Premature baby: breastfeeding successfully in NICU and at home

"Breastmilk is the best milk you can give your baby," says Kate Pinney, manager of the midwifery team for Tommy's, the charity that funds research into premature birth (as well as miscarriage and stillbirth). "It's rich in nutrients and not only helps babies to gain weight, but protects them from viral and bacterial infections, too."

Here's what to expect when you're breastfeeding a premature baby, either in hospital or at home...

If your baby is strong enough to hold and feed, you may be able to breastfeed them straightaway. If they're very small and/or very poorly, and perhaps in an incubator in neonatal intensive care (NICU), you'll probably be encouraged to express milk at first – as long as you're well enough yourself – until your baby is strong enough to nurse at your breast.

Of course, the shock of having given birth prematurely – and maybe having a poorly baby – may mean learning to breastfeed (or to express) seems too daunting to contemplate but you'll receive lots of practical support on how to do it, if you can.

What if my baby's in NICU and is too weak or too little to nurse at the breast?

If your baby is very unwell and/or very premature (born before 34 weeks), they may not be able to digest milk yet, so will be given fluids and nutrition through either through an intravenous (IV) line. If the doctors think your baby is capable of digesting milk but isn't yet strong enough to be held and breastfed, they may be given small quantities of milk through a nasogastric tube (passed up their nose and into their stomach) instead.

Either way, you will probably be encouraged to express soon after they're born, so that any milk you produce can be fed to your baby through the tube or, if your baby has an IV line, stored in the fridge or freezer for when they're stronger and able to digest milk.

And by soon after they're born, we mean very soon – maybe even within an hour of the birth. That's because research studies of mothers with premature babies³ has shown that the sooner you start expressing, the better and more quickly you can establish your milk supply.

You'll probably be encouraged to express every 3 hours (around 8 times every 24 hours⁴), either by hand or with a hospital-provided manual or electric pump (for and idea of the kind of help and info you'll be given, watch the NHS video below). In most

VIDEO: How to express breastmilk when your baby is born prematurely

NICUs, you'll probably be shown how to hand-express to begin with (see our guide to hand-expressing in our article on How to express breastmilk) before moving on to a manual or electric pump once your supply is established.

"You will only get a very small amount of milk at first," says Kate. "But do not be discouraged: even just a few drops are valuable to your baby's health."

You may find that sitting next to your baby as you express (ask for a screen) or listening to music will help you express more easily.

Above all, remember that your baby is unlikely to be able to take more than a very little milk at first anyway (and the medical team can always supplement with donor breastmilk or formula, if needed). And, as breastmilk is produced very much on a supply-and-demand basis, if you keep expressing regularly, you will stimulate your breasts to produce more milk.

Storing and freezing expressed breastmilk: find out how to do it safely

Why is breastmilk so important for premature babies?

Breastmilk is an responsive food – meaning that what's in it at any one time is made specially for your baby and their particular needs. So, any milk you make for your premature baby will be more densely nutritious than it would have been if your baby had arrived on its due date.

Your breastmilk (particularly in the 1st few days after the birth) also contains antibodies and other substances that will help protect your baby's immature gut and immune system from attack by the viruses and bacteria that can cause infections. Even just a few drops of your milk can be beneficial in this way.

There are studies, too, that highlight the advantages of breastmilk for premature babies. We've singled out 2 of them earlier in this article: 1 showing that giving breastmilk to preterm babies can help their hearts²and another showing that breastmilk helps brain connectivity.³

What else can I do to prepare for breastfeeding when my baby's strong enough?

Once you're able to hold your baby, spend as much time as you can with your baby held skin-to-skin on your chest, maybe with a blanket over the both of you (this is often called 'kangaroo care').

Being this close to you relaxes your baby and helps to regulate their breathing and body temperature. And, importantly, it also helps your baby to recognise your breasts as familiar and allow them to 'practise' breastfeeding by moving their head nearer to your nipples, and even nuzzling and trying to suck.

How will I know when my baby's ready to feed from the breast?

