Kangaroo Mother Care Method：袋鼠妈妈护理方法

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1、Kangaroo Mother Care Method Feeding strategies for preterm and Low birth infants Module 3 2Table of contents 1.Introduction and goal of the KMC feeding strategy2.Suction in newborns 3.Breastfeeding preterm infants4.Adaptation to the KMC feeding strategy5.Feeding modes in preterm infants 6.Feeding pr

2、eterm infants from the breast 7.Alternative feeding methods8.Stimulation of feeding in preterm infants 9.Milk extraction 10. Maternal difficulties to breastfeed11. Problems with insufficient milk production 12. Transition from hospital to home after discharge 13. Preterm infant formula 3KMC Componen

3、ts 1st : Kangaroo position The infant is placed almost naked in strict upright ventral position between the mothers breast, in direct contact with her skin, as long as possible 2nd : Kangaroo Feeding and Nutrition strategyIdeally exclusive breastfeeding to have a weight gain similar to the growth du

4、ring the intra uterine life ( 15 g/Kg/day )until full term3rd : Early Discharge and strict ambulatory follow up Discharge in kangaroo position regardless of weight and gestational age when the child is able to coordinate sucking, swallowing and breathing , gaining weight for 3 days and have parents

5、informed , trained and ready to come to follow up visits4Introduction The kangaroo nutrition strategy is intended for children who are in the “stable growth period”, after the transition period until the infant reaches full term This period is considered similar to the period of intra uterine growth

6、 which may have occurred if the infant was not born prematurely Children during this period face a double challenge: having to grow at the rate they would have grown while still “in utero”, and to recover from the deficits accumulated during the transition period KMC feeding strategy focusses on suc

7、cessful breastfeeding5Breast milk is the “must” “Human milk is species-specific ,and all substitute feeding preparations differ markedly from it, making human milk uniquely superior from infant feeding. Exclusive breastfeeding is the reference or normative model against which all alternative feeding

8、 methods must be measured with regard to growth, health , development , and all short and and long terms outcomes. In addition, human milk-fed preterm infants receive significant benefits with respect to protection and improved development outcomes compared with formula fed preterm infants “6Goals f

9、or the KMC Nutrition Obtain adequate growth and short term nutrient retention, which allow the preterm infant to come close to the intra uterine growth charts and to the fetal composition of reference Decrease neonatal morbidity by improving food tolerance; reduce the incidence of necrotizing entero

10、colitis (NEC) and minimize nosocomial infectionAchieve a nutrition that contributes to optimal short and long term neurological development Reduce atopy and allergy indexDecrease the potential risk of hypertension, cardiovascular disease and hypercholesterolemia in adulthood For the preterm infant,

11、milk from the infants own mother is the “must” and will be used whenever possible; the mothers milk is always supplemented with A, D, E and K vitamins up to term. Mother milk may be also fortified and supplemented whenever it may be necessary7Nutrition goal to the KMC method Obtain adequate growth a

12、nd short term nutrient retention, which allow the preterm infant to come close to the intra uterine growth charts and to the fetal composition of reference The goal is to reach a weight gain similar to the usual growth during the intra uterine life 15 g/kg/ day until full term If this goal is not re

13、ached through exclusive breast feeding it is necessary to identify and to correct conditions which may explain inadequate weight gain Once the abnormal condition is corrected, growth must improve. If not, or if there was no any secondary cause for inadequate growth, breast milk should be fortified o

14、r supplemented with special preterm formula 8Nutritional Supplements Kangaroo children who are not getting weight being fed by breast milk with or without hind milk and who do not present any pathologies, may receive a supplement, for a limited period of time in order to avoid losing the initial gro

15、wth potential and preventing them to become malnourished Supplement starts with 25 to 30% of the daily quantity, based on 180 to 200 ml /kg/day The mother must give the supplement using a syringe, a cup or a dropper but not a baby bottle and always before nursing the infant, so that the baby only ta

16、kes what he needs from the breast9Suction in NewbornsThe tongue fills the oral cavity and protrudes outside the mouth in response to the rooting reflex, it goes beyond the limit of the gums, envelops the nipple-areola complex, compressing it against the hard palate and making an undulating back and

17、forth movement: “tongue slither” which generates positive pressure Lips have a sealing function generating negative pressure during suction; by being everted and well adapted to the mothers breast, they provide a hermetic seal Eminences in the inner side of the lips have an anti-slid function Bichat

