Birth To 48 Hours - Questions & Answers

A. There is growing evidence that pacifier use is associated with decreased breastfeeding duration. Pacifiers may mask the early signs of hunger, when feeding is important for establishing and building a milk supply. In addition, it is normal for a baby to rest or pause during a feeding; should feeding be terminated early in favor of a pacifier, this may have adverse effects on baby’s intake and thus on mother’s milk supply. The more the baby takes in, the more milk the mother will make in response.

Mothers who use pacifiers often find that they do not make enough milk. While some parents successfully use pacifiers after breastfeeding has been well established, pacifier use is inappropriate in healthy term newborns in the first weeks of life.

If a baby is awake and alert, making movements with his mouth, or sucking his fist, he is probably hungry and needs to nurse. Sucking on a pacifier requires different motor groups than sucking on a breast, so using a pacifier may make it hard for a baby to learn how to suck on the breast.

A baby who wants to nurse for comfort will likely get the satisfaction he seeks more quickly from the warmth of his mother's breast than from a pacifier. Comfort suckling may help a mother make more milk through nipple stimulation. It may be helpful to explain to the mother that the breast is not a substitute for a pacifier. In fact, elsewhere in the world, pacifiers are called "dummies" because they are substitutes for the breast.

Q. Why is sleeping near the baby recommended?

A. There is a growing body of evidence showing the benefits of sleeping near the baby, rather than in a separate room. In the hospital, it has been shown that newborns who room-in with their mothers sleep more and cry less, and that mothers get the same amount of sleep whether they leave the baby in the nursery or keep the baby with them.

Sleeping near the baby facilitates breastfeeding at the earliest signs of hunger, thus helping build milk supply. Parents should be advised to continue this practice, even after they leave the hospital.

Bedsharing, in particular, has been shown to promote breastfeeding. There have been some concerns about bedsharing if not done safely. However, the Academy of Breastfeeding Medicine notes that there is insufficient evidence to routinely discourage co-sleeping. The ABM defines co-sleepers as those "who remain close enough for each to detect and potentially act on the sensory stimuli of the other, and this includes an infant sleeping alongside a parent on a different piece of furniture or object," as well as an infant who shares a bed with the parent.

Data about bedsharing show that such babies learn to respond to mother’s movements and breathing, and that mothers learn to respond to baby’s early feeding cues. Babies who bedshare have been found to spend more time nursing than babies who don’t, and this helps build milk supply. In addition, nursing the baby in the sidelying position allows both parents to wake up more well-rested in the morning.

Having the baby sleep in a separate room from the mother, even with a baby monitor, does not result in these benefits. Crying is a late sign of hunger, and it is important to feed the baby well before one can hear him crying down the hall. It is also harder to feed a crying baby.

If a mother shares a bed with her infant, it is important that she know how to do this safely:

The bed should be away from a wall on both sides to avoid entrapment.
Heavy blankets, duvets, or pillows should be avoided.
Soft surfaces such as waterbeds, couches, and daybeds should be avoided.
Neither parent should be under the influence of alcohol, illegal drugs, or medications that would interfere with their ability to wake up.
As with sleeping separately, the infant should be placed on his back.
A baby should not sleep alone on an adult bed.
No one except parents should share a bed with the baby.
Because the risk of SIDS is higher in children of smokers, it is advised that parents who smoke do not bedshare, but can sleep with the baby nearby.

Q. Why perform painful procedures while the baby is at breast?

A. Gray et al. found that babies tolerate heelsticks better if they are done while breastfeeding. Infants have less crying and grimacing, and substantially lower heart rates, compared to babies being swaddled in their bassinets during the procedure. Breastfeeding is thought to have a potent analgesic effect. Skin-to-skin contact itself can also have an analgesic effect.

Q. How can breastfeeding be supported through hyperbilirubinemia?

A. Jaundice is common in newborns and is usually normal, but can sometimes be a sign of serious illness. When jaundice is present in infants under 24 hours of age, it is never normal and needs further medical assessment.

"Jaundice" is non-specific term referring to yellowing of the skin from bilirubin. Because some jaundice can be normal, the term "hyperbilirubinemia" more accurately indicates a need for medical attention. When measuring bilirubin levels, the upper limit of normal varies depending on the age of the infant.

