Breastfeeding questions

LilPeanut, MSN, RN, NP · Feb 15, 2005

Nipple confusion happens and it's very frustrating. My son was in the NICU and got nipple confusion and we had to finger feed him once we got him home to train him how to breastfeed again. (related to the baby chugging down a bottle, babies will almost always chug down a bottle, especially a preemie because for them it's either drink or drown)

Breastmilk actually helps jaundice in most cases, because it has a natural laxative effect, as opposed to infant formula which is binding. In some cases of blood incompatibility, it can slightly slow the resolution of jaundice, but not enough to indicate the stoppage of nursing. Better in those cases to counsel mom before they go home, how to keep baby awake to nurse, to feed regularly and not go longer than 4 hours (even when sleeping) and to expose the child to sunlight to help with the bili.

If you thaw milk, it needs to be used or dumped, you cannot refreeze it.

pacifiers can be bad, but especially with preemies they help them learn to suck, so they're not all bad. But some kids who have nipple confusion need to stay away from them.

I'd probably disagree that bf is so encouraged in our current culture, there are a lot of pressures on moms to stop or to stop prematurely and they are constantly bombarded with advertising that says that formula A or B is almost as good as breastmilk, when it isn't anywhere close.

fergus51 · Feb 15, 2005

I personally don't believe in nipple confusion. I've had tons of women who bottle feed the first few days and then switch to breastfeeding without problems and had women who don't let anything other than their breast touch the babies mouth, have a hard time. That's just my personal opinion, I think it's just a convenient label.

As far as breastfeeding and jaundice, as long as the baby is feeding well it's not an issue in general like Lilpeanut said. I will point out there is a difference between breastfeeding and sticking a child on the breast to not eat. I have had too many admissions for hyperbilirubinenia because a child is dehydrated. It frustrates me immensely that the nurses where I used to work were so against giving a baby a little formula that they would wind up in my unit under triple photo or in the exchange transfusion range. It doesn't help breastfeeding if they are stuck in the NICU under lights!!! Even if they want to avoid nipple confusion, they can attach a lactation aid at the breast and use that to feed the baby formula (I've done that more times than I can count in the NICU).

As far as pacifiers, in the NICU they are a good thing. I worked in one place where we had to have parental consent to give them because of the fear of nipple confusion (yep, the same place with the constant admits for dehydration related jaundice cause the nurses wouldn't give formula). Once we explain the benefits for premies (which go beyond soothing, there are a lot of physical benefits to NNS in the NICU) most parents were ok with it. The parents who weren't were usually the hardcore breastfeeders, and I had to tell them that was the only thing I had to soothe their child. Without it, the kid will probably cry a lot and there is nothing I could do.

Jolie, BSN · Feb 15, 2005

My answers come from 11 years professional nursing experience, and 2 years of actually nursing my own children, so both a nurse's and mother's perspective.

1. Nipple confusion is highly over-rated! I don't believe that "nipple confusion" is really an issue for about 99.9% of newborn infants. In my experience, it is preferable to offer only the breast for the first several days, until mother and baby are both skilled at nursing, and a good milk supply is established. But I have never seen a baby's ability or desire to nurse be ruined by the occasional artificial nipple, either pacifier or bottle. Remember, breastfeeding is not instinctive. True, babies are born with certain reflexive behaviors that promote breastfeeding, but is a behavior that must be learned by BOTH mom and baby. Some moms and babies learn faster than others, just like any skill, and offering a few sips of formula to a hypoglycemic baby, or a pacifier to a newborn with an insatiable desire to suck is not going to ruin things. (Not that these things should be taken lightly, or done without consulting the parents, but they will not ruin the baby's desire to nurse!) In 11 years of OB/NICU nursing, I can only recall only 2 babies who were unsuccessful in establishing breastfeeding. We worked with these babies and mothers for weeks, long after hospital DC, utilizing a lactation consultant to do home visits, but neither was ever able to establish regular nursing. Frankly, neither of these kids were great bottle feeders either, which leaves me to wonder if there may have been some undiagnosed neurological reason for that. Usually, it is the mother who calls it quits, not the baby, which is too bad, because most times, it is possible to intervene and help establish nursing, if that is what is truly desired.

2. Yes, there is a correlation between breastfeeding and jaundice. The only flaw known to exist in breastmilk is that it contains a substance (the name of which escapes me) that delays the excretion of bilirubin, leading to a potential for newborn jaundice. Since breastfed babies typically receive less volume of fluid in the first few days of life, until mom's milk comes in fully, slight dehydration can also be a factor. Bilirubin levels tend to peak in healthy babies around day 4-5 of life, which is about the time that most mother's milk comes in. Many pediatricians will tolerate a slightly higher bili level in breastfed babies than bottle fed babies. Rarely is "breastmilk" jaundice severe enough to prompt treatment in a healthy full-term infant. Any infant who requires treatment for jaundice should be evaluated for other possible causes, such as undiagnosed infection, or blood type incompatibility.

