Evidence‐Based Practice to Improve Outcomes for Late Preterm Infants

Supporting Public Health Nurses with Breastfeeding Interventions for Late Preterm Infants

“…Teach parents and caregivers to recognize the signs of physiologic instability and stress that include: change in state of alertness; change in postural control or tone and movement patterns; change in cardiorespiratory behavior (change in baseline color to pallor or cyanosis, respiratory fatigue, tachypnea -greater than 60 breaths per minute, nasal flaring and or blanching, chin tugging -a movement in which the infant extends his/her neck and pulls the chin up in an attempt to open the airway for breathing, shallow short breaths instead of a series of deep breaths, bradycardia, apnea); uncoupling of swallowing and breathing (loss of bolus control orally or drooling; gulping, gurgling sounds in the pharynx, multiple swallows to clear bolus, coughing and/or choking) [36,37,40,41,42] Teach parents and caregivers how to recognize the early signs of stress and promote conservation of energy. This may set parents and LPIs up for successful feeding experiences [39] Assist parents and caregivers to think critically about what they are observing and respond accordingly.…”

“…For example, if they are observing a color change that may be related to shallow breathing, the parent may provide a break during the feed to provide time and space for the LPI to breathe deeply. If the color change is related to poor milk control, then the parent may think about whether the flow rate of milk is appropriate and potentially investigate swallowing problems [41] During the last 6 weeks of gestation, fetal muscle tone increases [5,40] LPIs ability to feed in terms of maintain oral motor control is dependent on their ability to maintain muscle tone and control throughout their bodies [6] Teach parents and caregivers that very subtle changes in oropharyngeal movements may be the first sign that the infant is losing control [41] LPIs are at risk for general low muscle tone, weak muscle tone around the mouth, decreased tongue strength, and inability to generate a strong suck and maintain strong vacuum pressure at the breast. LPIs muscle tone may be adequate at the start of a feeding but they cannot sustain the necessary tone to feed as required [5,6,40,43] Decreased muscle strength including poor oral motor tone of LPIs may lead to difficulties in latching, sucking, and swallowing [44] LPIs appear to go through the motions of feeding, moving their jaw up and down but the poor vacuum results in minimal milk transfer, due to decreased suckling strength [5,6] Teach parents and caregivers that LPIs interest in feeding, the length of time they are able to maintain muscle control and sucking and swallowing skills may vary from feed to feed [6] Explain to parents and caregivers that LPIs may require multiple feeding methods on their journey to exclusive breastfeeding [1,35,45] LPIs may have difficulties feeding since the muscles that are implicated in sucking, swallowing, and breathing develop at different points in time [46] The inability to maintain suction pressure could lead to ineffective feeding, poor growth, dehydration, and jaundice [22,44,47] Teach parents and caregivers that when an infant is feeding well, the following is typically observed: smooth, regular respirations (or significant increase in respiratory effort than what was observed before the feeding); infant's hands are actively near the face, strong and consistent postural control throughout body; the infant's color has not changed significantly from what was observed before the feeding; the infant is organized and calm with good coordination of sucking, swallowing, and breathing; the infant is focused and alert [41] Infants are not able to organize the management ...…”

“…The nutritive sucking pathway comprises two connected mechanisms: suck/ pharyngeal swallow/respiration that is related to safety and suck/pharyngeal swallow/esophageal activity that is about efficiency [46] LPIs thrive with short frequent feeds at the breast or bottle of combined feeds of around 30 minutes total feeding time [36] Help parents and caregivers recognize and interpret infant feeding behavior and develop competence and confidence in reading their infants cues [41,48,62] Teach parents and caregivers to differentiate between nutritive and non-nutritive sucking. Non-nutritive sucking is usually 2 sucks per second whereas nutritive sucking (and coordination of swallowing and breathing) is one suck per second [48] Help parents and caregivers to nurture the feeding relationship by responding to the LPIs communication about the feeding experience [41,42] LPIs swallowing functions, peristaltic functions, and sphincter control in the esophagus, stomach, and intestines are likely to be less mature [3] LPIs take longer to feed than term infants and this longer time frame may result in difficulties coordinating sucking and swallowing [3,63] Teach parents and caregivers that the goal of each feeding session should be an alert infant who allows for adequate intake without disorganized behaviours such as loss of milk from the sides of the mouth and pooling of milk in the mouth.…”

“…Non-nutritive sucking is usually 2 sucks per second whereas nutritive sucking (and coordination of swallowing and breathing) is one suck per second [48] Help parents and caregivers to nurture the feeding relationship by responding to the LPIs communication about the feeding experience [41,42] LPIs swallowing functions, peristaltic functions, and sphincter control in the esophagus, stomach, and intestines are likely to be less mature [3] LPIs take longer to feed than term infants and this longer time frame may result in difficulties coordinating sucking and swallowing [3,63] Teach parents and caregivers that the goal of each feeding session should be an alert infant who allows for adequate intake without disorganized behaviours such as loss of milk from the sides of the mouth and pooling of milk in the mouth.…”

“…Severe gastroesophageal reflux may lead to prolonged apnea and bradycardia [54] The symptoms of reflux, including frequent spitting up, vomiting, and apnea may compromise feeding interactions and feeding outcomes [22] Teach parents and caregivers to decrease flow of milk by adjusting the sucking burst length and respond to milk spilling out of lips with a period of rest. This will allow for the infant to reorganize swallowing function [41,62] LPIs' anatomy of oral and pharyngeal structures are not developed well-enough to facilitate successful breastfeeding. LPIs' mandible is disproportionately small when compared to the skull [57] The tongue of the LPI fills the oral cavity and is in contact with all areas of the mouth that leaves very little space for variation in tongue movements [57] Teach parents and caregivers that if the infant does not open his or her mouth spontaneously or the mouth does not open wide enough, they may exert gentle downward pressure on the infant's chin with their index finger as the infant approaches the breast [5] Teach parents and caregivers to be aware of smacking sounds at the breast as this signals loss of contact between the infant's tongue and the breast.…”