session 10 infants with special needs

SESSION 10 INFANTS WITH SPECIAL NEEDS

Breastfeeding Promotion and Support A Training Course for Health Professionals

Adapted from the Baby Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care (Section 3)

WHO/UNICEF 2009

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INTRODUCTION

• Human milk has been recognized as the gold standard for human feeding for centuries.

• Milk of other species that is fed to human infants have been known to contribute to increase in infant mortality.

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Which Baby Require Special Attention?

• Prematurity• Twin babies• Hypoglycemia• Neonatal jaundice• Dehydration• Cardiac problem• Babies with breathing difficulties• Cleft palate• Down Syndrome• Medical problems

– neurological condition– ill babies 3

1. The importance of Breastfeeding for Infants with Special Needs

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Importance of Breastmilk for Preterm/LBW/Ill Infants

Breastmilk contains:

1. Protective immune factors Help to prevent infection

1. Growth factorsHelps baby’s gut and other systems to develop as well as to heal after diarrhoea

1. EnzymesMake it easier to digest and absorb milk

1. Special Essential Fatty Acids

Help brain development

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Other Benefits

5. Calms the baby

6. Reduces pain from venipuncture etc

7. Gives mother important role in caring for baby

8.Comforts the baby & strengthen bonding

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Babies With Special Needs need breast milk as much as well babies

Feeding depends on each baby’s condition:•Not able to take oral feed•Able to take oral feeds but not able to suckle•Able to suckle but not for full feeds•Can suckle well•Not able to receive any breastmilk

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2. Breastfeeding ofPre-term and Low Birth Weight Infants

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Composition of Preterm Human Milk (26-36wks)

Comparison to mature term human milkProtein 50-100% higher during first 4-7 wks

Sodium 30-150% higher first 4-6 wks

Chloride 30-80% higher during 3-4 wks

Potassium 30-75% higher during first 3-4 wks

IgA Higher during first 2-3 months

Medium chain FA 40-80% higher during first 3 months

Polyunsat FA 40-70% higher in colostrum and transitional milk

Enzymes and growth factors

Equal to mature human milk

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Milk from mother giving birth preterm contains more protein,sodium and calcium than full term milk.

Benefits of Breastfeeding for Preterm Infants

Benefits References

Greater enteral feeding tolerance and more rapid achievement of full enteral feeding

Armand et al,1996Gross,1983Simmer et al,1997Uraizee &Gross,1989

Reduced risk and severity of infection (short and long term)

El-Mohandes et al,93,97Narayanan et al,81,82,84Uraizee & Gross,89

Reduced risk and severity of necrotizing enterocolitis

Albanese & Rowe,95Buescher,94Neu,96

Reduced risk of atopic disease for infants with family risk histories

Chandra,97Lucas et al,90

Enhanced retinal maturation and visual acuity Carlson et al,86Faldella et al, 96de Andreca & Uauy, 95

Enhanced developmental and neurocognitive outcome

Carlson et al,86Faldella et al, 96de Andreca & Uauy, 95Morley, 96

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Issues on Breastfeeding in Premature Infants

• Expressed Breast Milk (EBM) -if the infant cannot suck directly at the breast

• Hindmilk – has higher calories than foremilk for better

weight gain.• Human milk fortifier.• Non nutritive sucking

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Human Milk Fortifier (HMF)

• HMF provides additional nutrients to breast milk.(protein and minerals).

• Usu use in hospital setting for baby< 1.8 kg. • Fortification is usually started when feeds reach

100 ml/kg by adding 1 sachet (2 grams) to 50 ml of Expressed Breast Milk (EBM).

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Non Nutritive Sucking/ Comfort Sucking

• Used during gavage feeding and in the transition from gavage to breast/bottle feeding in preterm infants.

• Facilitates development of sucking behaviour in premature babies.

