It can be stressful for new mamas (and dads) to navigate the series of events that happen when their new little one is born ahead of schedule. The good news is that with today’s advancements in modern medicine, the incredible resilience of newborns, and parents’ nurturing love, babies born prematurely can thrive and grow quickly!
Today, around 10% of births in the United States are preemie births. And while health outcomes can depend on how young babies are at birth, many preemies have no long-term health complications. The reason we are blogging on this topic is to help new parents understand some of the typical challenges involved in breastfeeding a preemie who decided to arrive early!
Preemie Primer
A premature baby, or a “preemie,” is a newborn baby that is born more than three weeks before their due date. Babies can arrive early for a variety of reasons, including mama risk factors such as maternal high blood pressure during pregnancy, pre-eclampsia, gestational diabetes, cervical incompetence, fetal growth restriction, and infections during pregnancy.
Some preemies, typically those who are younger than 35 weeks, are likely to be admitted to the neonatal intensive care unit (NICU) after birth. In general, however, newborns born at 35 to 36 weeks—may be able to stay in the newborn nursery as they recover.
Fun fact: most twins are delivered at or around 36 weeks.
Tips For Feeding a Premature Baby
Breast milk is the best milk, especially for preemies! Here are just a few reasons why:
- Breast milk is much easier for preemies to digest than infant formula.
- Breast milk helps prevent necrotizing enterocolitis (an inflammatory bowel condition that affects preemies).
- Breast milk is loaded with antibodies that bolster premature babies’ immune systems.
- Breast milk is associated with improved long-term developmental outcomes.
Most people who work with preemies consider breast milk liquid gold and encourage mothers to provide breast milk for as long as they are able. New mamas should know that preemies often cannot immediately begin breastfeeding, so that means moms get to do a lot of pumping in the beginning.
Moms of preemies often need to pump milk for several months to have the most success in establishing a full breast milk supply, and NICU mothers should start to pump as soon as possible after giving birth. Research shows a significant increase in milk supply at three weeks postpartum if mothers’ first pumping sessions are within one hour after delivery. Early pumping for a preemie can be done with either a breast pump or hand expression.
We often hear that NICU mothers are worried about not being able to pump enough milk to feed their babies. While these fears are completely understandable, remember that premature babies require much less milk than full-term babies! The average early feedings for preterm infants are 1-5 ml per feed (5 ml = 1 teaspoon) compared to 30-60ml per feed for a full-term newborn. Your baby is likely getting plenty of milk!
Pumping Frequency
We recommend NICU moms 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 needed for mature breast milk production. Early hand expression, skin-to-skin contact or “kangaroo care,” and hospital-grade electric pumps are also used to help mothers establish milk supplies for their preemies.
It’s common for NICU moms to experience a dip in 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 and long enough during each session.
More Tips!
- Pump at your baby’s bedside in the NICU. Being able to see your baby (or hold them, if possible, for skin-to-skin contact!) while you are pumping will release hormones that help you make more milk! If you are separated from your baby, try looking at photos or watching a video of them as you pump.
- Invest in pumping accessories. Some of these tools can make your life so much easier. Try a hands-free pumping bra or a portable pump for when you are on the go.
- Ask for help. Let hospital staff (including your lactation consultant) know if you encounter any problems or need assistance with expressing milk or pumping right away.
- Create a community. Consider participating in a peer-to-peer NICU breastfeeding support group or finding other support communities, if available.
About Late Premature Babies
Late premature babies, also called “late preemies,” are born between 34 to 36 weeks. 70% of babies who are born prematurely are late preemies.
Some late preterm infants need to spend time in the neonatal intensive care unit (NICU) before leaving the hospital, especially if they are at higher risk of health problems. Although babies born between 34 to 36 weeks of pregnancy often look like full-term babies, just a bit smaller, it’s important to note that there are major physiologic differences—for example, the brains of late preterm infants are only 2/3 of the size of those of full-term infants. As a result of immature brain and nervous system development, late preemies have an increased risk of low birth weight, feeding difficulties, and breathing struggles.
