Oxford Handbook of Midwifery (147 page)

The baby may also exhibit signs of a thrush infection, such as:

Action

lactating mothers although the WHO recognizes it as compatible with breastfeeding.
³

miconazole oral gel is no longer considered suitable for use in babies

<4 months old due to being a potential choking risk. Responsibility for

use in a baby <4 months remains the responsibility of the person who
prescribes or recommends its use.

1. UNICEF UK Baby Friendly Initiative (2008).
   Breastfeeding Assessment Form
   . Available at:
   

   M
   www.babyfriendly.org.uk/page.asp?page=60 (accessed 12.4.10).
   

2. Bolling K, Grant C, Hamlyn B, Thornton A (2007).
   Infant Feeding Survey 2005.
   London: The Information Centre.
   
3. World Health Organization (2002).
   Breastfeeding and Maternal Medication
   . Geneva: WHO. Available at: M
   http://whqlibdoc.who.int/hq/2002/55732.pdf (accessed 12.4.10).
   

   CHAPTER 24
   Breastfeeding
   

   698‌‌
   

   Breastfeeding in special situations
   

   Twins and higher multiples
   

   The production of breast milk is based on a demand and supply system; therefore, provided the infants are suckling effectively, nature will supply the milk. In the early days postnatally, the mother will require a lot of reassurance and assistance to get breastfeeding established.
   

   There are no rights and wrongs for whether the babies should be fed separately or together. The RCM
   ¹
   advocates that in the early days the babies should be fed separately, so that common early problems can be resolved, whereas the Twins and Multiple Births Association
   ²
   believes that feeding the babies together in the early days will help to stimulate the milk supply, and feeding them together at night will ensure that the mother gets more sleep. Ultimately, the decision is up to the mother and the babies, as the infants’ feeding patterns may not synchronize. One option is to mix and match so that at some feeds the babies are fed together and at others separately. The mother may decide that each baby has its own breast, or she may wish to swap breasts at each feed.
   

   Positions for breastfeeding twins
   

   When breastfeeding both babies at the same time, positioning of the babies at the breast may take some time and practice to get it right. The mother should:
   

   • Ensure she has adequate cushions to provide support for both herself and the babies
     
   • Use a footstool under her feet if necessary, to create a lap
     
   • Find a position in which she feels comfortable to feed the babies. This may be the ‘double football position’, where the babies are tucked under the mother’s arms and their heads are opposite each other
     

at the front. This enables the mother to support each baby’s head.

Alternatively, one baby could be held conventionally in the cradle
hold and the other held in the football position, so that the babies are

parallel to each other. Another position is the criss-cross, where both

babies could be held conventionally, one lying across the other.

A mother who is breastfeeding twins must remember her own needs, she should eat well, and try to obtain some rest each day to prevent exhaustion.

Cleft lip and palate

Cleft lip and palate are congenital malformations that result in the incom- plete fusion of the upper lip and jaw.

Cleft lip should not present any problems for breastfeeding. Following surgery, some surgeons encourage breastfeeding soon afterwards, while others prefer an initial period of spoon-feeding.

A cleft palate, however, may present major difficulties. The baby is unable to form an effective seal between mouth and the breast, so that the breast and nipple cannot be formed into a teat. There are feeding plates/ palate seals (palatal obturator), which can assist in ‘closing’ the defect. A baby with a cleft palate will not usually stimulate the breast effectively, which will result in a diminished milk supply. A mother with large, elastic

BREASTFEEDING IN SPECIAL SITUATIONS

699

breasts and a ready milk ejection reflex may succeed in breastfeeding, but normally mothers will need to supplement with a nursing supplementer (b see Alternative methods of giving EBM/formula, p. 701). Alternatively, mothers may wish to express breast milk and feed it to the baby with a special bottle, teat, or spoon. Breastfeeding is both possible and beneficial following surgical repair, but the mother will need practical and accurate support from appropriately skilled professionals.

