Collaborative Approach to Breastfeeding Supplementation

Transcription

1 Collaborative Approach to Breastfeeding Supplementation Disclosures Dr. Bastek serves as a member of the Speakers Bureau for Mead Johnson Nutritionals She has no financial interests in the production or sales of infant formula or nutritional supplements. Tara K. Bastek, MD, MPH Art of Breastfeeding Conference October 3, 2016 Quality Improvement PDSA Cycles P = Plan D = Do S = Study A = Act PDSA 1 The Problem Winter Newborn services increasingly consolidated under fewer providers >50% newborns seen by WPP Neonatology Huge variation seen Indication/Timing Volume Product Request to develop protocol to standardize Sources Academy of Breastfeeding Medicine 20Supplementation.pdf Protocol #3 Supplementing Term Infant Protocol #10 Supplementing Pre-term Infant Effect of Early Limited Formula on Duration and Exclusivity of Breastfeeding in At-Risk Infants: An RCT Flaherman

2 Spring 2014 Spring 2014 ABM Guidelines Supplementation is NOT INDICATED for: Sleepy infant with fewer than 8-12 feedings in first hours with <7% weight loss and no signs of illness Healthy, term, AGA infant with bilirubin levels <18 mg/dl after 72 hours of age when the baby is feeding well, stooling, and weight loss is <7% Fussy infant Tired and sleepy mother ABM Recommendations Skin to skin Antenatal education and in-hospital support to support exclusive breastfeeding Healthy newborns do not need supplemental feedings for poor feeding for the first hours Babies who are too sick to breastfeed or whose mothers are too sick to breastfeed are likely to require supplementation ABM Hospital Guidelines for Supplementary Feedings of the Healthy Term Breastfed Neonate. Breastfeeding Medicine (2009). Volume 4, Number 3 ABM Hospital Guidelines for Supplementary Feedings of the Healthy Term Breastfed Neonate. Breastfeeding Medicine (2009). Volume 4, Number 3 ABM Recommendations Indications Spring 2014 Supplemental feedings should be documented Content, volume, method and medical indication If mother-baby separation is unavoidable, established milk supply is poor or questionable, or milk transfer is inadequate, mother should be encouraged to pump or manually express milk When supplementation is necessary, the primary goals are to feed the baby, maximize maternal milk supply, and determine cause of poor feeding Mothers should express milk each time the baby receives a supplemental feeding (q 2-3 hrs) ABM Hospital Guidelines for Supplementary Feedings of the Healthy Term Breastfed Neonate. Breastfeeding Medicine (2009). Volume 4, Number 3 2

3 ABM Recommendations ABM Recommendations Evaluate all infants for position, latch and milk transfer prior to the provision of supplemental feedings Most babies who remain with their mothers and breastfeed adequately lose <7% of their birth weight Weight loss >7% may be an indication of inadequate milk transfer or low milk production Notify caregiver if infant shows signs of illness, weight loss is >7%, or if the mother-infant dyad has risk factors Maternal illness, infant with inborn error of metabolism, infant unable to feed due to illness of congenial malformation, and maternal medications ABM Hospital Guidelines for Supplementary Feedings of the Healthy Term Breastfed Neonate. Breastfeeding Medicine (2009). Volume 4, Number 3 Evaluate all infants for position, latch and milk transfer prior to the provision of supplemental feedings Most babies who remain with their mothers and breastfeed adequately lose <7% of their birth weight Weight loss >7% may be an indication of inadequate milk transfer or low milk production Notify caregiver if infant shows signs of illness, weight loss is >7%, or if the mother-infant dyad has risk factors Maternal illness, infant with inborn error of metabolism, infant unable to feed due to illness of congenial malformation, and maternal medications ABM Hospital Guidelines for Supplementary Feedings of the Healthy Term Breastfed Neonate. Breastfeeding Medicine (2009). Volume 4, Number 3 ABM Guidelines: Indications for Supplementation Infant Indications Asymptomatic hypoglycemia documented by laboratory blood glucose that is unresponsive to appropriate frequent breastfeeding Clinical and laboratory evidence of significant dehydration (e.g., 10% weight loss, high sodium, poor feeding, lethargy, etc.) that is not improved after skilled assessment and proper management of breastfeeding Weight loss of 8 10% accompanied by delayed lactogenesis II ABM Guidelines: Indications for Supplementation Infant Indications Asymptomatic hypoglycemia documented by laboratory blood glucose that is unresponsive to appropriate frequent breastfeeding Clinical and laboratory evidence of significant dehydration (e.g., 10% weight loss, high sodium, poor feeding, lethargy, etc.) that is not improved after skilled assessment and proper management of breastfeeding Weight loss of 8 10% accompanied by delayed lactogenesis II ABM Guidelines: Indications for Supplementation Infant Indications Asymptomatic hypoglycemia documented by laboratory blood glucose that is unresponsive to appropriate frequent breastfeeding Clinical and laboratory evidence of significant dehydration (e.g., 10% weight loss, high sodium, poor feeding, lethargy, etc.) that is not improved after skilled assessment and proper management of breastfeeding Weight loss of 8 10% accompanied by delayed lactogenesis II ABM Late-Preterm Recommendations 2. On-going care - 3