18、s fat pads in the cheeks, prevent them to collapse due to negative pressure The nipple is elongated to allow the ejected milk to flow laterally to the air way on a zone called “comfort zone”, in the union of soft and hard palate10Feeding Reflexes (1) Fetus in utero sucks and swallows amniotic fluidT

19、he rooting reflex explored by rubbing, stroking or touching the corner of the mouth The infant turn his lips, head and open his mouth to follow and root in the direction of the stimulus This helps the infant to find the breast opening widely the mouth allowing a correct attachment It is present from

20、 week 32 of gestation.The suction reflex is assessed by placing a finger inside the infants mouth The infant begins to suck placing his tongue under the finger and applying pressure against the palate The sucking reflex appears and develops in parallel with the rooting reflex. The suckling reflex cr

21、eates negative pressure which associated to the positive pressure of the palate allows suction, swallowing and breathing. 11Feeding Reflexes (2) The swallowing reflex is visualized by the movements of the larynx It refers to the set of actions allowing the passage of solid or liquid from the mouth t

22、o the stomach It appears from week 16 of gestation Non-nutritive suction (NNS) as stimulation is recommended to develop suction reflexes At 34 weeks of gestational age, the suction/breathing pattern approximates 1:1 12Suction Disorders in Preterm Infants Oral motor dysfunction (OMD) is the alteratio

23、n of the infant capacity to attach himself to the breast it can be primary or secondary and may generate functional and anatomical distortions Primary OMD: due to transitory or permanent neurological problems or to anatomical abnormalities Hypertonicity: when suckling , the infant bites the nipple m

24、assaging the babys gums before nursing, and straddling him on the mothers lap while breastfeeding are recommended Hypotonicity: infants with low vitality falling asleep while nursing The ” dancer hand position” and milk extraction are recommendedSecondary OMD: occur when original sucking and swallow

25、ing reflexes are modified due to use of artificial teats or bottles This causes pain for the mother and inhibiting the let-down reflex making milk extraction difficult. It can be corrected by massaging the childs mouth with the finger pad, applying pressure on his tongue and gradually withdrawing th

26、e finger 13Prerequisites to Adaptation to the KMC Nutrition The kangaroo adaptation to the nutrition of a preterm infant is “a process of social and physical adjustment for the mother and family to the Kangaroo Mother Care Method” It is done through an education process with social and emotional sup

27、port It is vital for the success of the kangaroo nutritionExisting open door policy for parent to stay with their child The mother should be recognized as the babys primary care providerher stay next to her child should be done comfortable The health team is a central person to advocate and promote

28、satisfactory breastfeedingThe support given during the breastfeeding period should: Develop the mothers confidence ,paying attention to the mothers problems, Provide precise and practical information about the childs needs Offer options and allow the mother to make decisions Give timely pertinent in

29、formation on technical and scientific content14Breastfeeding preterm infants The American Academy of Pediatrics recommended officially since 2005 administering breast milk from the babies own mothers, to preterm and other high-risk babies Since then, breastfeeding has been the recommended mode of en

30、teral nutrition for preterm and LBW infants Breast milk has digestive enzymes, direct immune protective, immunomodulation, antioxidant and anti-inflammatory factors, hormones bioactive factors and multiple cellular elementsBreast milk allows a better cognitive ability development, better neurobehavi

31、oral organization and decrease infection Benefits of breast milk are recognized but it is still difficult to establish successful breastfeeding in Neonatal Units due to:the fragility of preterm babies and their illnessestheir different nutritional needs , the complexity of their care Infant- mother

32、separation and mother anxiety jeopardizing regular milk productionNo open door policy allowing parents to stay with children Fixed schedules for feeding 15Characteristics of preterm breast milkThe Colostrum is produced during the first 3 - 4 days of life It is a thick, yellowish liquid of high densi

33、ty From birth to day 3, the volume is from 2 to 20 ml per feeding It contains less lactose, fat and water soluble vitamins than mature milk but more protein, E, A and K vitamins carotene and zincPreterm colostrum contains more immunoglobulin A, lysozyme, lactoferrin and cells Mature milk The mature

34、milk not only vary from woman to woman but also from one breast to the other, from one nursing to the next and, varies also during the same feeding. The hind milk is richer in fat The preterm mothers milk contains 2 time more proteins, more sodium , it provides important amounts of taurine, glycine,

