1. Caring for the Family Whose Baby Requires Hospitalization Identify at least one way to promote the establishment of a good milk supply for the mother of a sick or preterm infant.

2. * Most babies at 22 weeks are not resuscitated because survival without major disability is so rare. COMPLETED WEEKS OF GESTATION AT BIRTH using last menstrual period SURVIVAL 21 weeks and less0% 22 weeks0-10%* 23 weeks10-40% 24 weeks40-70% 25 weeks50-80% 26 weeks80-90% 27 weeks>90% 30 weeks>95% 34 weeks>98%

3. Preterm Birth Timeline Fetus is not viable outside uterus Preterm Term Conception… 10 12 14 16 18 20 22 24 26 28 30 32 34 3638 - 42 Ideal time for at-risk mothers to attend Preterm Birth Prevention Class Gavage … Oral feedings Drugs to stop labor (“tocolytics”) Very preterm, VLBW

6. Teach about: The importance of breastmilk for a preterm baby –Protection from infection –Protection from necrotizing enterocolitis –Greater tolerance of feedings –Reduced risk of later allergy –Improved eye function –Enhanced neurological development

7. Pump Operation Help mother begin pumping by 6 hours after birth Show massage techniques Select flange size for best fit Demonstrate hand expression - may be more effective for collecting colostrum

9. Frequency of Pumping Pump 8 times per 24 hours Every 2-3 hours during the day and once at night May be able to go longer at night, depending on storage capacity

10. Length of Pumping Sessions During the colostrum phase: express for 5-10 minutes After Lactogenesis II: –pump until the flow slows down or stops –then pump for a few minutes more to “empty” the breasts completely For most women, this takes about 15 minutes

11. Teach the science of milk supply Keep prolaction levels high by pumping for 15 minutes at least 8 times a day Enhance oxytocin with warmth, massage, touch, food, and early skin- to-skin contact with baby Drain milk glands well for higher fat content and faster milk production

13. Milk Storage Guidelines Room temperature for 6 hours Refrigerator for 48 hours (8 days for term, healthy babies) Freezer for 6 months Deep freezer for 12 months Once thawed, use immediately or store in fridge for 24 hours Feed warmed milk within 1-4 hours

14. Picture of cooler bags here

17. Orientation to NICU pumping facilities, supplies, and resources

19. Effects of Kangaroo Care on Breastfeeding Increases milk volume (680 vs 400 ml/day) Increases breastfeeding incidence by 25-50% Increases breastfeeding duration at all time points

20. Effect of Kangaroo Care on Milk Volumes Over Time

23. Feldman, et al. Pediatrics July 2002 Kangaroo Care’s Effects on Parenting At 37 weeks gestational age: –Mothers showed more positive affect, touch, and adaptation to infant cues. –Infants showed more alertness and less gaze aversion. –Mothers reported less depression and perceived infants as less abnormal.

24. Feldman, et al. Pediatrics July 2002 Kangaroo Care’s Effects on Parenting, continued: At 3 months: –Mothers and fathers were more sensitive and provided a better home environment. At 6 months: –Mothers were more sensitive and infants scored higher on the Bayley Mental Developmental Index and the Psychomotor Developmental Index.

25. Fat Content in Human Milk Increases steadily until the end of feeding Fat percentage ranges from 3-12% Calorie count ranges from 16-35 kcal/oz Can be measured by “creamatocrit”

26. Teach Parents Preterm Infant Cues STOP — Spit-up, Gag, Hiccoughs, BM grunts, Gas, Flaccid limbs, Gape face, Grimace, Apnea, Duskiness, Desaturation episodes WATCH AND WAIT — Halt, Finger splay, Tongue extensions, Fussing, Averting eyes, Respiratory changes, Frequent tremors & twitches, Frequent squirming GO AHEAD — Flexion, Hand on face, Sucking, Suck search (lips forward),Clasping hands, Grasping, Holding on, Raising eyebrows, Frowning, Looking at

27. Halt sign Finger splay Preterm Cues: Gaze aversion

28. Enhancing milk transfer Pump just before or during breastfeeding Massage breast Use nipple shield –Meier’s 2000 study of 34 preterm infants –All consumed more milk nursing with shield –Average 18 ml (4 ml without shield )

35. Breastfeeding at home Until 40 weeks post-conceptual age, expect: –Immature feeding behaviors –Weaker suck –Subtler cues Plan to continue pumping Plan for close lactation follow-up

36. Skin to skin as much as possible Begin expressing milk within 6 hours Sucking on the “emptied” breast (breast as pacifier) Early feedings of human milk Rooming-in for 24-48 hours prior to going home Cue-based breastfeeding with continued gavage Breastfeedings begin to “count” (start test weights) Skin-to-skin contact as soon as possible Breastfeeding exclusively; wean from scale and pump Home with scale for determining intake at breast 1 2 4 38 9 10 65 7 Adapted from Berlith Persson, Helsingborg Hospital, Sweden