There are clear indicators that your baby's ready to breastfeed (that mainly centre on the ability to suck-swallow-breath in a co-ordinated way). Your midwife will be aware of them and will alert you to any signs.

As a general rule, though, these are the main cues to look out for in a preemie baby in NICU, according to the US-based The University of Rochester Medical Center:

Physical stability. Your baby needs to be strong enough to be held and to be fed from the breast
An ability to suck. Your baby might, for example, be able to suck on a dummy in brief bursts (more than 1 suck per second)
Gestational age. A baby should start showing bursts of sucking at around 32 weeks; at 34 weeks they'll hopefully start to develop a suck-swallow-breathe pattern
Being alert. Your baby must be able to remain awake for brief periods in order to feed at the breast
Oral reflexes. Your baby should be showing reflexes such as rooting, sucking, and coughing. And can tolerate touch to the mouth.

What if I'm really struggling to express or breastfeed?

If you have a premature baby who has to stay in hospital, the midwives will do all they can to help you either breastfeed or express milk for your baby, as it's the best thing for them.

Even if you only manage it for a few days or weeks.

We know that some mums who want to breastfeed or give their baby expressed milk struggle to do so for various reasons⁶ including:

low milk supply

painful breasts

difficulties trying to get their baby to latch

If one or more of these happen, it's worth remembering that you're not alone and that the medical staff in hospital will know what to do to help you and to make sure your baby gets what they need to thrive. You don't have to express or breastfeed for any longer than you want to.

How do I get my baby to latch on properly?

Donor milk

There are 16 milk banks across the UK, so it might just be that the hospital you're in is served by one of these and can provide you with donor milk, ie, breastmilk from someone else that's been stored for use by others who aren't able to provide milk for their baby for whatever reason.

Where's my nearest milk donor bank?

Formula milk

There is, of course, a formula-milk alternative if breastmilk – yours or from a donor – just isn't an option. Your baby's doctor will prescribe a special pre-term formula mik, either to supplement or to replace breastmilk, until your baby is well and grown enough to move on to 'normal' full-term formula.

How do I breastfeed my premature baby? Is there a particular hold or position that's best?

How you hold your premature baby when you start to breastfeed will inevitably depend on any monitors and tubes attached to their body. Kate suggests finding a position that's practical but comfortable but making sure, if you can, that you have as much skin-to-skin contact as possible.

"The best position depends on what’s comfortable for you and your baby," she says., "but cuddling them in close to your breast and giving them as much skin-to-skin contact as possible will help to release prolactin, which stimulates milk production, as well as oxytocin to help with milk ‘let down’.

Experts at La Leche League recommend the reclining or 'laid-back' hold, as it's thought to trigger your baby's natural reflexes to find your breast, and latch and feed successfully⁵. (It's also, as its name suggests, 1 of the more relaxing positions to breastfeed in.)

"It's worth knowing," says Kate, "that your baby may not take much milk to begin with, and will probably tire of sucking quite quickly."

This means that, while your baby is gaining strength, you may need to combine nursing at the breast with tube-feeding or even cup-feeding expressed breastmilk.

'How I breastfed my premature baby': 1 mum shares her story

Nicole P, from our Facbook community, had her 2nd child prematurely at 35 weeks and stayed in hospital with her for 2 weeks. Here she shares her experience of breastfeeding and expressing:

"When my daughter was born, she didn't have much strength to suck, so I did a lot of skin-to-skin to encourage her to feed from me. I had to pump every 4 hours round the clock and also try putting her to the breast.

"They fitted a NG (nasogastric) tube which we used to top up with breastmilk at each feed. When I offered her the breast, she only managed a few minutes.

"When they are born early it takes a lot for them to breastfeed, but with bottles they don't have to work as hard. We were told it was very important that we didn't give up and just offer the bottle.

"She was in hospital for the first 2 weeks with me – in a special unit which means I had a midwife with me in the room round the clock.

"It was difficult. I had a 12-month-old at home so I felt guilty. I felt very low at times. It was a very lonely experience, and with feed and pumping round the clock, it was hard work.

