Episode 197

In todays show, we will talk about babies who are born too early. We will discuss premature babies,, near term babies or what the AAP is now using the term late preterm babies. And if you stick with me through the whole show, there is a gift at the end that will be quite meaningful to all of my listeners, but particularly those who have recently given birth to babies well before their 30th week gestation.

If you are anything like I was, there comes a point in your pregnancy, where you are like – if the baby wants to come now, I wil be f ine with this. Or, better still, where you are making deals w ith your baby – If you come out now, I promise to buy you whatever car you want when you are 16. As uncomfortable as you are, once you learn about feeding complications, along with health complications for babies born before the 37 week, you will be begging your baby to stay in a little longer

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Let’s first make the distinction between full term – born between 37 and 41 weeks gestation.

late preterm – defined by birth at 34 weeks 7 days through 36 weeks 7 days. They are less physiologically and metabolically mature than term infants. Thus they are at higher risk of morbidity and mortality than term infants. They are often the same size and weight of some term infants, born between 37 weeks and 41 weeks Because of this fact, late preterm infants may be treated by parents, caregivers and HCP as though they are developmentally mature, when in fact they are at an increased risk for complications. They need to be evaluated on an individual basis and if necessary suggest guidelines to identify and manage possible complications.

Premature – Infants born before 37 weeks gestation are considered premature and may be at risk for complications. This affects more than one out of every 10 infants born in the US. Advances in medical technology have made it possible for infants born as early as 23 weeks gestation (17 weeks premature) to survive. They are surviving, however they are at higher risk for death or serious complications, which include heart defects, respiratory problems, blindness and brain damage.

Before we go further, I want to say is that I am not a physician giving a lecture on the risk factors that are specific to premature and late preterm babies and how we evaluate and differentiate the two. This is more of a broader look at babies who are born before 37 weeks and the challenges they face with regards to feeding in general and how this affects their ability to breastfeed.

Along this same line of thinking, I would like to say is that for the purpose of this show, I am going to use the term premature babies most of the time and at other times, highlight the difference when I need to make an important point.

There are some common problems that premature and late preterm babies have are as follows:

1. Higher risk for jaundice
2. More prone to be diagnosed with apnea – is defined as the absence of breathing for more than 20 seconds. It can occur in full-term babies, but is more common in premature babies. The more prematurethe baby, the greater the chances that apnea will occur. Apnea may be followed by bradycardia, which is a decreased h eart rate.
3. More likely to have difficulty regulating their body temperature, blood pressure and heart rate
4. Their lungs, digestive system and nervous system, including the brain are underdeveloped therefore making them more vulnerable to complications.

When babies are born before full term, these problems make it difficult for them to have good feedings on their own, so they will frequently need help, at least until they are feeding well on their own.

Now we are going to get more detailed about how these risk factors leave your baby more vulnerable and how this, in turn, affects your breastfeeding relationship –

Let’s start with talking about one of the common complications of prematurity which is..

Jaundice, a common condition in newborns, refers to the yellow color of the skin and whites of the eyes that happens when there is too much bilirubin in the blood.

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Bilirubin (bill-uh-ROO-bin) is produced by the normal breakdown of red blood cells. Normally, it passes through the liver, which releases it into the intestines as bile (a liquid that helps with digestion).

Jaundice happens when bilirubin builds up faster than a newborn’s liver can break it down and pass it from the body.

To be clear, I am talking about basic jaundice in the newborn. Typically, the excess red blood cells bind with the stool and that is how the body rids itself of the excess red blood cells.

We want your baby to be feeding frequently enough to take in plenty of colostrum. We know that colostrum has a laxative effect. The milk binds with the bilirubin which is excreted through the stools.

Premature and some preterm babies are more susceptible to jaundice because their digestive systems are not fully developed. They may be poor feeders and this makes for poor elimination. This makes the passage of meconium slower, which increases circulation of those very same red blood cells that need to be excreted. Babies are born with large amounts of red blood cells needed for fetal growth. After birth, too many red blood cells because of difficulty eating and eliminating them is what causes jaundice. Because of underdeveloped digestive systems, poor feeds, premature and later term babies are at greater risk of jaundice then full term babies – who, if feeding poorly can still get jaundice. The excess red blood cells circulate freely in the bloodstream and can be deposited in the brain, skin, muscle tissue and mucous membranes. They can pass the blood brain barrier and have a toxic effect on nerve cells in the brain. This can be very dangerous. So we want to be sure that babies are receiving enough fluids to help with proper elimination.

