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Beyond the NICU: Your breastfeeding preemie is home, now what?

Updated: Jan 31, 2020

How Common is Prematurity?

Shockingly, ten percent of babies born in the US are born prematurely—before 37 weeks’ gestation. That’s one out of every ten babies born! If your baby is born early, you and your baby may face some extra obstacles to make breastfeeding feel like it’s working well. Whether your baby is born just a tad early (like at 36 weeks), or very early (like 32 weeks or earlier), it’s important to find the support you need and breastfeed as long as you can because stopping breastfeeding too soon could lead to more health problems both in the short-term and long-term. Your baby needs your milk!

Breastfeeding help is usually available in the hospital, but once discharged home, you might need to seek additional guidance from a lactation consultant (IBCLC) and supportive pediatrician who will work with you to understand your baby’s specific needs. Each preemie is unique and will probably eat and act differently than a full term baby. Most general breastfeeding books teach breastfeeding with a healthy full term baby, but not as many prepare you for breastfeeding an early baby. Your experience with a preemie may be different than you planned or prepared for.

Don’t babies just naturally want to breastfeed?

Yes, they do! But, when babies are born early, they may not be physically ready to breastfeed. They may not be able to wake up to, or recognize their hunger cues. They may not be able to stay awake long enough to finish a meal. They may not have a strong enough or coordinated suck. They may need extra time to learn how to coordinate sucking, swallowing and breathing. They may be sick and need to heal from an infection before tackling basics of living outside the womb like breathing on their own, let alone eating.

Preemie mother-baby breastfeeding pairs say the biggest hurdles they usually face include getting the baby to latch and/or suck, the seemingly never-ending commitment to pumping, concern about not making enough milk or that the milk is not “rich” enough for baby. Just getting your preemie baby to latch can be one of the most difficult first steps in establishing breastfeeding. The physical and emotional demands on you and your premature baby are real and significant. Preterm babies are typically less alert, have less stamina and struggle more with latching/sucking/swallowing than full term babies, even though they have oral reflexes that make it look like they can eat well. Your preemie is a master of the Poker Face, meaning he may look like he is eating when he breastfeeds, but may not actually transfer enough milk while sucking to gain weight and grow well.

And these struggles don’t resolve magically just because your baby gets to graduate from the nursery and go home. It’s even possible that you may bring your baby home before you have a full milk supply or before your baby has transitioned off needing extra bottle feedings. Typically, the earlier a baby is born, the longer it will take for him to establish full breastfeeding, possibly even weeks beyond your baby’s original due date. It might take a while to learn how to interpret your preterm’s cues and behaviors and to have confidence in your skills, but the good news is that you can learn these things and you can make wonderful milk for your baby.

The (Super) Power of Your Milk

Through this transitional time, your milk is incredibly important for your baby! Mother’s milk supplies all the nutrition a baby needs but it is much more than that. Human milk is also like medicine that has a profound impact on your baby’s health, growth and survival. Human milk provides protection against infection, but premature milk components are highly specific for your baby. This means your milk has special ingredients that match the specific gestational age at which your baby is born, and changes based on what your baby needs each week as he grows!

All human milk has these awesome ingredients, but preterm milk has a higher concentration of protein, fat, amino acids, sodium and complex molecules (like oligosaccharides, cytokines, growth factors and lactoferrin) and lasts longer as premature milk before changing into more mature milk. These components are nothing short of being a super power for your baby—and don’t forget, you are a superhero for giving this milk to your baby! These breastmilk is more easily absorbed so your baby can utilize all of your milk to:

  • protect him from infections now and in the future

  • improve his growth and development, like eyesight and gut (GI) maturation

  • mature the nervous system and the brain, which helps with better sucking, temperature regulation and weight gain

But, the power of these protective factors is dependent on 3 things:

  • Giving as much of your milk as possible to your baby

  • Getting your milk to your baby as soon as possible after birth

  • Giving your milk to your baby for as long as possible.

“If you build it, they will come…”

This is a famous quote from the movie, “Field of Dreams” (one of my favorite movies!) that encourages an Iowa farmer, Ray, to build a baseball field in the middle of his farm that mysteriously draws people to watch old-time baseball legends play ball, gives them peace, and saves his farm from foreclosure. One of my colleagues translated this concept to the power of breastfeeding and always says, “If you’ve got milk, you’ve got options!”

There are lots of things you can do to support the process of your baby learning to breastfeed. Some of these steps may seem obvious and practical, and some may seem like they are fairly passive. These concepts are not a specific “how-to” and this list is not all-inclusive, but these bits of information can get your started and together, create a wholistic environment for you to make milk and for your baby to thrive. Implementing these steps with the guidance of a lactation consultant is important.

