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National Guideline Clearinghouse (NGC). Guideline summary: Breastfeeding the near-term infant (35 to 37 weeks gestation) In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): cited 2004. Available: http://www.guideline.gov.

Bibliographic Source(s)

• Academy of Breastfeeding Medicine. Breastfeeding the near-term infant (35 to 37 weeks gestation). New Rochelle (NY): Academy of Breastfeeding Medicine; 2004 Aug 22. 6 p. [13 references]

Guideline Status

This is the current release of the guideline.

Guideline Category

Evaluation
Management
Prevention
Risk Assessment
Treatment

Intended Users

Advanced Practice Nurses
Allied Health Personnel
Nurses
Physician Assistants
Physicians

Guideline Objective(s)

• To allow infants born at 35 to 37 weeks of gestation to breastfeed and/or breast-milk feed to the greatest extent possible
• To heighten awareness of difficulties near-term infants and their mothers may experience with breastfeeding
• To offer strategies to anticipate identify promptly and manage breastfeeding problems that the near-term infant and mother may experience in the inpatient and outpatient setting
• To prevent medical problems such as dehydration hypoglycemia hyperbilirubinemia and failure to thrive in the near-term infant
• To maintain awareness of mothers' needs

Target Population

Near-term (35-37 weeks gestation) infants and their mothers

Note: "Near-term infant" refers to infants born between 35^0/7 to 36^6/7 weeks of gestation. Many problems of the near-term infant are also found in the larger 34- to 35-week preterm infant and the borderline term infant of 37^0/7 to 37^6/7 weeks gestation and therefore the following guidelines may be applicable to these infants as well.

Interventions and Practices Considered

Evaluation/Risk Assessment

1. Inpatient care
   • Assessment/reassessment: gestational age and associated risk factors breastfeeding
   • Monitoring of clinical status of infant: vital signs weight intake and output milk transfer
   • Monitoring for frequently encountered problems: hypoglycemia hyperbilirubinemia dehydration excessive weight loss
   • Evaluation of breastfeeding by lactation consultant or other certified health professional with expertise in lactation management
   • Documenting of  breastfeeding (LATCH score Infant Breast-feeding Assessment Tool (IBFAT) Mother/Baby Assessment Tool)
   • Discharge planning (assessment of criteria for discharge readiness feeding plan follow-up appointment
2. Outpatient care
   • Outpatient monitoring of mother and infant
   • Initial visit: outpatient office or home visit
     • Review of inpatient maternal and infant records feeding history
     • Review of breastfeeding since discharge
     • Examination of infant (weight alertness hydration)
     • Observation of baby feeding at breast
     • Assessment of mother (breasts emotional status)
   • Follow-up
     • Weekly weight checks
     • Monitoring for adequate growth and normal biochemical indices

Management/Treatment

1. Inpatient care
   • Written feeding plan
   • Avoidance of separation of mother and infant
   • Avoidance of thermal stress: skin-to-skin (kangaroo) contact double wrapping incubator mother/baby sleeping together
   • Breastfeeding on demand
   • Communicating changes in feeding plan
   • Breastfeeding education
   • Supplemental feedings as indicated: supplemental nursing device at the breast cup feeds finger feeds syringe feeds or bottle
   • Communicating discharge-feeding plan to outpatient pediatric care provider
2. Outpatient care
   • Adjustment of feeding plan for babies not gaining weight well
   • Evaluation of latch difficulties
   • Management of jaundice
   • Use of galactogogues in mothers with documented low breastmilk supply
   • Vitamin D supplements as indicated
   • Iron supplements as indicated

Major Outcomes Considered

• Adequate weight gain growth and normal biochemical indices in near-term infants
• Morbidity associated with medical problems of inadequate lactation such as dehydration hypoglycemia hyperbilirubinemia and failure to thrive

Methods Used to Collect/Select Evidence

Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

An initial search of relevant published articles written in English in the past 20 years in the fields of medicine psychiatry psychology and basic biological science is undertaken for a particular topic. Once the articles are gathered the papers are evaluated for scientific accuracy and significance.

