Northside Hospital - Special Beginnings

Special

Beginnings

in the Special Care Nurseries

Dear Mom and Dad, By now you’re probably recovering from the shock that I decided to come early or have had a problem at birth. The Special Care Nurseries at Northside Hospital will be my new home for the next several days or weeks. My nursery staff wants to welcome you and to let you know that they will do their best to make this a warm and nurturing environment for our entire family. They created this folder of information to help you understand the sights and sounds you’ll experience and the words you’ll hear during my stay in the Special Care Nurseries. It also contains useful tools to help you become involved in my care, so that we get to know each other.

If you have questions, any of the nursery staff will be happy to help you.

Love,

Me

Special

Beginnings

in the Special Care Nurseries

© 2018 Customized Communications, Incorporated Arlington, Texas, 3/2018, 4/2020 1-800-476-2253 • email: cci@customizedinc.com Visit us at www.customizedinc.com All Rights Reserved

Table of Contents

Transitional Milk. . . . . . . . . . . . . .22 Mature Milk. . . . . . . . . . . . . . . .22 Steps to Making Milk. . . . . . . . . . . .23 Cleaning Your Breast Pump Parts . . . . . 25 Transporting Your Pumped Milk to the Hospital. . . . . . . . . . . . . . 26 Breast Pump for Home. . . . . . . . . . .26 Pumping Tips. . . . . . . . . . . . . . . 27 Milk Supply. . . . . . . . . . . . . . . .28 Maintaining Your Milk Supply. . . . . . . .28 Increasing Your Milk Supply. . . . . . . . 28 How Can My Partner or Spouse Help? . . . 29 Nutrition Tips. . . . . . . . . . . . . . .29 Beginning Breastfeeding Your Baby. . . . 30 Steps to Breastfeeding. . . . . . . . . . 31 Positioning/Latch-On . . . . . . . . . . . 32 Nipple Shields. . . . . . . . . . . . . . 33 Engorgement. . . . . . . . . . . . . . .33 Blocked Ducts. . . . . . . . . . . . . . 34 Mastitis . . . . . . . . . . . . . . . . . 34 Donor Milk . . . . . . . . . . . . . . . .35 Breastfeeding Plan for Discharge 36 Conclusion 36 Mom Pumping Log 37 Glossary 39

Your Baby’s Health Care Team 4 Who’s who on the SCN health care team. . . 4 Resources. . . . . . . . . . . . . . . . . 5 Communication About Your Baby’s Care. . . 6 Things You Should Know. . . . . . . . . . 6 How Can You Help?. . . . . . . . . . . . 6 7 Infection Prevention. . . . . . . . . . . . 8 Monitors and Alarms. . . . . . . . . . . . 9 Learning About Your Baby’s Behaviors. . . 10 Baby’s Signs. . . . . . . . . . . . . . . .11 Signs of Stress . . . . . . . . . . . . . . 11 Ways to Help Calm and Comfort Your Baby. . 12 Skin-to-Skin Care in the SCN. . . . . . . . 13 Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Feeding and Nutrition. . . . . . . . . . . 15 Baby Feeding Signs. . . . . . . . . . . . 16 Blood Sugar. . . . . . . . . . . . . . . 17 Medications . . . . . . . . . . . . . . . 18 Breastfeeding When You Are Separated from Your Baby. . . . . . . . . . . . . 20 Anatomy of the Breast . . . . . . . . . . 21 Physiology of the Breast. . . . . . . . . . 21 Stages of Milk Production. . . . . . . . . 21 Colostrum. . . . . . . . . . . . . . . . 22 Being With Your Baby Mother’s Milk 19

The information in this booklet is for general reference purposes only and cannot be relied upon as a substitute for medical care. For the purpose of clear and concise writing, the term “he” will be used to reference the baby.

Please Note: All words highlighted in TEAL are clearly defined in the glossary.

Your First Look

Congratulations to you and your family at this special time. We want to welcome you to the Special Care Nurseries (SCN) . The health and safety of you and your baby are very important to us. We realize how worried you are about your baby and how stressful and overwhelming this time can be. We also want to provide you with as much information as we can and answer your questions to the best of our ability. There will be a special team of doctors, nurses and therapists to care for your baby. Special equipment will monitor your baby’s progress. You may see and hear things that are unfamiliar to you and it’s normal to feel afraid and uncertain. Do not be alarmed; all of the equipment you will see is designed to help, not harm, your baby. There are ways you can help us while also participating in your baby’s care, as you will learn from this book and your health care team. Some of those include safety and security, communication with our staff, as well as feeding, bonding, touching, and skin-to-skin time with your baby. Your team of health care providers are here to help you and instruct you along the way.

Your Baby’s Health Care Team

Who’s who on the SCN health care team While in the SCN, your baby will have many essential caregivers, all specializing in the work they do. Some of these caregivers include:

Parents: Your baby’s most important caregiver.

