Breast Feeding Course

1. SESSION 10
INFANTS WITH SPECIAL NEEDS
Breastfeeding Promotion and Support
A Training Course for Health Professionals
Adapted from the Baby Friendly Hospital Initiative:
Revised, Updated and Expanded for Integrated Care (Section 3)
WHO/UNICEF 2009
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2. INTRODUCTION
• Human milk has been recognized as the
gold standard for human feeding for
centuries.
• Milk of other species that is fed to human
infants have been known to contribute to
increase in infant mortality.
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3. Which Baby Require Special Attention?
• Prematurity
• Twin babies
• Hypoglycemia
• Neonatal jaundice
• Dehydration
• Cardiac problem
• Babies with breathing difficulties
• Cleft palate
• Down Syndrome
• Medical problems
– neurological condition
– ill babies 3

4. 1. The importance of Breastfeeding for
Infants with Special Needs
4

5. Importance of Breastmilk for
Preterm/LBW/Ill Infants
Breastmilk contains:
1. Protective immune factors
Help to prevent infection
1. Growth factors
Helps baby’s gut and other systems to develop as well as to
heal after diarrhoea
1. Enzymes
Make it easier to digest and absorb milk
1. Special Essential Fatty Acids
Help brain development
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6. Other Benefits
5. Calms the baby
6. Reduces pain from venipuncture etc
7. Gives mother important role in caring for
baby
8.Comforts the baby & strengthen bonding
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7. Babies With Special Needs
need breast milk as much as well babies
Feeding depends on each baby’s
condition:
•Not able to take oral feed
•Able to take oral feeds but not able to suckle
•Able to suckle but not for full feeds
•Can suckle well
•Not able to receive any breastmilk
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8. 2. Breastfeeding of
Pre-term and Low Birth Weight Infants
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9. Composition of Preterm Human Milk (26-36wks)
Comparison to mature term human milk
Protein 50-100% higher during first 4-7 wks
Sodium 30-150% higher first 4-6 wks
Chloride 30-80% higher during 3-4 wks
Potassium 30-75% higher during first 3-4 wks
IgA Higher during first 2-3 months
Medium chain FA 40-80% higher during first 3 months
Polyunsat FA 40-70% higher in colostrum and transitional milk
Enzymes and growth
factors
Equal to mature human milk
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Milk from mother giving birth preterm contains more protein,
sodium and calcium than full term milk.

10. Benefits of Breastfeeding for Preterm Infants
Benefits References
Greater enteral feeding tolerance and more rapid
achievement of full enteral feeding
Armand et al,1996
Gross,1983
Simmer et al,1997
Uraizee &Gross,1989
Reduced risk and severity of infection (short and
long term)
El-Mohandes et al,93,97
Narayanan et al,81,82,84
Uraizee & Gross,89
Reduced risk and severity of necrotizing
enterocolitis
Albanese & Rowe,95
Buescher,94
Neu,96
Reduced risk of atopic disease for infants with
family risk histories
Chandra,97
Lucas et al,90
Enhanced retinal maturation and visual acuity Carlson et al,86
Faldella et al, 96
de Andreca & Uauy, 95
Enhanced developmental and neurocognitive
outcome
Carlson et al,86
Faldella et al, 96
de Andreca & Uauy, 95
Morley, 96
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11. Issues on Breastfeeding in Premature Infants
• Expressed Breast Milk (EBM) -if the infant cannot
suck directly at the breast
• Hindmilk
– has higher calories than foremilk for better
weight gain.
• Human milk fortifier.
• Non nutritive sucking
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12. Human Milk Fortifier (HMF)
• HMF provides additional nutrients to breast milk.
(protein and minerals).
• Usu use in hospital setting for baby< 1.8 kg.
• Fortification is usually started when feeds reach
100 ml/kg by adding 1 sachet (2 grams) to 50 ml of
Expressed Breast Milk (EBM).
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13. Non Nutritive Sucking/ Comfort Sucking
• Used during gavage feeding and in the transition
from gavage to breast/bottle feeding in preterm
infants.
• Facilitates development of sucking behaviour in
premature babies.
• Help to Improves
digestion of enteral feeds
• Calming effect on infants
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14. Method of Feeding in Premature Infants
• Oro/Nasogastric tube feeding
• Cup feeding
– when suck-swallow coordination has been
achieved
• Supplementer Nursing System
Session 10: Infants With Special Needs
Ministry of Health Malaysia
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15. Tube Feeding
Session 10: Infants With Special Needs
Ministry of Health Malaysia
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16. Cup feeding is a skill that is easily learned
by newborn and premature babies
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17. Supplementer Nursing System(SNS)
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Supplemental Nursing System (SNS) is a feeding tube device
provide babies supplemental feedings at the breast.
When a baby is at breast over a period of days or weeks, a horm
is triggered that causes milk to be produced.
Used for :Induce and maintain lactation