• Help to Improves

digestion of enteral feeds• Calming effect on infants

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Method of Feeding in Premature Infants

• Oro/Nasogastric tube feeding

• Cup feeding

– when suck-swallow coordination has been

achieved

• Supplementer Nursing System

Session 10: Infants With Special Needs Ministry of Health Malaysia 14

Tube Feeding


Cup feeding is a skill that is easily learned by newborn and premature babies

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Supplementer Nursing System(SNS)

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Supplemental Nursing System (SNS) is a feeding tube device to provide babies supplemental feedings at the breast. When a baby is at breast over a period of days or weeks, a hormonal mechanism is triggered that causes milk to be produced. Used for :Induce and maintain lactation

What are ways that a Special Care Unit can support breastfeeding?

1.For mother

2. For baby

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1.Arrange Contact Between Mother And Baby, Day and Night

• Encourage mother to visit, touch and care for baby as much as possible

Mother’s exposure to pathogen in NICU will stimulate antibody production which is passed to babies via breastmilk

• Kangaroo Mother Care (KMC)/Skin-to skin contact– Encourage mother to hold baby closed to breast– Baby can go to breast whenever he wants.– Helps regulate baby’s temperature and breathing,assists

in development and increases production of milk.

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2.Take Care Of The Mother

• Help mother to rooming in.• Provide place for mum to rest • Provide meals for mother.• Be parents friendly

– Answer parents’ questions and explain patiently • Let parents know breastfeeding is important

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3.Help To Establish Breastfeeding

• Assist mother to express her milk within 6 hours of birth ( > /= 6 x in 24 hours)

• Baby can go to breast while receiving a tube feed to associate the feeling of fullness with being at breast.

• Encourage and educate mother to give EBM via tube or cup before BF is established. Avoid artificial teats.

• Advise mum to express breast before putting baby on breast

premature babies do not have good sucking

swallowing coodination.22

Positioning a Preterm Infant

• Support baby’s head with mother’s hand (not grip) .Mother’s arm support baby’s body.

• Mother support her breast with her other hand to help baby keep breast in mouth.

• To increase milk flow, massage and compress breast each time baby pauses between suckling bursts

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Explain to mothers what to expect at feeds

• Longer feeding time Feed for a long time ( ~ 1 hour) and will pause frequently to rest during a feed.

• Gulping and choking Baby's low muscle tone and uncoordinated suckle.

• Stop trying to feed if baby seems too sleepy or fussy .

• Keep the feed as calm as possible. Avoid loud noises, bright lights, stroking or talking to

baby. 24

INFANTS WITH SPECIAL NEEDS

Approach to feeding will depend on baby’s condition.

1.Baby not able to take oral feeds. Encourage EBM and freeze it

2. Baby able to take oral feeds but is not able to suckle at breast. Give EBM by tube and by cup if baby is able.

3.Baby able to suckle but not for full feeds. Let baby suckle whenever baby is willing. Frequent short feeds .Give EBM by cup or tube in addition

4.Baby can suckle well. Encourage frequent feeds

5.Baby is not able to receive breast milk.

Discharge Plan For Premature Baby

• When to discharge?-baby able to feed effectively and gaining weight-Usual discharge weight is 1800 gram

• Encourage rooming in before discharge to build up mother confidence on care of baby at home.

• Counsel on feeding technique.

• Counsel on how to get assistance and arrange follow up care.

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3. ASSISTING MOTHERS TO BREASTFEED MORE THAN 1 BABY

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Issues in Feeding More than One Baby

• Mothers can make enough milk for 2 babies, even 3. - Volume of breastmilk produced by a mother depends on demand.

• Key factors :

Time ,support and encouragement from health care

providers and family

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How To Encourage Mother To Breastfeed More Than One Baby

Encourage mother to :•Get help with caring for other children/ household duties•Breastfeed lying down to conserve energy•Eat a varied diet and take care of herself•Try to spend time alone with each of the babies so that she can get to know them individually.

