The decision to breastfeed a preterm baby is not always an easy one, even for women who planned on nursing at term. A major attraction of breastfeeding, close mother–child contact, is usually absent, at least at first. Instead, a cold impersonal pump stands in the way of an
intimate experience, making nursing a mother–machine–child affair. But though almost all women find pumping their breasts exhausting and time-consuming, most persevere, knowing that this is the one way in which they can contribute to the well-being of the baby from whose care they otherwise feel excluded.
The following tips can make the effort to feed a preterm baby in the best possible way more efficient and less tedious:
See page 155 for tips on expressing breast milk. Ask about in-hospital facilities for expressing milk. Most hospitals have a special room (with comfortable chairs and an
electric breast pump) set aside for mothers to use.
Begin expressing milk as soon after delivery as possible, even if your baby isn’t ready to take it. Express every two to three hours (about as often as a newborn nurses) if your baby is going to use the milk immediately; every four hours or so if the milk is going to be frozen for later use. You may find getting up to pump once in the middle of the night helps build up your milk supply; or you may value a full night’s sleep more.
It’s likely you will eventually be able to express more milk than your tiny baby can use.
Don’t cut back, however, figuring you’re wasting too much. Regular pumping now will help to establish a plentiful milk supply for the time when your baby takes over where the
machine leaves off. In the meantime, the excess milk can be dated and frozen for later use.
Don’t be discouraged by day-to-day or hour-to-hour variations in supply. Such variations are normal, although you wouldn’t be aware of them if you were nursing directly. Also normal when milk is expressed mechanically are an apparently inadequate milk supply and/or a drop in production after several weeks. Your baby will be a much more efficient stimulator of your milk supply than even the most efficient pump. When actual suckling begins, your supply is almost certain to increase quickly.
When baby is ready for feeding by mouth, try to nurse first, before the baby is given a bottle. Studies show that low-birthweight babies take to the breast more easily than to the bottle. But don’t worry if yours does better on the bottle—use it while your baby gets the hang of breastfeeding (begin feeding sessions with nursing, then move to bottle), or use a supplemental nutrition system (see page 167).
Preemies who are ready to move on to nipple feedings can be nourished either with breast milk, fortified breast milk, or formula:
Breast milk. Breast is best not only when it comes to full-term infants. Most experts favor breast milk over formula for the preemie, too, and for a number of reasons: First of all, it’s custom designed for a preemie’s special nutritional needs. Milk from mothers who deliver early is different than milk from mothers who deliver at term. It contains more protein, sodium, calcium, and other nutrients than full-term breast milk does, but less than is found in formula. This preemie- perfect balance prevents tiny babies from losing too much fluid, which helps them maintain a stable body temperature. It’s also easier to digest and helps babies grow faster. Second, breast milk has important substances not found in formula. Colostrum (early breast milk) is extremely rich in antibodies and cells that help fight infection. This is especially important when babies are sick or premature and may have a higher chance of developing an infection. Third, research has shown that breastfed preemies have a lower risk of developing necrotizing enterocolotis, an
intestinal infection unique to preemies (see page 623); have a better tolerance of feedings, less risk of allergies, and enhanced development; and receive all the benefits that a full-term baby gets from breast milk (see page 3). Even if you don’t plan to breastfeed long term, providing breast milk for your baby while he or she is in the hospital gives your baby the best possible start at a time when that start has begun too soon.
To ensure your baby is still getting enough nutrition in the early stages of breastfeeding (when baby’s suck may still be weak or your breasts not producing sufficient amounts of milk), talk to the doctor about the following supplemental feeding methods that don’t interfere with nursing:
nursing with the gavage still in place
using a supplemental nutrition system (see page 167)
using a feeding system taped to your finger (finger feeding) cup feeding with specially designed cups
syringe feeding
bottle feeding with slower-flow bottle nipples
For more on breastfeeding your premature baby, see page 614.
Fortified breast milk. Sometimes, even the milk of a preemie’s mother isn’t adequate for the preemie. Since some babies, particularly very tiny ones, need even more concentrated nutrition—
including more fat, proteins, sugars, calcium, and phosphorus, and possibly, more of such other nutrients as zinc, magnesium, copper, and vitamin B6—the breast milk being fed through a tube or a bottle may be fortified with human milk fortifier (HMF) as needed. HMF comes in a powered form that can be blended with breast milk, or in a liquid form for use when adequate amounts of breast milk are not available.
Formula. Babies can do well, too, when they’re fed formula specially designed for preemies.
