Expressed breastmilk (EBM) is the optimum form of nutrition for newborn and young babies who are not able to be fed directly from the breast. This may be due to factors such as illness in mother or baby, prematurity, feeding difficulties, mother/baby separation.

Some breastfed babies will need supplementary EBM feeds for medical or social reasons (e.g. mother returning to work)

This guideline outlines methods of expressing, storing, transporting, checking and feeding EBM to breastfed babies.

Alternative methods of feeding EBM (and/or supplemental formula if required) should be used until the baby can breastfeed, in order to support the successful initiation and establishment of breastfeeding.

The objectives of this guideline are to :

• Provide adequate nutrition and hydration for a baby with EBM when direct breastfeeding is not possible

• Preserve the nutritive and protective properties of EBM through safe storage, handling and transport.

• Preserve the innate reflexes and natural instinctive behaviour of the breastfeeding baby.

• Ensure appropriate checking of EBM so that it is fed to the correct baby.

• Implement Step 5 of the Baby Friendly Health Initiative, 'Support Mothers to Initiate and Maintain Breastfeeding and Manage Common Difficulties"

• Implement Step 6 of the Baby Friendly Health initiative 'Counsel Mothers on the Use and Risks of Feeding Bottles, Teats and Pacifiers'

EBM - Expressed Breastmilk.

'Hands Off Technique' (H.O.T.) - use of teaching aids, such as a breast model to demonstrate how to hand express milk.

Nipple Confusion / Nipple preference - a baby may develop difficulty in achieving the correct oral configuration, latching technique and suckling pattern necessary for successful breastfeeding after bottle feeding or other exposure to an artificial teat. This is more likely in the early establishment stages of breastfeeding.

PN - Postnatal ward.

SCN - Special Care Nursery.

BPA - Bisphenol: An industrial chemical used in the manufacture of plastics that my be harmful to health.

All staff providing care for newborn breastfed babies and their mothers should be aware of and apply this guideline in clinical practice.

If alternative feeding is being considered and a feeding difficulty is present, multidisciplinary team input into planning and management is recommended. This may include an International Board Certified Lactation Consultant (LC), Speech Pathologist, Dietician, Paediatrician and other healthcare professionals as indicated.

• EBM is a living body fluid, therefore certain components are sensitive to refrigeration, freezing and heating.

• Many situations arise where a mother may need to express milk. Therefore, in the immediate postpartum period, all mothers should be taught how to express and store their breastmilk.

• Generally, expressing during the first few days following birth should be done by hand until the milk is in around day 3 to 5.

• However in some situations, a breast pump with an 'Initiate' program may be used in the first few days.

• Frequency of expressing will depend upon the reason for expressing.

• If a mother is discharged home expressing all feeds then she may need to hire a hospital grade electric breast pump until her milk supply is established.

• Expressing times and volumes for mothers on the PN ward can be documented on MR 450.0 Infant Care Chart.

• Mothers who are expressing long-term for preterm or unwell babies should be encouraged to maintain an expressing diary to monitor supply. They should be offered ongoing contact with an International Board Certified Lactation Consultant or Maternal and Child Health Nurse.

1. Expressing to establish and maintain an adequate breastmilk supply.

Standard expressing routine

• Commence hand expressing within 1 hour of birth if baby is not able to breastfeed

• Continue to express at least 8-10 times within every 24 hours for around 15-20 minutes

• Express at least once between midnight and 5 am

• Express until the milk flow ceases or for 15-20 minutes each side

• Refer to Appendix 1 for suggested method of expressing depending on clinical situation

• Refer to Appendix 2 for tips to increase breastmilk supply when expressing for a preterm or unwell baby.

2. Methods of Expressing

For information about the best method of expressing according to the clinical situation - refer to Appendix 3 - Initiating and establishing breastmilk supply when expressing.

2.1 General principles for all expressing methods

• Breasts should be handled gently as breast tissue is delicate and can be easily bruised or damaged

• Where possible, the mother should be with her baby when expressing as this often helps with milk flow. When this is not possible a photo of the baby may help, alternatively talk about the baby with the mother. Providing clothing or fabric with baby's scent may also assist when expressing.

