Breastfeeding the Premature Baby
Mothers too often have preventable problems with breastfeeding. Many
hospital routines make it difficult for mothers and babies to breastfeed
successfully. When the baby is born prematurely, mothers have even
more difficulty with breastfeeding, and this is unfortunate because
premature babies need breastmilk and breastfeeding even more than
healthy full term babies. The reason for mothers not getting the help
they need is that many of the “techniques” used to save the lives of
premature babies were developed during the 1960’s and 1970’s when
breastmilk, never mind breastfeeding, really wasn’t a priority in
neonatal intensive care units (NICU’s). Unfortunately, despite much
about what we have learned since that time about how to help mothers and
babies to breastfeed, NICU’s seem to be, in general, with some
exceptions of course, resistant to change the way babies should be fed.
Even worse, some techniques have been adopted that make the situation
even more difficult.
Some Myths About Premature Babies and Breastfeeding1. Premature babies need to be in incubators
Actually premature babies, even very small ones, often do better skin to
skin with the mother (or father) than they do in incubators. Evidence
shows that premature babies (and term babies too for that matter) are
more stable metabolically when they are skin to skin with the mother.
Their breathing may be more stable and less distressed, their blood
pressures are more normal, they maintain their blood sugars better and
their skin temperatures better in Kangaroo Mother Care (skin to skin
care for most of the day) than they do in incubators. Furthermore,
mothers and babies in Kangaroo Mother Care will more likely produce more
milk, she will get the baby to the breast earlier and the baby will
breastfeed better. A document from the WHO discusses this at length with
many references. Please show this document to your baby’s doctor(s).
You can get it at the website
http://www.who.int/reproductive-health/publications/kmc/text.pdf free of
2. Premature babies all need fortifiers
Actually, most don’t. If the mother is expressing enough milk, babies
over about 1500 grams (usually about 32 weeks gestation babies weigh
this much, though there are exceptions) can grow just fine with
breastmilk only, perhaps with the addition of vitamin D or phosphorus,
The real problem behind this “need” for fortifiers is that it has become
a gospel, carved in stone, for many NICU policies that babies must grow
at the same rate outside the mother as they would have had they not
been born so early. But there is no good evidence to prove that,
whereas there is evidence that babies who grow faster than the premature
baby on breastmilk has problems later in life with higher levels of
“bad” cholesterol, higher blood pressure, insulin resistance (which may
be an early finding of type 2 diabetes) and overweight. These studies
were done in premature babies given a) just breastmilk b) breastmilk
plus banked breastmilk or c) breastmilk plus preterm formula. The
babies who got the preterm formula did grow faster and bigger but there
was a price.
How can the baby be fed without using fortifiers? Well, first of
all, some babies will need fortifiers, true: really tiny babies and
babies whose mothers are not able to express enough milk. However,
fortifiers are now being made from human milk (breastmilk) but
admittedly they are not easily available yet and are very expensive as
well. There is no reason fortifiers need be made from cow’s milk.
However, most premature babies don’t need fortifiers because most
premature babies are “big” premature babies.
Many NICU’s have a rule that babies can receive only a certain amount of
liquid a day. This is usually kept at about 150 to 180 ml/kg/day,
sometimes less. If the baby also has an intravenous, the fluid given
orally is cut down even more. This restriction of fluid makes sense,
for example, if the baby is on a ventilator to help him breathe because
too much fluid may cause him to go into heart failure and prevent his
coming off the ventilator. So, restriction of fluid, plus the “baby
must grow as if he were still in the uterus” results in the “need” for
One way avoiding the need for fortifiers in some premature babies, I
learned when I worked with premature babies in Africa, was to give them
more breastmilk than what is ‘allowed’ in NICU’s. True, these babies
were not like babies in NICU’s in affluent countries; they were bigger,
not as sick and needed not more than a little oxygen to survive. But,
as a believer at that time in “the baby must grow as if he were still
inside the mother”, I increased the amounts of milk the baby received
well above the 150 to 180 ml/kg/day, sometimes up to 300 ml/kg/day and
the babies did fine and grew well. So as not to give the baby too much
milk at one time, the milk was dripped into the baby’s stomach
continuously, a few drops at a time.
There may be a need for additions to the breastmilk, depending on the
baby’s levels in the blood. It is possible to add vitamin D,
phosphorus, calcium, even human protein (albumin) and human milk fat
(from a breastmilk bank) to the baby’s milk without using fortifiers.
If the baby doesn’t need fortifiers, then fortifiers actually should be
considered diluters since they decrease the concentration of all those
elements that make breastmilk special and unique.
3. Premature babies cannot go to the breast until they are at 34 weeks gestation
This is simply not true. Work in NICU’s friendly to breastfeeding,
especially in Sweden, have shown that babies can start taking the breast
even by 28 weeks gestation and many are able to latch on and drink milk
from the breast by 30 weeks gestation. Indeed, some babies have gotten
to full breastfeeding by 32 weeks gestation. This means breastfeeding,
not receiving breastmilk in a bottle or tube in the stomach. With
Kangaroo Mother Care and early access to the breast, it can be done
elsewhere as well.
