Breastfeeding Infants with Problems

Breastfeeding Infants with Problems

Breastfeeding is the ideal and preferred feeding method for a newborn. Occasionally infant prob- lems interfere with breastfeeding and require the attention of the infant’s physician to diagnose and treat the problem.

Breastfeeding is a natural behavior for infants and provides the ideal nourishment, but some infants with complicating issues may need special assistance or adjustments.7Prematurity is discussed inChapter 15. Infants with structural abnormalities, metabolic challenges or neurologic difficulties, stres- sed infants, and twins and triplets will be discussed in this chapter.

Procedural Pain Relief

Systematic review and meta-analysis of procedural pain relief for neonates was reported by Shah et al.

Infants with congenital, developmental, and envi- ronmental problems in the newborn period are often subjected to multiple procedures. Compared to placebo, positioning, or no intervention, breast- feeding is best. Glucose and sucrose are a substitute of necessity when mother’s milk is not available.

Perinatal Issues: Postmature Infants

Postmature infants are full-grown, mature infants who have stayed in utero beyond the full vigor of the placenta and have begun to lose weight in utero.37 They are usually “older looking” and have a wide-eyed countenance. Their skin is dry and peeling, and subcutaneous tissue is diminished;

thus the skin appears too large. These infants have

lost subcutaneous fat and lack glycogen stores. Ini- tially they may be hypoglycemic and require early feedings to maintain blood glucose levels of 40 mg/

dL or higher. If breastfed, the infants should go to the breast early, taking special care to maintain body temperature, which is labile in postmature infants who lack the insulating fat layer. Blood sugar levels should be followed. Initially, these infants may feed poorly and require considerable prodding to suckle. If the infant becomes hypogly- cemic despite careful management, a feeding of 10% glucose in water should be considered. In extreme cases of hypoglycemia, an intravenous (IV) infusion may be necessary, and management should follow guidelines for any infant who has hypoglycemia that is resistant to routine early feed- ings. Because the infants lack glycogen stores, hypoglycemia may persist, and glucagon is contra- indicated because no glycogen stores are present to be stimulated. Calcium problems, on the other hand, although common in these infants, generally are rare if the infant is adequately breastfed early because of the physiologic calcium/phosphorus ratio in breast milk. After postmature infants begin to feed well, they tend to catch up quickly and adapt well. Problems with hyperbilirubinemia sel- dom occur because their livers are mature. Postma- ture infants gain well at the breast once they stabilize.

FETAL DISTRESS AND HYPOXIA AND LOW APGAR SCORES

Infants who have been compromised in utero or dur- ing delivery because of insufficient placental reserve, cord accidents, or other causes of intrauterine 483

hypoxia have very low Apgar scores at birth and need special treatment.131 An asphyxiated infant cannot be fed for at least 48 hours, and, depending on associated findings, it may be 96 hours or more before it is safe to put food in the gastrointestinal (GI) tract, which has been poorly perfused during the hypoxia. The infant must be maintained on IV fluids. If the mother is to breastfeed or donor milk is available, human milk can be started sooner.

Her colostrum will be valuable to the infant and will be better tolerated by the infant’s intestinal tract, which has usually suffered hypoxic damage in these circumstances. Small amounts of colostrum can be given in 24 hours. Hypoxia decreases the motility of the gut and decreases stimulating hormones.

The colostrum should be pumped and become the first oral feedings drop by drop.

Mothers will need help initiating lactation and understanding the pathophysiology of the infants’

disease. These infants often have a poor suck that does not coordinate with the swallow, making nurs- ing at the breast and bottle equally difficult. The mother may need to hold her breast in place and hold the infant’s chin as well. These infants are especially susceptible to “nipple confusion,” so means of sustaining nourishment other than a bot- tle should be sought. Cup feeding has been well tol- erated using a soft plastic one-ounce medicine cup.

Even infants who will not be breastfed but feed poorly from a bottle for neurologic reasons will do better with a cup.69,70,90Weaning slowly from the IV hyperalimentation fluids while introducing breastfeeding is helpful. Using a dropper and employing the nursing supplementer are options if milk supply from the breasts is low. These infants

may continue to feed poorly for neurologic reasons.

They do not do better with a bottle. If the mother is taught to cope with the problem, nursing should progress satisfactorily. She may always need to hold her breast in place, which would be the best evidence of residual damage from the hypoxia.

