zyxw zy New Diagnosis: In terrupted Breas tfeed ing Mary L. Henrikson, MN, RNC, WHCNP, Ginna A. Wall, MN, IBCLC, Vicki E. McClurg, MN, RN, Donna Lethbridge, PhD, RN Interrupted breastfeeding was approved by the nienibership to be added to the N A N D A zyxwvut zyxwvu zyxwvut taxononzy in 2992. The diagnosis was developed to nanie the response that occurs when a breastfed baby cannot be piit to breast for some or all of the fkdings. Tuio exnniples of life processeslevents, yrtvnatnre or sick infant and maternal cni~7loymcnt,illustrate the application and use of f l i r diagnosis. Nursing interventions for each sitiration arc discussed. A comparison describing flzr dflerenccs b e t z ~ w ninterrupted B r e a s t f e e d i n g is the act of a motlier producing anci providing her breast milk for her infant. It is a dyn,iniic aspect of childbearing and childrearing. Mothers ,djcrst their patterns of breastfeeding to changes in thcir ant1 their babies’ lives. Typical examples o f life prowsscIb/ events that necessitate a change in patterns of brcastfcwing include the separation of 1‘ mother and infant because of illness, and a return to or initiation of iii‘itt>rnal employment. breastfeeding and ineffective breastfeeding is Infant Illness iticluded to address the controversy of whether or not tlie diagnoses are the sanze. A sample dinpiosislcarc plan is added to demonstrate trse of the diagnoses in clinical practice. A preterm delivery or any condition of an infant th‘it results in maternal-infant separation for medical trcl‘itment of the infant imposes unique circumstanccs tor breastfeeding. Treatment modalitics such as respirators, level of consciousness, degree of fatigue, and other inf‘int factors will delay an infant being put to breast to nurst’. McCoy, Kadowalu, Wilks, Engstrom, and Mcier (1988) advocate the use of the following research-based indic<ltors for putting a baby to breast: clinical stability (e.g., absence of ventilatory support, parenteral fluids, neurologic problems), tolerance of enteral feedings, ability t o suck with a pacifier and swallow secretions, and ‘ibility to maintain body temperature outside tlie inc-uh‘itor when clothed and wrapped in blankets. Gestation‘3l A ~ C Y of 32-34 weeks, infant fatigue, infant weight, and matcrnal readiness have also been cited as factors to cis st^^^ before a premature baby is put to breast (Hawkins- zy 114 Nursing Diagnosis Volume 4, No. 3, July-September,IW3 zyxwvutsr zyx zyxwvut zyxw zy zyxwvu Walsh, 1988; Neifert & Seacat, 1988). In a study by Kaufman and Hall (1989), only 8 of 88 mothers of preterm infants in a neonatal intensive care unit who had chosen to breastfeed were able to initially nurse their babies d t the breast. The remaining 80 had to use manual or mechanical expression of breast milk until their infants were ”well” enough to attempt feeding. This pattern of breastfeeding exists throughout the infant’s hospital stay (Hawkins-Walsh;Neifert & Seacat). Total breastfeeding, where all feedings are taken at the breast, usually will not occur until the infant goes home, or one to two days prior to discharge if the mother can stay with the infant and be available to put the baby to the breast for all feedings (Hawkins-Walsh). Length of hospital stay for preterm infants can range from one or two days to four months. The decision to breastfeed a preterm infant is supported by health professionals because breast milk is nutritionally superior to cow’s milk, has unique antiinfective properties, and is gestational age-specific; that is, the caloric and nutrient content of breast milk is appropriate to the gestational age at birth (Forte, Mayberry, and Ferketich, 1987; Steichen, Krug-Wispe, & Tsang, 1987). Forte et al. also found that three quarters of the mothers of preterm infants in their study identified the nutritional or immunologic benefits as the primary reason tor expressing breast milk. Many health professionals will also support the decision of mothers of pretem infants to breastfeed because of the psychological benetits for both mother and baby that are related to breastftieding (Auerbach & Avery, 1979; Pereira, SchwartL, Gould, & Grimm, 1984). Many mothers of preterm babies admitted to the neonatal intensive care unit will state that they want to be able to provide breast milk for their babies because they know it is the best food for the baby and that is the one thing they can do to care for their infant that no one else can do (McCoy et al. 1988; Neifert & Seacat, 1988). Systematic education and support of mothers who choose t o breastfeed preterm infants is positively correlated with sigruficant improvement of both initiation and duration of breastfeeding. In his study, Pereira et al. Nursing