BREASTFEEDING CONNECTION
BREASTFEEDING CHALLENGES IN THE EARLY POSTNATAL PERIOD: BREASTFEEDING SUPPLEMENTS AND INFANT WEIGHT LOSS Breastfeeding problems are solved by fixing breastfeeding, not by replacing it. But during the early newborn period, there may be challenges that require interventions, including alternative ways to give breastmilk other than via the breast, and/or the use of some infant formula. The first ‘rule’ when it comes to any form of infant feeding is to feed the baby, and feeding plans need to first of all act on this, while taking into account how to cause the least disruption to continued breastfeeding for the mother and infant.
CAROL BARTLE POLICY ANALYST
Ideally, exclusive breastfeeding/breastmilk feeding is an important objective, but parental wishes are paramount and all feeding plans and interventions should be planned by midwives with parental involvement. Giving additional fluids to the infant can interfere with breastfeeding physiology, and supplements may cause reductions in breastfeeding frequency, breast stimulation, breastmilk production and breastmilk removal. All of these issues need to be taken into account as part of the feeding plan. As well as considering how a supplement can be given in a way that preserves breastfeeding, the volumes of milk given should also be considered. This involves limiting the amounts to what is necessary for newborn physiology, and ensuring support for the infant to continue practising at the breast (Kellams et al., 2017). The optimal supplement when required is expressed milk from the mother, followed by screened donor milk, with formula being the last option. If neither sufficient breastfeeding nor expressed milk from the mother or donor milk are available, then formula milk is obviously essential.
34 | AOTEAROA NEW ZEALAND MIDWIFE
INFANT WEIGHT The size of the newborn stomach indicates that small quantities of colostrum are perfectly appropriate to prevent hypoglycaemia in a well, full-term baby (Kellams et al., 2017). Newborn infants lose weight because of a physiologic diuresis and well, full-term breastfed infants regain their birthweight at an average between 8.3 and 21 days (97.5% by 21 days) (Kellams et al., 2017).
As well as considering how a supplement can be given in a way that preserves breast feeding, the volumes of milk given should also be considered. This involves limiting the amounts to what is necessary for newborn physiology, and ensuring support for the infant to continue practising at the breast.
Neonatal weight loss needs to be interpreted in a context which looks not just at the weight, but at the infant in general; the infant’s output, the birth process and good assessments of breastfeeding. Excess newborn weight loss is also correlated with positive maternal intrapartum fluid balance received via intravenous fluids, which needs to be taken into account (Kellams et al., 2017; Noel-Weiss et al., 2011). Difficult beginnings to breastfeeding may resolve relatively quickly despite an initial larger than expected weight loss. Taking into account the context in which a weight loss occurs and the many variables that can influence weight loss supports informed decision-making about when intervention is required, and when it is not. Reliance on weight assessments alone may lead to red flags being missed, so weight assessment needs to be viewed as one strategy within a holistic breastfeeding evaluation, that includes the experience of breast fullness, observing infant breastfeeding behaviour, observing milk transfer, and other indications of adequate infant hydration (Noonan, 2011). The UK National Institute for Health and Care Excellence (NICE) Faltering Growth Guidelines (2017) discuss concerns about excessive infant weight loss of 10% or more. Recommended actions include clinical assessment looking for evidence of dehydration, illnesses that might account for weight loss, taking a detailed history to assess feeding, direct observation of feeding, and provision of feeding interventions that support the mother to continue breastfeeding alongside supplementation where necessary. SUPPORTIVE STRATEGIES Women at risk of delayed lactation require additional early breastfeeding support to reduce the risk of excessive infant weight loss. Delayed lactogenesis II is associated with mother-infant separation, maternal obesity and other factors such as primiparity, breast surgery, maternal age over 30, labour/birth factors, and stress (Wambach & Watson Genna, 2021). Close monitoring of infants where there are any known maternal risk factors for delayed lactation and/or if the infant is having difficulties with latching or effective suckling, is essential. The NICE Postnatal Care Guidelines (2021) emphasise what is necessary for a breastfeeding assessment: frequency and length of feeds; audible swallowing and rhythmic sucking
