Preterm infants and ill infants are often too weak to suck at the breast or bottle and require specialized methods of feeding e.g. intravenous feeding or tube feeding until they are strong enough to suck efficiently.
All infants lose weight after birth (as much as up to 10% of their birth weight) and preterm infants can lose more than term infants. In addition they are slow to regain their birth weight.
When Will Your Infant Be Fed?
Preterm infants must learn to regulate their breathing and heart rate initially and digesting milk at this early stage may prove too difficult for them. It may take a little time before their stomachs are able to tolerate milk and to establish feeds.
Expressed Breast Milk (EBM)
If the infant is unable to breastfeed at your breast, you will need to express (pump) your breast milk so that it can be given to your infant through a feeding tube. It is advisable to commence expressing breastmilk soon after the birth of your infant (ideally within the first 6 hours).
The staff on the Neonatal Unit and Post Natal Ward will show you how to express your milk. Hand expressing is encouraged in the days immediately after delivery but it is also possible to commence expressing using one of the Hospital Grade Breast Pumps. Most of the NICUS provide an expressing room and pumps for mothers with infants on the unit however it is also advisable to organize a suitable hospital grade breast pump for use at home (even while your infant is still in the NICU) ; the NICU staff will provide you with the contact details for the various companies in your locality who offer a breast pump rental service.
Tips For Expressing Breast Milk (EBM)
- Wash hand thoroughly before you start.
- Massage each breast prior to expressing.
- Always hand express for a couple of minutes at the beginning and end of each session.
- Express 8-12 times per day, including during the night, in order to stimulate your supply.
- Once the supply is established continue to express 6-8 times per day to maintain your supply.
- Use a double-electric pump.
- Always store the breast milk in a sterile container.
- Refrigerate the EBM as soon as possible after pumping.
- Ensure that EBM is kept in a cooler bag during transport to the hospital.
- Ensure that EBM containers are properly marked with identification labels.
- EBM can be stored in the freezer in containers or breast milk storage bags.
- Eat a balanced diet, with regular meals and drink plenty of liquid.
- Advise the NICU staff if you are taking any medication.
- Wash the pump attachments after each use in hot soapy water and sterilize them.
- If you need to combine freshly expressed milk with frozen milk, cook the EBM first. Don’t add more than there is of the frozen, to avoid thawing.
- Allow frozen EBM to thaw in the refrigerator for 12 hours or overnight before use. Avoid letting EBM sit out at room temperature to thaw.
- For quicker thawing, hold the container of EBM under running water-start cool and gradually increase the temperature.
- Swirl the bottle of EBM gently before use if the creamier portion has separted-do not shake as this can cause some of the proteins to break apart
- To warm EBM, heat water in a container and place the EBM in the water to warm or use a bottle warmer –never microwave EBM or heat it directly on the stove.
- To avoid waste store EBM in 1-4 oz portions.
- If the infant does not drink all the EBM at one feed, the EBM can be returned to the fridge but must be consumed within 3-4 hours.
Breastmilk Storage Guidelines
Room Temperature: 4/5 Hours
Cooler With Frozen Ice Packs: Up to 24 Hours
Fresh Milk in Refrigerator: Up to 8 Days
Thawed EBM in Refrigerator: Up to 24 Hours
Freezer Unit: Up to 6 Months
Deep Freeze Unit: Up to 12 Months
Foods to Avoid when Breastfeeding
DONOR BREAST MILK
It is important that the premature infants early feeds are breast milk feeds as breastmilk is the most natural and easily tolerated feed for infants. Breastmilk contains an ideal source of nutrients and other ingredients to support the infant’s growth, development and long-term health. It protects against infections (including NEC), aids digestion and promotes brain development.
If for some reason the Mother is unable to express milk either due to the ill health of the mother, if the mother is located in another hospital to her infant or her supply may not need the infant’s needs, donor breast milk (EBM from a donor Mother) can be offered to the infant. Currently there is only one Donor Milk Bank in Ireland, “The Sperrin Lakeland Milk Bank” located in Co Fermanagh. The donated milk received at the Milk Bank is checked for bacteria and pasteurized. It is then stored at the bank until it is required by NICUs around the country. You can contact the milk bank on 048 68628333 or email firstname.lastname@example.org.
