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Hind Milk Collection
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Have containers ready, labeled “foremilk”
and “hindmilk”
Pump for 2-3 minutes after the milk begins
to flow into the “foremilk” bottles.
Stop pumping and save foremilk for later
use.
Switch to “hindmilk” labeled bottles and
continue pumping as usual.
Use only hindmilk for feedings until further
notice.
Riordan, page 305
Colostrum
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Colostrum should be provided as soon as possible.
– Even drops may be beneficial, by “priming” the
baby’s gut and giving protective SIgA. Drops can
be tolerated even by the tiniest baby and even
drops protect.
Many premature babies receive IV fluids, so quantity
of colostrum is not an issue
– Small amounts of colostrum are perfectly
acceptable, and safer than early introduction of
foreign proteins
– Giving the few drops to the baby sends a very
strong message even a few drops of breastmilk are
important and good

Even a drop or two of colostrum can be used for
mouth care of the ventilated baby
Talk Points for families to promote
use of human milk in the NICU
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Breastmilk is the best milk for your sick or
premature infant. Would you be willing to provide
breastmilk for your baby, at least during this
hospitalization ?
As a mother, you are the only one who can provide
your baby with your special first milk called
Colostrum.
Colostrum contains special factors that may help
protect your baby from infection and your
breastmilk is like medicine to help your baby while
in the hospital.
Breastmilk is usually easy to digest and gentle on
your baby’s tummy.
Talk Points for families to promote use
of human milk in the NICU continued…

Breastmilk may help prevent infections.

Breastmilk helps develop your baby’s eyes and
brain.

It is important to begin pumping and collecting your
milk right away.

You need to pump every 2-3 hours, even if you only
are getting a small amount of milk. Every drop is
important and will be used.

If you have not planned on providing milk for your
baby, it is not too late !
Characteristics of a Breastfeeding
Friendly Hospital Unit
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Written breastfeeding polices in place
Employs or trains staff capable of skilled
breastfeeding assessment and breastfeeding
interventions when needed
What are some benefits you can think of to discuss
with parents?
Facilitates milk expression by mothers who wish to
provide milk for infants who are unable to breastfeed
Provides parents with written and verbal benefits of
breastfeeding and breastmilk
Ways to Support the
Lactating Mother
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Encourage rest and good nutrition
Support kangaroo care as a way for mother
to rest
Do not necessarily discourage visitation
Allow & encourage holding/touching baby
Recognize her efforts to provide milk
Praise any milk brought in for the baby
Always ask if she has needs/problems with
milk supply or with her breasts
 refer to Lactation Consultant
Lactation Support in the Hospital

Reassurance is needed that breastfeeding or breastmilk
feeding will be possible

Review benefits of providing milk

Any breastmilk is good and will be used
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Assistance with securing pump & supplies (both physical
& financial)
Milk expression becomes more difficult the longer a baby
is in the hospital
Maternal Conditions
and Low Milk Supply
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Pregnancy
Primary mammary glandular insufficiency
Breast Surgery (Reduction or Augmentation)
High Blood Pressure
Retained placenta and/or Post Partum Hemorrhage
Stress
Autoimmune Disease
Thyroid disease
Poly Cystic Ovary Syndrome/ Infertility Issues
*Also smoking is a risk factor for low milk supply and poor weight gain in infant.
Infant causes of low milk
supply
– Causes:
– Infrequent feeding
– Ineffective suck and/ or latch
– Prematurity
– Neuromotor problems (Down’s Syndrome)
– Oral anatomic problems (cleft, etc.)
Early Skin to Skin Care


Has been shown to be an important and
valuable option for caring for hospitalized
infants
Underdeveloped countries have used this
process as a way to keep infants warm w/o
availability of incubators and to stabilize
infant’s breathing patterns w/o availability of
respirators
Kangaroo Mother Care

If medical condition
stabilized, infant is placed
naked between mother’s
breasts for extended
periods throughout the day
– Facilitates breastfeeding
– Maintains baby’s
physiological functions
at least as well as
incubator care
Kangaroo Mother Care

