Breastfeeding the premature and the sick baby

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Breastfeeding the premature and the sick baby

• Jack Newman, MD, FRCPC

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In retrospect, it has become obvious that
incubator care is a large factor in the
difficulty establishing breastfeeding in
premature and sick babies
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So we need to ask the question

• Is incubator care the only way, or even the best
  way, to take care of premature and sick babies?

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Early skin to skin care vs. incubator care

• Bergman NJ, Linley LL, Fawcus SR. Randomized
  controlled trial of skin-to-skin contact from
  birth versus conventional incubator for
  physiological stabilization in 1200-2199 gram
  newborns. Acta Paediatr 200493779-785

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Two groups

• All babies were put skin to skin with the mother
  after birth
• After the five minute Apgar, if the baby was
  stable (monitored continuously), the baby was
  randomly assigned to?
• Skin to skin care (SCC) for 6 hours
• Transferred to incubator and usual care

6
Protocol

• All babies had an IV line placed with glucose
  running at 4.17 mg/kg/min
• All had an orogastric tube placed
• All were started on theophylline by orogastric
  tube
• Oxygen given if required
• If the baby was well, breastfeeding attempted at
  50 min, 3 hours and 5 hours
• After 6 hours, all babies given routine care

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Parameters

• All babies were continuously monitored
• The following situations were considered
  exceeding parameters (see later slide)
• Skin temperature below 35.5C for two consecutive
  recordings
• Heart rate lt100 or gt180 for two consecutive
  recordings
• Apnea gt20 seconds
• O2 saturation lt87 despite support
• Blood glucose lt2.6 mmol/l confirmed by lab

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SCRIP score
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Kangaroo Mother Care
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Kangaroo Mother Care

• If medical condition allows
• Infant, wearing a diaper only, is placed between
  mothers breasts, with head in sniffing
  position
• Maintains babys physiological functions at least
  as well as, and often better than incubator care
• Facilitates breastfeeding

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Kangaroo Mother Care

• Fewer apneas and bradycardias
• Less frequent and less severe desaturation
• Oxygenation improved (even if not desaturated,
  allowing lower concentrations of inspired oxygen)
• Body temperature maintained
• Earlier discharge from hospital
• Improved arousal regulation and stress reactivity

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Kangaroo Mother Care

• 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 and cortisol release)
• Positive effects seem to be maintained after
  contact ended
• Better parent-child relationship
• Greater likelihood of full breastfeeding in
  hospital and at discharge

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Gas exchange

• Föhe K, Kropf S, Avenarius S. Skin to skin
  contact improves gas exchange in premature
  infants. J Perinatology 20005311-15
• 53 preterm infants lt1800 g in a prospective
  study, during incubator care (60 min), skin to
  skin contact (90 min)
• All babies on oxygen, 5 still being ventilated

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More References

• Cattaneo A, Davanzo R, Worku B, et al. Kangaroo
  Mother Care for low birthweight infants A
  randomized control trial in different settings.
  Acta Pædiatr 199887976-85
• Törnhage C-J, Sturge E, Lindberg T, Serenius F.
  First week Kangaroo Care in sick very preterm
  infants. Acta Pædiatr 1999881402-4
• Johnston CC, Stevens B, Pinelli J et al. Kangaroo
  Care is effective in diminishing pain response in
  preterm neonates. Arch Pediatr Adolesc Med
  20031571084-8

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More References

• Feldman R, Weller A, Sirota L, Edelman AI.
  Skin-to-skin contact (Kangaroo Care) promotes
  self-regulation in premature nfants sleep-wake
  cyclicity, arousal modulation and sustained
  exploration. Develop Psychol 200238194-7
• Charpak N, Ruiz-Peláez JG, et al. A randomized
  controlled trial of Kangaroo Mother Care Results
  of followup to 1 year corrected age. Pediatrics
  20011081072-9

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More References

• Ohgi S, Fukuda M, Moriuchi H, et al. comparison
  of kangaroo care and standard care Behvioral
  organization, development and temperament in
  healthy low birth weight infants through 1 year.
  J Perinatology 200222374-9
• Furman L, Minich N, Hack M. Correlates of
  lactation in mothers of very low birth weight
  infants. Pediatrics 2002109(4)
  www.pediatrics.org/cgi/content/full/109/4/e57

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WHO document on KMC (2003)

• http//whqlibdoc.who.int/publications/2003/9241590
  351.pdf
• All the references you could want
• Includes practical information for implementation
  of Kangaroo Mother Care

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Breastmilk and breastfeeding
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Breastmilk and breastfeeding

• We are dealing with a question of life and death
• You should be happy your baby is surviving
  breastfeeding is a minor issue
• ?saving the babys life and helping the mother
  with breastfeeding are not mutually exclusive
• Nor should they be

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The premature baby

• The word premature covers a lot of ground
• What may be true about the 26 week gestation
  baby, weighing 600 grams, being ventilated for
  weeks, may not be true of 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

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They both need breastmilk

• But the methods of feeding them, the need for
  fortification, the approaches are very different
• Each baby needs to be treated as an individual
• The one size fits all approach to feeding
  premature babies is inappropriate

