Baby Friendly Hospital Initiative in Neonatal Units Expansion of the original WHO/UNICEF BFHI program

Transcription

1 Baby Friendly Hospital Initiative in Neonatal Units Expansion of the original WHO/UNICEF BFHI program A developmentally supportive family centered breastfeeding strategy Soins de développement en néonatologie. Pourquoi? Comment? 9 May 2012, Brussels Kerstin Hedberg Nyqvist RN, PhD, Associate Professor Department of Women s and Children s Health Uppsala University, Uppsala, Sweden,

2 WHO/UNICEF BFHI BFHI. Ten steps to successful breastfeeding Global Strategy for Infant and Young Child Feeding: 6 months exclusive breastfeeding Continued breastfeeding first 2 years World Health Organization/UNICEF. BFHI. Revised, Updated and Expanded for Integrated Care. Neonatal care: Standards etc. not specified

3 Nordic and Quebec (Canada) Expert Group Draft for the 1 st international Conference and Workshop on the Expansion of the BFHI in Neonatal Units 14 TH -16 TH September 2011 in Uppsala, Sweden 10 Steps + 3 Guiding Principles Status of the document: presently informal. Will be presented for UNICEF in June 2012 Aim Uniform evidence-based standards/systems for breastfeeding support to mothers of infants who require neonatal care

4 Breast milk benefits for preterm infants Tolerate full enteral feeding earlier Absorption of nutrients Reduced risk for NEC, septicemia Intelligence (brain development: higher Bayley Scale Developmental Index - memory, habituation, problem solving, language, gross and fine motor movements Lower blood pressure in later life Reduced risk of metabolic syndrome Morley et al., 2004

5 Breastfeeding = Nutrition and also Infant s perspective: Attachment, self-regulation Mother s perspective: Bonding, becoming a mother

6 Breastfeeding: marker of good motherhood Breastfeeding = becoming a mother Risk: Mother interprets hospital feeding practices as: Breastfeeding = obligation to transfer a certain volume of milk Unability to succeed in lactation and breastfeeding: failure and shame Personal attention, empathy. Informed decision All mothers of preterm/ill newborn infants = vulnerable Lupton & Fenwick ; Nyqvist & Kylberg

7 Guiding principle 1: Staff approach to the mother must have a focus on the individual mother and her situation Delayed development of maternal identity: not passed all phases in becoming a mother. Preterm birth: crisis, traumatic experience, posttraumatic stress. Bonding problems: consequences for long-term mother-infant relationship

8 Standards GP 1 Treat every mother with sensitivity, empathy and respect for her maternal role. Special attention to particularly vulnerable mothers (families) Show respect to mothers who decide/advised not to breastfeed, or do not reach breastfeeding goal

9 Guiding principle 2: Provide family centered care and environment. UN Convention on the Rights of the Child Art. 9: A child shall not be separated from his/her parents against their will. Parents: most important persons in the infant s life infant s primary caregivers Nurse: Also coach, educator, substitute

10 Division: parent nurse roles

11 Intensive care nursery Environment: supports parents presence 24/7 involvement in infant care Privacy Adapted illumination Low sound level, calm Family room

12 Parent: Infant s care space during medical and nursing care Cardiac ultrasound Extubation

13 Parents daily life Prepare meals eat, meet other parents Communicate with family, friends, work place

14 Siblings, relatives: Welcome, participate in infant s care

15 Parent: Primary caregiver Early transfer of infants care to the parents Freedom of choice : tasks, advancement of taking over care Father: Mother s supporter, helps mother cope with breastfeeding Infant s caregiver

16 NIDCAP When the Neonatal Individual Developmental Care Assessment program principles are used during breastfeeding it supports the infant s breastfeeding behaviour

17 Standards GP 2 Encourage the father s/family s presence without unjustified restrictions The NICU transfers infant s care gradually to parents, ASAP after birth, with support by professionals. provides - parents with a place to rest and eat - environment: appropriate for infants, parents; facilitates breastfeeding.