"She was born at 4lb 4oz, which was a good weight for being early, but until she established a feeding routine. we weren't allowed home. The staff were amazing and very helpful with the whole experience."

Breastfeeding your premature baby when you're at home

Taking your premature baby home from hospital – whether you've been there for just a few days or for many, many weeks – will probably seem quite daunting. Having been used to lots of round-the-clock care and support for your baby and you, now you'll be on your own and in charge of everything to do with your baby yourself.

Obviously, the hospital isn't going to discharge your baby – especially if they've been in NICU – without your medical team being sure that your baby is healthy enough to go home and you have all the knowledge, info and skills you need to feed your baby enough milk to keep them growing well.

"And, importantly," says Peter Bradley, Information and Support Manager for Bliss, a charity that provides support to parents of babies born premature or sick, "you should feel it's the right time to bring your baby home, too."

So, if your baby is still tube-feeding, for example. the NICU nurses will make sure you can insert the tube and and check its position and give the feed, and they will make sure you know what to do if your baby vomits. They'll also encourage you to keep doing skin-to-skin and encouraging your baby to suck, so that you can move on to breastfeeding (or bottle-feeding) when your baby's ready.

But it can all still feel a bit daunting, for sure. "Leaving the neonatal unit," says Peter, " can bring up a lot of different emotions: relief and joy at being able to take your baby home, but some worry and uncertainty too.

It is important to give yourself permission to feel whatever emotions come up. It is OK if you are anxious about going home. Ask for support from healthcare professionals, friends and family

If you're breastfeeding confidently before you leave hospital, you may find breastfeeding at home a cinch. But be prepared, too, for the move from one environment to another to throw up a few challenges on the breastfeeding front. Maybe you can't find the right chair or sofa to sit on or the right cushion to raise your baby high enough to latch on well. Maybe breastfeeding suddenly becomes painful or simply exhausting now your baby is less sleepy and more hungry. Whatever the challenges, do get help from your health visitor or from a qualified lactation counsellor.

If you KNOW your baby's coming early: antenatal expression of colostrum

Sometimes you know your baby will be born early (a planned premature labour, as the NHS calls it) because, for whatever reason, it's thought safer to deliver your baby prematurely than wait for their due date.

If you're in this situation, breastfeeding experts at La Leche League say it might be worth discussing the option to hand-express colostrum before your baby arrives, so your breastmilk is available straightaway and your milk supply is already increasing.

But you must talk to your healthcare provider about this before you try it as it could bring on early labour before your planned delivery.

About our expert Kate Pinney

Kate Pinney is head of the midwife team for charity Tommy’s, and practises midwifery within the NHS, as well being an experienced London-based health visitor. Kate has a masters degree in public health, with a focus on antenatal mental health and pregnancy after miscarriage.

Pics: Getty

References

^{1. Breast Milk Consumption in Preterm Neonates and Cardiac Shape in Adulthood. Adam J. Lewandowski et al. Paediatrics, Official Journal of the American Academy of Paediatrics. DOI: https://doi.org/10.1542/peds.2016-0050}
^{2. Early Breastmilk Exposure Modifies Brain Connectivity in Preterm Infants. Biesa M et al. ScienceDirect. DOI: https://doi.org/10.1016/j.neuroimage.2018.09.045}
^{3. Pump Early, Pump Often: A Continuous Quality Improvement Project. Spatz, D et al. The Journal of Perinatal Education Vol 24 Issue 3 DOI: 10.1891/1058-1243.24.3.160}
^{4. Breastfeeding your premature baby NHS website}
^{5. Optimal Positions for the Release of Primitive Neonatal Reflexes Stimulating Breastfeeding. Colson SD et al. Early Hum Dev. 2008 Jul;84(7):441-9. doi: 10.1016/j.earlhumdev.2007.12.003. Epub 2008 Feb 19.}
^{6. Prevalance and Risk Factors for Early Undesired Weaning Attributed to Lactation Dysfunction Stuebe AM et al. Women's Health. DOI: 10.1089/jwh.2013.4506}