Diagnosis Volume 4, No. 3, July-September,1993 (1984) found that by implementing a program of education and support from breastfeeding ”counselors” selected on the basis of having successfully breastfed their own sick babies, the incidence and the mean duration of breastfeeding increased significantly. Neifert & Seacat (1988) strongly recommend that uniform, accurate information and ongoing support as the standard of care for all mothers of high-risk infants who desire to breastfeed. They further describe the breastfeedmg dormation and education as lengthy and specialized. A new mother experiencing interrupted breastfeedmg must be taught about the physiology of lactation and maintenance of milk production in the absence of a nursing infant. Routine emptymg of the breasts by hand or p m p becomes the cornerstone for successful breastfeeding of the preterm infant. Mothers must begin pumping their breasts as soon as possible after delivery ( H a w k Walsh, 1988; Neifert & Seacat, 1988). By the time their milk comes in (two to three days postdelivery) they should be pumping regularly. Mothers must be taught the different types of pumps, how to use the pump (or hand express), and schedules for milk expression for the most effective results (i.e., maintenance of milk supply). In addition, the handhg, storage, and transportation of expressed milk must be addressed with special emphasis on techniques that ensure the breast milk will have as few bacteria as possible (Forte et al., 1987; McCoy et al., 1988, Neifert & Seacat, 1988; WiLks & Meier, 1988). Working Mother Returning to work within a few months after their baby has been born is a reality for many women. It was not that long ago when the need or desire to return to work after the birth of a child was considered a contraindication to breastfeeding (MacLaughlin & Strelnick, 1984).In reality, more women working outside the home choose to breastfeed their infants than women who are full-time homemakers (Ryan & Martinez, 1989). Mothers who choose to continue to breastfeed totally after returning to work do it for the same reasons they chose to breastfeed in the first place; that is, the superior 115 zyxwvuts zyxwvu New Diagnosis: Interrupted Breastfeeding zyxwvuts zy nutritional value of breast milk and the psychological benefits for mothers and their babies. Levine (1987),in an article on breastfeeding and work, states: “Working mothers are finding that they don’t have to sacrifice the nurturing part of their nature just because they are realizing other ambitions” (p. 64).MacDonald (1983) listed a few of the advantages of breastfeedmg and working: The mother remains a special person, which increases her self-esteem; it reduces anxiety and guilt about returning to work; and it promotes the healthiest baby possible. Like the mothers of preterm infants, working mothers find breastfeeding as the one tlung only they can do for their baby (Broome, 1981). Reifsnider and Myers (1985) interviewed 17 women who had successfully balanced the tasks of breastfeeding and working outside the home. The mothers’ motivation resulted from closeness to and interaction with their infants, as well as a sense of renewal and satisfaction from breastfeeding. Uallard (1983)identified the importance of motivation, information, and support from family and healthcare provider to successful breastfeeding by working mothers. Auerbach (1984) noted that many problems encountered by mothers combining breastfeeding and work are preventable if the mother is informed about issues of engorgement and leaking, getting the baby to use the bottle, maintaining a milk supply, storing milk for later use, using the breast pump, breast infections, and breast tenderness from pumping. MxLaughlin and Strelnick (1984) found that when employed breastfeeding mothers were asked what information would have helped them combine breastfeeding successfully with working, they cited: combining the two roles; breast pumps and techniques of manual expression; and storage and transportation of breast milk. Other problems that employed breastfeeding mothers encounter include fatigue; colleagues, family, and employers who are critical of the decision; guilt about leaving the baby; and lack of time (Auerbach, 1984; MacLaughlin & Strelnick; Reifsnider & Myers, 1985). MacLaughlin & Strelnick’s (1984) respondents also identified three requirements essential to successful breastfeeding while working outside the home: (a) child care by a trusted person, (b)efficient hand expression o r availability of a good breast pump, and (c) support from significant other. This need for support from family, friends, coworkers, employers and healthcare professionals has been cited often (Auerbach, 