If treatment is necessary, it can be accomplished at home with home phototherapy. This is the route I chose when my healthy 36 week preemie required phototherapy. No way was I going to admit her to a NICU loaded with germs! Being at home enabled me to continue nursing her. Unless a baby's bili levels are so high as to be approaching exchange levels, it is usually not necessary to interrupt breastfeeding during treatment for jaundice. The quickest way to bring a bili level down is to encourage stooling, which breastmilk does very well!

allnurses Guide · Feb 15, 2005

Jolie and Fergus, great posts and I agree about nipple confusion.

steph

sparkyRN · Feb 15, 2005

In a term or near term baby I have not seen nipple confusion be a problem during the first 2-4 weeks of life. A premie who starts with OG feedings then bottle feedings may have a harder time latching onto the breast and may or may not be successfully trained to make the switch.

t2000JC · Feb 15, 2005

thanks to all those who have posted or who will post..i have been a nicu nurse for about 4 years but still like to hear that what i have been taught is still relevant, especially when i have parents ask questions...t.

so, do you still think that bf should be held for a patient readmitted for hyperbili (I guess it depends on how serious the level is). t.

fergus51 · Feb 15, 2005

We hold breastfeeding if the baby NEEDS to be under the lights. If a baby is under triple photo, I would not take him out to breastfeed. By that point we need to measure their intake. Plus at that level of jaundice, they're usually not going to feed well anyways. I will NG feed, cup feed or finger feed under the lights if the parents don't want them bottle fed. Most nurses will only NG or bottle where I work.

KRVRN, BSN, RN · Feb 15, 2005

Regarding hyperbili readmits... We don't see them that often, but if we do it's almost always a smallish, maybe even somewhat premature (35-36 wks) baby that's been exclusively BFing. When we question the mom about how the baby's been eating, we often hear something to the effect of "he would latch for a few minutes yesterday and then fall asleep, and then hasn't eaten all day today." Or if the baby has "breastfed," we discover that what mom is calling "breastfeeding" is what we would call "not latching and sleeping at the breast with the nipple in his mouth." Education without making an already tearful mom feel like a failure takes some skill!

We still allow moms to BF, we just don't remove the baby from under bili lights for longer than 30 minutes at a time, and we keep the baby on IV fluids at an NPO rate. If we want to wean the IV rate, we require the baby to bottlefeed a known amount of formula or pumped milk. We explain that feedings and fluid intake have just become extremely important and that formula or artificial feedings (other than exclusive BFing) are going to have to be done temporarily. On the rare occasion that a mom is still against anything but exclusive BFing, we give her the exchange transfusion and kernicterus talk.

Regarding pacifiers... A well baby that is close to the mom and able to BF or be cuddled whenever the baby wants can probably do without a pacifier. It is nothing short of barbaric to expect an NPO term baby that can't be taken off the bed to be cuddled and has to undergo painful procedures to do without a pacifier.

LilPeanut, MSN, RN, NP · Feb 16, 2005

I want to qualify slightly what I said. I think the term nipple "confusion" isn't really the problem.

With a bottle, a child must move their tongue up to regulate the flow of milk to keep from being overwhelmed with the liquid, it comes out really whether the child sucks actively or not. In breastfeeding, the child must actively work, plus keep their tongue down and forward. If you put your own thumb in your mouth, you normally revert to the correct nursing position for the tongue. Then they have to move their tongue in a wave motion to get the sinuses to eject milk and all in all, especially prior to let-down, it's a lot more work for a baby who is being breastfed (which is actually one of the benefits and why it promotes proper mouth and jaw development)

My son was "nipple confused", in that he had a few bottles and got used to the milk pouring down his throat. He liked that, it involved no work on his part, he just got all the milk easily. So, he would be put to the breast and scream, because here was a nipple and there wasn't milk pouring out. Or he'd fall asleep, again for the same reason.

Sometimes they forget how to get the coordinated motion for ejecting the milk, which is why fingerfeeding can help, retraining them to suck the "right" way. Or having the mom pump until she lets down and then putting the baby to breast then.

I do wish more moms would be taught fingerfeeding or cup feeding, because I know with both my kids (34w and 35w) they couldn't afford to skip any meals. So if they had a bad nursing session, or a questionable one, I would make sure they got enough milk. Too many moms aren't taught what successful nursing looks like and how to watch output to make sure input is adequate.

fergus51 · Feb 16, 2005

Lactation consultants have always told me that breastfeeding was not more work for the infant. With our premie nipples, it is actually a lot of work for kids to get formula from the bottle. We don't want it to pour down their throats for obvious reasons;) They don't normally get immediate milk from breastfeeding, but that's pretty easy to resolve either by having mom express a little milk onto the nipple before latching the baby or by using a lactation aid at the breast for the first few seconds. I know it is a different type of movement required for bottling, but I didn't think it was "easier" or "less work" than breast feeding. Anyone have any info on this?

deegale · Feb 16, 2005

I have sucsessfully breast fed two children and am now breastfeeding my third. Breastmilk is what nature intended and is in every case the best food for your baby. Humans are the only species of animal that feeds it's young milk from another animal (a elephant does'nt feed its young girraff's milk). None of my babies have ever had nipple confussion. You can express milk and refridgerate or freeze it, but you cannot refreeze breastmilk or warm it in the microwave. None of my kids ever took a pacifier.