Session 10INFANTS WITH SPECIAL NEEDS

Publication Details

Session Objectives

On completion of this session, participants will be able to:

Materials

Slides 10/1 and 10/2: Pictures of kangaroo mother care.

Slide 10/3: Positioning a preterm baby.

Slide 10/4: Twins.

Slides 10/5 and 10/6: DANCER hand position. Baby in slide 10/6 has Down’s Syndrome.

Two or three dolls (different size dolls to demonstrate feeding twins and feeding a preterm baby).

Does the baby need breast-milk substitutes? – One copy for each participant

Further reading for facilitators

World Health Organization. Breastfeeding and the use of water and teas. Division of Child Health and Development Update No. 9 (reissued, Nov. 1997).

World Health Organization. Persistent Diarrhoea and Breastfeeding. Division of Child Health and Development Update; Geneva, 1997.

World Health Organization. Hypoglycaemia of the Newborn – a review of the literature. Division of Child Health and Development and Maternal and Newborn Health/Safe Motherhood, 1997.

World Health Organization. Kangaroo Mother Care - a practical guide. Department of Reproductive Health and Research, Geneva, 2003.

Integrated Management of Childhood Illness: A WHO/UNICEF Initiative, In Bulletin of the World Health Organization, supplement no 1, vol. 75, 1997.

WHO/UNICEF/USAID. HIV and Infant Feeding Counselling Tools. World Health Organization, Geneva: 2005; 2008.

WHO/UNICEF Acceptable medical reasons for use of breast-milk substitutes World Health Organization, Geneva 2009.

1. Breastfeeding infants who are preterm, low birth weight or ill

20 minutes

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Continue with the ‘story’:

We last saw Fatima and her son having skin-to-skin contact following an emergency caesarean section. Fatima’s son was born four weeks early; however he was stable and started breastfeeding in the recovery room. Fatima was surprised that he was able to breastfeed and glad that he got some of her first milk that would help protect him. The nurse told her that breastfeeding is very important for a preterm baby.

Ask: Why is breastfeeding particularly important for a baby who is preterm, low birth weight, has special needs or any baby that is ill?

Wait for a few replies.

The importance of breast milk for preterm, low birth weight or special needs infants

  • Breast milk contains:
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    Protective immune factors, which help to prevent infection.

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    Growth factors which help the baby’s gut and other systems to develop as well as to heal after diarrhoea.

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    Enzymes which make it easier to digest and absorb the milk.

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    Special essential fatty acids that help brain development.

  • In addition, breastfeeding:
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    Calms the baby and reduces pain from drawing blood or related to the baby’s condition.

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    Gives the mother an important role in caring for her baby.

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    Comforts the baby and maintains the link with the family.

  • Babies with special needs such as neurological conditions, cardiac problems or cleft lip/palate and babies who are ill, need breast milk as much if not more than babies who are well. Breastfeeding continues to benefit older babies and young children who are ill.
  • The approach to feeding will depend on the individual baby and his or her condition. Overall, care can be divided into categories based on the baby’s condition:
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    Baby not able to take oral feeds.

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    Baby able to take oral feeds but is not able to suckle.

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    Baby able to suckle but not for full feeds.

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    Baby can suckle well.

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    Baby is not able to receive any breast milk.

Fatima’s baby is brought to the special care baby unit40 because there is some concern about his breathing, and Fatima goes to the postnatal ward. She is worried about how she will breastfeed if she is separated from her baby.

Ask: What are some ways that a special care baby unit can support breastfeeding?

Wait for a few responses.

Support for breastfeeding in the special care baby unit

  • Arrange contact between mother and baby, day and night.
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    Encourage the mother to visit, touch, and care for her baby as much as possible.

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    A mother produces antibodies (one kind of protective factor) against bacteria and viruses (germs) that she is in contact with. When she spends time with her baby in a special care baby unit, her body is able to produce the protective factors against many of the germs that her baby is exposed to in the unit.

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Show slides 10/1 and 10/2 - pictures of kangaroo mother care

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Skin to skin contact or ‘kangaroo mother care’ encourages the mother to hold her baby (dressed only in a diaper) beneath her clothing close to her breast. The baby can then go to breast whenever he or she wants. Skin-to-skin contact helps to regulate the baby’s temperature and breathing, assists in development, and increases the production of milk.

  • Take care of the mother. The mother is very important to the baby’s well being and survival.
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    Help the mother to stay at the hospital while her baby is hospitalised

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    If the mother comes from a long distance to visit her baby, ensure she has a place to rest when she is at the hospital.

