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Posts tagged ‘nicu’

Consumer ALERT–> FDA Bans “SimplyThick” Breastmilk Thickener

SimplyThick

Does anyone use this product in your

NICU??

Did you use this product for your baby?

This product is used to help thicken feedings of breastmilk or formula for infants with swallowing issues or even to help with reflux.

Some Preterm Infants have become ill with a serious condition called NEC (Necrotizing Enterocolitis– where the lining of portions of the intestine become inflamed, lack adequate blood supply and subsequently, parts of the intestine can die). This particular problem is most often found early in the premature baby’s life before discharge home.

“To date, the agency is aware of 15 cases of NEC, including two deaths, involving premature infants who were fed SimplyThick mixed with mothers’ breast milk or infant formula products. “

Symptoms to watch for:

  • Bloated distended abdomen

  • Bloody stools

  • Vomiting greenish tinted milk or

  • green fluid

If you see any symptoms like this, please

contact your babies doctor and get

prompt medical attention.

Read more:  FDA ALERT

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Happy to be a NICU Nurse Week w/ Video

Happy belated International Day of the Midwife

Happy Nurses Day

Here is a great video on what it means to be a NICU nurse

Here’s some live action of stabilizing a preemie…

Success! You CAN Do it Right with a Preemie!

Short Little Success Story

Recently had to attend a birth for a 34 weeker who had been threatening labor since 32 weeks. She had been given a regimen of steroids and antibiotics per our protocols. The parents had a beautiful birth plan. They wanted Skin to Skin at birth, baby nursing before any separation and were adamantly against formula if at all possible. Both were frightened of the preterm birth, worried for their child’s safe transition and concerned that none of their wishes would be carried out.
I had the opportunity to discuss some of these with the Neonatologist and the parents before the birth. The doc was all for doing as much as they’d wished for at birth (that we could) provided the baby did not require respiratory support…

The baby was delivered hollering at us, alert and pinked up nicely! After observing and examining him for a short period, the doc gave the go ahead for Skin to Skin as long as I could stay and observe. Happy to oblige, I had that 4 LB naked baby up on mom in no time surrounded by her warmth and love.
I did the babies first glucose check (while STS) which was at a great level. Mom proceeded to start latch attempts. The baby did nuzzle and lick the copious colostrum she offered but wasn’t able to accomplish a latch. Vitals were stable, they were snuggling… but by an hour– the Neo was getting antsy. I had to take him in to the NICU with Dad in tow. No resp symptoms. Pink stable and alert. Placed up on the warmer table and connected to all the monitors for observation, he had his second glucose check. We expect it to drop at this time which is the normal nadir. It was however 38 which meant we had to feed. I asked for 5 min. This mom had a copious colostrum flow. The baby was not symptomatic. I had another RN watch him while I scooted back to L&D with a pump and small collecting cups. I figured we may have to hand express because many moms don’t respond to a pump quickly. This mom did respond and in a few minutes we had about 10 ml !!
I took that right in to the NICU leaving mom to finish a pumping session. We syringe fed the 10 ml and a subsequent glucose check was 54. Mom sent in a container of 15 more ml 🙂
They got to have a beautiful experience with their preterm boy who never got any formula … at least not in the NICU before discharge.

Yay!

Breastfeeding Evolution amidst the NICU Technology

 

 

Powerful Skin to Skin

Evolution

I love babies. I love being a nurse.

I love all the evolution of technology through which I have practiced. I love how I have had to continually evolve myself. I love helping mothers help themselves, advocating for them and their infants, facilitate when needed to support them making their own choices and watch as they evolve….. becoming the best mother they can be!

I know I haven’t blogged lately and it is because I have been having a bit of a rough transition… my latest evolution…  in my new NICU job. Orientation is somewhat difficult for me. I had previously been arriving at work already at the top of my game (for the last 25 years or so) and I have now found myself a student…. every. single. day. It is almost like I have gone to a totally new facility! EVERYTHING seems new or different. All new equipment/monitors/procedures/policies/protocols/doctors/practitioners/and staff.

The babies are the same. Since some are much more preterm than we have cared for in the past… their issues are more complex. Some are the same as we have always cared for, but with neonatologists now on board, the approach to the care of these babies is evolving.