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Generalizing from the NICU

• Unfortunately, much of how we approach feeding
  the premature comes from NICUs, neonatologists
  and pædiatric nutritionists who deal with that 26
  week gestation premature baby, but never see a
  healthy 33 week gestation baby
• In fact, most premature babies fall into the
  latter group
• they are relatively mature and larger, often have
  only minor medical problems, and are in hospital
  essentially for nutritional support

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Lets not generalize

• We cannot take what may be appropriate for that
  26 week gestation baby in a NICU as a basis for
  the nutrition of the bigger premature babies
  found in nurseries in most community hospitals
• For example, if the mother is pumping enough
  milk, most babies of 33 or more weeks gestation
  do not need fortification
• Different approaches are necessary for this group

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Confession

• I did 6 months in a tertiary NICU as part of my
  training
• But most of my experience in feeding premature
  babies comes from my experience with prematures
  in Africa
• babies who did not make it on oxygen alone,
  didnt make it
• this is a different situation from NICU

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Still, this allows some perspective on the
question of feeding premature babies
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Why breastmilk for the premature?

• Breastmilk provides
• Protection against infection
• Protection against NEC
• Appropriate lipid profile (PUFAs)
• Better cognitive development
• Better visual development
• A role for the mother in the care of her baby
• this is very important

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Breastfeeding and sepsis

• Rønnestad A, et al. Late onset septicemia in a
  Norwegian national cohort of extremely premature
  babies receiving very early full human milk
  feedings. Pediatrics 2005215e262-e268

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Cumulative proportions of infants initiated on
enteral feeding (black bars) and established on
FEF with human milk (gray bars), according to
age, among extremely premature infants in Norway,
1999-2000
Ronnestad, A. et al. Pediatrics 2005115e269-e276
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Survival free from LOS according to week of
establishment of FEF with human milk among
extremely premature infants in Norway, 1999-2000
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RR of future LOS if FEF with human milk is not
established within a given age (in days) among
extremely premature infants in Norway, 1999-2000
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Why breastmilk for the premature?

• And, for the same reasons that breastmilk is best
  for the full term baby
• Premature babies dont need breastmilk less
• ?they need it more!

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Alternatives to breastmilk?

• There is lack of evidence for safety, superiority
  or even equality of the alternatives (preterm
  formulas and fortifiers) in the long term
• Unlike drugs, the formula companies do not have
  to prove they are safe, never mind useful
• We should be careful about using them routinely
• They should be used as drugs, if necessary, but
  not if not necessary

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Apparent deficiencies of breastmilk

• Not enough protein to support the growth of the
  premature baby
• Most of the protein in breastmilk is not even
  absorbed (dont tell anyone)
• Insufficient calcium, phosphorus and vitamin D
  for bone mineralization
• Insufficient calories for intrauterine growth
  rate
• Intolerance of some tiny premature babies to
  lactose

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Intrauterine growth rate

• Besides being intellectually satisfying, is there
  any proof that a baby is better off growing at
  intrauterine growth rates?
• How did we establish this standard?
• The physiologic situation is completely different
  for a baby outside the uterus
• Are there suggestions that more is not
  necessarily better?
• Yes
• There are advantages to exclusive breastfeeding
  (or breastmilk feeding) that go beyond growth
  rate
• A balance which is best for the baby needs to be
  struck

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Advantages to exclusive breastmilk feeding?

• Lipid profile in adolescents
• Singhal A, Cole TJ, Lucas A. Breastmilk feeding
  and lipoprotein profile in adolescents born
  preterm follow-up of a prospective randomised
  study. Lancet 20043631571-8

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Results

• The ratio of LDL to HDL cholesterol was
  significantly lower in adolescents who had been
  randomised to bank breastmilk compared with those
  who received preterm formula
• CRP concentration was also significantly lower
  in adolescents randomised to banked breastmilk
  compared with preterm formula
• CRPC reactive protein, a marker for
  atherosclerosis
• As expected, early weight gain was significantly
  greater in infants randomised to
  nutrient-enriched preterm formula than in those
  randomised to banked breastmilk

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Is more weight gain necessarily better?

• As expected, early weight gain was significantly
  greater in infants randomised to
  nutrient-enriched preterm formula than in those
  randomised to banked breastmilk

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The more breastmilk a baby got, the lower his LDL
to HDL ratio (better profile)
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Different study, same cohort

• Effects on blood pressure
• Singhal A, Cole TJ, Lucas A. Early nutrition in
  preterm infants and later blood pressure two
  cohorts after randomised trials. Lancet
  2001357413-9

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And theres more

• Singhal A, Cole TJ, Fewtrell M, et al. Is slower
  early growth beneficial for long term
  cardiovascular health? Circulation
  20041091108-13
• Singhal A, Fewtrell M, Cole TJ, Lucas A. Low
  nutrient intake and early growth for later
  insulin resistance in adolescents born preterm.
  The Lancet 2003361 (March 29)1089-97
• Singhal A, Farooqi IS, ORahilly S et al. Early
  nutrition and leptin cencentrations in later
  life. Am J Clin Nutr 200275 993-9

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Osteopænia, fractures etc.