Other challenges that late preemies may experience include:
- Pauses in breathing (apnea)
- Abnormal heart rate drops (bradycardia)
- Respiratory distress (due to premature lungs)
- Temperature instability
- Jaundice
- Infections
- Low blood sugar levels
- Excessive weight loss
- Slow weight gain
FAQs About Breastfeeding Late Premature Infants
Can I keep breastfeeding if I develop mastitis?
Healthy late preterm babies can continue to breastfeed while their mothers have mastitis (inflammation in the breast, often due to a clogged milk duct). If there is any concern that your newborn might have a compromised immune system, check with a breastfeeding specialist and health care provider before breastfeeding with mastitis.
Do I need to add a special human milk fortifier powder to my pumped milk?
Most late preemies who are breastfeeding do not need human milk fortifier supplements. But if your baby was born small for their gestational age, has had problems gaining weight, and has low levels of minerals needed for bone growth—such as calcium and phosphorus—they may need temporary fortification. The decision as to when to start or stop fortification of breast milk should ideally be made in consultation with your baby’s pediatrician and a pediatric nutritionist.
Breastfeeding Former Preemies and NICU Graduates
NICU graduates often grow and thrive on their mom’s breast milk without any fortification. However, preemie NICU graduates sometimes need extra nutrients and calories added to their mom’s breast milk to help them grow, develop, and make strong bones. The two main options for fortifying breast milk for premature babies are human milk fortifiers (HMFs) and transitional infant formulas.
Fortification of Breast Milk for NICU Graduates
Human milk fortifiers come in both powder or liquid form and contain extra protein, calories, and nutrients. They are added to bottles of pumped breast milk to enhance the benefits for your baby. The frequency and duration of breast milk fortification depends on a baby’s birth weight, 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 to 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 they should be avoided in little ones with allergies or intolerances to cow’s milk protein. There are HMFs on the market that are made with donor human milk, but they are only cleared for in-hospital use.
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 or nutritionist. The duration of post-NICU discharge breast milk fortification is a moving target. In most cases, breast milk no longer needs fortification by the time a NICU graduate is three months past their due date.
Helpful Tips for Breastfeeding Former Preemies and NICU Graduates
- Get help from lactation consultants. Breastfeeding specialists are experienced in helping moms of preemies and NICU graduates. Ask your NICU’s lactation specialists and health care professionals if they have any suggestions or resources for post-discharge breastfeeding assistance.
- Don’t forget to pump. Emptying your breasts regularly will ensure you 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.
- Be patient! Transitioning from bottle or tube feeding to direct breastfeeding can be a slow process. We typically recommend starting the transition slowly. So, if your baby is directly breastfeeding twice per day and receiving six bottle feeds per day, we typically recommend adding one direct breastfeeding session per day every week.
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 mom. Please be kind to yourself and remember that you are doing everything your baby needs. You are doing great, mama!
Postpartum Depression in NICU Mothers: What to Know
Mothers of premature babies are at a higher risk of postpartum depression (PPD) compared to those of full-term babies. According to recent studies, up to 70% of NICU mothers develop some degree of 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: 10 pm Pump | 2:30 am Pump | 7 am Pump
- Once Milk Supply is Fully Established: 11:30 pm Pump | Sleep | 5:30 am 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. This is normal and very common!
This said, it is important to remember the incredible benefits of providing at least partial breast milk to your preemie. Any breast milk is better than no breast milk!
If you’re looking to supplement breast milk, you have a few options. In most NICUs, donor breast milk is available at hospital milk banks. There are also many special formulas designed specifically for premature babies that can be used to supplement breastfeeding.
Don’t fret if you find you need to supplement. Many mamas supplement their breast milk to ensure that their babies are well-fed and ready to grow.
If you are a NICU mother who is pumping for a preemie, take care of yourself. If you have family nearby, supportive friends, or another support system, ask for help. This way, you’ll be able to focus your time and energy on making and pumping breast milk to nourish and feed your baby.
And of course, we hope you always know that our team of lactation consultants at Aeroflow Breastpumps is happy to help you on your breastfeeding and pumping journey.
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.
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