What Moms Can Do:

  • If you know you will be delivering early, you may have time to prepare. In this case:

  1. Plan to establish a full milk supply by hand expressing and/or pumping your breasts using a high quality double electric breast pump (sometimes called “hospital grade”) and you may need to plan on renting one for use at home. Learn how to hand express your milk-you often can express more colostrum (the first milk) by hand in the first 1-2 days than with the pump.

  2. Your milk supply is dependent on frequent and effective milk expression from the time your baby is delivered. Plan to express about 8 or more times per day, and if you can, start expressing within 1 hour of birth. Creating a milk supply and keeping it going becomes a full time job for you. You can do it!

  • Sometimes you don’t have any warning about delivering prematurely, or experience an illness or condition that requires baby to be born early. The stress and worry about this event can be overwhelming but you can get help from family and nurses in the hospital to pump or express your milk as soon as you are able.

  • Ask doctors and nurses to repeat information as much as you need to understand it. Written information may be more helpful. Invite your partner or other family member to be present when health care staff are giving your instructions because a second pair of ears is important to help remember all the information.

  • This will likely be one of the most physically and emotionally demanding events you have ever gone through.

  • Acknowledge common experiences of fatigue and overwhelm. Focus on what you can do at any given moment, prioritizing your health, your baby’s health. Work with an IBCLC to help develop a balanced plan that honors your ability with your desired breastfeeding outcome. Build a team of supporters to give you a boost when you need it. It may be friends, online groups, in-person groups, healthcare providers, family.

  1. Ask for help doing basic things at home like meal preparation, laundry, rides to doctor appointments. It’s ok!

  • If you are struggling to make as much milk as you want, talk with your IBCLC and your OB about possible herbal, homeopathic supplements or prescription medications that may increase your supply (called “galactagogues”).

  • Learn to identify how your baby cues when he is hungry—preemies have a much shorter window of time from when they recognize when they’re hungry to when they wear out and fall asleep again. Preemies get overwhelmed easily too—your baby may fall asleep quickly, turn his head way or stop eating mid-feeding.

  • Periodically evaluate your vision and definition of breastfeeding success. Things may go differently than you originally planned and if baby does not develop the ability to breastfeed directly, there are other ways to provide breastmilk successfully. What does “successful” breastfeeding mean to you?

What is Important for Baby:

  • Hold your baby skin-to-skin (STS) as much as possible. Partners can do this too! Even after your baby comes home, continued STS time together creates beautiful bonding and continued health benefits for your baby. STS is essential for brain maturation and your milk production.

  • Understand your baby’s condition and expectations for his ability to eat and breastfeed. Common preterm conditions that impact breastfeeding are:

  1. Needing extra time to coordinate how to suck/swallow/breathe

  2. Weak suck: baby may not be able to suck hard enough to transfer milk from the breast

  3. Baby may need extra body support to help keep the nipple in his mouth, may not respond well to oral stimulation/having a nipple in the mouth and need help recognizing what to do with the nipple. Nurses and an IBCLC can show you what is helpful for your baby.

  4. Limited energy: your baby may fall asleep before finishing a meal or not wake up when he is hungry. Your breastfeeding experience may include feeding your baby with a tube, a spoon, or a bottle to ensure he gets enough calories to grow. Your baby may need to be fed at scheduled times for a while, and then wean off the schedule to feeding just on-cue.

  • Get as much colostrum and breastmilk to your baby as possible, as early as possible. Ask about different ways your baby can take your milk if he is not sucking well.

  • Sometimes a premature baby needs additional calories and nutrients to support his premature body differently than a full term baby would. This may mean fortifying your breastmilk with a special type of formula. It’s important you understand why your pediatrician would prescribe this for your baby, so ask as many questions as you need.

  • Schedule a lactation consultation 2-3 days after you arrive home with your baby. An in-home consultation can be super helpful so you don’t have to pack baby up, drive to an office and hope that feeding time will coincide with your baby’s hunger. Regular weekly or bi-weekly visits can monitor your baby’s progress with effective latching/sucking/swallowing. Test weights can help reinforce your confidence that all your hard work is paying off. These visits can help you determine how breastfeeding is going, if you need any special tools, the need for a nipple shield, when to wean off supplementing and when to wean off all the extra pumping. These visits can provide feedback to your pediatrician to work together as a team for your baby.

You Can Do It!

Successful breastfeeding with a preemie is do-able when you have the support you need. Ongoing lactation support once you bring your preemie home ensures that your baby is getting the proper nourishment and your milk supply is well-developed and protected. Breastfeeding a preemie will take some time and progressive strategies can help guide you in understanding and anticipating your baby’s needs, identifying problems early, and managing changing breastfeeding issues quickly.

Your baby thanks your for all your hard work and dedication to giving him breastmilk. You are a Super Star!

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