• Wash and dry hands before beginning

• Ensure the mother is sitting comfortably

• Ensure warmth and privacy and drinking water nearby

• Relaxation can assist with milk flow, so minimise distractions as much as possible

• Gently massage the breast from the top down towards the nipple, including the underside of the breast. Do this a couple of times

• Gently roll or stimulate the nipple with the fingers for 10-30 seconds to stimulate the let-down reflex.

2.2 Hand expressing

Method of hand expressing may be demonstrated using a knitted breast. Ideally, the mother should express her own breasts, but may also require assistance.

• Follow general expressing principles as above

• Place the thumb and forefinger widely apart on the edge of the areola, opposite one another, then gently press the thumb and finger back towards the chest wall into the breast tissue. Gently squeeze the thumb and finger towards each other through the breast tissues, then release the pressure

• Avoid sliding the fingers forward over the nipple or pinching and squeezing the nipple

• Continue with a rhythmical compress / release action as the milk starts to flow

• It may take a few minutes until the let-down occurs, so the mother should be encouraged to keep trying

• Collect drops of colostrum with a clean spoon, syringe or cup. Larger volumes can be collected into a clean, wide mouthed container

• When milk flow slows down, rotate the position of the fingers and thumb around the areola to ensure thorough breast drainage

• Change hands a couple of times to avoid muscle fatigue

• Continue until the flow eases then begin on the other side. The mother can alternate breasts a couple of times with each expression

• Reassure that only a small amount of milk may be expressed at first while she is learning

• There may be mild discomfort at first but hand expressing should not be painful.

2.3 Expressing with a breast pump

• Follow general expressing principles as above

• Follow manufacturers instructions for the specific breast pump in use

• Instructions for use are attached to all Symphony Breast pumps within the hospital.

• Ensure all equipment is assembled correctly (disposable milk collection kits are supplied for inpatients)

• Select a suitable breast shield size (Medium, Large or Extra Large) to avoid compression and friction of the nipple. A breast shield sizing guide (stored with breast pump collection kits) may be useful.

• Beginning with hand expression as above may help to stimulate the flow of milk

• Place the breast shield over the nipple and areola, ensuring that the nipple is in the centre,

• Apply gentle pressure to hold shield in place and form seal.

2.3.1 If using a manual breast pump

• Rapid movement of the piston or handle to begin may help to initiate the let-down reflex

• Once milk is flowing, the piston / handle should be operated in a smooth, rhythmic compress/release action, avoiding prolonged suction

• Change to the other breast when milk flow slows significantly

• The pump can be alternated from breast to breast as often as required to maintain milk flow.

2.3.2 Using the Medela Symphony 'Initiate program

• The 'initiate program is available on all Symphony breast pumps in the Special Care Nursery (SCN) and PN ward.

• It is designed for use by a woman whose baby is not able to breastfeed in the first few days after birth. It can be used from Day 1

• It is a stimulatory program, mimicking the suction pattern of a baby in the first few days of life.

• Colostrum is often not easily collected when using the program due to it's thick consistency. To collect colostrum, the mother should hand express into a cup or syringe for at least 5 minutes on both breasts immediately after using the initiate' program.

• As soon as there are signs of milk coming in (breasts feeling heavy and firm), or after 48 hours, change to the 'maintain' (standard) program.

• See next section for use of the Symphony Pump when using either the initiate or the maintain program.

2.3.3 Using the Medela Symphony breast pump 'maintain' program'

• The 'maintain' program is designed to be used to 'maintain' lactation once the milk is in.

• Expressing both breasts at the same time (double pumping) is recommended when using an electric breast pump. However some mothers prefer to do one breast at a time

• Follow expressing with a breast pump principles as above

• Place one breast shield onto the breast

• Switch on the breast pump using the on/off button

• Adjust the vacuum to maximum comfort by slowly turning the central knob clockwise until the mother feels some slight discomfort (not pain) then decrease the vacuum slightly until it is comfortable

• Place the second shield over the other breast

• The pump will begin in the stimulation phase and continue for two minutes before automatically switching to the 'expression phase'

• If milk let-down occurs before two minutes, the pump can be manually switched to 'expression phase' by pressing the 'let-down button' (an arrow and drops on the button)

• Express until the flow slows and the breasts are softer and lighter; generally no longer than 15-20 minutes for both breasts is recommended

• If expressing one breast at a time, express the first breast until flow starts to slow, then switch to the second breast. Repeat the above procedure 2-3 times.

