Assisted Nursing: A Case Study of An Infant With a Complete Unilateral Cleft Lip and Palate

Background This case presents a mother’s feeding experience of an infant born with a complete unilateral cleft lip and palate from birth until both were repaired. She fed him directly at the breast with assistance, controlling the delivery of the mother’s own milk. The infant received only his mother’s own milk, no bottles, and the excess expressed milk was donated to a milk bank. Main issue The Cleft Team supported the mother’s wish to breastfeed but expressed realism that cleft lip and palate infants could not create suction. Success had never been observed in the unit. Instead, the team suggested expressing to deliver as much of the mother’s own milk. The mother had previously breastfed her three children and was keen on finding innovative ways to breastfeed. Management Several techniques were trialed with the help of an International Board Certified Lactation Consultant. The most sustainable and successful was the use of a nipple shield applied to the maternal nipple areola complex to cover the lip palate. Underneath, a nasogastric tube connected to a syringe delivered the mother’s own milk. Exclusive expressing protected maternal supply, the infant’s nutrition and growth were monitored carefully and this technique reinforced mother–infant bonding. Conclusion Feeding with the modifications was challenging at times. However, maternal satisfaction was high because the mother had achieved her goal of breastfeeding without assistance post cheiloplasty and palatoplasty. This case adds to the limited body of research about feeding infants with cleft lips and palates directly at the breast.

Effect of nipple shield use on milk removal: a mechanistic study

Background Concerns about reduced milk transfer with nipple shield (NS) use are based on evidence from studies with methodological flaws. Milk removal during breastfeeding can be impacted by infant and maternal factors other than NS use. The aim of this study was to control electric breast pump vacuum strength, pattern and duration across multiple study sessions to determine if NS use reduces milk removal from the breast. Methods A within-subject study with two groups of breastfeeding mothers (infants < 6 months) were recruited; Control Group (CG): no breastfeeding difficulties; Pain Group (PG) used NS for persistent nipple pain. Mothers completed three randomised 15 min pumping sessions using the Symphony vacuum curve (Medela AG); no NS, fitted NS, and a small NS. Sessions were considered valid where the applied vacuum was within 20 mmHg of the set vacuum. Milk removal was considered as pumped milk volume, and also percentage of available milk removed (PAMR), which is calculated as the pumped volume divided by the estimated milk volume stored in the breast immediately prior to pumping. Results Of 62 sessions (all: n = 31 paired sessions) a total of 11 paired sessions from both PG (n = 03) and CG (n = 08) were valid (subset) with and without a fitted NS. Only 2 small shield sessions were valid and so all small shield measurements were excluded. Both pumped volumes and PAMR were significantly lower with NS use for all data but not for subset data. (All: Volume and PAMR median: no NS: 76.5 mL, 69%, Fitted NS: 32.1 mL, 41% respectively (volume p = 0.002, PAMR p = 0.002); Subset: Volume and PAMR median: no NS: 83.8 mL, 72%; Fitted NS: 35.2 mL, 40% (volume p = 0.111 and PAMR p = 0.045). The difference in PAMR, but not volume, was statistically significant when analysed by linear mixed modelling. A decrease of 10 mmHg was associated with a 4.4% increase in PAMR (p = 0.017). Conclusions This experimental data suggests that nipple shield use may reduce milk removal. Close clinical monitoring of breastfeeding mothers using nipple shields is warranted.

Therapeutic delivery from a solid formulation during breastfeeding: a feasibility study

ABSTRACTBackgroundEnteral drug and nutrient delivery to breastfed infants depends on the use of oral syringes and liquid formulations. This can pose both practical and emotional challenges to drug delivery.ObjectivesThe presented study aimed to explore the potential of using solid formulations for therapeutic delivery during breastfeeding.MethodsSingle centre feasibility study within a tertiary level neonatal unit in the UK, involving twenty-six breastfeeding mother-infant dyads. Vitamin B12 was delivered to infants during breastfeeding from a solid formulation within a commercial silicon nipple shield. Outcomes included the quantitative measurement of change in serum vitamin B12 and a mixed methods assessment of maternal expectations and experiences.ResultsParticipants described the surprising ease of ‘drug’ delivery, with no negative impact on breastfeeding behaviour or sensation reported. Vitamin B12 levels rose on average from a baseline of 533 pg/mL (236 - 925 pg/mL) to 1871 pg/mL (610 – 4981 pg/mL) at 6 - 8 hours post-delivery. All mothers expressed their support for this approach, 85% a preference over the use of oral syringes. Reasoning for support related to the reduced medicalisation of this procedure compared to the use of oral syringes, and a desire for choices in relation to their infants’ health.ConclusionsThis study demonstrated that therapeutic delivery from a solid formulation within a nipple shield was feasible and acceptable to mothers and infants.