18. 
What are ways that a Special Care Unit
can support breastfeeding?
1.For mother
2. For baby
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19. 1.Arrange Contact Between Mother And Baby,
Day and Night
• Encourage mother to visit, touch and care for baby
as much as possible
Mother’s exposure to pathogen in NICU will stimulate
antibody production which is passed to babies via
breastmilk
• Kangaroo Mother Care (KMC)/Skin-to skin contact
– Encourage mother to hold baby closed to breast
– Baby can go to breast whenever he wants.
– Helps regulate baby’s temperature and breathing,assists
in development and increases production of milk.
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20. 20

21. 2.Take Care Of The Mother
• Help mother to rooming in.
• Provide place for mum to rest
• Provide meals for mother.
• Be parents friendly
– Answer parents’ questions and explain patiently
• Let parents know breastfeeding is important
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22. 3.Help To Establish Breastfeeding
• Assist mother to express her milk within 6 hours of
birth ( > /= 6 x in 24 hours)
• Baby can go to breast while receiving a tube feed to
associate the feeling of fullness with being at breast.
• Encourage and educate mother to give EBM via tube
or cup before BF is established. Avoid artificial
teats.
• Advise mum to express breast before putting baby
on breast
premature babies do not have good sucking
swallowing coodination.
22

23. Positioning a Preterm Infant
• Support baby’s head with mother’s
hand (not grip) .Mother’s arm
support baby’s body.
• Mother support her breast with her
other hand to help baby keep breast
in mouth.
• To increase milk flow, massage and
compress breast each time baby
pauses between suckling bursts
23

24. Explain to mothers what to expect at feeds
• Longer feeding time
Feed for a long time ( ~ 1 hour) and will pause
frequently to rest during a feed.
• Gulping and choking
Baby's low muscle tone and uncoordinated suckle.
• Stop trying to feed if baby seems too sleepy or fussy .
• Keep the feed as calm as possible.
Avoid loud noises, bright lights, stroking or talking to
baby. 24

25. 25

26. 26

27. 27

28. INFANTS WITH SPECIAL NEEDS
Approach to feeding will depend on baby’s condition.
1.Baby not able to take oral feeds.
Encourage EBM and freeze it
2. Baby able to take oral feeds but is not able to suckle
at breast.
Give EBM by tube and by cup if baby is able.
3.Baby able to suckle but not for full feeds.
Let baby suckle whenever baby is willing. Frequent short
feeds .Give EBM by cup or tube in addition
4.Baby can suckle well.
Encourage frequent feeds
5.Baby is not able to receive breast milk.

29. Discharge Plan For Premature Baby
• When to discharge?
-baby able to feed effectively and gaining weight
-Usual discharge weight is 1800 gram
• Encourage rooming in before discharge to build
up mother confidence on care of baby at home.
• Counsel on feeding technique.
• Counsel on how to get assistance and arrange
follow up care.
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30. 3. ASSISTING MOTHERS TO
BREASTFEED MORE THAN 1 BABY
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31. Issues in Feeding More than One Baby
• Mothers can make enough milk for 2 babies, even 3.
- Volume of breastmilk produced by a mother
depends on demand.
• Key factors :
Time ,support and encouragement from health care
providers and family
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32. How To Encourage Mother To Breastfeed
More Than One Baby
Encourage mother to :
•Get help with caring for other children/ household
duties
•Breastfeed lying down to conserve energy
•Eat a varied diet and take care of herself
•Try to spend time alone with each of the babies so that
she can get to know them individually.
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33. Breastfeeding Twins
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34. Breastfeeding Twins
• Nursing 1 twin in the cradle
hold, using the free hand to
comfort the twin not
nursing
• If 1 baby is a good feeder
and 1 baby less active,
make sure to alternate
breasts so that milk
production remains high in
both breasts.
.
34