Colostrum has a laxative effect and helps babies to stool, which helps with eliminating excess red blood cells.

Can you begin to understand the importance of recognizing a late preterm baby and the need to evaluate this baby. We would want to follow closely to ensure that they are getting enough food. We want to evaluate their feeding behavior to rule out any issues with regards to a weak or a poor suck or little to no interest in breastfeeding. We would not want parents to assume they have a good baby that sleeps well, with a baby that is too sleepy and not feeding well when awake. Premature babies may still have breastfeeding challenges, however, when properly evaluated, parents can be given accurate information to ensure they have a well fed baby. You will need to be more vigilant about feeding frequency and recognize the fact that you may not be able to follow a baby led feeding style, as this is when you totally let the baby decide when it is time to eat. When you have a baby that is sleepier and less energetic you have to lead a more parent led feeding style, until your baby is old enough, strong enough and feeding well on their own to rely on their cues.

Other complications with premature babies are:

Respiratory Distress Syndrome
necrotizing entercolitis
Intraventriular hemorrhage
APNEA
PATENT DUCTUS ARTERIOSUS
Retinopathy

RDS -The most common problem with RDS is that babies who have immature lungs. They have not developed a protective film that helps air sacs in the lungs to stay open – This is called surfactant. Extra oxygen can be supplied to the infant through tubes that fit into the nostrils of the nose, or by placing the baby under an oxygen hood. Sometimes the baby may receive air from a respirator or ventilator. Being like this makes it very difficult for mom to work on breastfeeding. She may not be able to try for days or weeks. When she does, it is for a specific period of time which is quite limited.

NEC – necrotizing enterocolitis – part of the baby’s intestines are destroyed as a result of a bacterial infection. It can be fatal if not diagnosed and treated quickly.

IVH – Intraventriular hemorrhage – condition which immature and fragile blood vessels within the brain burst and bleed into the hollow chambers normally reserved for cerebrospinal fluid and into the tissue surrounding them.

APNEA is a condition in which the infant stops breathing for periods lasting up to 20 seconds. it is often associated with a slowing of the heart rate. Some babies need medications to stimulate breathing or they may need oxygen through a tube inserted in the nose. or be placed on a ventilator.

PATENT DUCTUS ARTERIOSUS is a condition in which the duct that channels blood between two main arteries does not close after the baby is born. Normally this bypass duct closes within the first few hours after birth, however, in premature babies are at risk for this to not happen.

Premature babies are at greater risk to have retinopathy, which is a condition that results in blindness.

You may remember one of my running themes for the AAB show is to bring you information to help you make an informed decision and not shy away from bringing to you the “hard to hear” stuff” The stuff noone wants to talk to new parents about because it is scary and it makes you sound like gloom and doom, Who wants to hear about darkness during a time when we are happy and looking forward to a healthy full term baby and a wonderful joyous parenting life. None of us really wants to hear about the hard stuff and yet knowing the statistics, I take a different stance on this. While I do agree that dwelling on this information is not helpful, I do feel strongly that parents need to hear this information just so that you have an awareness that premature births do happen. You will not be totally taken off guard. You will have some tools in your toolkit to help you through the early days. Here are some recent statistics from the CDC which support why I think the subject of premature birth deserves more than no mention or a small mention to pregnant parents.

The preterm birth rate rose slightly in 2015 and about 1 out of 10 babies (10%) was born too soon in the United States. Additionally, racial and ethnic differences in preterm birth rates remain. In 2015, the rate of preterm birth among non-Hispanic black women (13%) was about 50% higher than the rate of preterm birth among non-Hispanic white women (9%).

The full report is linked in the show notes. The report is filled with lots of great information, including what you can do and what activities the CDC is engaged in to reduce preterm delivery and complications. We are also reminded more than ever, how important it is that our smallest babies have access to human milk as they are more susceptible to infections, particularly of their gut.

I am always fascinated by all the scientific details about human milk. Here is one that I think you will find of great interest too.

