Breastfeeding a premature baby

There are few things as stressful as when your baby is born too early. Not only do you have to adjust to being a mother sooner than you were expecting, but you also have to learn to be a mother in a very unfamiliar environment and with a very fragile baby. No doubt, this is not how you pictured the first days of your baby’s life.

But through many years of working in a neonatal unit, I’ve seen one thing very clearly: mothers are warriors who can and will do anything for their babies. In this post I want to share with you some of the realities of breastfeeding a premature baby, and what you can expect your journey to look like. I will also share some of my advice for making this journey as smooth as possible.

The realities of being born too early

A baby is considered premature if they did not complete 37 weeks of gestation. But there’s a big difference between a baby born at 36 weeks and one born at 26 weeks! In general, the earlier your baby is born, the more complications they are likely to have, and the longer they will have to stay in the neonatal intensive care unit (NICU). So while a 36-weeker may not even need to be admitted to NICU, a baby born at 28 weeks and weighing 1 kg will be there for several weeks.

Premature babies are, by definition, not quite ready for life outside the womb – they weren’t supposed to be eating and breathing and staying healthy on their own yet. For this reason, premature babies often have health problems, which can range from mild to severe. Some of the most common problems are:

• Breathing problems. The lungs are the last organ in the body to mature fully, so it makes sense that breathing problems should be the most common complication that premies face. In mild cases, baby may only need some oxygen through a face mask; in severe cases, baby may need to be intubated and placed on a ventilator, which is a machine that helps him breathe.
• Digestive problems. Premature babies often struggle to digest their milk, and it is not unusual for them to vomit. In the beginning, most babies will receive TPN, which is a specialized type of food that goes straight into a vein with a drip. This ensures that they get enough nutrients even when they can only tolerate small volumes of milk.
• Premature babies have very weak immune systems and they are very prone to getting infections. They often need antibiotics, and it is very important to observe strict hygiene measures when you work with a premature baby.
• Feeding problems. Premature babies have an immature suck-swallow reflex, so they usually can’t suck effectively at the breast. We’ll discuss this at some length in this post.
• Nutrient deficiencies. Babies fill up their nutrient stores in the third trimester of pregnancy. Because a premature baby did not complete the full third trimester, they are born with lower than normal stores of some nutrients, especially iron. They also have higher nutrient needs than full term infants. For these reasons, all premature babies are given some extra micronutrient supplements (usually a multivitamin, iron and vitamin D).
• Neurological problems. Premature babies are prone to eye damage, hearing problems and bleeding or water on the brain. Your healthcare team will monitor your baby closely for all these problems.
• Temperature control problems. Premies do not have a layer of fatty tissue to keep them warm, so they get cold very easily. If baby gets cold, they do not gain weight and they can also develop very low blood sugar, which can be very dangerous. For this reason, baby must always be either in skin-to-skin care or in an incubator.

Do premature babies need breast milk?

We all know that breast milk is the best food for babies, and this is especially true in the case of premature babies. The unique properties of breast milk make it ideal for premature babies:

• Breast milk digests more easily than any infant formula. For this reason, babies absorb breast milk better and are less prone to vomiting than when they are on formula feeds. Breast milk also dramatically lowers a baby’s risk of necrotizing enterocolitis, which is a serious infection of the intestines that premies can get.
• Breast milk contains immune factors that protect baby against illness. Premies who are fed with breast milk have a much lower rate of infections than those who receive formula.
• Breast milk helps the brain and eyes to develop normally. Premies who are fed breast milk do much better on developmental tests when they are older than premies who did not get any breast milk.

Did you know that mothers of premature babies make different breast milk to mothers of full term babies? It’s as if nature knows that this baby will have higher nutrient needs. If you gave birth prematurely, then for the first month or so your breast milk contains higher levels of protein, minerals and immune factors.

In some cases, the breast milk may need to be enriched by adding a fortifier. This is a powder that contains extra protein, carbs, vitamins and minerals. This is often needed for those babies who were born very early or very small, or for babies who do not tolerate large volumes of milk. Fortunately, using a fortifier does not seem to minimize any of the beneficial effects of breast milk.

The typical course of breastfeeding

How do a baby’s feeding skills develop?