18 Guiding principle 3: Ensure continuity of care Phases Prenatal care: parents anticipate arrival of infant Birth - delivery room stabilization. Admission to NICU - transport to another hospital. Hospital care: intensive intermediate care Back transfer to local hospital - continued care. Pre-discharge preparatory phase Early discharge: home care Discharge to home (intensive care at home) Follow-up

19 Phases in lactation and breastfeeding Mother: Initiate of lactation Attain - maintain adequate milk production Initiate breastfeeding Transition phase: feeding methods, nutrition policies that support breastfeeding Attain her breastfeeding goals (ideally exclusive breastfeeding)

20 Continuity Preterm/ill infants - cared by several care providers who may work at cross purposes Continuity = consistent care: infant s, mother s / family s needs

21 Shared policies and guidelines Infant care Parents role Parent education Policies shared by infant s all caregivers All adhere (no conflicting information/advice). Caregivers know infant s medical history current care plan

22 Standards GP 3 All health care providers involved in lactation and breastfeeding support collaborate. Consistent lactation and breastfeeding support during each phase of health care delivery

23 Step 1: Have a written breastfeeding policy that is routinely communicated to all health care staff Healthy term babies Compliance with BFHI 10 Steps: Number of BFHI steps implemented in a hospital breastfeeding duration + exclusivity Neonatal care Implementation of BFHI in delivery/postpartum units breastfeeding rates in NICU

24 Standards Step 1 NICU has a written breastfeeding/feeding policy (10 Steps, 3 Guiding Principles, Kangaroo Mother Care) Implementation of 10 Steps, 3 GPs. adheres to International Code of Marketing of Breastmilk Substitutes. available to all clinical staff summaries visibly posted language(s) and wording commonly understood by mothers/staff all mothers get breastfeeding/feeding support

25 Step 2: Educate and train all staff in the specific knowledge and skills necessary to implement this policy. Lactation, breastfeeding, breast milk: omitted from curricula in basic training of doctors, nurses Increase knowledge and skills Mandatory in-service training Change attitudes: Difference breast - bottle-feeding Necessary allocate staff time to breastfeeding support Avoid inconsistent/inaccurate information

26 Standards Step 2 All clinical NICU staff: familiar with the policy basic knowledge in lactation/breastfeeding support Plan for education/training of all new staff members (all professions) - 20 h. education - at last 3 h. supervised clinical training (WHO) regular continuing education.

27 Step 3 Inform hospitalized pregnant women at risk for preterm delivery or birth of an ill infant about the management of lactation and breastfeeding and benefits of breastfeeding. Antenatal classes Breast milk benefits, breastfeeding techniques, lactation - breast pump Prenatal consultation Benefits of breastmilk Information given hours, days before delivery: critical importance

28 Standards Step 3 Clinical NICU staff visit hospitalized pregnant women when infant will be transferred to NICU inform about parents access to NICU, importance of their presence, KMC, stimulation of early lactation, benefits for infant, early infant competence at the breast Written information Guideline for information to mothers/parents Given information is documented

29 Step 4 Encourage early, continuous and prolonged motherinfant skin-to-skin contact (Kangaroo Mother Care) without unwarranted restrictions. Early (as soon as possible after birth), Continuous (ideally 24 hours/day, 7 days/week) Prolonged (whole hospital stay / as needed to prevent hypothermia) mother/lbw infant (< 2500 g); also ill term infants In hospital + after discharge, Breastfeeding (ideally exclusive), Early discharge + adequate follow up.

30 KMC Effects Maternal and paternal identity Milk production Breastfeeding rate at discharge, also exclusive duration Infant development

31 Recommendations for KMC WHO Practical Guidelines (2003) High income settings: From 28 weeks, birth weight 600 g. WHO course: Essential Newborn Care (ENC)

32 Standards Step 4 Assure opportunities for mother/father or substitute to provide KMC: as early as possible, ideally from birth, without unjustified delay. as long periods per day as possible, without unjustified restrictions. Mothers who room in 24 h/d are supported in continuous KMC.

