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How to reduce mother-infant separation

◆Introduction
Aomori Prefecture is located on the northern top of Honshu Island and is located at a distance of about 650km from Tokyo. Our hospital is located at Aomori-city. We would like to outline in this article what we do to enable late-preterm infants born at 34-36 weeks of gestation to remain with their mothers as much as possible, even if they have been admitted to the neonata¬l¬ intensive care unit (NICU).
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◆ The hospital’s ‘NICU Infant-Breastfeeding at Maternity Ward’ initiative
We would like to outline ‘Rooming-in leaving NICU ’ initiative. It enables late-preterm infants born at 34-36 weeks of gestation to remain with their mothers as much as possible, even if they have been admitted to the neonata­l­ intensive care unit (NICU).
Our hospital aims to minimize the separation of infants from their mothers as much as possible, not only in the case of late-preterm infants but also relatively mildly ill infants, and provides support to allow breastfeeding to establish in as close to natural conditions as possible. ‘NICU Infant-Breastfeeding at Maternity Ward’ or ‘Rooming-in leaving NICU’ stands for the series of care actions where an infant in the NICU is brought to the mother who is cared for at the maternity ward to be breastfed. Find follow the details on the hospital’s medical care of late-preterm infants, focusing on the ‘NICU Infant-Breastfeeding at Maternity Ward’ principle.

◆ Late-preterm infant treatment/operating policy
1) Admission criteria
Infants born at less than 35 weeks of gestation are in principle admitted to the NICU. Infants born at 35 weeks of gestation or later, who have a birth weight of around 1900 g or above and who have no complications clearly requiring NICU admission including respiratory disorder, suckling disorder or hypoglycaemia, are cared for in the maternity ward.
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2) Medical care
Incubator temperature is managed with early transfer to a cot, and oxygen and fluid therapy are discontinued as early as possible. To discontinue this kind of care at an early stage, blood sugar or other checks must be frequently carried out. A lot of cares need to enable mother and infant to spend as time together as early on possible.

3) Supplementation (Supplementary Feedings: feedings in place of breastfeeding)
The first option in supplementation is expressed breast milk, and if that is not available, formula milk. Once oral feeding is possible, feeding is done as much as possible through using a syringe or a cup. Supplementary volumes are kept to the minimum required to maintain blood sugar levels, starting at 3-5 ml and stopped at a maximum of 10-15 ml, and decreased as appropriate if the breastmilk supply improves. Breastmilk volumes are measured using scales, and if insufficient, is supplemented with the indicated volumes of formula milk. If the supplemented volume is too high, the infant might be asleep by the time it has been taken to its mother, and overfeeding is therefore considered as the largest enemy.

4) ‘NICU Infant-Breastfeeding at Maternity Ward’ ‘Rooming-in leaving NICU’
Once oxygen and IV drip are stopped and the baby’s general condition is stable, infants are brought to the mother in the maternity ward for breastfeeding every three hours. This is possible even when the infant is still in an incubator and before transfer to a cot if the incubator temperature has been lowered to 31℃. Moreover, to maintain body temperature we use a cot with heater during transfer of the infant to the maternity ward. The duration of stay with the mother will also be extended to 30 or 60 minutes depending on its condition. Moreover, if general condition has stabilized the infant can remain with the mother for several hours at a time.

For natural births, this hospital discharges patients on day 4. If beds are available in the maternity ward, delayed discharge may be discussed with the obstetrician, and once discharged, the option of mother and child sharing a mother-baby room in the GCU is also considered. Monitoring is generally performed through SpO2 apart from during breastfeeding.

5) Discharge from hospital
The timing of hospital discharge is determined depending not on body weight or number of weeks, but on the baby’s general condition and breastfeeding status. Only when breastfeeding directly and when body weight has increased can an infant be discharged.
At the time of admission the mother’s wishes regarding breastfeeding are confirmed first and then the possibility of being discharged at the same time as the baby is explained. The infant’s condition and suckling status, the mother’s breastmilk supply as well as the home environment are considered for the subsequent process, and it is important to reach wardy of purpose with the mother with regard to the prospects of hospital discharge.

