The UNICEF UK Baby Friendly Initiative Orientation to Breastfeeding for Paediatric Medical Staff Orientation handbook unicef ¢@ UNICEF UK 2005 ‘The information in this teaching pack, including this handbook, may be freely reproduced by the purchaser of this pack, provided that copies are used solely for the purposes of ‘teaching within the purctasing heath care facility snd not in association with eny commercial purpose. ‘The Baby Friendly Initiative is @ global programme of UNICEF and the World Health Orgonisation which ‘works with the health services to improve practice so that parents are enabled and supported to make informed choices about how they feed and care for their babies. Health care facilities which adopt Practices to support successful breastfeeding recoive the prestigious UNICEF/WVHO Baby Friendly award. In the UK, the Baby Friendly Initiative is commissigned by various parts of the health service to provide advice, support, training, networking, assessment and accreditation. For more information about all aspects of the UNICEF UK Baby Friendly Initiative's work, visit our web site at www babyiriondly.org.uk 7 UNICEF UK Baby Friendly Initiative, Africa House, 64-78 Kingsway, London WC2B 6NB Tol: 020 7312 7652 Fax: 020 7405 2332 E-mall: bfi@unicet org.uk UNICEF is a Registored Charity, No, 1072672.An orientation to breastfeeding for paediatric medical staff ‘This booklet is intended to be used as a quick reference guide for paediatric medical staff It has been designed chiefly as an aide-memoire to support breastfeeding orientation sessions ‘The booklet provides basic information on why breasticeding is important, how breastfeeding works and what paediatricians can do to support broestfeeding whilst stil protecting the safety of the neonate. Some of the commonly-faced challenges to successful breastfeeding encountered by medical staff on the postnatal wards are outlined, with suggestions for appropriate management. Although the menagement recommendations are based on strong evidence, Trust policies and procedures must also be referred and adhered to. Implementing best practice: the paediatrician's role Active support to enable babies to benefit from breastfeeding is an important part of the paediatrician’s role. This can be summarised as follows. © Discussing the benefits of breastfeeding with now mothers and outlining the particular benefits for vulnerable and preterm infants © Supporting and encouraging practices known to facilitate breastfeeding © Avoiding and discouraging practices which have bean shown to jeopardise breastfeeding © Referring breastteeding problems to appropriately-skilled members of stalf Further information Lawrence RA, Lawrence RM (2008). Breastfeeding - A guide for the medical profession, Mosby St Louis, Fiordan J (2008. Breastfeeding and human lactation, Jones and Bartlet: London, ‘The Baby Friendly Initiative web site wow babyriendty. org.uk) isthe best place to find up to dete information about the work ofthe Intative, synopses of the atest research and links to other useful sites. For Workd Heath Oxganisation publications, follow the links at ‘vrwwawho inyhealth topies/oreastleedinglery UNICEF UK Baby Friendly Initiative: An oriontaton to breastfeeding for paclntc mecial staf! Contents 1. Benefits of breastfeeding 2. What's in breastmilk? 3, The Baby Friendly Initiative 4. Anatomy and physiology of kectation 5. The value of colostrum 6. How aBaby feeds at the breast 7. Skinsto-skin contact 8, Understanding demand feeding 9. Supporting and protecting breastfeeding 10. The trequent feeder 11. Tho reluctant feeder 12, The atrisk infant 18. Breastieeding and jaundice 14, Weight loss1. Benefits of breastfeeding There is strong evidence that breastfeeding reduces the risk of gastroenteritis in babies. There is also evidence for a reduction in the incidence of: © Respiratory illness © Ear infections © Urinary tract infections © Atopic disease © Diabetes ‘Additionally, there is evidence that breastfeeding may be protective against necratising enterocolitis (NEC). Research by Lucas and Cole (1990) found up to 2 20-fold increase in the incidence of NEC among babies who received no breastmilk, A possible mechanism for this effect is suggested by Minokawea (2004) who reported that breastmilk dramatically suppresses the activation of interleukin (IL-8 (a proinflammatory cytokine which plays an important role in the pathophysiology of NEC). A Cochrane review (2001) found no evidence of an effect of breastfeeding on the incidence of NEC, but the authors note that only one of the six tials reviewed evaluated NEC ‘as a pre-defined outcome. Breastfeeding has been linked to @ lower plasma cholesterol and low density lipoprotein in childhood, as well as lower blood pressure. These findings suggest a protective effect extending into adulthood, with implications for the health of the nation. |n contrast to almost all other health outcomes, there is now evidence to ‘Suggest that breastfed babies born into the lowest socio-economic groups have better health outcomes than formule-fed