1984, 1990; Levine, 1987; Morse & Bottorff, 1989; Reifsnider Ct Myers, 1985). Recommendations for education for the breastfeeding mother working outside the home include how to express milk by hand or by pump; advantages and disadvantages of different types of pumps; storage ,ind transportation of breast milk; maintaining milk supply; establishing a regular pattern for releasing milk; ways to establish a support system; and methods to cope with fatigue, guilt, and negative criticism (Auerbach, 1984, 1990; Ballard, 1983; Broomc, 1981; Levine, 1987; MacDonald, 1983; MacLaughlin & Strelnick, 1984; Morsci & Bottorff, 1989; Reifsnider & Myers, 1985; Ryan & Martinez, 1989;Shepard & Yarrow, 1982). zyxwvuts 116 zy zy zyx zy Comparison of Ineffective Breastfeeding and Interrupted Breastfeeding Since nursing diagnoses related to breastfeeding w m ’ introduced, controversy has existed regarding whethcr irwffictive bren~tfe~ding and intiwirptid brcnstfr.L.diii<qwerc. thch same diagnosis. The argument for combining these di+noses has centered around the etiologies and signs and symptoms (L. Carpenito, personal communication, 1989). Table 1 presents a comparison of the two diagnose;. Prematurity is the only identical related factor sh‘ircci by the two diagnoses and is appropriate for both diagnoses. With irituruptcd br~~stfL’~diri:i, the separation ot mother and infant and the need to express breast milh for a period of time may be related to the baby’s pretnture age and inability to take oral fluids or suckle at t h t x breast . For irir@ctizv brcnstfird ir 13,prema t u r i ty 1‘ nd t h delay of putting the baby to breast, and the use of rubht~r nipples for feeding prior to being put to the breast (nipple confusion) may be to blame. When prematurity is thc etiology, the time frames are different for these ciidgt b Nursing Diagnosis Volume 4, No. 3, July-September,l W 3 zyxwvutsrqp zy noses. With interrupted b r c m f j d i i z g , the time frame includes the period during which the baby cannot be put to breast for some or all of the feedings With ineflectivc breastfr.diirg, the time frame is after the baby is put to breast but, because of the events leading up to t h s time, does not e h b i t adequate proficiency of effective breastfeeding behaviors. The diagnoses are also very different in terms of expected outcomes and, consequently, nursing interventions. For interrupted breastfeeding the desired outcome is to maintain lactation; nursing interventions are designed accordingly. Those interventions center around expression and storage of breastmilk. For iizeflectizie breastfi.ding, the desired outcome is effective breastfeeding. zyxwvu zyxwv zyxwvutsrq Table 1. Comparison of Two Nursing Diagnoses Label Interrupted Bremtj&dLiincy Label Iviefective Bremtjeediq Definition The state in which there is a break in the continuity of the breastfeeding process as a result of inability to put baby to breast for feeding. Definition The state in which a mother, infant, or child experiences dissatisfaction or difficulty with the breastfeeding process. Defining Characteristics Defining Characteristics . Major Infant does not receive nourishment at the breast for some or all of feedings. . Minor Maternal desire to maintain lactation and provide (or eventually provide) her breastmilk for her infant’s nutritional needs. .Major .Minor Separation of mother and infant. Lack of knowledge regarding expression and storage of breastmilk. Unsatisfactory breastfeeding process Actual or perceived inadequate milk supply; infant inability to attach on to maternal breast correctly; no observable signs of oxytocin release; observable sip’s of inadequate infant intake; nonsustained suckling at the breast; insufficient emptying of each breast per feeding; persistence of sore nipples beyond the first week of breastfeeding; insufficient opportunity for suckling at the breast; infant exhibiting fussiness and crying within the first hour after breastfeeding; unresponsive to other comfort measures; infant arching and crying at the breast; resisting latching on Related Factors Related Factors Maternal or infant illness I’remabity Maternal employment C’ontraindications to breastfeeding (e.g., drugs, true breastmilk, jaundice) Need to wean infant abruptly Prematurity; infant anomaly; maternal breast anomaly; previous breast surgery; previous history of breastfeeding failure; infant receiving supplemental feedings with artificial nipple; poor infant sucking reflex; nonsupportive partner/family; knowledge deficit; intermption in breastfeeding; maternal anxiety or ambivalence zyxwvutsrq zyxwvuts Nursing Diagnosis Volume 4, No. 3, July-September,1993 117 New Diagnosis: Interrupted Breastfeeding zyxwv zyxwvu zyxwvuts