• Once milk is able to be easily collected using the 'maintain' program on the symphony pump, a short period of hand expression after pumping becomes optional.

3. Cleaning and storage of expressing equipment

3.1 In hospital

• All equipment used for expressing should be washed after use as follows:

  • Remove kit AND tubing form the pump. (Tubing should not be shared between mothers)

  • Tubing does not need to be washed but can be wiped with a Clinell wipe if soiled

  • Dismantle kits and wash in warm soapy water

  • Rinse in warm water

  • Air dry

  • Store kit and tubing in clean container or plastic bag and keep at bedside or cotside until needed again.

• Disposable kits should be discarded after 24 hours or 8 uses

• Re-usable kits purchased by the mother do not routinely need to be sterilised but should be washed and dried as above. Re-usabale kits should not be shared between mothers

• Containers used for storage or feeding are single use only within the hospital. Used containers may be taken home by parents and re-used after cleaning and sterilising as per section 3.2

• Breast pumps should be wiped over after every use with Clinell wipes.

3.2 At home

• Sterilisation of equipment used for expressing and storage of breast milk is not routinely required

• Equipment should be washed and dried as above

• If containers taken home from hospital are used to store or feed infant formula they must be sterilised in between each use by boiling or steam sterilising methods

• If any breast infection is present (e.g. Thrush) or the kit/equipment is contaminated by others, then it should be sterilised by boiling or steaming.

4. Storage of EBM

4.1 Storage containers

EBM should be stored in a sealed, clean food grade container. Appropriate storage containers include:

• breastpump kit collection bottles

• oral syringes (if only small volumes of EBM)

• hard plastic containers with a fitted lid e.g. a sterile specimen container

• breastmilk collection bags

• Bisphenol A (BPA) free feeding bottles

EBM which has been cooled in the fridge can be added to already cooled or frozen EBM.

If freezing EBM, a space should be left at the top of the container to allow for expansion during freezing.

4.2 Storage in hospital areas

4.2.1 If mother is expressing antenatally

• Mother must label with MOTHER's name, UR and Date of Birth - use a Bradma label if preferred

• Colostrum is stored in the mother's home freezer until brought into hospital during labour and birth

• Store in PN milk room freezer - do not thaw until required.

4.2.2 Special Care Nursery (SCN) and Paediatric unit (2 South)

Storage containers must be labelled with:

• BABY's name, UR number and Date of Birth.- use milk labels or Bradmas if preferred

• Time and date of collection

• If thawed, date and time of thawing

• Any additives (e.g. human milk fortifier).

EBM is stored in SCN or 2 South milk room.

4.2.3 Postnatal (PN) ward

Storage containers must be labelled with:

• MOTHER's name, UR and Date of Birth. - use a Bradma label if preferred

• Time and date of collection

• If thawed, date and time of thawing.

EBM is stored in the PN milk room refrigerator. If mother and baby are in a private room with a fridge, EBM may be stored there.

If EBM is to be used within the next 6-8 hours, it may be labelled and stored at the mother's bedside or the baby's cotside as long as the ambient room temperature is 26C or lower.

EBM to be used immediately does not need to be labelled as long as it does not leave the bedside.

4.2.4 Other hospital areas

Storage containers must be labelled with:

• MOTHER's name, UR and Date of Birth. - use a Bradma label if preferred

• Time and date of collection

• If thawed, date and time of thawing.

As EBM is a food item it can be stored in food refrigerators in ward kitchens. Containers can be placed into a plastic bag if preferred.

4.2.5 Storage times

5. Preparing EBM for a feed.

5.1 Warming EBM

• Use the oldest stored EBM first

• Gently swirl the container to mix EBM before using (inform mothers that milk may separate into two layers)

• Warm EBM by placing the bottle/container into a small bowl with warm tap water (not boiling) or in a bottle warmer

• Do NOT warm in a microwave as this can:

  • destroy some of the nutrients and

  • heat the EBM unevenly increasing the risk of burns to the baby's airway

• Warmed milk should be fed to the baby immediately - test that it is not too hot before feeding

• Discard any leftover EBM within 1-2 hours after the baby has finished feeding

• Never refreeze or reheat breastmilk.