Developmental Rehabilitation: A team made up of a physical therapist, occupational therapist and/ or speech therapist. These professionals are available for babies with special developmental and medical needs as identified by the medical team. Care Coordination: A Care Coordinator will follow your baby while in the SCN. Typically, she will contact you within 7 days after your baby is born to offer resource information, guidance and support. She will assist with discharge planning needs and keep in touch with your insurance company until your baby goes home. Atlanta..........................................................404-851-6886 Forsyth..........................................................770-292-2243 Cherokee......................................................770-224-1809 Registered Nurse (RN): A nurse, licensed by the state of Georgia, that works closely with the neonatologist, and you, in planning your baby’s care. A RN will coordinate the day-to-day care by monitoring your baby closely, directing feedings and giving medications. There are numerous nurses in the SCN and your baby will receive care from different nurses depending on the shift and day. Lactation Consultant: Lactation consultants are health care professionals with special training and experience in helping breastfeeding mothers and babies. Volunteer: Adjunct support for assisting staff, parents and family in meeting the infant’s needs to be held, rocked, consoled and fed. The volunteers receive specialized education to work with the SCN population. You may reach a Care Coordinator by calling:

Neonatologist: A physician with advanced and specialized training in the care of sick newborns and premature infants. The neonatologist will oversee your baby’s care while in the SCN. Pediatrician: A physician specializing in the health care of infants and children. Your baby will need to see the pediatrician you select within a week after going home from SCN. Consulting Physician: A physician specializing in a particular area of medicine such as heart, lungs, bowels, eyes, brain and infections. Occasionally, we may call such a specialist to lend his/her expertise in the care of your baby. Nurse Practitioner: A licensed, advance practice, registered nurse who works together with the neonatologist to diagnose and treat illness. Pharmacist: The pharmacists in the SCN, experienced in neonatal medicine, review, monitor and dispense the medications ordered by your baby’s providers. Respiratory Therapist (RT): A licensed health care practitioner trained in respiratory care that works closely with the neonatologist in managing your baby’s respiratory needs and monitoring the equipment used in the healing process. Dietitian: Registered dietitians specialize in the nutritional well-being of preterm and term infants. The dietitian works closely with the neonatologist to provide optimal nutrition to promote adequate growth and development for your baby.

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Resources Emotional Health Support: To obtain support from a licensed mental health professional, you may request an order for an emotional health consultation from your baby’s physician or nurse. This service is available free of charge, and can be beneficial in managing the stress you are probably experiencing.

Discharge Coordinator: A RN who works closely with you and the medical team to facilitate your baby’s discharge from the SCN. You may reach the Discharge Coordinator by calling 404-851-8626. Atlanta only

Parent Groups: Atlanta: The Parent Group meets every Thursday at 6:30 p.m. Forsyth: The Parent Group meets weekly. Please ask your nurse for more information.

Lactation Consultants Atlanta and Forsyth.............................. 404-303-3329 Cherokee ..................................................... 770-224-1970 CPR Class ................................................. 404-845-5555 *Specify Atlanta, Forsyth or Cherokee campus when calling.

Chaplains Atlanta ......................................................... 404-851-8754 Forsyth ........................................................ 770-844-3341 Cherokee ................................................... 678-880-3784

*These numbers are “voicemail only” after 4:30 p.m.

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Communication About Your Baby’s Care The doctor or nurse practitioner will call you daily after they have examined your baby. The nurses will update you at the bedside or by telephone. Together you can discuss your parenting focus for the day. Your baby’s health care team will answer questions and give you information to be able to make informed decisions for your baby. Things You Should Know • When you receive a call from the SCN, Northside Hospital’s general telephone number may appear in your caller ID. • If you screen your calls and see this number, PLEASE answer! • You may reach the hospital operator if you use redial to call back. • Working together we can stay informed and help your baby. Thank you for your help in promoting communication, and maintaining your privacy and confidentiality. How Can You Help? • Provide the BEST telephone number for the SCN staff to call. It should be a number that nurses and physicians can use to contact you every day. The nurse will write this number on the baby’s information sheet. • Give us permission to leave a message on your voicemail if you are not available to take the call. • Create a greeting on your voicemail to include your name and number, “Hello, you have reached ________________, at ________________, please leave a message”. To maintain confidentiality, we want to be certain that we are leaving a message at the correct number. • Clear your voicemail inbox regularly so that there is space to leave a detailed message if you do not answer. • We ask that you refrain from calling us between 6:45-8:00 in the morning AND 6:45-8:00 in the evening. During these times, the nurses are exchanging important information about the babies in their care. • When you call the SCN please tell us your unique access code to verify your identity.

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Being With Your Baby You are welcome at your baby’s bedside. There are times, however, when we will ask you to wait in the family waiting area. On rare occasions, for example, when staff must concentrate on helping an infant in distress, we may ask you not to be at the bedside. Please understand, our goal is to ensure that each baby receives the best care possible. The first few days after delivery are usually when your baby will need the most care. This is also when mom is recovering from childbirth. Remember it is important to care for yourself so you can care for your baby. Your baby already knows your voice and needs the love and support that only you can give. We encourage you to be active partners in the care of your baby. At first, it may be something as simple as helping the nurse change a diaper, but as your baby gets stronger you can begin to assume more of their daily care. The health and safety of you and your baby are very important to us. For the safety of your infant, the SCN is a limited access area and only authorized persons are admitted. Information about your baby is confidential. We can only give information to the ID band wearers who have a unique access code to receive any patient specific information by telephone.

Visitation guidelines To ensure the best start in life for your baby, we would like to share our visiting guidelines.

