Breastfeeding a premature baby is a tough job of importance that cannot be minimized. Should your feeding relationship include your own breast milk, donor milk, formula, or a combination, the whole journey will be a meaningful and deeply nourishing one for you and your baby.
This aspect of raising your baby may not have gone exactly as planned or imagined, but remember that unexpected adjustments are a normal part of the feeding routine. Feelings of sadness, disappointment, or fear are valid and worth discussing with supportive loved ones who can be motivated to help you breastfeed despite facing obstacles related to prematurity.
Who Has Premature Babies?
The prevalence of prematurity has been rising, with now 1 in 8 U.S. babies born at any point prior to 37 weeks of gestation. Factors found at greater incidence among those having a premature baby include:
- Previous premature birth
- Carrying multiples
- Uterine or cervical problems
- Chronic high blood pressure
- Cigarette use
- Alcohol use
- Mothers under age 18 or over age 30
- Lack of or delayed prenatal care
- Poor nutritional status
- Untreated infections
Not Always Truths
How many of these statements do you think are true about preemies?
- Premature babies need to be in incubators.
- Premature babies all need fortifiers.
- Premature babies cannot go to the breast until they are at 34 weeks gestation.
- Mothers of premature babies need to use nipple shields to get their babies latched on well and getting milk well.
- Premature babies need to learn to take a bottle which teaches them how to suck.
- Premature babies get tired at the breast.
- Test weighing (weighing the baby before and after a feeding) is a good way of knowing how much milk the baby got at a feeding.
- Premature babies need to continue getting fortifiers once they leave hospital.
According to Dr. Jack Newman, they’re all myths about premature babies and breastfeeding. He elaborates upon each one here.
That all said, premature babies often do have early difficulties with latching and/or being strong enough to transfer a sufficient amount of milk. Babies born before 32 weeks may struggle greatly with coordinating sucking, swallowing, and breathing.
Premature Breast Milk
Premature babies need the benefits of breast milk and breastfeeding even more than full-term ones without medical problems.
For the first few weeks, premature breast milk will be higher in protein and minerals like salt, plus different types of easily digestible fats. The milk produced in the first few days contains high concentrations of antibodies to help baby ward off infections. This is nature’s design for providing your individual baby with exactly what he or she needs at this time in their development.
Though donor milk is a great option, keep in mind that pasteurization removes the infection-fighters in fresh milk so try to pump your own milk for your preemie if possible and prioritize alternative feeding methods over bottles.
Even if baby is not yet capable of nursing, expressing breast milk between feeds can help boost and maintain a solid milk supply for when baby reaches that milestone. Pump early, often, and well!
- First get acquainted with G-tubes/NG-tubes. Understand the pros and cons and incidences when feeding tubes are medically warranted.
- Ask the hospital to loan a hospital-grade pump. Check with insurance about covering a supplemental full-size electric pump.
- Consider combining hand expression with pumping to maximize milk production.
- Make an appointment with an IBCLC or other lactation specialist early on to create a personalized feeding plan.
- The first round with a pump should ideally be within 6 hours of birth.
- While baby is in NICU, it’s recommended to pump often enough to mimic a newborn’s typical nursing pattern (8-10 times per 24 hour period, every 2-3 hours during the day and 3-4 hours at night or during work).
- Time pumping sessions from the start of the last one. For example, if you start at 5 p.m. you would start again between 7 and 8 p.m. Don’t forget overnight pumping sessions as these will help prepare you for middle of the night feedings once baby is home.
- Follow typical guidelines for successful pumping. Things to learn: how long you should expect to spend on the pump each session, depending on the time of day and other factors; how to set a pumping routine in relaxing conditions; what is the “magic hour”; how to massage your breasts before/after pumping to increase milk; how to avoid “nipple confusion/nipple preference.”
- Ensure that you’ve established a solid milk production, then taper down pumping sessions to maintenance level (at least 7 times in a 24 hour period every 3-4 hours, day and night).
It may take a long time for a premature baby to learn how to effectively nurse. Sometimes they may not end up fully breastfeeding. Still, any time spent at the breast is great for stimulating mental and physical growth for your baby. Stay flexible, patient, and enjoy being with your baby as you embark on this new chapter. Join a support group to help you through any challenges and to commiserate with feelings of frustration (or to celebrate your achievements!).
- Notify your baby’s medical team that you wish to breastfeed.
- They may first provide a nursing supplementer or similar device that delivers your expressed breast milk, donor milk, or a fortifier from a bottle or syringe through a thin tube that’s taped across your breast and next to your nipple. This allows baby to practice nursing behaviors while still getting required nutrients.
- The best time to attempt nursing is when baby is alert and awake but calm.
- Try expressing some milk and spreading it across your areola to entice baby to taste it. Baby will learn to associate this taste/smell sensation with nourishment.
- Medical complications may require that baby receives special fortifiers for adequate calories. Even if your baby cannot be sustained solely on your expressed or direct milk, continue pumping and store the milk for later use. Your baby’s nutritional needs will change and adapt as baby grows stronger.
- When there is medical clearance for exclusive breastfeeding, nurse on demand (on cue) whenever baby indicates an interest.
