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Successfully Breastfeeding Babies Born Prematurely and/or Affected by Neonatal Abstinence Syndrome (NAS)


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Title: Successfully Breastfeeding Babies Born Prematurely and/or Affected by Neonatal Abstinence Syndrome (NAS)

Successfully Breastfeeding Babies Born
Prematurely and/or Affected by Neonatal
Abstinence Syndrome (NAS)
  • Ruth Munday, BSN, RN-BC, IBCLC, RLC
  • Lactation Consultant
  • Le Bonheur Childrens 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.)
  • 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
  • Continue for 12 months, thereafter as long as
    mom/baby mutually desires

AAP Contraindications to Breastfeeding
  • Infant with galactosemia
  • Mother has active herpes lesions on breast
  • Mother has untreated active TB
  • 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
    lt1500 grams

Note maternal substance abuse is not a
categorical contraindication to
breastfeeding-adequately 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
  • 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
  • Thomas Hale Infant Risk Center
  • 806-352-2519
  • Medications and Mothers Milk-updated every 2
  • LactMed http//

Breastfeeding Benefits for Baby
  • Protects against/ lessens the severity of many
    illnesses such as
  • 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

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 moms decision
  • Skin to skin

Skin to Skin for all Babies
  • Promotes bonding
  • Helps increase moms milk supply
  • Calming for the baby (recognizes moms heartbeat)
  • Regulates babys temperature and stabilizes vital
  • Promotes healthy brain development

Hunger/Feeding Cues
  • Rooting
  • Mouth opening
  • Lip licking
  • Hands in mouth
  • Sucking on fingers
  • Flexion of arms
  • Last sign crying

Cradle Position
  • 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 Moms forearm, near her elbow
  • Your arm and hand support the babys back,
    keeping him hugged in close
  • Use free hand to support the breast

Football Position
  • Have Mom sit up straight with good back support
  • Use pillows at her side to raise baby to breast
  • Turn baby slightly in toward Mom
  • Support the base of the babys neck and shoulders
    in Moms hand
  • Hug babys body close
  • Use free hand to support the breast

Cross Cradle Position
  • Have Mom sit up straight with good back support
  • Use pillows to raise baby to breast level
  • Hold the base of babys neck and shoulders in
    hand, opposite the breast from which he is
  • Have Mom hold babys body in forearm, with his
    bottom hugged in near the crook of arm
  • Use free hand to support the breast

Side-Lying Position
  • Mom and baby lie on sides, facing each other
  • Place babys head on Moms forearm near elbow or
    on the mattress
  • Put pillows under Moms head to help her see baby
  • Pull babys 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
  • 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
  • Aim nipple toward nose upper lip
  • Brush upper lip with nipple to encourage baby to
    open WIDE

Proper Latching Technique (cont.)
  • WAIT for baby to open mouth wide , with tongue
  • Press on babys back between shoulder blades and
    quickly bring baby to breast

Proper Latching Technique (cont.)
  • Babys 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
  • 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
  • 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!
  • Proper position, latch-on, 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 babys 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

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When Mom should call for help
  • 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
  • Well balanced
  • No dietary restrictions
  • Drink until thirst is satisfied
  • Limit caffeine to 2 or less servings per day
  • Continue taking prenatal vitamins
  • Helpful foods
  • Oatmeal
  • Almonds
  • Protein
  • 3 meals, 2 snacks

Latching Difficulties
  • 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
  • Uses
  • Flat or inverted nipples
  • Latch-on difficulties
  • Overactive let-down
  • Helpful to transition baby from bottle to breast
  • 16mm, 20mm or 24 mm
  • Washable and reusable

Lactation Aid - SNS
  • Supplementation
  • Help infants with poor suck-swallow coordination
  • Can be used
  • At breast
  • Fingerfeed
  • Starter SNS is only for 24 hour use per
    manufactures guidelines
  • Wash between uses.

Test Weights
  • Weighing a baby before and after breastfeeding to
    determine intake.
  • Weigh baby in exact same manner before and after
  • Subtract the first (before) weight from the
    second (after) weight. The difference in grams
    is the intake in milliliters. (1gram1ml)
  • Riordan, page 304

Separation from Infant at Birth
  • 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
  • Family hospital staff need to be supportive

Breast Pumps
  • Provide each mom with a sterile breast pump kit
  • Instruct on assembling kit per manufacturing
  • Provide mom with breastmilk collection and
    storage guidelines and supplies

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Pumping Guidelines
  • 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
  • double-pumping for 10-15 minutes is preferred to
    increase milk supply
  • 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.)
  • 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 is classified as a clear liquid.
  • Mother should pump at least 8 times in a 24
    period-pump 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
  • 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. Patients 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
  • Do not place in hot or boiling water or microwave

Tips for when your patient is receiving
  • Frozen Breastmilk
  • When breastmilk is moved from freezer to
    refrigerator, the time it was taken out of the
    freezer should be written on the bottles 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
  • Orient syringe tip to vertical position for
    continuous tube feedings to enhance fat delivery.