Adults who are important to you can visit your baby. The ID band wearer may designate up to four “special visitors” over the age of 18. These visitors are the only ones who may be with the baby when the ID band wearer is not in the nursery. For the safety of our infants, these visitors must present a photo ID prior to entering the nursery. Any visitor who exhibits signs of illness, or appears impaired or disruptive will not be allowed to visit. To promote a healing environment, and due to the size of the rooms, we recommend that only 4 people are at the bedside at the same time. Your visitors are to remain in your baby’s room or the family waiting area outside the SCN only and cannot be in the SCN during report. Please do not leave young children unattended. Siblings are welcome to visit as long as they are old enough, healthy and accompanied by an ID band wearer. We regret that for infection control reasons, sibling visitation may be suspended during flu and RSV season. If you have questions about visitors for your baby, please ask.

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Infection Prevention Parents share the responsibility of preventing their baby’s exposure to visitors who are sick. You may consider limiting visitors to protect your baby. If you or any visitor has a cold, cough, skin infection, fever blister, diarrhea or other such contagious diseases, please postpone your visit until you are completely recovered. • WASH YOUR HANDS THOROUGHLY WITH SOAP AND WATER FOR 15 SECONDS EACH TIME YOU ENTER THE SCN AS WELL AS BEFORE AND AFTER PARTICIPATING IN YOUR BABY’S CARE. • To protect your baby consider placing cell phones/ devices in a baggie when you enter the SCN. • Please remember to wash your hands after using any electronic device while holding your baby. Remember to wash your hands after every electronic device use. Chicken pox: Chicken pox is a highly contagious, airborne disease that is life threatening to the babies in SCN. Chicken pox is contagious 2 days before bumps appear. Visitors who have never had chicken pox but have been exposed to it must wait 21 days after exposure before entering the SCN. Baby’s personal items: We encourage you to bring personal items for your baby. Please check with your baby’s nurse regarding appropriate clothes and toys. Save valuable, breakable or sentimental items for when your baby goes home, as we cannot be responsible for lost items. Please label all items and wash all clothing you bring for your baby.

Wash your hands thoroughly each time you enter the SCN. Our SCN babies are very susceptible to infection.

Photos: You may take pictures of your baby at any time.

Privacy: Privacy is very important. Please do not ask us about the other babies in the SCN. Please stay with your baby when you are in the SCN and do not walk around looking at the other babies. We also ask you to share this information with your visitors.

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Monitors and Alarms Why is that alarm going off? Is my baby ok? An oxygen saturation monitor, also called pulse ox , is a medical monitor that measures the amount of oxygen in your baby’s blood. When your baby is admitted to the SCN the pulse ox monitor is placed on your baby with a band-aide like sensor. The sensor is wrapped around the wrist, hand, foot or toe. A red light from the sensor will shine through the skin and measure the amount of oxygen in your baby’s blood. The sensor is neither hot nor painful. The sensor site is changed as needed. Monitoring oxygen levels in your baby’s blood helps your baby’s physicians, nurses and respiratory therapists determine your baby’s oxygen needs. Your baby’s physician will determine the optimal range for your baby, and this range is programmed into the monitor.

The pulse ox monitor may alarm while you are with your baby. We set the alarm limits so we can come to your baby’s bedside if it appears their oxygen needs are changing. Most of the time your baby will return to the optimal range without needing a change in the amount of oxygen he is receiving. The sensor may react to movement, bright lights, changes in circulation or skin temperature giving a false alarm. The staff will assess the situation and respond as needed. Often a quick glance at your baby and the monitor can provide enough information to make a judgment to intervene, or to allow the monitor to reset. We can teach you how to identify these false alarms if you would like; however, if you leave the alarm sounds to the staff, you can focus on your baby. We want to assure you that we are attentive to alarms.

The pulse ox is only one method we use to monitor your baby’s well-being. We monitor your baby’s heart rate, breathing rate, blood pressure and temperature continuously while they are in the hospital. Each bedside monitor is programmed to alert the staff to events happening at other bedsides throughout the pod. This Alarm Watch program is one way for the staff to watch your baby from another baby’s bedside. The nurses caring for your baby may also carry a pager that alerts them to changes in your baby’s condition that require attention.

Please discuss with your baby’s nurse any concerns you have about monitor alarms and what they mean for your baby.

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Learning About Your Baby’s Behaviors

Babies in SCN can be very sensitive. They can handle only one kind of stimulation at a time. Our goal is to help you understand your baby’s need for special care, while helping you experience the joys of new parenthood.

