Freeflow- Establishing Breastfeeding When a Baby Arrives a Bit Early

Kathryn Stagg IBCLC

Breastfeeding Support and Education at home, group or online, Holistic Sleep Support

@kathrynstaggibclc

Summary

Babies born between 34+0 and 36+6 weeks are considered late preterm, and those born between 37+0 and 38+6 weeks are early term. While these babies are often healthy enough to stay with their parents after birth, breastfeeding can still be challenging. Many struggle to feed effectively due to being sleepy or not yet coordinated enough, which can lead to weight loss and low blood sugar. Frequent support and guidance are essential to help parents understand feeding cues, ensure a good latch, and navigate the transition to exclusive breastfeeding. Specialised help from an IBCLC can make a significant difference in these early days.

Freeflow- Establishing Breastfeeding When a Baby Arrives a Bit Early

A baby born between 34+0 weeks and 36+6 weeks gestation is defined as a late preterm baby. A baby born between 37+0 weeks and 38+6 weeks is defined as an early-term baby. Many premature babies are discharged home at around this gestation.

Babies who are born later than 36 weeks gestation are often well enough to remain on the postnatal ward with their parents, which is great as they do not have to go to the neonatal unit. However, establishing breastfeeding a baby born a bit early can be quite challenging. They are generally discharged home quite quickly with only minimal support.

Because of this, these early-term babies are often treated the same as full-term babies and left to feed responsively or “demand feed.” The problem is that these babies often do not “demand” enough and prefer to sleep. They are often too sleepy for the parent to be able to follow their lead completely. And if they do not feed enough, they get even sleepier and even harder to rouse to feed as their blood sugar drops.

Some slightly early babies are not physically strong enough or coordinated enough to breastfeed fully, often until they are coming up their 40-week due date or even a bit after. They can be quite skinny in their face as they have not had a chance to do that last bit of growing and putting on weight which can also make breastfeeding more challenging. A full-term baby’s round cheeks help them stabilise on the breast and feed more efficiently. So these babies may latch, have a few sucks, take on a little milk, and then fall asleep before they have had their fill.

All of this can lead to real problems! Babies can lose too much weight, have unstable blood sugar or jaundice can set in. The parent’s milk supply may not be stimulated sufficiently. Then after a week or two, the babies have lost too much weight or are not put on enough, and it is decided they need supplementing, but the low supply caused by inefficient feeding may mean they need to use formula.

Parents of more premature babies also experience these problems as they are often discharged around what would have been 36-37 weeks gestation with minimal breastfeeding support. They are often given the chance to “room in” for a couple of days to practise feeding and looking after their baby or babies full time, and this is often the first time the breastfeeding parent is allowed to follow their babies’ lead. All the same pitfalls can happen, and they may lose their hard-earned milk supply if they were pumping frequently in the Neonatal Unit.

These families need lots of support. They need good quality face-to-face breastfeeding support after discharge. They need to be shown the subtle cues their baby makes to show that they need to feed; stirring, mouth opening, turning head from side to side, and the later cues including stretching, moving arms and legs, trying to bring hand to mouth. Crying and agitation are late cues. (Marie Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. Dr Tena Fry said in her interview with Marie Biancuzzo: “If a baby’s eyes are open they should be offered food”. Parents also need to be supported to understand when their baby is not cueing frequently enough and when to wake their baby. Not letting a baby of this gestation go longer than 3 hours from the start of each feed ensures they have a minimum of 8 feeds in 24 hours which should be enough to begin with. 

Parents should also be shown how to ensure the babies are latching on well to feed. Breast compressions are a very useful tool to help transfer a bit more milk to the babies during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end of the feed. Sometimes a baby of this gestation may have trouble latching directly onto the breast. Babies who are a little early sometimes latch better and feed more efficiently when using nipple shields. Close attention should be paid to milk weight gain and nappy output if shields are used as they can inhibit milk transfer. Most babies will be able to wean off shields onto the breast once they are a few weeks old and feeding more efficiently.

Parents may need support with continuing to pump for top-ups if the baby is not ready to fully breastfeed. Explaining how to tell that their baby is developmentally ready and feeding efficiently enough to move away from 3 hourly feeds and on to baby-led, cue-based feeding will empower the parents to move forward towards exclusive breastfeeding.

The issue is each baby is different. Some will be ready to fully breastfeed at 36 weeks gestation, it may take others until 42 weeks, and everything in between. Parents often continue to supplement and schedule feeds far longer than they need to due to being worried about weight gain and milk intake.

Before reducing supplementary feeds or moving to responsive feeding, the baby should be putting on weight as expected, generally waking themselves for feeds, beating the parent to the 3-hour schedule, and having a good proportion of “active feeding” during a breastfeed. Then if the parent is pumping for top-ups this can be gradually phased out. They will be safe to move on to responsive feeding. If parents are using formula to top up the baby will need to be encouraged to come to the breast more frequently and cluster feeding can be encouraged to help boost supply, then the formula can be gradually phased out.

Ideally, each family would be guided by somebody highly qualified, such as an IBCLC or experienced Breastfeeding Counsellor. This scenario deserves specialist breastfeeding support in the home on discharge from the hospital to ensure parents can maximise their babies’ breast milk intake.