3. Communication and timely coordination of care are critical to achieving a breastfeeding success story in situations like this. The fact that I had a copy of the discharge summary allowed me to better understand the circumstances of the delivery and Jane's illness that resulted in separation from her mother for the first two to three days of life, introduction of a bottle for the first feeds and delay in initiation of breastfeeding. The ability to see Jane in the office within two days after discharge, even on a weekend, is of great importance since the feeding plan often needs to adjusted and the health of the infant needs to be evaluated within 24 or 48 hours of discharge.

Let me finish where I left Jane's story. I felt that Jane was not strong enough to try to suckle at the breast for 20-30 minutes, and I also respected the parents' opinion that the SNS feeding routine was too cumbersome for them. I suggested they put her to the breast for a maximum of 10-12 minutes each feed then give her as much expressed breastmilk as she would take with finger feedings every two to three hours. I saw her twice in the first week and weekly until she was four weeks old. She gradually nursed more effectively and for longer periods at the breast and took less supplemental breastmilk after each feed. At four weeks she was thriving, had transitioned to full breastfeeding and was not requiring supplemental feeds. She was able to accomplish this as she developed greater stamina, strength and oral motor coordination.
As a result of careful monitoring and breastfeeding-oriented inpatient care and outpatient care, Jane did not experience any of the potential medical problems these infants may experience. Such problems may include low blood sugar, dehydration, fever, rehospitalization, and brain damage from severe jaundice. On the other hand the benefits of breastmilk may even be greater for the near-term infant than the full-term infant. For these reasons it is important that medical providers are equipped to meet the challenge of helping mothers breastfeed their near-term infant to the greatest extent possible. The success of this breastfeeding story was the result of a dedicated family, comprehensive and coordinated inpatient lactation breastfeeding program, and close outpatient follow-up.

References:

1. Reynolds, A. Breastfeeding and Brain Development. PCNA 2001(1) 159-171.
2. Jensen, D., Wallace, S., and Kelsay P. J obstet Gynecol Neonatal Nurs. 1994: 23: 27-32.
3. Wight, N. Breastfeeding the Borderline (Near-Term) Preterm Infant. Pediatric Annals. 2003:32:5. 329-336.

1. Communication
   1. Establish pathway and an order set specifically for breastfeeding the near-term infant
   2. Develop a written discharge feeding plan for each mother-infant dyad
   3. Facilitate communication between 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
   1. Objectively assess gestational age and associated risk factors of every infant
   2. Assess breastfeeding daily on the postpartum floor
   3. Assess breastfeeding issues in the outpatient setting carefully
3. Timely lactation support in the inpatient and outpatient setting
4. Avoid separation of mother and infant
   1. Immediate postpartum period as much as possible
   2. In cases when either mother or infant is hospitalized for medical reasons
5. Monitor and prevent frequently encountered problems in breastfed near-term infant
   1. Hypoglycemia
   2. Hypothermia
   3. Hyperbilirubinemia
   4. Dehydration and/or excessive weight loss
6. Education
   1. Ensure ongoing education of staff and care providers of issues specific to breastfeeding the near-term infant in the inpatient and outpatient settings
   2. Train one or two outpatient office support persons (RN or lactation educator) in breastfeeding support, simple 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 discharge feeding plan
   3. Facilitate outpatient follow-up to assure effective breastfeeding after discharge
   4. Careful outpatient monitoring of mother and infant

*The "Principals" are in addition to and assume that most of the "Baby Friendly Hospital Initiative" ten steps are in place. Developed in collaboration with Yvonne E. Vaucher, MD, MPH.