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## Complete Summary

#### GUIDELINE TITLE

Breastfeeding the hypotonic infant.

#### BIBLIOGRAPHIC SOURCE(S)

Thomas J, Marinelli KA, Hennessy M, Academy of Breastfeeding Medicine
Protocol Committee. ABM clinical protocol #16: breastfeeding the
hypotonic infant. Breastfeed Med 2007 Jun;2(2):112-8. \[38 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661583)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Hypotonia (\"floppy infant syndrome\")

-   Infant health/nutrition

#### GUIDELINE CATEGORY

Counseling\
Evaluation\
Management\
Prevention\
Risk Assessment\
Screening\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Medical Genetics\
Neurology\
Nursing\
Nutrition\
Obstetrics and Gynecology\
Pediatrics\
Speech-Language Pathology

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Dietitians\
Nurses\
Physician Assistants\
Physicians\
Speech-Language Pathologists

#### GUIDELINE OBJECTIVE(S)

To promote, support, and sustain breastfeeding in children with
hypotonia

#### TARGET POPULATION

Infants with hypotonia

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation/Counseling**

1.  Patient education on the benefits of breastfeeding

2.  Frequent assessment of baby

    -   Ability to latch, suck, and transfer milk; frequency of
        breastfeeding

    -   Adequate milk transfer (test weighing)

    -   Hydration status

    -   Jaundice

3.  Counseling of mother and family about breastfeeding in the early
    weeks

4.  Assessment of maternal milk supply

**Management/Treatment**

1.  Facilitation and assessment of feeding at the breast in the
    immediate postpartum period

    -   Initiation of first feeding

    -   Kangaroo (skin-to-skin) care

    -   Strategies to facilitate breastfeeding (skin-to-skin, head and
        body support, sling or pillow, the \"Dancer hand\" position)

    -   Other strategies (hand compression, nipple shield)

    -   Alternative modes of feeding in baby who is not breastfeeding
        effectively (cup, spoon, bottle, nipple shield)

    -   Supplementation

2.  Preventative measures to protect a milk supply

    -   Maintenance of lactation (pumping, hand expression)

    -   Transitioning from tube or bottle feeding to breastfeeding

    -   Breast pumping

    -   Completion of a pumping/feeding diary

3.  At discharge and in the neonatal period

    -   Maintain mother\'s milk supply when baby remains hospitalized

    -   Provide information on local support groups

    -   Encourage maternal rest and analgesics as needed

    -   Use of galactogogues

    -   Increasing caloric density of breastmilk

    -   Use of hindmilk

#### MAJOR OUTCOMES CONSIDERED

-   Ability to breastfeed

-   Breastfeeding rates and duration

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

An initial search of relevant published articles written in English in
the past 20 years in the fields of medicine, psychiatry, psychology, and
basic biological science is undertaken for a particular topic. Once the
articles are gathered, the papers are evaluated for scientific accuracy
and significance.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)\
Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

I Evidence obtained from at least one properly randomized controlled
trial

II-1 Evidence obtained from well-designed controlled trials without
randomization

II-2 Evidence obtained from well-designed cohort or case-control
analytic studies, preferably from more than one center or research group

II-3 Evidence obtained from multiple time series with or without the
intervention. Dramatic results in uncontrolled experiments (such as the
results of the introduction of penicillin treatment in the 1940s) could
also be regarded as this type of evidence.

III Opinions of respected authorities, based on clinical experience,
descriptive studies and case reports; or reports of expert committees

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

An expert panel is identified and appointed to develop a draft protocol
using evidence based methodology. An annotated bibliography (literature
review), including salient gaps in the literature, are submitted by the
expert panel to the Protocol Committee.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Draft protocol is peer reviewed by individuals outside of lead
author/expert panel, including specific review for international
applicability. Protocol Committee\'s sub-group of international experts
recommends appropriate international reviewers. Chair (co-chairs)
institutes and facilitates process. Reviews submitted to committee Chair
(co-chairs).

Draft protocol is submitted to The Academy of Breastfeeding Medicine
(ABM) Board for review and approval. Comments for revision will be
accepted for three weeks following submission. Chair (co-chairs) and
protocol author(s) amends protocol as needed.

Following all revisions, protocol has final review by original author(s)
to make final suggestions and ascertain whether to maintain lead
authorship.

Final protocol is submitted to the Board of Directors of ABM for
approval.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Education**

1.  All mothers should be educated about the benefits of breastfeeding
    for themselves and their infants. A significant percentage of
    hypotonic infants can feed at the breast without difficulty.

