Breastfeeding a premature baby – how to begin, what to expect, how to deal with the problems you experience?

The baby appeared in a period in which his/her development is not yet completed. The volume of the brain of a baby who is born in the 34th-35th week of gestation is only 65% of that of a healthy term infant. In the 36th week, the volume of the brain reaches 80% of that of term infants. Therefore, it is normal for the baby's reflexes and abilities to be immature and not sufficiently prominent or synchronised. This immaturity affects the control of breathing, the periods of sleep and wakefulness, as well as the strength and coordination required for feeding.

The earlier the baby is born, the more immature his/her reflexes and skills are. In the womb, the baby is feeding through the umbilical cord and his/her digestive system is not involved in the absorption of nutrients. The situation is similar with his/her oral abilities and reflexes. After 24-25 weeks of gestation, the baby in the womb can swallow amniotic fluid and the thumb sucking is observed as early as the 14th-15th week. However, this happens in the womb, where the conditions are quite different. The baby swims in an aquatic environment, which requires much less muscular effort. There is no air and no coordination between swallowing and breathing is needed. Therefore, the underdeveloped skills in the womb will not be applicable to life on earth for a long time.

Around the world, placing the baby at the breast depending on his/her condition begins after 32 weeks of gestation. However, at this stage feeding at the breast is not expected at all. The baby rather stays at the breast and feels it – he/she still can neither hold the nipple at will, nor suck.

Here comes the kangaroo care. It allows the baby to spend as much time as possible on your body, i.e. you hold him/her in skin-to-skin contact for at least a few hours a day. Besides maintaining body temperature, it gives your infant a “womb substitute” and the interactions your baby would have with you if he/she were still in your belly. Touching the skin of the breast continuously stimulates the feeling of the breast; the smell and taste of milk are next to the baby's face and this triggers his/her instincts and ability to breastfeed. Infants held like this breastfeed more often and in a better way – and thus grow and mature faster.

Around the 34th week of gestation the baby has already developed the root reflex and can hold the breast in his/her mouth, make several non-nutritive sucks (sucking without getting milk) for a short period of time and lick or swallow the spontaneous flowing breast milk.

However, with most infants a good coordination of sucking and swallowing is observed after 35 weeks of gestation. More efficient breastfeeding is expected sometime after 36 weeks of gestation.

Therefore, unlike with a term baby, the objectives regarding breastfeeding of premature babies are in the reverse order.

With term babies, latching is the most important because it will provide a good stimulation of the breasts and the baby will get enough calories. With premature babies, first and foremost we are careful to provide enough calories (with means that complement the breastfeeding), for which purpose there has to be a good stimulation of the breasts, expressing breast milk to maintain a sufficient quantity. Latching and sucking come later, developing gradually in the process of maturation and strengthening of the baby.

Maintaining the milk supply is more complicated and more difficult when the baby cannot help. If the amount is insufficient and the milk flow is slower and harder to get, it troubles the infant and slows the process of his/her getting accustomed to active nutritive (nourishing) sucking at the breast. It is very important for you to achieve and maintain plenty of milk (over 600 ml per 24 hours on the 14th day after delivery) until the time when your baby will be able to make his/her first attempts at sucking. The easily flowing milk will allow him/her to feed with a minimum of effort. This way you will be able to switch to feeding only at breast faster.

What to expect when feeding a premature baby?

Depending on the gestational age, the baby’s weight and condition at birth, the differences in the feeding skills and their progression can be enormous. The approach described here is the most common approach applied at Bulgarian hospitals (although it does not correspond entirely to the best recommendations and practices to promote breastfeeding according to medicine based on evidence) for a baby that is born approximately in the 34th week of gestation.

During the first day or two your baby may not receive anything through the mouth – and then he/she will be gradually given small amounts of milk by gavage, most often only 1-5 ml for the first feedings.

From the moment the baby is able to receive food the best for him/her is to be breastfed!

Depending on the gestational age, the baby’s weight and condition at birth, the differences in the feeding skills and their progression can be enormous. The approach described here is the most common approach applied at Bulgarian hospitals (although it does not correspond entirely to the best recommendations and practices to promote breastfeeding according to medicine based on evidence) for a baby that is born approximately in the 34th week of gestation.