babies bom into the highest groups. Increasing breastfeeding rates in the poorest families would therefore do much to address inequalities in health. ‘There is also evidence that breastfeeding has health benefits for the ‘mother. In particular, that it reduces the incidence of: © Breast cancer © Ovarian cancer * hip fractures For a fuller list of evidence for the health advantages of breastfeeding, visit wuubabyfriendly.org.uk/health UNICEF UK Baby Fondly Matis: An erentation to breastfeeding for paecitic metal staff ‘Acmstrong Jt al (2002). Breasteedlng and lowering the risk of childhood obesity, Lancet 359: 2003 04, Duncan 8 etal, (1996). Exclusive breast feeding for at loast 4 months protects ‘against otitis media, Podiaties 6: 867-872. Forsyth S.‘nfluonce of infant feocing practice on health inaqualies during chilrood, Presented at the UNICEF UK Baby Friondy Initiative Annual Conference, November 2004. wan babyriendiy.ora, ‘npdfs/04programme,pat Gerstein HC (1984). Cons rik exposure and type 1 dabetes melts, Diabetes Care 71349, Henderson G, Anthony MY, McGuire W. Formula mik versus preterm hurnan rik for feeding protein or low bith weight infants. The Cochrane Databaso of ‘Systematic Reviews 2001, Issue 3. Ar, No. 60002972. DOI: 10.1009/1465 1868. Howe PWY eta (1990), Protective affect of breastfeeding against infection. BM 300, 1196, Lucas A, Cole (1890) Broast mk and neonatal necrotsing enteracoitis, Lancot 336 1519-23, ‘Minekawa R et a (2004), Human broast milk suppresses the transcriptional regulation of I-1Ibstabinduced NF¢kappalB signaling in human intostina calls. Am J Physiol Col Physiol 287: C1404-C 141 (Oddy WH tal (2008), The relation of breastfescing and body mass index to astlima and atopy in chikken: @ prospective ‘cohort study to age 6 years. Arr J Pubic Hath 9a: W831 ‘Owen CG et al (2002). Infant Fooding and Blood Cholesterol A Study in Adolesoonts and a Systematic Review. Pediatrics 110: 597-608. Favel AC etal (2000) Infant foacing and edkit glucose tolerance, pid profile, blood pressure, and obesity. Arch Dis Chil a2: 28.82 Searinan UM & Kajossari M (1995), Breastfeeding as prophylaxis against atepie disease: prospective folowup study uni 17 | years old. Lancet 246; 1065-1069. Wilson AC otal (1986). Relation of infane clot to childhood health: seven yoo folew "up cohort of citdron in Dundes infant feeding study, BM/316: 2125,2. What's in breastmilk? Breastmilk is a complex living fluid containing numerous ingredients ‘Ako J (1969). Infant Fooding Tho specifically designed to meet the needs of the newborn human infant. ‘hysoogical basis. WHO Bulletin 87 Breastmilk varies fromm woman to woman and changes over time to meet (Pl) Work! Heath Orseniation: Geneva the baby's growing needs. It cannot be replicated and the full effect on human health of not receiving breastmilk - or of not receiving enough breastmilk is stil not fully understood. ‘A few of the significant ingredients which help protect the baby from infection are: © Immunoglobulins including: a) antibodies against infections the mother has had in the past. b). Secretory IgA (slgA, most of which remains on the surface of the baby's gut to prevent pathogens sticking to the mucosal surface. ©} antibodies provided via the entero- and broncho-mammary pathways, which work specifically to protect the infant in its own environment. If a mother is exposed to a pathogen via her digestive Or respiratory system, she creates antibodies which are immediately transforred to her breastmilk to protect her infant. © Bifidus factor: This carbohydrate facilitates the growth of lactobacillus bifidus to create an acidic environment in the gut. Pathogons tend to profer an alkaline environment. © Lysozyme which breaks down and kills susceptible pathogens. © Hormones including insulin, thyroid stimulating hormone and growth hormone, which help the immature baby to adjust to extra-uterine lite and to stimulate growth. Epidermal growth factor helps the gut to ‘mature - and so become more resistant to pathogens. © Lactoferrin which assists with the absorption of iron. It also binds tree iron to make it unavailable to iron-dependent bacteria. 70% of the iron in breastmilk is absorbed compared with 10% of the iron in breastmilk substitutes. © White cells. © Viral fragments which are thought to trigger the baby’s immune response. ‘The formula-fed infant lacks this protection, meking him vulnerable to infection. This is over and above the risks posed by the possible contamination of the feads and feeding equipment used. + UNICEF UK Baby Friendly ntintve: An eriertatan te breestlading for poecetic mecical stat3. The Baby Friendly Initiative The UNICEF/WHO Baby Friendly Initiative is @ worldwide initiative which Word Heath Organisation (1868). Evidence aims to improve standards of care within the health service by supporting (0 the Ten Steps to Suncessfut health professionals to implement best practice in relation to breastfeeding. _5”*astfeeding, WHO: Geneva, Best practice is represented by the Ten Steps to Successful Breastfeeding, which summarize the practices necessary to support breastfeeding. All standards set down in the Ten Steps have a strong evidence base. 1. Have a written breastfeeding policy that is routinely communicated to all staff, 2. Train all health care staff in skills necessary to implement the policy. 