35. Twins Grow
Well on
Breastmilk
UNICEF/HQ92-0260/LaurenGoodsmith,Mauritania
10/4
Session 10: Infants With Special Needs
Ministry of Health Malaysia
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36. 36

37. Breastfeeding a Baby and Older
Child(Tandem Nursing)
When a new baby arrives
• No need to stop breastfeeding an older
baby
• Mother will produce enough milk for
both if she cared for herself
• Abrupt cessation of breastfeeding should
be avoided to prevent older child from
risk of malnutrition
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38. 38

39. 4. Prevention and Management of
Common Clinical Concerns
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Practises to avoid newborn’s problem :
Early skin to skin contact
Early and frequent BF
Rooming in
Breast expression
Cup feeding
Avoid water supplements

40. Neonatal Hypoglycemia
• Babies at risk of hypoglycemia
– premature, SGA, LGA, infant of diabetic mothers and
sepsis
• Babies fed on breastmilk may be better able to
maintain their blood glucose levels than babies
artificially fed on formulas.
• Term, healthy babies do not develop
hypoglycemia simply through under-feeding.
• If a healthy full term baby develops signs of
hypoglycemia, the baby should be investigated
for any underlying problem eg IEM, sepsis.
40

41. Breastfeeding and Neonatal Jaundice
41

42. Breastfeeding Jaundice
• Result from inadequate breast milk volume or
insufficient milk intake
– Lead to dehydration, low caloric intake
• May occur in 1st
week of life in breastfed infants
• May be reduced by:
– Encouraging early feeds
– Increasing frequency of feeds
– Avoiding use of water to replace breastmilk
42

43. Breastfeeding Jaundice – Causative Factors
43

44. Breastmilk Jaundice
• Occurs in 1% to 2% of breastfed babies.
• Causes prolonged indirect jaundice.
• Can persist until 12 weeks
• Etiology:
– Increased concentrations of nonesterified free fatty
acids
(NEFA) that inhibit hepatic glucuronyl transferase.
– Increased enterohepatic circulation of bilirubin due to
(1) increased content of beta glucuronidase activity in
breast milk and, therefore, the intestines of the
breastfed neonate
(2) delayed establishment of enteric flora in breastfed 44

45. Prevention of Severe Jaundice
• Early initiation of breastfeeding
- Colostrum helps infants to pass meconium,
removes excess bilirubin from the body
• Encourage demand feeding
- 8 – 12 feeds a day
• Effective suckling
– ensure effective milk transfer
• No supplementary fluid
• Cup feeding with EBM if baby refuse to suck
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46. Treatment of Severe Jaundice
• Phototherapy.
• Very frequent breastfeeding to avoid
dehydration.
• Give expressed milk if the baby is sleepy.
• Water or glucose water supplements do not help
as they reduce the intake of breastmilk and do
little to reduce the jaundice.
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47. Dehydration
• Healthy exclusively breastfed infants do not
require additional fluids to prevent dehydration.
• Babies with diarrhoea should be breastfed more
frequently.
– Frequent breastfeeding provides fluid,
nutrients, and protective factors.
– Growth factors in breastmilk aid in the re-
growth of the damaged intestine.
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48. 5. Management Of Breastfeeding For
Infants With Special Needs
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49. Babies who have Breathing Difficulties
• Should be fed small amounts frequently
as they tire easily.
• Breastfeeding provides the infant with
nutrients, immune bodies, calories, fluid
and comforts the distressed baby and
mother.
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50. Babies with Cardiac Problems
• Babies may tire easily
• Short frequent feeds are helpful.
• Breastfeeding is less stressful and
less energy is used >> better weight
gain
• Breastmilk provides protection from
illness thus reducing hospitalization
and helping growth and development.
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51. Breastfeeding and Cleft Palate
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Baby with clefts are at risk for :

52. Babies with Cleft Lip/Palate
• Babies with cleft lip only should be able
to breastfeed - tissue of the breast can
help the baby to create a seal more
effectively
• Babies with cleft palate are less likely to
breastfeed directly from their mother's
breast.
• Cleft palate babies often have problem
with sucking, and may choke or gag on
food that gets into their nose.
52

