A baby is a “preemie” if he or she is born more than three weeks before their due date. Some older and “healthier” premature babies, such as those born between 35-36 weeks, may be able to stay in the newborn nursery, but most who are younger than 35 weeks need to be admitted to the neonatal intensive care unit (NICU) after birth. This is because preemies have difficulty maintaining their body temperatures and staying warm, often have problems with their lungs and breathing, are prone to hypoglycemia (drops in their blood sugar levels), and encounter challenges with feeding. Prematurity-related newborn feeding problems are a result of not yet having the brain maturity and motor skills to suck, swallow, and breathe at the same time. I often tell parents that expecting a baby who is born 3 months early to be able to take a full breast or bottle feed is like expecting someone to run a marathon who has never run more than a mile or two in their entire life!
Most NICU patients receive at least some of their nutrition via special feeding tubes called nasogastric (NG) tubes. The transition from partial or total NG tube feedings to bottle feeding and/or breastfeeding can take several weeks to months. For the smallest and sickest preterm babies in the NICU, this attainment of “full” oral feedings may not occur until after the actual due date has passed. Moms of preemies often need to pump milk for several months, so for mothers of premature infants, breastfeeding includes a lot of pumping.
The Importance of Breast Milk for Premature Babies
It is extremely important for premature babies to receive their mothers’ own breast milk. Breast milk is much easier to digest than infant formula, prevents necrotizing enterocolitis (a potentially deadly infection of preemies’ bowels), is loaded with antibodies and other components that bolster babies’ immune systems, and is associated with improved long-term developmental outcomes. Those of us who work with preemies in the healthcare setting consider breast milk to be “liquid gold” and we encourage our patients’ mothers to pump and provide breast milk for as long as they are able.
To have the most success in establishing a full breast milk supply, NICU mothers should start to pump as soon as possible after giving birth. Premature babies benefit from an immune and digestive standpoint if they receive at least one feeding with their mother’s breast milk during the first 24 hours of life. Research has shown a significant increase in milk supply at two weeks postpartum if mothers’ first pumping sessions are within 4-6 hours after delivery. It’s common for NICU mothers to worry that they will not be able to pump enough milk to feed their babies, but premature babies’ early feedings are very small compared to those of full-term babies. The average early feedings for preterm infants are 1-5 ml per feed (5 ml = 1 teaspoon).
It’s recommended for NICU moms to pump 8-10 times per day (every 2-3 hours) for the first few weeks after delivery. Although these early pumping sessions may not yield much, or any, colostrum, or milk, they are very important for stimulating the release of hormones that are needed for mature breast milk production. It is also essential that electric hospital-grade breast pumps, like the Medela Symphony, are used in the postpartum period as mothers establish milk supplies for their preemies. Early hand expression and the “skin-to-skin” care of mothers and newborns, termed “kangaroo care,” can also help preemie moms make more milk.
“Kangaroo care” is an excellent way to help NICU mothers produce breast milk for their babies. Even the smallest and most fragile premature babies can “kangaroo” if their mothers have enough help and support. Additional benefits of kangaroo care include stabilization of breathing, mother-infant bonding, a lower risk of maternal development of postpartum depression, maintenance of babies’ body temperatures, and improved developmental outcomes.
Many NICU moms experience a dip in their breast milk supply around 2-3 weeks postpartum. This is a critical time to check in with a lactation consultant to make sure you have the correct technique while pumping, that your flanges are fitting correctly, that you aren’t experiencing pain while pumping, and/or that you are pumping frequently enough and for a long enough duration each time. I recommend that all moms who are pumping for preemies check in with a lactation consultant at least 1-2 times per week during the first month after delivery.
Tips for Moms of Preemies to Establish and Maintain Breast Milk Supply
- Be sure to use a hospital-grade electric pump for the first few weeks as you build up your breast milk supply. It’s important to be certain that your pump flanges are the correct size, as using ones that are too small or too large can impact the amount of milk that you pump.
- Participate in “kangaroo care” with your baby in the NICU as early and often as possible.
- Pump at your baby’s bedside in the NICU – being able to see your baby while you are pumping will help you make more milk.
- If you are separated from your baby, look at photos of your baby or watch a video of your baby as you pump.
- Invest in pumping accessories that can make your life easier, like a hands-free pumping bra and/or portable battery-powered pump for when you are on the go.
- Be sure to let your babies’ nurses and NICU lactation consultants know if you encounter any problems or need assistance with expressing milk or pumping right away.
- Consider participating in a peer-to-peer NICU breastfeeding support group, if available.
It’s important to check with your baby’s doctor to make sure that all medications and supplements you are taking are compatible with breastfeeding a premature baby. Galactagogues are supplements that are taken to increase breastmilk production. Galactagogues, including fenugreek, are generally safe for mothers of preemies to take but should only be used if necessary. Other medications, such as antihistamines, can decrease milk supply and should be used with caution. Alcohol consumption should be limited and it’s best to wait to pump or breastfeed until 2-3 hours after each alcoholic beverage is consumed. Marijuana should always be avoided when pumping and breastfeeding premature babies. This is because THC, one of the main components of marijuana, passes directly into breast milk and may have negative effects on the brain development of premature babies. NICU health care professionals also recommend that mothers refrain from all forms of smoking and vaping while pumping and breastfeeding.
Postpartum Depression in NICU Mothers
Mothers of premature babies are at high risk of postpartum depression (PPD) compared to those of full-term babies. According to recent studies, up to 40% of NICU mothers develop PPD. Symptoms of PPD can be exacerbated by sleep deprivation, including the loss of sleep that may occur when mothers pump “around-the-clock” for their babies. Once a mom’s breast milk supply is fully established, she may benefit from being able to sleep for a longer stretch at night without having to pump. Examples of night-time pumping routines for mothers who are being treated for PPD, or at a high risk of PPD, include the following:
- While Establishing Milk Supply: 10pm Pump | 2:30am Pump | 7am Pump
- Once Milk Supply is Fully Established: 11:30pm Pump | Sleep | 5:30am Pump
Many breastfeeding mothers are not able to pump enough breast milk to exclusively feed their preemies for the duration of their entire NICU hospitalization. It’s important for moms of preemies to know that there are huge benefits to providing partial breast milk and that any breast milk is better than no breast milk. In most NICUs donor breast milk is readily available as a supplement to mothers’ breast milk. There are also special formulas designed for premature babies that can be used to supplement breastfeeding.
Pumping is hard work and is truly the equivalent of a full-time job! If you are a NICU mother who is pumping for a preemie, it’s essential that you take care of yourself and surround yourself with others who can help and support you. This way you’ll be able to focus your time and energy on making and pumping breast milk, or “liquid gold,” to nourish and feed your baby.
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.