Why is my baby sleeping so much? Premature babies demonstrate six different states of activity that help explain their different behaviors. They are Sleep, Light or Deep, Drowsy, Alert, Fussy and Crying. The more premature your baby is, the less of a change you will observe in their state. The predominant state for premature babies is sleep, either light or deep. As your baby grows, you will observe more of these states. Here is a brief description of each state with the emphasis placed on how it relates to their sleep state. Sleep 23 - 27 weeks gestation At these early weeks your baby will be sleeping most of the time. They may only have brief moments when they may be in a drowsy or partially awake state. Due to their immature nervous system their movements are jerky with a trembling quality even in their sleep. Your baby should be sleeping 23 - 24 hours per day. Sleep 28 - 29 weeks gestation Premature babies at this age start having periods of REM sleep, Rapid Eye Movement. In this type of sleep you see the babies eyes flutter beneath their closed lids. This kind of sleep is crucial for learning and memory. Your baby at this age is only capable of brief short moments of wakefulness. They are still not yet ready to focus on your loving face. During this light sleep you will observe irregular breathing, sucking movements and occasional brief eye openings. Your baby may respond to voices and other noises. Your baby should be sleeping 22 - 23 hours per day. Sleep 30 - 33 weeks gestation Your baby’s sleep is now cycling regularly between active and quieter stages. They are still unable to reach a deep sleep but they do enter a quieter stage, which facilitates growth and development. Your baby still requires approximately 21 - 22 hours per day. Sleep 34 - 36 weeks gestation Babies at this age still sleep 18 - 20 hours per day; only a few more hours than full term infants who require 16 - 17 hours per day. At about 35 - 36 weeks comes the first appearance of really deep, quiet sleep, which is essential for growth, and development of the body and brain. Your baby is in a deep sleep when you observe no movements except for occasional startles or jerky movements. Your baby’s eyes are tightly shut and your baby’s breathing is regular.

Drowsy At this time your baby will have a dazed look. Your baby’s eyes are dull with droopy eyelids. Your baby’s movements may increase and they may startle. You may observe a delayed reaction to voices or other noises. Alert Your baby has a bright awake look. They can focus their attention on a face or an object. Your baby’s breathing is regular and there is little body movement. This is the best time to interact with your baby.

Fussy Your baby may be thrusting their arms or legs, and their breathing may be irregular. Your baby may be irritable and your baby may need comfort measures.

Crying Your baby is actively moving. Your baby is crying intensely, your baby may be difficult to calm.

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Baby’s Signs Your baby’s cues or signs can tell you how much socialization they can handle at this very young age. Please use quiet voices around your baby. A stressed infant takes longer to grow and get well. Your baby needs your loving attention just as much as your baby needs food, warmth and oxygen. When you see these signs you know your baby is comfortable and enjoying the sensory input they are receiving.

Signs that your baby is happy and ready to interact: • Eyes are open and alert • Able to focus on your face or an object • Breathing pattern is regular • Face, arms and legs are relaxed • Able to gaze at your face for awhile Signs your baby is self-soothing: • Clasping their hands • Grasping your finger • Sucking on hands or fingers • Tucking their arms and legs in close to their body

Signs of Stress As parents of a baby in the SCN, it is important for you to understand the signs or cues indicating your baby may be stressed.

Some common signs your baby is stressed: • Changes in breathing patterns or increases in your baby’s oxygen needs • Changes in your baby’s vital signs, such as, an increase or decrease in heart rate, oxygen

• Avoids looking at you • Outstretches arms and fingers as if to say “enough” or “stop” • Legs stretched as if sitting on air • Hand extends outward and upward, similar to “saluting” • Crying and fussy • Arches back and neck

saturation or blood pressure • Your baby looks exhausted • Hiccups • Yawns • Frowns or grimaces

When you observe one of these signs it indicates your baby needs some kind of change or rest. Try limiting the stimulation your baby is receiving and try some comfort measures. Remember your baby can be very sensitive and can only handle one kind of stimulation at a time. They can be talked to or held. Too much socialization at one time, such as rocking and talking, may be very stressful for your premature baby. As your baby grows, so will their socialization skills. Let them guide you with their cues.

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Ways to Help Calm and Comfort Your Baby

• Hug your baby with your hands by placing one hand around their head and the other hand supporting their feet. These hand hugs help your baby to curl up and relax.

• Swaddle your baby in a blanket.

• Help your baby into a curled position with their legs flexed and assist them in bringing their hands up to their mouth.

• Place your baby in their developmental positioner.

• Offer your baby a pacifier.

• Let your baby hold your finger.

• Hold your baby quietly to reduce stimulation.

• Turn down the lights and decrease the noise around your baby’s bed.

• Speak softly to your baby.

• Placing your warm hands gently on your baby is soothing and calming. However, premature infants prefer not to be stroked, tickled or rubbed because their neurological system isn’t ready for this type of touch. • Premature babies like to be curled up on their tummy or side-lying supported with a positioning device. This allows them more control over their movements.

• Your baby may need their diaper or their position changed.

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Skin-to-Skin Care in the SCN No one can prepare you for the first time you hold your new baby. It’s a special experience like no other. This experience can be enhanced by skin-to-skin contact when you hold your baby unwrapped and placed on your bare chest under a blanket. Both parents are encouraged to bond with their baby by doing skin-to-skin care. Most babies are able to be held skin-to-skin. Your health care team can help you decide when the time is right. When skin-to-skin holding needs to be postponed, the perfect alternative is to hold your baby with a “hand hug”. Skin-to-skin holding can help with breastfeeding and milk supply. If you choose not to breastfeed or provide breast milk, skin-to-skin is important for the following reasons: • Increased parent-infant bonding and comfort from hearing the parent’s heart beat. • Possible decreased length of stay in the hospital. • Improvement in baby’s temperature stability. • Improvement in baby’s sleep. • Decrease in oxygen requirements. • Possible decrease in apnea episodes (breathing pauses) and bradycardia episodes (slow heart rate). • May decrease crying and fussiness. Come to the SCN prepared to hold your baby skin-to-skin! • Let your nurse know when you arrive at the bedside that you would like to hold your baby skin-to-skin. • Wear comfortable clothes. A button down shirt that opens in the front is optimal. • Moms may need to remove their bra/camisole. • Plan to hold your baby for at least one hour. • Avoid wearing perfumes or colognes. • You may wish to bring your pillow or breastfeeding cushion for comfort. • All bed spaces have a curtain that can be pulled for privacy while you are with your baby. • If you are here during a feeding time and your baby is