Number of Source Documents

69

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

I Evidence obtained from at least one properly randomized controlled trial

II-1 Evidence obtained from well-designed controlled trials without randomization

II-2 Evidence obtained from well-designed cohort or case-control analytic studies preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.

III Opinions of respected authorities based on clinical experience descriptive studies and case reports; or reports of expert committees

Methods Used to Analyze the Evidence

Systematic Review

Description of the Methods Used to Analyze the Evidence

An expert panel is identified and appointed to develop a draft protocol using evidence based methodology. An annotated bibliography (literature review) including salient gaps in the literature are submitted by the expert panel to the Protocol Committee.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

Draft protocol is peer reviewed by individuals outside of lead author/expert panel including specific review for international applicability. Protocol Committee's sub-group of international experts recommends appropriate international reviewers. Chair (co-chairs) institutes and facilitates process. Reviews submitted to committee Chair (co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. Chair (co-chairs) and protocol author(s) amends protocol as needed.

Following all revisions protocol has final review by original author(s) to make final suggestions and ascertain whether to maintain lead authorship.

Final protocol is submitted to the Board of Directors of ABM for approval.

Major Recommendations

Principles of Care

1. Optimal communication
   1. Pathway and order set for breastfeeding the near-term infant
   2. Written feeding plan to follow on hospital discharge
   3. Facilitate communication among physician nurses and lactation consultants in the inpatient and outpatient settings
   4. Avoid conflicting advice to mother and family of the near-term infant

2. Assessment/reassessment
   1. Objective assessment of gestational age and associated risk factors
   2. Daily assessment of breastfeeding on the postpartum floor or special care nursery
   3. Careful assessment of breastfeeding issues in the outpatient setting

3. Timely lactation support in the inpatient and outpatient setting
4. Avoid separation of mother and infant
   1. Immediate postpartum period
   2. In cases in which either mother or infant is hospitalized for medical reasons

5. Prevent frequently encountered problems in breastfed near-term infant
   1. Hypoglycemia
   2. Hypothermia
   3. Hyperbilirubinemia
   4. Dehydration or excessive weight loss

6. Education
   1. Ongoing education of staff and care providers of issues specific to breastfeeding the near-term infant in the inpatient and outpatient settings
   2. Have one (or two) outpatient office support person (registered nurse [RN] or lactation educator) trained in breastfeeding support assessment basic breastfeeding problem solving and near-term breastfeeding issues
   3. Educate parents about breastfeeding the near-term infant

7. Discharge/follow-up
   1. Develop criteria for discharge readiness
   2. Establish a feeding plan to follow after discharge
   3. Facilitate timely and frequent outpatient follow- up to assure effective breastfeeding after discharge
   4. Careful outpatient monitoring of mother and near-term infant

Inpatient: Implementation of Principles of Care

1. Initial steps:
   1. Communicate the feeding plan through a prewritten order set that can be easily modified.
   2. Encourage immediate and extended skin-to-skin contact to improve postpartum stabilization of heart rate respiratory effort temperature control metabolic stability and early breastfeeding.
   3. Assessment of gestational age by obstetrical estimate and Dubowitz scoring. Observe infant closely for 12 to 24 hours to assure physiologic stability (e.g. temperature apnea tachypnea hypoglycemia).
   4. Encourage rooming in 24 hours a day. If the infant is physiologically stable and healthy allow the infant to remain with the mother while receiving intravenous (IV) antibiotics or phototherapy. Depending on the individual situation use of the bili-blanket during breastfeeds as well as limiting time outside more intense phototherapy may be necessary.
   5. Allow free access to the breast encouraging initiation of breastfeeding within 1 hour after birth. Encourage continuous skin-to-skin contact as much as possible.
   6. Breastfeeding ad libitum (on demand) should be encouraged. It is very important that the infant be breastfed (or breast-milk fed) at least eight times per 24-hour period. Sometimes it may be necessary to wake the baby if he or she does not indicate hunger. A mother may need to express her milk and give it to the baby using a cup or other alternative feeding method. Mothers should be warned that use of bottles at this stage might prevent breastfeeding in some babies.