3, Inform all pregnant women about the benefits and management of breastfeeding, 4. Help mothers initiate breastfeeding soon after birt. 5. Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants, 6. Give newborn infants no food or drink other then breastmilk, unless clinically indicated 7 Practise rooming:n, allowing mothers and babies to remain together 24 hours a day. 8. Encourage breastfeeding on demand, 8. Give no antitical teats or dummies to breastfeeding babies. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospital. The UNICEF/WHO Baby Friendly initiative also requires health caro staff to ct in accordance with the Intemational Code of Marketing of Breastmilk Substitutes. This means that they must not, either intentionally or unintentionally, promote the use of breastmilk substitutes, bottles, teats or dummies, as these have the potential to harm breastieeding. UNICEF UK Baby Fiiendly Initiative: An oventation to breastfeeding for paeclatic medical staff 64. Anatomy and physiology of lactation Milk is produced within the alveoli by the acini cols. Anatomy of ‘The myoepithelial cells propel milk along the lactiferous ducts and out of - the breast the nipple. . . Milk tends to pool in the area of the lactiferous ducts behind the areola. SS hateose et Montgomery's tubercles secrete @ scented fluid which lubricates the nipple and attracts the baby. ‘The areola darkens during pregnancy to attract the baby, Milk production is stimulated by prolactin, while delivery to the baby is ttiggored by oxytocin, Both hormones are secreted by the pituitary gland, Counter balance is provided by the feedback inhibitor of lactation (FIL), an ‘enzyme present in breastmilk, which acts to prevent overproduction. Hormoneffactor [Functions Practice implications iH Prolactin © Works by touch alone. © Encourage frequent and prolonged access to the Stimulates milk breast and skin contact to stimulate milk production | production © Levels highest in the early @ Encourage early and frequent feeding/expressing to postpartum period maximise milk production | © Levels rise during a breastfeed! @ Ensure effective attachment and allow the baby to and peak after the feed feed for as long as he chooses to maximise milk supply @ Stimulates mothering © Keep mothers and babies together and encourage frequent breastfeeding to promote a strong mother baby bond i ‘Oxytocin © Breastfeeding stimulates © Ensure effective attachment to encourage the milk | Stimulates milk oareen lease deliver to flow ejection : i @ Sight, sound, touch of baby © Keep mothers and babies together and encourage will increase levels skin contact. Encourage regular visits to the neonatal unit and kangaroo care if mothers and babies ara ‘separated @ Induces wellbeing but | © Provide skilled help and support with breastfeeding | inhibited by stress to increase confidence: Feedback inhibitor) @ Acts within the breast to 3@ Encourage frequent effective breastfeeding to : of lactation inhibit milk production when remove breastmilk and so ensure continued Inhibits milk | the breasts become full production production | ; UNICEF UK Baty Fienly Intistive: An eration o cara 7 |5. The value of colostrum During the first few days of life, a healthy, term baby will excrete the extra Ake (1968). Infant Feeding The intracellular fluid which he or she has stored during gestation, The degree of Prvsiological basis, WHO Buon 67 fivid excretion is controlled by anti-diuretic hormone (ADH). The small fee eee ee volumes in which colostrum is produced during this time are appropriate for Raval College of Midwives (2002) the baby's needs and help prevent the kidneys being overloaded, See Church Livingstono; London, The volume of the average feed in the first 24 hours is just 7mis. Foed volumes then gradually increase to meet the baby's changing requirements. In contrast, the kidneys of formula-fed babies are given an extra load to deal with. It appears that babies adjust to being fed large volumes via a compensatory lowering of circulating ADH. Attisk babies may release too litle ADH, resulting in them losing too much fluid and therefore requiring extra fluid intake. Colostrum should always be given to these infants first and other fluids given only if colostrum is not adequate. Average quantities of colostrum ate as follows: Day [Normal volume [Average volume [Average volume range per day | per day per feed 1 7128 ml 37 mi 7 mi 2 | 44-335mi 84 ml 4m 3 | 98 aml a8 mi 38 mi fa 378 -876 ml 625 mi 58 ml 5 452 876 ml 700 mi rom Key points to note 1. Colostrum is particularly rich in anti-nfective factors such as secretory 'gA 2. Colostrum acts as a laxative which speeds up the passage of meconium, thus reducing r@-absorption of bilirubin through the gut wall and helping to minimise jaundice. UNICEF UK Baby Friendly nitive: An criantstion to breastfeeding for paediatric medical stat 86. How a baby feeds at the breast How a baby attaches to the breast determines how much milk he is able to take during the feed. External view: The baby on the loft of this picture is effectively attached. He has used his Woolidae MW (1996). The ‘enatomy’ of ‘tongue to scoop up a large mouthful of breast tissue which is formed into a ‘fant suckang. Micknfory. 