Hyperbilirubinemia can be a sign of inadequate milk transfer. It does not usually mean that a baby needs to take formula, but should prompt an evaluation by a certified lactation consultant. Frequent nursing can help jaundice resolve more quickly, provided there is audible or visible swallowing, which indicates that the baby is actually getting milk. According to the Academy of Breastfeeding Medicine, supplements are not indicated in the infant with bilirubin levels less than 20 mg/dl after 72 hours of age when the baby is feeding well, stooling adequately and has weight loss of less than 7%. (They do not comment on younger infants). At birth to 48 hours, there is no indication to interrupt breastfeeding for diagnostic purposes in the evaluation of jaundice.

Q. What are the risk factors for breastfeeding difficulties, and why?

A. In general, a more stressful labor and delivery are associated with delayed onset of lactation and/or infant suckling difficulties. Delayed onset of lactation is defined as greater than 72 hours. Dewey et al. (2003) found that Caesarean section and primiparity are the two of the most important risk factors. First time mothers have several reasons for breastfeeding difficulties: they tend to have longer labors, they are more likely to have received labor analgesia, and they also lack breastfeeding experience.

Other risk factors for both delayed onset of lactation and infant suckling difficulties include: flat or inverted nipples, maternal obesity (BMI>27), and total labor that lasted more than 14 hours. In addition, infants whose 1-minute Apgar was 7 or less also tended to have suckling difficulties. Hall et al. demonstrated that vacuum extraction is linked with feeding difficulties, as well. All these mother-infant pairs may need additional breastfeeding guidance.

Even when infants started out with excellent suckling behaviors on the first day of life, Dewey et al. found that subsequent use of pacifiers or non-breastmilk fluids in the first 48 hours was linked with subsequent development of suckling difficulties at day 3 and day 7. Numerous other studies have also linked the use of pacifiers and non-indicated supplements to early weaning.

Excess weight loss can result from either delayed onset of lactation or infant suckling difficulties or both.

Breast surgery can disrupt the anatomy of the breast and may potentially cause problems with breastfeeding. Periareolar incisions are of particular risk, as is any incision that may damage the nerve supply to the nipple, and thus affect the let-down reflex. Many women who have had breast surgery can still breastfeed, but they should be monitored closely because of the risk that they may not be able to meet their infant’s full nutritional needs, and may need to supplement.

Many factors may also lower milk volume, such as cigarette smoking, trauma or surgery to the breast or chest, and inadequate feeding frequency. Smoking causes a decrease in milk volume in a dose-dependant manner. There is also some evidence that hormonal contraceptives may reduce milk volume, particularly those containing estrogen, as estrogens may suppress milk production. However, much is still not known about the effects of hormonal contraceptives on milk volume. Concern has been raised about the administration of Depo-Provera prior to the establishment of a full milk supply. [The manufacturer recommends waiting until six weeks post-partum, while noted pharmacologist Thomas Hale recommends delaying administration of all progestin agents "until three days post-partum, if not longer."] Of note, exclusive breastfeeding in the early months has been shown to reduce fertility significantly.

Q. What does tongue-tie look like?

A. Tongue-tie, or ankyloglossia, occurs when the lingual frenulum under the tongue is too short or displaced anteriorly. This may limit mobility of the tongue. When the baby attempts to stick out the tongue, the tongue appears heart-shaped or has a V-shaped notch at the tip. Tongue-tie occurs in about 5% of infants. Significant tongue-tie may result in breastfeeding difficulties, including inadequate milk transfer and sore nipples. If tongue-tie results in breastfeeding difficulties, it may be corrected with a simple procedure, frenotomy, or with a more elaborate procedure, frenuloplasty.

Q. My newborn won't latch on. What do I do?

A. If this happens after you leave the hospital, it generally requires immediate attention by a lactation consultant. Sometimes the answer is simple. If your baby has been crying hard, it may help to cuddle and perhaps burp her to calm her down first. If your breasts are overly full, your baby may not be able to get her mouth around your breast -- if that's the case, just squeeze out a few drops of milk first, to soften the breast.

Try holding the baby upright against your chest, skin-to-skin (her bare skin against your bare skin). Stroke her back and talk gently to her, even if she already seems calm. After a few minutes, she may start moving her head toward one of your breasts. You can guide your nipple toward her, but let the baby lead the way.

Make sure her rump is supported as you hold her, and that her chest is directly against your chest.

Q. Which babies should be screened for hypoglycemia?

A. According to the Academy of Breastfeeding Medicine, the following babies are at risk for hypoglycemia and should be screened:

Screening is not recommended in other infants. Infants of diabetic mothers should be screened at approximately 30 minutes; other high risk infants can be screened at 2 hours. Screening can be done using a bedside dextrose-stick. However, a low reading must be confirmed with a laboratory test on plasma or serum.

