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Jan 1, 2013
Ngala Elvis Mbiydzenyuy
CEO/Founder Maternal and Child Aid Cameroon
The terms preterm and post-term have gradually replaced the seemingly derogatory words premature and overdue babies respectively. A full term infant is described as an infant who is between 37 weeks zero days (37 0/7) and 41 weeks 6 days (41 6/7) gestation. These infants can usually be breastfed without major problems. On the other hand the post-term infant is described as an infant who is 42 0/7 weeks gestation or greater.
Preterm infants can be categorized based on gestation (duration of pregnancy) and weight. Each group brings a unique set of challenges. The preterm infant is described as an infant who is 36 6/7 weeks gestation or less. The advantages of breastfeeding for preterm infants seem to be even greater than for full term infants. The late-preterm infant is described as an infant who is between 34 0/7 and 36 6/7 weeks gestation. This is a subset of the preterm infant. Although these infants are often the size and weight of some full term infants, they are less physiologically and metabolically mature than full term infants. These infants are often well-developed, vigorous at birth, and display behaviors that mimic their full term counterparts, however if feedings are observed closely, often these infants will present with immature feeding behaviors. They may be unable to transfer enough breast milk directly from the breast unaided. Late preterm infants look as though they are developmentally mature, but this is not the case and can be confusing for parents, caregivers, and even some health care professionals. For this reason, special anticipatory guidance is warranted for these infants.
On the basis of weight preterms could be low birth weight (LBW) infants and are described as weighing 2500 grams to 1500 grams. One in every thirteen births results in a low birth weight infant. Very Low Birth Weight (VLBW) infants are described as weighing 1500 grams to 1000 grams at birth, while the Extremely Low Birth Weight (ELBW) infant is described as weighing between 401 and 1000 grams. Center for Disease Control (CDC) figures show that one in every 10 low birth weight infants is categorized as ELBW
Preterm and late-preterm infants are not just “smaller” term infants as many have mistakenly thought. They have unique problems that scientists and physicians are only beginning to understand. Thanks to the development of modern medicine even the smallest of the preterm infants (ELBW) have an increased chance for survival. Some of the problems that preterm infants may encounter are: feeding difficulties, low blood sugar (hypoglycemia), yellowish discoloration of the skin and eyes (jaundice), excessive weight loss, respiratory distress, inability to maintain body temperature, infection, slow weight gain, intracranial hemorrhage, bonding issues, chronic lung disease, risk of re-hospitalization etc
Our preliminary findings confirm standing research which shows that mothers who deliver preterm infants are more likely to show underlying maternal pathologies that may reflect either primary milk insufficiency and/or delayed milk production. Some of these conditions include: diabetes, obesity, excessive blood loss, pregnancy-induced hypertension, prolonged rupture of membranes, preeclampsia etc
Exclusively feeding human milk to the preterm and late-preterm infant is exceptionally important. It has been reported to improve host defenses, gastrointestinal development and function, digestion and absorption, and brain development outcomes. Breast milk establishes enteral (oral) tolerance, allowing for earlier discontinuation of parenteral nutrition. Breast milk offers the advantages of receiving maternal amino acids and fat while providing a greater bioavailability of nutrients with a lower kidney solute load, enzymes to digest, and immunologic properties, which protect these small infants from infection. Breastmilk decreases the incidence of infection and necrotizing entercolitis (NEC). Preterm breast milk also contains higher concentrations of sodium, chloride, and nitrogen. For infants weighing 1500 grams or more, human milk provides the ideal protein balance. Infants less than 1500 grams at birth may benefit from the temporary addition of nutrients. For these infants, the best option is the addition of human milk fortifiers, which are reported to improve short-term weight gain. Human milk fortifiers augment the much needed levels of calcium and phosphorous, in addition to protein, calories, carbohydrate, vitamins, and minerals. Reassessment should be made at the estimated date of confinement (EDC) in an effort to eliminate the addition of human milk fortifier.
Kangaroo Care refers to skin-to-skin contact, exclusive breastfeeding, and support for the mother/infant dyad. The ideal skin-to-skin position for the infant is between the mother’s breasts.
For infants born prematurely, it is very important that they continue gestation by getting as much skin-to-skin contact as possible. Skin-to-skin contact enhances the infant’s immune system by exposure to the colonized normal flora of the mother. Skin-to-skin contact provides infants with better physiologic stability including oxygenation, heart rate, temperature, and immunity. Skin-to-skin contact provides the mother with an opportunity to provide a safe place for her developing infant. It is usually best to initiate skin-to-skin with the infant’s mother; however fathers and other family members should be encouraged to enjoy sharing the skin-to-skin benefits with their infant as well. Mothers of preterm and late-preterm infants who keep their infants skin-to-skin have higher milk volumes than those who do not. Skin-to-skin contact has been shown to increase both prolactin and oxytocin in the breastfeeding mother, (hormones required for the production and flow). Breast milk production becomes threatened whenever mother and infant are separated. Routinely removing infants from the mother’s room for observation in the nursery interrupts the skin-to-skin contact and interferes with breastfeeding. Support for the mother/infant dyad is very important during this time.
Suckling at the human breast is much easier for the preterm infant than suckling an artificial nipple due to the soft, supple tissue of the breast. Suckling at mother’s breast offers the preterm infant many rewards beyond what bottle feeding has to offer. The mother talks softly and delights in her infant. The infant given the opportunity to nuzzle, lick, and grasp the breast will experience the sweetness of mother’s milk and gradually learn the skills necessary for breastfeeding. Feeding at the breast may cause anxiety for the mother. She may feel as though her body will be unable to produce enough breast milk for her infant. The first feedings at the breast should be looked at as “practice sessions” for both infant and mother. The infant may have a poor rooting and sucking reflex, and may be unable to latch on or may be sleepy at the breast. This may cause the infant to appear disinterested in breastfeeding. Anticipatory guidance should be given to the mother in this situation. While bottle feeding delivers milk faster into the infant’s mouth, breastfeeding tends to pace the infant. The mother’s breast responds to the infant suckling and delivers milk at a slower pace allowing the infant to gradually develop coordination of suck, swallow and breathing. This maturity for feeding readiness is usually seen between 32-36 weeks. Stable infants as young as 28 weeks should be given the opportunity to suckle at the breast. Preterm infants often display negative reactions to over-stimulation. During feeding times, instruct family members to dim the lights, and keep voices soft. It is important to recognize the alertness and the maturity level of the infant. Constant stroking and physical stimulation rarely work well to keep a sleepy preterm infant awake, but may be required for a late preterm infant.
The use of evidence-based techniques to optimize suckling and breast milk intake is warranted. Such techniques include the use of positioning techniques such as the cross cradle or football holds, the use of nipple shields, and/or supplemental nursing systems. Nipple shields provide a more stable nipple for the weak suck of the infant. This will help reduce the muscle fatigue of the infant’s jaw. Nipple shields should be ultra-thin. Preterm and late-preterm term infants are prone to gastroesophageal reflux. They may benefit from being held upright following feeds. During the first few days of pumping, mothers should be instructed in the art of hand expression. Hand expression may yield higher volumes of colostrum than pumping alone due to the compression of the breast. Our next edition focuses on hand expression of breast milk