5.1 Thawing frozen milk

• There are different options for thawing frozen EBM:

  • Remove container from freezer and place it in a small bowl or jug of lukewarm water. Do not leave out for more than 30 - 60 minutes. After this time place container in fridge

  • Remove container from freezer and place into fridge to thaw overnight

  • Use thawing function on bottle warmers in SCN

• Do not thaw in a microwave (see above)

• Once thawed, prepare and warm as above (point 5,1)

• Use thawed EBM within 24 hours

• Do not re-freeze thawed or warmed EBM

• Write date and time of thawing on the container label.

6. Procedure for checking EBM before feeding

For the purpose of this section, the original storage container is the container which was used to store the EBM in the refrigerator.

The feeding device refers to a bottle, cup, syringe or any other device which holds the EBM during the time the baby is fed.

When a baby is to be fed with EBM the following steps must be followed:

1. The original storage container is removed from the fridge. The date and time of collection is noted, if this exceeds recommended storage times as above, it should be discarded and not used

2. If a feeding device (not the original container) is to be used, a label with the baby's name, UR number and Date of Birth should be attached to the feeding device

3. The amount of EBM for the feed is measured into the labelled feeding device if required

4. The original storage container and labelled feeding device should be checked by two people - midwife, nurse, doctor, or the baby's parent/carer - to ensure that the baby's name, UR number and Date of Birth match

5. The labelled feeding device is then taken to the baby and the same two people check the baby's name, UR number and Date of Birth against the baby's ID bands

6.. The infant's feeding / fluid balance chart is initialled in the appropriate column by the two people checking the ID.

N.B. Mother's are not expected to sign these charts - if EBM is checked by a staff member and a mother, the staff member can write 'mother' in the 2nd person's signature area.

 7. Transporting EBM

• Transport EBM in an insulated container such as a small esky with a freezer brick

• There should be no undue delay in transport in this manner - less than 2 hours is ideal

• If some EBM has thawed during transport, it should be placed in the refrigerator and used within 24 hours

• Do not refreeze EBM

• Place the EBM in the freezer immediately on arrival if it is still frozen.

 8. Alternative feeding methods for breastfed babies

8.1 Choice of alternative feeding methods - general principles

• Breastfeeding mothers should be counselled about the use and risks of using feeding bottles and teats before breastfeeding is established. In order to improve the long term duration of breastfeeding, it is essential to explore with the mother / parent all available alternative feeding options prior to offering the baby an artificial teat

• Choice of alternative feeding methods must primarily consider the clinical needs of the individual baby, however parental preference should also be considered

• Choice of alternative feeding method should take into account

  • volume to be given

  • short or long term use anticipated

  • maternal preference

  • any potential stress for the baby

  • how the method may impact on development of breastfeeding skills for both baby and mother

• Once an option is chosen, the mother / parent is supervised with the alternative feeding technique until they are confident and the baby is able to take adequate amounts of milk via the chosen method

• Flexibility is required and chosen options may need to be modified depending on changing needs

• Education is provided regarding the initiation and maintenance of milk supply through breastmilk expression

• Frequent skin-to-skin contact is encouraged

• An infant feeding plan should be documented for the parents and all staff

• Babies experiencing feeding difficulties should be considered for referral to appropriate services such as Speech Pathology and an International Board Certified Lactation Consultant.

• When direct breastfeeding has not been possible, it should be resumed or commenced as soon as possible.

8.2 Before the feed is commenced:

• The baby should be in the quiet, alert state prior to feeding by alternative methods. Therefore, the baby is not crying, has a focused gaze, with regular respirations and heart rate

• The baby should be observed for signs of stress when feeding with alternative methods. If the baby becomes stressed, feeding should be paused, and the baby supported to return to the quiet alert state before resuming the feed

• Stress signs include stiffening, fussing, crying, gagging and colour change. If the baby does not return to the quiet alert state, the method of feeding should be re-evaluated and an alternative method selected

• Skin-to-skin contact, or wrapping and rocking will assist in calming the baby.

