NHD issue 99: Preterm infant nutrition

preterm infant feeding: case study

Establishing breastfeeding in a preterm baby Case Study: Early discharge home from the Neonatal Unit (NNU)

Shona Brennan Specialist Neonatal Dietitian, Sheffield Teaching Hospitals NHS Foundation Trust

Shona’s post as Specialist Neonatal Dietitian includes being part of the multidisciplinary and developmental care teams. Her particular interest is in supporting mothers in establishing lactation, breastfeeding and weaning. Shona is a member of the Paediatric Group of the BDA and Neonatal Dietitians’ Interest Group.

On our NNU, parents are actively encouraged to become involved in feeding their baby as soon as they feel ready and, for many, this will involve learning how to tube feed. Some preterm babies remain on the NNU solely because they are unable to take all of their feeds orally and need nasogastric feeds to supplement their nutritional requirements until they are mature enough to do so. For some babies and families this may take many weeks.

Early discharge home of stable preterm infants still requiring some nasogastric feeds has the benefit of uniting families sooner and allows a more consistent approach to feeding by parents.

Reducing the length of stay in hospital for preterm infants has been suggested to have emotional and psychological benefits for the family and for the infant’s development (1). Home tube feeding programmes have also been associated with successful weight gain and infants have not required readmission related to tube feeding (2, 3, 4). To ensure successful home tube feeding, parents need to be competent, confident, committed and well supported by community health professionals experienced in this area.

On our NNU, any baby fulfilling the criteria in the Early Discharge guideline will be considered (5).

Tube feeding at home could be an increased burden for some families and there is the possibility of complications relating to the tube feeding. Some parents choose not to take their baby home partially tube fed, preferring them to remain on the NNU until oral feeding is fully established. In our experience, however, most parents do choose to take their baby home early to continue to establish oral feeds (6).

This is a case report of a preterm infant who was discharged home early to continue to establish breastfeeding.

Case study Baby D was born at 34 weeks gestation weighing 1.628kg (2nd to 9th centile).

He was born by elective caesarean section for intrauterine growth retardation and placental insufficiency. He did not require any resuscitation at birth and was transferred to the NNU to start intravenous fluids. On the NNU, our aim is to support mothers to express their milk within two hours of birth.

Midwifery staff explained the benefits of breast milk to Baby D’s mother, to encourage her to express her milk and she was shown how to hand express as it was her intention to breastfeed. By day six of life, Baby D had established full feeds via nasogastric tube using his mothers’ breast milk and he tolerated this well. Vitamin and iron supplements were started.

As well as tube feeds, baby D was beginning to try and feed from the breast. His mother had been expressing regularly and had established a good milk supply, sufficient to support exclusive breastfeeding. Baby D was then transferred to Transitional Care. Transitional Care is part of the unit that enables mothers to stay with their babies and, with the support from neonatal staff, learn how to feed and care for their baby. This would include continuing to learn to tube feed and pass a nasogastric tube if early discharge was being considered.

Baby D was discussed as part of the weekly Multidisciplinary Team (MDT) NHDmag.com November 2014 - Issue 99

17

preterm infant feeding: case sutdy sleepy but did have periods when he was awake and alert. He was still having full nasogastric tube feeds. He was nine days old. His weight was 1.55kg.

To help the transition from tube feeding to breastfeeding, a ‘Top Up’ plan is used. This helps to assess whether a tube top up is needed. The Top Up plan is based on the quality, as well as the time of breastfeeds and it also helps to continue to support growth during the transition process.

Baby D was 13 days old the next time he was seen with his mother and was observed feeding at the breast. His mother was using a nipple shield which helped baby D achieve and maintain an effective latch at the breast. He demonstrated competent feeding skills, limBy ceejayoz (www.flickr.com/photos/ceejayoz/3579010939/) (GFDL (www.gnu.org/copyleft/ ited only by his energy reserve. At this fdl.html) or CC-BY-2.0 (creativecommons.org/licenses/by/2.0)), via Wikimedia Commons stage he was feeding from the breast four times with top ups and four of his ward round. He was seven days old. Early dis- feeds were full tube feeds in a 24-hour period. His charge had been mentioned to baby D’s mother and weight was 1.64kg (0.4th to 2nd centile) having this was something she was keen to do. She was regained his birth weight. The following evening, already doing all his cares and feeds and she was Baby D was discharged home at 36 weeks corvery eager for him to start breastfeeding. Until this rected gestational age on day 14 of life. point, baby D’s feeding attempts were mostly non- Community follow-up was arranged two days nutritive with no or minimal milk transfer. Early after discharge and he was reported to be feeding Discharge requires the baby to be making progress well with a similar pattern to that on the NNU, and with oral feeding as assessed by the MDT. he gained a further 40g. At the next home visit four Preterm infants are born before their feeding days later, his weight had increased to 1.80kg. He development is complete, so parents need to be continued to feed well, waking every three to three given realistic expectations at each stage of their and a half hours. His mother was still using a nipple baby’s feeding journey. Co-ordination develops shield. A week later he was fully demand breastwith increasing gestational age and is thought not feeding and his weight was 1.940kg. Community to be fully established before 35 to 37 weeks gesta- follow-up continued for a further two weeks; Baby tion. However, there is ongoing debate as to how D’s weight at the final visit was 2.370kg and he much is determined by gestational maturation continued to demand to breastfeed. and how much by experience (7, 8). Baby D was This case illustrates the benefits and success asleep the first time he was seen with his mother of early discharge home for Baby D, his parents on Transitional Care. She said that he was still very and the NNU. References 1 Casiro et al. Earlier discharge with community-based intervention for low birth weight infants: A randomised trial. Pediatrics 1993; 92: 128-34 2 Wakefield J, Ford L. Nasogastric tube feeding and early discharge. Paediatric Nursing 1994; 6: 18-19 3 Evanochko et al. Facilitating early discharge from the NICU: the development of a home gavage program and neonatal outpatient clinic. Neonatal Network 1996; 15:44 4 Swanson SC, Naber MM. Neonatal integrated home care: nursing without walls. Neonatal Network 1997; 16:33-8 5 Gastric tube feeding - early discharge (neonatal) Jessop Wing Unit guideline 2012. Jane Shaw Speech and Language Therapist 6 Bathie J, Shaw J. Early discharge home from the neonatal unit with the support of nasogastric tube feeding. Journal of Neonatal Nursing 2013; 19: 213-216 7 Gryboski JD. Suck and swallow in the premature infant. Pediatrics 1969; 43:96-102 8 Casaer P, Daniels H, Devlieger H et al. Feeding behaviour in preterm neonates. Early Hum Dev 1982; 7:331-346

18

NHDmag.com November 2014 - Issue 99