I am unlearning some of what I have always known and relearning things in new ways.

Evolution

I was able to prepare and submit the mission statement and policy on Breastfeeding for our NICU population. The neo’s are extremely awesome on breastfeeding or breastmilk feeding promotion and support! So we have a very good start for breastfeeding support in our new unit. Excellent actually! I am happy to report that since opening our unit, most of the babies thus far have had a total exclusive diet of breastmilk or fortified breastmilk! I think that is fabulous! There have been some moms who after discussion and encouragement to provide breastmilk, wished to formula feed and their choice was supported without further discussion or question. My new co-workers have been very professional about that. There were a few who provided colostrum initially and then decided not to continue. This was also supported.

Coming from my previously comfortable world of lactation in the full term nursery, I find myself on a journey to find a balance between technology and nature……  precision, absolutes and finite accuracy vs the inconsistency, variables, and imprecise intake of an infant at the breast. We are calculating daily the actual fluid and kcal energy intake of each baby and comparing that with the kcal/fluid requirement per kilogram of weight. Changes are then made accordingly. Most of the preterm population is unable to take in their required fluid and caloric needs solely by mouth. Most have parenteral nutrition in the form of a glucose/ Amino Acid protein and Lipid (fats) at first by a central line or an IV (TPN) and gradually switch over to taking all their requirement by their GI system (Enteral). They don’t have the stamina to take it by sucking/drinking and they require a nasogastric (NG) tube so the remainder of food can go in by gravity or feeding pump (gavage feeding).

 

NG tube

I actually love learning all this. I thrive on having a detailed clear clinical picture of my patient. I am very detail oriented which is a good thing. Because of this precision, the measurements and the calculations—> actual breastFEEDING is not often seen until much later in the game. I understand this. I do. I want so much to be very helpful at transitioning to full feeds at the breast. I have to wrap my head around it each time (all the while being a student in all other aspects of the infant’s care) researching how to best advise each mother. We range from visits every other feeding to visits once or twice a day. Skin to skin is the most powerful tool I can use when faced with limited exposure or opportunity. Sometimes when the mom is arriving for my patient, I’m involved in other things and unavailable to do anything other than providing some private skin to skin time. Encouraging any licking, suckling or other feeding behaviors at the breast during gavage feeds is also good. When the baby gets more and more ready to take oral feeds… what I’ve seen so far is that they are already preferenced to the bottle nipple. The weight gain has been established, the precision of measurement seems to have become slightly less rigid. It seems that there is adequate physician support to encourage full feeds at the breast. There are hundreds of experts out there who have gone thru this, and reorganized policy and procedure to protect breastfeeding in the NICU.

I have to evolve myself again and re-learn more about transitioning to feeds at the breast before the bottle becomes a primary feeding implement. Once I can  find my footing- I hope to be strong and confident enough to start teaching moms and my co-workers.

Breastfeeding is NOT an exact science!

I need to figure out when the exact science of Neonatology can accept that….

into the feeding plan for each individual baby!

Our new NICU policy–>Breastmilk IS our babies food!

Yes! This HAS been accepted!!!


Here is an excerpt from our NEW NICU policy:

Policy Statement: It is the policy of the NICU to provide all mothers with factual information regarding the superior nutritional, immunological and therapeutic beneficial effects that human milk and breastfeeding will have on the health outcomes of their preterm or sick newborn so that their feeding decision will be evidence based. The healthcare professional has an ethical responsibility to avoid withholding information because of any unfounded concerns that informing mothers of research-based options may make them feel guilty if they choose not to breastfeed. The mother’s informed decisions will be totally supported and her infant will be provided nourishment in accordance with her decisions.  All mothers should be considered breastfeeding candidates until they specify intent to bottle feed.

Purpose: To promote and support human milk as the preferred method of providing nutrition. Provide assistance to the mother in establishing and maintaining breastfeeding.

