Prematurity, NEC, and breastfeeding. 9
Necrotising enterocolitis (NEC) is a serious inflammatory condition of the gut and primarily affects preterm infants. It is characterised by inflammation, ischaemia, and bacterial translocation across the neonatal bowel wall. 50% of infants with serious NEC require an operation to removed necrotic bowel, many babies end up with a stoma post-operatively, and overall risks of death are around 30-50%. Some babies go on to develop complications such as hepatic dysfunction (associated with prolonged use of parenteral nutrition), poor growth and nutrition (due to ‘short gut’ and nutrient malabsorption), or cognitive impairment.
Mother's own expressed breast milk significantly decreases the risks of NEC in a ‘dose-response’ fashion i.e. the more maternal milk, the lower the risk. There is also some evidence that donated human breast milk may also be associated with lower risks than formula.
Supporting mothers of preterm babies to provide their own breast milk will therefore decrease mortality, improve long-term outcomes and significantly reduce NHS costs.
Recognising breastfeeding problems and how to help
What to consider in a history for a woman experiencing breastfeeding problems.8
Breastfeeding history:
•Previous breastfeeding experience, problems, pain.
•Any breast or nipple sensitivity before pregnancy.
•Milk supply issues (engorgement, low or oversupply).
•Pattern of breastfeeding (frequency, duration, night feeds, one or both breasts offered).
•Expressing of milk (frequency, hand or pump used).
•Maternal beliefs, ideas, concerns, and expectations about breastfeeding.
•Other fluids or foods given (when started, quantity, and frequency).
Maternal history + specific areas:
•Any complications during pregnancy, labour, or post-partum.
•Known medical conditions, such as thyroid disorders, Raynaud's, eczema or psoriasis, recent candida or bacterial infection, chronic pain syndromes, family history of ankyloglossia (tongue-tie).
•Previous breast surgery and indication.
•Medications and allergies.
•Alcohol and smoking history.
•Associated insomnia, stress, anxiety, or depression.
Infant history:
•Birth gestation, any birth trauma or known medical conditions or congenital abnormalities.
•Birth weight, weight gain, general health and behaviour (settled or crying).
•Behaviour at the breast (pulling, biting, coughing, breathlessness, sleepiness) which may be a consequence of nasal congestion, teething, or an overactive milk ejection reflex.
•Gastrointestinal symptoms which may suggest oversupply of milk, gastro-oesophageal reflux disease, or cows' milk protein allergy. For more information, see the CKS topics on GORD in children and Cows' milk protein allergy in children.
•Known ankyloglossia or cleft lip and/or palate; any treatments to date.
•Use of a dummy or pacifier.
Breast and/or nipple pain history:
•SOCRATES
•Site (unilateral or bilateral, nipple and/or breast, superficial or deep).
•Onset post-partum.
•Character and severity (burning, itching, sharp, dull).
•Associated signs and symptoms (fever, breast skin changes, nipple colour changes, nipple shape or appearance after feeds).
•Any nipple trauma (abrasions, fissures, bleeding).
•Timing (with attachment, during breastfeeds, between breastfeeds, with expressing of milk) and whether intermittent or constant.
•Exacerbating or relieving factors (cold, heat, massage or touch).
•Previous treatments (analgesia, topical or oral drugs including antibiotics).
Examination
Always gain patient consent.
Ensure that a professional with appropriate training and expertise is present as a chaperone.
Examine the:
Woman's nipples: (FTDS)
- Flat or inverted nipples.
- Tenderness on palpation.
- Discharge.
- Skin integrity, discolouration, lesions, or rashes.
Woman's breasts: (LTS)
- Lumps (?galactocele).
- Tenderness to light or deep palpation.
- Skin discoloration, lesions, or rashes.
Infant: (SHONM)
- Signs of dehydration.
- Head and neck symmetry and facial features.
- Oral anatomy (ankyloglossia, palate, jaw, and lips) or oral pathology e.g. candida infection that may affect sucking and swallowing.
- Nasal congestion.
- Muscle tone, neurological maturity, behaviour.