2: 164-71 lerge teat comprising one-third nipple and two-thirds surrounding breast Wootridge MW (1988) Astiology of sore tissue. The breast tissue fills his mouth and is held in place by the tongue. _—_"iPhles. Midwifery. 2: 172.6. The lactiferous ducts are in the mouth and can be compressed with the tongue against the palate to expel the milk. He will be seen and heard to swallow with a rhythmie movernent while feeding, The baby on the right is ineffectively attached. He has only the nipple in his mouth. He will get little mik (even though he may ‘feed! for a long period) and he may make his mother sore because the nipple will rub against his hard palate and tongue. Since a significant quantity of milk will be left in the breast after the feed, milk production will be slowed down, Ineffective attachment is usually caused by the mother not positioning her baby at the breast in a way which will alow him to scoop up a large mouthful of breast. Help from @ skilled practitioner is often required to teach a new mother how to position and attach her baby effectively for broasticoding Consequences of ineffective attachment Rubbing of the nipple can cause the mother pain and the nipple to become sore and cracked. The inability of the baby to compress the lactiferous ducts and stimulate hormone production will result in the baby not receiving ‘enough breastmilk. This may resutt in prolonged frequont feods, breast refusal and poor weight gain. The mother's breasts may initially become ‘engorged; this will cause the feedback inhibitor of lactation to suppress milk production, with the result that the mother will not produce enough milk to feed her baby. ‘ Itis therefore crucial that all mothers are teught how to effectively position and attach their babies for breastfeeding. Medical staff who suspect that a baby is not breastfeeding effectively should urgently refer the mother to a suitablytrained midwife or neonatal nurse for skilled help and support. UNICEF UK Baby Friendly Initiative: An onentation to breastieeding for paediatric medical staff 97. Skin-to-skin contact Skin-to-skin contaot between a newboin and his mother provides a crucial start to breastfeeding because it: '® Stimulates hormone release in the mother, so triggering the onset of lactation; '® Stimulates instinctive feeding behaviour in the baby; © Facilitates the mutual bonding process. In addition, skin contact © Is the most effective way to reguiate the beby's body temperature; © Calms both mother and baby; © Steadies the baby's heart and respiration rates. ‘Those benefits exist equally for the baby who is to be bottle fed. Also, ‘experience has shown that many mothers who did not imagine they would breastfeed have changed their mind when given their baby to hold in skin contact. For these reasons, skin contact should be the default method of care at delivery for all mothers and babies. Immediately the baby is born, or as soon afterwards as possible, he should be placed on his mother’s chest in skin-to-skin contact for an unlimited, unhurried period. A blanket can be tucked around both of them so that heat is not lost, After an initial quiet period, the normal newborn will begin to search for the breast, attach and feed. An early breastieed: ‘© Provides the baby with both food and protection from infection; © Tiggers lactation in the mother; © Increases the chances of effective attachment at subsequent feeds, Where possible, examination and care of the baby following delivery should be carried out without removing him from his mother. If the baby needs to be removed, itis the paediatrician's responsibility to ensure that he is placed in skin contaat with his mother as soon as possible. Babies who are sedated at birth (through maternal medication) tend to take longer to exhibit breast seeking behaviour. It is important that the period of skin contact be allowed to continue uninterrupted until the first breastfeed has taken place. Kangaroo care ; IF the baby needs to be admitted to the neonatal unit,skin-to-skin contact should be facilitated as soon as the baby's condition allows, and as frequently as possible thereafter. Ideally, the mother can be holped to hold the baby securely on her chest beneath her clothes. This is known as kangaroo care (or kangaroo mother care). UNICEF Ux Baby Friendly nitive: An eiantation to breastfeeding for pacdatic medica ste Bauer J otal (1996). Metabolic rate and ‘onorgy balance in the very low bith weight, infants during kangaroo holding by their mothers and fathers. J Pedlatr 129 (4), 608- n CChistensson K etal (1992). Temperature, metabolic adoptaton and crying