2.  All babies should be followed closely both before and after
    discharge from the hospital for assessment of further needs.

**Facilitation and Assessment of Feeding at the Breast in the Immediate
Postpartum Period**

1.  The first feeding should be initiated as soon as the baby is stable.
    There is no reason this cannot occur as early as the delivery room
    if the baby is physiologically stable.

2.  Kangaroo (skin-to-skin) care should be strongly encouraged. If the
    baby does not feed well, the touching may be stimulating, so that
    the baby is easier to arouse for feedings. Skin-to-skin care has
    also been shown to help increase mother\'s milk supply (Hurst et
    al., 1997), and it can assist with bonding, which may be especially
    important for these families.

3.  Assess the baby\'s ability to latch, suck, and transfer milk. This
    assessment should involve personnel specifically trained in
    breastfeeding evaluation and management.

4.  Skin-to-skin contact will facilitate frequent attempts at breast.
    For those attempts, particular attention should be given to
    providing good head and body support since the baby needs to spend
    effort sucking, not supporting body position. Use of a sling or
    pillows to support the infant in a flexed position allows the mother
    to use her hands to support both her breast and the infant\'s jaw
    simultaneously.

5.  The \"Dancer hand\" position (see Figure 1 in the original guideline
    document) may be helpful to the mother to try because it supports
    both her breast and her baby\'s chin and jaw while the baby is
    nursing. This involves cupping her breast in the palm of her hand
    (holding her breast from below), with the third, fourth, and fifth
    fingers curling up towards the side of her breast to support it,
    while simultaneously allowing the baby\'s chin to rest on the web
    space between her thumb and index finger (see Figure 1 in the
    original guideline document). The thumb and index finger can then
    give gentle pressure to the masseter muscle, which stabilizes the
    jaw (McBride & Danner, 1987; Danner, 1992). Additionally, pulling
    the jaw slightly forward may allow the infant to better grasp the
    breast and form a seal. The other hand is free to be used to support
    the baby\'s neck and shoulders.

6.  Other strategies to help the infant latch and transfer milk may also
    be effective. Some mothers facilitate milk transfer with the
    technique of breastfeeding used in conjunction with hand
    compression. Instead of placing the thumb and index finger on the
    baby\'s jaw for support (Dancer position), the fingers are kept
    proximal to the areola, and milk is hand expressed as the baby
    suckles. A thin silicon nipple shield may be useful, if production
    is generous (\>500 mL/day) and mothers learn how to keep the
    reservoir filled by synchronizing breastfeeding with hand
    compression or using a nursing supplementation device simultaneously
    inside the shield (Meier et al., 2000). By making the mother aware
    of various techniques, aids, and ideas, she is empowered to
    experiment and discover the best repertoire to fit her and her
    baby\'s individual needs.

7.  The mother, and family who is supporting her, should be counseled
    that more time may be necessary in the early weeks to complete a
    feeding. They should also know than in many cases the baby\'s
    ability to feed will improve over the first weeks to months.

8.  Trained personnel must reassess the baby frequently (a minimum of
    once every 8 hours) because these babies must be considered high
    (breastfeeding) risk, similarly to the near-term baby (see Academy
    of Breastfeeding Medicine Protocol #10: Breastfeeding the Near-Term
    Baby) (Academy of Breastfeeding Medicine, 2004). Encourage frequent
    nursing throughout the day as the ability to sustain suck may be
    impaired. Infants should go to breast as often as possible, aiming
    for at least 8 to 12 times per 24 hours. Prolonged periods of
    skin-to-skin contact will facilitate these frequent attempts at
    breast. Assessments should include state of hydration and jaundice,
    as possible complications of poor intake.

9.  Once transitional milk is present, test weighing with an appropriate
    digital scale may be an option to judge adequate milk transfer.
    Infants are weighed immediately prior to the feed on an electronic
    scale with accuracy at minimum [+]{.underline}5 g, and then
    reweighed immediately after the feed with the exact same diaper,
    clothing, blankets, etc. worn during the prefeed weight. Intake
    during the feed is reflected by weight gain, 1 g = 1 mL. Term
    infants with Down syndrome gain weight more slowly than normal
    full-term infants (Cronk et al., 1988), so this must be taken into
    consideration during the early weeks and months. Growth charts
    specific for Down syndrome are found at
    <http://www.growthcharts.com/charts/DS/charts.htm> (last accessed
    Jan 21, 2007).

