Feeding your premature baby breast milk

It’s especially important for a premature baby to have breast milk, but breastfeeding directly can be challenging. Read our expert’s advice to help you give your preemie all the benefits of your milk

Feeding your premature baby breast milk
Medela expert Katsumi Mizuno
Professor Katsumi Mizuno, Department of Paediatrics, Showa University Koto Toyosu Hospital:
One of Japan’s leading neonatal paediatricians and a certified lactation consultant, Katsumi is also Professor of Paediatrics at Showa University of Medicine. His research interests include infant sucking, milk banking, and the use of breast milk to help premature babies in neonatal intensive care units.

If your baby is born before week 37 of your pregnancy, he’ll be classed as premature.1 We don’t always know what causes premature birth, but there are factors that increase the likelihood. These include a twin or multiple pregnancy, certain health conditions affecting the mom or foetus, or having had a premature baby previously.

Because premature babies have had less time in the womb, they have some extra growing to do, and may be more vulnerable to illnesses and infections. They may also need to spend time in a neonatal intensive care unit (NICU).

Why is breast milk so important for a premature baby?

Breast milk is important for the optimal growth and development of full-term infants, and it’s even more important for premature babies.

Important factors, such as DHA (a fatty acid vital for healthy brain and eye development) and immunoglobulin G (an antibody), are transported from mom to foetus via the placenta throughout pregnancy.2,3 Because they arrive early, premature babies have not fully received these important factors in the womb, but milk from moms of premature infants contains more fats and secretory immunoglobulin than milk from moms of full-term babies.4

Premature babies also have immature gastrointestinal tracts, which can cause difficulties with digestion and absorption of nutrients, so they need a food that’s easy for their delicate guts to process. Your breast milk contains enzymes that help your baby with digestion,5 as well as epidermal growth factor, which in turn helps his intestine mature.6 Premature babies fed mainly on breast milk have significantly lower intestinal permeability than those predominantly given formula, which means that fewer (potentially disease-causing) particles can pass through the lining of their intestines into their bloodstream.7

Breast milk is so important for preemies that if their own moms can’t, for whatever reason, provide them with enough milk at first, they may be fed donor milk from other breastfeeding moms to bridge the gap, rather than formula. 

Does breast milk give preemies better outcomes?

Your breast milk includes protective agents that can help prevent serious conditions your preemie is susceptible to,8 such as severe infections,9 retinopathy of prematurity (which can cause loss of vision)10, and bronchopulmonary dysplasia (a chronic lung disease).11

The more breast milk your baby has, the lower his risk of disease.12 Each additional 10 ml (0.3 fl oz) a day, per kg (2.2 lb) of a baby’s weight, reduces the risk of sepsis by 19%.9 And the risk of necrotising enterocolitis (NEC), a potentially fatal bowel condition, is also up to ten times lower in preemies who have breast milk compared to those who are formula-fed.13 So every drop counts!

Most importantly, premature infants fed with their mom’s milk tend to be discharged two weeks earlier on average than those who are formula-fed.14 They’re also almost 6% less likely to be readmitted to hospital in the first year.15

In the longer term, breast milk is also proven to improve mental and physical development – research shows that low-birthweight infants who were given breast milk in intensive care have as much as a five-IQ-point advantage over those who weren’t15 – as well as having better cardiac function in later life.17

Will I have milk if my baby is unexpectedly early?

Yes – moms are ready to produce breast milk in mid pregnancy. When the placenta is delivered after your baby’s birth, your levels of the pregnancy hormone progesterone drop, allowing your breasts to start producing colostrum, your early milk. Usually a mom’s milk supply will be triggered by her newborn baby latching on to her breast and suckling rhythmically, but if your baby comes early, he may not be able to breastfeed at first.

You can reproduce the sensations that trigger supply by stimulating your breasts and nipples with your hands, or by using a breast pump, which could help you collect that nutrient-rich colostrum to give to your baby18 – see below for more on what to do if your preemie can’t breastfeed yet.

A mother’s milk usually ‘comes in’ around two to four days after the birth but if you’ve delivered prematurely this can sometimes be delayed. However, a recent study showed that mothers who pumped within one hour of delivery had their milk come in at the expected time.19 That’s also why it’s important to start expressing breast milk as early as possible.

How can I prepare if I know my baby will be premature?

