2.1 Staff & equipment
All staff should be aware of and competent in following the unit breastfeeding protocol.
Prevention of infection and cross infection will be optimised with excellent hygiene and aseptic techniques on the part of staff and mothers.
As with all equipment and utensils used for feeding neonates, cleaning and sterilisation procedures should be followed. In the majority of cases a policy of single patient use should be adhered to.
· Bottle
· Syringe
· Cup
· Cup and Spoon
· Finger feeding
· Nursing supplementer (proprietary or tube and bottle)
· Nasogastric tube
Bottle
· Much has been made of the possible “nipple confusion” a baby may suffer as a result of being offered anything teat shaped other than the mother’s nipple. There is little researched evidence for this, but the physiology of sucking at a bottle is quite different to that of suckling at the breast. Babies who learn to suck from a bottle may subsequently refuse the breast because of other factors besides the different shape, often being unwilling to suckle at the breast unless milk is dripping freely from the nipple as when a bottle is tipped into the mouth, or refusing to take the nipple far enough into the mouth in order to commence suckling. Using a bottle, the sucking reflex is forced upon the baby as the hard teat touches the junction between soft and hard palate.
· Babies who have little difficulty suckling at the breast may switch happily between a bottle and the breast, but if this is so, in the early days there will no need to supplement the baby in normal circumstances.
· As is stipulated in the Breastfeeding Protocol, staff should not recommend artificial teats when mothers choose to breastfeed.
Cup
· Thorough research on cup feeding, especially with term babies, is scanty but anecdotally and in small research studies it has been shown to be a successful way of feeding babies without them establishing a preference to bottle feeding.
· It is a method used in preference to bottles for all babies not breastfed or who need expressed milk in many developing countries.
· Cup feeding must be carried out properly. The baby must have control not the mother or carer.
· The baby should be held sitting upright with the hands gently restrained.
· The cup should be tilted to allow milk to just reach the baby’s lips.
· The cup should rest lightly on the baby’s lower lip, and the edges of the cup should touch the outer part of the baby’s upper lip.
· The baby will lap or sip the milk; it should not be poured into the baby’s mouth.
· Term infants tend to spill milk while cup feeding.
· When the baby has had enough, the baby will close his or her mouth and refuse to take any more.
· A baby who has not taken enough may take more the next time, or you may increase the frequency of feeding.
· Preterm infants appear to cupfeed well and it may provide a positive oral experience for them when the mother’s breast is not available, and is less tiring for them than bottle-feeding.
· For babies who are not alert and refuse to cup feed, consider whether it is necessary to give the baby a feed at all. Is he just not hungry? If it is medically necessary despite the baby not demanding to be fed, another method of feeding should be considered such as a nasogastric tube.
Cup and spoon
· Although infrequently used, this may be a useful method of feeding very small amounts to babies, for example when small volumes of colostrum are given.
· Occasionally this method is useful for feeding babies with a cleft lip and palate.
Syringe
· This method is only really of advantage if used for very small amounts of fluid, as when giving small volumes of colostrum. The syringe should be inserted into the side of the baby’s mouth after encouraging the baby to root and open the mouth wide. Very small amounts of fluid should then be slowly dripped into the mouth – for example: 0.1-0.3 millilitres at a time.
· A syringe is not advised if the baby needs large volumes as it requires the carer to push milk into the baby’s mouth and takes control of the rate of flow away from the baby, with the risk of choking.
Finger Feeding
· This can be a very successful way of feeding a baby who is having suckling difficulties as it also involves suck training.
· The mother should be taught how to finger feed from the first instance to avoid the health carer using her own finger.
· Nails must be short and the hands clean.
· Either fill a syringe with milk or dip the capped end of a nasogastric tube in a bottle of milk with the other end threaded through a teat, with an enlarged hole, screwed to the top of the bottle.
· If the baby seems unable to suck efficiently, perform some tongue exercises before proceeding. (Allow a finger to be taken back to the far back of the mouth, nail side down, turn the finger over and draw the tongue forwards while withdrawing the finger.)
· Lie the nasogastric tube along the middle (biggest) finger, encourage the baby to root and gape wide for the finger.
· Allow the baby to suck the finger well back into the mouth.
· Feel the baby’s tongue with the finger and wait until the tongue is curved around the finger with a good seal, and the baby begins to suck deeply.
· If using the tube dipped in a bottle the baby’s sucking will draw milk through the tube, if using a tube attached to a syringe, slowly drip milk into the mouth as sucking commences. The finger can feel the rate of flow at the same time as watching the baby’s response and swallowing.
Nursing Supplementer
· When supplementation of the breast is required for a period of days or weeks, this method has the advantage of keeping the baby at the breast at the same time.
· Particularly useful when lactation is inhibited or delayed, as is sometimes the case after breast reduction, severe post partum haemorrhage, or in older primiparae.
· This method may also be successful if a baby needs teaching how to suckle properly but otherwise latches well.
· This method is not advised when the baby has difficulty latching at the breast as enabling the baby to take the tubing and the breast may present difficulties.
· A Medela Supplemental Nursing System may be used (seek the advice of a specialist breastfeeding practitioner) or a nasogastric tube with syringe or dipped in a bottle through a teat as described under “finger feeding”.
Nasogastric Tube
· A nasogastric tube should not be used when other methods of oral feeding could be sufficient.
· Insertion of a nasogastric tube is invasive and upsetting for parents, particularly so on the postnatal ward.
· When a baby is either too unwell or too immature to be fed orally, feeds may be given via a nasogastric tube.
· When the tube is required for feeding for a prolonged period of time, it should be changed every 5 days. It is therefore important to note the date of a tube change on the baby’s care plan.
· As soon as the baby is able to take a sufficient volume orally, even if this is not yet the breast, the tube should be removed.
2.3 Potential complications / Risk Management
Any “unnatural” method of feeding carries a risk.
The main risks to be aware of are:
· Choking – The baby must be encouraged to use his or her own rooting, sucking and swallowing reflexes.
· Nasogastric tubes must be positioned correctly.
· Infection – equipment should be of single patient use. Hand hygiene must be excellent.
· Failure to establish breastfeeding and the associated risks involved. Use of formula carries increased risks of infection, allergy, etc.
2.4 After care
Where a baby needs to have supplementary feeds, extra advice and assistance should be offered to the mother to establish breastfeeding successfully.