Infants can be held in positions that may help an individual baby adapt better. The “football hold” is a popular but poorly named position in which an infant is held close to the mother’s body with the feet to her side. The head and face are squarely in front of the breast and steadied by the mother’s arm and hand on that side. Cupping the breast and the jaw in one hand facilitates the infant’s seal around the breast with the mouth (Figure 14-1).

This position has been called the “dancer hold.”104 One of the most valuable suggestions is the use of a sling or pleat-seat to hold an infant’s body in a flexed position, thus giving the mother both hands free to hold the head and the breast in position for feeding (Figure 14-2).

Pacing the feedings and pumping after feedings will increase a mother’s milk supply when the infant is unable to suck vigorously enough. Giving the pumped milk by lactation supplementer, small cup, or dropper ensures proper weight gain in the early weeks.104Holding an infant in a flexed posi- tion that mimics the fetal position relaxes an infant who is hypertonic or arching away from the breast.

In a study of energetics and mechanics of nutri- tive sucking in preterm and term neonates, Jain et al.80compared 38-gestational-week infants with 35-gestational-week infants and noted that preterm infants use less energy to suck the same volume of milk. The preterm infant took only up to 0.5 mL per

A B

Figure 14-1. Dancer hold.A,Hand position of mother.B,Infant in position at breast with support. (From McBride MC, Danner SC: Sucking disorders in neurologically impaired infants: assessment and facilitation of breastfeeding,Clin Perinatol 14:109, 1987.)

suck and generated lower pressures and a lower frequency.

Exploring the hypothesis that milk flow achieved during feeding contributes to ventilatory depression during rubber-nipple feeding, Mathew103compared nipples with different flow rates. Decreases in minute ventilation and breathing frequency were significantly greater with high-flow nipples, thus confirming that milk flow influences breathing in premature infants who are unable to self-regulate the flow.

Tracings were made from the first oral feeding to time of discharge in term and premature infants.

Serial oxygen pressure values showed small undula- tions across baseline (above and below) while breastfeeding. Substantial dips while bottle feeding were shown with recovery, but not above baseline.

The quality and quantity of variation were different in the two modes of sucking (i.e., breast or bottle), with large drops in oxygen saturation occurring during actual sucking of the bottle but only dur- ing burping or repositioning while breastfeeding.

Meier106,107 concludes that the findings do not support the widely held view that breastfeeding is more stressful. The comparative data suggest that both pacifier and bottle feeding are more stressful than suckling at the breast. For further discussion of the stress of breastfeeding versus bottle feeding seeChapter 15, feeding the 28 to 32 week prema- ture infant. If an infant has significant motor tone

disabilities or lacks the usual oral reflexes in response to stimulus of the rooting and sucking reflexes, a neonatal neurologist should assess the infant before any routine exercises are initiated.

It has been suggested that perioral stimulation enhances an immature or neurologically impaired infant’s ability to suck and to coordinate suck and swallow.91 Perioral stimulation, consisting of stimulating the skin overlying the masseter and buc- cinator muscles by manually applying a quick-touch pressure stimulus lasting 1 second, was studied.

This is accomplished by simultaneously squeezing the buccal fat of both cheeks. Suck-monitoring equipment revealed that perioral stimulation increased the sucking rate, suggesting that this may facilitate sucking.91Exercising the mouths of infants who already have excessive mouth stimula- tion may not be appropriate. Many infants in a neo- natal intensive care unit (NICU) are being suctioned, tube fed, and orally stimulated for other reasons, which may lead to oral aversion.

Kangaroo care is recommended for full-term infants who are neurologically or metabolically impaired. It involves holding the infant skin to skin inside the parent’s shirt. It can stabilize tempera- ture, respirations, and heart rate and be neurologi- cally calming. For a mother who is to breastfeed, it facilitates milk production and helps a mother learn to handle her infant.72Kangaroo care is further dis- cussed inChapter 15.

GALACTAGOGUES: MEDICATION- INDUCED MILK PRODUCTION WHEN PUMPING

Stimulating milk production pharmacologically in mothers of LBW infants who are pumping to pro- vide milk for their infants has been recommended by several authors, as reported by Ehrenkranz and Ackerman.48 They used 10-mg metoclopra- mide orally every 8 hours for 7 days, tapering dur- ing 2 days more. Milk production increased within 2 days, but after therapy decreased, milk produc- tion decreased. Prolactin levels also increased dur- ing the treatment. Extensive use (more than 2 weeks) may cause cardiovascular symptoms in the mother.