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    Make sure the mother has a suitable seat near the baby.

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    Encourage the health facility to provide food and fluids for the mother.

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    Answer the parents’ questions and explain patiently. The parents may be upset, overwhelmed and frightened when their baby is ill.

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    Let the parents know that you believe breast milk and breastfeeding are important.

  • Help to establish breastfeeding:
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    Assist the mother to express her milk, starting within 6 hours of birth, and expressing six or more times each 24 hours.

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    Encourage babies to spend time at the breast as early as possible even if they are not able to suckle well as yet. If the baby has the maturity to lick, root, suck and swallow at the breast, he or she will do so without harm.

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    Describe the early times at the breast as ‘getting to know the breast’ rather than expecting the baby to take full feeds at the breast immediately.

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    The baby can go to the breast while receiving a tube feed to associate the feeling of fullness with being at the breast.

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    Weight is not an accurate measure of ability to breastfeed. Maturity is a more important factor.

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    Until a baby is able to breastfeed, he or she may be fed expressed breast milk by tube or cup41. Avoid using artificial teats.

Putting a baby to breast

  • Put a baby to the breast when the baby is just starting to wake up, as seen with rapid eye movements under the eyelids. When ready to feed, a baby may make sucking movements with his or her tongue and mouth. A baby may also bring her or his hand to her or his mouth. Help a mother learn how to anticipate feeding time to avoid her baby using up energy by crying.
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Show picture 10/3: Positioning a preterm baby. Use a doll to demonstrate positions.

  • Show the mother how to hold and position her baby. One way to hold a small baby is with the baby’s head supported – but not gripped - by the mother’s hand. The mother’s arm can support the baby’s body. The baby can be to the mother’s side (as in this picture), or the mother can use her hand from the opposite side to the breast that the baby is feeding at.
  • The mother can support her breast with her other hand to help the baby keep the breast in his or her mouth. Show her how to put four fingers under the breast and her thumb on top.
  • To increase milk flow, massage and compress the breast each time the baby pauses between suckling bursts (unless the flow is more than the baby can swallow already).

Explain to mothers what to expect at feeds

  • Expect that the baby will probably feed for a long time, and that the baby will pause frequently to rest during a feed. Plan for quiet, unhurried, rather long breastfeeds (an hour or so for each feed).
  • Expect some gulping and choking, because of the baby's low muscle tone and uncoordinated suckle.
  • Stop trying to feed if the baby seems too sleepy or fussy. The mother can continue to hold her baby against her breast without trying to initiate suckling.
  • Keep the feed as calm as possible. Avoid loud noises, bright lights, stroking, jiggling or talking to the baby during feeding attempts.

Prepare the mother and baby for discharge

  • A baby may be ready to leave hospital if she or he is feeding effectively and gaining weight. Usually it is necessary for the baby to weigh at least 1800 – 2000 g before being discharged, but this varies with different hospitals.
  • Encourage the health facility to provide a place for the mother to come and stay with the baby 24 hours a day for the day or two days before going home. This helps to build her confidence as well as helping her milk production to match her baby’s needs.
  • Ensure that the mother can recognise feeding signs, signs of adequate intake and that she is able to position and attach her baby well for breastfeeding.
  • Make sure that the mother knows how she can get assistance with caring for her baby after she goes home. Arrange with the mother for follow-up care.

2. Breastfeeding more than one baby

5 minutes

  • Mothers can make enough milk for two babies, and even three. The key factors are not milk production, but time, support and encouragement from health care providers, family, and friends.
  • Encourage the mother to:
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    Get help with caring for other children and doing household duties.

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    Breastfeed lying down to conserve energy, when possible.

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    Eat a varied diet and take care of herself.

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    Try to spend time alone with each of the babies so that she can get to know them individually.

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Show slide 10/4: Twins. Use a doll to demonstrate positions also

  • A mother of twins may prefer to feed each baby separately so that she can concentrate on the positioning and attachment. When the babies and mother are able to attach well, then the mother can feed them together if she wishes to reduce feeding time.
  • If one baby is a good feeder and one baby less active, make sure to alternate breasts so that the milk production remains high in both breasts. The baby who feeds less effectively may benefit from breastfeeding at the same time as the baby who feeds more effectively, thereby stimulating the oxytocin reflex.

