8 minute read
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. 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).
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
(audible swallowing will be limited initially); infant waking for feeds; weight gain/loss and output.
Prolonged skin-to-skin contact with the mother can be useful for infants who are disinterested in breastfeeding. Mother contact can rouse and stimulate sleepy infants to feed (Couread et al., 2006; Doucet et al., 2007). Skin-to-skin contact is initiated at birth, but continuing this at any time in the post-birth period can support breastfeeding and calm an anxious mother or a distressed infant. Continuing skin-to-skin contact in the home environment if there are still breastfeeding issues is recommended.
Because breastmilk is the ideal source of energy during postnatal metabolic adaptation, support to establish effective breastfeeding is critical (British Association of Perinatal Medicine [BAPM], 2017). The Academy of Breastfeeding Medicine (ABM, 2021) also emphasise maximising breastmilk provision to early full-term and full-term infants in an updated clinical protocol about glucose monitoring and treatment of hypoglycaemia. ABM also noted that after the initial infant awake period of around two hours, some infants have a sleep/rest period of six to eight hours, with very brief periods of semi-wakefulness. It is recommended that infants with any risk for hypoglycaemia are offered breastfeeding opportunities during these six to eight hours (ABM, 2021).
In one study, support and information from health professionals enabled women to identify signs that their infant was receiving sufficient breastmilk, which included waking for feeds, alertness when awake, the number of wet nappies, attachment and sucking patterns, and changes in firmness of the breast before and after feeding (Kent et al., 2021).
SUPPLEMENTATION Prevention of the need for supplementation is the first aim and this is supported by the Ten Steps to Breastfeeding (World Health Organisation/UNICEF, 2018).
• Step 4 (skin-to-skin)
• Step 5 (support for the initiation and maintenance of breastfeeding & management of common difficulties)
• Step 6 (no food or fluids to breastfed infants unless medically indicated)
• Step 7 (rooming-in)
• Step 8 (responsive feeding/feeding cues)
• Step 9 (counsel mothers on the risks of feeding bottles, teats and pacifiers)
These steps support exclusive breastfeeding and recognise the importance of decisions made about why, what, how much, and when supplementary feeds are given and how they are given. As previously noted, when supplementary feeds are medically necessary the primary goals are feeding the infant, and optimising maternal milk supply.
In terms of methods of giving supplements, no method is really without potential risk or benefit (Kellams et al., 2017). Breastfeeding policy documents in Aotearoa New Zealand outline indications for supplementation and some include guidance on methods of supplementary feeding which may include cups, finger feeding and supplementary nursing systems.
Initially, small amounts of colostrum are often given to a non-latching baby via a syringe, dropper or spoon. There has been limited research evidence to support the syringe feeding of infants despite this evolving into common practice in maternity facilities. Taking care to keep any intervention as gentle as possible is recommended to avoid causing any infant distress or generating feeding aversion. Putting a hard syringe into an infant’s mouth is likely to be experienced as unpleasant by the infant, particularly if a bolus of milk is ejected rapidly, and if a syringe is used it is better to place it on the infant’s lips and not directly into the mouth. Buldur et al., (2020) compared finger feeding and syringe feeding methods in supporting sucking skills of pre-term infants, and found that the finger feeding method was an effective way of increasing sucking abilities, accelerating transition to breastfeeding, and shortening the duration of hospitalisation in pre-term infants. Buldur et al., provide a useful technique for finger feeding in their article and although their work is based on pre-term infants, it is applicable to full-term infants also. A study of International Board Certified Lactation Consultants (IBCLC) (n= 2,308) and supplemental feeding methods for breastfed infants, found that they had no preferred method of supplementary feeding although supplementary feeding systems, cup feeding and finger feeding were reported as being used very often and bottles were always offered as a last resort (Penny et al., 2019).
Because supplementation is also associated with a reduction of maternal breastfeeding self-efficacy, it is also important to consider the effects that feeding issues are having on the mother’s emotional health (Blyth et al., 2002). Blyth et al., (2002) suggest taking note of whether the mother experiences discomfort, anxiety, frustration or a sense of failure and recommend explicitly acknowledging these feelings as normal experiences during breastfeeding challenges, while also ensuring tailored support for all breastfeeding ‘attempts’ to avoid undermining breastfeeding self-efficacy. Again, it is always necessary to acknowledge the challenges this presents for midwives in providing care for breastfeeding complexities in understaffed areas with increased rates of birth interventions. A salutogenic framework for midwifery practice, in terms of the promotion of maternal wellbeing, is useful (Mathias, et al., 2021). The use of alternative feeding methods may overwhelm mothers to different degrees (Penny et al., 2019) and manageability, comprehensibility and meaningfulness, as well as sustainability of method need consideration. Once the infant has managed to latch, supplementary breastfeeding systems are useful if more milk needs to be given, particularly for the shortterm, because infants learn to breastfeed by breastfeeding, and respond well to a milkflow, and because mothers learn to breastfeed by breastfeeding.
The Academy of Breastfeeding Medicine (Kellams et al., 2017) provides a list of criteria to be considered when selecting a supplementation method:
• Cost and availability
• Ease of use and cleaning
