My preemie story took place 28 years ago, but the memories remain on my heart and mind like it was yesterday. My husband and I already had three young daughters (4, 9, and 11 years old), and had sadly lost one baby by miscarriage just a few months before, when we found out that I was pregnant again. Needless to say, we were ecstatic!!! At my first sonogram of this pregnancy, the technician did not say much, which worried me immediately. At previous sonogram when we found out that we had lost our last baby, the technician was also silent. I looked over at my husband with a face of deep concern, so my husband asked the technician if there was a problem. The technician asked me, “Have you been taking fertility drugs?” I told him no. My husband then asked, “Why? How many babies are in there?” The technician said, “There are two. Definitely two.” Although twins run on both sides of the family, the occurrence took us by surprise! We later found out that one of the twins was a boy, which was an even greater, delightful surprise for us because he was our first son! My pregnancy with twins was thankfully uneventful, until I started having contractions at 31 weeks gestation. My obstetrician started me on medication to stop contractions and instructed me to rest at home. The contractions stopped and for the next five weeks, while I didn’t stay in bed all day long, I took it easy and pretty much stayed home. Having three other children in the house to care for was definitely a challenge, but my husband, family, and friends were wonderful in stepping in to help with our other children and support me through this time. At 36 weeks gestation, I went in for a regular prenatal visit with my obstetrician. The babies and I were healthy, and my obstetrician told me that since I was 36 weeks gestation at that point, I could discontinue taking medication to stop contractions because the babies were good to deliver any time forward. So now we just wait. Well, we did not have to wait long! I delivered our twins that same day shortly before midnight. I chose to deliver them by cesarean section because one of the babies was breach, and thank GOD, all went well. The babies were healthy and did not require NICU care: our son was 7 lbs 5 ozs and our daughter was 5 lbs 10 ozs. After spending time with our babies briefly, our twins were taken to the newborn nursery, accompanied by my husband. They kept our twins in the nursery for monitoring because I was “knocked out” for several hours, and my husband went home to check on our other children who were with a neighbor. When the babies came to my room, I immediately attempted to breastfeed. I decided not to tandem breastfeed that first time, knowing that it would be a learning experience for me, having not done it before. So I initially breastfed each baby individually as I had done with all my previous children. My son latched and nursed without difficulty, but my daughter took some enticing before she latched. From there, the breastfeeding was a “roller coaster ride,” with highs and lows of the twins latching and suckling, sometimes well and sometimes not at all. They were after all premature at 36 weeks gestation. We did a lot of skin to skin and my husband helped too. Hand expression of colostrum to entice each baby to latch and suckle was part of the routine at the beginning. Both babies developed jaundice while in the hospital, and phototherapy and formula supplementation were ordered by the pediatrician. Because I was doing well post- cesarean section and we had experience of jaundice treatment with our other children, both our obstetrician and pediatrician allowed us to be discharged home within a couple days. Under the direction of our pediatrician, at home we used bili-light blankets provided by a medical supplier, put the twins in indirect sunlight as much as possible, and continued to formula supplement until my milk increased. Having breastfed my other three daughters, I was confident in the knowledge that I would be able to produce enough breast milk to feed our twins. And I did! I later also tandem fed and pumped but because I was a stay-at-home mom at the time, I only pumped to have freezer supply when I knew I would be away from the babies for an extended period.
Our twins were considered late preterm babies, which are those born 34-37 weeks gestation. Each mom and baby will have their own birth story, and baby may come even earlier than 34 weeks gestation. While my premature twins were not admitted into NICU, as a lactation nurse, I have assisted and supported countless moms and babies in their NICU journeys. The tips I provided in this blog will hopefully help you too!
