Summary

Infants who are preterm, low birth weight, ill or have special needs

• Breast milk is important for babies who are preterm, low birth weight or have special needs. It protects, provides food, and aids in growth and development.

• The approach to feeding will depend on the individual baby and his or her condition.

Overall, care can be divided into categories based on the baby’s ability to suckle:

- Baby not able to take oral feeds. Encourage the mother to express her milk to keep up her supply for when her baby can take oral feeds. If possible freeze her expressed breast milk and use it later.

- Baby able to take oral feeds but is not able to suckle at the breast. Give expressed milk by tube and by cup if baby is able.

- Baby able to suckle but not for full feeds. Let baby suckle whenever baby is willing. Frequent short feeds may tire the baby less than long feeds at long intervals. Give expressed milk by cup or tube in addition to what the baby can suckle.

- Baby can suckle well. Encourage frequent feeds for milk, for protection from infection, and for comfort.

- Baby is not able to receive breast milk. For example, if the baby has a metabolic disease such as galactosemia, and needs a specialized formula.

• Take care of the mother with fluid, food, rest, and help her to be in close contact with her baby.

• Expect that the baby will pause frequently to rest during the feed. Plan for quiet, unhurried, rather long breastfeeds. Avoid loud noises, bright lights, stroking, jiggling or talking to the baby during feeding attempts.

• Prepare the mother and baby for discharge by rooming-in, encouraging skin-to-skin contact, allowing time to learn to breastfeed and recognise feeding signs (cues), and to know how to get help when at home.

• Arrange early follow up for any baby that has special needs.

Breastfeeding more than one baby

• Mothers can make enough milk for two babies, and even three. The key factors are not milk production, but time, support and encouragement from health care providers, family, and friends.

Prevention and management of common clinical concerns

• Implementing practices such as early skin-to-skin contact, early and frequent

breastfeeding, rooming-in, and milk expression and cup feeding if the baby is sleepy or weak and avoiding water supplements can avoid many instances of hypoglycaemia, jaundice and dehydration.

Medical indications for food other than breast milk

• Infants with medical conditions that do not permit exclusive breastfeeding need to be seen and followed-up by a suitably trained health worker.

Does the baby need breast-milk substitutes?

Exclusive breastfeeding in the first six months of life is the norm, and is particularly

beneficial for mothers and infants. Nevertheless, a small number of health conditions of the infant or the mother may justify recommending that she does not breastfeed temporarily or permanently. These conditions concern very few mothers and their infants.

It is useful to distinguish between:

• Infants who should not receive breast milk or any other milk except specialized formula.

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

Infants who should not receive breast milk or any other milk except specialized formula may include infants with certain rare metabolic conditions such as galactosemia who may need feeding with a galactose free special formula, or Maple syrup urine disease: a special formula free of leucine, isoleucine and valine is needed, or phenylketonuria where a special phenylalanine-free formula is needed (some breastfeeding is possible, under careful monitoring).

Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period This group may include very low birth weight infants (those born weighing less than 1500 g) very preterm infants, i.e. those born less than 32 weeks gestational age, newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age or who have experienced significant intrapartum hypoxic/ischaemic stress), those who are ill and those whose mothers are diabetic if their blood sugar fails to respond to optimal breastfeeding or breast milk feeding.

Additional information for Session 10

Using expressed breast milk

• Milk from a mother giving birth preterm contains more protein, sodium and calcium than full term milk. Preterm infants often need extra protein, so this is helpful.

• Breast milk with an energy value of 65 kcal/100 ml at a volume of 200 ml/kg/day will result in an energy intake of 130 kcal/day. If the mother has more milk than her baby needs, the expressed breast milk can be left to stand for a short while and the fat rich hind milk will rise to the top. The ‘cream’ can be added to the regular milk feed, which will make it even higher in energy value.