in healthy {ul tarm newboms cared for skinte-skin of ine cot. Acta Paedlat 81: 488-8. Christonsson K etal (1988). Rendomised “study of skinto-skin versus ineubator care for rewarming lowtik hypothermic neonetes. Lancet 352: 1118. De Chatoau P Wiberg B (197) Long-term cffect on motherinfant behaviour of extra Contact duting the fist hour pestpartum, Acta Paediatr 68: 146.51 Folie Ket al (2000), Skinto-skn contact improves gas excange in premature infants. J Perinatol 20 (6): 317, Kambararni RA et al (1998). Kangaroo care vorsus incubator care in tho management of ‘well potorm infants. Annals Tiop Paediatr 18818. Mossmeor R ota (1997). Effect of kangaroo cate on slegptime for neonates. Pedltr Nurs. 23 (4): 408-14. Fighaid L, Alade MO (1990), Effect of delivery room routines on success of first brpastfeed. Lancet 336: 11057 Rosenblatt JS (1992). Psychobiology of maternal behaviour: contribution to clinical understanding of matemal behaviour among humans, Acta Paediatr 81; 488-63, Wahlberg Vet al (1992). A retrospective ‘comparative study using the kangaroo method as a complement tothe standard incubator care, Eur. Pub bth 2 (34-7 ‘Widstrom AM otal (1990), Short-term ‘ffacts of early sucking and touch of the Inpple on maternal behaviour. Earty Hum Dev21: 15953, 108. Understanding demand feeding Demand feeding means allowing the baby to feed whenever he wants for as long as he wants. Along with effective attachment, demand feeding is essential for successful breastfeeding as it ensures en adequate milk supply and a satisfied baby. Both frequency and length of feeds vary over time and from baby to baby. The following is a guide only. ‘Age of baby [Frequency of feeds [Length of feeds <24hours | Infrequent, commonly as few | Variable, a8 3 feeds in first 24 hours. | <7 days Rapidly increasing in Very variable, both frequency, commonly between babies and from, peaking around day 5. May —_| feed to feed. ] be as many as 12 or more feeds 2 dey. >7 days Frequent feeds continue, | Still variable, but each most babies feeding 8 or —_| baby will begin to develop more times in 24 hours. | his own unique pattern ‘Cluster’ feeding is common. | over a 24-hour period. UNICEF Uk Baty Fiend Intinive: An crienttion 10 breesttescing fr pactatic medical sta lWingworth FS, Stone DG (1952). Sot. demand feeding ina matemity unit. Lanoet “vt 683687 ‘Yarnauchi, Yamanouchi (1990). Breast ‘eading freavency during the fst 24 hours ater bith in ful-term neonates. Pecatries 86: 1714175, 119. Supporting and protecting breastfeeding Medical staff can support and protect breastfeeding by being aware of the practices which enhance breastfeeding end those which can make it more difficult for mothers to achieve. The following practices enhance milk production Practice Outcomes Additional benefits ‘Skin-to-skin contact between mother and baby Hormonal response triggers prolactin release ‘Spontaneous behaviour of mother and baby leads to breastfeeding Calms baby Regulates temperature, breathing and heart rate ‘Teaching mothers positioning, attachment and hand expressing Increases chance of effective attachment and thus effective feeding Increases mothers’ confidence Prevents engorgement Frequent feeding Increases circulating prolactin Reduces levels of FIL, Enables practice of new skills Prevents engorgement Unrestricted length of feeds Ensures adequate fat intake Allows baby to regulate milk supply Ensures a ‘satisfied baby Reduces ‘colic’ Rooming-in Permits frequent feeding Raises oxytocin levels Allows mother and baby to get to know each other - especially feeding cues The following practices may jeopardise milk production breast, so reducing mik tansfer and future milk production ‘ Practice Outcomes Additional risks Supplementary feeds _| ills stomach and reduces appetite, so Increases risk of many adverse health reducing stimulation of the breast outcomes: Longer digestion time further dampens desire | Supplementary feeds suggested by {to feed at the breast health professionals have been shown to reduce mothers" confidence in the adequacy of breastfeeding Drinks of water Fills stomach and reduces appatite, so Increases risk of gastroenteritis reducing stimulation of the breast Use of a teat May cause difficulty with attachment at the | Risk of infection Use of a dummy May cause difficulty with attachment at the breast, so reducing mik transfer and future milk production Pacifies baby, so reducing number of breastfeeds and hence breast stimulation Risk of infection Risk of orthodontic and speach problems ~ LUNICEE UK Baty FrinalyIniative: An arentation ta broastleding for poetic modal stat 12Itis recognised that supplementary feeds may sometimes be clinically indicated and thet, in a neonatal unit, dummies may also sometimes be required. However, even when the circumstances are less than ideal, itis important that medical staff make an effort to convey to mothers theit ‘support for breastfeeding and their belief that it is worthy of protection. It is worth remembering that the word of a doctor can carry far more weight than that of any