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

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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

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General Breastfeeding Overview

• Have basic knowledge of breastfeeding to be able
  to better support the special needs of the
  Premature/Neonatal Abstinence Syndrome Infant

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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.

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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
  vegetables.
• Continue for 12 months, thereafter as long as
  mom/baby mutually desires

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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
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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

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Medication Resources

• Thomas Hale Infant Risk Center
• 806-352-2519
• Medications and Mothers Milk-updated every 2
  years
• LactMed http//toxnet.nlm.nih.gov

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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

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Breastfeeding Benefits for Mom

• Promotes skin to skin bonding with baby
• Decrease risk of PP depression
• Uterus returns to normal size quicker
• Helps reduce blood loss
• Lose weight faster
• Lowers risk of female organ cancers and
  osteoporosis

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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

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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
  signs
• Promotes healthy brain development

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Hunger/Feeding Cues

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

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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

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Football Position

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

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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
  feeding
• Have Mom hold babys body in forearm, with his
  bottom hugged in near the crook of arm
• Use free hand to support the breast

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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

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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

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Proper Latching Technique

• Aim nipple toward nose upper lip
• Brush upper lip with nipple to encourage baby to
  open WIDE

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Proper Latching Technique (cont.)

• WAIT for baby to open mouth wide , with tongue
  down
• Press on babys back between shoulder blades and
  quickly bring baby to breast

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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

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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

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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

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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!

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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

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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

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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

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Types of Nipples
Compress nipple where baby will latch on to breast
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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

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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.

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Test Weights

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

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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
  production
• Family hospital staff need to be supportive

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Breast Pumps

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

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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

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Pumping Instructions

• Mother should wash hands before expression of
  breast milk
• Instruct to pump at least 8 times a day
• pump every 2-3 hours during the day and at least
  once over night with only one 4-5 hour break from
  pumping
• double-pumping for 10-15 minutes is preferred to
  increase milk supply
• 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.

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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.

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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

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Tips for when your patient is receiving
breastmilk

• 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

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Tips for when your patient is receiving
breastmilk

• Expressed breastmilk storage guidelines
• Labels Label per hospital policy with patient
  sticker, date and time milk was expressed
• Place milk bottles in individual bins or a single
  zip-lock bag for storage. 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
  discarded.
• Do not place in hot or boiling water or microwave
  breastmilk.

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Tips for when your patient is receiving
breastmilk

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

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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

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Breastmilk Specificity
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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
  6.

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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.

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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.

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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

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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!

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Hind Milk Collection

• Have containers ready, labeled foremilk and
  hindmilk
• Pump for 2-3 minutes after the milk begins to
  flow into the foremilk bottles.
• Stop pumping and save foremilk for later use.
• Switch to hindmilk labeled bottles and continue
  pumping as usual.
• Use only hindmilk for feedings until further
  notice.
• Riordan, page 305

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Colostrum

• 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

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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.
• 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.

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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
  brain.
• It is important to begin pumping and collecting
  your milk right away.
• You need to pump every 2-3 hours, even if you
  only are getting a small amount of milk. Every
  drop is important and will be used.
• If you have not planned on providing milk for
  your baby, it is not too late !

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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
  breastfeed
• Provides parents with written and verbal benefits
  of breastfeeding and breastmilk

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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

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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

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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.

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Infant causes of low milk supply

• Causes
• Infrequent feeding
• Ineffective suck and/ or latch
• Prematurity
• Neuromotor problems (Downs Syndrome)
• Oral anatomic problems (cleft, etc.)

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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

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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

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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 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
  breastfeeding
• empty breast feeding allows practice even
  before infant is ready to take oral feeds
• Kangaroo care (mother baby or father baby)
  will prepare infant for breastfeeding

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Pholosong Hospital - South Africa
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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

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28 weeks and breastfeeding
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31 wk GA - 3 days old Breastfeeding
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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!

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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

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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
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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

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34 weeks, well latched on
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Breastfeeding Considerations for Specific
Conditions

• 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
  children.
• Consider use of nipple shield for a firmer
  texture for latching and maintaining seal.
• Dancer hand position for latching.

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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.)

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Human Milk Banking

• Allows human milk for infants in the very first
  days whose mothers do not yet have enough milk
  available
• Early feeding is now felt to be best for most
  premature babies
• Donor human milk recommended as first alternative
  to mothers own milk before artificial feeding

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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

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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
  pasteurization
• 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

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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

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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,
  family-
• centered care and best practice, health
  professionals also
• seeking information on establishing banks

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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)

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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.

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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.

