small preemie-l logo

Breastfeeding your premature baby

A Preemie-L FAQ
by Justine Diamond and Anne Casey

For most new mothers, breastfeeding is something you expect to happen as a natural result of childbirth. When a baby arrives prematurely, you are suddenly thrust into a critical life and death situation. Your baby will be rushed off to intensive care to be hooked up to breathing tubes, IVs and monitors. You may not be able to touch or hold her. The baby's immediate care seems to eclipse every other concern and thought you may have had. So now you may ask, with some concern "Can I still breastfeed my baby?"

Yes, you can. There are many good reasons for supplying your baby with breastmilk. It is something that only you can do, and it enables you to take a more active role in the baby's care. The breastmilk of mothers who deliver prematurely is ideally suited to the special needs of the premature baby. Colostrum and breastmilk contain white blood cells, antibodies and other valuable immune properties that may help a premature baby resist infection. Recent studies have shown that breast milk may improve the neurological development of premature infants.

It isn't easy. Supply can be very difficult to build up and maintain. You'll need to use a breastpump until your baby is mature enough for direct breastfeeding, and sometimes for longer. Here are some basic questions and answers to help get you started while your baby is still in hospital:

1. When can my premature baby begin to breastfeed?
If your baby is stable and relatively well, breastfeeding can be gradually introduced from about 32-33 weeks. Before this stage, expressed breastmilk can be given to your baby via a gavage tube, and baby's interest in breastfeeding encouraged by the skin-to-skin contact of kangaroo care.

2. How do I get started?
You'll need to begin expressing by the day after your baby's birth, and even earlier if possible. Some mothers prefer to begin with hand expressing. A nurse or lactation counsellor should show you the proper way to express either by hand or with a breastpump. Once your milk has come in, you'll need to begin using a good breastpump. The pump may feel uncomfortable at first, so try to use a low setting. In time, you will be able to increase the speed and the suction setting of the pump.

3. How often and for how long do I need to express?
For the first day or two, before your milk comes in, you'll should pump for about 5 minutes every three hours during the day, and once during the night. Once your milk comes in (no matter how small the amount produced ), you should try to express at least 6-8 times in each 24 hour period, for as long as it takes to completely empty your breasts. You'll need to rent or buy a hospital grade electric breastpump to use at home.

Frequent pumping can be difficult to manage with a sick baby but will help to build and maintain your supply. If your baby is in hospital for a long time, you may decide that it would be better for you to sleep through the night, but try to never go longer than 8 hours without expressing. When you know your baby will soon be coming home, you can begin begin expressing during the night again.

4. What is the best way to store and freeze/thaw milk?
Some hospitals don't allow the use of frozen milk. Your NICU will be able to guide you on their practices and procedures, however these general guidelines should help:


Containers used for collection or storage of breastmilk should be clean and sterile. Most hospitals supply sterile containers or bottles, or small bottles of sterile water (discard water) which can be used to store breastmilk. Small plastic bags or disposable bottle liners (double bag) can be used to freeze milk. Some of the breastpump manufacturers make bags specifically for the purpose of storing milk though these can be expensive.

You need to label each collection with your name and the date, as the oldest milk will be used first. It is safest to refrigerate or freeze milk promptly after pumping. Fresh milk can be refrigerated and transported on ice to the NICU. Many NICUs have a refrigerator or freezer where you can store your milk. Make sure that you don't overfill any bag of milk that will be frozen as the milk will expand in the freezing process.

Storage times: Recommendations provided by The Nursing Mothers Association of Australia

Fresh milk(6 hours at room temperature), refrigerator (3-4 days, at the back of the fridge where it is coldest), freezer compartment of your refrigerator (2 weeks), if the refrigerator has a separate door (3 months), deep freezer (6-12 months).

Frozen milk : if thawed in the fridge but not warmed (4 hours or less at room temperature), thawed in the fridge (24 hours but don't refreeze), thawed in warm water (only for the duration of the feed, or back in the fridge for a maximum of 4 hours).


To defrost: Thaw under warm running water or in a tepid water bath. Do not use hot water, as this can destroy some of the milk's benefits. Do not thaw by leaving on the counter for a long period of time (the refrigerator is O.K. though). Do not microwave breastmilk to heat it or thaw it. Breast milk also separates, so gently swirl to remix
.

5. Is there anything I can do to increase my supply?
Maintaining a breastmilk supply without a nursing infant is very difficult. Here are some suggestions from Preemie-L mothers:

    A. Fluids and rest
    The stress and fatigue that come with having a premature baby can be counter-productive to your milk supply. A good diet and plenty of fluids are essential, and need to be planned for as best you can. If you find your supply is dwindling despite your best efforts, try to spend a day or two in bed, getting up only to eat and express.

    B. Increase frequency of pumping
    Most women find that frequent shorter pumping sessions work better than longer ones spaced further apart, for example, 10 minutes every three hours rather than 20 minutes every four hours. You need to experiment and find out what works and what is practical for you. If your baby is still in the hospital, you may not have the opportunity to express freqently.

    C. Herbal and Medicinal preparations
    There are various herbal remedies that are popular and worth trying (but not all at once!). These include brewer's yeast, fenugreek tea or capsules, blessed thistle (also called milk thistle) and mother's milk tea (a U.S. product). These are usually available at health food stores. A Guinness stout in the evening is also a popular remedy, at the very least it is nutritious and will help you sleep.

    There are also medicines which can help your let-down such as Metoclopraminde, available as Reglan in the U.S.A. and as Maxalon or Pramin in Australia and England. The lactation consultant at your hospital can advise you on these. They aren't suitable or effective for everyone.