Probiotics are “friendly” micro-organisms that live in the gut. They help to maintain gut health and make it harder for harmful bacteria to grow. However, they are very sensitive and are killed by most antibiotics; so sometimes when antibiotics are give, “friendly” organisms in the gut may be replaced by harmful ones. Also probiotics are less plentiful in the gut of preterm infants than in healthy term infants, children and adults. Many units will give probiotics to the infants on the NICU.
BREAST MILK FORTIFIER
Preterm infants require extra protein, minerals and vitamins over and above what they get in breast milk and for this reason Breast Milk Fortifier may be added to EBM to provide these extra nutrients.
INTRAVENOUS FEEDING (IV)
Glucose and nutrients can be given directly into the infant’s bloodstream through a cannula. A vein through the umbilicus (belly button) may be used at first and later a vein in the arm, leg or occasionally the scalp (if the scalp is used, a small area of the hair will need to be shaved). Sometimes a line inserted into a deeper vein so that it will last for a longer period of time and this is referred to as a Percutaneously Inserted Central Catheter (PICC) line or Long Line. IV nutrition is also referred to as Parenteral Nutrition (PN). This solution contains a mixture of protein, carbohydrate, fat, vitamins and minerals and the amount of this nutrition will be reduced as the amount of milk feeds increases.
Even after your infant’s stomach has matured to enable him/her to digest milk, it may be some time before he/she is strong enough to suck from the breast or bottle. The sucking reflex usually matures around weeks 33-35 gestation. In the interim the infant will be fed through a soft fine plastic tube passed through the nose (naso-gastric tube, NG tube) or mouth (oro-gastric,OG tube) and into the stomach. A syringe is attached to the tube and the milk is placed in the syringe. All feeding into the gut is referred to as “enteral nutrition”.
Gravity gradually pulls the milk down into the infant’s stomach. Initial feeds will be as little as one or two mls every 3 hours. Occasionally the infant’s may not tolerate even these small amounts of milk and this feeding method will be stopped for a day or two before being tried again. After 32 weeks of gestation breast or teat feeds will be introduced in tandem with tube feeds which will gradually be phased out as the infant grows stronger.
As your infant grows and learns to co-ordinate sucking, breathing and swallowing, they may show signs that they are ready to commence feeding by mouth (oral feeds). Oral feeding requires more effort than tube-feeding and the transition can take some time. Infants under 35 weeks of gestation are not expected to be able to manage full oral feeds and may have their oral feeds complimented by tube-feeds to ensure that the infant receives all of his/her nutrition requirements.
Infection or the need for extra oxygen support may affect your infant’s ability to oral feed as can an over-stimulating environment. The optimum time to give your infant his/her first breast feed is when the infant is wide awake and alert. The NICU nurse will show you:
- How to latch on
- How to recognise feeding cues
- When the infant is feeding well
If you require additional support in order to establish breastfeeding make an appointment with the Lactation Consultant and enquire about Breastfeeding Support Groups in the hospital. The HSE Publication “Breastfeeding & Expressing For Your Premature or Sick Baby” is another useful resource.
The four most common breast feeding problems are:
Many new mothers experience milk leakage at one time or another — especially early on when milk production levels are still being established. While leaking is harmless physically, it can be kind of embarrassing.
How to Avoid It: Try not to miss feedings or go longer than normal between feedings.
How to Treat It: Place disposable nursing pads in the cups of your bra to absorb wetness and prevent milk from leaking through your shirt. Avoid pads with plastic liners that can trap moisture against your skin and cause sore nipples. If you feel your milk letting down in a situation where you can’t nurse your baby, gently pressing your breasts to your chest wall (you can do it inconspicuously by crossing your arms and squeezing your arms against your breasts gently) will often stop the leaking.
It is normal for your breasts to feel full and heavy during the first few weeks of nursing, but if you find that you are feeling discomfort beyond that time — specifically, your breasts feel hard and uncomfortable — you may be experiencing engorgement. The cause is usually inadequate milk removal. For example, your baby doesn’t nurse often or long enough and your breasts become overfilled with milk.
How to Avoid It: Nurse your baby often — eight to 12 times a day with both breasts, if you can. Don’t skip feedings, and continue to nurse your child during the night as well as during the day. Be sure that your baby is positioned correctly and is latching on well so that your breasts are emptying of milk.
How to Treat It: Express milk between feedings, either manually or with a breast pump. Take a warm shower or place a warm compress on your breasts to encourage milk flow. Some doctors recommend using a warm compress while nursing and following up with a cold compress between feedings. If you are severely engorged, warmth may aggravate the situation (by increasing blood flow to the area), so consider trying cool compresses as you express the milk.