Skin-to-skin is a great beginning

receiving tube feedings, you can still hold your baby during the feeding. This may encourage your baby to root and it is good stimulation for your milk production if you choose to breastfeed. • Your nurse will assist you in positioning your baby for skin-to-skin. • Your baby may need to wear a hat. • Your baby’s temperature will be monitored throughout your skin-to-skin time. • Once you and your baby are comfortable, just relax! Talk quietly to your baby, sing softly or just cherish the special time. • If you feel yourself getting sleepy, alert the nurse so she can assist you in putting your baby back in their bed.

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Pain It can be difficult to tell if a baby is having pain. Sometimes babies, especially preterm babies, cannot let us know when they are having pain. We realize that your baby may have some painful experiences while in our unit. We are continually trying to make everything less painful. This is very important to us, and we are sure, important to you. Please be assured we are doing all we can to keep your baby comfortable.

Signs that your baby might be in pain: • Crying, a worried face or frown. • Tightly fisted hands and feet.

• A higher than normal heart rate and blood pressure. • The baby’s oxygen levels may change when touched or handled. Of course a hungry baby will cry, tense up, and have a high heart rate, but this stops when he is fed or given a pacifier. We are using a method of assessing your baby’s pain called the Premature Infant Pain Profile (PIPP). Questions or concerns can be discussed with your nurse and doctor.

Medications used to prevent and treat pain Some of the things that cause pain are procedures such as heel sticks , IV or chest tube placement. Infants placed on a ventilator can be uncomfortable and may need medication. Treatments and procedures known to cause pain can be treated with narcotics given through an IV. The medication can be given in very small amounts continuously by IV or when the infant shows signs of needing comfort. Some babies require short term use of narcotics. Babies who are on a low-dose continuous narcotic drip will be slowly weaned to prevent symptoms of withdrawal. However, this does not mean that your baby is addicted to the medicine, his body has gotten used to them. Non-medical ways to prevent or treat pain Sucrose is a sugar used to provide short term pain prevention and management for procedures like heel stick, feeding tube placement, vein sticks, and shots. A few drops of sucrose on the baby’s tongue using a dropper or with a pacifier before, during and after the procedure can provide effective pain control. In addition, swaddling, nesting, hand hugs and verbal reassurance can calm the infant who has discomfort or is fussy. Ways you can help Your presence at the bedside can be very comforting to your baby. Your baby’s nurse will help you decide what works best for your baby. Keeping the area quiet and lowering the lights can be helpful. Some babies like to be held, talked to, massaged, or given a pacifier. Some babies like to be wrapped snugly or nested between your hands. Some babies like to be left alone.

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Feeding and Nutrition If your baby is unable to receive nourishment by mouth, your baby will receive nourishment by vein (IV). At first your baby will receive mainly sugar water for calories. Within a few days, he may be started on total parenteral nutrition (TPN or “hyperal”). With TPN, protein, fat, sugar, vitamins and minerals are added to the fluids that the baby receives by vein. Your baby can receive complete nutrition and grow on TPN alone. As your baby tolerates milk feedings, the TPN will be decreased.

Your baby may be started on gavage (tube) feedings . A tube is passed through the mouth (OG tube) or the nose (NG tube) into your baby’s stomach. Milk is put through the tube. This may be as a constant slow drip, called continuous drip feeds, or as prescribed amounts given every few hours, called bolus feeds. Either way, the amount will be very small at first and gradually increase. There is often a transition period where the amount of nutrition from TPN slowly decreases as the amount from tube feeding increases. Almost all babies lose weight before they begin to gain weight. This weight loss typically is 5-15% of the baby’s birth weight. Sometimes very sick babies gain weight the first few days. This is not real weight gain; it is retention of water. Usually babies do not regain their birth weight until two or more weeks of age.

Beginning feeding by breast or bottle When babies are born prematurely their sucking is not well coordinated with their breathing. This suck- swallow-breathe pattern usually becomes coordinated enough to safely breast or bottle-feed at about 34 weeks of gestation. Before your baby is ready to feed by breast or bottle, he may enjoy sucking. A pacifier may be used to encourage sucking. When the baby is being tube fed, he may like to suck on a pacifier or the breast that is empty of milk. This is called non-nutritive sucking. Based on your baby’s feeding cues , the doctors and nurses will determine when to start nipple feedings. At first your baby may have only one or two feedings a day that are not by tube. This will gradually increase as the baby gets used to the extra work of feeding. Babies who have had severe respiratory problems may be slower to start and slower to advance on feedings.

Cues that your baby is ready to feed (cue based feeding) Prior to a feeding they should: • Be awake. • Hold their body in a flexed position with arms/ hands at midline.

• Demonstrate energy for feeding by maintaining good muscle tone and flexion. • Search for nipple or opens mouth promptly when lips are stroked and the tongue drops to receive the nipple.

