Cases

Chapter 10 Infant feeding

Case 1: Making sure babies get enough milk and managing complications (1)

Janet had an actively managed labour including the administration of pethidine, culminating in a lower segment cesarean section. Janet did not receive the opportunity for skin-to-skin contact in theatre or in the first few hours after the birth. The first breastfeed was attempted at 7 hours of age without midwifery assistance.

The community midwife is visiting Janet and her baby Sam on the 4th postnatal day. Sam is not waking frequently to demand feeds and is still passing meconium with the last stool passed 18 hours ago. Sam is passing small amounts of urine. Janet's breasts are not appearing to show signs of onset of lactogenesis II and she has sore, painful nipples.

Questions

• a) What are the key areas of concern here and why?

  Show Answer

  Correct answer:

  • Not having the opportunity for skin-to-skin contact to facilitate mother and baby bonding and to stimulate initiation of breastfeeding.
  • Not providing the mother with support with the first feed which should have been offered within 1-2 hours after birth.
  • At 4 days postnatal, a normal healthy newborn baby would be expected to wake spontaneously and breastfeed effectively and frequently (6-8 times in 24 hours).
  • If a baby has initiated breastfeeding effectively from birth, it would be expected that by day 3, the baby would be passing changing stools and the urine output should be increasing in frequency and volume. (By day 5 it would be having at least 6 wet nappies a day.)
  • The mother would normally begin to experience changes to her breasts about 72 hours after the birth and delivery of the placenta and membranes. These changes include a feeling of increasing weight and size of the breasts; an increasing flow of milk, changing from the yellow colostrum to a more translucent white milk; the pattern of veins under the surface of the breast skin become more pronounced, as the blood supply to the breast increases - known as 'venous engorgement', which is normal and not to be confused with 'milk engorgement'.
  • The nipples and areola should not be sore or damaged. Damaged nipples are an indication that the baby has not been attaching well to the breast.

• b) What would your assessment involve?

  Show Answer

  Correct answer:

  • Take a full verbal history from the mother, of the number, frequency and nature of the feeds since birth.
  • Read the documentation of the feeds in the mother and baby care plans and assess whether the detail gives you further insight.
  • Enquire whether the mother has been shown how to 'hand express' and been taught the key points of achieving optimum positioning and attachment.
  • Ask to examine the sore nipples to gauge the nature of the tissue damage, e.g. epithelial cells rubbed off the anterior aspect by the tongue, indicates that the baby has only been attaching to the nipple in its attempts to feed and would not have been accessing the colostrum effectively; a scabbing, linear crease across or down the nipple tissue, indicates compression of the nipple against the anterior part of the palate, as the baby has struggled to maintain a latch and when the breast tissue has not been far enough back in the baby's mouth; bruising of the areola also indicates, misaligned attachment.
  • Ask to undertake and document the baby's current clinical wellbeing which includes five points (skin colour/temperature/respiration rate/muscle tone/responsiveness to handling). Examine the baby's oral cavity and tongue to assess whether the baby has a well-organized suckle reflex with a peristaltic wave of action, from the front to the back of the tongue; to assess whether the baby is able to create a good vacuum seal. A baby with a cleft palate is unable to achieve this due to the opening from the palate to the nasal passages - occasionally a small cleft in the soft palate can be missed at the neonatal examination. Assess whether the baby can bring its tongue well forward over the lower gum ridge and can lift it up towards the roof of the mouth; examine for any lingual membrane present; carefully feel the palate with the little finger for any irregularities in shape.
  • Develop a feeding plan with the mother, which she understands and agrees to work with, for the next 24 hours, when it will be reviewed and altered according to the progress made in the clinical condition of both mother and baby.

• c) What would your feeding plan include?