(c) Nipple Confusion
Babies who are given a pacifier or bottle in the early weeks of breastfeeding may become confused when faced with their mother’s breast. The result: Baby may not be able to latch on correctly or may reject the breast completely. This means that he may not get enough milk and your breasts can become engorged from not emptying.
How to Prevent It: Don’t give your baby a pacifier or bottle until your nursing routine is firmly established — usually at least three to four weeks after delivery.
How to Treat It: Depending on how long your baby has experienced nipple confusion, you may want to contact a lactation consultant for advice. In the meantime, monitor your baby’s diapers to determine whether he’s getting enough to eat.
(d) Cracked and Sore Nipples
Improper positioning of your baby during breastfeeding is the most common cause of cracked or sore nipples. When your baby is positioned correctly, your nipples will be at the back of his mouth, safely away from the pressure of the gums and tongue.
How to Prevent It: Make sure your baby has the proper latch-on technique. If you feel pain, gently remove your baby from your breast and let him latch on again. Also, position your baby close to your body with his mouth and nose facing your nipple to make it easier for him to latch on properly.
How to Treat It: When nursing, start with the less painful side since your baby is likely to suck most vigorously early in the feeding. At the end of the feeding, apply some fresh breast milk to your nipples to soothe them. Human breast milk has antibacterial properties so it can reduce the chance of infection. If you are still in pain, talk to your doctor about using a cream or vitamin E on your nipples. He can also check for signs of infection.
Preterm infants may be given specially designed formula milk (available in pharmacies) which has extra energy and nutrients. Continue to use this formula until your infant’s medical team deem it no longer necessary. Bottle fed newborn babies drink about 1 1/2 to 3 ounces of milk every 2 to 3 hours. Prior to discharge from the NICU talk to NICU staff about how much your baby was eating in the hospital. Neonatologists use complex equations to figure out how many calories a preemie should be eating for good growth, and won’t discharge a baby until he is eating at least that much. If your baby is drinking at least as much in the early days at home as he was in the hospital, he should grow well.
If your baby is not getting enough milk, he or she will show signs of dehydration, including:
- Fewer than 6 wet diapers in a 24-hour period
- Sunken eyes
- Sunken fontanelles (soft spots)
- Crying with no tears
If your baby seems to be taking in less milk at home than he or she was in the hospital, or isn’t growing well, talk to your pediatrician about how to get your baby to eat.
Tips for Bottle Feeding Your Preemie
- Feed your baby as soon as he’s hungry: Crying is a late hunger sign. Babies may breastfeed better or drink more milk if you feed them as soon as they begin to look hungry. If your baby is sucking on his fist or gumming her blankets, offer a feeding.
- Sit the infant upright not cradled in the arms. To help the infant stay awake and to promote good positioning, sit the infant on your lap, supporting his/her head and shoulders with your non-dominant hand.
- Burp your baby during feeding: If your baby’s belly is full of air, there won’t be room for milk. Burp your baby midway through a feeding, or whenever he starts to slow down.
- Use chin and cheek support. With the infant sitting up, supported by your non- dominant hand, your dominant hand is free to hold the bottle and support the infant’s chin and cheeks. The nursing team will show you how to provide gentle chin and cheek support to help your infant get a good seal on the nipple.
- As the NICU Nurse or NICU Physiotherapist to show you a series of mouth exercises you can perform on your infant to help prepare him/her for feeding. Exercises like circling the lips with your fingers, stroking the chin and gently squeezing the cheeks together can help your infant to feed better.
- Premature babies may have trouble coordinating bottle feeding with breastfeeding and may experience apnoea or bradycardia during a feed. Watch your infant for signs of trouble, and pause the feeding if your baby has trouble breathing, gags, goes limp, or has a drop in heart rate or oxygen saturation (indicated by the monitors).
- As your baby starts taking more milk by bottle, ask to try a few feedings without the feeding tube in situ.
Most babies spit up once in a while, but some do it a lot. This is called reflux. Reflux is short for gastroesophageal reflux or GER. Reflux happens when food in the stomach comes back up during or after a feeding. It often happens to babies who were born early. Most of the time babies outgrow the condition in a few months. Most babies don’t seem to be upset by reflux.
If your baby had reflux in the NICU, the nurses may have shown you how to feed and position your baby to minimize spit up. These tips may help:
- Hold your baby upright during feeding.
