The purpose of this guideline is to support the establishment of breastfeeding for vulnerable newborn babies at Grampians Health Ballarat. Babies within the scope of this guideline have an increased risk of medical morbidities, feeding difficulties, Special Care Nursery admission and hospital re-admission in the early postnatal period.

Optimal care is provided to babies at risk of feeding difficulties.

Preterm baby: A baby born at less than 37 completed weeks gestation

Late preterm baby: A baby born between 36+0 and 36 completed weeks gestation

Early term baby: A baby born between 37 and 38 completed weeks gestation

Low birth weight baby: Birth weight equal to or less than 2500gm

Abbreviations

SCN: Special Care Nursery

SSC:Skin to Skin Contact

EBM:Expressed Breast Milk

BGL: Blood Glucose Level

MCHN: Maternal and Child Health Nurse

LC: Lactation Consultant

BF: Breastfeeding

BHS: Ballarat Health Services

NEWT: Newborn Weight Loss Tool

All midwifery, nursing, medical and allied health staff providing care to babies within the scope of this guideline have the responsibility to provide evidence based care according to their scope of practice.

This guideline includes care of babies in the postnatal ward (PNW) Special Care Nursery (SCN), paediatric unit, babies at home receiving Domcare and babies receiving allied health care.

This guideline will facilitate evidenced based care but should not replace individualised assessment of each mother/baby dyad

1.     Babies within the scope of this guideline may include (but are not limited to):

• Late preterm and early term babies (see definitions)

• Birth OR current weight equal to or less than 2500g (in hospital or at home)

• Small for gestational age babies

• Babies with hypoglycaemia - refer to GHB Clinical Guideline CPG 0110 Neonatal Hypoglycaemia Prevention and Management.

• Babies with jaundice requiring phototherapy

• Baby re-admitted to hospital for feeding related issues

• Baby with conditions which may affect breastfeeding e.g. Down Syndrome, Cleft Lip and Palate, Ankyloglossia (Tongue-tie). Refer to relevant Clinical Practice Guidelines listed in related documents.

• Any other concerns or risk factors for poor feeding challenges indicating referral to paediatric medical staff, a lactation consultant, speech pathologist or other allied health services.

2.     Care in Labour and Postnatal Wards

2.1    Identify the 'at risk' baby.

• Babies under the scope of this guideline are more at risk of hypoglycaemia, hypothermia, jaundice, significant loss of weight and poor feeding. Their care and attention should be reflective of closer observation for these conditions

• Review mother and babys medical history to identify risk factors for medical morbidities and feeding difficulties

• Ensure early referral to paediatric medical staff for babies within the scope of this guideline if required

• Consider admission to Special Care Nursery (SCN) as per GHB Clinical Guideline CPG 0077 Special Care Nursery Admission, Discharge And Transfer Criteria.

2.2 Prevent hypothermia and feed soon after birth

• Immediate and uninterrupted skin-to-skin contact (SSC) unless baby or maternal medical condition require separation. If separation has occurred for medical care, return baby to SSC as soon as possible

• Observe for readiness to feed and assist mother to initiate breastfeeding (BF) within 1 hour of birth

• If baby has not BF effectively for at least 10 minutes within 1 hour of birth, express and feed available Expressed Breastmilk (EBM) by oral syringe or cup. If no fresh EBM is available, use antenatally expressed colostrum if available.

• For babies at risk of hypoglycaemia, if baby has not breastfed within 1 hour of birth and no EBM is available, consider the need to feed 5-10ml infant formula after gaining written informed consent of parents (see 2.6 below). Refer to GHB Clinical Guideline CPG 0110 Neonatal Hypoglycaemia Prevention and Management.

• If mother has chosen not to breastfeed, baby should be bottle fed infant formula within 1 hour of birth. If baby has not fed by bottle within 1 hour of birth give formula by oral syringe or cup

• Maintain warmth and continue skin to skin contact during and after transfer to postnatal ward where possible

• Consider paediatric review and incubator care if babys temperature remains < 36.5C for 2 hours despite sustained skin to skin contact

2.3 Monitor and assess the baby

• Monitor vital signs, tactile warmth, colour within 1 hour of birth then 4 hourly for 24 hours, or as requested by paediatric medical staff

• Monitor blood glucose levels (BGLs) if indicated, according to the GHB Clinical Guideline CPG 0110 Neonatal Hypoglycaemia Prevention and Management

• Monitor output & hydration each shift

• Document all baby care on the Infant Care Chart MR450.0 and/or progress notes

• Observe for jaundice and refer to GHB Clinical Guideline CPG 0253 Neonatal Jaundice (Hyperbilirubinaemia)

• Weigh baby at 48 hours then second daily whilst in the care of GHB unless otherwise indicated or ordered

• If the baby is to be discharged home prior to 48 hours (not recommended) weigh baby prior to discharge and plot weight on the Newborn Weight Loss Tool to determine if weight loss is within normal parameters (Appendix 6).

