Supporting Breastfeeding in High Risk Infant Populations

Neonatal folks are fixated on the gestational age of a neonate. We rely on this information to direct us toward the most likely diagnosis, expected care management, and outcome prediction. The difference in outcome between 23 weeks and 6 days and 24 weeks is significant.

But I have noticed that as gestation increases closer to term, weeks are the focus, not days, particularly outside the NICU. Often, in older gestational age infants, days are not recorded consistently. The difference between 35 weeks and 6 days versus 36 weeks is not that great.  However, it has been shown that there is a difference between premature infants, late preterm infants (34 – 36 6/7 weeks) and now what is being called the early term infant (referring to infants 37 weeks to 38 6/7 weeks).¹ In this respect, days DO make a difference!

Risk factors for readmission in the late preterm infant were identified as hyperbilirubinemia, failure to thrive, and dehydration.^1,2 These are then related to poor feeding, and found more often in infants whose mothers are breastfeeding. Therefore, support for breastfeeding in the late preterm infant has become a standard part of care.

More recently, studies have reported that infants less than 39 weeks are still at risk for these feeding related issues when breastfed.² They are often less alert and less vigorous about communicating their need for food and for feeding than their term counterparts.  Some may have difficulty with latching and transferring milk, but spend adequate time at the breast creating an impression that they are feeding well when, in fact, they are not.

Here are some recommendations that may help support breastfeeding overall but particularly in a high-risk group:

First, recognize infant’s correct gestational age by either obstetrical measurement or, when this is not accurately available, by a standardized neonatal assessment. This creates an awareness of risk factors for a specific gestational age. Many 35 and 36 week infants, and even more so, 37 and 38 week infants, are difficult to recognize as less than term infants. Having an accurate gestational age communicates risk factors, particularly poor intake when breastfeeding.

Secondly, allowing and encouraging time with mother and infant together and at the breast is important. While skin-to-skin care during the first hour has become rather common, this population may also be at risk for medical problems, making it less practical. However, skin-to-skin is also more important for this population, so if it can’t happen during this time, it is still important to encourage skin-to-skin and time at the breast as much as possible with 24 hours/day of rooming in. Reminding parents that these infants may not be as vigorous and may need to be awakened for feedings is also important.

Scoring breastfeeding episodes during the hospitalization serves to communicate breastfeeding success or highlight problems. A standardized tool should be used such as the LATCH Score, IBFAT or the Mother/Baby Assessment Tool.^{3, 4, 5, 6} In addition, this will help to educate parents about breastfeeding cues and support. Mothers may need to pump to supplement milk fed from the breast if the infant is unable to latch or suckle well enough. Pre- and post-weights may be helpful in identifying those infants who are not taking in sufficient quantities.  Overall excessive weight loss or slow weight gain is also helpful, but may be a late indicator of insufficient intake.

Supplementation during breastfeeding is often a controversial topic.  For this population, the need for supplementation should always be considered and when needed, given to avoid feeding related problems as mentioned before.⁷ The method of providing this supplementation should be considered in such a way as to support ongoing breastfeeding. First, if the latch is ineffective, using nipple shields may help with transfer of milk directly.^{7, 8} If supplementation is still determined to be needed, it may be provided by cup, syringe, a supplemental device, or a bottle.⁷ While there is some literature supporting one method over another, ultimately one method will be more or less successful based on the experience of the staff supporting the mother.⁷ This, along with the mother’s preference and the clinical situation, should be considered when selecting a method for supplementation.

Discharge planning for any breastfeeding infant should include evaluation of breastfeeding success.  Educating parents about what to watch for after discharge to ensure feedings remain adequate is critical. However, in spite of this education, early follow up for any preterm, whether late preterm or early term, is also important. The subtleties of poor feeding may not be reliably recognized until too late unless there is follow up by a healthcare provider. It is recommended that this follow up happen within 1-2 days of discharge for this population and should include assessment of risk of hyperbilirubinemia, a weight check, and discussion or observation of breastfeeding, if the mother is breastfeeding.⁹

There are several other interventions that may be necessary in some cases, such as the use of galactogogues and additional expressing or pumping. If other problems are identified in an initial follow up, a referral to a lactation consultant should be made to pursue other options as indicated.

In spite of the risks of breastfeeding in this population, parents and staff should be reminded that babies are born to breastfeed. These infants, because they are not full term infants, just need a little extra help in attaining these skills at breastfeeding and deserve our time and attention to become competent at this skill.

 

References:

1. Ray, KN & Lorch SA (2013). Hospitalization of early preterm, late preterm and term infants during the first year of life by gestational age.  Hospital Pediatrics, 3(3), 194-203
2. Young PC, Korgenski K, Buchi KF. Early readmission of newborns in a large health care system.  Pediatrics 2013; 131:e1538-e1544.
3. Jensen D, Wallace S, Kelsay P. LATCH: A breastfeeding charting system and documentation tool.  J Obstet Gynecol Neonatal Nurs  1994; 23:27-32.
4. Matthews MK. Developing an instrument to assess infant breastfeeding behaviors in the early neonatal period.  Midwiffery  1988;4:154-156
5. Mulford C. The Mother-Baby Assessment (MBA): An “Apgar score” for breastfeeding.  J Hum Lact  1992;8:79-82.
6. Ingram J, Johnson D, Copeland M, et al. The development of a new breastfeeding assessment tool and the relationship with breastfeeding self-efficacy.  Midwifery 2015;31:132-137.
7. Boies EG, Vaucher YE, Academy of Breastfeeding Medicine. ABM Clinical Protocol #10:  Breastfeeding the late preterm (34 – 36 6/7 weeks of gestation) and early term infants (37-38 6/7 weeks of gestation), second revision 2016.  Breastfeeding Medicine. 2016 Dec 1;11(10):494-500.
8. Chow S, Chow R, Popovic M, Lam H, Merrick J, Ventegodt S, Milakovic M, Lam M, Popovic M, Chow E, Popovic J. The use of mipple shields: A review.  Frontiers in public health.  2016 Nov 1; 3:236.

American Academy of Pediatrics. Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics. 2010; 125(2):405–409