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Fewer apneas and
bradycardias
Less frequent and less
severe desaturation
Oxygenation improved
Body temperature
maintained
Earlier discharge from
hospital
Improved arousal regulation
and stress reactivity
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Infants cry less and cry is not
of distress type
Provides analgesic effects
during painful procedures
Less stress in baby (shown by
decreased ß endorphin
release, cortisol)
Positive effects seem to be
maintained after contact
ended
Better parent-child
relationship
Greater likelihood of full
breastfeeding in hospital and
at discharge
Starting at the Breast

As soon as the baby is stable
– babies can start nuzzling the breast very early
(kangaroo care allows for this)
– let them learn to take the breast
– waiting for coordinated suck and swallow
wastes valuable time; needed for bottle
feeding--not breastfeeding
– “empty breast” feeding allows practice even
before infant is ready to take oral feeds

Kangaroo care (mother & baby or father &
baby) will prepare infant for breastfeeding
Pholosong Hospital - South Africa
Breastfeeding is physiologic




Many premature infants
respond by rooting and
sucking on the first
contact with the breast
Efficient rooting, areolar
grasp, & latching can be
observed at 28 weeks
Nutritive sucking
appears from 30 weeks
Full breastfeeding is
possible as early as
33 weeks
28 weeks and breastfeeding
31 wk GA - 3 days old Breastfeeding
Encouraging proper latch &
adequate milk intake


Early kangaroo care (skin-to-skin)
Prevent slow milk flow to keep infant
awake and actively transferring milk
– best latch possible
– have mother use compression when baby
doesn’t actually drink
– switch sides as flow slows
– can use lactation aid to supplement

Observe the baby at the breast!
Lactation Aid

Is the best way to
supplement because
babies learn to
breastfeed by
breastfeeding.


Baby continues to get
milk from breast
There is more to
breastfeeding than
breastmilk
Finger Feeding



Position
of tube
for
finger
feeding
Used essentially to help
a reluctant baby to
take the breast.
It calms him, gets him
suckling properly.
After a few seconds to
a minute or two of
finger feeding, baby
should be put to the
breast.
The key for milk transfer:
positioning & latch


Important for the NAS/premature baby as
much as in the full term healthy baby
A good latch allows the baby to get milk
better from the breast
– teaches the baby to suckle properly
– prevents nipple soreness

Babies learn to breastfeed by breastfeeding
34 weeks, well latched on
Breastfeeding Considerations
for Specific Conditions
Altered Neurological Function:
1.
2.
3.
4.
5.
Assess ability for safe and effective feedings (consider
Speech consult as well as Lactation)
When at the breast, observe for signs of weak suck, lack of
effective tongue movement and poor lip seal.
Positioning, head support, maternal breast support and
easy milk flow may assist these children.
Consider use of nipple shield for a firmer texture for
latching and maintaining seal.
Dancer hand position for latching.
When babies are not
breastfed…





Higher incidence of infections (NEC,
RTIs, otitis media, UTIs, bacterial
meningitis, bacteremia, diarrhea,
late onset sepsis in preterm infants)
21% higher rate of post-neonatal
infant mortality rate in the U.S.
When older, these children score
lower on cognitive tests
Increased risk of over-feeding &
becoming obese
Greater chance of developing Type
1 & 2 Diabetes, lymphoma,
leukemia, Hodgkin dz,
hypercholesterolemia, asthma.)
Human Milk Banking



Allows human milk for
infants in the very first
days whose mothers do
not yet have enough
milk available
Early feeding is now felt
to be best for most
premature babies
Donor human milk
recommended as first
alternative to mother’s
own milk before
artificial feeding
Common Diagnosis for Use of
Human Donor Breastmilk

Prematurity

Mal-absorption

Feeding /formula intolerance

Necrotizing enterocolitis

Congenital anomalies

Post-op feedings


Failure to thrive
Short gut syndrome
Current State of Milk Banking

1.
2.
3.
4.
5.
Now about a dozen donor milk banks
operating in North America---all are
regulated by the FDA and abide by the
HMBANA guidelines:
Donors screened & approved
Stored @ -20°C until selected for
pasteurization
Pasteurization eliminates potentially
harmful bacteria, viruses, & pathogens
Major food components as well as most
immunoglobulins are preserved
Holder pasteurization is used in HMBANA
milk banks: donor milk submerged &
heated in shaking water bath & held at
62.5°C for 30 minutes
How is Donor Milk Packaged ?




