Until recently it was assumed that coordination of suckling and swallowing is only present in pre-term infants from 34 weeks gestation onwards and that breast- or bottle-feeding can only be introduced thereafter.
With the advent of Kangaroo Mother Care for very premature babies where the baby, wearing only a nappy, is placed on the mother’s chest and breastmilk feeding forms an essential component, it became immediately obvious that very premature infants can suckle from the breast from a much earlier gestational age than was previously practiced.
However, there is a big difference between establishing breastfeeding in a term infant and doing so in a very premature infant of less than 30 weeks gestation. Kangaroo Mother Care is now the official form of care for premature babies in the Western Cape. It is essential that general practitioners and all other health care workers become familiar with the technique of establishing premature infants on the breast.
Problems associated with breastfeeding the premature infant
Breastfeeding the premature baby has many hurdles that need to be overcome before full breastfeeding is established. Prematurity-related problems may prevent the immediate placing of a very premature infant directly onto the breast.
- Respiratory complications such as surfactant deficient respiratory distress syndrome and wet lung syndrome.
- Increased heat loss due to a large body surface area and little subcutaneous fat may result in hypothermia. The very premature infant is therefore initially cared for in an incubator.
- Inability to coordinate sucking and swallowing. Although foetuses swallow amniotic fluid from early pregnancy, they still have to learn to attach to the breast and to coordinate suckling on the breast and swallowing. Initially, premature babies do not suckle strongly, tire very quickly and fall asleep at the breast. This especially tends to happen if the infant is placed between the mother’s breasts in the so-called kangaroo position.
- Early separation of the mother and her premature baby due to a policy of early discharge of the mother. Frequent skin-to-skin contact between the mother and baby as well as two- to three-hourly breastmilk expressing are diminished. Ongoing support, patience and encouragement of the mother will eventually result in successful breastfeeding.
There are very few maternal contra-indications to breastfeeding a premature baby. These include certain anti-thyroid drugs, Aids and uncontrolled psychotic conditions. With serious conditions such as eclampsia, expressing of breastmilk can continue until the mother is well enough to place the baby at the breast. Although HIV positive mothers can express breastmilk if it is pasteurised before administration to the baby, actual breastfeeding by these women must be an informed decision.
Intravenous feeding and tube feeding
For the first few days, the very low birth weight infant (birth weight <1500g) receives intravenous fluids. Breastmilk feeding must be started as soon as possible after birth as the premature infant receives his passive immunity from the IgA, IgG and lymphocytes in breastmilk. During this time, expressed breastmilk is administered through an oro-gastric tube. The mother is taught the technique of Kangaroo Mother Care at this time.
The establishment of breastfeeding
Sucking and emptying of the breasts stimulate the release of maternal prolactin and oxitocin and this in turn stimulates milk production and secretion.
As most very premature babies cannot suck immediately on the breast, it is important that the mother begins to express breastmilk either manually or with her own breast pump as soon as she is able, preferably within two to three hours of delivery of her baby.
Milk flow during expressing is increased if the baby is in the kangaroo position and licks or suckles on the other breast. The contact of the infant with the nipple will encourage milk production and flow. When expressing at home, milk flow will increase if the mother looks at a photograph of her baby.
Guidelines for expressing breastmilk
- The mother should be trained in the technique of breastmilk expression, milk collection and storage.
- Washing of hands before expressing is important to prevent bacterial contamination of breastmilk. Milk may only be expressed into a sterile bottle.
- Milk can be expressed manually or by breast pump. Under no circumstances is sharing or buying of second hand pumps acceptable as viruses such as HIV, hepatitis B or CMV can be transmitted through breastmilk.
- Electric pumps that have a totally isolated electric motor, with no connection between the flange, tubing and the motor (Medela Lactina), are suitable for multiple use provided that individual users buy their own kit (tubing, piston apparatus and bottles) for use with the pump. The milk expression kit can double up for use as a hand pump or be upgraded to a mini electric pump.
- Milk expressing should be done eight to 10 times a day (two hourly) with the last expression at 22h00. It is important for the mother to have a good night’s sleep as lack of sleep will suppress milk production.
- To prevent transmission of viruses through breastmilk, sterile bottles containing expressed breastmilk should be labelled with the mother’s and baby’s name, folder number, time and date of expression.