As difficult as it may be, if your baby is not showing all of these cues at feeding time, it is better for your baby to be held skin-to-skin during the gavage feeding than attempt a bottle or breastfeeding.

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Baby Feeding Signs Feedings are most successful when your baby is awake but calm. Notice how your baby behaves before and during the feeding. If the behavior changes he may be trying to communicate that he can no longer stay focused on the task of coordinating the feeding with suck, swallow, and breathing. Some signs of behavior to look for include:

Signs that your baby needs to take a break: • Stares or avoids looking at you • Face has a look of panic or worry • Cannot wake up, yawns a lot • Anxious activity such as back arched, arms extended, hands open, fingers separated • Color changes • Breathing rate is increased

Signs that your baby needs to stop feeding: • Makes gulping, coughing or choking sounds • Milk drools out of the mouth • Makes a face, grimaces, furrows the brow • Pushes away or turns head away • Stops sucking often or for a long time • Body, arms and legs are limp, mouth is open • Falls asleep, or “shuts down” • Breathes faster than 60 times a minute • Stops breathing, heart rate slows, does not get enough air (oxygen)

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Blood Sugar What kind of blood sugar problems can babies have? Their blood sugar may be either too low or too high. Low blood sugar is common soon after birth. High blood sugar is more common in babies who are getting most or all of their nutrition by vein. How is blood sugar monitored? It can be monitored by placing a drop of blood onto a chemical strip (Dextrose stick/D-stick) . A sample of blood can also be sent to the laboratory for a blood sugar determination. How is low blood sugar treated? It is treated by giving the baby more sugar. If your baby is on feedings by vein (IV), the amount of sugar in the intravenous fluids is increased. If your baby does not have an IV, he may be fed sooner and/or more often, or an IV may be started in order to give your baby sugar water. How is high blood sugar treated? If your baby is being fed by vein, the amount of sugar in the IV fluids may be decreased. Or, your baby’s doctors may decide to give your baby insulin to help your baby use more sugar in his body. Do blood sugar problems in a baby mean he will get diabetes? Sugar problems in a baby do not relate to whether he will develop diabetes later on in life. However, infants of mothers who have had gestational diabetes in pregnancy, are more likely to have low blood sugar in the newborn period. Once a baby is feeding regularly, blood sugar problems seldom recur.

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Medications These medications are commonly given to infants in the SCN.

Medication Name Why does my baby need this medication?

Possible side effects of this medication May cause a rash and/or fever (rare in babies) May cause restlessness or increased urination May cause changes in heart rate; may be irritating to veins May cause high blood sugar

How will my baby receive this medication? Given through an IV or as a shot in the leg Given through an IV or by mouth Given through an IV or by mouth A small amount of ointment will be placed into each eye soon after birth Given through an IV as your baby needs it, or as a continuous IV infusion Given through an IV or as a shot in the leg Given through an IV

Given to prevent and treat infections

Ampicillin

Given to stimulate breathing

Caffeine Citrate

Given to prevent and treat low calcium levels

Calcium Gluconate

Given to treat low blood sugar Given to prevent & treat infections of the eye that can be acquired upon delivery Given for comfort and pain relief

Dextrose (D10W Bolus)

May appear as drainage in your baby’s eyes

Erythromycin ointment

May affect breathing, may cause decreased urination May cause decreased urination; in rare cases may affect hearing

Fentanyl

Given to prevent and treat infections

Gentamicin

Lactobacillus Reuteri (Gerber Soothe Probiotic Drops)

Given to help establish normal (good) bacteria in the bowel (gut)

No known side effects

Given by mouth

May affect breathing and/ or cause muscle twitching Rapid infusion increases the risk of intraventricular hemorrhage May cause discomfort and swelling at the injection site May cause drops in oxygen levels while being administered

Given through an IV or by mouth

Lorazepam (Ativan)

Given for agitation

Given to treat low blood volume/low blood pressure Given to prevent and treat bleeding disorders in newborn babies Given to make the lungs more elastic (usually given to premature babies whose lungs aren’t fully developed) Given to assess IV sites and when giving IV medications Given for pain relief prior to minor procedures (i.e. heel sticks, IV starts)

Normal Saline Bolus

Given through an IV

Given as a shot in your baby’s leg soon after birth Given through the breathing tube. The first dose is often given in the delivery room. Given through an IV as needed

Phytonadione (Vitamin K)

Poractant Alpha (Curosurf)

Saline/ Heparin Flush

No known side effects

No known side effects

Given by mouth

Sucrose

This document provides limited information on the medications used in the SCN. It is not inclusive of all side effects. Please contact your infant’s nurse, physician, nurse practitioner or pharmacist if you require further information.