When born before 37 weeks gestation, baby is considered preterm. Premature babies are often not encouraged to breastfeed until they are 34 weeks gestation, but per Jack Newman, MD, Pediatrician at International Breastfeeding Centre, “experience and evidence clearly show that babies can go to the breast well before 30 weeks gestation and as early as 27 weeks gestation. Not only can they go to the breast and latch on, but also they can actually be getting milk from the breast by 28 to 30 weeks gestation.” Additional evidence shows “that breast milk made by the mother of a premature baby is tailor made for the needs of the premature, different than the milk of a mother of a baby born at term. Breast milk contains all sorts of very important compounds we never expected existed even just a few years ago.” Some medical viewpoints about premature babies <34 weeks gestation that disallow breastfeeding include baby not developmentally having the coordination to suck, swallow, and breathe, feeding breast or bottle may result in apneas (breathing stopped) and bradycardias (slow heart rate), breastfeeding takes more energy and tires baby, and the necessity to feed measured, fortified breast milk. Moreover each baby’s medical condition at their preterm delivery will be different and subsequent care needs to be developed on an individual basis.
Breastfeeding premature babies is challenging, but with a lot of patience, support and education from lactation consultants and your medical professionals, you can do it!
- If baby is admitted into NICU, start pumping within the first 3 hours after delivery. If baby is late preterm and not admitted into NICU, but is having difficulties breastfeeding, then you may also want to pump for stimulation because baby is not providing stimulation from suckling. Hand express to obtain colostrum for baby in the first few days in either situation. Colostrum may be fed to baby by syringe or used for mouth care. Double pump (i.e. pump both breasts at the same time) every 3 hours for 15 minutes; don’t go longer than 4 hours between pumping sessions at night. The hormone prolactin which boosts milk production, peaks at night. This increase in prolactin levels, along with stimulation from pumping or breastfeeding, increases milk production. Early start of pumping is critical to initiating milk production and establishing a plentiful milk supply.
- To initiate milk production and establish milk supply, use a hospital-grade double electric breast pump. A hospital-grade breast pump is more efficient in stimulation of breasts and withdrawal of milk. Most hospitals have hospital-grade breast pumps for your use while on the postpartum unit or visiting NICU at the hospital. You may rent a hospital-grade pump for home as well, through medical supply companies. There are numerous national companies that rent Medela Symphony hospital-grade breast pumps (the #1 Hospital breast pump) through online order and will ship the pump directly to your home. Check with your insurance provider about hospital-grade pump rental, especially if your baby is in NICU.
- A simple tip when milk flow slows and baby begins to fall asleep, is to do breast compressions. Babies don’t necessarily fall asleep at the breast because they are tired or that breastfeeding takes up a lot of energy. Babies fall asleep in response to the flow of milk from the breast: if the flow of milk is slow, baby slows suckling and may fall asleep. Massaging the breast, and compressing the breast periodically throughout the feeding to stimulate milk let-down and flow, will keep baby awake and drinking.
Learn more about latch and how to do breast compressions at these links:
Latching and Feeding – International BreastFeeding Centre (ibconline.ca)
Breast Compression – International BreastFeeding Centre (ibconline.ca)
Breast Compression Videos (ibconline.ca):
https://www.dropbox.com/s/mqabslxtfhqazoo/5.Using%20breast%20compressions-English%20text.docx?dl=0 - Use of a lactation tool/aid to supplement baby while baby is breastfeeding, is another way to increase flow of milk at the breast and encourages baby to stay awake and keep suckling. Talk to the lactation consultants or nurses at the hospital about lactation tools to help baby nurse at the breast. Examples are Supplemental Nursing Systems which involve a feeding tube attached at the breast or finger, syringe feeding at the breast or finger, or a feeding cup. A nipple shield is another tool to help baby latch and is especially useful when transitioning from bottle-only feedings to breastfeeding. The more help and practice you receive while baby is in the hospital, the more confident you will become to continue breastfeeding, even if you must continue using lactation tools/aids at home. Eventually most tools will not be necessary after baby practices consistently and gets better with breastfeeding.
- Do as much kangaroo care/ skin to skin time as possible with baby. Skin to skin is essential to baby’s stabilization and transitioning from fetal life to life outside the womb, bonding time with mom and dad, and to encourage and enhance breastfeeding. If baby is not in NICU, room-in with baby versus sending baby to the nursery. When baby is with you, skin to skin is possible anytime. It will also allow you the opportunity to learn and see baby’s hunger cues, and breastfeed baby immediately when he wants to nurse. Breastfeeding is encouraged 8-12 times every 24 hours, but that does not give you the exact times to nurse. Baby is the “clock” for breastfeeding. Watch for baby’s hunger cues, and feed on demand.