Formula & NEC
Some babies, those classified as Very Low Birth Weight (VLBW – under 1500 gms/3.5 lbs) may require a prepared human milk fortifier for growth in addition to breast milk. The risks of feeding formula virtually always outweigh the benefits for preemies, which include ease of availability, greater convenience for doctors and parents, faster weight gain for the baby, and possibly lower financial expense. The risks of feeding formula rather than breast milk to a VLBW baby include, among other things, sepsis and necrotizing enterocolitis.
Did that last thing sound kind of scary? Well, you should really know about necrotizing enterocolitis (NEC), the “most common life-threatening gastrointestinal emergency” facing preemies in the NICU. A diet of exclusive human breast milk can lower the risk of NEC by 79% percent. (Wait, how much??). Best for Babes gives us some fast facts about NEC: It’s an excruciatingly painful disease of the bowels that involves necrosis (tissue death) of parts of the intestines. About 500 babies die from this largely preventable disease every year –- about 1 in 7 cases of NEC ends in death.
New science has proven “digested formula but not digested fresh human milk cause[s] death of intestinal cells in vitro,” with significant death of neutrophils (an essential part of the immune system) ranging from 47-99% with formula versus 6% with breast milk.
Nearly 60% of NICUs in the U.S. don’t use any donor milk for their vulnerable preemies, and many don’t even mention to new parents that it’s an option. So, how can YOU help? Donate milk, donate funds, and educate your health care providers! Find out how you can save babies from NEC through Best for Babes’ Miracle Milk program, and get details about donating milk here.
Kangaroo care (skin-to-skin, nestled between the breasts around the clock if possible) is fortunately becoming more popular as a method of improving and stabilizing a preemie’s health. Dr. Nils Bergman describes the “original” paradigm (as opposed to one born from cultural traditions) of breastfeeding and infant care as characterized by “niche and habitat.” Niche includes the basic needs (oxygen, warmth, nutrition and protection) and habitat is the setting wherein these needs are fulfilled. Let’s consider what Lisa Albright wrote about it:
“Anthropologists theorize humans appear to be born about one year ‘too early.’ For many mammals, brain size at birth is about 80 percent of adult size, whereas that of humans is about 25 percent. Humans don’t achieve 80 percent of adult brain size until approximately 21 months gestational age or 12 months postpartum. It has been suggested that this is an evolutionary compromise to the narrowed pelvic structure of humans as they began walking on two legs: the human newborn completes its gestational brain growth outside of the womb. The correct habitat or place for this is being in skin-to-skin contact with the mother, with breastfeeding providing the human milk that is uniquely adapted to the needs of the human infant’s ‘immaturity.’ Up to a point, prematurity can be thought of as an early transition to a habitat that is already designed to cope with human infants’ immaturity.”
This habitat continues to be crucial throughout the Fourth Trimester. Haven’t heard of it? Read more about external gestation in my section here. Bergman explains the relevance of kangaroo care to this theory:
“[T]he human newborn’s natural habitat is maternal-infant skin-to-skin contact. All newborn mammals that have been studied exhibiting a sequence of behaviors that leads to the initiation of breastfeeding. The newborn’s actions elicit a set of care-taking responses from the mother. He emphasized that breastfeeding is a niche, or set of pre[-]programmed behaviors, which the mammalian newborn exhibits that are appropriate for its habitat. Thus in the newborn habitat, the newborn gets oxygen through the air, warmth and protection through skin-to-skin contact with the mother, and nourishment through breastfeeding.”
Albright says Dr. Bergman’s case is that “the current paradigm of separation of the infant from its mother…has turned prematurity from an early habitat transition into a disease state.”
Other ways to bond with your premature baby:
- Check with the NICU nurses about baby’s schedule. If baby is being tube fed you can still change diapers, observe health assessments, and assist with baths.
- Ask if you can hold baby during feedings.
- Ask if you may try cup feeding.
- Some mothers find pumping near baby in the NICU room to be a very healing activity.
- Find out if you are allowed to stay overnight with baby, during the whole NICU stay, or if there is a nearby hotel that will allow you to remain as close as possible to baby.
- Many hospitals now have special nursing areas if you wish for a private space for feeding, if your baby is capable of suckling.
Did you breastfeed a premature baby? What was your experience like?
- “Breastfeeding a Preterm Infant After NICU Discharge: Reflections on Ryan’s Story” – Paula P. Meier, RN, DNSC, FAAN
- “Breastfeeding the Late Preterm Infant…” – The Academy of Breastfeeding Medicine
- “Breastfeeding My Premature Baby” – Laura Colon-Liebergen
- Breastfeeding Premature Infants categories by LLLI; includes stories and articles
- “How Do I Position My Pre-Term Baby at the Breast?” – LLLI
- “Human Milk Storage (Guidelines for Premature Infants)” – Kellymom
- “Kangaroo Mother Care: Easing Baby’s Transition into the World” – Teresa Pitman
- “Kangaroo Mother Care: Restoring the Original Paradigm for Infant Care and Breastfeeding” – Lisa Albright
- NEC Society web site
- Preemie posts list by Kellymom