• Bone demineralization is often cited as a reason
  to use fortifiers
• And there does appear to be a benefit to giving
  extra calcium and phosphorus to prevent
  osteopænia in very small premature babies
• But of course, it is not necessary to give cows
  milk (from which fortifiers are made) in order to
  give extra calcium and phosphorus
• Calcium and phosphorus can be added to breastmilk
  without using fortifiers, based on individual
  evaluation of biochemical factors

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One long term study

• Bishop NJ, Dahlenburg SL, Fewtrell MS, et al.
  Early diet of preterm infants and bone
  mineralization at age five years. Acta Pædiatr
  199685230-6
• Compared banked donor milk vs preterm formula as
  a supplement to mothers breast milk in 54
  children aged five years
• Increasing human milk intake was strongly
  positively associated with later bone mineral
  content.

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Implications?

• a period of mineral deprivation in the newborn
  period is good for long term bone mineralization!
  This would represent another example of
  programming. It could represent the action of
  other factors within breastmilk, such as growth
  factors¹
• ¹Ryan S. Bone mineralization in Preterm Infants.
  Nutrition. 199814745-747

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Lets look at how feeding of the premature
baby is often undertaken
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Case study

• Twins girls born at 33 weeks gestation
• Normal delivery
• Mother breastfed a previous child 7 months
  without problems
• MH born at 2.02 kg (4lb 7oz),VH born at 1.6 kg
  (3lb 8oz)
• They are relatively big babies
• No medical problems at all in hospital
• The twins in hospital 5 weeks total, 3 weeks in
  one, then 2 weeks in another hospital

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Feeding in hospital

• Intravenous for first 4 days
• Formula started early, nasogastric feedings at
  first
• Bottles started within the first week
• Breastfeeding only attempted after several weeks
  (mother not sure exactly when)
• Pumping started in hospital but mother not sure
  when (not within first days)

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Whats wrong with that?

• The mother should have started expressing
  immediately (but it was not encouraged)
• No kangaroo mother care
• The babies could have been tried on the breast as
  soon as it was obvious they were stable (lt24
  hours in this case)
• Cup feeding would have been preferable to bottles
  and even to ng feedings
• Formula was not necessary in the first days

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On discharge from hospital

• Mother was essentially bottle feeding both
  babies, with babies taking the breast a little on
  the left, refusing the right side completely
• Each feeding consisted of approximately 60 ml
  (2oz) of formula with 30 ml (1oz) of expressed
  milk

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First visit to our clinic

• The babies are 83 days old
• MH weighs 3.35 kg (7lb 6oz)
• birthweight was 2.02 kg (4lb 7oz)
• weight gain 16 g/day, well below intrauterine
  growth rate
• VH weighs 3.25 kg (7lb 2oz)
• birthweight was 1.6 kg (3lb 8oz)
• weight gain 20 g/day, better but still below
  intrauterine growth rate

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Intra-uterine growth rate

• The experts say that premature babies need to
  grow at intra-uterine growth rates of 12 to 16
  grams/kg/day
• Nutrient needs and feeding of premature babies.
  Statement of the Canadian Paediatric Society,
  1995

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Intra-uterine growth rate

• Therefore, when they left the hospital, according
  to this standard
• MH should have weighed 2.85 kg (6lb 6oz)
• VH should have weighed 2.27 kg (5lb even)
• This is using the lower 12 g/kg/day and not even
  taking into consideration the increasing weight
  with time

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What does this mean?

• If they had, in fact, grown at 12 g/kg/day
• MH would have gained only 140 g (5oz) since
  discharge from the hospital 5 weeks before
• VH 710 g (llb 9oz) in the same time
• So two possibilities
• They didnt grow at intra-uterine growth rates in
  hospital (which is the likely answer, despite all
  the fortifier and preterm formula they received)
• They didnt grow well since leaving hospital
  despite being mostly formula fed, and shouldnt
  we be concerned about that?

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What does this mean?

• As long as babies are formula fed, we dont seem
  to worry too about intrauterine growth rate
• We probably believe that were doing the best
  that can be done
• because formula is the best
• If the babies were strictly breastfed or
  breastmilk fed
• We have to do something!

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After 4 visits to our clinic over 3 weeks

• MH weighs 4.02 kg (8lb 14.5oz)
• Increase of 530 g (1lb 3oz)
• VH weighs 3.81 kg
• Increase of 460 g (1lb even)
• They are getting 120 cc/day (about 4oz) of
  supplemental formula a day or 60cc/baby/day
• Both are breastfeeding beautifully

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Lets look at the weights

• Did they gain enough, on almost exclusive
  breastfeeding?
• MH gained 530/2125 g/day
• VH gained 460/2122 g/day
• At this age (12 weeks of age), its just fine!
• Do we really truly need to check weight gain/day?
• Nobody seemed to be worried that the weight gain
  was not up to intra-uterine rates when they were
  being supplemented with formula, were they?