If a baby is born at term (38 weeks or more), they have all the feeding skills that they need, and they can thrive on feeding directly from the breast. However, the earlier a baby is born, the more they will struggle with breastfeeding. This is because certain feeding skills develop at certain ages. To breastfeed, a baby needs to be able to do a few things: latch on, suckle and swallow – and very importantly, co-ordinate all of this with breathing to ensure that the milk doesn’t end up in the lungs. Here’s a rough breakdown of when all these feeding skills develop during a normal pregnancy:

• Swallowing is the first feeding action to start, at around 15 weeks of gestation. By 22-24 weeks, most babies are swallowing amniotic fluid consistently.
• Sucking develops next: the first sucking movements start from around 18 weeks, and most babies are able to suck on their fingers from around 24 weeks.
• The reflexes needed for a baby to latch on and suckle at the breast develop around 28 weeks – this includes rooting (the reflex that allows baby to search for and locate the nipple), latching and “grasping” the breast, and the correct tongue movements for suckling. However, these actions are still immature and usually not very strong.
• Co-ordination of suckling, swallowing and breathing occurs at around 34 weeks’ gestational age. Only once baby can co-ordinate suckling, swallowing and breathing is it safe to give baby anything to drink by mouth. Interestingly, premature babies who are carried skin-to-skin in kangaroo mother care can develop these feeding skills much earlier – even as early as 28 weeks! In the absence of KMC, however, you can expect that you will start to feed baby by mouth any time from 34 weeks onward.

Feeding through a tube

Most premature babies start out by taking their milk through a tube. The tube is passed through the nose or mouth directly into the stomach. A feeding tube allows us to safely give milk to a baby that cannot yet swallow: if you feed baby through his mouth before the swallowing reflex is mature, there is a big risk that the milk may go into baby’s lungs instead of into the stomach; this can cause life-threatening pneumonia. By the way, the best person to assess whether your baby can swallow safely is an experienced speech therapist – a guesstimate based on baby’s age or weight is not very accurate.

Starting feeds through the mouth

Once baby’s swallowing reflex is mature and he can swallow safely, you will start to feed baby some milk through the mouth. This means different things in different NICUs:

• Some units start baby with bottle feeds. I am not at all a fan of this practice; it very often causes babies to refuse the breast later on. Also, contrary to what your doctor may tell you, it is harder work for a premie to drink from a bottle than from the breast, because they struggle to manage the quick flow of milk. Studies have found that premies use more energy and have worse oxygen levels, heart rate and breathing while bottle feeding than while breastfeeding. So I say avoid the bottle whenever possible!

• Alternative feeding methods can be used instead of a bottle: the most common is to start with a syringe and then move on to cup feeding. We used to do this in the government hospitals where I worked, and it works beautifully. The only challenge is that it takes a bit of time to learn to do it properly, and sadly a lot of NICU staff are not willing to take that time. The advantage of this method is that it allows you to be discharged a lot sooner, since most babies can handle full cup feeds a few weeks before they are strong enough to take all their feeds directly from the breast. I have had an amazing success rate with this protocol.

• A third option is the one I encountered in my new workplace in the private sector, which is to go directly from tube feeds to breastfeeding with no other feeding methods in-between. You will start to gradually introduce breastfeeds, and decrease volume of the tube feeds as baby’s breastfeeding skills improve. This method has much better breastfeeding success rates than when you use bottles, but it does take a longer time for baby to learn to drink from a breast than from a cup. In practical terms, this means it takes quite a bit longer before you can be discharged.

Progressing to breastfeeding

Breastfeeding – getting baby to take all his feeds directly from the breast – is the ultimate goal. After all, who wants to be pumping for months and years on end? And based on all my years of experience, I can assure you that it is not an unrealistic goal. As long as you can keep your milk supply up, and you can teach baby the necessary sucking skills, you have a very good chance of getting to exclusive breastfeeding.

