Premature babies at home

How do I make sure my premature baby gets enough milk at home?

Many premature babies have trouble breastfeeding and need extra milk for at least a few weeks after leaving hospital. Before mothers leave hospital, they need to understand how to feed their baby. At home, mothers need to ensure the baby gets enough milk. If the baby breastfeeds exclusively, mothers need to make sure it’s working well. And if they are expressing, it has to be effective to prevent a decrease in milk supply. To monitor the baby, consider feeding patterns, behaviour, and appearance. Weight gain should be plotted on a chart to ensure it is normal for a premature baby. These babies also need close monitoring by health-care providers coupled with gradual, appropriate removal of breastfeeding supports such as nipple shields and supplements. Supplement amounts decrease as breastfeeding improves.

A) Reasons for support at home

Premature babies are more likely to have feeding problems than babies of the same post-conception age but born at term (Pineda 2020). These can persist even after the baby leaves hospital.

In general, babies born before 38 weeks of pregnancy often need feeding support until they are between 42 and 44 weeks after conception and their mothers need to express during this time. Some mothers’ breastfeeding challenges, such as having a low milk supply or a baby with a latching problem, can last the whole period of breastfeeding.

B) Working with your health-care providers

Before leaving hospital, you should understand how to feed your baby (Noble 2018). Once at home, you need to ensure your baby is taking in enough milk. Premature babies need close monitoring by health-care providers. The first visit to a provider should be within three days after going home (Boies 2016).

We believe these babies also need weekly monitoring by a knowledgeable health-care provider coupled with a slow and appropriate removal of breastfeeding supports such as milk supplements and nipple shields until the baby is breastfeeding effectively or the baby’s feeds have stabilized. 

Premature babies often need extra medical attention long-term. They benefit from early intervention to help their brain develop in the first year of life and support up to preschool age (Spittle 2015).

Please discuss these issues with your health-care providers and consider other resources for premature babies.

C) Making sure the baby gets enough milk

If babies are breastfeeding exclusively, they need to breastfeed effectively. If they are supplemented with extra milk, it should be in appropriate amounts. Also, mothers who express need to ensure they do it effectively to prevent a decrease in milk supply.

Babies need to be monitored to make sure they are growing well. Below are some guidelines.

1) Normal feeding patterns

Babies need to breastfeed 7 to 10 times every 24 hours and be supplemented if necessary with appropriate amounts.

2) Normal behaviour 

They need to be generally happy when fed and held.  

3) Normal appearance

Premature babies are much thinner than full-term babies when born but become fleshier with time. First the tummy becomes wider and bigger, then the cheeks and neck fill in, and finally the loose skin on the insides of the thighs becomes tighter and the thighs become fatter.

4) Reasonable weight gain

Premature babies’ weight gain should be followed on a breastfed baby growth chart for premature babies. Once babies are too old for this, they are followed on the regular WHO growth chart.

If you use a regular growth chart for a premature baby, you need to adjust the age of the baby to get a more accurate graph. To do this, move the weight plots back by the number of weeks the baby was born premature.

For example, if the baby was born at 35 weeks (5 weeks premature) and is now 6 weeks old, the weight measurement is plotted at 1 week on the chart. Another term for this is the corrected age. In this example, the baby’s corrected age is 1 week.

Babies should be weighed regularly to ensure their growth is not too slow. Slow growth can affect the baby’s brain and bone development.

They should also not grow too quickly. Babies born premature are at a higher risk of adult obesity and heart disease (Kerkhof 2012; Ni 2020; Rito 2020).

D) Supplementing with milk

Many babies born premature have trouble removing enough milk from the breast even if they can latch and suck. They need extra milk for at least a few weeks after leaving hospital. As the baby becomes better at removing milk from the breast, the amount of supplement decreases, and if mothers are expressing, the amount of expressed milk will also decrease.

Some mothers cannot establish a full milk supply because of the challenges of having a premature baby. Others may have other medical issues or their milk supply may have decreased. If the milk supply cannot be increased, children of these mothers need long-term supplementing and are at risk of earlier weaning (Bonnet 2018). Babies with latching problems will also need long-term supplements.

Before leaving hospital, mothers should understand:

  • How to supplement.
  • The amount of milk supplement required.
  • The type of milk to be used.
  • Which tool will be used.

Most healthy, recovering premature babies are supplemented according to their hunger signs: If your baby acts hungry after breastfeeding, give as much milk as the baby asks for. Ensure that you are not mistaking other behaviour for hunger.

Bottles are commonly used in this situation, but cups and tube-at-the-breast systems are also appropriate. Premature babies can also benefit from returning to the breast (the third breast) for a few minutes after being supplemented.