10. Consider alternative modes of feeding if the baby is unable to nurse
    at the breast or sustain adequate suckling, including the use of a
    cup (Marinelli, Burke, & Dodd, 2001), a spoon, or a wide-based
    silicone bottle. The use of a nursing supplementation aid alone
    (without a nipple shield) may not be as helpful, as it works best
    with a baby who has an effective latch, the lack of which is often
    one of the significant problems of hypotonic infants.

11. If supplementation is necessary, please see Academy of Breastfeeding
    Medicine Protocol #3: Hospital Guidelines for the Use of
    Supplementary Feedings in the Healthy Term Breastfed Infant (Academy
    of Breastfeeding Medicine, 2002). If the baby is attempting to
    suckle, following each breastfeeding encounter with breastmilk
    expression (see below), followed by spoon or cup feeding of the
    expressed milk to the baby, provides more stimulation to the breasts
    and more milk to the baby.

**Preventative Measures to Protect a Milk Supply**

1.  If the infant is unable to successfully and fully breastfeed, or if
    the mother is separated from her infant (e.g., neonatal intensive
    care unit admission), lactation must be initiated and/or maintained
    through pumping or hand expression. Anticipating the initial
    difficulty a hypotonic infant will likely have with sustaining
    frequent and effective milk removal, insufficient milk production
    may be prevented by encouraging mothers to express milk shortly
    after delivery, ideally within 2 hours (certainly within the first 6
    hours as is recommended with preterm mothers) (Hill, Brown, &
    Harker, 1995), and approximately every 3 hours thereafter. Aim to
    remove milk at least eight times in a 24-hour period, mimicking the
    stimulation of a vigorous term breastfeeding baby. Even if the baby
    shows some ability to go to breast, latch, and transfer milk, the
    mother will likely need to express or pump extra milk in the early
    weeks in order to build and maintain her milk supply at the higher
    level. A plentiful milk supply will enhance letdown for these less
    vigorous babies, and facilitate their feeding effort.

2.  Most of the research on initiating and maintaining milk supply by
    expressing milk has been done on mothers of preterm infants. The
    strongest determinant of duration and exclusivity of breastfeeding
    the preterm infant is the volume of milk produced by the
    pump-dependent mother, while insufficient milk production is the
    most common reason for cessation of efforts to provide milk for
    these infants (Sisk et al., 2006; Killersreiter, et al., 2001;
    Furman, Minich, & Hack, 2002). As the baby begins to improve with
    milk transfer, developing rhythms, and showing feeding cues, pumping
    times can be led by these cues (i.e., breast emptying by expression
    after each attempt at breast). This pattern should continue until
    the couplet is reunited and/or the infant is able to sustain
    successful breastfeeding. It is critical that mothers be instructed
    on effective pumping, including both the use of a hospital grade
    electric pump if available and manual expression.

3.  Extrapolating from preterm research for guidance in the hypotonic
    baby, the production of 500 mL/day is commonly cited as the minimum
    volume enabling premature babies \<1500 grams to transition from
    tube or bottle feeding to successful, exclusive breastfeeding
    (Meier, 2003). Until studies are done in the hypotonic infant
    population, this is a minimum volume from which to start, and can be
    adjusted based on calculations of intake necessary for growth.

4.  Simultaneous pumping of both breasts with a hospital-grade pump has
    been shown to be more effective than single pumping. Recent research
    suggests manually assisted pumping improves effective emptying and
    production in pump-dependent women. In contrast to the usual
    practice of passively depending on the pump to suction milk from the
    breast, manual techniques, used in conjunction with pumping, enable
    mothers to enhance emptying by using their hands for breast
    compression, massage, and expression (Jones, Dimmock, & Spencer,
    2001).

5.  A pumping/feeding diary or log, to enable health care providers to
    track maternal milk supply and intervene when needed, can consist
    simply of a piece of paper with columns for date, time started
    pumping, time ended pumping, amount of milk expressed, and comments
    (such as where pumped, unusual stressors, etc.), or can be ordered
    or used as a model from various Web sites, including:
    <http://www.cpqcc.org/quality_improvement/qi_toolkits>, appendix
    \"O\" (last accessed January 21, 2007).

**At Discharge and In the Neonatal Period**

1.  If the baby will remain hospitalized, the mother\'s milk supply
    should be assessed daily including pumping frequency, 24-hour milk
    total, and any signs of breast discomfort. Carefully monitor the
    baby\'s weight gain and consider supplementation as necessary.

2.  Inform mothers that sucking efficiency frequently continues to
    improve over the first year, such that the breastfeeding experience
    may \"normalize\" and may not continue to require interventions
    initially necessary for their own infant, for example,
    supplementation, pumping, more frequent nursing, etc.