Visit the neonatal intensive care unit (NICU) to see what it looks like and how staff take care of premature babies. It’s also a good idea to find out how breast milk is produced and expressed, and understand its importance not only for nutrition, but also as a medicine for these babies – read more in Medela’s free ebook The Amazing Science of Mother’s Milk.

What if my preemie can’t feed from the breast?

Many babies born before 34 weeks struggle to coordinate their sucking, swallowing and breathing. Until your baby is ready, nurses will gently place a tube into his tummy through his nose or mouth to feed him. All your baby’s feeds can be given this way until he is ready to start feeding from your breast.

If your baby is too weak to stay latched on to your breast and feed, you can use your hospital or birth facility’s breast pump to ‘be the baby’. Stimulating your breasts with research-based initiation technology20 – which mimics the sucking patterns of human infants – in the first hours21 is important to help initiate and maintain your milk supply.

You’ll need to express milk as often as a healthy newborn would normally feed. This means pumping every two to three hours – in other words, a minimum of eight to 12 times over 24 hours.

Some moms may be able to administer small amounts of expressed breast milk into their baby’s mouth with a syringe. Or you can put cotton buds soaked with breast milk inside your baby’s mouth.22 This allows your baby to taste your milk – which can make it easier to move on to full breastfeeding – and coats his mouth with your milk’s immune-boosting, protective components. There are many ways to be involved, so ask your healthcare professionals what you can do for your baby. 

Very low birthweight babies, under about 1.5 kg (3 lb 5 oz), often need extra protein, calcium and phosphorous­, so a fortifier is given to them along with mother’s milk. In some countries, human-derived milk fortifiers are available, but here in Japan they’re derived from cow’s milk.

Do you have any tips for expressing milk?

If your baby is expected to stay in the NICU for a while, neonatologists recommend using a double breast pump to express milk for him – I always recommend the Medela Symphony. Double pumping doesn’t just enable you to express more quickly, it also delivers 18% more milk on average than pumping from one breast at a time.23

I also encourage moms to find the most comfortable situation they can for expressing. It’s widely recognised that the best time to pump is immediately after or during prolonged skin-to-skin contact with your baby (see below for more on this ‘kangaroo care’), or while you’re at his bedside and can look at him while you express. Oxytocin, the hormone that induces your let-down reflex, is released by watching, touching, smelling and thinking of your baby,24 so NICU staff should offer a comfortable place and relaxed atmosphere where you can do this.

What is kangaroo care for premature babies?

Kangaroo care is when parents keep their newborn skin-to-skin against their bare chests for extended periods, and it can have many incredible benefits for you, your baby and your milk supply. Skin-to-skin contact helps calm and regulate your baby’s breathing and heartbeat, as well as keeping him warm and letting him rest close to you or your partner. Kangaroo care is also associated with better health in premature babies.25 For moms, it is associated with higher volumes of expressed milk26 and a longer duration of breastfeeding.27 Making time for skin-to-skin at least 30 to 60 minutes before a feed gives your baby time to wake up and feel hungry, rather than rushing him.

What if NICU staff offer formula milk?

Don’t hesitate to let them know you want to give your baby breast milk, not formula. If your breast milk is not enough for your baby, ask NICU staff for more support to increase your milk production.

It is normal for all moms with babies in the NICU to feel worried or stressed. These feelings can sometimes affect milk production, so it’s really important to ask for as much help as you need. Remember, it’s your right to ask for support. Your healthcare professionals can introduce you to the right person to give you breastfeeding help, such as a lactation consultant.

What about milk banks for donor milk?

The American Academy of Pediatrics has stated that if own mother’s milk is unavailable, despite significant support with breastfeeding, pasteurised donor milk should be used.28 Certified milk banks have high standards for screening and testing potential donors, for pasteurisation, and for testing milk prior to being used in hospitals, to minimise the potential for transmitting infections.

How can I move from expressing to direct breastfeeding?

Whatever the gestational age of your baby, if he is stable enough to be held skin-to-skin then you may find he seeks your breast for some practice (non-nutritive) sucking. This is the perfect way for him to start learning how to breastfeed before he is ready to fully coordinate sucking, swallowing and breathing.

Babies love the smell of breast milk, so expressing some on to your nipple before putting your baby on the breast may help him find your nipple and make him want to suck. He may even be able to get a little milk when latching on. Don’t worry if he seems to be doing very little – he’s learning every time. Eventually he may start having one or two sucks and move to a full breastfeed. Until then, he can be fed milk through a tube while you hold him close to your breast, as this may help him to associate having a full tummy with your breast and milk.