8.3 Cleaning alternative feeding equipment

• All equipment should be clean and standard infection control measures taken

• All equipment used should be disposable or dedicated equipment which is sent to CSSD between users.

8.4 Methods

8.4.1 Finger feeding

• Finger feeding facilitates proper use of the oral muscles, promotes optimal coordination of the suck-swallow-breathe and allows the baby to pace the feeding

• May be useful for a baby who is sleepy and not interested in above techniques

• May be used with a syringe alone (smaller volumes) or a syringe and milk straw or feeding tube (for larger volumes)

• May be considered invasive and a full explanation should be given to the mother

• Not ideal if the baby displays oral aversion.

Method

1. Wash hands and assemble equipment which includes a syringe of required volume and a milk straw or 5fg nasogastric tube

2. The baby is wrapped and held in a semi-upright position. Alternatively the baby can be lying supine but slightly elevated in their cot

3. Warm the EBM if required and draw up the entire volume to be offered into the syringe

4. Put on gloves unless the baby is being fed by it's parent

5. Use a large finger (as the breast would normally fill the baby's mouth)

6. Gently stimulate pouting (touch/tap the lip in the mid-line) and rooting reflexes by stroking from the corner of the baby's mouth to the cheek

7. Slide the finger (pad up, nail down) slowly and gently into the baby's open mouth, until it is near to the junction of the hard and soft palate limiting extent of excursion to prevent a gag reflex

8. Gentle upward pressure on the posterior hard palate will stimulate the sucking reflex

9. Insert the syringe or feeding tube gently into the corner of the baby's mouth alongside the finger. If using a feeding tube, the tubing can be taped to the finger, with the end of the tube close to the end of the finger

10. As the baby sucks, carefully deliver a small amount of milk into the baby's mouth using the syringe

11. Milk should be delivered slowly and only when the baby sucks on the finger

12. Avoid moving the finger in and out of the mouth during the feed - the finger pad should stay in contact with the palate throughout the feed

13. Allow the baby to pause frequently as required during the feed

14. Some babies are able to suck milk from the syringe or tubing without the feeder having to push on the plunger

15. Monitor the baby's colour and vital signs, especially if the baby is low birth weight, has poor muscle tone or structural defects and refer as indicated to the appropriate discipline/s

16. Stop the feed immediately if the baby shows signs of distress, gags, or vomits

17. Document volume, type and feeding method on baby's feeding chart.

8.4.2 Spoon feeding

• Ideal for giving small amounts of colostrum in the first few days after birth

• Easy to express small amounts onto spoon

• Can drop small amounts of colostrum/breastmilk directly into baby's mouth

• Has the advantage of being able to scoop up milk that has been spilt or spat out by the baby so that none is wasted

• Mother can manage with minimal instruction

• Readily available in the home setting

• Not ideal for large volumes of milk

• Risk of spillage.

Method

1. Wash hands and obtain equipment

2. Demonstrate hand expressing to the mother using knitted breast model and 'hands off technique'

3. Milk is expressed straight onto the spoon, or into container

4. The baby is wrapped and held in a semi-upright position

5. Place the spoon at an angle to the baby's lips

6. Allow the baby to pace the feed and lap from the spoon: do not tip milk into the mouth

7. Feed small amounts at a time, allowing the baby to swallow frequently

8. Document volume, type and feeding method on baby's feeding chart.

8.4.3. Cup Feeding

• May help to preserve breastfeeding duration when multiple supplemental feedings are required

• May be easier and faster than other methods when the mother is not present

• May be more successful when the baby is wide awake and showing active feeding cues

• The baby is usually more physiologically stable during cup feeding than bottle feeding

• Provides a positive oral experience for babies, and stimulates jaw and tongue movements

• Encourages eye contact

• Risk of spillage

• No sucking stimulation, therefore, the baby may settle better if sucking the mother's finger post-feed

• Avoid cup feeding with babies who have a poor gag reflex, (e.g. cranial nerve dysfunction), neurological deficits and respiratory problems.