- Expressed breastmilk for premature infants can be left at room temperature for one hour before being refrigerated for 48 hours. It can be frozen for up to three months.
- Each drop of milk, especially colostrum, is precious. Although the mother may only produce a small quantity of milk during the first few days, it is important that she continues to express as milk production will start to increase between days three and five.
- Once the mother expresses about 750ml of milk per day, milk expressing may be decreased to six times per day.
Suckling from the breast
- All premature babies, irrespective of age, are ready to be taught to suckle from the breast as long as they are stable enough to be placed in the kangaroo position.
- Premature infants differ in their ability to initiate suckling from the breast. Some will be able to breastfeed at 30 weeks while others will only latch on to the breast at 32 – 34 weeks. It is more difficult for a premature baby to drink from a bottle than from the breast as breathing is better regulated during breastfeeding.
- Every time a baby is placed in the kangaroo position, he should be taught how to suckle from the breast by allowing his lips to touch the mother’s nipple.
- During tube feeding, the baby’s lips should touch the nipple. Teaching the baby to latch takes time but the smell and taste of the breastmilk and the contact between mother and baby will help increase milk production.
- Help and support are needed for the first few feeds. The football or alternatively the Madonna position can be useful for the premature baby.
- Premature babies have particularly weak neck muscles, so it is important for the mother to support the neck of the baby by placing her hand behind the neck and her index finger and thumb lightly over the ears.
- If the mother notices that her infant tends to be awake at a particular time of day, she should introduce breastfeeding at that time.
- The first breastfeeds are practised on an empty breast (after milk expression). This is also known as non-nutritive suckling. Until a premature baby learns to latch properly and the suck/swallow reflex is in place, his suckling should be non-nutritive.
- It is important to get the nipple as deeply as possible into the infant’s mouth. This is accomplished by tickling the baby’s mouth with the nipple. The baby will yawn or open his mouth wide and then, while supporting his neck, the mother aims the nipple into the back of the mouth. A few drops of breastmilk squeezed onto the nipple or into the baby’s mouth may also serve as encouragement for the infant to open his mouth.
- Frequently a premature baby will take only four or five sucks and fall asleep; they may even fall asleep before the mother is able to start the feed.
- Premature babies may have difficulty staying on the breast. Support of the baby’s neck and the index finger under the jaw will help to keep the baby latched.
- While he is breastfeeding, the mother should observe her baby to see whether he: falls asleep; suckles; breathes and suckles with ease; swallows and suckles strongly.
- The infant’s sucking and swallowing reflexes will gradually improve. When the mother is confident that the baby is managing to drink from the breast, she can offer him a partially expressed breast. The mother should express milk until she has a letdown before offering the breast to him. This expressing may have to continue for a while as premature babies may struggle to create strong enough negative pressure to allow the letdown reflex to take place, before they tire and fall asleep.
- Once the baby has the breathing, sucking and swallowing reflexes well co-ordinated, it will no longer be necessary to initiate the letdown reflex by expressing before the breastfeed at all.
- As the baby becomes established on the breast, he will gradually be weaned off tube feeds. He will still need two hourly breastfeeds during the day and three hourly at night.
- Ensure that the infant gets enough hind milk by allowing him to take as much as he wants on the first breast before the second is offered.
- The daily weight gain must be monitored carefully throughout the stay in hospital. A daily weight gain of 25g or more is acceptable. Inadequate weight gain should be corrected by excluding the following: incorrect breastfeeding techniques; nursing the baby on the lap instead of in the kangaroo position (heat loss); drinking only low caloric containing fore milk (changing to the other breast too quickly).
- A breastmilk fortifier which provides additional calories, calcium and phosphorous should be added to the expressed breastmilk of all breastfed, very low birth-weight infants.
Breastfeeding at home
Once at home, the baby should be breastfed at least eight times per day even if he does not appear to be hungry. A decrease in breastmilk production often occurs during the first week after discharge as the mother may be concerned about managing her tiny infant at home. It is important at this time for her to continue expressing milk which she then can feed to her baby by spoon or cup.
It is important that the infant’s weight gain be assessed within 48 hours of discharge and then twice again during the first week. If weight gain is adequate, the baby can be followed weekly at a clinic. – (Prof GF Kirsten, Department of Paediatrics, Tygerberg Hospital)