othor health professional and that their overt support of breastieoding can therefore do much to increase confidence and the value placed on breastmilk. UNICEF UK Baty Friendly Initiative: An orientation to breastfeeding for paedatic medica tet World Hoaith Organisation (1998). Evidenco for tho Ton Stops to Successful Breastfeeding. WHO: Geneva Rentraw M, Wealidge M, Ross McGill H (2000). Fnatting Women to Bresstised. The Stationery Office: London, 1310. The frequent feeder Itis very common for parents and health professionals to believe that @ ‘nottnal’ feeding pattern is for a baby to feed every 3-4 hours. In reality & breastfed baby may feed much more frequently than this and at irregular intervals, This can cause much unnecessary anxioty about the adequacy of the breastmilk supply. ‘There are many reasons why babies may demand feeds frequently, for ‘example: © As part of a natural feeding pattern which includes ‘clusters' of feeds; © For thirst, in a warm environment; © For comfort, or as a way to enjoy mother's company: @ As. a means to increase the milk supply (usually a temporary phase). Management of the frequent feeder ‘Although frequent and irregular feeding is quite normal, there is also the possibilty that the frequent feeding is a result of the baby not being effectively attached to the breast, Therefore, babies who demand very frequent breastieeds, or who show unsettled behaviour while at the breast, should be referred to a suitably-trained member of staff for assessment of their feeding technique. The following management may also be indicated: © Exclude any underlying illness or condition which may be causing the baby to be distressed/nsettled. This may be as simple as a blocked nose or a more complex medical condition. © Refer to an infant feeding specialist for help with the feeding technique. © Ask the mother to express her milk and give by cup or syringe. IF feeding has been observed to be effective, the following may help © Reassure the mother that this is her baby's normal feeding patter. It may not always be this way but it is important to let the baby lead the way. ® Skin-to-skin contact may help to calm both mother and baby. Building confidence Mothors aro vulnerable to the belief that they do not have enough milk for their baby or that their milk is not good enough. If their baby is unsettled or demanding feeds more frequentty than they think he Should, they may be tempted to give formula feeds. This action, while offering a short-term solution, will have @ detrimental effect on the milk supply and put the baby at risk of infection. All staff should encourage mothers to believe in the value of their milk and the importance of exclusiva breastfeeding. As mentioned earlier, doctors can be particulaty influential in this regard, UNICEF UK Baby Fiendly ntatve: An onentetion to breastoding for pacaitic medical stat 1411. The reluctant feeder Itis very common for healthy, term babies to feed infrequently in the first 24 hours after birth and this is rarely a cause for concem. However, lack of interost in feeding can also be the fist sign of illness in a baby and therefore it is essential that such babies are monitored closely to exclude underlying illness. Following delivery a healthy, term baby wil: © Inhibit the secretion of insulin to help sustain blood glucose levels © Break down glycogen reserve: © Synthesize glucose from stores in the liver © Generate alternative fuels such 2s ketone bodies to provide protection for the brain and other vital organs. Therefore, healthy term babies do not develop symptomatic hypoglycaemia a a result of simple underfeeding, If an infant develops signs suggesting hypoglycaemia look for an underlying condition, Detection and treatment of the cause is as important as correctian of the blood glucose level (World Health Organisation, 1997). Management of the reluctant feeder Regular monitoring of vital signs to exclude underlying illness. © Skin-to-skin contact and frequent prolonged access to the breast to encourage feeding. @ Frequent hand expression of breastmilk to stimulate lactation and provide milk for the baby. © Expressed breastmilk to be given via syringe for small amounts of colostium, or by cup for larger volumes of milk 1._ If previously healthy baby develops signs of illness then a full examination by a paediatrician should be carried out to determine the cause. A biood glucose estimation may or may not form part of this assessment. However, it should be remembered that in a term, previously healthy baby @ low blood glucose value may be a sign of Underlying illness but is not the cause. ‘Where blood glucose estimation is considered necessary, it should be noted that reagent strips have poor sensitivity and specificity at low levels. They should therefore not be relied upon as an alternative to laboratory measurements in the care of newborns." LUNICE UK taty Frnaly Inthe: An onentaton to bresstleeding for paccate medical stat World Health Organization (1897), ‘Hypoalyeaemua of the newborn -A review of the torature. WHO: Geneve, Yarauchi, Yamanouchi | (2990). Breast- fooding froquoncy during tho fst 24 hours after bith in fulkterm neonates. Pecatries 86 2): 1715. Cornblath M, Hawdlon JM et al 2000) Contioersies regarding definition of ‘neonatal hypoglycaemia: suggested ‘operational throshokds, Pedkatrics 105:1141- 5 Deshpande §, Ward Platt M (2008). The investigation and management of neonatal bypoahcaemia, Semirars in Fetal and Noonatal Medicina. 