Development and Psychometric Testing of the Maternal Nipple Shield Satisfaction Scale

Background and PurposeNipple shield use is common among breastfeeding mothers, yet no instrument measures maternal satisfaction. The new Maternal Nipple Shield Satisfaction Scale (MNSSS) was evaluated for reliability and validity.MethodsThe MNSSS for was tested in two phases: women (N = 128) using nipple shields in the previous 6 months and the second, women, (N = 57) within the first 3 weeks postpartum.ResultsFrom the original 21-item scale, content validity analysis, Cronbach's alpha, item to total correlation testing, exploratory factor analysis resulted in a one factor scale consisting of nine items with a Cronbach's alpha of .90. Convergent validity testing resulted in a small, but significant negative correlation.ConclusionThe MNSSS may be a useful instrument for examining satisfaction of women using nipple shields for breastfeeding.

Nipple Shield Use: Families' Stories

BackgroundMost IBCLCs interact with nipple shields in their work whether families bring nipple shields they are already using into consultations or professionals are suggesting the mothers use this lactation tool. Are nipple shields being used too much or too little? What is working and what is not?MethodsThe results of two online surveys on nipple shield use are presented: one for families and one for professionals.ResultsWith over 4,600 responses from families and 600 responses from professionals, this new information helps reveal what is actually happening with families and the use of this common tool.ConclusionsFor some families, nipple shields saved their breastfeeding experiences. Other families had negative experiences, especially when they were misapplied or given without follow-up. IBCLCs need standard protocols for nipple shield use. Providing support and guidance for nipple shield use greatly increases a family's odds of having a successful experience, and IBCLCs are the perfect people to provide this.

O18 Therapeutic delivery during breastfeeding: a feasibility study

BackgroundAt an age when breastfeeding is the optimal nutritional support for infants, enteral drug delivery can be physically and emotionally challenging for parents. Delivery during breastfeeding could serve as an alternative to currently existing approaches. This study aimed to explore its feasibility and acceptability.MethodsVitamin B12 was administered as part of a single-centre feasibility study to breastfed infants at the University of Cambridge Addenbrooke´s Hospital NHS Trust. Hereby a solid formulation (tablet) was placed inside an ultra-thin silicone nipple shield, and worn by a mother during the feed. The study investigated i.) quantitative changes in B12 blood serum levels at baseline and 6–8 hours after the study feed, ii.) mothers’ expectations and experiences via a mixed method approach by a single investigator. Local ethics approval was obtained prior to any study procedures being undertaken (18/LO/0551).ResultsTwenty dyads completed the study protocol. In all cases, no residual tablet was left after the feed, and the tablet’s presence within the shield did not appear to impact feeding. A pharmacokinetic-dependent vitamin B12 increase to 1871 pg/mL (610–4981 pg/mL) from a baseline of 533 pg/mL (236–925 pg/mL) was observed. Mothers described the nipple shield´s surprising ease of use and comfort for delivery, not affecting normal breastfeeding behaviour/sensation, while decreasing infant/maternal distress compared to the use of an oral syringe. All mothers expressed their wish for this approach to become available to parents in the future. Reasoning included the desire (1) of parents to have choices in relation to their infants’ health, (2) to replace a medical intervention with one that was felt to be more ‘natural’.ConclusionsThis study showed that solid formulations can be used for therapeutic delivery whilst breastfeeding and is viewed by mothers as advantageous compared to currently available methods.Disclosure(s)FundingThe research was supported by a WD Armstrong PhD studentship for the Application of Engineering in Medicine, University of Cambridge, the German Academic Scholarship Foundation, and the Kurt Hahn Trust, University of Cambridge. Competing interests (applicable to all authors): None declared.