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Mother’s Milk

Providing breast milk for a premature or sick baby is a gift that only a mother can give to her child. Breastfeeding and providing expressed breast milk offer many health advantages which will benefit your baby during his entire lifetime. Breast pumping and feeding is the beginning of a very special relationship between you and your baby. Mother’s Milk Providing breast milk for your baby in the SCN One of the most important things you can do for your baby is to give him your breast milk. Breast milk is recommended for every baby in the SCN. It contains many of the nutrients required and is perfectly matched for your baby’s needs for proper growth and development. Studies have proven that breast milk provides optimal health and benefits to the newborn for as long as you choose to breastfeed. It may even prevent medical problems and infections. Some babies may actually go home sooner because they receive mother’s milk. Mother’s own milk for premature infants: • Is different than breast milk for full-term babies • Is better tolerated than formula • Provides antibodies specific for your baby • Has been proven to decrease chance of Sudden Infant Death Syndrome • Is the most important medicine you can give your baby Medical research shows us feeding human milk results in: • Smarter babies with better vision • Proteins are easier to digest • Fewer infections and other life-threatening or chronic illnesses • Reduces the risk of asthma, allergies, and anemia • Better blood pressure and lower risk of heart problems when older • Decrease obesity in childhood and later in life Breastfeeding When You Are Separated from Your Baby

We know it is difficult for new parents when your baby is born too early or is sick. It is important for us to help you in every way possible to ensure that you get off to a great start with breastfeeding.

Mother’s milk is more than food, it’s medicine for your baby.

• Fewer feeding problems • Less allergies and eczema

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Anatomy of the Breast The breasts are delicate organs made of glandular, connective and fatty tissue. The nipple contains tiny openings through which the milk can flow. These tiny openings are surrounded by muscular tissue that causes the nipple to stand erect when stimulated. Surrounding the nipple is an area of darker skin called the areola . This area will become darker and larger in size during pregnancy due to hormonal changes. The areola contains pimple- like structures near its border that are called Montgomery glands . These glands secrete a substance that helps to lubricate and cleanse the area. Physiology of the Breast Stimulation of the nipple by the baby’s sucking or use of a breast pump sends a message telling the brain to produce prolactin . Prolactin stimulates milk production. This occurs after the baby is born and the placenta detaches and comes out of the birth canal. The second hormone that is released is known as oxytocin . This hormone causes the cells around the milk glands to contract. This contraction squeezes the milk down through the milk ducts and out of the nipples. The milk pools behind the nipple and beneath the areola. This response is known as let-down or milk ejection reflex.

Milk Producing Cells

Milk Ducts

Nipple

Areola

Fatty Tissue

If the milk is not emptied from your breast routinely, your body will decrease production of breast milk. Eventually, your body will stop producing milk.

Sensations of let-down that you may notice: • Tingling sensation • Warm upper body sensation • Feeling your breasts become full

It may take a minute to several minutes of sucking by the baby or pumping until the milk ejection reflex occurs. Some mothers only know that their milk has let-down by seeing milk spraying more than dripping.

The sensations commonly associated with let-down may not be felt until your milk is in greater supply.

Stages of Milk Production By 16 weeks of pregnancy, your breasts are fully capable of producing milk. Some women will notice drops of fluid on the nipple during these early months. This fluid, known as colostrum , is the “first milk.” It is what the baby will receive until your higher volume milk is produced.

Colostrum

Transitional

Mature

Thick, yellow-colored milk, high in protein, antibodies and some vitamins and minerals.

Thin and white in appearance. Composition is approaching mature milk .

More watery appearance, slight bluish in color as the feeding begins and becoming white by the end of a feeding as the fat content increases.

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Colostrum Colostrum is the first stage of breast milk that develops during pregnancy and lasts for a few days after the birth of the baby. It is also much thicker than the milk that is produced later in breastfeeding. Colostrum is high in protein, fat-soluble vitamins, minerals and immunoglobulins . Immunoglobulins are antibodies that pass from the mother to the baby and provide protection for the baby from a wide variety of bacterial and viral illnesses. Colostrum will be replaced by transitional milk 2 to 4 days after birth.

Facts about colostrum: • Commonly called “Liquid Gold” • Can be yellow to clear in color • Beneficial in loosening mucus in baby • Easily digested • Serves as a laxative and helps clear the baby’s intestinal tract • Very high in protein • Contains antibodies which help the baby fight infection • Coats the stomach and intestines and protects against any invading organisms

Transitional Milk Transitional milk occurs after colostrum, and you will find your milk changing character and increasing in quantity. When you pump or breastfeed regularly, your breasts will be stimulated to produce transitional milk. The content of this milk includes high levels of fat, lactose and water-soluble vitamins. This milk contains more calories than colostrum and is very high in protein content. Mature Milk Mature milk begins to appear near the end of the 2nd week after the baby is born. It may take longer depending on when breastfeeding or pumping was initiated. Mature milk is mostly water, which is necessary to maintain correct fluid balance for the infant. The rest is comprised of carbohydrates, proteins, and fats that are necessary for both growth and energy. It is also composed of wonderful immunologic properties. These properties do not disappear after colostrum, but remain throughout breastfeeding.

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Steps to Making Milk The following steps should start as soon as possible after the birth of your baby. Breast Massage and Hand Expression Breast massage and hand expression before and after pumping will help increase your milk volume. Anytime you move a drop of milk it sends signals for your breast to make more milk. This technique will also help with the removal and collection of the colostrum in the early days.

Remember, as with everything, practice will help you feel more confident in your ability to hand express your breast milk. Be patient with yourself.

1 Wash your hands with soap and water.

2 Have a clean container ready to catch your milk.

3 Gently massage your breasts to make the milk flow more easily. Stroke gently from the top of your breast towards the nipple.

4 Use the C-Hold to place your fingers on the breast.

5 Press your hand straight into the chest.

6 Gently compress/roll your fingers to express milk.

7 Relax your fingers and repeat. Rotate the position on the breast periodically.

Watch this great video: Northside.com/HandExpression (Link to Stanford Medicine website video)

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Using the breast pump: • Use one of the hospital double electric pumps.