• Assessment of weight loss should consider the complete clinical picture, utilising the online Newborn Weight Loss Tool (NEWT)  and the Weight loss at 48 hours flow chart (Appendix 5) to aid clinical decision making.

2.4   Apply extra vigilance to assessment and support of feeding

• Continue to offer 8-10 breastfeeds / 24 hours from birth when baby is in the quiet alert state and showing readiness to feed

• Consider any need for supplementation after breastfeeds as per 2.6 below

• Offer both breasts twice if baby falls asleep easily (switch feeding)

• Assess at least one breastfeed per shift for effective attachment and signs of effective milk transfer

• Re-consider management each shift - refer to Appendix 2 - Management Flow Chart

• Offer at least 6-8 feeds / 24 hours to formula fed babies

• Consider referral of mother and baby to Lactation Consultant within 24-48 hours of birth.

2.5 Initiate and establish adequate maternal breast milk supply

Establishment of maternal milk supply may be compromised if the baby is not effectively breastfeeding from birth. To facilitate initiation and establishment of milk supply:

• Early, frequent and effective breastmilk expression in addition to breastfeeds may be required from birth.

• Refer to Appendix 3 - Initiating and Maintaining Breastmilk supply.

• The following consumer information pamphlets can be offered to the mother as she learns how to breastfeed, and express breastmilk:

  • Hospital Grade Electric Breastpump Hire

  • Expressing Breastmilk Right from the Start

2.6   Supplemental feeding of breastfed babies

Babies within the scope of this guideline and those experiencing feeding difficulties may require supplementation after breastfeeds, preferably with EBM until effective breastfeeding is established. Following thorough assessment of mother, baby and breastfeeding, consider supplementation for the following reasons:

• Inability to maintain attachment and sustain effective breastfeeding for at least 10 minutes at most feeds

• Less than 10 minutes of audible swallowing at most feeds after 48 hours

• Weak, disorganised, non-nutritive sucking patterns

• Signs of insufficient milk transfer: little or no swallowing heard, breasts not well drained after feeds (after milk is in).

• Urine output is not appropriate for age and urine is concentrated

• Presence of urates after 96 hours (4 days)

• > 7-10 % weight loss from birth

• Weight gain less than 20gm per day after 96 hours (4 days) or after milk has come in

• Stools not changing to transitional by 96 hours (4 days)

• Less than 1 bowel action per day after milk has come in

• Signs of dehydration: loss of skin turgor, dry mucous membranes, low urine output, concentrated urine, sunken fontanelles.

Supplementation guidelines if indicated

• Offer expressed breastmilk (EBM) supplementation as the first choice

• Donor breastmilk may be used at the request of the parents as per GHB CPP0395 Use of Donor Breastmilk

• Use formula only if insufficient EBM is available. Informed written consent from a parent is required using MR/055.0 Supplementary feeds consent

• 0-24 hours of age small amounts, 5-10 ml after a breastfeed

• 24 - 48 hours of age - 10-20 ml after a breastfeed or more if indicated after assessment of hydration

• 48 hours onwards - depending on assessment of feeding, milk supply and continuing indication for supplementation, volumes will usually follow those recommended for exclusively formula fed babies

• Refer to the GHB Clinical Guideline CPG 0074 Supplementary Feeding of the Breastfed Baby

• Consider the most appropriate method of supplementary feeds depending on the clinical situation and parental preference.

  • Finger or cup feed if small or infrequent volumes e.g. less than about 30-40ml.

  • Avoid teats and bottles until effective breastfeeding is established. However if larger and frequent volumes are required and the baby is struggling to take required top ups by finger feeding, then bottle top ups may be necessary.

  • Refer to the GHB Clinical Guideline CPG0186 Breastmilk - Expressing, Storing and Feeding.

2.7 Allied health support

Consider the need for allied health specialist assessment and support for baby and mother such as

• Speech pathology

• Physiotherapy

• Social work

• Dietetics

Refer to NCG0046 - Acute Allied Health Services Electronic Referral System on Bossnet.

3.    Discharge

3.1 Discharge Planning

• Planning for care after discharge should commence within the first 24-48 hours of birth

• Discharge home before 48 hours of age is often not recommended for babies within the scope of this guideline. Inform the mother that an extended length of stay may be needed for her baby

• If the mother is ready for discharge but the baby does not meet the discharge criteria under 3.2 below, the options below should be considered:

  • the baby may be admitted under the paediatric medical unit care and remain as a patient on the postnatal ward. The mother is 'discharged' but remains on the postnatal ward as a 'boarder' and as the baby's primary carer

  • if admission of the baby to the postnatal ward is not appropriate or feasible, the baby should be admitted to SCN

  • If the baby is admitted to SCN, the mother can be accommodated short term either in a parent flat or as a boarder on the postnatal ward.

3.2 Criteria for readiness for discharge from hospital

• A written discharge feeding plan has been prepared in baby's Electronic Medical Record (EMR) using e-form MR135.2 Infant Feeding Plan and a copy given to the mother.