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After 5 weeks of help in our clinic, with
the mother obviously very determined, babies are
exclusively breastfeeding and gaining weight well
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Known deficiencies of artificial feedings

• No protection against infection
• No trophic factors
• epidermal growth factor, nerve growth factor,
  insulin-like growth factor etc, etc
• Long chained polyunsaturated fatty acids (PUFAs)
  are likely not added in proper amounts
• Bioavailability of many elements poor or much
  reduced
• Interaction of elements does not occur

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Breastmilk made to measure
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Fortifiers

• Because of the insufficiencies of each, then the
  use of fortifiers is the ideal solution?
• Benefits of both, right?
• No, because fortifiers dilute the benefits of
  breastmilk alone
• They may be helpful or even necessary, but in the
  case of liquid fortifier, dilute breastmilk or in
  the case of powder, makes it hyperosmolar
• Always necessary? No!

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Overcoming deficiencies of breastmilk

• Feed more!
• a healthy, unstressed premature may tolerate a
  lot more than a sick, tiny one
• we had no option in Africa babies could get
  breastmilk only I was convinced by the
  intrauterine growth rate argument
• so we gave them more, and when the roof didnt
  cave in we gave even more

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How much more?

• Usually it is said that premature babies can take
  only up to 180 to 200 cc/kg/day fluid
• This total includes IV fluid, so that enteral
  feeds are correspondingly reduced
• In some NICUs, the rule is even less
• In an NICU this may make sense since the babies
  are sick and some may go into heart failure with
  more fluid, especially if they are on ventilators
• but the well premature baby can take more,
  especially if given by continuous ng feeding
• We gave 300 cc/kg/day with no trouble except
  occasionally babies would get diarrhea

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Continuous drip

• It has been said this isnt as good as
  intermittent feedings, because of greater loss of
  fat
• Others studies suggest the opposite?less fat loss
  with continuous flow
• But if the syringe is tip upwards, we lose less
  fat
• Ultrasound homogenization can decrease fat loss
  as well
• In utero the baby gets continuous flow

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Continuous feeding better?

• Dslina A, Christensson K, Alfredsson L, et al.
  Continous feeding promotes gastroentestinal
  tolerance and growth in very low birth weight
  infants. J Pediatr 200514743-49
• In VLBW infants, continous feeding seems to be
  better than intermittent feeding with regard to
  gastrointestinal tolerance and growth

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Lecithin to decrease fat loss

• Chan M, Nohara M, et al. Lecithin decreases human
  milk fat loss during enteral pumping. J Ped
  Gastroenerol Nutr 200336613-15
• Adding 1 g of soy lecithin to 50 ml of human milk
  decreased fat loss from 58 (13) to 2 (2)

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Overcoming deficiencies

• Use hindmilk (more fat, faster growth)
• Use fresh milk immediately after pumped
• In Africa, we found that when mothers had to
  leave, and refrigerated milk was used, babies
  grew less well (but then this may be due to less
  KMC)
• Add calcium, vitamin D and phosphorus without
  using fortifiers
• Use commercial lactase to incubate with expressed
  milk
• Kangaroo mother care

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Need more weight gain?

• If the mother is producing sufficient milk, why
  not centrifuge some of the mothers milk, skim
  off the fat, and add it to the babys feedings?
• Easy to do
• We did it in Africa, with no equipment except a
  centrifuge
• Actually you can just let the breastmilk stand
  and the fat rises to the top
• Being done in some NICUs in the US

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Individualize care

• The approach is different depending on the baby
• bigger babies (gt1500 g) usually do not need
  fortification
• dilution would be the appropriate word in this
  case
• a healthy baby, even small, presents fewer issues
  than a sick one
• this does not mean a sick baby should not get
  breastmilk

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Human milk banking

• Why do fortifiers need to be made with cows
  milk?
• The technology is there (after all we make
  fortifiers from cows milk) to make fortifiers
  from human milk
• This has been done and it is being done, and it
  is conceivable that individual items can be
  ordered up
• baby needs more protein?phone the milk bank to
  get human milk protein
• baby needs to gain more?get human milk fat

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Human milk banking

• Human milk banking also affords us the luxury of
  getting human milk into the baby from the very
  first days, if the mothers supply does not yet
  allow getting significant amounts
• Early feeding is now felt to be best for most
  premature babies
• Usually a small amount of human milk is much
  better than large amounts of formula (preterm or
  otherwise)

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Getting breastmilk

• First of all you need to get the milk
• Milk from a breastmilk bank is one option
• Some mothers have no intention of breastfeeding,
  but they should be approached
• This is the one thing you can do for your baby
  that nobody else can
• You will be providing the best medicine there is
  for your premature baby. Wont you help us help
  him?

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Early feeds

• Colostrum should be provided as soon as possible
  
• Even drops may be beneficial, by priming the
  babys gut and giving protective SIgA
• Drops can be tolerated even by the tiniest baby
  and even drops protect
• Many premature babies have IV lines up, so there
  is no rush to get fluids into them
• Small amounts of colostrum are perfectly
  acceptable, and safer than early introduction of
  foreign proteins

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From the Canadian Paediatric Society

• Nutrient needs and feeding of premature babies
  1995
• During the transition period, when growth is
  variable and infants are metabolically unstable,
  all infants, regardless of birth weight, should
  receive a combination of parenteral and enteral
  nutrition.
• Expressed preterm-mothers milk, without
  fortification, is the first choice for enteral
  feeding during this period.