Massachusetts Breastfeeding Coalition uses this operational definition of hypoglycemia:

Infant parameters Age in hours Threshold glucose

values postbirth for intervention

Asymptomatic near term (34-37 weeks)

No risk factors
1st 24 hours
after 24 hours <30-35 mg/dL
<40-50 mg/dL

Symptomatic infant

Signs of hypoglycemia
Any gestational age
any age <45 mg/dL

At-risk infant

(see above for criteria)
any age <36 mg/dL

NOTE:

Infants with glucose levels <20-25 mg/dL require IV glucose and close monitoring.
Asymptomatic healthy term infants with no risk factors should NOT be screened.

Q. What is symptomatic hypoglycemia and how should it be treated?

A. According to the Clinical Protocol on Hypoglycemia from the Academy of Breastfeeding Medicine:

It cannot be emphasized enough that all the clinical signs of hypoglycemia are non-specific, and the physician must assess the general status of the infant by observation and physical examination to rule out disease entities and processes that may need additional laboratory evaluation and treatment. Some common signs include:

MANAGEMENT RECOMMENDATIONS
Healthy term neonates do not develop symptomatic hypoglycemia as a consequence of underfeeding. Underlying illness must be excluded in such infants.
Bedside screening tests must be confirmed by true laboratory glucose measurements.

Monitoring should begin within 30 minutes for infants of diabetic mothers and no later than 2 hours of age for infants in other risk categories. At-risk infants should be monitored every 2 to 4 hours prior to a feeding, until a normal blood glucose concentration is observed after serial measurements while receiving feedings.

Hypoglycemia can be minimized by early initiation of breastfeeding, within the first 30-60 minutes after delivery. Early breastfeeding is not precluded just because the infant meets the criteria for glucose monitoring.

Initiation and establishment of breastfeeding is facilitated by skin-to-skin contact of mother and infants. Such practices will maintain normal infant body temperature and reduce energy expenditure while stimulating suckling and milk production. Feedings should be frequent, at least 10 to 12 breastfeedings per 24 hours, and the infant should be put to the breast at the earliest signs of hunger (note that crying is a late sign of hunger).

In a symptomatic infant, intravenous glucose should be given. Initiate intravenous glucose using 2 cc/kg 10% glucose bolus followed by a continuous infusion of 6 to 8 mg/kg/min glucose (approximately 100 cc/kg/day). Do not rely on oral or intragastric feeding to correct hypoglycemia. Such an infant is not normal and requires a careful examination and evaluation.
Encourage frequent breastfeeding after relief of symptoms.
Adjust intravenous rate by blood glucose concentration.
Once blood glucose stabilized, resume breastfeeding and slowly reduce intravenous infusion. Check glucose concentrations before feedings until values are stabilized off intravenous fluid.
Carefully document signs, physical examination, screening values, laboratory confirmation, treatment and changes in clinical condition.

Q. How should asymptomatic hypoglycemia be managed?

A. According to Clinical Protocol on Hypoglycemia from the Academy of Breastfeeding Medicine:

Continue breastfeeding (approximately every one to two hours) or feed expressed breast milk or breast milk substitute (approximately 10-15 ml/kg). According to ABM’s Protocol on Supplementation, breast milk substitutes are recommended only if the hypoglycemia is unresponsive to frequent breastfeeding.
Recheck blood glucose concentration before subsequent feedings until value is stable.
If neonate is unable to suck, avoid intragastric feeding and begin intravenous therapy. Such an infant is not normal and requires a careful examination and evaluation in addition to more intensive therapy.
If enteral feeding otherwise is not tolerated, begin intravenous glucose infusion. Such an infant also is not normal and requires a careful examination and evaluation as well as more intensive treatment.
Intravenous therapy: 2 cc/kg of 10% glucose by bolus followed by a continuous infusion of 6-8 mg/kg/min of glucose (approximately 100 cc/kg/day). Repeat serum glucose within 30 minutes, and serially thereafter until stable.
A baby should not sleep alone on an adult bed. If glucose is low despite feedings, begin intravenous 10% glucose infusion of 6-8 mg/kg/min (approximately 100 cc/kg/day).
Adjust intravenous rate by blood glucose concentration.
Once blood glucose is stabilized in the normal range, continue breastfeeding and slowly reduce intravenous infusion. Check glucose concentrations before feedings until values are stabilized off intravenous fluid.
Carefully document signs, physical examination, screening values, laboratory confirmation, treatment and changes in clinical condition.