35、 leucine and cysteine, more fat , more calories and more calcium and phosphorus Only during the first 4 weeks after birth , mothers of preterm babies produce milk with a special composition that adapts to the estimated nutritional requirements of their children16Feeding modes for preterm infants Fee

36、ding based on maternal milk from his own mother plus vitamins A,D,E and K: Exclusive, with no fortifiers or supplements Fortified (fortifiers added to extracted milk) Supplemented with artificial milk for preterm infants Supplemented with fortified and pasteurized human milk from a donor (preterm or

37、 full term) Feeding based on artificial formula for preterm infants Exclusive or supplementary use of other forms or oral or enteral nutrition; protein hydrolysats, element and semi-element preparations For infants less than 1500g or born before 32 weeks GA breastfeeding is probably not sufficient t

38、o cover the calcium, phosphorus and occasionally, protein requirements and milk must be fortified with these elements 17Feeding on schedule preterm infantsPreterm babies do not demand to be fed until they reach full term nursing must be done on a schedule rather than on demandInfants weighing less t

39、han 2000 g or less than 37 weeks of GA, need short intervals between feedings in order to receive enough nutrients and to allow for adequate thermoregulation, growth and development Feeding intervals must be approximately every 1 hour and during the day and 2 hours during the night Controlling the f

40、requency of feedings is useful: Decrease energy loss by suction Provide the needed nutrients in sufficient quantities Create a routine for mother and child strengthening their bond Give the mother a clear timeline.18Breastfeeding a preterm infant (1)The transfer of maternal milk to the infant depend

41、s of the interaction between the volume of breast milk, the let-down reflex and the preterm infants suctionCheck signs of readiness for breastfeeding: Gestational age 32 weeks Baby able to coordinate breathing, sucking and swallowing Babys health is clinically stable (no serious breathing problems)

42、Baby can suckle with rare episodes of apnoea and bradycardia Apparent signs of being alert/ready to attachBreastfeeding a small baby requires patience and dedication because he/she: Suckles for a short time then rests Can fall asleep while breastfeeding Can take frequent pauses making breastfeeding

43、longer Is not always awake for breastfeeding19Breastfeeding a preterm infant (2)Reassure the mother that she is able to feed her baby Train the mother to watch the baby completes at least 6 suctions, alternated with pauses to breathe The weight test can be used to determine the volume of ingested br

44、east milk, but it may stress the mother, daily weight is enoughActively counsel her to: Feed the baby every 1 -2 hours Wake the baby up for feeding Keep the baby at the breast longer Let the baby takes long pauses and breastfeed more slowly Do not interrupt breastfeeding if the baby is still trying

45、to suckle Express some milk before the baby attaches if milk flow needs to be reinforced Breastfeed the baby with hind milk if the baby does not gain weight20Oral breastfeeding through suction -1Skin-to-skin contact has a positive effect on milk production, even before suckling begins Putting childr

46、en to the breast for the non nutritive suction, increases the rooting response and stimulates the suckling functions Direct oral breastfeeding Promote the milk let-down reflex by a gentle massage of the breast Awake the baby and placed him in a recommended nursing position The mother must surround t

47、he base of her breast with 4 of the 5 fingers and place the 5th finger on the edge of the areola forming the letter “C” The mother must hold the childs neck base to control it and to bring the baby close to the breast, offering him a secure position and orient the nipple in the direction of the chil

48、ds nose , stimulating the rooting reflex When the baby naturally tilts his head back and opens his mouth wide, the mother must bring him to the breast in one single swift and gentle motion of her hand or arm21Oral breastfeeding through suction -2The babys lower lip must be turned outward, the tip of

49、 his nose near the mothers breast, his chin touching it. The child will be able to breathe effortlessly.Nursing must not cause painThe newborn will begin suckling, according to his maturity, from 5 to 15 successive suctions, followed by a breathing pause as long as the suckling period, and then resu

50、ming the activity10 minutes after beginning nursing, it is possible for the child to fall asleep or to slow down the suckling rate.Once the baby is awake, he can settle again to resume nursing or to make sure he is satisfied22Breastfeeding Techniques The breastfeeding technique is a procedure by whi