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Priming the gut

• The baby is much more likely to tolerate oral
  feedings earlier
• Trophic factors (epidermal growth factor is
  present in high concentrations in colostrum) help
  the gut mature
• growth of villae and digestive enzymes
• promote gut closure
• increase absorption of nutrients
• improve gut motility

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Sending a message

• Even a drop or two of colostrum can be used for
  mouth care of the ventilated baby, even mixed
  with some water
• Giving the few drops to the baby sends a very
  strong message
• even a few drops of breastmilk are important and
  good
• Treat the milk as if it were precious!
• Because it is

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What if no IV is necessary?

• Small amounts of fluids may be adequate
• colostrum in drops for a day or two
• if mother not yet producing, and more calories
  needed?how about banked milk?
• IV should be seriously considered to avoid
  formulas in the first days, so as not to lose the
  advantage of the babys getting only breastmilk
  orally during this most important time

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Starting out expressing

• Start as soon as possible after the babys birth
• The sooner one starts, the more milk the mother
  is likely to produce, and the sooner the baby has
  colostrum available to him
• The mother has more practice
• Hand expression is often easier when quantities
  are small

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Hand expressing in the NICU
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Pumping milk

• Use double setup electric pump if possible
• less time involved than single
• more milk
• results in higher prolactin levels
• most mothers prefer double setup

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How frequently?

• Mother should express as much as reasonable
• eight times a day for about 20 minutes/side?
• compression can be used as well towards end of
  pumping (increases milk supply, gets more milk)
• dont forget hand expression!

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Support for the mother

• It can be extremely difficult
• She needs support in hospital
• all health professionals should be expected to
  convey the message of the importance of
  breastmilk
• there will be rough moments
• She needs support outside hospital
• La Leche League, outside LC

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Handling milk

• Best to use fresh pumped milk given to the baby
  immediately after pumping
• Refrigerated better than frozen
• The more you handle milk, the more you lose
  beneficial factors
• but remember, even if you lose some SIgA, for
  example, there is no SIgA in formula
• Glass and hard plastic presently the preferred
  containers

92
Cytomegalovirus

• There was considerable concern with mothers who
  were carriers for cytomegalovirus a few years ago
• The worry was that the tiny premature baby could
  get seriously ill from virus in the milk
• The virus is killed by freezing, so freezing of
  milk was recommended before giving the thawed
  milk to the baby if the mother was positive for
  IgG antibodies to the virus in her blood
• This is no longer felt to be a concern

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Cytomegalovirus and prematures

• Pædiatr Child Health, volume 11, no 8, October
  2006 page 490 (Statement from the Canadian
  Pædiatric Society)
• recent studies suggest that the relative
  incidence and severity of CMV disease
  inpremature infants are lowproviding further
  support for fresh breastmilk feeding even if the
  mother is CMV positive.

94
What about breastfeeding?

• As one mother said to me about a Toronto hospital
  where she gave birth to two premature babies a
  few years apart,
• Theyve changed
• They now believe in breastmilk and are urging me
  to express my milk,
• but I dont think they believe yet in
  breastfeeding

95
When to start at the breast?

• As soon as the baby is stable
• babies can start nuzzling the breast very early
• let them learn to take the breast
• if you wait until they can coordinate suck and
  swallow, you will have lost much valuable time
• Kangaroo care, mother and baby (or father and
  baby) skin to skin as much as possible is ideal

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Pholosong Hospital, South Africa
97
31 weeks, 3 days old, and breastfeeding
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Note latch
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When can the baby start breastfeeding?

• Nyqvist KH, Sjö P-O, Ewald U. The development of
  preterm infants breastfeeding behaviour. Early
  Hum Dev. 199955247-264
• 71 singleton (26.7-35.9 weeks gestation) studied
  prospectively
• Mothers made most of the observations, with help
  from experienced observers
• 4321 records of infants behaviour

100
When can the baby start?

• Irrespective of postmenstrual age, the infants
  responded by rooting and sucking on the first
  contact with the breast
• Efficient rooting, areolar grasp and latching on
  were observed at 28 weeks
• Nutritive sucking appeared from 30.6 weeks
• Sixty-seven (out of 71) infants were breastfed
  at discharge.  Fifty-seven of them established
  full breastfeeding at a mean postmenstrual age of
  36.0 weeks (33.4-40.0)

101
Bottle feeding mentality again

• Restrictions in breastfeeding policies for
  preterm infants are commonly based on studies of
  bottle feeding, where it has been established
  that infants with immature cardio-respiratory
  control show a less coordinated
  suck-swallow-breathe pattern, resulting in apnea,
  hypoxia and bradycardia