Breastfeeding a baby and older child

  • There is generally no need to stop breastfeeding an older baby when a new baby arrives. The mother will produce enough milk for both is she is cared for herself, which includes eating well and resting.
  • Whether there is a shortage of food in the family or not, breast milk may be a major part of the young child’s diet. If breastfeeding stops, the y0ung child will be at risk, especially if there are no animal foods in the diet. Feeding the mother is the most efficient way of nourishing the mother, the new baby, and the young breastfeeding toddler. Abrupt cessation of breastfeeding should always be avoided.

3. Prevention and management of common clinical concerns

10 minutes

  • Many instances of hypoglycaemia, jaundice and dehydration can be avoided by implementing practices such as:
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    Early skin-to-skin contact to provide warmth for the baby.

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    Early and frequent breastfeeding.

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    Rooming-in so that frequent feeding is easy.

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    Encouraging milk expression and cup feeding if baby is unable to breastfeed effectively because he/she is too weak or sleepy.

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    Do not give water to the baby. Water is not effective at reducing jaundice and may actually increase it.

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    Observe all babies in the first few days to ensure that they are learning to suckle well.

Hypoglycaemia of the newborn

  • Hypoglycaemia means a low blood glucose level. Babies who are born prematurely or small for gestational age, who are ill or whose mothers are ill may develop hypoglycaemia.
  • There is no evidence to suggest that low blood glucose concentrations in the absence of any signs of illness are harmful to healthy, full term babies.
  • Term, healthy babies do not develop hypoglycaemias simply through under-feeding. If a healthy full term baby develops signs of hypoglycaemia, the baby should be investigated for another underlying problem.

Jaundice

  • It is common for babies to have a yellow colour (jaundice) to their skin in the first week of life due to high levels of bilirubin in the blood. The colour is most easily seen in the white part of the eyes. Colostrum helps infants to pass the meconium, and this removes excess bilirubin from the body.

Dehydration

  • Healthy exclusively breastfed infants do not require additional fluids to prevent dehydration.
  • Babies with diarrhoea should be breastfed more frequently. Frequent breastfeeding provides fluid, nutrients, and provides protective factors. In addition the growth factors in breast milk aid in the re-growth of the damaged intestine.

Babies who have breathing difficulties

  • Babies with breathing difficulties should be fed small amounts frequently as they tire easily. Breastfeeding provides the infant with nutrients, immune bodies, calories, fluid and comforts the distressed baby and mother.

The baby with neurological difficulties

  • Many babies with Down’s syndrome or other neurological difficulties can breastfeed. If the baby is not able to breastfeed, breast milk is still very important. Some ways to assist include:
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    Encourage early contact and an early start to feeding.

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    The baby may need to be awakened for frequent breastfeeds and stimulated to remain alert during feeding.

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    Help the mother to position and attach the baby well.

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    It may help if the mother supports her breast and her baby's chin to stabilise the baby's jaw and maintain good attachment throughout the feed. She can gently cup the baby's chin between her thumb and first finger, and cup the remaining three fingers under her breast.

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Show slide 10/5 and 10/6: Picture of DANCER hand position. Baby in slide 10/6 has Down’s Syndrome

  • In addition,
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    Feedings may take a long time regardless of feeding method. Help the mother to understand that it is not breastfeeding of itself that is taking time.

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    The mother may need to express her milk and feed it to her baby in a cup.

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    Avoid artificial teats and pacifiers as these babies may find it very difficult to learn to suck from both a breast and an artificial teat.

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    Some babies with neurological difficulties gain weight slowly even if they receive enough breast milk.

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    Some babies with neurological difficulties may have other health challenges, e.g. cardiac problems.

4. Medical reasons for food other than breast milk

10 minutes

  • Sometimes breastfeeding is not started or it is stopped without a clear medical indication. It is important to distinguish between:
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    Babies who cannot be fed at the breast but for whom breast milk remains the food of choice.

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    Babies who should not receive breast milk, or any other milk, including the usual breast-milk substitutes.

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    Babies for whom breast milk is not available, for whatever reason.

  • Babies who cannot feed at the breast may be fed expressed milk by tube, cup, or spoon. Ensure the baby gets the hind milk that has a high fat content to help the baby grow.
  • A very few babies may have inborn errors of metabolism such as galactosemia, PKU, or maple syrup urine disease. These infants may require partial or complete feeding with a special breast-milk substitute, which is appropriate to their specific metabolic condition.
  • The mother may be away from the baby, severely ill, have died, or is HIV-positive and made an informed decision not to breastfeed. These babies will need replacement feeding. Situations related to maternal health that may require food other than breast milk will be discussed in a later session42.
  • Babies with medical conditions that do not permit exclusive breastfeeding need to be seen and followed-up by a suitably trained health worker. These infants need individualized feeding plans and the mother and family needs to be clear how to feed their baby.
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Give handout: Does the baby need breast-milk substitutes? Discuss any points as needed.