2. Ongoing care:
   1. Communicate daily changes in feeding plan either directly or with use of written bedside tool such as a crib card.
   2. Formal evaluation from a lactation consultant or other certified health professional with expertise in lactation management should be completed within 24 hours of delivery.
   3. Assess and document breastfeeding at least three times per day by at least two different providers with use of a standardized tool (e.g. LATCH Score [Jensen Wallace & Kelsay 1994] Infant Breast-feeding Assessment Tool [IBFAT] [Matthews 1988] Mother/Baby Assessment Tool [Mulford 1992]).
   4. Educate the mother about breastfeeding her infant (e.g. position latch duration early feeding cues etc.).
   5. Monitor vital signs weight change stool and urine output and milk transfer. Pre-post feeding weights where available may be helpful especially once lactogenesis II has occurred. Monitor for frequently occurring problems (e.g. obtain bilirubin if jaundiced before discharge glucose screen before feeds for the first three feeds or until stable if hypoglycemia has occurred [see The Academy of Breastfeeding Medicine Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Breastfed Neonates]). It is recommended to routinely screen for hyperbilirubinemia in near-term infants and to use standardized nomograms to assess risk of hyperbilirubinemia as well as plan for follow- up testing.
   6. Avoid excessive weight loss or dehydration. Losses greater than 3% of birth weight by day 1 or greater than 7% by day 3 ineffective milk transfer or exaggerated jaundice are considered excessive and merit further evaluation and monitoring.
      1. The infant may need to be supplemented after breastfeeding with small quantities (5 to 10 mL per feeding on day 1 10 to 30 cc per feeding thereafter) of expressed breast milk or formula. Mothers may supplement using a supplemental nursing device at the breast cup feeds finger feeds syringe feeds or bottle depending on clinical situation and mother's preference. Cup feedings have demonstrated safety in both preterm (Marinelli Burke & Dodd 2001) and term infants (Howard et al. 1999). Cup feeding may also preserve breastfeeding duration among both preterm (Collins et al. 2004) and term (Howard et al. 2003) infants that require multiple supplemental feeds. However there is little evidence about the safety or efficacy of other alternative feeding methods or their effect on breastfeeding. When cleanliness is suboptimal cup feeding may be the best choice (United Nations Children's Fund 1996).
      2. If supplementing the mother should pump or express milk regularly (use of a hospital grade electric pump is recommended when feasible) during the day (e.g. every 3 hours) until the baby is breastfeeding well or if the mother and infant are separated and unable to breastfeed.
      3. Consider use of an ultrathin silicone nipple shield if there is difficulty with latch or evidence of ineffective milk transfer (Meier et al. 2000). The use of nipple shields is controversial and generally requires close supervision of a trained lactation consultant or knowledgeable health care professional. Inappropriate or prolonged nipple shield use can decrease milk supply and in some situations nipple shields decrease rather than increase milk transfer.
   7. Avoid thermal stress by using skin-to-skin (e.g. kangaroo) care or by double wrapping if necessary and by dressing the baby in a shirt and hat. Consider intermittent use of an incubator to maintain temperature. Where it is culturally acceptable mothers can sleep with their babies to provide warmth.

3. Discharge planning
   1. Assess readiness for discharge including physiologic stability and adequate intake exclusively at breast or with supplements. May use 24-hour test weights with a scale designed with adequate precision for such weights for infants with >7% weight loss (Meier et al. 1994).
   2. Develop discharge-feeding plan. Consider diet milk intake (mL/kg/day) and method of feeding (breast bottle supplemental device etc.). If supplementing determine method most acceptable to mother for use after discharge.
   3. Make an appointment for follow-up within 48 hours of discharge to recheck weight feeding adequacy jaundice.
   4. Communicate discharge-feeding plan to pediatric outpatient provider. Written communication is preferred.