4 Indications Spring 2014 ABM Guidelines: Possible Indications for Supplementation Infant Indications Delayed bowel movements or continued meconium stools on day 5 Insufficient intake despite an adequate milk supply (poor milk transfer) Hyperbilirubinemia Macronutrient supplementation indicated Guidelines for phototherapy in hospitalized infants of 35 or more weeks gestation.note: These guidelines are based on limited evidence and the levels shown are approximations. Subcommittee on Hyperbilirubinemia Pediatrics 2004;114: ABM Guidelines: Possible Indications for Supplementation Maternal indications: Delayed lactogenesis II and inadequate intake by the infant Retained placenta Sheehan s syndrome (postpartum hemorrhage followed by absence of lactogenesis) Primary glandulary insufficiency Breast pathology or prior breast surgery resulting in poor milk production Intolerable pain during feedings unrelieved by interventions 2004 by American Academy of Pediatrics Volume Spring 2014 Volume Spring

5 Effect of Early Limited Formula on Duration and Exclusivity of Breastfeeding in At-Risk Infants: An RCT Concern their milk supply is insufficient Most common reason given by mothers for discontinuing breastfeeding before 3 months Hypothesis: Adding early use of limited volumes of formula in addition to breastfeeding before the onset of mature milk production would decrease breastfeeding discontinuation ELF Population Flaherman, V., Aby, J., Burgos, A., Lee, K., Cabana, M., & Newman, T. (2013). Pediatrics, 131(6), Flaherman, V., Aby, J., Burgos, A., Lee, K., Cabana, M., & Newman, T. (2013). Pediatrics, 131(6), ELF Protocol ELF Results Enrolled hours if lost >5% birthweight ELF Group 10mL of formula by syringe after breastfeeding Control Group No supplement and taught soothing techniques Flaherman, V., Aby, J., Burgos, A., Lee, K., Cabana, M., & Newman, T. (2013). Pediatrics, 131(6), Formula Spring 2014 Why that order? Fully hydrolyzed protein less impact on microbiome Milk Bank - limited supply Stewards of scarce resources 5

6 Spring 2014 Spring 2014 Supplementation Protocol Goals Improve consistency among ordering providers Increase nursing autonomy Follow the Academy of Breastfeeding Medicine supplementation guidelines Improve discharge feeding plans for infants who are discharged home <48 hours of life (before mother s milk supply is established) Incorporate ELF (early limited formula) study into guidelines Supplementation Protocol: Successes Improved nursing awareness re: supplementation indications Education about why >7% weight loss matters, why persistent hypoglycemia is a probem Supplementation initiated earlier Begun when weight done, not waiting until next morning Improved supplementation in the late preterm population Earlier focus on initiating breastfeeding/pumping Nutramigen use instead of Enfamil (per ABM guidelines) PDSA 2 The Revision Supplementation Protocol: Challenges Nutramigen 1st choice VS Pumped maternal breast milk VS donor breast milk Weight threshold 7% or greater? Different weight loss limits for different scenarios (eg., cesarean deliveries)? Confusion re: supplementation volume Protocol is NOT mandatory Inconsistent use WHO/UNICEF Baby-Friendly Hospital Initiative 6