There are a number of tools to help mothers see how much milk their baby is taking from the breast (Hurst et al. 2004).

The process of breastfeeding, supplementing, and expressing has been called triple feeding. It can be time consuming and tiring. It is our opinion that the whole process should never take longer than one hour and preferably takes less.

If mothers are expressing, they can stop once the baby can breastfeed well and the milk supply is maximized.

E) Other nutrition

 1) Extra calories

Some babies who grow poorly when receiving breast milk, are born very small, or have a chronic disease may need extra calories and nutrients. In hospital, premature babies frequently receive fortifier in their milk.

Outside hospital, mothers may be advised to add regular or preterm formula powder to breast milk or use higher calorie infant formula (Noble 2018). The use of these products usually ends by three months after discharge.

The long-term benefits of giving premature babies extra calories and nutrients after leaving hospital is uncertain (Arslanoglu 2019). It may increase the risk of obesity (Amissah 2018; Santiago 2018; Young 2016; Zachariassen 2013).

2) Iron

Babies who are born very small are often given iron drops. 

3) Solid foods

Some experts recommend starting solid foods when the baby is around six months of corrected age (Noble 2018).

F) Avoid or minimize pacifier use

Hospitals use pacifiers when mothers are not available or breastfeeding is not an option. They are appropriately used to:

  • Calm the baby.
  • Decrease pain during a medical procedure.
  • Support sucking skills.

Once babies go home, pacifiers are generally no longer needed. They may prevent the baby from showing they are hungry, which can be particularly dangerous for a recovering premature baby. Pacifers can be used to calm babies if they cannot breastfeed.

References

Amissah EA, Brown J, Harding JE. Protein supplementation of human milk for promoting growth in preterm infants. Cochrane Database Syst Rev. 2018 Jun 22;6:CD000433
 
Arslanoglu S, Boquien CY, King C, et al. Fortification of Human Milk for Preterm Infants: Update and Recommendations of the European Milk Bank Association (EMBA) Working Group on Human Milk Fortification. Front Pediatr. 2019 Mar 22;7:76
 
Boies EG, Vaucher YE. ABM Clinical Protocol #10: Breastfeeding the Late Preterm (34-36 6/7 Weeks of Gestation) and Early Term Infants (37-38 6/7 Weeks of Gestation), Second Revision 2016. Breastfeed Med. 2016 Dec;11:494-500
 
Bonnet C, Blondel B, Piedvache, et al. Low breastfeeding continuation to 6 months for very preterm infants: A European multiregional cohort study. Matern Child Nutr. 2018 Aug 23:e12657
 
Hurst, NM, Meier PP, Engstrom JL, et al. Mothers performing in-home measurement of milk intake during breastfeeding of their preterm infants: Maternal reactions and feeding outcomes. Journal of Human Lactation 2004: 20(2);178-187
 
Kerkhof GF, Willemsen RH, Leunissen RW, et al. Health profile of young adults born preterm: negative effects of rapid weight gain in early life. J Clin Endocrinol Metab. 2012 Dec;97(12):4498-506

Ni Y, Beckmann J, Gandhi R, Hurst JR, et al. Growth to early adulthood following extremely preterm birth: the EPICure study. Arch Dis Child Fetal Neonatal Ed. 2020 Jan 6:fetalneonatal-2019-318192  

Noble LM, Okogbule-Wonodi AC, Young MA. ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018. Breastfeed Med. 2018 May;13(4):230-236

Pineda R, Prince D, Reynolds J, et al. Preterm infant feeding performance at term equivalent age differs from that of full-term infants. J Perinatol. 2020 Apr;40(4):646-654

Rito AI, Buoncristiano M, Spinelli A, et al. Association between Characteristics at Birth, Breastfeeding and Obesity in 22 Countries: The WHO European Childhood Obesity Surveillance Initiative - COSI 2015/2017. Obes Facts. 2019;12(2):226-243

Santiago ACT, Cunha LPMD, Vieira NSA, et al. Breastfeeding in children born small for gestational age and future nutritional and metabolic outcomes: a systematic review. J Pediatr (Rio J). 2019 May - Jun;95(3):264-274
 
Spittle A, Orton J, Anderson PJ, et al. Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants. Cochrane Database Syst Rev. 2015 Nov 24;(11):CD005495
 
Young L, Embleton ND, McGuire W. Nutrient-enriched formula versus standard formula for preterm infants following hospital discharge. Cochrane Database Syst Rev. 2016 Dec 13;12:CD004696
 
Zachariassen G. Nutrition, growth, and allergic diseases among very preterm infants after hospital discharge. Dan Med J. 2013 Feb;60(2)