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Breastfeeding Twins

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Breastfeeding Twins• Nursing 1 twin in the cradle

hold, using the free hand to comfort the twin not nursing

• If 1 baby is a good feeder and 1 baby less active, make sure to alternate breasts so that milk production remains high in both breasts.

.

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Twins Grow Well on

Breastmilk

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Breastfeeding a Baby and Older Child(Tandem Nursing)

When a new baby arrives • No need to stop breastfeeding an older

baby • Mother will produce enough milk for

both if she cared for herself• Abrupt cessation of breastfeeding should

be avoided to prevent older child from risk of malnutrition

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4. Prevention and Management of Common Clinical Concerns

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Practises to avoid newborn’s problem :

Early skin to skin contactEarly and frequent BFRooming in Breast expressionCup feedingAvoid water supplements

Neonatal Hypoglycemia

• Babies at risk of hypoglycemia– premature, SGA, LGA, infant of diabetic mothers and

sepsis• Babies fed on breastmilk may be better able to

maintain their blood glucose levels than babies artificially fed on formulas.

• 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 any underlying problem eg IEM, sepsis.

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Breastfeeding and Neonatal Jaundice

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Breastfeeding Jaundice

• Result from inadequate breast milk volume or insufficient milk intake– Lead to dehydration, low caloric intake

• May occur in 1st week of life in breastfed infants• May be reduced by:

– Encouraging early feeds– Increasing frequency of feeds– Avoiding use of water to replace breastmilk

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Breastfeeding Jaundice – Causative Factors

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Breastmilk Jaundice• Occurs in 1% to 2% of breastfed babies.• Causes prolonged indirect jaundice.• Can persist until 12 weeks• Etiology:

– Increased concentrations of nonesterified free fatty acids

(NEFA) that inhibit hepatic glucuronyl transferase. – Increased enterohepatic circulation of bilirubin due to

(1) increased content of beta glucuronidase activity in breast milk and, therefore, the intestines of the breastfed neonate

(2) delayed establishment of enteric flora in breastfed infants

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Prevention of Severe Jaundice

• Early initiation of breastfeeding- Colostrum helps infants to pass meconium,

removes excess bilirubin from the body• Encourage demand feeding - 8 – 12 feeds a day• Effective suckling

– ensure effective milk transfer

• No supplementary fluid

• Cup feeding with EBM if baby refuse to suck

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Treatment of Severe Jaundice

• Phototherapy.

• Very frequent breastfeeding to avoid dehydration.

• Give expressed milk if the baby is sleepy.

• Water or glucose water supplements do not help as they reduce the intake of breastmilk and do little to reduce the jaundice.

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Dehydration• Healthy exclusively breastfed infants do not

require additional fluids to prevent dehydration.

• Babies with diarrhoea should be breastfed more frequently.

– Frequent breastfeeding provides fluid, nutrients, and protective factors.

– Growth factors in breastmilk aid in the re-growth of the damaged intestine.

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5. Management Of Breastfeeding For Infants With Special Needs

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Babies who have Breathing Difficulties

• Should be fed small amounts frequently as they tire easily.

• Breastfeeding provides the infant with nutrients, immune bodies, calories, fluid and comforts the distressed baby and mother.

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Babies with Cardiac Problems

• Babies may tire easily• Short frequent feeds are helpful.• Breastfeeding is less stressful and

less energy is used >> better weight gain

• Breastmilk provides protection from illness thus reducing hospitalization and helping growth and development.

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Breastfeeding and Cleft Palate

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Baby with clefts are at risk for :

Babies with Cleft Lip/Palate

• Babies with cleft lip only should be able to breastfeed - tissue of the breast can help the baby to create a seal more effectively

• Babies with cleft palate are less likely to breastfeed directly from their mother's breast.

• Cleft palate babies often have problem with sucking, and may choke or gag on food that gets into their nose.

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• Cleft palate babies can be given EBM via special cleft palate bottle (Haberman feeder), spoon or cup.