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Ask if there are any questions. Then summarise the session.

Session 10 Knowledge Check

Jacqueline has a 33-week preterm baby in the special care nursery. It is very important that her baby receive her breast milk. How will you help Jacqueline get her milk started? How will you help her with putting the baby to her breast after a few days?

Yoko gives birth to twin girls. She fears she cannot make enough milk to feed two babies and that she will need to give formula. What is the first thing you can say to Yoko to help give her confidence? What will you suggest for helping Yoko breastfeed her babies?

Session 10. Summary

Infants who are preterm, low birth weight, ill or have special needs

  • Breast milk is important for babies who are preterm, low birth weight or have special needs. It protects, provides food, and aids in growth and development.
  • The approach to feeding will depend on the individual baby and his or her condition. Overall, care can be divided into categories based on the baby’s ability to suckle:
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    Baby not able to take oral feeds. Encourage the mother to express her milk to keep up her supply for when her baby can take oral feeds. If possible freeze her expressed breast milk and use it later.

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    Baby able to take oral feeds but is not able to suckle at the breast. Give expressed milk by tube and by cup if baby is able.

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    Baby able to suckle but not for full feeds. Let baby suckle whenever baby is willing. Frequent short feeds may tire the baby less than long feeds at long intervals. Give expressed milk by cup or tube in addition to what the baby can suckle.

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    Baby can suckle well. Encourage frequent feeds for milk, for protection from infection, and for comfort.

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    Baby is not able to receive breast milk. For example, if the baby has a metabolic disease such as galactosemia, and needs a specialized formula.

  • Take care of the mother with fluid, food, rest, and help her to be in close contact with her baby.
  • Expect that the baby will pause frequently to rest during the feed. Plan for quiet, unhurried, rather long breastfeeds. Avoid loud noises, bright lights, stroking, jiggling or talking to the baby during feeding attempts.
  • Prepare the mother and baby for discharge by rooming-in, encouraging skin-to-skin contact, allowing time to learn to breastfeed and recognise feeding signs (cues), and to know how to get help when at home.
  • Arrange early follow up for any baby that has special needs.

Breastfeeding more than one baby

  • Mothers can make enough milk for two babies, and even three. The key factors are not milk production, but time, support and encouragement from health care providers, family, and friends.

Prevention and management of common clinical concerns

  • Implementing practices such as early skin-to-skin contact, early and frequent breastfeeding, rooming-in, and milk expression and cup feeding if the baby is sleepy or weak and avoiding water supplements can avoid many instances of hypoglycaemia, jaundice and dehydration.

Medical indications for food other than breast milk

  • Infants with medical conditions that do not permit exclusive breastfeeding need to be seen and followed-up by a suitably trained health worker.

Does the baby need breast-milk substitutes?

Exclusive breastfeeding in the first six months of life is the norm, and is particularly beneficial for mothers and infants. Nevertheless, a small number of health conditions of the infant or the mother may justify recommending that she does not breastfeed temporarily or permanently. These conditions concern very few mothers and their infants.

It is useful to distinguish between:

  • Infants who should not receive breast milk or any other milk except specialized formula.
  • Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period.

Infants who should not receive breast milk or any other milk except specialized formula may include infants with certain rare metabolic conditions such as galactosemia who may need feeding with a galactose free special formula, or Maple syrup urine disease: a special formula free of leucine, isoleucine and valine is needed, or phenylketonuria where a special phenylalanine-free formula is needed (some breastfeeding is possible, under careful monitoring).

Infants for whom breast milk remains the best feeding option but who may need other food in addition to breast milk for a limited period This group may include very low birth weight infants (those born weighing less than 1500 g) very preterm infants, i.e. those born less than 32 weeks gestational age, newborn infants who are at risk of hypoglycaemia by virtue of impaired metabolic adaptation or increased glucose demand (such as those who are preterm, small for gestational age or who have experienced significant intrapartum hypoxic/ischaemic stress), those who are ill and those whose mothers are diabetic if their blood sugar fails to respond to optimal breastfeeding or breast milk feeding.