Breastfeeding and HIV

Mother-to-child transmission of HIV can occur through breastfeeding. WHO
³
advises that HIV-infected, pregnant mothers should consider their infant feeding options. It stipulates that ‘when replacement feeding (formula milk) is acceptable, feasible, affordable, sustainable, and safe, HIV infected mothers should avoid breastfeeding completely’. This view is endorsed by the DH,
⁴
which recommends that HIV-infected women should avoid breastfeeding. Advice and counselling should be given to mothers during the antenatal period. If a mother decides to breastfeed once she has received advice, there may be a child protection issue, espe- cially if she has a high viral load, which will place the baby at severe risk.

Breastfeeding and diabetes

Diabetes is not a contraindication to breastfeeding. It can be advantageous to the mother’s and baby’s health.

lactation allow the physiological changes that follow childbirth to occur more gradually.

Considerations for diabetic mothers when breastfeeding

extra 50g of carbohydrate per day has been suggested.
⁶
These extra
carbohydrates are best spread equally over the day, remembering

especially to increase the supper snack to cover the night-time feeds.

CHAPTER 24
Breastfeeding

700

Care of the new born infant of a diabetic mother

• Babies of diabetic mothers are more prone to hypoglycaemia this is because in intrauterine life the hypertrophic islets of Langerhans
  

  produce more insulin in response to the maternal blood sugar levels. After birth the pancreas initially continues to produce excess insulin thus causing hypoglycaemia.
  

• Preparation for prevention of neonatal hypoglycaemia can commence in pregnancy with the expressing and storage of colostrum for use in the immediate postnatal period. Expression and storage of colostrum should be discussed with the hospital during the antenatal period.
  
• The baby should be given its first feed as soon as possible (within 30min of birth) and then 2–3h until pre-feeding blood glucose levels are maintained at 2 mmol/L or more.
  ⁷
  
• The baby’s blood glucose levels should be monitored until stabilized. The frequency and timing of testing neonatal blood glucose levels may vary according to hospital policies but NICE
  ⁷
  recommends routine testing 2–4h after birth and prior to feeds until the blood sugar levels are stabilized.
  
• The mother and baby should not be transferred to community care until the baby’s blood sugar levels have stabilized and feeding is established.
  
• The mother should be given the opportunity for peer support with breastfeeding.
  ⁸
  

  Separation
  

  There are many reasons why a baby may be separated from its mother. The usual cause of separation of mother and baby immediately following delivery is that the baby requires specialist care in a special care baby unit, neonatal surgical unit, or paediatric ward. Alternatively, the mother may be seriously ill, requiring care in either an intensive care or high-dependency unit. Whenever possible, mothers and babies should be cared for together.
  

  If the mother intends to breastfeed, expression of breast milk should commence as soon as her condition allows (if the mother is ill) or as soon
  

  as possible following delivery (if the baby is on a special care baby unit). The mother should be encouraged to express breast milk and will need extra reassurance and support in these circumstances, especially if the baby is in a unit where there are no midwives to assist and support her. For detailed guidance on expression and storage of breast milk b see Expression of breast milk, p. 680.
  

  Breast surgery
  

• Advice should be sought from the surgeon prior to surgery if the woman is of an age where she may wish to breastfeed.
  
• There are two types of breast reduction, pedicle and free-nipple. With the former, the mother may be able to breastfeed but with the latter, it is not possible.
  
• Augmentation is not a contraindication to breastfeeding but if a peri- areolar surgical technique has been used then the mother may find she has an insufficient milk supply.
  
• Women can breastfeed successfully following unilateral mastectomy.
  

  BREASTFEEDING IN SPECIAL SITUATIONS
  

  701
  

  Alternative methods of giving EBM/formula
  

  Breastfeeding is the natural way to feed infants, but occasionally some infants may not be able to breastfeed immediately or the mother may require assistance to help improve her milk supply. The method of choice will depend upon the individual situations, and the aim of any alternative method of feeding should be to attain full breastfeeding as soon as pos- sible. The alternative methods of feeding include cup, syringe, dropper, spoon, pipette, Lact-Aid
  ^®
  , and nasogastric feeding. The means used will depend upon the age of the baby and the reason for not breastfeeding. The main methods discussed in this text are nasogastric feeding, cup feeding, and supplementing with a Lact-Aid
  ^®
  device.
  

  Nasogastric feeding