During the first day or two your baby may not receive anything through the mouth – and then he/she will be gradually given small amounts of milk by gavage, most often only 1-5 ml for the first feedings.

From the moment the baby is able to receive food the best for him/her is to be breastfed!

Although the composition of infant formula reflects the specific needs of premature infants, it lacks all living protective ingredients of breast milk, which support the maturation of the digestive system and protect the baby from infections. This is a well-known fact and therefore the world's largest consumers of donor milk (if the mother still does not have enough) are precisely premature babies. They are the main reason for the creation of milk banks around the world – because the “liquid gold” of colostrum and breast milk quite literally saves the lives of the so vulnerable premature babies.

If your baby was born weighing less than 1500 g, he/she has specific needs. Therefore, it is possible to enrich breast milk with a special fertiliser, which increases the content of protein and various trace elements. This ensures a better growth of the baby, without his/her being deprived of breast milk.

At first, your baby will probably feed by gavage, which passes through the nose or in the corner of the mouth and reaches the stomach. Thus, the milk (breast milk, enriched milk or special milk for premature babies) is fed directly into the stomach since the baby, in most common cases, does not possess the skills to coordinate sucking, breathing and swallowing and is not strong enough to take the right amount of milk with active efforts on their side.

When the baby’s skills and reflexes mature, around the 34th week of gestation at the discretion of the neonatologists, the baby can be offered a special miniature baby pacifier for premature infants. It is given while the stomach receives milk by gavage. This starts building the connection between the act of sucking and the filling of the stomach with food.

The same can also be done at the breast when you go to feed your baby – although the infant cannot be fed at the breast yet, it is enough for him/her to be able to keep it in their mouth or even just to feel it close to their face and lips as a first step towards breastfeeding, while receiving milk by gavage.

At Bulgarian hospitals, infants are not placed at the breast before the 34th week of gestation (most often, in fact, after the 36th week and if done earlier, it is a big exception). Generally, no attention to non-nutritive sucking is paid (sucking without milk intake), while it is very important for the faster progress of the baby’s sucking skills. It is among the things that you as parents can monitor and request in dialogue with the professionals who take care of your infant.

When the neonatologist finds that the baby has developed enough coordination of sucking, breathing and swallowing, the first attempts begin to feed the baby through the mouth, not only directly in the stomach.

Although feeding at the breast requires maturity and skills on the part of your baby, research shows that it is less stressful than bottle feeding. Apnea (pauses in breathing), bradycardia (slower heart rate), lower oxygen saturation (saturation), cyanosis (bluish coloration of the skin) – all these, considered “normal” while bottle feeding, are usually caused by the rapid stream from the bottle and the control over the feeding on the part of the person giving the milk. At the breast, the baby is competent and in control – he/she can take breaks, set the rhythm on their own and adjust the flow.

In our country, however, in most cases, the bottle of milk still precedes the placing of the baby at the breast. The first bottle feedings can be supplemented with feeding through gavage, depending on the infant’s skills. At this stage infants progress rapidly and the next step is to remove the gavage and switch to bottle feeding for all meals.

At our hospitals, the first attempts at breastfeeding usually start at this stage only.

Obstacles to feeding

Unfortunately, in our country the parents’ access to the intensive care unit for premature babies is quite limited. The staff is small and often unable to pay sufficient attention to the mother. Their efforts are mainly aimed at ensuring the best possible care for the baby. Most of the medical staff still thinks that the contact between the mother and the baby can have a negative impact on the infant. All this heavily hinders the early placing at the breast and is the reason why the latter often happens for the first time only at home.

The baby’s condition, too, can either stimulate or hinder the attempts at breastfeeding, and therefore it is important to watch your baby and find the appropriate time to try.

The periods of sleep and wakefulness are not regulated with premature infants. A premature baby is more languid and sleepy compared to term babies. He/she can sleep longer and not wake up often enough for feeding. Premature babies generally need to be fed more frequently at shorter intervals, since the volume of their stomach is smaller. Moreover, they easily get tired and fall asleep while feeding and this is also why they do not take enough food.

The signals for awakening and hunger are often less visible and less pronounced than in term infants. If you have no experience and do not know what to look for, you can easily miss them. This is yet another reason to keep the baby on you at every opportunity – thus you will easily feel and notice the changes in his/her movements and the first signs of hunger, even if your baby does not open his/her eyes completely and does not look “awake and ready” as you would expect.