Non-nutritive breastfeeding can begin as soon as you feel comfortable with kangaroo care as long as your baby does not have bradycardia (a slow heartbeat) or desaturation (low blood oxygen). Your baby can move to breastfeeds when he is capable. He’ll gradually build strength to sustain a longer latch and take more milk over time.

References

1 World Health Organization. Geneva, Switzerland; 2018. Media Centre: Preterm birth fact sheet; November 2017 [26.03.2018]. Available from: http://www.who.int/mediacentre/factsheets/fs363/en/

2 Duttaroy AK. Transport of fatty acids across the human placenta: a review. Prog Lipid Res. 2009;48(1):52-61.

3 Palmeira P et al. IgG placental transfer in healthy and pathological pregnancies. Clin Dev Immunol. 2012;2012: 985646.

4 Underwood MA. Human milk for the premature infant. Pediatr Clin North Am. 2013;60(1):189-207.

5 Pamblanco M et al. Bile salt‐stimulated lipase activity in human colostrum from mothers of infants of different gestational age and birthweight. Acta Paediatr. 1987;76(2):328-331.

6 Dvorak B. Milk epidermal growth factor and gut protection. J Pediatr. 2010;156(2):S31-35.

7 Taylor SN et al. Intestinal permeability in preterm infants by feeding type: mother's milk versus formula. Breastfeed Med. 2009;4(1):11-15.

8 Newburg DS. Innate immunity and human milk. J Nutr. 2005;135(5):1308-1312.

9 Patel AL et al. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatol. 2013;33(7):514-519.

10 Zhou J et al. Human milk feeding as a protective factor for retinopathy of prematurity: a meta-analysis. Pediatrics. 2015;136(6):e1576-1586.

11 Patel AL et al. Influence of own mother's milk on bronchopulmonary dysplasia and costs. Arch Dis Child Fetal Neonat Ed. 2017;102(3):F256-F261.

12 Meier PP et al. Improving the use of human milk during and after the NICU stay. Clin Perinatol. 2010;37(1):217-245.

13 Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990;336(8730-8731):1519-1523.

14 Schanler RJ et al. Randomized trial of donor human milk versus preterm formula as substitutes for mothers' own milk in the feeding of extremely premature infants. Pediatrics. 2005;116(2):400-406.

15 Vohr BR et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 2006;118(1):e115-123.

16 Victora CG et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-490.

17 Lewandowski AJ et al. Breast milk consumption in preterm neonates and cardiac shape in adulthood. Pediatrics. 2016;138(1):pii:e20160050.

18 Meier PP et al. Which breast pump for which mother: an evidence-based approach to individualizing breast pump technology. J Perinatol. 2016;36(7):493-499.

19 Parker LA et al. Effect of early breast milk expression on milk volume and timing of lactogenesis stage II among mothers of very low birth weight infants: a pilot study. J Perinatol. 2012;32(3):205-209.

20 Meier PP et al. Breast pump suction patterns that mimic the human infant during breastfeeding: greater milk output in less time spent pumping for breast pump-dependent mothers with premature infants. J Perinatol. 2012;32(2):103-110.

21 Parker LA et al. Association of timing of initiation of breastmilk expression on milk volume and timing of lactogenesis stage II among mothers of very low-birth-weight infants. Breastfeed Med. 2015;10(2):84-91.

22 Lee J et al. Oropharyngeal colostrum administration in extremely premature infants: an RCT. Pediatrics. 2015;135(2):e357-366.

23 Prime PK et al. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression. Breastfeed Med 2012; 7(6):442–447.

24 Uvnäs Moberg K, Prime DK. Oxytocin effects in mothers and infants during breastfeeding. Infant 2013; 9(6):201–206.

25 Boundy EO et al. Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics. 2015;137(1): e20152238.

26 Acuña-Muga J et al. Volume of milk obtained in relation to location and circumstances of expression in mothers of very low birth weight infants. J Hum Lact. 2014;30(1):41-46

27 Nyqvist KH et al. Towards universal kangaroo mother care: recommendations and report from the first European conference and seventh international workshop on kangaroo mother care. Acta Paediatr. 2010;99(6):820-826.

28 American Academy of Pediatrics - Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-841.