102
From Kersten Nyqvist (email sent August 16, 2004)

• the postmenstrual age (PMA, corresponding to GA
  after birth) when preterm infants in the Uppsala
  NICU reach full breastfeeding has been decreasing
  gradually, with an increasing number of 34- and
  33-weekers being discharged with full
  breastfeeding
• We also see some 32-weekers fully breastfed, and
  recently one baby attained full breastfeeding at
  a PMA of 31 weeks and 6 days (GA verified by
  ultrasound)

103
Another personal communication from Kersten
Nyqvist (July 2006)

• Feeding premature babies by the clock delays
  transition to full breastfeeding

104
More from Dr. Nyqvist

• Early attainment of breastfeeding competence in
  very preterm infants. Acta Paediatr
  200897776-781
• A study of 15 babies born at 26-31 weeks
  gestation
• Five babies were able to latch on by 29 weeks
  gestation
• Kangaroo Mother Care was routine
• Bottles are not given unless mothers insist
• Only 4 of the 15 premature babies ever used a
  nipple shield

105
And

• One baby achieved exclusive breastfeeding at 32
  weeks gestation
• Fortifiers were not used routinely and only 7
  received any
• Full breastfeeding was achieved at a median of 35
  weeks gestation
• The 26 week gestation baby left hospital
  exclusively breastfeeding

106
And

• Twelve of the 15 mothers achieved exclusive
  breastfeeding in hospital
• Note that breastfeeding means feeding at the
  breast, not breastmilk feeding

107
28 weeks gestation, two weeks old, latched on,
getting milk
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28 weeks and breastfeeding
110
Consider this

• Apparently in some or many Scandinavian NICUs,
  mothers are encouraged not only to touch their
  babies, but also to hold them skin to skin, and
  also to lick their skin all over
• Why on earth?
• Think of the common causes of sepsis in premature
  babies

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112
Positioning, latching on

• This is no less important for the premature baby
  than in the full term
• A good latch allows the baby to get milk better
  from the breast
• this teaches the baby to suckle properly
• babies learn to breastfeed by breastfeeding
• A good latch helps prevents nipple soreness

113
Good position, good latch
114
Nipple points to roof of mouth
115
Two errors?
116
Two errors?

• Nipple is pointing to the lower lip, not upper
  lip (or the mother has moved baby too much to her
  left side)
• Mother is squeezing nipple to put it into the
  babys mouth

117
Better
118
Well latched on
119
34 weeks, not badly latched on
120
31 weeks, drinking beautifully
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123
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124
A few contentious points

• Do premature babies need nipple shields?
• Maybe some, but give them a chance to latch on
  without them
• Whats the rush?
• If we did more skin to skin care (Kangaroo Mother
  Care), we would have babies latching on better
  and earlier
• If we didnt feed premature babies by schedules,
  we would also not need nipple shields

125
A few contentious points

• Are test weighings so important?
• Do you really believe they tell you anything?
• What if you get a negative test weight?
• Why not just follow the babys weight from day to
  day?
• Observe the baby at the breast!

126
Study on test weighings

• Savenije O E M, Brand P L P. Accuracy and
  precision of test weighing to assess milk intake
  in newborn infants. Arch Dis Child Fetal
  Neonataol Ed 200691F330-F332
• Test weighing is an imprecise method for
  assessing milk intake overestimation and
  underestimation of up to 30 ml are possible,
  probably caused by the use of insensitive
  scales

127
A few contentious points?

• Do premature babies fall asleep at the breast
  because the are tired?
• Or because the flow of milk is slow? Right!
• Just as with a full term baby!
• Get the flow going, and they will keep awake just
  as they would on a bottle

128
How to prevent slow flow?

• Best latch possible
• Teach the mother how to know the baby is getting
  milk
• See websites www.nbci.ca
• Use compression when the baby doesnt actually
  drink
• Switch sides as the flow slows
• Use a lactation aid to supplement
• preferably expressed milk

129
Lactation aid

• Use only after baby has nursed both sides and
  only after the baby no longer actually drinks
• Is the best way to supplement because babies
  learn to breastfeed by breastfeeding
• Even if there is no such thing as nipple
  confusion, lactation aid still best
• baby continues to get milk from breast
• there is more to breastfeeding than breastmilk

130
Show video clip insertion of lactation aid
131
Does nipple confusion exist?

• Mizuno K, Ueda A. Changes in sucking performance
  from nonnutritive sucking to nutritive sucking
  during breast- and bottle-feeding Pediatr Res
  200659728-31
• It is evident from the results of this study
  that bottle feeding is a completely different
  feeding method regardless of attempts to make
  bottle feeding more closely resemble
  breastfeeding

132
Does nipple confusion exist?

• Gomes CF, Trezza EMC, Murade ECM, Padovani CR.
  Surface electromyography of facial muscles during
  natural and artificial feeding of infants J
  Pediatr (Rio J) 200682(2)103-9
• Essentially, the study shows that different
  muscles are involved in breastfeeding than in
  bottle feeding

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Lactation aid in place
135
Inserting tube-1
136
Inserting tube-2
137
Inserting tube-3
138
Inserting tube-4
139
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141
Cup feeding

• Best used when mother isnt present
• Used to avoid a bottle
• Some people say that if used correctly, helps the
  baby to learn to breastfeed because he must stick
  out tongue to drink from cup
• In any case it is easy, and better than bottle

142
Cup feeding
143
Cup feeding
144
Cup feeding
145
Show video of cup feeding
146
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, try the baby on the breast
• If mother not there, cup feeding is better, there
  is no reason to use finger feeding

147
Finger feeding
148
Positioning of tube for FF
149
Positioning of tube for FF
150
So what about the older premature baby (35-37
weeks)?