    D. Expressing techniques
    Many Preemie-L mothers have found that warm compresses and breast massage prior to pumping helped them to relax, and that this in turn resulted in a higher yield of milk. Stopping several times during pumping to reposition the pump cones can sometimes help. Alternating hand expression with machine pumping during a session may also provide a greater yield. If you are not using a double pump, this is something you should consider.

    E. Have your breastpump checked
    This is so obvious that many times it is overlooked. Make sure that your pump is working correctly and that the suction is correct and the gaskets are all tight. If there is a problem, you can usually return the pump or get new attachments.

    F. Supplemental Nursing System [SNS] (only if you are actually Nursing)
    A supplemental nursing system may help increase your supply because it allows your breasts to be stimulated while the baby is fed either expressed breast milk or formula. There are two widely available models the Lact_aid Nursing Trainer and the Medela Supplemental Nursing System. A SNS consists of a bag or bottle that hangs around your neck and is filled with formula or expressed milk. Thin tubes taped to your breasts with surgical tape deliver milk to the infant as he sucks. They can be fiddly to use but some mothers have found them to be a good solution for low supply.

6. What can I do if my baby fails to thrive?
If your baby fails to gain weight, it may be recommended that you supplement your nursing with formula or your milk may be enhanced with a fortifier. This does not mean that you have failed, and it does not necessarily mean that you must give up your efforts to breastfeed your baby.

7. Can I supplement breastfeeding with bottles?
If your milk supply remains low, you can continue to breastfeed with supplements of formula or EBM. Supplemental feedings can be given by bottle, supplemental nurser, cup or by one of the special feeding devices. Depending on the health of your baby, your neonatolgist may prescribe a higher calorie formula, or have a breastmilk fortifier added to your expressed milk. Remember that any milk you can supply, no matter how little, is a precious gift, one that only you are able to provide.

8. What can I do if my baby is unable suck well?
Some premature babies never learn to suck well, even though they may be growing and developing in other ways. You can continue to provide breastmilk for your baby by expressing and giving EBM in bottles. A good routine is to feed your baby EBM from a bottle, and then express for the next feed while your baby is close-by. It sounds awkward but it's actually nice (and time-saving) to combine feeding and expressing this way rather than separating the two activities.

9. Will my baby suffer if I give up trying to breastfeed?
No, your baby won't suffer if you are unable to provide breastmilk. Sometimes, even with the best of intentions and the best of efforts, supply just does not increase. It happens more frequently than the books and the lactation specialists would have you believe, and it is NOT an indication of failure. Milk supply is not a simple equation, especially with a premature baby. The stress of having a premature baby, your own physical condition as a result of the birth all come into play as well as how quickly you are able to actually nurse, and how soon after the birth you are given access to a pump.

While it is possible to build a supply through exclusive pumping, it is very difficult, and most women will experience a decrease in their supply after about 6 weeks of exclusive pumping. Sometimes this can be overcome, and sometimes it cannot.

10. Is there anything husbands can do to help?
For mothers struggling with the demands of pumping, a husband's support is very important. Husbands can help by encouraging rest, shopping for food and cooking, providing companionship during the endless breastpump sessions, offering backrubs, borrowing magazines and videos to help make the time spent expressing more tolerable.

And remember to praise. Expressing milk for months on end can feel like a thankless task. Husbands who nurture their wives through this long and demanding process are helping to provide their premature babies with a unique gift of love.

Sometimes it becomes clear that breastfeeding isn't working out. This can be devastating for a mother who has always hoped to breastfeed, and the love and support of a husband can be a great comfort.

11. When should I wean my baby?
The simple answer to this is when you are ready. It may be when the baby is several months old (or younger) or several years old. As your baby grows, breastfeeding continues to be a source of comfort as much as nutrition. This is part of a unique relationship which can continue as long as you and your child enjoy it, regardless of the amount of milk provided.

Recommended books:

Neifert, Marianne, Dr. Mom's guide to breastfeeding Penguin Group, 1998. Excellent information on breastfeeding high risk infants. A good source for information on increasing supply. One of the only books to address the emotional concerns of not being able to supply an adequate amount of milk.

Eiger, Marvin S, and Olds, Sally Wendkos The complete book of breastfeeding Workman Publishing,1987. Excellent section on expressing and storing milk.

Expressings - Thoughts and advice on breastfeeding from The Early Edition newsletter

Selected Websites:

Breastfeeding your premature baby This is a very helpful and informative page taken from the For Parents of Preemies web site.

The emotional side of breastfeeding a preemie by Preemie-L member Kerry Bone.
The more technical side of breastfeeding a preemie by Preemie-L member Kerry Bone.

Breastfeeding a premature baby supplied by Ameda/Egnell, a company that makes hospital grade pumps.

Breastpumps and breastfeeding solutions the home page of Medala, who make breastpumps and other nursing aids.

Pumping moms listserve provides information and support for breastfeeding mothers who are working, or who have premature babies.

Organisations like LaLeche League and Nursing Mothers' Association of Australia (NMAA) provide breastfeeding support, breastpump and SNS hire, regular social meetings and special information booklets (breastfeeding preemies, building supply, returning to work and so on).

Disclaimer: The writings and opinions contained in this FAQ are simply that, and are in no way meant to be considered as medical advice, nor are they meant to replace any medical advice.Ê Always discuss concerns with your doctor.
This document is copyright to Preemie-L. It may be reproduced in any format so long as it is reproduced in its entirety, including the contact link to the Preemie-L home page at http://www.preemie-l.org
Return to the Preemie-L Home Page since July 4, 1999