In premature infants, the transitions between the different states are usually sharp and fast because of immaturity. For example, from obvious crying the baby can “turn off” and suddenly go to sleep or vice versa, from a condition that resembles a deep sleep he/she can suddenly start crying directly, without going through the phases of activity. It is therefore important to recognize the baby’s first signals from the start and be able to act quickly in line with them.

Another problem lies in the fact that the immature baby does not have enough muscle strength and very easily gets tired, thus not being able to take enough food.

Since the opportunities to compensate premature babies are very few, any anatomical peculiarities, which otherwise might not create a big problem or pose only a temporary inconvenience to a healthy term baby with a good weight, can seriously hinder breastfeeding immature babies (e.g. flat nipples, non-corresponding size of the nipples to the baby's mouth, tongue-tie, etc.).

How should I begin to breastfeed my baby?

One of the most important things in the preparation for the first breastfeeding is to sit back and ensure the best support for the infant's body. A premature baby is not strong or capable enough to compensate. If his/her body is not well supported and he/she has to waste energy keeping their position, breastfeeding cannot happen or it will be difficult for the baby.

The breastfeeding position that is most commonly used with premature babies is the cross-cradle position. It provides a good support and control on your part of the baby's head and latch. Depending on the individual anatomical features, the clutch position is also a suitable option providing good visibility and control.

Your baby has to be on a pillow at breast height, tightly pressed against you. Your hand supports the neck, your forearm their back, and you can easily hold them in the right position. Your baby is “soft” and easy to place in the starting position. His/her chin is resting firmly on your breast, the head is slightly bent back so that your nipple lies entirely on the baby's lips. If you can express a few drops of milk on the nipple in advance, this will remind your baby what he/she is supposed to do.

Do not expect too much – the first attempts at sucking most often remain only attempts. The baby’s reactions can vary significantly. Some babies cry and move away or rotate their head in a disoriented manner (especially if their chin does not touch the breast!). Others simply fall asleep, drifting off in mom’s huddle, warmth and smell. It is better if the baby opens his/her mouth to lick the nipple. Some babies manage to take the nipple in their mouth, although they still do not close their lips around it and do not latch on. Others are so advanced and enthusiastic that even from the beginning they start making very determined efforts “to make this thing work”.

Whatever the first reaction of your baby to the breast, do not be discouraged. Try to analyse what happened and how to continue the next time.

• Is the baby in the right condition – awake and able to focus quietly?
• Does the baby need swaddling to feel stable and comfortable?
• Can the position be improved even more?
• Is there anything in the surroundings that disturbs him/her – e.g. the direct bright light on their face can make them keep their eyes closed and fall asleep easily.
• Is it simply the time of day when he/she responds best and feels most comfortable – this is different for the different babies and you can try observing when he/she is most active and feeds in the best possible way.

If you had the opportunity to put the baby in skin-to-skin contact several times a day, he/she already knows the feeling of the breast and will soon begin to attempt to latch on. In such a situation you can notice that he/she manages to suck with varying success.

When the baby latches on and sucks, their way of sucking is still very different from that of term infants. A premature baby makes short bursts of sucking (3-4 sucks) followed by long pauses during which they can nap.

Their sucking is not yet quite skillful, may be much slower than usual because the baby is not so strong physically, and cannot maintain sufficiently high vacuum. Therefore, swallowing is irregular and the baby quickly gets tired and easily falls asleep at the breast.

Breast compression is an indispensable technique for breastfeeding premature infants – it allows you to increase the flow of milk to the baby, maintains their interest for a longer time and facilitates the baby to take a larger amount of milk at each feeding than the amount the baby can get only on their own. Wrap your hand around your breast and just watch the baby. When it starts to suck, squeeze the breast between your fingers and hold it until the baby stops sucking. When he/she stops, release the pressure and wait for the next sucks to repeat the same.

During the first weeks breastfeeding usually needs to be complemented by other types of feeding in order to ensure an adequate intake of calories. The best supplement is your expressed milk (unless your doctor advises otherwise or if the quantity is insufficient).