Improved lactation occurred in 67% of mothers with no breast milk at onset and in 100% of mothers with poor supply given metoclopramide (10 mg three times per day for 10 days) by Gupta and Gupta.61They reported that the improvement per- sisted when the drug was discontinued. None of the 32 women had any symptoms or side effects. This drug is a substituted benzamide, which has selective dopamine-antagonist activity.

Although growth hormone has been observed to enhance milk supply, no recommended protocol

Figure 14-2.Pleat-seat or sling baby carrier holds the infant in a flexed position that facilitates infant suckling, leaving the mother’s hands free to support her breast and the infant.

(Redrawn from McBride MC, Danner SC: Sucking disorders in neurologically impaired infants: assessment and facilita- tion of breastfeeding,Clin Perinatol14:109, 1987.)

exists for its clinical use.60In one study, 20 healthy mothers with insufficient milk who delivered between 26 and 34 weeks were given growth hor- mone, 0.2 international units/kg/day subcutane- ously for 7 days. A group of 10 mothers received a placebo. Milk volume increased in the treated mothers. No change was noted in plasma growth hormone levels, but an increase was seen in insulin-like growth factor. No other changes were noted during this short-term therapy.60

Other drugs have been noted to enhance milk pro- duction. Domperidone (Motilium) is currently una- vailable in the United States because the FDA banned its distribution. It is widely available in Can- ada, Europe, and Australia. It is fully discussed in Chapter 12. A dosage of 10 mg three times per day is reported to increase milk supply in some women.

The drug is not without side effects, however. Other galactagogues are discussed inChapter 12.

Breastfeeding Twins and Triplets

Many case reports support that a mother can nurse twins and triplets. It has been documented for centuries that an individual mother can provide adequate nourishment for more than one infant.

In seventeenth-century France, wet nurses were allowed to nurse up to six infants at one time.

Foundling homes provided wet nurses for every three to six infants.

The key deterrent to nursing twins is not usually the milk supply but time. If a mother can nurse both infants simultaneously, the time factor is reduced (Figure 14-3). Many tricks have been suggested to achieve this. As the infants become larger and more active, it may be difficult to keep them simul- taneously nursing with only two hands to cope.

However, twins trained from birth to nurse simul- taneously will often continue to nurse in a position that allows both to nurse when they are older, even if the other is not nursing at the moment. If a

mother has help at home to assist with feedings, breastfeeding can be accomplished. The first year of life for a mother of a set of twins is an extremely busy one and really requires additional help, partic- ularly if the mother is going to breastfeed. She will need time for adequate rest and nourishment. She often benefits from suggestions from other mothers of twins. The incidence of prematurity with twins is 3 in 10, with triplets 9 of 10, and with singletons just 1 in 10 pregnancies.

The challenge of breastfeeding twins was inves- tigated by questionnaire of mothers who were members of the Mothers of Twins Clubs of South- ern California, a national organization that offers help and advice to mothers of twins. No other socioeconomic information was available. Of the respondents, 41 mothers (23.7%) breastfed from birth, although 30% of the infants were premature.

Of those who did not breastfeed, 9% were told not to do so by their physician, 11% did not think it was possible, and 11% did not think they would have enough milk for two. Of multiparas who had breastfed their first child, an equal number breastfed and bottle fed. Of the mothers who breastfed, 39 breastfed more than 1 month and 12 breastfed more than 6 months.

Eight healthy women who were breastfeeding twins and one breastfeeding triplets participated in a study by Saint et al.128to determine the yield and nutrient content of their milk at 2, 3, 6, 9, and 12 months postpartum. At 6 months, they fed an average 15 feeds per day. Fully breastfeeding women produced 0.84 to 2.16 kg of milk in 24 hours. Those partially breastfeeding produced 0.420 to 1.392 kg in 24 hours. The mother feeding triplets at 2ẵ months produced 3.08 kg/day, and the three infants were fed a total of 27 times per day. At 6 months the twins received 64% to 100% of total energy from breastfeeding and at 12 months received 6% to 13%. This further dem- onstrates that breasts are capable of responding to nutritional demands.

Figure 14-3. Premature twins nursing simultaneously, resting on a nursing pillow.