Outpatient: Implementation of Principles of Care

1. Initial visit
   1. The first outpatient office or home health visit should be when the infant is 3 to 5 days of life or 1 or 2 days after discharge.
   2. Review the inpatient maternal and infant records including prenatal perinatal infant and feeding history (e.g. need for supplement in the hospital problems with latch need for phototherapy etc). Gestational age birth weight and weight at discharge should be recorded in the outpatient chart.
   3. Physician review of breastfeeding since discharge needs to be very specific regarding frequency approximate duration of feedings and how baby is being fed (e.g. at breast expressed breast milk with supplemental device such as supplemental nursing system finger feeds or bottle with artificial nipple). Information about stool and urine output color of stools baby's state (e.g. crying not satisfied after a feed sleepy and difficult to keep awake at the breast during a feed etc.) should be obtained. If parents have a written feeding record it should be reviewed.
   4. Examination of the infant must include an accurate weight without clothes and calculation of change in weight from birth and discharge state of alertness and hydration. Assess for jaundice with cutaneous bilirubin screen and/or serum bilirubin determination if indicated.
   5. Assess the mother's breast for nipple shape pain and trauma engorgement and mastitis. The mother's emotional status and degree of fatigue should be considered especially when considering supplemental feeding routines. Observe the baby feeding at the breast looking at the latch suck and swallow.

2. Problem solving
   1. Poor weight gain (<20 g/day) is most likely the result of inadequate intake. Median daily weight gain of a healthy newborn is 26 to 31 grams per day (National Research Council Food and Nutrition Board National Academy of Science 1989). The care provider must determine whether the problem is insufficient breast milk production inability of the infant to transfer enough milk or a combination of both. The infant who is getting enough breast milk should have six to eight voids and yellow seedy stools daily by day 4 have lost no more than 8% of birth weight and be satisfied after 20 to 30 minutes of nursing. Consider feeding more frequently or supplementing (preferably with expressed breast milk) after suckling if the mother is not already doing so or increasing the amount of supplement. Consider instituting or increasing frequency of pumping or manual expression. Consider referral to a lactation specialist.
   2. For infants with latch difficulties the baby's mouth should be examined for anatomical abnormalities (e.g. ankyloglossia [tongue-tied] [Ballard Auer & Khoury 2002] cleft palate) and a digital suck exam performed. A referral to a trained professional lactation specialist or in the case of ankyloglossia a referral to someone trained in frenotomy may be indicated.
   3. The jaundiced near-term infant poses more of a problem when considering management of hyperbilirubinemia. Keep in mind all risk factors should be determined and if the principal factor is lack of milk the primary treatment is to provide milk (preferably through improved breastfeeding or expressed breast milk) to the baby. Institution of phototherapy for breastfeeding jaundice either in the home or in the hospital may actually interfere with the primary treatment of getting increased quantities of milk to the baby.
   4. Consider the use of a galactogogue (a medicine or herb that increases breast milk supply) in mothers who have a documented low breast-milk supply (see The Academy of Breastfeeding Medicine Protocol #9: Use of Galactogogues in Initiating or Augmenting maternal Milk Supply).
   5. The mother's ability to cope and manage the feeding plan needs to be evaluated. If the mother is not coping well work with her to find help and or modify the feeding plan to something that is more manageable.

3. Follow-up

   The near-term infant should have weekly weight checks until 40 weeks postconceptual age or until it is demonstrated that he or she is thriving with no supplements.

   1. Babies who are not gaining well and for whom adjustments are being made to the feeding plan may need a visit 2 to 4 days after each adjustment. A home health provider preferably trained in medical evaluation of the newborn and in lactation support who reports the weight to the primary care provider could make this visit.
   2. Near-term infants have less vitamin D stored at birth increasing their risk for later deficiency. Depending on sunlight exposure and skin color vitamin D supplements (200 IU/day) may be indicated if the infant is exclusively breastfed. Strong consideration should be given to starting these supplements earlier than the 2 months of age recommended for term infants in the United States. Consideration should also be given to supplementing the near-term exclusively breastfed infant with iron as iron stores in these infants are not those of the full-term infant. The American Academy of Pediatrics Committee on Nutrition recommends 2 mg/kg/day of elemental iron for preterm breastfed infants in the form of iron drops from 1 to 12 months of age.
   3. After the first week infants should be monitored for adequate growth and evidence of normal biochemical indices (See Table P-4 in The Academy of Breastfeeding Medicine Protocol #12: Transitioning the Breastfeeding/Breastmilk-fed Premature Infant from the Neonatal Intensive Care Unit to Home) Weight gain should average more than 20 g/day and length and head circumference should each increase by an average of more than 0.5 cm/week.