Not many people realise this – not even paediatricians – but a premature baby can usually be introduced to the breast almost immediately. The only criterion is that the baby’s heart rate and oxygen levels must stay within normal range when you hold him. If baby is still very immature, he may not be able to swallow safely yet. In this case, you need to pump the breast dry before allowing baby to suckle. This allows baby to practice his breastfeeding skills without there being any risk of choking. This kind of “dummy sucking” at the breast is one of the most effective ways to help a baby to learn to breastfeed easily.

As baby’s feeding skills improve, you will begin to leave a little bit of milk in the breast – just pump for a few minutes before to take care of that first rush of milk with the first let-down. This will allow baby to start associating suckling at the breast with food. Once baby has shown that he can handle direct breastfeeding without any complications, you don’t need to pump before a feed anymore – just breastfeed and enjoy it!

Initially, baby won’t be able to take a full feed from the breast, because he will get tired quickly. This is perfectly okay – you will still be giving expressed breast milk as the main source of food. Only once baby becomes stronger and is shown to be suckling effectively will you begin to decrease the amount of expressed breast milk that you offer at each feed.

How to breastfeed a premie: practical tips

Even when they reach their expected birth date, premies aren’t always as easy to breastfeed as full-term babies. There are two main reasons for this: firstly, the development of their feeding reflexes was interrupted (as I explained above) and secondly, they have poor muscle tone, which makes it harder for them to latch on, keep the breast in the mouth and suckle effectively (this also causes them to tire out quickly. Fortunately, there are quite a number of things that you can do to compensate for these problems

Kangaroo Mother Care

Kangaroo mother care – keeping your baby skin-to-skin for as many hours a day as you can – is the very best thing you can do to help your baby breastfeed. I honestly cannot exaggerate the nearly miraculous effects of KMC. I’ve written a whole separate post on KMC that you can find here – please, do yourself a favour and read it!

Suck training

There are certain exercises that you can do to strengthen the muscles of baby’s mouth and help him learn how to suck. Ideally, you want to do these exercises before every feed, but even doing it a couple of times a day will make a difference.

These are the simple exercises that a speech therapist colleague taught me and that we’ve been using for many years now. Using your forefinger, stroke baby’s face gently but firmly (as if you’re giving a massage) in the following areas, repeating each movement 5-10 times:

• Stroke the cheek in a line running from the centre of the ear to the corner of the mouth.
• Stroke the skin above the upper lip, moving from the centre of the lip to the corner of the mouth (repeat to both sides).
• Stroke the lower lip from left to right and from right to left.
• Place a finger under baby’s chin and gently massage in small circles – this stimulates baby’s tongue from below.
• Use your fingertip to gently tap baby’s lips. If baby opens his mouth and roots for your finger, allow him to suck on it (with the pad of your finger on his tongue and the nail at the palate). It is a very good idea to allow baby to suck on your finger while you give a tube feed: it teaches them to associate sucking with feeding and the feeling of satiety.

Positioning

Because of their low muscle tone, premature babies often struggle to hold their position at the breast. Their heads tend to roll around a lot, making them lose their grip on the nipple. You can compensate for this by supporting baby’s entire body and neck while he is at the breast.

With premies, it is doubly important to make sure that they are positioned “tummy-to-mummy” and right up against you, so that they can reach the nipple without having to bend or stretch their necks. The traditional cradle or Madonna position can be quite difficult, since it doesn’t support baby’s head very well; I would recommend using either the cross-cradle or the football position.

Nipple shields

Nipple shields can be a useful tool for a premie that’s learning to breastfeed. The main benefit of a nipple shield is that it makes it easier for baby to maintain his latch on the breast. Babies who have been bottle fed also seem to take to the breast more easily if you use a nipple shield. However, not all premies need nipple shields, and some babies actually don’t do well on them at all. If you use nipple shields, it’s best to do so under the guidance of a lactation consultant. I’ve also written a whole post on nipple shields (here) that will give you a lot of extra information.

In conclusion

When your baby is born too early, your breastfeeding journey may end up looking nothing like what you were expecting. It may be a lot more work, and take a lot more time, but the good news is that breastfeeding is still absolutely possible. I salute every mother who has ever gone through the process of breastfeeding a premature baby: you ladies inspire me to keep helping every mother to experience the amazing, rewarding relationship of breastfeeding!

Please share your premie stories, struggles and triumphs with us by leaving a comment!