Why breastmilk for the premature infant ?
  • Preemies dont need breastmilk any less than
    full-term infants, they need it more !
  • 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
    which is very important

Breastmilk Specificity
Enteromammary CirculationIgA, Immunoglobulin A
  • Maternal mucosal surfaces encounter microbes in
    her own and babys 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

Providing Breastmilk to the Premature Baby
  • 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
  • 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 lt1500 grams at birth
  • Pasteurized donor human milk, appropriately
    fortified should be used if mothers 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
  • Liquid fortifiers dilute breastmilk
  • Powder fortifiers increase osmolality
  • Always necessary ? No!

Hind Milk Collection
  • Have containers ready, labeled foremilk and
  • 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
  • Riordan, page 305

  • 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 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
  • 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 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 babys tummy.

Talk Points for families to promote use of human
milk in the NICU continued
  • Breastmilk may help prevent infections.
  • Breastmilk helps develop your babys eyes and
  • 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
  • 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
  • Provides parents with written and verbal benefits
    of breastfeeding and breastmilk

Ways to Support the Lactating Mother
  • 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
  • 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
  • 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 (Downs 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 infants breathing
    patterns w/o availability of respirators

Kangaroo Mother Care
  • If medical condition stabilized, infant is placed
    naked between mothers breasts for extended
    periods throughout the day
  • Facilitates breastfeeding
  • Maintains babys physiological functions at least
    as well as incubator care

Kangaroo Mother Care
  • Infants cry less and cry is not of distress type
  • Provides analgesic effects during painful
  • 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
  • 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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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
  • 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 doesnt
    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
  • 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.

Position of tube for finger feeding
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
  • Altered Neurological Function
  • 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
  • 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
  • Early feeding is now felt to be best for most
    premature babies
  • Donor human milk recommended as first alternative
    to mothers 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
  • Now about a dozen donor milk banks operating in
    North America---all are regulated by the FDA and
    abide by the HMBANA guidelines
  • 1. Donors screened approved
  • 2. Stored _at_ -20C until selected for
  • 3. Pasteurization eliminates potentially harmful
    bacteria, viruses, pathogens
  • 4. Major food components as well as most
    immunoglobulins are preserved
  • 5. Holder pasteurization is used in HMBANA milk
    banks donor milk submerged heated in shaking
    water bath held at 62.5C 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 fat-free
    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,
  • centered 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 1980s 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
  • Standardization of treatment is difficult
    symptoms of withdrawal vary with each infant
  • Pharmacological and Nonpharmacological

Intrauterine Drug Exposure
  • May cause
  • -Congenital anomalies and/or fetal growth
  • -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
  • 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

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 Tremors
  • Hypertonia Hypoglycemia Feeding
    difficulties Jitteriness
  • Respiratory distress Sleep disturbance

Preterm Infants and NAS
  • Lower risk of drug withdrawal and/or less severe
  • 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
  • Finnegans 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 DrugsGuidelines 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
  • Methadone and Buprenorphine are synthetic
  • 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 infants 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
  • May be able to wean more aggressively from
  • -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

Breastfeeding and NAS
  • Assists with bonding under difficult
  • 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
    babys mouth

Well latched on
Home Breastfeeding Plan for the Premature or NAS
  • 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
  • Focus on babys body language---
  • Is baby doing sucking motions or sticking out his
  • 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 re-wake baby
    and then try latching again.
  • Use the following wake up techniques
  • Undress your baby
  • Change your babys diaper
  • Hold your baby skin-to-skin
  • Rub your babys hands, feet, legs, etc.
  • Massage or stroke your babys cheeks, lips, and
  • Wipe your babys face with a warm washcloth

Home Breastfeeding Plan continued
  • Call your babys 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 babys average intake at each feeding has

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
  • 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 hoursgtgt6-8 wet diapers 2-4 dirty

Discharge education specific to breastfed NAS
  • Call your babys Dr if the baby is irritable, not
    consolable, jittery, does not settle down between
  • If you are ready to wean from breastfeeding
    consult with the babys Dr and lactation
    consultant to gradually wean off breastmilk

Referring Mothers for Breastfeeding Support
  • International Board Certified Lactation
    Consultant (IBCLC) in physicians office,
    hospital, private practice, local WIC program
  • Shelby County Breastfeeding Coalition
  • La Leche League (1-800-LaLeche)
  • Mothers are influenced by partner, family,
    friends, OB, their babys doctor and You !

Sweet Success
  • Babies Were Born to Be Breastfed!

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    Lui K, Oei, J. Effects of Breastmilk on the
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  • American Academy of Pediatrics. (2012). Policy
    Statement Breastfeeding and the use of human
    milk. Pediatrics. 2012129e827.
  • Hale TW. Medications and Mothers Milk,
    Fifteenth Edition, 2012.
  • Hudak ML, Tan RC, The Committee on Drugs and the
    Committee of Fetus and Newborn. Neonatal Drug
    Withdrawal. Pediatrics. 2012129e540.
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    Evidence-based interventions for Neonatal
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    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. 200929
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    Transfer of Drugs and Therapeutics Into Human
    Milk An Update on Selected Topics. Pediatrics.
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