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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

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NAS Overview

• Medical management aimed at treating symptoms of
  withdrawal
• Standardization of treatment is difficult
  symptoms of withdrawal vary with each infant
• Pharmacological and Nonpharmacological
  interventions

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Intrauterine Drug Exposure

• May cause
• -Congenital anomalies and/or fetal growth
  restriction
• -Increased risk of preterm birth
• -Signs of withdrawal or toxicity
• -Impair normal neurodevelopment

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Red Flags to consider Drug Screen

• Absent, late, or inadequate PNC
• Documented history of drug abuse or admitted drug
  use
• Previous, unexplained late fetal demise
• Precipitous labor
• Abruptio placenta
• Myocardial infarction
• Severe mood swings
• Repeated spontaneous abortions
• Cerebrovascular accidents
• Legal implications of testing vary among
  states. Each hospital should have a policy on
  maternal and new born screening to avoid
  discriminatory practices and comply with local
  laws

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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

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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

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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

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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

92
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

93
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

94
Preterm Infants and NAS

• Lower risk of drug withdrawal and/or less severe
  symptoms
• Some studies have shown the lower gestational age
  correlated with lower risk of neonatal withdrawal
• May be related to immaturity of the CNS,
  differences in total drug exposure, or lower fat
  deposits of drug
• Also, may be more difficult in preterm infants
  because scoring tools are geared more toward term
  or late preterm infants

95
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

96
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

97
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

98
Pharmacological Interventions

• Drug therapy is indicated to relieve moderate to
  severe NAS and to prevent complications such as
  fever, weight loss, and seizures when neonate
  does not respond to nonpharmacologic support
• Morphine or Methadone usually drugs of first
  choice
• Methadone and Buprenorphine are synthetic
  opiates
• Phenobarbital as second drug
• New studies indicate Clonidine may also be a good
  first line drug

99
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

100
Breastfeeding and NAS

• Breastfeeding may decrease the severity of NAS
• Breastfeeding may delay onset of NAS
• Breastfeeding may decrease need for pharmacologic
  treatment
• May be able to wean more aggressively from
  methadone
• -Breastfeeding recommended in stable mothers on
  methadone and buprenorphine maintenance therapy
  who are not concurrently using illicit drugs
• -Transfer of methadone and buprenorphine into
  breastmilk is minimal and unrelated to maternal
  dose

101
Breastfeeding and NAS

• Assists with bonding under difficult
  circumstances
• Decrease stress response of the mother and lead
  to a calm interaction with the infant
• Decrease length of stay
• Need support for increased breastfeeding duration
• -24 of opioid dependent mothers breastfeed
• -60 stop on average after 5.9 days

102
Good Position, Good Latch
103
Nipple points to roof of mouth
104
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

105
Better
106
Well latched on
107
Home Breastfeeding Plan for the Premature or NAS
infant

• Offer the breast _____ times each 24 hours when
  baby is awake and alert.
• Have baby latch with top and bottom lip out
• Let baby suck as long as baby shows signs of
  interest
• Focus on babys body language---
• Is baby doing sucking motions or sticking out his
  tongue?
• Is baby attempting to open his mouth?
• Is baby trying to latch?
• If baby is falling asleep, use breast compression
  to stimulate more sucking. If baby still seems
  too sleepy, stop nursing and try to 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
  mouth
• Wipe your babys face with a warm washcloth

108
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
  been____________

109
Home Breastfeeding Plan continued

• When baby is taking half the original amount from
  the bottle after breastfeeding, then the bottle
  should be given after every other feeding. When
  the amount again is decreased by half, the bottle
  should be offered every third feeding.
• Remember to pump any time your baby is
  supplemented at a feeding. This means to pump
  when your baby is not breastfed at the feeding,
  or when he is supplemented following a
  breastfeeding.
• When your baby reaches 40 weeks corrected age
  (his due date) and/or his medical issues have
  been resolved, supplemental bottle feedings may
  no longer be needed. Your baby should be
  breastfed on cue. When your baby is gaining
  weight well, you may no longer need to use your
  breast pump.
• Keep a record of the following for each 24 hours
• When baby was fed
• How baby was fed
• Wet and dirty diapers for each 24 hours
• (minimum in 24 hoursgtgt6-8 wet diapers 2-4 dirty
  diapers)

110
Discharge education specific to breastfed NAS
infant

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

111
Referring Mothers for Breastfeeding Support

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

112
Sweet Success

• Babies Were Born to Be Breastfed!

113
References

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  Lui K, Oei, J. Effects of Breastmilk on the
  Severity and Outcome of Neonatal Abstinence
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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,
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• Hudak ML, Tan RC, The Committee on Drugs and the
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• MacMullen MJ, Dulski LA, Blobaum P.
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  Publishers 2005.
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• Sachs HC and The Committee on Drugs. The
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