- Take care of yourself: eat healthy foods, drink a lot of water/fluids, and get plenty of rest. Decrease stress with self-care like taking an extended tub bath, getting a manicure or pedicure, or having lunch with friends. Accept help offered by family and friends.
- Make your wishes to breastfeed baby known from the very start at admission of baby to NICU. If not allowed to breastfeed at all, ask if you may have baby at breast to do non-nutritive sucking sessions. This helps baby practice coordination of the suck, swallow, breathe reflex and provides stimulation for mom’s milk production. If NICU allows you to breastfeed, but not EVERY feeding, then at least nurse as much as they will allow. Try not to miss these opportunities to practice breastfeeding with baby. However, what’s important is that baby is fed, keeps improving, and remains healthy. If bottle-feeding expressed/pumped breast milk, donor milk, or fortified breast milk is recommended by your doctor because of baby’s condition at the start of NICU care, breastfeeding may still follow later on. If baby is exclusively bottle-feeding, ask the NICU nurses or lactation consultant to teach you paced bottle-feeding. This is a bottle-feeding technique that supports your breastfeeding and will cause less confusion for baby when you start breastfeeding. Of course, keep asking to breastfeed your baby. You are ultimately baby’s voice and advocate!
- Always ask questions and request assistance from your medical team taking care of baby. If baby is in NICU, this includes doctors, nurses, lactation consultants, speech therapists, physical therapists, and others. They are a wealth of knowledge for you to learn how to care for your premature baby! Moreover your medical team is there to care for baby and support you.
- Plan on follow-up with a lactation consultant after being discharged home, especially for additional assistance and support of breastfeeding. A lactation consultant can help you continue to work on latch, positioning, and other breastfeeding basics that still need practice. During each visit, a lactation consultant will also do a weigh and feed assessment, in which baby is weighed, breastfed by you for a full feeding session, then weighed again. This assessment is done to see how much milk volume baby consumed and transferred from mom while breastfeeding. If baby has any difficulties in latch, suckling, or has not been gaining weight within normal growth parameters, weigh and feed assessments provide evidence as to whether baby is transferring milk from mom’s breast efficiently. The results direct the lactation consultant as to how mom and baby may be assisted in breastfeeding, can inform the pediatrician about the status of breastfeeding, and may indicate the need for referral to another medical professional for further assessment, such as in cases of restrictive frenula.
- Join a NICU support group, a mothers’ group, or breastfeeding support group like La Leche League in your community. Talking with others, especially those who are experiencing similar situations may help support you through this challenging time. Good advice can also be helpful.
If you would like further information about breastfeeding babies <34 weeks, Dr. Jack Newman offered these references:
Blaymore JA, Ferguson AE, Morales Y, Liebling JA, Oh W, Vohr BR. Breastfeeding Infants Who Were Extremely Low Birth Weight. Pediatrics 1997:100(6)
Hedberg Nyqvist K, Ewald U. Infant and Maternal Factors in the Development of Breastfeeding Behavior and Breastfeeding Outcome in Preterm Infants. Acta Paediatr 1999;88:1194-203
Nyqvist KH, Sjoden P-O, Ewald U. The Development of Preterm Infants’ Breastfeeding Behavior. Early Human Development 1999;55:247-264
Nyqvist KH, Early Attainment of Breastfeeding Competence in Very Preterm Infants. Acta Paediatrica 2008;97:776-781
Here are some recommended books about breastfeeding and preemies to check out:
What Doctors Don’t know About Breastfeeding by Jack Newman, MD and Andrea Polokova: https://amzn.to/4ePaQDQ
Breastfeeding the Brave by Lyndsey Hookway: https://amzn.to/3xRqeP7
The Preemie Primer: A Complete Guide for Parents of Premature Babies by Jennifer Gunter, MD: https://amzn.to/3xOVhuT
Understanding the NICU: What Parents of Preemies or other Hospitalized Newborns Need to Know by Gary Weiner, MD, FAAP and Meera Meerkov, MD, FAAP: https://amzn.to/4eFTIQN
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