Usually in 3-4 oz. bottles
Available in term or preterm;
20, 22, & 24 kcals/oz; some
banks have non-dairy or fatfree milk also available
Each bottle/syringe labeled with
kcals/oz, grams protein, and
expiration date
Good frozen for 1 year
Important choice in
“Family-Centered Care”
*Many families have become
aware of problems associated
with artificial feeding products &
request donor milk, esp. when ill or
premature infant is involved or
maternal milk insufficient or N/A
*With increasing emphasis on informed choice, familycentered care and best practice, health professionals also
seeking information on establishing banks
How is donor milk ordered?

Milk can be ordered by Rx for a specific patient, or in bulk as a
standing supply in case it is needed (allows milk to be readily
available)

Milk ordered by calling closest milk bank

Usually sent out weekly, so weekly usage
should be estimated before ordering

Amounts may be adjusted as needed

Milk banks send invoice just as formula
companies do & can be paid the same way

Current cost of donor milk $4.13 per ounce
(cost of processing only---HMBANA donors are NOT paid)
Donor Milk and NEC

NEC is such a
devastating disease
common among VLBW
premature infants,
human milk may be
used to prevent it, and
may be the only
feeding tolerated for
those infants who
develop it.
Neonatal Abstinence
Syndrome (NAS)
NAS mainly describes neonatal
symptoms occurring after in-utero
exposure to opioids.
Other substances may produce
neurobehavioral dysfunction in the
neonatal period consistent with an
abstinence syndrome.
NAS Overview


Since the 1980’s NAS has increased by
300%
Symptoms and length of withdrawal
depends on:
-Type of drug used
-Frequency of drug use
-Trimester of drug use
-Timing of withdrawal
-Genetic susceptibility of the fetus/neonate
NAS Overview



Medical management aimed at
treating symptoms of withdrawal
Standardization of treatment is difficult
symptoms of withdrawal vary with
each infant
Pharmacological and
Nonpharmacological interventions
Intrauterine Drug
Exposure
May cause:
-Congenital anomalies and/or fetal growth
restriction
-Increased risk of preterm birth
-Signs of withdrawal or toxicity
-Impair normal neurodevelopment
Red Flags to consider
Drug Screen
Absent, late, or inadequate PNC
 Documented history of drug abuse or admitted drug use
 Previous, unexplained late fetal demise
 Precipitous labor
 Abruptio placenta
 Myocardial infarction
 Severe mood swings
 Repeated spontaneous abortions
 Cerebrovascular accidents
**Legal implications of testing vary among states. Each hospital
should have a policy on maternal and new born screening to
avoid discriminatory practices and comply with local laws

Drug Screen Testing

Maternal and neonatal urine analysis:
-collect from infant asap after birth because drugs are
rapidly metabolized/eliminated
-positive urine screen may only reflect recent drug use

Meconium analysis:
-useful when history and clinical presentation suggest neonatal withdrawal but
maternal and neonatal urine screens are negative
-must be collected before it is contaminated by human milk or formula stools


Maternal and neonatal hair analysis
Testing of umbilical cord tissue
Effects of Drug Withdrawal on
the Neonate


Opioids are the most common cause
of NAS
Among neonates exposed to opioids in
utero, withdrawal will develop in 55%94%
Effects of Drug Withdrawal
on the Neonate
Opioids:
-Hyperirritability
-GI dysfunctions (excessive sucking, poor feeding, regurgitation,
diarrhea)
-Tremors
-High pitched cry
-Increased muscle tone
-Seizures
-Nasal congestion
-Hyperthermia
-Tachypnea
Effects of Drug Withdrawal on
the Neonate
Cocaine:
-No significant withdrawal symptoms
Benzodiazapines:
-Few infants have withdrawal symptoms
Cannabis/marijuana:
-Most commonly used illicit drug
-Jitteriness, tremors, impaired sleeping
Effects of Drug Withdrawal on
the Neonate
Alcohol:
-Hyperactivity
-Central nervous system
dysfunction
-Fetal alcohol syndrome
-Jitteriness
-Irritability
-Hyperreflexia
-Hypertonia
-Poor suck
-Tremors
-Seizures
-Poor sleep patterns
-Hyperphagia
-Diaphoresis
Effects of Drug Withdrawal on
the Neonate
Selective Serotonin Reuptake Inhibitors:
(Paxil, Prozac, Zoloft, Celexa, Lexapro, Luvox)
-Most frequently used drugs to treat
depression in pregnant women
-Third trimester use may be linked with
neonatal signs of: Continuous crying
Shivering
Fever
Hypertonia
Tremors
Hypoglycemia
Feeding difficulties
Jitteriness
Respiratory distress
Sleep disturbance
Preterm Infants and NAS