Additional information for Session 10

Using expressed breast milk

  • Milk from a mother giving birth preterm contains more protein, sodium and calcium than full term milk. Preterm infants often need extra protein, so this is helpful.
  • Breast milk with an energy value of 65 kcal/100 ml at a volume of 200 ml/kg/day will result in an energy intake of 130 kcal/day. If the mother has more milk than her baby needs, the expressed breast milk can be left to stand for a short while and the fat rich hind milk will rise to the top. The ‘cream’ can be added to the regular milk feed, which will make it even higher in energy value.
  • Some units add fortifiers and formula to the breast milk in order to make the baby grow more quickly. The long-term effect of early rapid growth is not known. These additions to her breast milk can make the mother worry that her milk is not good enough for her baby. Reassure her that her milk is good for her baby. If there is a medical need for additions to the breast milk, explain that for a short period her baby has extra needs.
  • If both breast milk and formula are given, the formula will be better absorbed if it is mixed with the breast milk rather than giving alternate feeds of formula or breast milk. Additions to breast milk should be decided for each individual infant, not a standard policy for all infants in the unit43.

Hypoglycaemia of the newborn

  • Babies fed on breast milk may be better able to maintain their blood glucose levels than babies artificially fed on formulas. Babies compensate for low blood sugar by using their body fuels (e.g. glycogen stored in the liver).
  • Term, healthy babies do not develop hypoglycaemia simply through under-feeding. If a healthy full term baby develops signs of hypoglycaemia, the baby should be investigated for an underlying problem. Signs of hypoglycaemia include reduced level of consciousness, convulsions, abnormal tone (‘floppy’), and apnoea. A doctor should see any baby with these signs immediately.

Physiological jaundice

  • This is the commonest kind of jaundice, and does not indicate an illness in the baby. It usually appears on the second or third day and clears by the tenth day. The fetal red blood cells, which are not needed by the baby after birth, break down faster than the baby’s immature liver can handle. As the baby’s liver matures, jaundice decreases. Bilirubin is mainly excreted in the stools, not in the urine; therefore water supplements do not help to reduce the level of bilirubin.
Prolonged jaundice
  • Sometimes jaundice may persist for three weeks to three months. The baby should be checked to rule out abnormal jaundice. In an infant who is breastfeeding well with a good weight gain and only a mild level of jaundice, prolonged jaundice is rarely a problem.

Abnormal or pathological jaundice

  • This type of jaundice is not usually related to feeding, and is evident at birth or within the first day or two. Usually the baby is ill. Breastfeeding should be encouraged, except in the very rare metabolic condition of galactosemia.

Treatment of severe jaundice

  • Phototherapy is used in severe jaundice to breakdown the bilirubin. Very frequent breastfeeding is important to avoid dehydration. Give expressed milk if the baby is sleepy. Water or glucose water supplements do not help as they reduce the intake of breast milk and do little to reduce the jaundice.

Cardiac problems

  • Babies may tire easily. Short frequent feeds are helpful. The baby can breathe better when breastfeeding. Breastfeeding is less stressful and less energy is used so there is better weight gain. Breast milk provides protection from illness thus reducing hospitalization and helping growth and development.

Cleft lip and palate

  • Breastfeeding is possible, even in extreme cases of cleft lip/palate. As babies with clefts are at risk for otitis media and upper respiratory infections, breast milk is especially important.
  • Hold the baby so that his or her nose and throat are higher than the breast. This will prevent milk from leaking into the nasal cavity, which would make it difficult for the baby to breathe during the feed. Breast tissue or the mother’s finger can fill a cleft in the lip to help the baby maintain suction.
  • Feedings are likely to be long. Encourage the mother to be patient, as the baby tires easily and needs to rest. The mother probably will need to express her milk and supplement. She can feed expressed milk with a cup or breastfeeding supplementer44. Following surgery to repair the cleft, breastfeeding can resume as soon as the baby is alert.

Infants requiring surgery

  • Breast milk is easily digested so requires a shorter fasting time than formula milk or other foods. In general, the baby should not need to fast for more than three hours. Discuss with the parents ways of comforting the baby during the fasting period. Breastfeeding can usually commence as soon as the baby is awake after the surgery.
  • Breastfeeding soon after surgery helps with pain relief, comforts the baby and provides fluid and energy. If the baby is not able to take large amounts of breast milk immediately, the mother can express and let the baby suck on an ‘empty breast’ until the baby is more stable.

Footnotes

40

The term special care baby unit is used for any area that provides care for babies that are ill or have special needs. This unit may be part of the maternity unit or part of the paediatric unit or in a different hospital from the maternity unit.

41

Milk expression and cup feeding are discussed in Session 11.

42

Further information on maternal health concerns and breastfeeding is in Session 13.

43

Mothers who are HIV-positive should either exclusively breastfeed or exclusively formula-feed rather than do mixed feeding.

44