Many babies who go to the neonatal intensive care unit (NICU) after birth are born prematurely (before 37 weeks’ gestation), but NICUs also admit full-term babies. Common reasons for NICU admissions after birth include infections, birth defects, heart problems, premature lungs, seizures, metabolic disorders, low blood sugar, surgical problems, having too much fluid in the lungs, and jaundice.
Breastfeeding Former Preemies and NICU Graduates
Breastfeeding in the NICU can be challenging. As we’ve discussed in a previous blog post, most NICU moms who opt to breastfeed need to pump to establish and maintain a full breast milk supply and milk production. If a mom is separated from her baby, we recommend that she start to express milk (pump) and colostrum in the first 30-60 minutes after giving birth, if possible. Colostrum is early breast milk that is chock full of antibodies, nutrients, and other important proteins, calciums, and components that strengthen the immune & digestive systems of newborns. This is why early feeding is vital.
There are times when breastfeeding mothers are not able to pump. In these cases, NICUs supplement babies with donor breast milk from a source or milk bank if their mothers cannot breastfeed or make enough milk during their baby’s NICU stay. It is most important for baby’s health as NICU infants who receive their mothers’ milk have been found to have lower risks of infections, improved digestion, shorter hospital stays, and less long-term problems with their lungs and breathing.
Some mothers pump for days to weeks, while those with the smallest and most fragile babies in the NICU often need to pump for several months. Newborns who are born with lung, heart, and/or brain and nervous systems problems usually cannot coordinate their “suck-swallow-breathe” reflexes to be able to safely feed. In addition, most preemies born before 34 weeks’ gestation do not have the strength and endurance to be able to feed at the breasts without tiring out. This is why it’s crucial to use a high quality electric pump to produce the amount of milk the baby needs. Speak to your NICU lactation specialist about the best breast pump for you so you do not waste one drop of your liquid gold!
Supplemental Feedings in the NICU
NICU patients receive supplemental feeds of their mothers’ milk through either a bottle or a small plastic tube. Feeding tubes can go into the nostril and down the esophagus into the stomach (nasogastric tube) or into the mouth and down the esophagus to the stomach (orogastric tube). Some infants are discharged home from the NICU with gastrostomy tubes (g-tubes). Infants who are fed with g-tubes get their feedings directly into their stomach, bypassing the mouth, throat, and esophagus. At the time of NICU discharge, most breastfeeding preemies’ diets consist of direct breastfeeds along with supplemental feeds of milk or formula via a bottle or feeding tube (or both).
According to neonatal experts, the average premature infant will be able to take all of their feeds at the breast, without needing bottle or tube supplements, somewhere between 42-44 weeks corrected age (or 2-4 weeks past their due date).
Fortification of Breast Milk for NICU Graduates
NICU “graduates” who are full-term infants often grow and thrive on their mom’s breast milk without any fortification. However, preemie NICU graduates often need to have extra nutrients and calories added to their moms’ expressed breast milk to help them grow, develop, and have strong bones. The two main options for fortifying breast milk for premature babies are human milk fortifiers (HMFs) and transitional infant formulas.
Human milk fortifiers (HMFs) come in both powder or liquid form, contain extra protein, calories, and nutrients, and are added to bottles of pumped breast milk. The frequency and duration of breast milk fortification depends on babies’ birth weights, how early they were born, their growth patterns in the NICU, and bone strength. It’s important to monitor low birth weight infants to make sure they are getting enough breast milk. Some NICU graduates only need to be fed 1-2 bottles of breast milk with added HMF per day, while others need to have almost every milk feed fortified once home.
Of note, HMFs are made from cow’s milk protein, so need to be avoided in cases of known cow’s milk protein allergies and intolerances. There are HMFs on the market which are made with donor human milk, but they are very expensive and currently for in-hospital use only.
The other option for fortifying breast milk is to give babies a few bottles of a transitional infant formula every day. Transitional formulas are special formulas for preemies that contain extra protein, calories, calcium, and other nutrients for bone growth. The two transitional formulas in the U.S. market are Neosure (Similac) and Enfacare (Enfamil).