  Show Answer

  Written Feeding Plan:-

  1. 3-hourly feeds from both breasts using skin-to-skin contact for every feed and seek midwifery support to oversee the positioning and attachment of the baby to the breast. A range of positions of both mother and baby can be explored to establish which works best at this time. The mother needs to be in a position that she can maintain comfortably throughout the feed.
  2. Undertake some gentle breast massage prior to the feed to stimulate oxytocin release. Hand express a few drops of milk forward to encourage the baby to pick up the smell and taste of the milk, triggering its behaviour to attach, offering a wide gape, with tongue down and forward and leading with the chin as the baby instinctively tilts its head slightly back.
  3. Show the mother and father how to observe the baby's suckle/swallow pattern and to look for the 'pauses'. When the baby pauses, the baby should be stimulated to return to effective suckling again, by providing gentle pressure massage to the palm of the uppermost hand, whilst keeping this arm flexed forwards and inwards. At the same time, tactile stimulation down the baby's back provides extra stimulation. (Fathers/partners enjoy being responsible for doing these two things, and both parents gain confidence in the breastfeeding process.)
  4. Inform the parents that if they continue to stimulate the baby after pauses in suckling, the baby will eventually release the vacuum seal and push the breast out of its mouth, and have a satisfied expression. Check if the baby has any wind to release and then repeat all of the above, on the other breast. This is to ensure the baby takes as much of the available milk, as efficiently as possible, not allowing the baby to fall asleep mid feed.
  5. Encourage the mother to hand express any residual breastmilk from both breasts, post feed, collecting it in a syringe or cup. This extra drainage, stimulates further prolactin secretion and will increase milk production. The milk obtained (even just a few drops) should be labelled and stored safely at 4°C in a designated milk storage fridge and then fed to the baby as a top up by syringe or cup, immediately after the next feed. In this way, the mother gets one feed ahead, in that the top up is available immediately after the feed - the mother is not becoming anxious and stressed trying to express the milk at the time of the feed. The baby will be receiving the calorie rich hind milk, which provides energy and will stimulate the baby to begin to wake up spontaneously for its feeds (demand feed).
  6. Monitor and document all the baby's urine and stool output, including colour and frequency.
  7. Monitor and document changes in the mother's breasts, including any sense of them filling for feeds and feeling softer, lighter, well drained after feeds. Include any change or improvement to the nipple tissue. The mother may choose to apply a small amount of purified lanolin-based ointment to the sore area after each feed, assuming she is not allergic to it.
  8. Arrange for a review of the feeding plan and assessment of the clinical condition of mother and baby, in 24 hours. Given the age of the baby, it may be due for weighing on Day 5, depending on local protocols. Warn the mother that the baby is likely to have lost weight, but the feeding plan will begin to correct this over the next few days as breastfeeding becomes better established and the milk supply improves.

Case 2: Making sure babies get enough milk and managing complications (2)

Gainer had a normal birth with her second baby Jasmine who weighs 3310 grams. Gainer formula-fed her first baby and is keen to breastfeed this time. The community midwife visits Gainer on the 5th postnatal day at home. During the postnatal examination the mother reports that she thinks Jasmine is feeding well, but both her breasts are engorged and painful with an area on the lateral side of the right breast which is showing signs of hard lumpy tissue under hot, red, shiny skin.

The mother also states that the baby is demanding frequent short feeds, lasting about 10 minutes, but is not settling afterwards. She says Jasmine seems to prefer the left breast and has passed two small green changing stools in the last 24 hours and had three voids of urine.

Baby was weighed = 2946 grams.

(The percentage weight loss was calculated as follows:
Birth weight (3310 g) minus actual weight (2913 g) = 397 g loss
Then to calculate the percentage loss:
364 g ÷ 3310 g × 100 = 10.99% weight loss - rounded up is 11% loss of weight since birth.)

Questions

• a) What are the key areas of concern here and why?

  Show Answer

  Correct answer:

  • The development of mastitis in the right breast.
  • The combination of her baby feeding frequently for a short time and then remaining unsettled would indicate that the baby is not accessing sufficient breastmilk during its time at the breast.
  • The above, in association with breast engorgement would indicate that the mother and baby have not yet gained optimum positioning and attachment for effective breastfeeding.
  • The degree of weight loss indicates insufficient milk intake over the first 5 days.
  • The stool output and colour and the limited urine output is also an indication of insufficient milk intake / ineffective breastfeeding.
  • A full clinical well-being assessment of the baby should be undertaken (temperature, respiration rate, skin colour, muscle tone and responsiveness to handling), to identify any further areas for concern, which might require paediatric referral and assessment.
  • Assess the baby's readiness for a feed; feeding cues; offering wide gape; tongue down and forward in readiness for attachment (a tongue tied baby is not able to bring its tongue forward far enough over the lower gum ridge to gain a deep attachment to the breast tissue for effective milk transfer). Check the palate to exclude any abnormalities, e.g. cleft palate, high palate or narrow V shaped palate; check the nature of the suckling reflex on a clean little finger - it should be a rhythmical peristaltic action from front to back.
  • Closely examine both the mothers' breasts to determine the extent of the engorgement and mastitis and observe for any nipple tissue damage or inverted nipples.
  • Ask the mother how she is feeling generally and assess her emotional wellbeing.
  • Ask her how she positions herself and her baby for a feed and whether she uses the same 'hold' at every feed and whether she has been offering the left breast more than the right in view of her comment.
  • Discuss your concerns and reassure her that a robust feeding plan will help resolve the engorged breasts and mastitis and will contribute to increasing the baby's milk intake over the next few days to correct the weight loss and improve the urine and stool output. (At 5 days the baby should be passing at least 6 voids of urine in 24hrs and at least 2 yellow stools.)

• b) What would your immediate feeding plan include?