- Try smaller, more frequent feedings.
- Burp your baby often, especially if you are feeding him with a bottle.
- Try a different nipple on your baby’s bottle so he swallows less air.
- Keep your baby still after feeding.
These symptoms may mean that your baby has other problems digesting food:
- The spit-up is bright yellow or green.
- There is a large amount of spit-up.
- Your baby arches his back or cries during feeding.
- Your baby vomits with great force (projectile vomiting).
To learn more about recognising the signs of reflux, the various treatment options available and the healthcare professionals that you need to engage with please visit the “Living With Reflux” website.
Tongue-tie (ankyloglossia) happens when the string of tissue under your baby’s tongue (frenulum), which attaches her tongue to the floor of her mouth, is too short. If your baby has tongue-tie, her tongue can’t move freely, and this can cause problems. If your baby has mild tongue-tie, it may not affect her. But if she has severe tongue-tie, her tongue may almost fuse to the bottom of her mouth.
Doctors differ in the way they diagnose tongue-tie, especially in mild cases, so it’s difficult to know how common it is. There is no evidence that tongue-tie is something that babies inherit. Your baby may be diagnosed with tongue-tie during her first routine check up. Your GP will put her finger in your baby’s mouth to check the roof of her mouth and her tongue. But tongue-tie is not always easy to spot. It may not be found until later, for example, if your baby has feeding problems. If you and your baby are finding breastfeeding difficult, ask your midwife, health visitor or doctor to check for tongue-tie.
If your baby has mild tongue-tie, she may not have any feeding problems at all. But if her tongue can’t move freely, she may:
- Have trouble latching on.
- Slip off your breast while feeding.
- Not gain weight as expected.
If your baby is struggling to feed because of tongue-tie, you may have sore, painful nipples, which may make you both feel frustrated. Babies who are bottle-fed and who have tongue-tie occasionally have trouble with making a good seal around the bottle teat. This may mean that the milk leaks, and your baby may suffer from wind due to swallowing air.
The treatment for tongue-tie is a straightforward operation called a frenulotomy. A doctor or specially-trained midwife puts a snip in the string at the base of the tongue (the frenulum). In young babies, this snip is often done after just numbing the area. It shouldn’t cause your baby any pain, and if she’s very young, she may even sleep through it. If your baby is older, she may need to have a general anaesthetic, and the operation could be more complex.
UPPER LIP TIE
Related to tongue tie (and its posterior hidden variant) which may cause problems with breast-feeding, upper lip tie is when the upper lip is tethered to the upper gum. Though most infants have some degree of upper lip tie, when it becomes large and tight enough, it may prevent the upper lip from flaring out or curling up which is essential for breast-feeding in order to create an adequate seal with the breast. Also, some infants with upper lip tie will exhibit an upper lip crease in an attempt to flare up during breast-feeding.
If the upper lip tie is tight enough, an infant may have trouble feeding even from a bottle.
- Prolonged breast-feedings.
- Difficulty with latching.
- Painful nipples (secondary to infant’s struggling to achieve an adequate seal against the breast).
- Infant is excessively gassy.
A good seal helps the baby draw the nipple deeply into the mouth and assists in the suck in order to swallow the milk produced by the breast. When a good seal is absent, excessive amount of air is introduced into the infant’s mouth which is also swallowed along with the milk causing a too-gassy infant. Furthermore, lack of a good seal makes it more difficult for the infant to maintain the nipple’s position in the mouth making for a prolonged and uncomfortable feeding.
Treatment is recommended ONLY if the upper lip tie is causing a problem. If no symptoms are exhibited, one does not need to pursue any treatment. Upper lip tie release treatment itself is fairly straightforward. If the child is less than 12 months of age, it may be possible to perform in the clinic under topical anesthesia only. If older than 12 months, sedation in the operating room may be required as the child is usually uncooperative.
When introducing solid food to premature babies it is important to use their corrected age as it will be more of an indicator on when they are developmentally ready.
Can take food without choking or gagging.
Can indicate desire for food by opening the Mouth and leaning forward.
Can indicate feelings of fullness by leaning back and turning away.
Strong extrusion reflex has faded, and infant demonstrates ability to swallow non-liquid foods, to transfer food from the front of the tongue to the back, and to draw in the lower lip as the spoon is removed.
Grasp large pieces of food such as thick, dry toast in a palmer grasp.