Pediatric Primary Care (12 page)

G.  Complete all consults.

H.  Staff nurses will have covered discharge instructions of bathing, cord care, bulb syringe, diapering, dressing, fingernail care, holding, feeding.

I.  If concerns, infants should be scheduled for office visit within two days, otherwise parents need a two-week follow-up appointment assigned before discharge. Make them comfortable knowing they can call with any concerns.

BIBLIOGRAPHY

Ballard JL, Khoury JC, Wedeg K, et al. New Ballard Score expanded to Include extremely premature infants.
Pediatrics.
1991;119:417-423.

Fouzas S, Mantagou L, Skylogianni SM, et al. (2009). Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates.
Pediatrics.
2009;125(1):e52-e57. Retrieved from American Academy of Pediatrics website:
http://www.pediatrics.org/cgi/content/full/125/1/e52
. Accessed June 2, 2011.

Car Safety Seats: A Guide For Families 2010. American Academy of Pediatrics Healthy Children website:
http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Information-for-Famiies-2010.aspx
. Accessed June 2, 2011.

DeMichele AM, Ruth RA. Newborn Hearing Screening. Medscape Reference; 2010:
http://emedicine.med-scape.com/article/836646
. Accessed June 2, 2011.

Hagan JF, Shaw JS, Duncan P, eds.
Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents.
3rd ed. American Academy of Pediatrics; 2008:
http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html
. Accessed June 2, 2011.

Porter ML, Dennis BL. Hyperbilirubinemia in the term newborn.
Am Family Physician.
2002;65(4):599-607. American Academy of Family Physicians website:
http://www.aafp.org/afp/2002/0215/p599.html
. Accessed June 2, 2011.

Recommended Immunization Schedule for Persons Aged 0 through 6 Years–United States 2010. Centers for Disease Control and Prevention website:
http://www.cdc.gov/vaccines/recs/acip
. Accessed June 2, 2011.

Thureen PJ, Hall D, Deacon J, et al. Obstetric considerations in the management of the well newborn. In:
Assessment and Care of the Well Newborn.
2nd ed. Philadelphia: W.B. Saunders; 2005:3-20.

Wolf A, Hubbard E, Stellwagen LM. The late preterm infant: A little baby with big needs.
Contemporary Pediatrics.
2007;24(11):51-59.

CHAPTER 5

Guidelines for Breastfeeding

Amy L. Feldman

I.  INTRODUCTION

A.  Breastfeeding provides optimal nutrition for newborns and infants, protecting against many diseases and infections and improving maternal and infant health. Exclusive breastfeeding is recommended for the first 6 months of life, with continued breastfeeding throughout the first year and beyond with the addition of appropriate complementary foods.

II.  PHYSIOLOGY OF LACTATION

A.  Mammary glands are complex organs that function independently in response to an intricate combination of hormones and stimulation to produce milk. After expulsion of the placenta following delivery, a significant drop in progesterone readies the body for milk production
(
Figure 5-1
).

B.  Oxytocin and prolactin are two of many important hormones in controlling lactation.

C.  Optimal milk production depends on several factors including release of lactation hormones, frequent, effective milk removal, and adequate breast stimulation.

D.  Full lactation can be produced by breasts from 16 weeks of pregnancy forward.

E.  Important to understand balance of supply and demand to optimize lactation.

F.  Lactation begins as a result of hormonal control (endocrine) but changes to autocrine (frequent emptying of breasts) over time.

Figure 5-1
Physiology of lactation.

Source:
Thibodeau GA, Patton KT.
Anatomy and Phiysiology.
5th ed. St Louis: Mosby; 2003.

III.  HUMAN MILK

A.  Human milk is exceptional in its ability to sustain appropriate growth and development for infants.

B.  “Liquid gold,” as human milk is often referred to, is living tissue, which encompasses fats, proteins, carbohydrates, antibodies, and hundreds of components.

C.  Composition of human milk changes to provide optimal nutrition as infant grows.

1.  Colostrum, the first milk, is produced during pregnancy and is considered the infant's first immunization, providing protection to the newborn from viruses and bacteria.

2.  Transitional milk is produced after colostrum, then mature milk as lactogenesis stage II (production of large quantities of milk) begins.

IV.  CONTRAINDICATIONS FOR BREASTFEEDING

A.  Occasionally there are circumstances that preclude mothers from breastfeeding.

1.  Maternal contraindications include:

a.  HIV positive mother (in the United States).

b.  Maternal drug abuse.

c.  Maternal chemotherapy.

d.  Herpetic lesions on mother's nipple, areola.

e.  Untreated, active tuberculosis.

f.  Certain radioactive compounds and other medications may require temporary cessation of breastfeeding.

g.  Positive HTLV-I and HTLV-II (human T-cell lymphotropic virus).

2.  Infant contraindications include:

a. Galactosemia.

V.  MATERNAL ASSESSMENT

A.  Breastfeeding goals and family support.

B.  Previous breastfeeding experience.

C.  General health and nutritional status.

D.  Breast, nipple, or thoracic surgery.

E.  Medications, prescriptions, supplements, and OTC.

F.  Pregnancy, labor, birth history.

G.  Inverted or flat nipples.

VI.  INFANT ASSESSMENT

A.  General health, including gestational age.

B.  Congenital circumstances.

C.  Birth history.

D.  Medications received and procedures experienced.

E.  Initial feeding attempts.

F.  Oral facial assessment.

VII.  BREASTFEEDING IN THE EARLY DAYS

A.  Initial feedings.

1.  Facilitate skin-to-skin contact immediately after birth and as often as possible.

2.  Encourage breastfeeding within first hour after birth during quiet alert phase. Do not restrict length or frequency of feedings.

3.  Promote rooming in 24 hours a day.

4.  Encourage exclusive breastfeeding; this helps to establish and maintain a sufficient milk supply.

5.  Instruct parents in correct latch-on techniques.

6.  Educate parents regarding initial feedings of colostrum: quantity is very small, but sufficient nutrition as baby is learning to breastfeed.

7.  Discourage use of any supplements unless medically indicated.

8.  Avoid use of bottles and pacifiers until breastfeeding is well established.

9.  Teach parents to breastfeed in response to infant feeding cues (rooting, increased alertness, fists in mouth), at least 8-12 times/day. Crying is a late sign of hunger.

10.  Baby should finish feeding on one breast, then be offered second if he/ she will take more. Fat content of milk is higher at end of feeding than at beginning. Forcing baby to switch breasts too soon may decrease amount of higher calorie milk consumed.

11.  Babies who sleep for long periods of time without eating or feed only for few minutes should be encouraged to nurse (i.e., unwrap, rub feet).

B.  Positioning and latch.

1.  Mother and infant should be comfortable with infant on his/her side at nipple height supported by pillows or blankets.

2.  Support infant's head so he/she can easily reach areola without turning neck.

3.  Infant's ear, shoulder, hips should be in alignment.

4.  Mother can align her nipple with infant's nose, quickly bringing infant to breast only when his mouth opens widely getting more of the areola on the bottom than top into his mouth, creating an asymmetrical latch (see
Figure 5-2)
.

5.  Infant's lips should be flanged outward with chin touching breast. When latched properly, the tongue is drawn back to the junction of the hard and soft palate (see
Figure 5-3
).

6.  Infant's tongue will protrude over gum ridge and “cup” breast.