Policy:

  1. Any mother desiring to breastfeed or provide breastmilk for her baby will be given consistent current and correct evidence-based information, emotional support and encouragement she may need to reach her individual goals. Healthcare professionals will avoid conveying information based on any personal breastfeeding experience as it may not be appropriate or applicable in discussions with mothers.
  2. Mothers may be asked/encouraged to temporarily pump/express and provide colostrum for their infant’s immediate protection and health needs regardless of their feeding choice.
  3. The mother will be involved in all feeding plans as soon as possible.
  4. All NICU infants will be fed according to their nutritional requirements as ordered by the physician.
  5. Early trophic feedings of colostrum/milk to stimulate intestinal maturity will be utilized as ordered and when there is colostrum available. It is beneficial for infant to wait a day or two until colostrum is available to maximize the transfer of protective components. Colostrum should be given to infant in the order it was pumped.
  6. Oral care/ mouth swabbing will be done using colostrum/ breastmilk.
  7. A multidisciplinary approach involving the physician, NICU team, the mother and a lactation professional to develop an individualized feeding plan will be utilized as soon as feasible in accordance with each infants requirements and feeding abilities.
  8. Cue-based feedings will be encouraged and utilized as soon as possible. All mothers will be provided educational information and encouraged to understand and participate in reading their infant’s feeding cues.
  9. Kangaroo care and/or skin-to-skin will be utilized and encouraged as much as possible..
  10. Stable premature infants should be allowed to go to mother’s breast during gavage feedings to ready infant for transition to breastfeeding.

Etc etc etc……………………………….. much more……………..

The policy I submitted was written using Marsha Walker’s  “Breastfeeding Management for the Clinician. Using the Evidence” as a major guide. I think I even used her words a lot. (Seriously-who can say it better?)

YAY! Thank you to my team and thank you Marsha!

DUE TO REPEATED REQUESTS FOR THE WHOLE POLICY… HERE IS WHAT I HAVE… I HAVE INCLUDED THE REFERENCES

 

Policy  Statement:      It is the policy of the Special Care Nursery/NICU to provide all mothers with factual information regarding the superior nutritional, immunological and therapeutic beneficial effects that human milk and breastfeeding will have on the health outcomes of their preterm or sick newborn so that their feeding decision will be evidence based. The healthcare professional has an ethical responsibility to avoid withholding information because of any unfounded concerns that informing mothers of research-based options may make them feel guilty if they choose not to breastfeed. The mother’s informed decisions will be supported and her infant will be provided nourishment in accordance with her decisions.  All mothers should be considered breastfeeding candidates until they specify intent to bottle feed.

 

Purpose:         To promote and support human milk as the preferred method of providing nutrition. Provide assistance to the mother in establishing and maintaining breastfeeding for optimal growth and development.

 

Policy:

  1. Any mother desiring to breastfeed or provide breastmilk for her baby will be given consistent current correct evidence-based information, emotional support and encouragement she may need to reach her individual goals. Healthcare professionals will avoid conveying information based on any personal breastfeeding experience as it may not be appropriate or applicable in discussions with mothers.
  2. Mothers may be asked/encouraged to temporarily pump/express and provide colostrum for their infant’s immediate protection and health needs regardless of their feeding choice.
  3. The mother should be involved in all feeding plans whenever possible.
  4. All SCN/NICU Infants will be fed according to their nutritional requirements as ordered by the physician.
  5. Early trophic feedings of colostrum/milk to stimulate intestinal maturity will be utilized as ordered and when there is colostrum available. It is beneficial for infant to wait a day or two until colostrum is available to maximize the transfer of protective components. Colostrum should be given to infant in the order it was pumped.
  6. Oral care/ mouth swabbing will be done using colostrum/ breastmilk.
  7. A multidisciplinary approach involving the physician, SCN/NICU team, the mother and a lactation professional to develop an individualized feeding plan will be utilized as soon as feasible in accordance with each infants requirements and feeding abilities.
  8. Cue-based feedings will be encouraged and utilized as soon as possible. All mothers will be provided educational information and encouraged to understand and participate in reading their infant’s feeding cues.
  9. Kangaroo care and/or skin-to-skin will be utilized and encouraged as much as possible..
  10. Stable premature infants should be allowed to go to mother’s breast during gavage feedings to ready infant for transition to breastfeeding.
  11. Promoting non-nutritive suckling at mother’s recently pumped/drained breast will be encouraged whenever applicable. Although pacifiers are not routinely used for healthy term breastfeeding infants, preterm infants in the Special Care Nursery/NICU or infants with specific medical conditions may be given pacifiers for non-nutritive sucking.
  12. Feeding at the breast will be introduced as soon as possible for those sick or preterm infants as they improve and display appropriate feeding readiness cues.
  13. Supplementation, complimentary feedings and use of alternative feeding devices including nipple shields will be individualized in accordance with the multidisciplinary feeding plan above. (#7)
  14. Human milk fortifier may be indicated and will be added as ordered by the physician.
  15. Breastfeeding Policy  #6250-OB-B-3 and Breastmilk Collection and Storage Policy #6250-OB-B-3A will apply wherever applicable.
  16. If a mother is unavailable for feeding and/or has chosen to pump and store her breastmilk for infant feedings, she will be provided with written pumping instructions. These pumping practices to maximize early production and volume include:
  1. Begin pumping within 6 hours after delivery whenever possible (as clinically indicated by infants and/or mothers medical condition). Early and frequent pumping in the first week is crucial.
  2. Double pumping with high quality hospital grade pump (or pump which cycles 48-50 times/minute and with vacuums not exceeding 240mm Hg.)
  3.  Simultaneous pumping with properly fitting flange and added breast massage yields more milk and higher fat content.
  4. Pump at least 6 times in 24 hours (100 total minutes/day). Mothers pumping at least 8-12 times in 24 hrs yielded higher milk output.
  5. Evaluate any mother’s concerns over low milk volume promptly to promote maximal adequacy of milk expression.
  6. A mother may be encouraged to use the breast pump at the infant’s bedside as a means to increase milk production.
  7. Collect milk in plastic tightly lidded containers (ie Snappies) which are self labeled by mother with infant’s name, date of birth, MR#, date and time milk was pumped.
  8. Freshly expressed milk that can be immediately given to infant provides optimal protection factors.
  9. Milk must be promptly stored in the refrigerator if it is to be used within the next 48 hours.  Breast milk may be placed in the freezer for 3 months or in a deep freeze for up to 6 months.  If the infant is preterm or a sick term infant, frozen breast milk should be used within 3 months, however, it is preferable to use outdated breast milk as opposed to artificial milk.
  10. Mother should transport her milk to the hospital frozen in a cooler with an ice pack.  Thawed breast milk must be used in 24 hours.
  11. If milk brought by the Mother is thawed, it must be placed in the refrigerator.  It cannot be refrozen.

 

 

References:

Bakewell-Sachs, S. and Brandes, A. (2003).  Nutritional Management. In Verklan, M.T. and Walden, M.  Core Curriculum for Neonatal Intensive Care Nursing, 3rd Ed. St.Louis,MO: Elsevier Saunders.

Crosson, D.D and Pickler, R.H. (2004). An Integrated Review of the Literature on Demand Feedings for Preterm Infants.  Adv Neonatal Care. 4(4): 216–225.

Dougherty, D.  and Luther, M. (2008). Birth to Breast—A Feeding Care Map for the NICU: Helping the Extremely Low Birth Weight Infant Navigate the Course. Neonatal Network. (27) 6.  Pp 371-377

Kirk, A.T., Alder, S.C., King, J.D. (2007).  Cue-based oral feeding clinical pathway results in earlier attainment of full oral feeding in premature infants:  Cue-based oral feeding clinical pathway.  Journal of Perinatology (27) 572-578.

Meier PP, Engstrom JL, Patel AL, Jegier BJ, Bruns NE. Improving the use of human milk during and after the NICU stay. Clin Perinatol. 2010 Mar;37(1):217-45. Accessed via PubMed July 17 2010

Walker, Marsha (2011). Breastfeeding Management for the Clinician- Using the Evidence 2nd ed. Jones and Bartlett, Sudbury MA

No Prenatal Care? …..What are YOU Hiding??

No Prenatal Care is usually a symptom of something--hiding some type of underlying problem. Sometimes it's very ugly. The most common encounters we have involve illicit drug use during pregnancy. We need to develop a comprehensive Maternal and Neonatal Drug Screening protocol to protect the newborn.

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