Even if you are breastfeeding, your baby may get additional feedings with a bottle or supplemental nutrition system. Preemies are fed using small plastic bottles marked in cubic centimeters (cc) or milliliters (ml). The nipples are specially designed and require less sucking strength from your baby. Ask a nurse to show you the correct position for bottle feeding a preemie—it may differ slightly from that for a full-term infant.
FEEDING AT HOME
Once you’ve arrived home with your preemie, feedings will be as challenging and time-consuming as they were in the hospital. You’ll need to experiment with different nipples, bottles, nursing positions, and so on. As a general rule, preemies need to be fed smaller amounts and more often than full-
termers. They feed slowly and tire easily. Depending on your baby’s progress, you may or may not need to continue using formula specifically designed for preemies. Often parents continue to use the same small bottles that were used in the hospital. But keep in mind that what worked in the hospital might not work as well once you’re home and your baby continues to grow in both size and maturity.
You can expect to encounter one or all of the following feeding concerns at home (though some lucky parents experience none at all):
Sleepy baby. Many preemies tire easily and the desire to sleep sometimes overrides the desire to eat. But since all babies, especially those born small, need regular feedings, it is all the more important that you make sure your baby doesn’t sleep through feedings. For tips on how to rouse a sleepy baby, see page 122.
Breath holders. Some preemies, especially those who were born without good suck-breath coordination, will forget to breathe when feeding. This is tiring for your baby and anxiety- producing for you. If you notice your baby hasn’t taken a breath after a number of sucks or looks pale while feeding, remove the nipple from baby’s mouth and let him or her take a breath. If your baby seems to be holding his or her breath all the time during feedings, regularly remove the nipple after every three to four sucks.
Oral aversion. Babies who have spent a lot of time in the NICU may have come to associate the mouth with unpleasant experiences (feeding tubes, ventilator tubes, suctioning, and so on) and often develop a strong aversion to having anything in or around their mouths once they are home.
To combat this, try to replace the unpleasant oral associations with more pleasant ones. Touch your baby around the mouth in a soothing manner, give your baby a pacifier or your finger to suck, or encourage your baby to touch his or her own mouth or suck on his or her thumb or fist.
Reflux. Many preemies are prone to excessive spitting up or GER because of their immature digestive systems. For tips on coping with spitting up and GER, see pages 174 and 558.
Starting solids. Like full-term babies, preemies should start receiving solids somewhere between four and six months. But for preemies, that date is based on their corrected age rather than
chronological age (which means a preemie wouldn’t be ready for solids until six to eight
chronological months). Because some preemies experience delays in development, solid feedings should not be started until the baby shows signs of readiness (see page 292), even if the corrected age says “it’s time” for solids. Some preemies have a more difficult time with solids—especially once they graduate to chunkier foods.
What You May Be Concerned About
NEONATAL INTENSIVE CARE UNIT (NICU)
“My baby was rushed to the NICU immediately after birth. What can I expect when I visit him there for the first time?”
A first look at a neonatal intensive care unit can be frightening, especially if your baby is one of the tiny, helpless patients in it. Knowing what you’re looking at can keep your fears from overwhelming you. Here’s what you can expect in most NICUs:
A main nursery area comprising a large room or a series of rooms, with designated bed areas along the walls. There may also be a couple of isolation rooms in an area separate from the main nursery. Adjoining may be several small family rooms where mothers can express milk (breast pumps are usually provided), and where families can spend cuddling time with their babies as they get stronger.
A bustling atmosphere. There will be many nurses and doctors busily moving about, treating and monitoring babies. Parents may also be caring for or feeding their own infants.
Relative quiet. Though it’s one of the busiest places in the hospital, it’s typically also one of the quietest. That’s because loud noises can be stressful for tiny babies or even harmful to their ears.
To help keep the sound level down, you should talk quietly, close doors and isolette portholes gently, and take care not to drop things or place items loudly on the tops of incubators. (One sound that is important for your preemie, however, is the sound of your voice; see page 611.) Since still- sensitive eyes need protection, too, NICU staff usually tries to control the brightness in the nursery.
Occasionally, however, the lights in certain areas can become intense to allow doctors and nurses to perform procedures.
Strict hygiene standards. Keeping germs that can spread infection (and make sick babies sicker) out of the nursery is a major priority in the NICU. Each time you visit, you’ll need to wash your hands with antibacterial soap (there’s usually a sink for this purpose right outside the nursery doors). You may be asked to put on a hospital gown, too. If your baby is in isolation, you may also need to wear gloves and a mask.