Studies have shown that the milk moms with premature babies produce, is more rich in proteins and has slightly different fats that are easier to digest and be absorbed, then later breastmilk. It’s specially designed to help a premature infant through those first difficult weeks. Their are differences in the minerals and iron in preterm milk than in term milk. Preterm babies fed human milk are less likely to develop intestinal infections such as NEC ( necrotizing enterocolitis like we talked about. Premature infants who receive human breastmilk have the best outcomes – medically, nutritionally and developmentally.

And yet, the struggles can range from minor to difficult in getting your baby to have your milk.
So, what can you do to help yourself and your baby.

How can mothers maximize their breastfeeding success when you are separated from your baby in the NICU

More than likely the hospital staff will have a team of specialists to help guide you. Do not be shy. Utilize this team of, yes admittedly are strangers to you now, but will soon become near and dear to you. Many parents say the staff becomes their lifeline. I know of many NICU staff who are the main reason parents can make it to the next day with their sanity intact. Giving birth early, particularly well before the 37th week is a shock to your system. You were not physically or emotionally prepared for any of this.

Because of all the well known and documented health benefits of human milk, more hospitals are accessing and encouraging parents to use donor milk if mom is not able to collect enough milk for her baby, just yet. More hospitals have partnerships with milk banks now then ever before. You can find this out ahead of time just by asking them. On Episode # I interviewed Julie with the NY Milk Bank. This 2 part interview is a wonderful testament to a group of people who understand the importance of human milk for human babies and in particular the importance of human milk for premature and sick babies. A small group of mighty motivated people worked hard to open the doors of the NYMB and you will really enjoy their story in Episode
AAB 114 Breastfeeding Part 1 interview with Julie Bouchet-Horwitz, FNP, IBCLC and Episodes #114

What are some of the ways that your baby can take your milk? This will depend on many variables and your baby will be evaluated for this. Remember that you are a partner in your babies health care and need to be updated every step of the way and part of the decision making process.

How early can your baby breastfeed? There are many variables. This depends on their diagnosis, are they sick, what gestational age they are at. If all is well you will be encouraged to try between 31 and 33 weeks because developmentally this is when a baby can begin to learn how to suck, swallow breathe, which is what happens during breastfeeding. Some babies who are born really early have limited or reduced sucking pads, also called cheek or fat pads or buccal pads. These buccal pads develop toward the end of pregnancy when other fat is forming on the baby’s body. The buccal pads are very important to breastfeed. They help a baby attain pressure needed within the mouth to properly feed. Without use of the buccal pads, babies tire easily, do interesting things with their tongue like thrusting or biting down. Your lactation consultant can share some techniques that might help with this.

Your baby may prove everyone wrong and actually breastfeed quite well. You may have enough milk and they are strong enough to transfer a full feeding right away and not need to be supplemented. If not, you will be encouraged to continue working on breastfeeding, supplementing, all while you are also pumping on a regular basis to build and increase your supply.

Even if your baby is breastfeeding well during the day, and yet still needs to be in the NICU, but you cannot be there 24/7, your baby will more than likely be bottlefed your pumped milk when you are not there. More variables here… Perhaps you have other children at home to tend to, perhaps there are your own health care concerns that preclude her from spending significant time in the hospital. You may not have transportation. She may not be able to drive herself and need to wait for another adult to drive her back and forth.

Another scenario could be that your baby is not strong enough to bare breastfeed, but does really well with a nipple shield, which is a silicone teat placed over your nipple that can make it easier for your baby to transfer milk. In this case, you will perhaps not need to supplement at all as your baby is strong enough to get a full feeding. Perhaps your baby does well, but tires easily, transfers some, but not enough before tiring, and may need to be supplemented. You will keep pumping if your baby is using a nipple shield and/or needs to be supplemented. Please note that once evaluated on an individual basis, the recommendation may be different then what I am suggesting commonly happens. This is also frequently a fluid plan that may likely change from day to day or every few days, based on the variables – your supply, your babies medication condition, your ability to spend time with your baby.

Your hospital will have protocols. Please ask your nurse to help you familiarize yourself with the most up to date protocols. Don’t be afraid to speak up and ask questions. The NICU environment can be intimidating, however, remember you are the parents and it is okay to ask as many questions as you need to. If noone tells you otherwise, inquire if your baby is a good candidate for s2s, for early breastfeeding tries.

Some decisions will be made perhaps with moms health in mind. Perhaps there was significant birth trauma to the mom and she needs to take care of her medical needs which may not necessarily jive with her ability to spend time in the NICU breastfeeding. Her health issue may also conflict with her ability to pump immediately.