51、ch suckling is carried outThe mothers position: The mother can nurse sitting or lying down The mother should be in a comfortable and relaxed position able to hold the baby close to her without undue effort, her feed be supported Check the infants position: The babys head and body must be perfectly l

52、ine up The babys face must face the mothers chest, with his nose in front of the nipple The babys body must be close to the mothers , turned towards her If the baby is newly born, the mother must cradle him with one arm and give support to the buttocks, not just to the head and shouldersCheck the In

53、fant attachment to the breast: The mouth is wide open The chin touches the breast (or close to) The lower lip turn outwards More areola is visible above the infant top lip23Nursing Positions for preterm infants -1The preterm baby must be nursed in a position supporting his head and neck to prevent t

54、he obstruction of airway causing apnea and bradycardia during breastfeedingFootball or watermelon positionThe baby faces the mother while his body is tucked under one of her arm. The babys upper back rests on the mothers forearm, while she holds his neck with her hand. The babys hips rest against th

55、e back of the chair or bed. Crossed or inverse cradling positionThe hand opposite the breast offered to the baby is placed behind the babys head, in order to support and guide it. The hand of the same side may support the breast. 24Nursing Positions for preterm infants -2The “dancer hand “position.

56、This is a technique that supports the childs jaw in order to improve the up and down excursions during suckling, made difficult by hypotonia. Modified football position. The baby sits facing the mother, by her side, on the sofa or a pillow, with his legs at his mothers side and his feet at her back.

57、25Alternative Feeding Methods 1.Cup/spoon/syringe/dropperDoes not interfere with breastfeedingCup is easy to washSafeSmall baby gets the quantity she/he needsCup-feeding can complement breastfeeding if the baby is weak or tired26Alternative feeding techniques Cup-Feeding Technique Measure the quanti

58、ty of milk needed into a cupHold the baby in semi-upright positionTouch the babys lips with the cupDo not pour the milk into the babys mouthAllow the baby to lap or sip the milk and swallow at own rateThe baby stops feeding when his/her mouth closes and doesnt show further interest in feeding27Gavag

59、e-Feeding Technique (1)Used to feed very low-weight or sick babyTube insertion Select a thin gastric tubeMeasure the distance from the tip of nostril to the lower tip of the ear and from the ear to the stomach Mark this distance on the tubeInsert the tube gently into the stomach through the noseChec

60、k the correct position of the tube by: Aspirating some stomach content, or Blowing air (1-2 ml) in the stomach and listening with stethoscope Leave the tube in the stomach maximum 3 days 28 Gavage-Feeding Technique (2)Use colostrum or expressed breast milk During gavage feeding: Mother holds syringe

61、 5-10 cm above baby; milk runs down tube by gravityStimulate the babys suckling reflex and taste Encourage mother-baby skin-to-skin contactFeed slowly over 15-20 minutes Intermittent feeding for at least 15-20 minutes is considered to be similar to “physiological feeding”When it is possible, start c

62、up-feedingContinuous enteral milk infusion method requires constant monitoring of the babys tolerance Click to edit Master title style2929Teach the Mother Colostrum/Milk Expression TechniquesIf the mother extracts manually her milk, it is recommended to extract it 8 to 10 times a day Mothers must ex

63、tract their milk until it no longer flows, usually after 10 or 15 minThe last drops have a high lipid concentration and may significantly contribute to caloric intake30Hygiene for milk extraction Breast milk is not sterile since it has its own micro flora The mother must follow strict hygienic measu

64、res: Hand washing with soap and water and brush under the fingernail Wash the milk container, with hot soapy water and rinse it with boiled water The container must have a wide opening and a cap it must be made of glass or hard polycarbonate suitable for food preservation it must never be a polyprop

65、ylene bag because of the risk of liberating toxic substances into the milk Previous cleansing of the nipples is not necessary It is also unnecessary to discard the first drops of milk Recommend the mother not to talk during extraction and only touch the exterior of the containers and the breasts.31M

66、anual milk extraction techniquea) Stimulating the let-down reflex : The mother may stimulate gently the breast She may roll it gently between thumb and index finger, or have a pleasant beverage , or might imagine herself as a “fountain of milk” With practice, the mother gets used to stimulate the let-down reflex b) Locating the milk ducts : The mother is asked to gently feel her breast, 3-4 cm behind the nipple to find the milk ducts similar to a cord with knots or a string of peas The mother mu