7 Changing Times Nov 2015 Large Journal Club Conference LCs, Neos, NNPs, PNPs, Nurse Management, Nursing Leadership Women s Services, Neonatal Nutritionist Led by LC and Neo Discussed Challenges Reviewed Literature 3 campus similarities/differences Update on Milk Bank renovation and capacity Common Ground NON-SEPARATION is #1 priority More than one method can achieve same goals Flexibilty within reasonable parameters When in doubt, person-to-person communication is key WakeMed Supplementation Protocol Protocol Winter 2016 Indications Milk Volume Indications Winter 2016 Indications Winter

8 Indications Winter 2016 Indications Winter 2016 Indications Winter 2016 Bilirubin and Other Indications sections unchanged Volume Winter 2016 Volume - Winter 2016 No Change Average Reported Intakes of Colostrum by Healthy Breastfed Infants per Feed 1 st 24 hours: 2-10 ml hours: 5-15 ml hours: ml hours: ml WM Recommendations GOAL: Avoid overfeeding Up to 10mL if 1st 24 hrs Up to 15mL if hrs Up to 30mL if >48 hrs 8

9 Milk Winter 2016 Milk Winter Expressed Breast Milk/Colostrum 2. Donor Breast Milk** 3. Nutramigen 4. Enfamil (20kcal vs. 22kcal) 5. Prosobee if infant has NAS ** - If Milk Bank has supply. Presumption is yes and notification if cannot meet need. Milk Winter 2016 Anything other than maternal milk is approached same as a MEDICATION Given for specific indication Given in specific amounts Given for a specific length of time Given education for specific s/sx of failure, specific s/sx of success, and expected natural history of clinical condition PDSA 3 The Refinement On-Going Challenges Mixed population/demographics at 3 sites Increasing percent of high-risk OB moms Growing MFM service generating more Mom- Baby dyads with concerns Disparities in LC Staffing among sites Baby Friendly Hospital Initiative application Baby Friendly Initiative Step 1: Written breastfeeding policy that is routinely communicated to all health care staff Step 2: Train all health care staff in the skills necessary to implement breastfeeding policy Step 3: Inform all pregnant women about the benefits and management of breastfeeding Step 4: Help mothers initiate breastfeeding within one hour of birth Step 5: Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants Step 6: Give infants no food or drink other than breast milk unless medically indicated 9

10 Baby Friendly Initiative Step 1: Written breastfeeding policy that is routinely communicated to all health care staff Step 2: Train all health care staff in the skills necessary to implement breastfeeding policy Step 3: Inform all pregnant women about the benefits and management of breastfeeding Step 4: Help mothers initiate breastfeeding within one hour of birth Step 5: Show mothers how to breastfeed and how to maintain lactation even if they are separated from their infants Step 6: Give infants no food or drink other than breast milk unless medically indicated Baby Friendly Initiative Step 6 Exceptions Medical conditions where breast milk is contraindicated 1. Classic galactosemia 2. Maple syrup urine disease 3. Phenylketonuria Baby Friendly Initiative Step 6 Exceptions Limited supplementation is allowed in the following conditions: 1. VLBW (<1500 g) 2. Very preterm infants (<32 weeks) 3. Newborn infants who are at risk for hypoglycemia if their blood sugar fails to respond to optimal breastfeeding/breast-milk feeding Impaired metabolic adaption for gestational age Intrapartum hypoxic/ischemic stress Sick Infants of diabetic mothers Baby Friendly Initiative Step 6 Exceptions Mothers who may need to avoid breastfeeding temporarily: HSV-1 Maternal medications: sedating psychotherapeutic drugs, anti-epileptic drugs and opioids, radioactive iodine-131 Mothers who may need to avoid breastfeeding: HIV infection Baby Friendly Initiative Step 6 Exceptions Mothers who can continue breastfeeding, although health problems may be of concern: Breast abscess Hepatitis B Hepatitis C Mastitis Tuberculosis Substance use: nicotine, alcohol, ecstasy, amphetamines, cocaine, benzodiazepines and cannabis 10