53. Breastfeeding and Cleft Palate
• Cleft palate babies can
be given EBM via special
cleft palate bottle
(Haberman feeder),
spoon or cup.
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54. Breastfeeding and Cleft Palate
• Encourage mom to put
baby on breast for
suckling and bonding
• Following surgery to
repair the cleft,
breastfeeding can
resume as soon as the
baby is alert.
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55. Cleft Lip And Palate - How To Feed?
• Hold baby so that his nose and throat are higher
than breast
– prevent milk from leaking into the nasal cavity,
 Breast tissue or the mother's finger can fill a cleft in
the lip to help baby maintain suction.
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56. Benefits of Breastmilk to Cleft Palate Babies
• Provides immunities against infection,
especially ear infections
• Less irritating to mucous membranes of nose
and gastro-intestinal system than formula.
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57. Benefits of Breastmilk to Cleft Palate Babies
• Encourages proper
development of baby's mouth
and face.
57

58. Breast Feeding and Down Syndrome
58
 Can they be BF ?
 If not able to
suck?

59. Babies with Down Syndrome/Other Neuro
• Hypotonia and poor sucking reflex
• Encourage early contact
• Might need to wake baby
• Stimulate during feed
• Help mother to position
59

60. 10/5
©UNICEFC107-21
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Supporting the breast and baby’s chin to stabilize baby’s jaw
and maintain good attachment
DANCER’S HAND HOLD FOR PRETERM/HYPOTONIA

61. Breast Feeding and Down Syndrome/Neuro Problems
• Feeding need longer time
• May need cup feeding
• Avoid teats
• Weight gain might be slow even with enough
breast milk
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62. Infants Requiring Surgery
• BF can usually commence as soon as
baby is awake after surgery.
• BF soon after surgery helps with pain
relief, comforts baby and provides
fluid and energy.
• If baby is not able to take large
amounts of breastmilk immediately,
mother can express and let baby suck
on ‘empty breast’ until baby is more
stable.
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63. 6. Medical Reasons For Food Other
Than Breastmilk
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64. Acceptable Medical Reasons For Use
Of Breastmilk Substitute
Imp TO DISTINGUISH BETWEEN :
1.Babies who cannot be fed at breast but for
whom breastmilk remains food of choice
2.Babies who should not receive breastmilk or
any other milk
3.Babies for whom breastmilk is not available
for whatever reason
64

65. 1.Infants for whom breast milk remains the best
feeding option but who may need other food in
addition to breast milk for a limited period :
• Very low birth weight infants ( < 1500g )
• Very preterm infants ( < 32 weeks gest age)
– These infants may be fed expressed milk by tube,
cup or spoon.
• Newborn who are at risk of hypoglycaemia if the
blood sugar fails to respond to optimal breastfeeding
or breast-milk feeding.
65

66. 2.Infants who should not receive breast
milk or any other milk :
Baby with Inborn Error of Metabolism
1. Galactosemia:
require special galactose-free formula
1. Maple syrup urine disease:
require special formula free of leucine, isoleucine and
valine
1. Phenylketonuria:
–require special phenylalanine-free formula (some
breastfeeding is possible, under careful monitoring).
66

67. 3.Babies for whom breastmilk is not
available for whatever reason
Need replacement feeding
1.Mother away from baby
2 Severely ill
3.Medical condition eg HIV +
•need to be seen and followed-up by trained health
worker.
• Need individualized feeding plans
67

68. SESSION 10 SUMMARY
INFANTS WITH SPECIAL NEEDS
• BF is imp for infants who are preterm, LBW ,Ill or
have special needs.
• It protects,provides food , and aids in growth and
development.
• Breastfeeding more than one baby / Clefts/
Heart/Breathing difficulties/ Down syndrome
• Prevention and management of common clinical
concerns
• Does the baby need breast-milk substitutes?
Infants with metabolic conditions /HIV mother
Limited period – preterm, LBW. ill etc
68

69. SESSION 10 SUMMARY
INFANTS WITH SPECIAL NEEDS
Approach to feeding will depend on baby’s condition.
1.Baby not able to take oral feeds.
Encourage EBM and freeze it
2. Baby able to take oral feeds but is not able to suckle
at breast.
Give EBM by tube and by cup if baby is able.
3.Baby able to suckle but not for full feeds.
Let baby suckle whenever baby is willing. Frequent short
feeds .Give EBM by cup or tube in addition
4.Baby can suckle well.
Encourage frequent feeds
5.Baby is not able to receive breast milk.

70. THANK YOU
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