• Some units add fortifiers and formula to the breast milk in order to make the baby grow more quickly. The long-term effect of early rapid growth is not known. These additions to her breast milk can make the mother worry that her milk is not good enough for her baby. Reassure her that her milk is good for her baby. If there is a medical need for additions to the breast milk, explain that for a short period her baby has extra needs.

• If both breast milk and formula are given, the formula will be better absorbed if it is mixed with the breast milk rather than giving alternate feeds of formula or breast milk. Additions to breast milk should be decided for each individual infant, not a standard policy for all infants in the unit⁴³.

Hypoglycaemia of the newborn

• Babies fed on breast milk may be better able to maintain their blood glucose levels than babies artificially fed on formulas. Babies compensate for low blood sugar by using their body fuels (e.g.

glycogen stored in the liver).

• Term, healthy babies do not develop hypoglycaemia simply through under-feeding. If a healthy full term baby develops signs of hypoglycaemia, the baby should be investigated for an underlying problem. Signs of hypoglycaemia include reduced level of consciousness, convulsions, abnormal tone (‘floppy’), and apnoea. A doctor should see any baby with these signs immediately.

Physiological jaundice

• This is the commonest kind of jaundice, and does not indicate an illness in the baby. It usually appears on the second or third day and clears by the tenth day. The fetal red blood cells, which are not needed by the baby after birth, break down faster than the baby's immature liver can handle. As the baby's liver matures, jaundice decreases. Bilirubin is mainly excreted in the stools, not in the urine; therefore water supplements do not help to reduce the level of bilirubin.

Prolonged jaundice

• Sometimes jaundice may persist for three weeks to three months. The baby should be checked to rule out abnormal jaundice. In an infant who is breastfeeding well with a good weight gain and only a mild level of jaundice, prolonged jaundice is rarely a problem.

Abnormal or pathological jaundice

• This type of jaundice is not usually related to feeding, and is evident at birth or within the first day or two. Usually the baby is ill. Breastfeeding should be encouraged, except in the very rare

metabolic condition of galactosemia.

Treatment of severe jaundice

• Phototherapy is used in severe jaundice to breakdown the bilirubin. Very frequent breastfeeding is important to avoid dehydration. Give expressed milk if the baby is sleepy. Water or glucose water supplements do not help as they reduce the intake of breast milk and do little to reduce the

jaundice.

43 Mothers who are HIV-positive should either exclusively breastfeed or exclusively formula-feed rather than do mixed feeding.

Cardiac problems

• Babies may tire easily. Short frequent feeds are helpful. The baby can breathe better when

breastfeeding. Breastfeeding is less stressful and less energy is used so there is better weight gain.

Breast milk provides protection from illness thus reducing hospitalization and helping growth and development.

Cleft lip and palate

• Breastfeeding is possible, even in extreme cases of cleft lip/palate. As babies with clefts are at risk for otitis media and upper respiratory infections, breast milk is especially important.

• Hold the baby so that his or her nose and throat are higher than the breast. This will prevent milk from leaking into the nasal cavity, which would make it difficult for the baby to breathe during the feed. Breast tissue or the mother's finger can fill a cleft in the lip to help the baby maintain suction.

• Feedings are likely to be long. Encourage the mother to be patient, as the baby tires easily and needs to rest. The mother probably will need to express her milk and supplement. She can feed expressed milk with a cup or breastfeeding supplementer⁴⁴. Following surgery to repair the cleft, breastfeeding can resume as soon as the baby is alert.

Infants requiring surgery

• Breast milk is easily digested so requires a shorter fasting time than formula milk or other foods. In general, the baby should not need to fast for more than three hours. Discuss with the parents ways of comforting the baby during the fasting period. Breastfeeding can usually commence as soon as the baby is awake after the surgery.

• Breastfeeding soon after surgery helps with pain relief, comforts the baby and provides fluid and energy. If the baby is not able to take large amounts of breast milk immediately, the mother can express and let the baby suck on an ‘empty breast’ until the baby is more stable.

44 See Session 11.

SESSION 11