If a baby is sent home from the NICU with fortification, whether it be with HMF or formula, it’s important to have their weight gain and growth closely followed by both their pediatrician and a pediatric dietician/nutritionist. The duration of post-NICU discharge breast milk fortification is a moving target. In most cases, breast milk should no longer need to be fortified by the time a NICU graduate is 52 weeks corrected age, or 3 months past their due date.
Helpful Tips for Breastfeeding Former Preemies and NICU Graduates
- Get help from lactation consultants and breastfeeding specialists who are experienced in helping moms of preemies and NICU graduates. Ask your NICU’s lactation specialists and health care consultants if they have any suggestions for resources for post-discharge assistance with breastfeeding.
- Don’t forget to pump every time that your baby gets a bottle or tube feed! Emptying your breasts on a regular basis will ensure you to continue to have a full milk supply. Early breast milk expression can be accomplished by hand expression, using a manual pump, or a double-electric breast pump.
- Make sure to continue to do “kangaroo care,” or skin-to-skin care, once you come home from the NICU. This will help your baby to feel calm and content near your breast(s) and will also help to boost the levels of hormones that your body needs to make breast milk. We recommend spending time bonding with your baby with as much skin-to-skin contact as possible. Even very small and sick babies or preterm babies should be able to have short kangaroo sessions in the NICU with their moms.
- Be patient! It can be a slow process to transition from bottle or tube feeding to direct breastfeeding. I typically recommend starting the transition slowly. So, if a baby is directly breastfeeding twice per day and receiving six bottle feeds per day, I typically recommend adding one direct breastfeeding session per day every week. In this example, it will take a baby about six weeks to transition from being mostly bottle fed to exclusively feeding at the breast.
- There will be good days and bad days, as well as good baby feedings and not-so-good feedings. Ask for help from your NICU lactation consultants, nurses, pediatrics, and other healthcare providers and support groups. It is important to have breastfeeding support on your journey. Like so many other aspects of parenting, breastfeeding a NICU graduate is a marathon, not a sprint!
No matter how your NICU graduate gets your breast milk, whether it be directly from your breast, in a bottle, and/or through a feeding tube, you are a breastfeeding mama and your baby is breastfed. Please don’t ever forget that you are an incredible breastfeeding mama!
About the Author
Jessica Madden, MD, is the Medical Director at Aeroflow Breastpumps. Dr. Madden has been a board-certified pediatrician and neonatologist for over 15 years. She's currently on staff in the neonatal intensive care unit (NICU) at Rainbow Babies and Children’s Hospital in Cleveland, OH. She previously worked in the Boston and Cleveland Clinic Children’s Hospitals. In 2018 she started Primrose Newborn Care to provide in-home newborn medicine and lactation support. She also enjoys traveling, yoga, reading, and spending time with her children.
Information provided in blogs should not be used as a substitute for medical care or consultation.
References
- Encyclopedia, M. and infants, F., 2022. Feeding tube - infants: MedlinePlus Medical Encyclopedia. [online] Medlineplus.gov. Available at: https://medlineplus.gov/ency/article/007235.htm [Accessed 13 September 2022].
- HealthyChildren.org. 2022. Corrected Age For Preemies. [online] Available at: https://www.healthychildren.org/English/ages-stages/baby/preemie/Pages/Corrected-Age-For-Preemies.aspx [Accessed 13 September 2022].
- Hospital, U., 2022. An Introduction to Your Child's Gastrostomy Tube | Patient and Family Education | UC Davis Children. [online] Health.ucdavis.edu. Available at: https://health.ucdavis.edu/children/patients_family_resources/Patient_and_Family_Education_A_to_Z/Introduction-to-Gastrostomy-Tube.html [Accessed 13 September 2022].
- Medela. 2022. How to Hand Express Your Breast Milk When Needed. [online] Available at: https://www.medela.us/breastfeeding/articles/how-to-hand-express-your-breast-milk-when-needed [Accessed 7 September 2022].
- Noble LM, Okogbule-Wonodi AC, Young MA. ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018. Breastfeed Med. 2018 May;13(4):230-236.
- Taylor, S, Martin, C. Evidence-based Discharge Nutrition to Optimize Preterm Infant Outcomes. NeoReviews. 2022. 23: e108-e116.
