Freeflow- Establishing Breastfeeding with Premature Babies

Kathryn Stagg IBCLC

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

@kathrynstaggibclc

Summary

When a baby or babies arrive early, it is common to feel stressed and helpless. One thing the birthing parent can do is provide colostrum and milk for their baby. This is often a great source of comfort for mothers.

Establishing Breastfeeding with Premature Babies

Preterm human milk is different to that of someone who delivers at term. It has higher levels of energy, fats, protein, vitamins and minerals, and most importantly it has higher levels of immune factors. It is highly valued in the neonatal unit, and hand-expressing colostrum is encouraged within the first 6 hours after birth. Continuing to hand express every 2 to 3 hours will tell the breasts to prepare to make lots of milk by priming the prolactin sites, as well as provide colostrum to feed the baby or use for oral care. The pump can be used to stimulate a letdown but the small volumes of thick, sticky colostrum will get lost in the pump so hand expressing works better for collecting the colostrum. Once volume increases and milk begins to come in, the pump can then be used to collect the milk. The hospital should be able to advise on renting a hospital-grade double pump to be used when the parent is discharged home. Make sure the flange size is correct as this can have an impact on yield. Try one the same diameter as the nipple to start with. Often smaller with some lubrication yields more milk. It is important to pump frequently; we recommend 8-10 times in 24 hours for 20-30 mins. Massaging before and during the pumping session increases oxytocin and helps the milk flow. Having a baby in the neonatal is a stressful and worrying time, but the stress hormone cortisol inhibits the flow of oxytocin and can prevent the milk from flowing as effectively. Listening to music, relaxation tracks or just distracting with a chat to a friend or watching something light-hearted can increase yield. Also, try covering the bottles.

Once premature babies are around 32-33 weeks gestation they often begin to start developing a suck, swallow, breathe pattern in short bursts and may start rooting for the breast. This is a good time to prioritize kangaroo care and begin the process of getting the baby to latch.

Learning to breastfeed when you are a premature baby is a long, slow, tiring process and it requires everybody to have lots of patience. To start with babies can have skin-to-skin time, or kangaroo care, be encouraged to root and nuzzle the nipple and if they are ready possibly have a few sucks. A baby can begin with non-nutritive sucking at a recently pumped breast to provide a gentle experience without an overwhelming flow of milk. Then a fuller breast can be introduced. At this early stage, the majority of any feed will still be expressed milk through the feeding tube. Once or twice a day is sufficient, to begin with so as not to tire the baby out. Once they become stronger and start to suck and swallow more effectively the breast can be offered more frequently. Baby can have their tube fed during the breastfeed so they will begin to associate the act of breastfeeding with the feeling of having a nice full tummy.

There is evidence that suggests a nipple shield can increase milk intake in preterm infants in the early days, so this can be worth considering, especially if pumping is challenging. Most babies can move away from shields once they are term.

When the babies appear to be feeding better and getting much more milk we can move on towards exclusive breastfeeding. Whilst some babies will be able to move straight on to exclusive breastfeeding from tube feeding, this new enthusiasm for feeding can be a bit misleading as the suck can still be uncoordinated and inefficient and the babies can still tire easily. If we move on to exclusive breastfeeding too quickly, it can cause problems with babies not taking enough milk, becoming too tired and then starting to reduce their weight gain. So top-ups of expressed milk may be necessary for a little while. Parents may choose to top up by a different method than tube feeding so the baby can go home, although some hospitals will discharge a baby still tube feeding.

To minimise the impact of using a bottle on breastfeeding, a paced bottle-feeding technique should be encouraged. Paced bottle feeding means letting the baby take control of the speed of the feed when to take breaks and when to finish. Babies can be positioned in a more upright position or elevated side-lying position. Baby should be encouraged to latch onto the bottle like the breast, so touching the top lip to encourage baby to route and bring baby onto the bottle chin first, teat into the roof of the mouth. Start with an empty teat to encourage them to wait for the let-down when breastfeeding. Pause frequently. With this slower feeding technique, the baby will be able to tell they are full and finish the feed when satisfied and they will be less likely to be overwhelmed by a fast flow of milk.

The chance to ‘room in’ for a night or two before discharge home may be available to the breastfeeding parent. During this time, it’s often encouraged to move on to responsive feeding as opposed to hospital routine-based feeding. But babies may still be sleepy and not wake for feeds at this stage, so it is important to make sure that they feed at least every 3 hours as a minimum, measured from the start of each feed.

For a lot of families, their first experience of being at home with their early baby is to be in an intense breastfeeding, top-up, express routine, every 3 hours or more, day and night. This is called triple feeding and is utterly exhausting and overwhelming and it is often difficult to see past this stage. This should only be for a short time, and with support in the community, exclusive breastfeeding should be possible, if that is the parent’s wishes. Babies are individuals and it is often somewhere between 36 weeks and 42 weeks gestation where they begin to feed efficiently enough to fully breastfeed.

The breastfeeding parent will need lots of support. This routine is so full on that there is not much time for anything else, especially sleep! Somebody to do the top-up whilst pumping saves time. Someone to cook, look after older siblings and keep the house can make all the difference. Every single breastfeed given and every single drop of expressed milk should be valued and encouraged. Emotional support is vital and reminding them that soon it will become easier can keep everyone going through this incredibly tough time.

Support can be invaluable at this time, but a lot of parents feel unsure about taking their preterm baby out to groups due to the risk of infections. This is where home visits from well-informed healthcare professionals and well-moderated online support can step in. Peer-to-peer support is incredibly valuable.

So how do we know when a baby is feeding well enough to fully breastfeed? Their suck, swallow breathe pattern becomes more coordinated and they can remove more milk from the breast. Deep sucks and swallows are obvious. Longer bursts of sucking and maintaining active feeding for more than a few minutes are all signs to watch out for. Breast compressions can help babies take more milk, especially when sleepy at the breast.

Premature babies often have a big feeding frenzy at around the 40-week due date and sometimes want to cluster feed at this time. This can be very unnerving for a preterm parent who is used to having a sleepy baby who needs to be woken for feeds. Cluster feeding should be encouraged and explaining that this is completely normal behaviour will help the baby get lots of milk and boost the supply helps parents understand.

Sometimes when babies move on to more direct breastfeeding, their weight gain can flatten a little on the growth chart. This can be discouraging for parents who are working so hard at feeding. Encouraging frequent feeds with a deep latch, breast compressions and switch nursing should mean this is only a blip. But if weight gain continues to be problematic, a few top-ups can be added back in temporarily

 Breastfeeding is so important for babies, but even more so for premature babies. But establishing breastfeeding in the neonatal unit is like a marathon, not a sprint. It is a slow process taking every ounce of patience and determination. But it is worth every bit of stress.