10: 25181, De Roy L, Haweon J (2002). Nutritional Factors that affect the postnatal motabote ‘ceptation of fultterm smal for gestation axe infants. Pecistics, 109:642 Hawdon JM, Ward Platt MP Aynsley Groen ‘A (1992), Pater of metabokc adaptation for preterm and term infants in tho first neonatal week. Archives of disease in childhood. 67: 257.65, Hewdon J. Hypoglycaemia and the neonatal bran (1999). European Journal of Pedkatrics 168, Suppl 1: 9-812, Ward Platt M, Dashpande S. Metabolic adaptation at birth (2005). Seminars in Fetal ‘and Neonatal Mecicine. 10: 341-50, 1512. The at-risk infant Intants at risk of hypoglycaemia include those who: © Aco preterm ‘© Ave small for gestational age © Have suffered intrapartum asphyxia © Ave sick © Were born to a diabetic mother The tisk of hypoglycaemia is greatest in the first 24 hours of life as the infant adapts to extre-uterine life. Regular blood glucose estimations are therefore appropriate for these babies, Management of the well at-risk baby © Skineto-skin contact and an carly first breastfeed. Expressed breastmilk to be given if the baby does not breastfeed, Formula milk to be given only if no breastmilk is available. © The first blood glucose estimation to be taken prior to the second feed". ‘© Broastfeed at least Shourly”, giving expressed breastmilk (EBM) supplements (by cup or syringe) if feeding is not effective. Formula milk to be given only if there is no breastmilk available. © Pre-feed blood glucose estimations? to be taken prior to feeds, then © If blood glucose below 2.6mmoli, feed the baby again. Repeat estimation in one hour. © If blood glucose still below 2.6mmol, consider admission to the neonatal unit. ‘© Regular observations of vital signs and overall condition, © Reassessment at frequent intervals (see Trust guidelines). IF the at-risk infant is unwell or shows signs associated with hypoglycaemia (e.g, apnoea, cyanosis, jtteriness4 or convulsions), urgent blood glucose estimations are required and intravenous glucose should be considered. Notes 1. There is an immediate fallin blood glucose concentration after birth. This normally rises significantly by around 3 hours of age, regardiess of nuttitional intake. Taking a blood glucose reading Before this naturel fall and rise has happened is of litle value and can cause unnecessary alarm. Taking the first bload glucose estimation at around 4 hours of age (commonly prior to the second feed) will give the blood glucose level a chanoe to rise and will indicate how well the baby is coping with intermittent feeds, UUNICE® UK Baby Friendly Intatine: An orientation to breasiceding for paediatric medial staff World Health Organization (19971, Hypagtvcsemia of the newborn -A review (of the fitrature. WHO: Geneva, Crnblath M, Hewson JM ot a (2000) Controversies regarding dfiniton of neonatal hypoglycaemia: suggested ‘operational thresholds, Pedtetrics 105:1141- 5. Deshpande S, Werd Platt M (2005)-The investigation and management of neonatal hypogycaomia. Sominars in Fetal and Neonatal Medicine, 10: 357-61 De Rey L, Hawdon J (2002). Nutitionel Factors that affect the postnatal metabolic ‘adaptation of fulHterm sera for gestation ‘age infants, Pediatrics, 108642. Hiawdon JM, Ward Platt MP Aynsley Green A (1992) Patterns of metabolic adaptation {or preterm anid term infants inthe frst neonatal wack. Archives of disease in chitctiood. 87. 957-65, Hawcon J. Hypogyeaemia and the neonatal brain (1996), European Journal of Pecaties. 188, Suppl 1: $9-S12. Ward Piatt M, Deshpande $. Metabolic ‘eeptation ot birth (2006). Seminars in Fotal ‘and Noonstal Medicine. 10: 11-80, 162. ‘There is no reason why the baby should not feed (or be fed) more frequently than every three hours, indeed this should be encouraged, However, there is no need to carry out blood glucose estimations more often than 3-hourly, 3. Reagent strips have poor sensitivity and specificity in newboms and should not be relied upon as an alternative to laboratory measurements. 