Tips on Feeding a Premature Baby in the NICU
By Teri Brown
Having a premature baby in the neonatal intensive care unit (NICU) can be as confusing as it is frightening. For a new mom, breastfeeding a baby can be nerve-racking enough, let alone when that baby may be sick, weak or otherwise impaired.
Elizabeth Thelen, mother of two from Rochester, N.Y., remembers all too well what that was like. Her son was born five weeks early and his lungs were not fully developed yet. “Before we went [to the NICU] the nurses explained how to get him to latch on,” Thelen says. “This was a little confusing and embarrassing, trying to feed my son with everyone watching. He had jaundice, so was under the lights. I was only allowed to feed him for 30 minutes, and he went back under the lights.”
Getting a baby to latch on can be a trying experience. Because premature babies are so fragile, it’s even more difficult.
A Different Experience
Michelle DiMattia, a speech and language pathologist for New York Hospital in Queens, part of the New York Presbyterian network of hospitals, has specialized in pediatric, infant and NICU feeding for the past 10 years. She says the breastfeeding experience in a NICU is very different than in a regular hospital setting with a full-term baby.
“Typically, the earliest time a NICU staff will initiate feeding by mouth of any kind is 32 weeks gestation,” DiMattia says. “Many hospitals wait until the baby is closer to 34 weeks old. A lot depends on the baby’s weight, gastrointestinal health and cardiac and respiratory status. If a baby has breathing problems and needs supplemental oxygen or breathing assistance through a ventilator machine, then initiation of feeding by mouth is delayed.”
According to DiMattia, if the baby is born before 32 weeks, the NICU staff typically feed the baby exclusively through a feeding tube that enters the mouth or nose and goes directly into the stomach, and the baby may also be receiving nutrition/hydration through an IV.
“What this means for the mother is that she may be encouraged to pump breast milk for the baby, but may not be able to put the baby to the breast for days/weeks later,” DiMattia says. “In addition, because the babies are often in enclosed beds called ‘isolettes’ with strange tubes, lights, monitors, etc., it can be overwhelming, scary and stressful for parents. Moms tell me frequently that this stress affects their milk supply.”
A Challenge for Mom and Baby
Another challenge is the fact that NICU staff tend to need to measure how much a baby consumed in a feeding and how long it took (typically measured in milliliters – 1 ounce is equivalent to 30 milliliters).
“This gives them a tangible way to mark how well the baby’s feeding abilities are advancing, since learning how to eat by mouth requires building up endurance and respiratory coordination, similar to learning to run a long-distance race,” DiMattia says. “Coordinating sucking, swallowing and breathing can be difficult for premature babies and sometimes they expend too much energy doing it, resulting either in difficulty breathing comfortably during or after the feeding, or weight loss, or both.”
DiMattia says this can be problematic for moms who want to breastfeed, since you can’t see how much fluid from the breast was swallowed. Some NICUs weigh the baby before and after breastfeeding to get an idea of how much they took. Others allow mothers to put the baby to breast, but then give the full amount they are expected to take by bottle afterwards, and don’t count how much they swallowed while nursing.
“In addition, even when babies are strong enough to take all of their feedings by mouth, babies born under 35 weeks are usually fed every three hours, rather than on demand,” DiMattia says. “On demand is a much more natural way to breastfeed babies, but it’s hard to achieve that in a NICU, as delivery of medicine, changing of diapers, checking the baby’s temperature and vital signs, etc., all tend to happen on a regular schedule. As a result, feeding tends to happen on a regular schedule, which can be hard for mothers who want to breastfeed.”
Because premature babies are working hard to use internal organs (heart, lungs, stomach, brain, muscles) that aren’t meant to be in use yet, their muscles of the face, jaw, tongue and neck as well back and chest are often weak and they become fatigued much more easily.
Working with the Staff
The staff is an important part of the mother’s ability to feed her premature baby. According to DiMattia, the comfort level of the staff may vary – even within the same NICU – when it comes to breastfeeding, or other activities that promote bonding and improved lactation, such as skin-to-skin contact, kangaroo care and latching on to an emptied breast to practice positioning and latching, etc.
“What this means for parents is that they may have to request daily with each different nurse if it’s OK to attempt breastfeeding or do kangaroo care,” DiMattia says. “For some parents, this can be intimidating. Understandably so!”
Communication is key. While in the NICU, tell each nurse daily what you’d like to try. They may say no, especially if the baby is having a harder time that day. Request kangaroo care frequently if it’s appropriate. A consultation with the lactation consultant while in the NICU is helpful to discuss concerns/ideas.
DiMattia gives the following tips to make breastfeeding your premature baby easier:
- When home, try positions that allow the baby’s body to be elongated because this makes breathing easier for the baby. The football hold often works well for this, since the baby has the support of a pillow or a Boppy under him/her.
- Pump, pump, pump. This will keep your supply high even when your baby is just taking small amounts.
- Also, keep trying to offer the breast as often as you feel comfortable, even after you’ve emptied your breast. Babies may latch on to a soft, empty breast after feeding as a source of suckling/comfort when they are not frantic with hunger (because they’re less likely to be stressed).
- Consult people – friends, family, lactation consultants, therapists, support groups, etc. – that are familiar with preemies, since their needs are so different.
Supplementing Your Preemie
According to DiMattia, a product called “human milk fortifier” is often added to expressed breast milk to promote weight gain because it will increase the number of calories in each ounce of expressed breast milk. If mothers are pumping or putting the baby to breast and their supply is insufficient, then doctors will supplement with commercially available formula. In preemies, giving formula that has more calories per ounce is a typical practice until they are closer to their discharge date. She says 20 calories per ounce is the typical density of formula, but it can be concentrated to 22, 24, 27 or even 30 calories per ounce depending on the baby’s needs.