When supplementing, the method used is typically based on what your baby can manage.

The most common ways are to be either:

Gavage fed – a tube is placed through your baby’s nose which carries your milk to your babies stomach.It is often referred to as nasogastric feeding or NG for short.

syringe fed, cup fed, spoon fed – milk is put in a syringe or in a cup or on a spoon and fed to your baby, with the user doing their best to provide a paced feeding so your baby does not drink too much, too fast.
Your baby may be able to be put to the breast and breastfeed with a SNS if the volume of milk you have is not yet meeting your babies needs.

SNS definition – The supplemental nursing system (SNS) consists of a container and a capillary tube leading from the container to the mother’s nipple. The SNS container can be filled with fresh pumped breastmilk, with fresh donor milk, with pasteurized donor milk, or, if no human milk is available, with infant formula. I will post a picture of an SNS in the show notes as an example.

Bottlefeed – Your baby may show signs of readiness to feed from a bottle, which of course can have your milk or donor milk in it.

You may start off with one method and then as your baby grows and matures, you may move to another method, perhaps several different way of feeding your baby before you breastfeed.

My hope is that you will have an IBCLC as part of your team who will meet with you and suggest a care plan and ensure that you have all the tools you need to follow the care plan. Information on hand expression if need be, pumps to use, how to use the pump so you will be pumping efficiently and comfortably, or any other tools, like nipple shields or SNS that you are given.

Let’s not forget the power of skin to skin – Doesn’t cost anything. Doesn’t take too much effort and it does a world of good to keep your baby warm and tucked in close to you.

You will want to request as much skin to skin time as your baby is able to as this provides so many benefits to you and your baby. Moms report being able to pump more milk then usual when they pump right after skin to skin time. If your baby can, but you cannot, then your partner can provide skin to skin with your baby. This helps reduce their needs for oxygen and keeps them more stable in other ways too. helps with blood sugar levels, they breathe better, if they need to be on ivs and oxygen therapy, they can still spend some time sts. the NICU staff will help you to navigate this.

HGEP if unable to breastfeed – Frequent breast stimulation by hand expression or pump is necessary.

Having given birth earlier than expected puts most moms and babies in a compromising situation. Request and accept all the help you can get. Ask your HCP for referrals to groups in your community. the help and support of your family, physician and support group will be important in helping you during this time.

As I write my notes for this show, I am sitting here thinking that I hope that noone listening to this show ever needs this information. And yet I know, that statistically speaking, some of you will.. Or you will know someone else who needs this information.

As always, my hope is that I have provided you with good solid information to get you started. As you can see, there are too many variables for me to be specific about your premature or later preterm baby and breastfeeding.

There is a lot you learned today. One of them is the distinction between premature and late preterm babies. Knowing that you have a late preterm baby will help alert you to their possible breastfeeding challenges and adjust feeding plan accordingly. You will realize that there might be a very good reason to supplement, even though you don’t want to.. if your baby tires easily, or lacks the buccal pads to suck properly, or has lost too much weight because of poor feeding, now you will understand why and the rationale behind suggestions made to you by your babies NICU team will make sense. tand You will understand more why the need to practice parent led feedings vs. baby led feedings. You will undersbetter why you will need to make adjustments before you are exclusively breastfeeding.

You have learned what jaundice is and that this is a common concern with premature and late preterm babies. It causes babies to be very tired, which causes them to feed poorly. This lack of intake is what I call – “not enough breastmilk”, particularly stooling which is what we need for your baby to do to reduce the red blood cells in their system.

Not getting enough calories and hydration causes excessive weight loss, which causes a baby to tire easily at the breast. Many times there is lots of good reasons for the decisions made in NICU about your babies feeding plan. When parents don’t understand it and are very anxious to breastfeed, they sometimes become more frustrated and anxiety ridden then you need to be. I hope this information helps reduce your fears and aids you in being pro=active and positive during trying times.