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◆ Details on ‘Rooming-in leaving NICU’
○ Preparations
The cot used to transport the infant is heated in preparation and to prevent loss of body heat from the head a hat is provided too. Before the infant is moved to the maternity ward for breastfeeding, its vitals and body temperature are checked.

○ Transfer
SpO2 monitoring is essential during transfer. To check feed volumes body weight is measured before the infant is moved to the mother’s room for breastfeeding.

○ Details on breastfeeding
Before starting breastfeeding, the nipple is made softer by pre-massaging.

○ Expressing breast milk: Sucking of preterm infant is very weak, compared to full-term babies, forms a handicap in creating mother’s milk supply even when the baby is brought to the mother to breastfeed in this way. The use of a breast pump alongside is therefore considered very important, and this hospital uses a Medela Symphony breast pump to this end.

○ Measuring volume of one feed: As insufficient volumes carry the risk of hypoglycemia and overfeeding may cause a reduction of suckling capacity during the next feed. Insufficient breast feeding volumes are supplemented by either tube feeding or through syringe or cup feedin g.
Breastfeed volumes will in the beginning be 0 g for any baby. With staff noting that ‘it was 0 g again’ between each other it is sometimes difficult to maintain motivation, but it is important that there is a common understanding amongst staff and mothers alike that since the volume is 0 g today it will be X g the day after tomorrow.

◆ Management of late-preterm infants that are not in the NICU
1) Care immediately post-birth and during early stage post-birth (within 24 hours)
Kangaroo care (skin-to-skin care) immediately after birth.
Incubator for first 24 hours, brought to mother for breastfeeding every 3 hours minimum.
Fit with SpO2 monitor; discontinue once trends have stabilized.
Blood sugar level checks (At 1, 2, 4 hours post-birth, then according to the decision by the neonatal paediatrician and continuing twice daily minimum until weight gain is observed. Blood samples are collected using a lancet.).
2) From day 2 onward
Daily check-ups by neonatal paediatrician.
No major difference in breastfeeding care compared to full-term infants, but if breastfeeding problems occur assessments will be carried out into its cause.
If despite supplementation with expressed breast milk, hypoglycemic tendencies or weight loss of ca. 7% or higher is seen at age 3 days, formula milk supplements will be given of around 5-10 ml.
Jaundice treatment is done in the mother-baby room using a fibreoptic blanket.
In the case of a natural birth, regular hospital discharge at age 4 days is postponed as appropriate, until breastmilk supply and breastfeed volumes increase.
Expressing using the Symphony breast pump as appropriate is considered for infants with little capacity to suckle.
3) Other
The medical care described above are all on outpatient basis, at medical service fees.
If weight gain is not achieved even when hospital discharge of the mother has been postponed, mother and infant staying in a GCU mother-baby room is considered.
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◆ Conclusion.
A mother whose baby has been admitted to the NICU is often worried that she was unable to have a regular delivery, and often experiences a sense of loss regarding the delivery she had imagined before. Up until now NICU always signified separation of mother and child and the care was mainly done by NICU staff with mothers only visiting at visiting hours. Although mothers received guidance before the infant was discharged, it was not uncommon that even when a body weight of 2500 g is reached the baby was still felt too small for a first-time mother. Bonds and ties of love from parent to child are not formed when parents are kept separated from their child through its admission to NICU, and it is key that a healthy sense of self-esteem as a parent is fostered by taking care of their baby. When milk supply has improved to some degree by allowing the baby to be touched by its mother from an earlier stage even when in the NICU, and by gradually increasing the number of things the mother can do herself, mothers will ask when they can be discharged since they can only breastfeed the whole day, whether at the hospital or at home (last image). We hope that, if your baby was born even a little bit early, we can help you return home as if nothing had happened.
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2013.09.25
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