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• Encourage mom to put baby on breast for suckling and bonding

• Following surgery to repair the cleft, breastfeeding can resume as soon as the baby is alert.

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Cleft Lip And Palate - How To Feed?• Hold baby so that his nose and throat are higher

than breast– prevent milk from leaking into the nasal cavity,

Breast tissue or the mother's finger can fill a cleft in the lip to help baby maintain suction.

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Benefits of Breastmilk to Cleft Palate Babies

• Provides immunities against infection, especially ear infections

• Less irritating to mucous membranes of nose

and gastro-intestinal system than formula.

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Benefits of Breastmilk to Cleft Palate Babies

• Encourages proper development of baby's mouth and face.

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Breast Feeding and Down Syndrome

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Can they be BF ? If not able to

suck?

Babies with Down Syndrome/Other Neuro

• Hypotonia and poor sucking reflex

• Encourage early contact• Might need to wake baby• Stimulate during feed• Help mother to position

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Supporting the breast and baby’s chin to stabilize baby’s jaw and maintain good attachment

DANCER’S HAND HOLD FOR PRETERM/HYPOTONIA

Breast Feeding and Down Syndrome/Neuro Problems

• Feeding need longer time

• May need cup feeding

• Avoid teats

• Weight gain might be slow even with enough breast milk

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Infants Requiring Surgery

• BF can usually commence as soon as baby is awake after surgery.

• BF soon after surgery helps with pain relief, comforts baby and provides fluid and energy.

• If baby is not able to take large amounts of breastmilk immediately, mother can express and let baby suck on ‘empty breast’ until baby is more stable.

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6. Medical Reasons For Food Other Than Breastmilk

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Acceptable Medical Reasons For Use Of Breastmilk Substitute

Imp TO DISTINGUISH BETWEEN :

1.Babies who cannot be fed at breast but for whom breastmilk remains food of choice

2.Babies who should not receive breastmilk or any other milk

3.Babies for whom breastmilk is not available for whatever reason

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1.Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period :

• Very low birth weight infants ( < 1500g )• Very preterm infants ( < 32 weeks gest age)

– These infants may be fed expressed milk by tube, cup or spoon.

• Newborn who are at risk of hypoglycaemia if the blood sugar fails to respond to optimal breastfeeding or breast-milk feeding.

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2.Infants who should not receive breast milk or any other milk :

Baby with Inborn Error of Metabolism1. Galactosemia:

require special galactose-free formula

1. Maple syrup urine disease: require special formula free of leucine, isoleucine and valine

1. Phenylketonuria: –require special phenylalanine-free formula (some breastfeeding is possible, under careful monitoring).

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3.Babies for whom breastmilk is not available for whatever reasonNeed replacement feeding

1.Mother away from baby

2 Severely ill

3.Medical condition eg HIV +•need to be seen and followed-up by trained health worker.• Need individualized feeding plans

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SESSION 10 SUMMARY INFANTS WITH SPECIAL NEEDS

• BF is imp for infants who are preterm, LBW ,Ill or have special needs.

• It protects,provides food , and aids in growth and development.

• Breastfeeding more than one baby / Clefts/ Heart/Breathing difficulties/ Down syndrome

• Prevention and management of common clinical concerns

• Does the baby need breast-milk substitutes? Infants with metabolic conditions /HIV mother

Limited period – preterm, LBW. ill etc68

SESSION 10 SUMMARYINFANTS WITH SPECIAL NEEDS

Approach to feeding will depend on baby’s condition.

1.Baby not able to take oral feeds. Encourage EBM and freeze it

2. Baby able to take oral feeds but is not able to suckle at breast. Give EBM by tube and by cup if baby is able.

3.Baby able to suckle but not for full feeds. Let baby suckle whenever baby is willing. Frequent short feeds .Give EBM by cup or tube in addition

4.Baby can suckle well. Encourage frequent feeds

5.Baby is not able to receive breast milk.

THANK YOU

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session 10 infants with special needs

Health & Medicine