Method

1. Wash hands and obtain equipment

2. A small disposable smooth rimmed container such as a pill cup is suitable

3. Milk can be expressed directly into the cup if small volume

4. The baby is wrapped and held in a semi-upright position

5. Bring the cup to the baby's mouth and rest lightly on the lower lip with the edges of the cup reaching the outer corners of the baby's mouth to prevent overflow

6. Tip the cup so that the milk is touching the baby's lower lip

7. The baby will extend the tongue to take a bolus of milk into the mouth, by 'lapping'

8. Allow the baby to pace the feed and lap from the cup: do not tip milk into the mouth

9. Leave the cup in the same position throughout the feed. There is no need to remove the cup as the baby will self-regulate their intake

10. Document volume, type and feeding method on baby's feeding chart.

8.4.4. Tube feeding device at the breast (Supply line)

• May require support from an International Board Certified Lactation Consultant

• Useful for situations of low supply, re-lactation, induced lactation, adoptive breastfeeding

• Often referred to as a 'supply line' or a 'nursing supplementer'

• A bottle of breastmilk (or formula) is placed around the mother's neck with a fine tube taped near the nipple

• When the baby feeds at the breast they can get milk via the supply line at the same time

• May be a useful method of supplementation for a baby who is awake and will latch and suck at the breast

• Encourages the baby to breastfeed as he/she will be rewarded for their sucking efforts

• Beneficial for a mother who needs to give supplementary feeds to the baby for long periods of time

• Requires commitment from the mother as it can be challenging and time consuming

• For short term use may use a disposable 5fg nasogastric feeding tube with a 20-50ml syringe with the plunger removed

• For long term use the mother may purchase a "supply line" kit.

• PLEASE REFER TO APPENDIX 4 FOR GUIDELINES FOR SHORT TERM USE OF TUBE FEEDING DEVICE ON THE PN WARD

Method

1. Wash hands and prepare equipment, either 5fg NGT and syringe or dedicated supply line kit

2. Ensure privacy and support for the duration of the feed

3. Warm the EBM (or formula if used)

4. Place bottle around mother's neck or support the syringe for the mother

5. The top of the bottle or syringe should be at nipple level

6. Use tape to keep the tip of the supply line in place and align it with the nipple

7. Assist the mother to attach the baby to the breast and when attached unclamp the tube on one side

8. Milk from the bottle will siphon into the baby's mouth as the baby sucks

9. The milk flow can be adjusted by increasing or decreasing the height of the bottle if required

10. Repeat on the second breast if required

11. When the feed is complete if the equipment is not disposable it may be washed in hot soapy water, rinsed well and air dried

12. Document volume, type and feeding method on baby's feeding chart

8.4.5. Bottle feeding

• Bottles and teats are only used for babies who have not yet established breastfeeding if other alternative feeding methods are not practical or feasible for a mother/baby dyad

• A bottle and teat may be effective to stimulate the sucking reflex if the mother and baby are separated and long term feeding is required

• The use of a bottle may shorten the duration of breastfeeding and some babies may develop a preference for artificial teats

• The use of a bottle may lower the mother's confidence in her ability to breastfeed her baby

• The mother should have a full informed consent documented in the baby's notes prior to using bottles and teats and all other options should be explored first

• 'Paced' bottle feeding allows the baby to feed more slowly with pauses, similar to breastfeeding

• Intermittent use of bottles and teats when breastfeeding is well-established for infants whose mothers are returning to work, studying or attending social engagements does not appear to have detrimental effects.