• Nothing really
• The same approach is necessary
• An early start, good positioning and latching
• No forcing of the baby to the breast
• No rush to get him breastfeeding
• Avoidance of bottles
• Skin to skin contact (most of the day)
• Alternative feeding methods if necessary
• Discharge with good outside followup

151
Discharge planning

• There is no need to wait for the baby to
  breastfeed well, if the mother and baby can get
  early, reliable, frequent and knowledgeable
  followup, starting within a day or two of
  discharge
• Should we intimidate mothers into giving bottles,
  so the baby can go home?
• short term gain, for long term pain (mothers and
  babys not the staffs)

152
Attrition of Breastfeeding In NICU from Admission
to Discharge
153
Attrition of Breastfeeding In NICU from Admission
to Discharge ? 1500 gms
154
27 weeks gestation
155
1 year old (8 months corrected)St
ill breastfeeding by his mother who adopted him
at birth
156
Breastfeeding the baby with congenital
heart disease
157
Why is it important to breastfeed?

• For the same reasons as for any baby
• Why do babies with cardiac disease need
  breastfeeding (or breastmilk) less?
• They need it more!
• They spend a lot of time in hospital, and
  infection rates are not minimal
• Indeed infection is not rarely cause of
  complications, prolonged hospitalizations and
  death

158
What obstacles are there?

• Same as any mother-baby pair plus
• Breastfeeding is more difficult than bottle
  feeding
• Fluid restriction is necessary for the baby
  with congestive heart failure
• Cardiac disease often associated with other
  problems
• A baby who has had a cardiac transplant cannot
  breastfeed

159
Is breastfeeding more difficult?

• Not according to the data
• Anyone who takes the trouble to watch a baby
  breastfeeding at the breast knows this is not
  true
• See the video clip Inserting lactation aid
• Marino BL, OBrien P, LoRe H. Oxygen saturations
  during breast and bottle feeding in infants with
  congenital heart disease. J Pediatr Nurs
  199510360-4

160
Fluid restriction

• Fluid requirements can be managed clinically
  (daily weights, physical examination, increased
  use of diuretics)
• Even, if one must, pre and post feeding weights
• If truly necessary, though, the mother could
• use a lactation aid with expressed milk while the
  baby nurses on a dry breast
• Still possible to avoid bottle with cup feeding

161
Associated problems

• Babies with cardiac problems often have other
  associated problems
• Trisomy 21
• large tongue, hypotonia
• most babies will take the breast
• Tracheo-oesophageal fistula (other gi anomalies,
  such as gastroschisis)
• no need for favourite surgeon formulas
• breastmilk is best

162
Cardiac Transplantation

• Will antibodies in the milk increase the risk of
  rejection?
• Ridiculous!
• An example of breastmilk is guilty until proved
  otherwise, whereas formula is innocent until
  proved guilty

163
Antibodies in various fluids
164
Do maternal antibodies in breastmilk cause infant
illness?

• The predominant immunoglobulin in human milk is
  secretory IgA
• there is no evidence that secretory IgA is a
  pathogenic antibody in autoimmune disease or
  rejection
• In any case, secretory IgA is not absorbed via
  the gastrointestinal tract
• There is no evidence that IgG in human milk is
  absorbed into the circulation of the infant
• IgM also excluded from the infants circulatory
  system

165
In rare cases

• It would seem as if white cells in the milk can
  give information (via cytokines?) to the baby
  which has resulted in an immune response to
  platelets in baby when the mother had idiopathic
  thrombocytopenic purpura, for example
• Has never been reported with cardiac
  transplantation.
• Rare!!
• Often gets better after a few weeks
• Freezing milk kills white cells
• But would these cytokines overcome the powerful
  immunosuppressives?

166
Chylothorax

• Not a rare complication of cardiac surgery
• The thoracic duct is nicked, and lymph drains
  into the right chest cavity
• Occasionally, a baby without any cardiac disease
  is born with chylothorax without any obvious
  reason

167
Usual treatment of chylothorax

• Chest tube drainage
• Low fat diet (to decrease lymph flow in the
  thoracic duct)

168
Low fat diet?

• You cannot give an infant a low fat diet this
  will result in poor growth
• So if we give him milk with medium chained
  triglycerides, the baby will get fats in the milk
  which is not absorbed into the lymph, but rather
  directly into the blood stream
• This will decrease the flow of lymph in the
  thoracic duct and decrease the drainage into the
  chest cavity

169
Does that mean no breastmilk?

• Thats what it meant until some people started to
  think about it a little
• People who felt breastfeeding, or at least
  breastmilk, was important
• Why give Portagen (formula with medium chained
  triglycerides) when we can give breastmilk?