• Urine output appropriate for age and urine is pale in colour;

  • at least 2 wet nappies between 24-48 hours

  • at least 3 wet nappies between 48-72 hours and increasing in heaviness

  • at least 4 heavy wet nappies between 72-96 hours

• At least one stool per 24 hours appropriate to age and stage of lactation

• Weight loss <10% of birth weight AND/OR at least 1 weight gain prior to discharge. If weight loss >7-10% delay discharge for 24 hours

• The online Newborn Weight Tool (NEWT) can be used to check that the percentage of weight loss is within normal parameters for the age and weight of the baby (Appendix 6)

• Domcare follow up within 24 hours is available

3.3 Parent education prior to discharge

Provide routine postnatal pre-discharge education to parents and additional information as follows:

Inform parents to observe for the following in the baby:

• Lethargy, increasing sleepiness

• Feeding poorly

• Vomiting large amounts after several feeds,

• Vomiting green fluid parents should bring baby to emergency urgently

• Pale

• Excessive crying

• Jaundice especially if increasing since discharge

• Less than 5 to 6 heavy wet nappies in 24 hours after day 5

• Fever, rash

And then either:

a.    Discuss concerns with domicilliary midwife OR

b.    Bring baby without delay into the nearest Emergency Department OR

c.    Take the baby without delay to their GP

Inform parents to call an ambulance immediately if the following signs occur:

• Baby has difficulty breathing

• Baby appears blue

3.4    Ensure correct discharge/transfer procedures are followed:

The mother and baby are referred to Domcare as per standard procedures.

Consider a referral to a Lactation Consultant for a follow-up appointment at around 1 week after discharge.

Ensure mother has contact details for:

• Breastfeeding Support Clinic - BHS and Parent Place

• Australian Breastfeeding Association 24 hour helpline

• MCHN helpline

4     Ongoing care and assessment of mother and baby at home

• Ongoing care and assessment will be provided routinely by Domcare midwvies in the first week after discharge.

• Referral to BF clinic, Post Acute Care, MCHN and for medical care should be provided as per Appendix 4 - Post Discharge Problem Solving Flow Chart

• Consider referral to Paediatric Feeding Clinic if feeding problems persist. Use Allied Health Outpatient Referral Form MR/023.0

• Consider referral for outpatient allied health assessment and support as per point 2.7 if not already done. Use Allied Health Outpatient Referral Form MR/023.0

4.1 Recommended frequency of routine follow up visits

Routine follow up visits may be provided through a combination of Domcare, MCHN, BF support clinic and Post Acute Care.

Regardless of which services are providing follow up care, the recommended frequency should be as follows:

• Day after hospital discharge

• Daily until >20gm weight gain per day

• 2-3 times/week until above birth weight

Each service has the responsibility of referring onwards to the next service to ensure this frequency is maintained.

4.2  Assessment of baby and mother after discharge, with increased focus on baby assessment.

Maternal Assessment

Conduct routine maternal postnatal assessment.

Baby assessment

• Vital signs during the first home visit. Repeat at subsequent visits if indicated.

• Assess for jaundice, tactile warmth, colour, alertness and frequency of feeds.

• Output and hydration frequency, quantity and description

• Mothers description of contentment, behaviour, sleeping and crying patterns

• Weight daily/second daily according to clinical circumstances

• Supplementation: type, amount and frequency if applicable

• Utilise the Appendix 4 - Post Discharge Problem Solving Flow Chart to decide on appropriate actions following assessment

4.3     Problem Solving

For conditions such as poor weight gain (<20 g/day), poor feeding, low urinary and stool output refer to Appendix 4 - Post Discharge Problem Solving Flow Chart

Breastfeeding difficulties

• Assess mothers technique and provide guidance as required

• Increase skin to skin contact and baby led attachment

• Consider switch feeding for sleepy baby / poor weight gains

• Oral examination of structural and neurological anomalies such as tongue-tie, motor weakness or asymmetry - consider referral to BF Clinic, Allied Health &/or Paediatric Feeding Clinic

• Consider short term use of a nipple shield if attachment difficulties persist despite attention to positioning and attachment technique

• If low supply is suspected, refer to BGHB Clinical Guideline CPP0010 Breastfeeding Challenges Low Supply (see related documents)

• Refer to BHS Breastfeeding Clinic if required

• Consider referral to paediatric feeding clinic and other allied health services if feeding problems persist.(see point 4.2.6) Use Allied Health Outpatient Referral Form MR/023.0

5. Evaluation, monitoring and reporting of compliance to this guideline

Compliance to this guideline or procedure will be monitored, evaluated and reported through the following:

• All staff consulting with women and their babies within the scope of this guideline should review the documented treatment plan to determine consistency with this guideline

• Where a treatment plan significantly deviates from this guideline resulting in suboptimal care, the staff member should complete a VHIMS report.

• Breastfeeding Services will review all reported incidents of non-compliance reported through VHIMS and develop an action plan to address issues as required.