Guidelines for success in breastfeeding twins reported by Hattori and Hattori66admit that many obstacles exist but suggest that health care profes- sionals should provide extended support to mothers of multiples to promote successful breastfeeding.66 An extra pair of helpful hands provide significant assistance and relieve some of the fatigue. The ini- tiation and duration of breast milk feedings by mothers of multiples compared with mothers of sin- gletons were studied by a mailed questionnaire to 555 women.57 The 358 mothers with multiples who answered were older, had higher incomes, were married, and were less likely to return to work by 6 months postpartum. Initiation of breastfeeding was comparable between mothers of multiples and singletons, but mothers of multiples provided milk for a shorter period of time, and mothers of preterm multiples breastfed the shortest period of time. At 6 months, 33% of mothers of term singletons were breastfeeding partially compared with 37% of mothers of term multiples. For preterm singletons, 31% were breastfed compared with 16% of preterm multiples.57

The medical literature on nursing twins or trip- lets or multiples in general is lean. It is well estab- lished that mothers can make enough milk. On the other hand, books, pamphlets, and websites supply personal stories and advice for mothers, fathers, and families. LaLeche League International, mothers of twins, pregnancytoday.com, parentingweb.com, multiplebirthsfamilies.com, and others have copi- ous commentaries for mothers. Coping strategies can be helpful. Wisdom from Gromada59is shared with mothers in her bookMothering Multiples, Breast- feeding and Caring for Twins or More. A case of a mother successfully nursing quadruplets is reported by Ber- lin.23A helpful device is the “breastfeeding pillow,”

which is a pillow that wraps around the mother as she sits to nurse. The two infants can be supported by the pillow.

Full-Term Infants with Medical Problems

Infants who have self-limited acute illnesses, such as fever, upper respiratory infection, colds, diarrhea, or contagious diseases such as chickenpox, do best if breastfeeding is maintained. Because of breast milk’s low solute load, an infant can be kept well hydrated despite fever or other increased fluid losses. If respiratory symptoms are significant, an infant seems to nurse well at the breast and poorly with a bottle. This observation has been docu- mented many times when nursing mothers have roomed-in with their sick infants in the hospital.

The studies of Johnson and Salisbury82 on the

synchrony of respirations in breastfeeding in con- trast to the periodic breathing or gasping apnea pattern of the normal bottle-fed infant may well provide the underlying explanation for the phe- nomenon of an acutely ill infant continuing to nurse at the breast.

In addition to the appropriateness of human milk for a sick infant, nursing and closeness with the mother provide comfort. If an infant is suddenly weaned, psychologic trauma is added to the stress of the illness.8The American Academy of Pediatrics (AAP) Committee on Nutrition has reversed its recommendation and does not recommend repla- cing breastfeeding in a sick child.

It may be difficult to distinguish the effect of trauma of acute weaning from the symptoms of the primary illness, such as poor feeding or leth- argy, if the acutely weaned infant fails to respond to adequate treatment. Returning to breastfeeding may be the treatment because the stress of acute weaning will be removed.

It is not appropriate to give a mother medicine intended to treat the infant, especially antibiotics.

This has been tried to the detriment of the child because variable amounts of the drug reach the infant depending on the dose, dosage schedule, and amount of milk consumed. Maternal drugs can produce symptoms in an infant in some cases,76 and thus maternal history of ingestants is important in assessing symptoms in a breastfed infant (see Chapter 12).

BUCCAL SMEARS IN BREASTFEEDING INFANTS

Guidelines for buccal smear collection in breastfed infants should be followed when genetic review is indicated. A buccal smear is a noninvasive, fast, and relatively inexpensive diagnostic method for collecting genetic material. It is used for sex deter- mination as well as aneusomy, microdeletion syn- dromes, and a variety of polymerase chain reaction-based molecular genetic tests. Maternal cells can contaminate smears taken from breastfed infants. The recommendation is to wait at least 1 hour after a feeding. Buccal mucosa should be cleansed thoroughly with a cotton swab applicator.

These procedures apply to both neonates and older nursing children.16

GASTROINTESTINAL DISEASE

Bouts of diarrhea and intestinal tract disease are less common in breastfed infants than in bottle-fed infants, but when they occur, the infant should be maintained on the breast if possible.8,130Human milk is a physiologic solution that normally causes neither dehydration nor hypernatremia. Occasionally, an