Of course, every baby is different and some babies may take longer
depending on whether they were sick with respiratory problems or other
issues, but waiting until the baby is 34 weeks gestation before trying
the baby on the breast is using the bottle-fed baby as the model for
See the following articles or refer your doctor to them:
Nyqvist K. The development of preterm infants’ breastfeeding behavior. Early Human Development; 1999;55:247–264
4. Mothers of premature babies need to use nipple shields to get their babies latched on well and getting milk well
Nyqvist K. Early attainment of breastfeeding competence in very preterm infants, Acta Pædiatrica 2008;97:776–781
This is certainly not true most of the time from my experience in Africa
(actually, we never used nipple shields in Africa) and the experience
of the NICU’s in other countries such as Sweden. The second article by
Nyqvist had babies born as small as 26 weeks gestation and up to 31
weeks gestation and only a small minority ever used a nipple shield.
Yet, unlike what happens generally in North American NICU’s from which
very few babies leave the hospital breastfeeding (at best they are
getting breastmilk in the bottle and frequently the mother is not
putting the baby to the breast), almost all the babies actually left the
The key is to take time to get the baby to take the breast well. This
does take extra time compared to using a nipple shield with the mother,
but in the long run the result is worth it. Nipple shields eventually
lead to a decrease in the milk supply which makes getting off the nipple
shield very difficult (see the information sheet The Baby Who Does Not Yet Latch On).
The way to get the premature baby latched on is not essentially
different from the baby who was born at term. See the information sheet
When Latching and the video clips at the website nbci.ca. These video
clips do not show premature babies but the principles of a good latch
are the same.
5. Premature babies need to learn to take a bottle which teaches them how to suck
Well, I don’t know what to say about this. It’s just not true.
Premature babies can learn to suck without getting bottles as shown,
once again, from experience elsewhere in the world. Too often, mothers
and babies are hurried out of hospital with the “advice” that the baby
will be discharged earlier if he starts taking a bottle. This is not a
way to help the mother and baby. In any case it would not be true that
the baby needs a bottle to learn. Kangaroo Mother Care and getting the
baby to the breast before the “magic” 34 weeks gestation would do a lot
to avoid this situation. Furthermore, as different muscles are used when
bottle-feeding vs. breastfeeding, bottle-feeding ‘teaches’ baby poor
sucking skills and these can sometimes be extremely difficult to
6. Premature babies get tired at the breast
This is believed to be true because babies, not only premature babies,
tend to fall asleep at the breast when the flow of milk is slow
especially in the first few weeks. The baby is given a bottle and
because the flow of milk is rapid, the baby wakes up and sucks
forcefully. The false conclusion? The baby tired out at the breast
because it’s hard work and the bottle is easier.
Premature babies often do not latch on well, partly because we teach
latching on so poorly. With a good latch, the use of breast compression
and, if necessary, using a lactation aid at the breast to supplement if
necessary, the baby will get good flow and not fall asleep at the
breast. Get that flow increased and you will see that breastfeeding is
neither difficult for the baby nor tiring for him.
7. Test weighing (weighing the baby before and after a feeding) is a good way of knowing how much milk the baby got at a feeding
Test weighing presupposes that we know what a breastfed baby is supposed
to get. How can we know since the rules that say a baby of this weight
and this age should get x amount of milk are based on babies fed formula
by bottle? And how can we say how much the baby would have gotten if he
had been well latched on, with the mother using compression, especially
if the breastfeeding is limited to a particular time or schedule like
10 or 20 minutes (because of the concern that the baby will tire out)?
The best way to know if a baby is getting milk well from the breast is
to watch the baby at the breast. See the video clips at the website
8. Premature babies need to continue getting fortifiers once they leave hospital
This is a relative new wrinkle in the undermining of breastfeeding the
premature baby. Perhaps someone presented a paper at a conference that
showed the baby gained better if the fortifiers were continued even
after his discharge from hospital. But, again, more is not necessarily
better and breastfeeding is more important than more weight gain, which
is not necessarily good. See the information on fortifiers above.
Premature babies and their mothers run into breastfeeding problems much
more frequently than do babies born at term. But these can be fixed.
Get good hands on help as soon as possible. See also the following
Protocol To Manage Breastmilk Intake
The Baby Who Does Not Yet Latch On
Questions? First look at the website nbci.ca or drjacknewman.com. If the information you need is not there, go to Contact Us and give us the information listed there in your email. Information is also available in Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate Breastfeeding Book of Answers in the USA); and/or our DVD, Dr. Jack Newman’s Visual Guide to Breastfeeding (available in French or with subtitles in Spanish, Portuguese and Italian); and/or The Latch Book and Other Keys to Breastfeeding Success; and/or L-eat Latch and Transfer Tool; and/or the GamePlan for Protecting and Supporting Breastfeeding in the First 24 Hours of Life and Beyond.
To make an appointment online with our clinic please visit www.nbci.ca. If you do not have easy access to email or internet, you may phone (416) 498-0002.
Written by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman, IBCLC, 2009©