• Position the shields over your nipples. • Begin with the suction on minimum. • Adjust the suction to comfort – you should feel a slight tugging sensation. • Pump for 15 minutes. • Pump at least 8 times in 24 hours, 10 times for multiples. • Pump at least once at night. • Having the suction set at the highest level does not remove more milk. • Pump often until breasts feel well drained. This is important for complete removal of the milk. When your breasts still feel full after pumping, the rate of milk production decreases because of high levels of FIL. FIL is a protein in your milk that tells the cells in the breast to stop making milk. It can be normal to pump only a few drops or nothing at all in the first few days. It is the regular pumping of the breasts that will increase the amount of milk each day.

Do not throw away any pumped milk. Every drop should be saved.

Hands on pumping: Using your hands along with pumping can assist with more milk removal and can increase your milk supply by 48%. For some mothers, pumping alone may not remove all the milk from the breasts. • While pumping, massage and compress your breasts as much as you can. • Continue pumping until milk flows to a trickle. • Massage your breasts again, concentrating on areas that feel full. • Finish by either hand expressing your milk into the pump’s breast shield or single pump, which ever yields the most milk.

Watch this video for instructions: Northside.com/HandsonPumping (Link to Stanford Medicine website video)

A Hands-Free Pumping Bra is highly recommended to use with your breast pump which makes pumping easier. It will help hold your pump parts so your hands are free to massage your breasts during pumping, drink fluids or eat a snack. Another good reason to drain your breasts completely when you pump is to increase the amount of calories in the milk. It ensures collection of hind milk, the milk that is released last. Hind milk is high in fat and contains the calories your baby needs to grow.

Collection of pumped breast milk: • Use new clean bottles each time you pump. • You can combine pumped milk from both breasts into (1) bottle from (1) pumping session. • Do not combine milk from different pumping sessions. • Do not fill the bottles more than two thirds full.

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Labeling your milk • Use the breast milk label provided by the staff. Please carefully review the label before placing the label on your expressed milk . • Write the date, time of pumping and any new medications you are taking on the label. • Remember to call the Lactation Center when starting any new medications. Tracking your milk: • Write on the pumping log the time and amount you pump. • Set an alarm or reminder to help you remember to pump. • Tracking your pumping will help you make more milk.

Cleaning Your Breast Pump Parts Always remember to: • Clean your breast pump parts immediately after pumping. • Do not clean the breast pump parts in the sink, use a separate container used only for this purpose. Washing by hand • Rinse all parts (except the tubing) that come in contact with breast/breast milk under cool running water to remove remaining milk. • Place the parts in the clean container used only for infant feeding items. • Add soap and hot water to the container. • Scrub items using a clean brush used only for infant feeding items. • Rinse under running water, or by submerging in fresh water in a separate container. • Air dry breast pump parts thoroughly. • Clean container and bottle brush. Rinse them well and allow them to air dry after each use. • Place pump parts , container and bottle brush on a clean, unused towel or paper towel in an area protected from dirt and dust.

Sanitizing • Sanitize breast pump parts in microwave steam bags daily. • Use the manufacturer’s directions for microwave steam bags. Store safely • Ensure the clean breast pump parts, bottle brush, and wash container have air-dried thoroughly before storing in order to help prevent germs and mold. • Store dry items in a clean, protected area. Tubing • If your tubing has water droplets in it at the end of a pumping session, disconnect the tubing from the pump parts and run the pump a few more minutes until tubing is dry. • If the outside of the tubing is soiled, wipe it with a disinfectant wipe. • If your tubing has milk in it, discard and replace with new tubing.

For detailed instructions visit: Northside.com/BreastPumpKitCleaning (Link to CDC website)

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Storing Your Breast Milk for Your Baby in the SCN

Refrigerate within 1 hour of pumping.

Fresh Pumped Milk

Refrigerate for 96 hours then freeze.

Fresh Pumped Milk Refrigerated

Transporting Your Pumped Milk to the Hospital

• It is important to always transport your breast milk in an insulated cooler container with frozen coolant packs. • Always keep your pumped milk cold or frozen. • Drop off all your labeled expressed breast milk bottles at the Special Care Nursery reception desk. Breast Pump for Home There are many types and brands of breast pumps. It is important to choose the correct breast pump from the start since it can have a substantial impact on your milk supply. An automatic double electric breast pump is recommended for pumping when you are separated from your baby. This type of pump is most effective in stimulating release of the milk producing hormone, prolactin, which results in the greatest amount of milk. Some considerations: • Can the pump parts be sanitized daily? • Are the collection bottles, given by the SCN compatible with the pump? • Is it recommended for long term exclusive pumping? Pumping after discharge in the SCN: Please remember to take ALL the pump parts you use with the hospital pump with you when you go home, including the caps and tubing. If you leave these pieces behind, you will have to purchase replacement parts. Breast pumps are available in the SCN for you to use so be sure to bring your pump parts with you. Microwaves are also available for sanitizing your pump parts.

Call your insurance company or Medicaid provider to see if they can assist with getting a pump. The hospital also has pumps available. Your lactation consultant can assist you with selecting a pump and answering any questions you may have.

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