3.  Provide information about local support groups for breastfeeding and
    for specific diagnoses such as Down syndrome families. Support and
    encouragement is particularly important for these mothers and
    families with the additional patience and time that is sometimes
    required to breastfeed these infants.

4.  Maternal milk supply is affected by ineffective or infrequent
    pumping/expressing. Although stress, fatigue, and pain are
    frequently cited as determinants of slow milk supply, recent
    evidence refutes this (Hill et al., 2005). However, it is not
    unreasonable to encourage maternal rest and analgesics as needed.
    Review and optimize breastmilk expression frequency, schedule, and
    type of pump used, if necessary. A pumping diary/log (see earlier)
    can be useful.

5.  If maternal milk supply does not equal or exceed the infant\'s
    needs, or begins to slow despite optimal pumping, the use of
    galactogogues to enhance maternal milk supply may be considered.
    Please see Academy of Breastfeeding Medicine Protocol #9: Use of
    Galactogogues in Initiating or Augmenting Maternal Milk Supply
    (Academy of Breastfeeding Medicine, 2004).

6.  In the presence of significant cardiac, gastrointestinal, or renal
    complications, it is sometimes necessary to increase the caloric
    density of breastmilk with extra fat, carbohydrate, or protein. If
    the mother\'s milk supply is greater than the baby\'s needs, a trial
    of feeding hindmilk (higher fat content, therefore more fat
    calories), either by expressing some of the foremilk before putting
    the baby to breast, or if supplements are being used, by pumping off
    a small volume of milk first (foremilk) and then in a separate
    container pumping the rest of the milk present (hindmilk) and
    feeding the baby only the hindmilk.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=11282)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

The recommendations were based primarily on a comprehensive review of
the existing literature. In cases where the literature does not appear
conclusive, recommendations were based on the consensus opinion of the
group of experts.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Improved breastfeeding outcomes for mothers and hypotonic infants

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

A central goal of the Academy of Breastfeeding Medicine is the
development of clinical protocols for managing common medical problems
that may impact breastfeeding success. These protocols serve only as
guidelines for the care of breastfeeding mothers and infants and do not
delineate an exclusive course of treatment or serve as standards of
medical care. Variations in treatment may be appropriate according to
the needs of an individual patient.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Foreign Language Translations

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Thomas J, Marinelli KA, Hennessy M, Academy of Breastfeeding Medicine
Protocol Committee. ABM clinical protocol #16: breastfeeding the
hypotonic infant. Breastfeed Med 2007 Jun;2(2):112-8. \[38 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17661583)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 Jun

#### GUIDELINE DEVELOPER(S)

Academy of Breastfeeding Medicine - Professional Association

#### SOURCE(S) OF FUNDING

Academy of Breastfeeding Medicine

A grant from the Maternal and Child Health Bureau, US Department of
Health and Human Services

#### GUIDELINE COMMITTEE

Academy of Breastfeeding Medicine Protocol Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Caroline J. Chantry MD, *Co-Chairperson*; Cynthia
R. Howard, MD, MPH, *Co-Chairperson*; Ruth A. Lawrence, MD; Kathleen A.
Marinelli, MD, *Co-Chairperson*; Nancy G. Powers, MD, FABM

*Contributors*: \*Jennifer Thomas, MD, Department of Family Medicine and
Pediatrics, Medical College of Wisconsin, Wheaton Franciscan
Healthcare---All Saints Medical Group; Racine, WI; \*Kathleen A.
Marinelli, MD, Pediatrics, University of Connecticut School of Medicine,
Connecticut Children\'s Medical Center, Hartford, CT; \*Margaret
Hennessy, MD, Wheaton Franciscan Healthcare---All Saints Medical Group,
Racine, WI

\*Lead authors

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

None to report

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/ace-files/protocol/Protocol_16_07.pdf).

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following is available:

-   Procedure for protocol development and approval. Academy of
    Breastfeeding Medicine. 2007 Mar. 2 p.

Print copies: Available from the Academy of Breastfeeding Medicine, 140
Huguenot Street, 3rd floor, New Rochelle, New York 10801.

A Korean translation of the original guideline document is available
from the [Academy of Breastfeeding Medicine Web
site](http://www.bfmed.org/ace-files/16hypotoniakorean081008.pdf).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on November 15, 2007.
The information was verified by the guideline developer on October 31,
2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

Single copies may be downloaded for personal use. Copyright permission
to be requested for use of multiple copies by e-mailing requests to
<abm@bfmed.org>. An official request form will be sent electronically to
person requesting multiple copy use.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/24/2008