Lower risk of drug withdrawal and/or less severe
symptoms
Some studies have shown the lower gestational age
correlated with lower risk of neonatal withdrawal
May be related to immaturity of the CNS,
differences in total drug exposure, or lower fat
deposits of drug
Also, may be more difficult in preterm infants
because scoring tools are geared more toward term
or late preterm infants
Evaluating NAS

Finnegan’s Neonatal Abstinence
Scoring Tool:
-predominant tool use in US
-comprehensive instrument
-assumes cumulative score based
on interval observation of 21 items
relating to signs of neonatal
withdrawal
Evaluating NAS


Each nursery/NICU should have a
protocol for evaluation and
management of NAS
Staff should be trained on correct use
of abstinence assessment tool
AAP Committee on Drugs
Guidelines for Care of NAS




Utilize NAS scoring system
Drug therapy if indicated
Supportive care
Breastfeeding if not contraindicated
-supervised methadone maintenance program
-negative HIV and illicit drug use
Pharmacological Interventions
 Drug therapy is indicated to relieve moderate to severe NAS



and to prevent complications such as fever, weight loss, and
seizures when neonate does not respond to nonpharmacologic
support
Morphine or Methadone usually drugs of first choice
Methadone and Buprenorphine are synthetic opiates
Phenobarbital as second drug
New studies indicate Clonidine may also be a good first line
drug
Nonpharmacological
Interventions








Decrease environmental stimuli
Cluster care activities with gentle handling
Use swaddling, supine or side-lying positioning
Apply gentle pressure over infant’s head and body
for calming effects
Encourage breastfeeding and Kangaroo care
Rooming in with mother if possible
Encourage non-nutritive sucking
Small, frequent feedings
Breastfeeding and NAS




Breastfeeding may decrease the severity of NAS
Breastfeeding may delay onset of NAS
Breastfeeding may decrease need for
pharmacologic treatment
May be able to wean more aggressively from
methadone
-Breastfeeding recommended in stable mothers on
methadone and buprenorphine maintenance therapy
who are not concurrently using illicit drugs
-Transfer of methadone and buprenorphine into
breastmilk is minimal and unrelated to maternal dose
Breastfeeding and NAS




Assists with bonding under difficult circumstances
Decrease stress response of the mother and lead to
a calm interaction with the infant
Decrease length of stay
Need support for increased breastfeeding duration
-24% of opioid dependent mothers breastfeed
-60% stop on average after 5.9 days
Good Position, Good Latch
Nipple points to roof of mouth
Two Errors:


Nipple is pointing to
the lower lip, not
upper lip (or has
moved baby too
much to the side)
Mother is squeezing
nipple to put it into
the baby’s mouth
Better
Well latched on
Home Breastfeeding Plan for
the Premature or NAS infant











Offer the breast _____ times each 24 hours when baby is awake and
alert.
Have baby latch with top and bottom lip out
Let baby suck as long as baby shows signs of interest:
– Focus on baby’s body language--– Is baby doing sucking motions or sticking out his tongue?
– Is baby attempting to open his mouth?
– Is baby trying to latch?
If baby is falling asleep, use breast compression to stimulate more
sucking. If baby still seems too sleepy, stop nursing and try to rewake baby and then try latching again.
Use the following wake up techniques:
Undress your baby
Change your baby’s diaper
Hold your baby skin-to-skin
Rub your baby’s hands, feet, legs, etc.
Massage or stroke your baby’s cheeks, lips, and mouth
Wipe your baby’s face with a warm washcloth
Home Breastfeeding Plan
continued