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Ballard JL Auer CE Khoury JC. Ankyloglossia: assessment incidence and effect of frenuloplasty on the breastfeeding dyad. Pediatrics 2002 Nov;110(5):e63. PubMed



• Collins CT Ryan P Crowther CA McPhee AJ Paterson S Hiller JE. Effect of bottles cups and dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ 2004 Jul 24;329(7459):193-8. PubMed



• Howard CR de Blieck EA ten Hoopen CB Howard FM Lanphear BP Lawrence RA. Physiologic stability of newborns during cup- and bottle-feeding. Pediatrics 1999 Nov;104(5 Pt 2):1204-7. PubMed



• Howard CR Howard FM Lanphear B Eberly S deBlieck EA Oakes D Lawrence RA. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003 Mar;111(3):511-8. PubMed



• Jensen D Wallace S Kelsay P. LATCH: a breastfeeding charting system and documentation tool. J Obstet Gynecol Neonatal Nurs 1994 Jan;23(1):27-32. PubMed



• Marinelli KA Burke GS Dodd VL. A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed. J Perinatol 2001 Sep;21(6):350-5. PubMed



• Matthews MK. Developing an instrument to assess infant breastfeeding behaviour in the early neonatal period. Midwifery 1988 Dec;4(4):154-65. PubMed



• Meier PP Brown LP Hurst NM Spatz DL Engstrom JL Borucki LC Krouse AM. Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact 2000 May;16(2):106-14; quiz 129-31. PubMed



• Meier PP Engstrom JL Crichton CL Clark DR Williams MM Mangurten HH. A new scale for in-home test-weighing for mothers of preterm and high risk infants. J Hum Lact 1994 Sep;10(3):163-8. PubMed



• Mulford C. The Mother-Baby Assessment (MBA): an "Apgar score" for breastfeeding. J Hum Lact 1992 Jun;8(2):79-82. PubMed



• National Research Council Food and Nutrition Board National Academy of Science. Recommended daily allowances. 10th ed. Washington (DC): U.S. Government Printing Office; 1989.



• United Nations Children's Fund. Feeding low birth weight babies. UNICEF Division of Information and Public Affairs; 1996.

Type of Evidence supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated.

The recommendations were based primarily on a comprehensive review of the existing literature. In cases where the literature does not appear conclusive recommendations were based on the consensus opinion of the group of experts.

Potential Benefits

Improved breastfeeding outcomes for mothers and infants prevention of medical problems such as dehydration hypoglycemia hyperbilirubinemia and failure to thrive in the near-term infant

Potential Harms

Not stated

Qualifying Statements

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Foreign Language Translations

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

• Academy of Breastfeeding Medicine. Breastfeeding the near-term infant (35 to 37 weeks gestation). New Rochelle (NY): Academy of Breastfeeding Medicine; 2004 Aug 22. 6 p. [13 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau US Department of Health and Human Services

Guideline Committee

Academy of Breastfeeding Medicine Protocol Committee

Composition of Group that Authored the Guideline

Committee Members: *Eyla Boies MD; Caroline J. Chantry MD FABM Co-Chairperson; Cynthia R. Howard MD MPH FABM Co-Chairperson; *Yvonne Vaucher MD

*Lead author(s)

Financial Disclosures/Conflicts of Interest

None to report

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Academy of Breastfeeding Medicine Web site.

Print copies: Available from the Academy of Breastfeeding Medicine 140 Huguenot Street 3rd floor New Rochelle New York 10801.

Availability of Companion Documents

The following is available:

• Procedure for protocol development and approval. Academy of Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine 140 Huguenot Street 3rd floor New Rochelle New York 10801.

A Japanese translation of the original guideline document is available from the Academy of Breastfeeding Medicine Web site.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on November 2 2007. The information was verified by the guideline developer on November 12 2008.

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Single copies may be downloaded for personal use. Copyright permission to be requested for use of multiple copies by e-mailing requests to abm@bfmed.org. An official request form will be sent electronically to person requesting multiple copy use.

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