When a baby or babies have arrived early, it is common to feel stressed and helpless. One of the few things lactating parents can do is to provide colostrum and milk for their babies. Preterm human milk is different to that of a 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 parents are usually supported to hand express colostrum within the first 6 hours after birth, and then move onto the pump to provide breast milk for tube feeds. The hospital should be able to advise on renting a hospital grade double pump to be used when the parent is discharged home. It is important to pump frequently; we recommend 8-12 times in 24 hours making sure at least one is between 2-5am when hormone levels are at their highest. A more detailed blog on establishing milk supply is available here.
But what next? How do we go about actually breastfeeding? Is it possible to move to exclusively breastfeeding when you have had such a traumatic entrance to the world? The answer is yes, but it will take time.
Once premature babies hit 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. Hopefully you will have already been given the chance to have lots of kangaroo care with your babies before now, but at this point it can really help transition the baby from tube feeds onto breastfeeding.
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 lick the nipple and if they are ready to 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. But at this early stage the majority of any feed will still be expressed milk through the feeding tube. The staff will encourage you to try each baby at the breast once or twice a day so as not to tire them out too much. Once they become stronger and start to suck and swallow more effectively its a good time to move to more frequent feeds. It can be a good plan to try baby at the breast during their tube feed as they will begin to associate the act of breastfeeding with the feeling of having a nice full tummy. A nipple shield can help the smaller baby to latch onto the breast, especially if they have been given bottles. There is evidence that suggests shields can increase milk intake in preterm infants in the early days, so this can be worth considering, especially if you are struggling with pumping. Remember ask for lots of support from the hospital staff during this time. This is actually one of the benefits of having babies in special care.
When the babies appear to be feeding better and getting much more milk we can move on to the next stage. This can be at different ages for different babies. For some it can be around the 36-37 week gestation mark, others need to get to near full term. The hospital staff will help give confidence that it is time to move to the next stage. 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 for many babies its advisable to continue to top up with expressed for a little while. A lot of parents choose to top up by a different method than tube so the babies can get home, although some hospitals will discharge a baby still tube feeding. Hospital staff may use a tool like the Breastfeeding Assessment Score below to calculate how much top up to give baby. They will calculate to work out exactly how much milk depending on baby’s weight, gestation, growth about how much a full feed is.
For twins and triplets it is important to remember that they are individuals. One baby may be much better at feeding than the other. It can be hard not to compare and be worried and frustrated if one baby is not managing to feed as well. But, with time, it is very likely that they will catch up and both will feed well from the breast when ready.
Generally hospitals prefer to use bottles to feed babies their top ups, or during the night when the parent is not there. They are easier, there’s less waste and staff are pushed for time so go for the easier option. So to minimise the impact on breastfeeding of using a bottle, it is important to use a paced bottle feeding technique. Paced bottle feeding means letting the baby take control of the speed of the feed and when to take breaks and when to finish. Sit baby in an upright position and keep the bottle as horizontal as possible whilst still filling the teat with milk to avoid intake of air. Baby should be encouraged to latch on to 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, they do not swallow air if teat is totally empty. Stop frequently and make sure you do not force baby to have a certain amount. With this slower feeding technique, the baby will be able to tell it is full and finish the feed when satisfied. And baby will be more able to transfer between bottle and the slower flow of the breast.
The chance to ‘room in’ for a night or two before you are discharged home will hopefully be available. During this time it’s often encouraged to move on to responsive feeding as opposed to hospital routine based feeding. But babies can still be sleepy and not wake for feeds at this stage so its 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 preemie parents, their first experience of being at home with their early baby is to be in an intense breastfeed, 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. However with good feeding support from health visitors and breastfeeding specialists and the discharge team from NICU, exclusive breastfeeding is generally eventually possible. 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.
Whilst the baby still needs top ups it is imperative that there should be somebody to look after the breastfeeding parent. 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. Breastfeeding makes you hungry and it’s important for energy levels that you eat properly, so having someone to feed you whilst you feed the babies 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 that soon it will become much 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 risk of infections. This is where home visits from well informed health care professionals and good online support can step in. Online support especially can be great, as long as it is properly moderated, as parents can make contact with others who have been in the same position or are going through it at the same time. Peer to peer support is incredibly important. There is also often somebody around at 3am during the night feeds to sympathise!
So how do we know when a baby is feeding well enough to fully? Their suck becomes more coordinated and they can remove more milk from the breast. You can watch for the full term feeding pattern of sucking fast for a minute to stimulate the let down, and then move on to deep slower jaw movements with pauses in between. You may be able to hear swallowing. Breast compressions can help to get a bit more milk into the baby if they are still seeming a little inefficent or sleepy at the breast. They often have a big feeding frenzy at around 40week 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 it is completely normal behaviour and will help baby get lots of milk helps understanding. However it does not necessarily translate in to weight gain immediately. It can be very discouraging when baby has been feeding all night and only put on a small amount the next day. However you often find a day or two later and it pays off.
It is a good plan to get some support with tandem feeding. Tandem feeding maximizes the time spent feeding as there’s less waiting time for babies and it is a more efficient use of time. It helps synchronize the babies’ feeding times and more importantly sleeping times! A strong feeder can help a weak feeder by stimulating the let down and getting the milk flowing. It also increases milk supply and the milk has a higher fat content.
Dropping or reducing the top ups gradually can make it a bit less stressful. For more detailed info in reducing top ups see our other blog here
But here’s an overview: Parents can reduce the volume of top ups and put babies back on to the breast if not settled. Babies are often more settled during certain times of day or night and these can be the first feeds to just breastfeed. Encourage the babies to have a second or third go on the breast if they do not settle after the first feed. Twins or triplets can be put back on the same breast, they will trigger another let down of milk. Nappy output and weight gain should be kept a close eye on during this process.
Sometimes when babies move on to more direct breastfeeding, their weight gain can flatten off a little bit. This can be really discouraging but it can take a bit more energy to fully breastfeed and they can tire themselves out and burn more calories. As long as they are still gaining this is usually ok and they will set off following their curve again given a bit of time. This may be a good time to get some reassurance from a breastfeeding specialist.
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.
Kathryn Stagg ABM BFC, Updated May 2021
Breastfeeding and Human Lactation, enhanced 5th edition, Wambach & Riordan, 2016
The Breastfeeding Atlas, 6th edition, Wilson-Clay and Hoover, 2017