4. Itis essential to differentiate between true jtteriness and the normal Moro or startle reflex. Jitteriness is an unprovoked movement of one or more limbs, indicating cerebral irritation, it does not occur in isolation in healthy, term neonates as a result of simple underfeeding but is indicative of a more serious underlying problem. UNICEF UK Baby Fienaly native: An eientaton to breastloding ‘or paedatic medical stall13. Breastfeeding and jaundice Some degree of jaundice in the early postnatal period appears to be a normal physiological phenomenon. Physiological jaundice typically begins on the second or third postnatal day and peaks on Day 3 or 4 ‘The prompt resolution of ghysiological jaundice rolies on the early establishment of effective and frequent feeding. Without this, slowing of the infant's metabolism results in further poor feeding responses and prolongation and/or worsening of the jaundice through reabsorption of bilirubin from the gut. Management of the breastfed jaundiced baby @ Assessment of the baby to exclude underiying iliness. © Frequent breastleeds - at least 3-hourly but more frequent if possible. ® Expressed breastmilk to be given after breastfeeds if the baby does not feed adequately or if extra fluid is required." © Mother and baby to be kept together and skin contact encouraged to faciitate frequent feeding? © Assessment of breastfeeding by an appropriately trained member of staff and extra helo provided with posttioning and attachment if needed. Notes 1. Supplements of water do nothing to reduce bilirubin jovels and may ‘even make them rise by reducing the intake of milk and thus the rate at ‘which meconium is passed. 2. Phototherapy should, wherever possible, be carried out by the mother's bodside. UNICEF UK Baby Fiendly Initiative: An erentation to bxeasteading for psec medica stat Do Carvalho M, Kiaus M, Merkarz RB (1982), Frequency of beastieeding and serum bilmbin congentration, American Journal of Disaases in Childhood. 196: 737 8 De Carvalho M, Robortson S, Friedman & et 91 (1989) Effect of frequent breastfeeding ‘on early ik preduction ad infant weight an, Pediatrics, 7213 307.1. 1814. Weight loss Babies commonly lose up to 10% of their birth weight in the first 3 days of life. Some or all of this may be accounted for by excretion of the extra intracelluler fluid which he or she has stored during gestation, passing meconium and taking in only small volumes of colostrum, While all mothers and babies should receive help and support to establish early and effactive breastfeeding, weight loss in excess of 10% should trigger a full assessment of both the baby's general condition and feeding technique, Possible causes of excessive weight loss Insufficient milk intake. This may be the result of: ‘© Inadequate milk transfer from mother to baby, through ineffective attachment at the breast or inirequant or restricted feeding Inadequate milk production in the mother (rare in the immediate postnatal period) Illness or infection in the baby. In this case weight loss may be the result oft © Inadequate feeding responses and behaviour, or © The process of the illness itself Inaccurate measurement. This may be the result of: © Use of inaccurate scales © Inaccurate interpretation or recording of weight © Failure to weigh baby naked © Failure to weigh at the same time on each occasion (e.g. in relation to feeding) Finding the cause Itis important to establish the reason for excessive weight loss so that the correct management can be implemented. This involves: © Full clinical assessment to exclude underlying illness ‘© Assessment of breastfeeding (including a full feeding history) by an appropriately-trained member of staff © Monitoring of urine output! ' © Monitoring of frequency and consistency of stools? (NB: This is less valuable s a guide in babies over a month old.) ‘UNICEF UK Baby Frisndy ntiative: An orientation te breastfeeding for paodtic medical stat Dewey KG, otal (1994) A randomised study of the effects of aerobic exorcise by lactating women on breastmilk volume and ‘composition. N Engl J Med330 (7: aaa. ingworth PJ, et al (1986) Diminution in lonergy expenditure during lactation, BM 292: 497-441 Salarya EM, Robertson CM [1989) The development of a neonatal stool colour ‘comparator. Midwifery 9: 36.40 19Management of the healthy, term breastfed baby with a weight loss >10% in the first 3 days © Assessment of breastfeeding by an appropriately-trained member of staff © Help with positioning and attachment as needed © Frequent breastfeads - at least 3-hourly but more frequent if possible © Expressed breastmilk to be given after breastfeeds by cup or syringe © Close monitoring of urine and stool output to assess breastmilk intake © Reweighing after a few days Notes 1. The baby may not pess much urine in the first 24 hours, but as the mill: supply increases so the urine output should also increase. The urine should be pale and cilute. 2. Abreastfed baby's stools may take longer to change from black to yellow than an artificially fed baby’s stools because the volume of feeds in the first 48 hours is smaller. However, if @ healthy, term baby is breastfeeding well the stools should have started to change by 48 hours and be yellow by 72-96 hours. A delay in changing stool colour can be a sign that the babyy is not feeding adequately. 3, Matemal diet, exercise and strass levels are very unlikely to have any direct effect on milk supply. 4. Supplementation with formula will further compromise the mother's milk supply and increase the risk of infection for the baby. This should be considered only if the baby's health is at risk UNICEF UK Baby Friendly Initiative: An orientation to breastfeeding for paediatric medical statt 20