33 In delivery room In operating room (c section) Transport to NICU, in hospital With ventilator KMC clothing Adequate support by professionals No unfounded restrictions

34 Step 5. Show mothers how to initiate and maintain lactation and establish early breastfeeding with infant stability as the only criterion Breast milk expression: Within 6 hours, ~ 8 times/day Gentle breast massage Goal: >500 ml/day after 2 weeks Preterm: Root, latch, suck from 28 w, ingest milk ~ 29 w Extremely preterm: Free access to breast, frequent small feedings: exclusive breastfeeding from 32 w, md 35 w

35 Standards Step 5 Inform all mothers: expression (pump, hand) infant stability: only criterion for initiation of breastfeeding positioning indications of infant suckling well Special support to mothers with lactation problems

36 Step 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. Breast milk Species-specific All formulas differ markedly from it. Preterm infants: special benefits - host protection - developmental outcome Pasteurized, screened human donor milk If unavailable: Next best option preterm formula

37 Fortifier Use varies between/within countries Extremely low birth weight infants: Individualized fortification (protein and minerals) growth Indication controversial (short term benefits) Option: Increase milk volume >200 ml/kg / day Powdered fortifier compared to liquid: preferred by parents breastfeeding duration BUT interferes with breastfeeding after discharge

38 Standards Step 6 Newborns: no food or drink other than breast milk, unless medically indicated Inform mother about prescription of fortification : mother s own milk = optimal nutrition No promotion material or group discussions on formula (Code) Mothers who do not /unable to breastfeed or breastfeed partly: - support decision - individual counseling about safe preparation of formula and feeding

39 Step 7. Enable mothers and infants to remain together 24 hours a day UN Convention on the Rights of the Child Article 9: Infants shall not be separated from their parents against their will. Bonding attachment Parent empowerment Breastfeeding Ideally rooming-in: Offer opportunity: Single care room In nursery

40 Standards Step 7 NICU policy: Parent-infant non-separation Mothers and infants together. If not: justifiable reasons (infant surgery, maternal illness/treatment, family reasons) NICU provides possibilities for mothers/parents to stay with infant as long as they want.

41 Policy of non-separation

42 Step 8. Encourage demand feeding or, when needed, encourage semi-demand breastfeeding as a transitional strategy for preterm and ill infants Demand feeding: baby led (term infant) Semi-demand breastfeeding: Prescription of total daily milk volume only Breastfeeding at infant signs of interest + mother actively offers infant the breast (not fixed times + volumes) Strategies for reduction of supplementation: Test weighing or gradual reduction

43 Standards Step 8 Feeding process: (semi-demand demand, tube breast) guided by infant s competence and stability, not PMA, age Strategy for reduction of supplementation: selected by mother No routine administration of milk after each breastfeed Care, procedures, medications: scheduled not to disturb breastfeeding

44 Step 9. Use alternatives to bottle feeding at least until breastfeeding is well established and only use pacifiers and nipple shields for justifiable reasons Cup - bottle: Cup = higher breastfeeding rates at discharge Breast bottle: Oral movements differ Cup + breast: Same oral muscles Bottle: Chewing muscles Bottle: Lower saturation, tc po 2, desaturations

45 Cup: From ~ 29 weeks Tube feeding

46 Pacifier pain relief stress and anxiety reduction (self-regulation) infant relaxed during tube feeding Nipple shield: helpful for preterm and ill infants sucking milk transfer

47 Standards Step 9 Not introduce bottles to breastfed infants unless justifiable reasons discussion with mother mother s approval Use, recommend and teach parents to use tube, cup (instead of bottle) before breastfeeding is fully established 1st oral feeding experience should be at the breast.

48 Pacifiers: For appropriate reasons while infant is in the NICU Parents are informed: appropriate reasons for use of pacifier in NICU alternative ways of soothing the infant how to minimize use at home Nipple shields: when justifiable reasons

49 Step 10. Prepare parents for continued breastfeeding and ensure access to support services/groups after hospital discharge Make parents confident in feeding before discharge Information: Where obtain lactation/breastfeeding support: Feeding plan with mother, support, follow-up Infant is discharged before breastfeeding is established: Plan for attaining full breastfeeding Most vulnerable period for breastfeeding: 1st month after discharge Mobile phone, video-conference, Skype

50 Standards Step 10 Plan discharge in collaboration with family and health care support system. Give mother oral + written information: where breastfeeding peer support after discharge Hospital fosters establishment and coordinates activities with - breastfeeding support groups - networks for parents of infants treated in neonatal care.

51 Baby Friendly Neonatal Care Thank you for your attention