This means that you cannot stop expressing just because the baby has latched. It will take weeks before the baby learns to suck well and his/her physical abilities grow to such an extent that he/she is able to receive all the necessary milk at the breast.

You cannot rely on the premature baby alone to stimulate your breasts and you need to continue to express breast milk. At least until you reach the term and make sure that the baby is gaining enough weight only at the breast, pumping remains a necessary and integral part of your day.

Although infants are usually released from the hospital on bottle feeding (plus breastfeeding attempts, which most often only start at home), there are other possibilities for the baby to receive the necessary calories.

According to research, cup feeding is a safe and efficient way of feeding a premature infant. The cup is also less stressful than the bottle and trains some sucking skills (the sticking of the tongue and the movements of the mandible are similar to those as the breast, although there is no vacuum creation and the movements of the tongue are not the same). This way of feeding, however, is not applied at our hospitals and parents are not shown or given the chance to practice it under supervision before they take their baby home. That is why the very idea of it usually causes stress and anxiety and consequently is not used. If you want to try, it is best if someone shows you how to cup feed your baby and you exercise at least a few times under the guidance of a skilled person. Your baby is little and vulnerable and you yourself need certainty before you can feel confident that this is your way.

Supplementation by gavage at the breast is a proper way of supplementation for premature babies. The baby must have already demonstrated that he/she can create vacuum and suck well but just gets tired easily and falls asleep quickly when the flow diminishes. On the one hand, feeding your baby by gavage is familiar to you and therefore it is not so stressful for you. On the other hand, it completely eliminates the bottle and allows your baby to feed only at the breast.

Gavage feeding is used in a slightly different way than supplementing by gavage a term and well-sucking infant. You need to actively give the milk to the baby through the syringe so that he/she does not get too tired. However, this is easily achievable and may be a preferred and convenient way for the time when you need to supplement with expressed milk.

If your baby still has difficulty taking the breast, does not create a good vacuum or fails to keep the breast in his/her mouth, silicone nipples can be an apt transition and convenience. Studies have shown that with premature babies silicone nipples lead to taking more milk and to more successful breastfeeding. When the baby grows and starts doing well at the breast, the use of the silicone nipples gradually stops.

Silicone nipples can also be a great transition between the bottle and the breast. They create a feeling similar to that of the bottle. They are very useful in times when the baby is still not certain what to do and how to suck at the breast.

All this takes time – your baby’s maturation is slow because they grow in conditions very different from those in the womb and they have to spend considerable effort on things that are granted in the womb and do not require their participation (e.g. breathing, feeding and maintenance of body temperature). On the other hand, their condition may be further hampered by infections, serious loss of weight or medical problems related to the premature birth. Therefore, it is difficult to make predictions when the baby will be able to make their full transition to the breast. Every infant develops at their own rhythm and at a different pace, but growing and maturing are inevitable. Be patient and understand the initially limited abilities of the baby. The calm, gentle and non-pressing offering of the breast teaches babies to breastfeed. You will see for yourself that with every week that gets you closer to the term breastfeeding becomes better and better. And if during the first weeks of attempts the baby hardly took anything, around the 36th week he/she will probably manage to get about one third or even more of the required amount. Two to three weeks later more than half the milk may be taken directly at the breast. A week or two after the term you may happily find out that your baby feeds entirely at the breast. This will allow you to stop pumping gradually, which was your constant concern in the last couple of month, and you can celebrate your success.

The road you need to walk is not easy either for you or for your baby and is filled with constant changes. Things hardly ever run smoothly and in the right direction. Regress and reversion by a step or two often occur. At times you will be discouraged and it will seem to you that nothing happens and the baby will never learn. At such moments, just give yourself a chance for a little rest – nothing bad is going to happen if for a few days you do not offer the breast at every feeding or allow yourself a day-long break from the sucking attempts at a time when things look particularly bad. Sometimes this is enough to calm both you and your baby. At the same time such a stop along the way will allow you to detach yourself from the problem a little and look at it from a different perspective and hence you will gain the strength to continue and try again and again. Do not take it as a failure – just as a break necessary for regrouping, changing the strategy and gathering strength for the way forward. The end result is what matters, not every sub-total – just keep the ultimate goal in front of your eyes and continue to fight hard. :)