  Show Answer

  Immediate Feeding Plan:

  • 1. Encourage the mother to sit in a comfortable and private place where she is relaxed and then begin to massage the right breast for a few minutes, followed by stimulating the nipple tissue, to encourage the 'milk ejection reflex' in response to oxytocin release.
  • 2. Hand express very gently to encourage the milk to begin to flow, checking the mother's technique and correcting where necessary. When there is significant engorgement, this sometimes takes several minutes.
  • 3. Continue to hand express until the nipple and areola complex is softened and the nipple is protracted.
  • 4. Ask her to hold the baby in the 'under arm' position and make any adjustments necessary to facilitate optimal attachment of baby to the breast. (When mastitis is developing on the outer, lateral aspect of the breast; milk drainage from this area is improved using this position because the lower jaw of the baby is on the same side as the overfull milk cells and ducts and the action of the jaw during suckling helps the milk to drain from this area).
  • 5. Ask the mother to use her left hand to provide extra support under the right breast, during the feed.
  • 6. Assist the mother to achieve optimal attachment and ensure she understands the key points of successful attachment and is experiencing a more comfortable and effective feed.
  • 7. Show her and her partner ways to encourage the baby to return to effective suckling and swallowing after brief pauses (palm massage; skin stimulation - back massage).
  • 8. After the baby completes the feed on this breast, assess whether the mother detects a more significant softening of that breast.
  • 9. After the baby has been given an opportunity to bring wind up and the mother has stimulated and triggered the milk ejection reflex and softened the nipple/areola complex in the left breast, ask her to position and attach the baby for a further feed using all the strategies to stimulate the baby to feed for as long as possible. The baby will spontaneously release the breast when it feels satisfied.
  • 10. Again assess whether the mother's breast feels softer and more comfortable.
  • 11. If either or both breasts still feel congested and painful (especially the right breast), the mother should pump express, massaging the most congested areas gently, continuing until the breast feels softer, well drained and comfortable. The expressed milk to be stored in the fridge at 4°C.
  • 12. Check that the mother is wearing a well-fitting bra, which is providing good support and does not have under-wires which can put undue pressure on the breast tissue.
  • 13. Ask the mother whether she now feels more confident and comfortable and develop a feeding plan with her, which she understands and agrees to work with, for the next 24 hours. The feeding will be reviewed and altered according to the progress made in the clinical condition of both mother and baby.

• c) What would your feeding plan include over the next 24 hours?

  Show Answer

  Written Feeding Plan:

  • 1. 3-hourly breastfeeds, paying particular attention to optimal positioning and attachment and alternating which breast she begins the feed on.
  • 2. Offer both breasts at every feed.
  • 3. Only post feed express if the breast still feels too full and uncomfortable. Take particular care to ensure the right breast is well drained and closely observe the area where the mastitis was developing. The signs and symptoms should be receding over the 24 hour period. If not, medical assessment is required.
  • 4. Any post feed expressed milk (hind milk with high fat content) could be offered as a top up preferably by cup or spoon (or by bottle if the parent chooses to and understands the risks of introducing teats at this early stage). A 30 mL, 1 oz) feed should be sufficient if the baby has breastfed well.
  • 5. Take 1 g paracetomol, up to four times in 24 hours for pain relief.
  • 6. When showering, it can help to relieve engorgement, if the mother gently massages the breasts, while the water is running over her back and shoulders. Also, gently circling her arm backwards, moves the breast tissue and may help the milk to release and begin to drip/spray out.
  • 7. The mother or father to note down the urine and stool output over the next 24 hours, as well as the length and effectiveness of each feed and the baby's satisfaction post feed.
  • 8. Arrange to visit the next day and either continue with the same plan or make any changes and as needed.
  • 9. Arrange to re-weigh the baby after 2 days (Day 7) to confirm clinical progress is being made.
  • 10. Ensure the mother knows how to contact a midwife or local Peer Supporter if she has any concerns.

  Additional information:
  Once the mother and baby have established effective breastfeeding, with resolved engorgement and mastitis and the baby is gaining weight adequately and is stooling and voiding well, the feeding plan can be discontinued. The mother can feed on demand.
  NB The average weight gain by a baby during the first 3 months is 30 g (1 oz) a day.

Case 3: Formula feeding

The community midwife is in the house of a new mother Sarah. This is now the sixth postnatal day, following a normal birth. The midwife is visiting Sarah on the 4th postnatal following discharge from hospital on day three, she was bottle feeding her baby and was using the readymade infant milk in hospital. She and her husband are inexperienced new parents in their early twenties. They are the first among their peers to become parents; they do not have the support of close family members and did not come from big families.

Questions

• Sarah has a lot of questions. She is quite nervous but also eager to get things right.
  She asks you:
  1. How often the sterilising solution needs to be changed in the water steriliser she is using?
  2. What temperature should the water be when making up the milk feed from powder?
  3. Sarah thinks it would be quicker to heat the milk in a microwave - what would your advice be to her?
  4. How shall I store feeds when going out?

  Show Answer

  Correct answer:
  1. Every 24 hours.
  2. The advice is to use tap water that has been freshly boiled and should be left to cool in the kettle for no more than 30 minutes so that it remains at a temperature of at least 70°C. Once the feed is prepared, it is important to cool the formula appropriately so it is not too hot for the baby to drink.
  3. Microwaves should never be used to warm up milk due to the presence of hot spots and risk of scolding the baby's mouth.
  4. The safest method is to take a sterilised bottle and teat and a fresh carton of liquid formula and pour it straight into the sterilised bottle when required and feed the baby.