Call your baby’s name or sing to your baby
More breast compression
Use breast compression while baby nurses as long as needed
Use football position or cross cradle position
Use breast pump as needed to stimulate let-down reflex before
putting baby to breast
At each breastfeeding session, breastfeed first. If instructed to do
so, offer the prescribed amount of your expressed breastmilk or
substitute after the breastfeeding. (Always use your breastmilk
when it is available. If not, use the breastmilk substitute the doctor
has prescribed.)
What: _________________________________________________
How much: _____________________________________________
Feeding method: _________________________________________
Your baby’s average intake at each feeding has been:____________
Home Breastfeeding Plan
continued








When baby is taking half the original amount from the bottle after
breastfeeding, then the bottle should be given after every other
feeding. When the amount again is decreased by half, the bottle
should be offered every third feeding.
Remember to pump any time your baby is supplemented at a
feeding. This means to pump when your baby is not breastfed at
the feeding, or when he is supplemented following a breastfeeding.
When your baby reaches 40 weeks corrected age (his due date)
and/or his medical issues have been resolved, supplemental bottle
feedings may no longer be needed. Your baby should be breastfed
on cue. When your baby is gaining weight well, you may no longer
need to use your breast pump.
Keep a record of the following for each 24 hours:
When baby was fed
How baby was fed
Wet and dirty diapers for each 24 hours
(minimum in 24 hours>>6-8 wet diapers; 2-4 dirty diapers)
Discharge education specific to
breastfed NAS infant


Call your baby’s Dr if the baby is
irritable, not consolable, jittery, does
not settle down between feeds
If you are ready to wean from
breastfeeding consult with the baby’s
Dr and lactation consultant to
gradually wean off breastmilk
Referring Mothers
for Breastfeeding Support


International Board Certified Lactation
Consultant (IBCLC) in: physician’s office,
hospital, private practice, local WIC program
Shelby County Breastfeeding Coalition
www.shelbycountybreastfeeding.org


La Leche League (1-800-LaLeche)
Mothers are influenced by partner, family,
friends, OB, their baby’s doctor and You !
Sweet Success
Babies Were Born to Be Breastfed!
References
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Abdel-Latiff ME, Pinner J, Clews S, Cooke F, Lui K, Oei, J. Effects of Breastmilk on the
Severity and Outcome of Neonatal Abstinence Syndrome Among Infants of Drug-Dependent
Mothers. Pediatrics. 2006;117;e1163
American Academy of Pediatrics. (2012). Policy Statement: Breastfeeding and the use of
human milk. Pediatrics. 2012;129;e827.
Hale TW. Medications and Mother’s Milk, Fifteenth Edition, 2012.
Hudak ML, Tan RC, The Committee on Drugs and the Committee of Fetus and Newborn.
Neonatal Drug Withdrawal. Pediatrics. 2012;129;e540. Available at:
www.http://pediatrics.aappublications.org/content/129/2/e540.full.html
Jansson LM, Velez M. Neonatal Abstinence syndrome. Curr Opin Pediatr. 2012;24
MacMullen MJ, Dulski LA, Blobaum P. Evidence-based interventions for Neonatal
Abstinence Syndrome. Pediatric Nursing. 2014; 165-203.
Riordan, J. Breastfeeding and Human Lactation, 3rd Edition. Sudbury, MA: Jones and
Bartlett Publishers; 2005.
Rodriguez NA, Meier PP, Groer MW, Zeller JM. Oropharyngeal administration of colostrum to
extremely low birth weight infants: theoretical perspectives. Journal of Perinatology.
2009;29; 1-7.
Sachs HC and The Committee on Drugs. The Transfer of Drugs and Therapeutics Into
Human Milk: An Update on Selected Topics. Pediatrics. 2013;132;e796. Available at :
www.http://pediatrics.aappublications.org/content/early/2013/08/20/peds.2013-1985
Sublet J. Neonatal Abstinence Syndrome: Therapeutic Interventions. MCN American
Journal Maternal Child Nursing. 2013;38(2) 102-7.