Tiny babies everywhere. You’ll see them in clear incubators or isolettes (bassinets that are totally closed except for four porthole-like doors that allow you and the staff to reach in and care for your baby) or in open bassinets. You’ll also see some on warming tables under overhead heat lamps.
Some babies may be wrapped in cellophane to minimize the loss of fluids and body heat through the skin. This helps preemies keep warm (particularly those under 4 pounds, who lack the fat necessary to regulate body temperature, even when they’re swaddled in blankets).
An endless array of apparatus. You’ll notice an abundance of technology near each bed. Monitors that record vital signs (and will warn, by setting off an alarm, any changes that need prompt
attention) are hooked up to babies via leads that are either stuck on the skin with gel or inserted by needle just under the skin. In addition to a monitor, your baby may also be linked to a feeding tube, an IV (via the arm, leg, hand, foot, or head), a catheter in his umbilical stump, temperature probes (attached to his skin with a patch), and a pulse oximeter that measures the oxygen level in his blood with a small light attached to his hand or foot. A mechanical ventilator (breathing machine) may be used to help your baby breathe normally if he’s under 30 to 33 weeks’ gestation.
Otherwise, he may receive oxygen through a mask or delivered into the nose through soft plastic prongs attached to tubing. There will also be suction setups that are used periodically for
removing excess respiratory secretions, as well as lights for phototherapy (bililights), used to treat babies with jaundice. (Babies undergoing this treatment will be naked except for eye patches, which protect their eyes from the bililights.)
A place for parents to sit and cuddle their babies. In the midst of all this high-tech equipment, there will likely be rocking chairs where you can feed or hold your baby.
A large team of highly trained medical specialists. The staff caring for your baby in the NICU might include a neonatologist (a pediatrician who has had special training in newborn intensive care); pediatric residents and neonatal fellows (doctors undergoing training); a physician assistant or nurse practitioner; a clinical nurse specialist; a primary nurse (who will most frequently take care of your baby and teach you how to care for him); a nutritionist; a respiratory therapist; other physician specialists depending on your baby’s particular needs; social workers, physical and occupational therapists; X-ray and lab technicians; and lactation specialists.
Being part of the team yourself. Remember that you are one of the most important partners in your baby’s care. Educate yourself as much as possible about the NICU’s equipment and procedures, and familiarize yourself with your baby’s conditions and progress. Ask for explanations of how
ventilators, machines, and monitors are helping your baby. Request written information that
explains the medical jargon you’ll be hearing. Learn as much as you can about the routine: visiting hours and visitor restrictions, when nurses change shifts, when doctors make rounds. Find out who will give you updates on your baby’s progress and when you’ll get them. Give the staff your cell phone and pager number, so they can always reach you if necessary.
“The nurses warned me that having my daughter in the NICU would be like being on a roller coaster with all its ups and downs. But I’m surprised at the incredible range of emotions I’m feeling.”
You’re not alone. Most parents whose babies are in the NICU experience a wide spectrum of ever- changing emotions, including shock, anger, stress, panic, fear, numbness, frustration, disappointment, confusion, sadness, intense grief, and equally intense hope. All for good reason. You may feel
overwhelmed by all the medical equipment attached to your baby and the constant activity of nurses and doctors. You may be frightened of the procedures your baby is undergoing or frustrated by feelings of helplessness. You may feel disappointed that your daughter isn’t the dimpled, adorable full-term baby you’d been expecting (and envisioning) throughout your pregnancy, frustrated that you can’t take her home to begin your life together, and guilty about both emotions. You may also feel guilty for not feeling happy about your baby’s birth or guilty about not being able to keep the pregnancy going longer (even if there was absolutely nothing you could have done to prevent your daughter’s prematurity). You may feel distraught at the uncertainty of your baby’s future, particularly if she’s very small or sick. You may even unconsciously distance yourself from her for fear of
becoming too attached or because you find bonding difficult to accomplish through the portholes of an isolette. Or, you may feel unexpectedly strong feelings of affection, deepened, instead of
compromised, by the challenges you and your baby are facing. You may be angry at yourself for your reactions, at your spouse for not reacting the same way you are, at your family and friends for not understanding what you’re going through or for acting as if nothing has happened, at your doctor for not preventing this. Confusing these emotions may be the fact that they may often conflict or fluctuate wildly—for instance, leaving you feeling hopeful one minute, hopeless the next, deeply in love with your baby one day, afraid to love her the next. Compounding them may be the physical exhaustion that comes from keeping a round-the-clock vigil at your baby’s bedside, which may be more debilitating still if you haven’t yourself recovered from childbirth.