Interventions are focused on correcting/adjusting the specific related factor/etiology. Both diagnoses offer the nurse a tool for communicating precise maternal/human responses to life processes/events. A diagnosis such as high riskfor ineffective breastfieding related to interruption of breastfeeding and insufficient knowledge to maintain lactation leaves the nurse unsure of the real problem. The nurse will wonder whether to help the mother learn how to maintain her milk supply and express and store breastmilk, or how to put the baby to breast. It is more descriptive and prescriptive to state interrupted bremfeeding related to maternal medication ("'Iodine). This diagnosis tells the nurse the focus is on maintaining milk supply until the mother can once again put her baby to the breast. lnterrupted breastfeeding related to maternal employment tells the nurse to focus on helping the mother maintain her milk supply and express and store her milk for her baby's nutritional needs while she a i d the baby are separated during her work day. References zyxwvut zyxwvu zyxwvut zyxwvut zyxwvutsrqponm zyxwvut Sample Diagnosis and Interventions h i terrrrpted tireasfeeding related to rmtml ingestion of '"lodine Expected outcome. Mother's milk supply will be maintained until it is safe to breastfeed infant. Interventions 1. Reassure mother that she will be able to resume breastfeeding. 2. Assess knowledge base regarding concepts of breastmilk supply & demand. Instruct as necessary. 3. Complete loan agreement for and demonstrate use and care of electric breast pump. Have mother return the demonstration. 4. Encourage pumping q3h while awake. 5. Assess infant's ability to adjust to alternate feeding method (bottle/syringe). Provide assistance as needed. 6. Determine (with mother) schedule for follow-up instruction. 7. Provide additional support measures: printed materials, public health nurse, breastfeeding hotline, mother support group, as needed. 118 Auerbach, K . ( I 990). Assisting the cmploytd breastfeeding mot1it.r ]oirnin/ qf Nurst, Midw@ty, 35,26-34. Auerbach, K. (1984). Employed breastfeeding mothers: I'niblt~ns thcy encounter. Birth, 11, 17-20. Auerbach, K., & Avery, J. (1979). Rt~/l?ctt?tiotrmid t / w p r i w i i t i i r t ' itifritit R~7tortfiorriII sirni~y.Resources in H u m m Nurturing Monogi-.ilih (No. 3). Denver: Resources in Human Nurturing, Intrm.itlonal. Ballard, P. (1983). Breastfeeding for the working mother. Cr,iriprc.lit.nsI~~,Pedintric Niirshy, h, 24Y -250. /,,,it[,\ it1 Bnx,me, M. (1981).Breastfeedingand the working n i o h /(X;NN, ~ .3,201-2()1- Forte, A., Mayberry, L., & Ferketich, S. (1987). Breast milk collc~ction and storage practices among mothers o f hospit'ilireci ntv)n.itt,h /ounia/cfPtTinnto/otty,7,35539. Hawkins- Walsh, E. (1988).Breastfeeding the premature intant. / i f ~ d i l ~ r r l , Nursing Forirtri, 3(4), 3-13. Kaufman, K., & Hall, L. (1989). Infltiences of the social ncBtwtirk. on choice and duration of breastfcvding in mothers of prc,tcmi int,iiit> Rcsenrc/i iti Niirsirrgarid Hedtlr, 12, 11Y-15(~. zyx Levine, K. (1987).Breastfeeding and work. Poriwts, 62(12), 64,hh-hl( MacDonald, J. (1983). The working mother and her infant. Ct~iindi~iti Nirrst', 79(3), 21-23. hrc,'ihttt,~,'iiiit; MacLaughlin, S., & Shplnick, E. (198.1).Bwastftvding and workiig oiitside the home. lssites iri CoriiiJrc.lwrsirlcPtdhtric. Nirrsiq, 7,67-8 1 McCoy, R., Kadowaki, C., Wilks, S., Engstrom, J., & Mcicr, I' (198s) Nursing management of breast fecding for preterm inf,int.z. / o i r t - i i t i / of Ptrinntd N~~~tiatol NursiriS, 2,42-55. Morse, .I., & Bottorff, J. (1989). lntrnding to breastteed ]OGNN, 79,493-500. 'id worh Neifert, M., & Seacat, J. (1988).Practice aspects of breastfecding the. pr" mature infant. P ~ ~ r J r i t i ~ ~ / ~ ) ~ ~ ~ / - NI?( ~ ~1o),t i21-3 r i ~ iI i/ii~~, Pereira, G., Schwartz, D., Gould, I:, Grimm, N. (1Y8.1). t3nmttcudiny: in neonatal intensive care: Beneficid effects of mcitcwi.ilc ( i u i i ~ ~ 4 i n t ; P c . r i r i a t o / o ~ ~ ~ ~ - N i r i 8(2), ~ i t ~ 35~ / ~ i12. ,~y, lieifsnider, E., &Taylor Myers, S. (1985). Employed niothtm c,in feed too. MCN, 10,256-259. lir~u51 Ryan, A., & Martinez, C . (1989). Breastfeeding 'ind thc worhiiib; mother: A profile. Pcdihtrics, 83,524-531. Shepard, S., & Yarrow, R. (1982) Breastfeeding and ttic bJorhiiig mother. ]orrriin/ c$NirrstT MidrciIfi.n/,27(6), lh-20. Stetchen, T., Krug-Wispe, S., & Tsang, I<. (1087).Brtw4fctuiing the, low birth weight preterm infant. Cliriiis i t i Pc~iti~itii/ii,yI/, 1 , 131- 171 Wilks, S., & Meier, I? (1988).Helping mothers express niilk s u i t h l c s IOI preterm and high-risk infant fcvding. MCW, 1.3, 121-123. Nursing Diagnosis Volume 4, No. 3, July-September,1943