In todays show you have learned that some babies are born with a weak suck, they are missing fatty cheek pads, high jaundice levels makes them too sleepy to have a good breastfeeding. They have immature lungs and underdeveloped digestive systems and you have learned how this can all affect your ability to breastfeed at first. Heart, lung, digestive, swallowing issues, infections. BIRTH MATTERS – giving birth early does create breastfeeding challenges. And yet, mothers and babies amaze me all the time. I have long ago removed “can’t out of my vocabulary when working with mothers. There have been too many times when mothers and babies have proved me wrong, wrong, wrong. There are also babies who amaze us and do things we would not have yet expected them to do. Like have a decent suck, transfer milk better than we would have expected at a gestational age that shocks us… in a good way.

While babies have their own set of problems and complications, moms have their own too:

You need to surround yourself with positive, knowledgeable professionals, friends and famly who will be encouraging you to work toward the goal of direct breastfeeding and be there to help you through dealing with the heavy work load you will find yourself in as you are doing all that is recommended to keep up your supply.

Through it all, it is not uncommon to have struggles such as:

inadequate milk production
feelings of vulnerability
lack of confidence
bottle feeding is convenient and no anxiety
hardship of pumping and storing milk
lack of emotional and informational support

You may have heard of skin to skin and the importance of it. Now you really know how helpful it can be for premature moms and babies. NICU parents need to adopt skin to skin as one of your superpowers as a NICU mommy. Your love, your heartbeat, your warmth, your voice has extraordinary powers that can calm your baby, help your baby breathe better, provide just the right warmth to your baby and help them regulate their blood pressure and heart rate better. I would say those are superpowers that both you and your partner have. Never underestimate the positive force of these superpowers.

A special not to family and friends and co-workers of a NICU family. Take time to ask the family – What can you do to make their day easier? If they don’t know or you can’t ask them – take up a collection of money. Believe me, they will be grateful and put it to good use. They will use it towards meals out as there is no time too cook. A house cleaner – they have not time to clean house. Transportation – if it is lacking. Replace sick days when they run out.

I hope that I have achieved my goal of:

1. Letting you know that if you do give birth early, you can still breastfeed.
2. The road to breastfeeding may be more difficult than you planned.
3. It may take longer then you expected.
4. With a good milk supply, lots of motivation and a growing well fed baby,
5. It is very likely that you will reach your goals. Until then…..
6. Feed the baby and protect the milk supply – This is our mantra for all moms and
7. babies who are having breastfeeding challenges.
8. You are not alone.

I believe that we gain strength from others on a person level. Through their words. Through their actions. Through their energy. Seeing is believing. Knowledge is powerful. It takes a village to help you through NICU to home From NICU staff and parents who have lived through a long NICU stay.

A video about the SPIN MOMMAS program at. SPIN – Supporting Premature Infant Nutrition program

A team of physicians and nurses and at UC San Diego Health have developed a whole program. When you go to their site, you will have access to so much information it is too long for me to mention here. The one thing that I do want to mention is the gift I am passing on to you.

This is an amazing video where you will meet Kimberly and her twins born at 27 gestation. Baby Riley was 1 lbs. 10 oz and baby Jack was 1 lbs 11 oz. You will follow them through the 33rd week and see their progress as they grow, gain, and develop. Kimberly pumped regular, was given lots of support to bring her to the place of learning how to breastfeed with her babies.

Click on the link and you will have access to 5 videos that cover Kimberlys journey that hightlight

skin to skin
beginning pumping
signs of readiness in babies at breast
using a nipple shield
bottlefeeding
signs of good sucking behavior
position and latch
making the transition to go home

Links:

SPIN Videos

https://health.ucsd.edu/specialties/obgyn/maternity/newborn/nicu/spin/video/Pages/default.aspx

Source

New Mother’s Guide to Breastfeeding, 2nd Edition (Copyright © 2011 American Academy of Pediatrics)

https://www.cpqcc.org/sites/default/files/NUTRITIONAL_SUPPORT_OF_THE_VLBW_INFANT_%E2%80%93_REVISED_2008EntireToolkit.pdf

https://health.ucsd.edu/specialties/obgyn/maternity/newborn/nicu/spin/Pages/default.aspx

https://health.ucsd.edu/specialties/obgyn/maternity/newborn/nicu/spin/staff/Documents/ContemporaryPediatricsThelatepreterminfant_AlittlebabywithbigneedsCME.pdf

http://pediatrics.aappublications.org/content/pediatrics/120/6/1390.full.pdf

https://www.cdc.gov/features/prematurebirth/index.html

http://bit.ly/2u5mt2s – – Supplementer Nursing System