170
What to do?

• Mother expresses milk
• Milk is centrifuged and fat skimmed off
• Fat is replaced by medium chained triglycerides
• Its not quite breastmilk, but its better than
  Portagen
• Baby is also at lesser risk for infection and
  receives most of the other benefits of breastmilk

171
And then?

• Once the thoracic duct heals, the baby goes back
  to breastmilk, and attempts are made to get the
  baby breastfeeding
• It may not be easy, as most surgeons and
  cardiologists want the chest dry for several
  weeks before abandoning the milk with medium
  chained triglycerides
• If the baby were fed on a dry breast with a
  lactation aid?

172
Making skimmed breast milk

• See www.lalecheleague.org and search for
  Chylothorax

173
Breastfeeding the baby with cystic fibrosis
174
Why is it important to breastfeed?

• For the same reasons as for any baby
• Why do babies with cystic fibrosis need
  breastfeeding (or breastmilk) less?
• They need it more
• They spend a lot of time in hospital, and
  infection rates are not minimal
• Indeed infection is a common cause of
  complications, prolonged hospitalizations and
  death
• Nutrition is a serious issue for these babies
• Breastmilk is best

175
Breastmilk has lipase

• These babies usually do not have good pancreatic
  function and are unable to digest fat well
• But breastmilk contains lipase
• These babies usually do not digest protein well
• But breastmilk contains proteases

176
Most babies will need enzymes

• These can be given, dissolved in some expressed
  milk, by lactation aid
• Sometimes, because they are digestive enzymes,
  the mothers nipples can become sore
• So use all purpose nipple ointment before passing
  enzymes through the tube

177
Fat excretion studies

• Part of the routine workup for cystic fibrosis
  is to do fat excretion studies
• The baby is given milk of which the fat content
  is known
• His bowel movements are collected for five days
  and the amount of fat in the bowel movements is
  measured
• The amount of fat excreted in the stools is
  expressed as a percentage of the total fat
  ingested
• Not every hospital centre is doing this any more

178
Normal fat excretion

• Normally, a baby will not have more than about
  10 of the total fat intake recovered in the
  stools
• An older child or adult, no more than 5
• Babies with cystic fibrosis usually pass much
  more than 10 of their fat intake in the bowel
  movements

179
What are the implications?

• It means taking the baby off the breast and
  feeding by bottle for 5 days
• Often they are not even offered the mothers milk
  because the amount of fat in breastmilk is
  variable
• It means that many babies will then refuse to
  breastfeed, having gotten used to the bottle

180
Is it necessary to do this?

• It helps to decide how much enzyme replacement
  the baby will need
• It helps to get research published to know this
  figure of fat excreted
• But enzyme replacement is, in any case, a bit of
  a guess, and can be adjusted
• And is it worth depriving the baby of
  breastfeeding and breastmilk?

181
Breastfeeding protects pulmonary function in
children with CF

• Colombo C, Costantini D, Zazzeron L, et al.
  Benefits of breastfeeding in cystic fibrosis A
  single-centre follow-up survey. Acta Paediatr
  200796(8)1228-32

182
Breastfeeding and PKU
183
Phenylketonuria

• A relatively rare inborn error of metabolism,
  characterized by the childs inability to oxidize
  phenylalanine to tyrosine
• It is caused by the absence of active
  phenylalanine hydroxylase in the liver
• Up until about 1980s, it was thought that
  breastfeeding was impossible (another example of
  bottle feeding mentality)
• Then it was shown that breastmilk had less
  phenylalanine than formula

184
Can the baby breastfeed?

• A baby with PKU needs some phenylalanine, but not
  too much, so breastfeeding can be encouraged
• How do we make sure the baby with PKU gets some,
  but not too much, since the amount a baby would
  get from full breastfeeding is usually too much
  for him?

185
First approach at PKU clinic

• Mother weighs baby before feeding
• Mother feeds baby 10 minutes on each side
• Mother reweighs baby after feeding
• Mother gives rest of calculated total of feeding
  as low phenylalanine containing formula

186
Why didnt it work?

• The mother had to take a scale with her wherever
  she went
• Babies started to refuse the breast. Is anyone
  surprised?
• Babies usually stopped by 2-3 weeks of age

187
Another way?

• Calculate the approximate quantity of low
  phenylalanine formula the baby would require
• Give this amount of formula at the beginning of
  the feeding at the breast with a lactation aid
• Allow the baby to finish the feeding on the
  breast

188
Results?

• During the first year, breastfeeding continued
  much longer
• One baby made it to 18 months of age
• Several made it to 6 months
• One baby who had atypical PKU was able to be
  breastfed exclusively
• If you look, you may find a way

189
Lactation aid
190
Cup feeding
191
Finger feeding
192
Summary

• If you believe in the importance of
  breastfeeding, both to the mother and the baby
• and you have imagination and determination
• and develop the necessary skills,
• even in the most difficult, complex, or
  previously untried situations,
• you may find a way!

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