Method

1. Wash hands and collect disposable bottle and teat. Select teat type according to baby needs but generally a straight slow flow teat is needed

2. Place milk in bottle and warm gently

3. Apply teat to bottle and check the temperature of the milk

4. The caregiver should cradle the baby in the arm and cuddle close, holding gently but firmly

5. The baby should be in a semi-upright position

6. Stimulate the rooting reflex by brushing the teat on the lips and slide the teat into the mouth until the sucking reflex is stimulated

7. The neck of the bottle should be kept at a slight angle so it is filled with milk until the baby has finished

8. Withdraw the teat slightly every few minutes to allow the baby to take a pause

9. Allow the baby to pace the feed - most babies will finish a feed in around 10- 20 minutes depending on the volume

10. Document volume, type and feeding method on baby's feeding chart.

8.4.6. Nasogastric tube feeding

• This is invasive and may be indicated for a baby who is not able to suck and swallow effectively

• A baby requiring nasogastric tube feeds may have more serious medical issues that require investigation and involvement of a multidisciplinary team

• Suitable for the administration of EBM and/or formula over a long period

• Ideal for the preterm baby who is yet to develop a strong sucking reflex and unable to maintain nutritional requirements through suck feeding

• Should only be inserted and managed by an experienced clinician

• A nasogastric tube may remain in-situ for up to 7 days

• Advantage is no spillage

• Not ideal for the term baby unless medically indicated

• The baby is not able to regulate volume and must be observed for vomiting and aspiration

• Nasogastric feeds can be given while the baby is held in skin to skin contact or at the breast.

Method
See Ballarat Health Services Clinical Practice Guideline: Neonatal Oro/Nasogastric tube - insertion and feeding (in development)

Paediatric Insertion & Confirmation Of Correct Placement Of Nasogastric And Orogastric Tubes

8.4.7 Specialist Feeding Equipment

• A number of specialist feeding teats and bottles exist such as the Pigeon Cleft teat, ChuChu teat, squeeze bottle and Haberman/Special Needs Feeder. These can be used for babies with feeding difficulties, including those with cleft palate

• The Haberman special needs feeder is available in different sizes and volumes for term and preterm babies. It rewards babies who have a weak sucking effort and the one-way valve prevents flooding and overwhelming the baby.The special needs feeder can also help the baby develop facial muscles and improve the sucking response.

• The Haberman Special needs feeder is not disposable and should be sterilized between users in the hospital setting. If it is to be used as an ogoing feeding option after discharge from hospital, the family will need to purchase their own.

• The Pigeon Cleft Palate teat is designed specifically for infants with a cleft palate. These infants are often diagnosed in-utero; in this case the mother should be referred to an International Board Certified Lactation Consultant and Speech Pathologist antenatally. Speech Pathology can arrange an inital supply of the Pigeon Cleft Palate bottles and teats, after which the family will need to purchase their own supply.

Method - Haberman Special Needs feeder - This is usually demonstrated to the parents by a Speech Pathologist or International Board Certified Lactation Consultant

1. Wash hands

2. Prepare equipment, place milk in feeder and warm gently

3. Position the baby as above "bottle feeding" or feed in an upright position to decrease the amount or air regurgitated

4. The slit valve in the teat regulates milk flow from zero to maximum depending on the position in the baby's mouth

5. Milk is drawn out of the teat by the slightest action of the baby's tongue and gums and air enters the bottle at the same rate through an inlet groove in the disc

6. Milk flows in one direction into the reservoir behind the teat and then to the baby with minimal effort from the baby

7. If the baby has no sucking effort the teat may be squeezed gently to release a limited amount of milk (about teaspoon) from the reservoir into the bay's mouth

8. The squeezes can be paced to the rate the baby can drink and the caregiver should observe the suck swallow breath pattern to ensure the baby doesn't gag, cough or vomit

9. Document volume, type and feeding method on baby's feeding chart.

Method - Pigeon Cleft Palate Bottle and Teat - This is usually demonstrated to the parents by a Speech Pathologist

1. Wash hands

2. Prepare equipment, place milk in feeder and warm gently

3. Ensure that the white milk flow regulator is always used with the teat. Push the teat into the ring cap or platform. Ensure that the notch (air valve) on the teat is visible. Check that the y-cut on the teat is working.

4. Tip the bottle upside down, squeeze the teat with your finger so that the milk runs into the teat before starting the feed

5. Position the baby as above "bottle feeding" or feed in an upright position to decrease the amount or air regurgitated

6. When feeding the baby, make sure that the air valve (notch on teat) is in line with the baby's nose.

7. Refer to the Paediatric Speech Pathology Infant Feeding Equipment and Procedures guide for Nursing Staff in SCN for further information about using the Pigeon Cleft Palate Bottle and Teats.