When discussing breast-feeding and the use of human milk (HM) both within the NICU and postdischarge, mothers, neonatologists, and primary care providers are all concerned with whether or not exclusive HM feedings (eg, without additional formula or formula powder supplements) support adequate infant growth. In order to answer that question, we must know (1) Is the infant getting enough milk during breast-feeding? (2) Does mom have the tools to facilitate adequate milk intake by the infant during breast-feeding? (3) How long does mom need to continue breast pumping? (4) Does exclusive HM actually provide adequate nutrition for preterm and high-risk infants?
Sucking
While the infantile suck reflex develops quite early during gestation, suction pressures in the infant, which are essential for effective latch onto the breast and milk transfer, continue to mature through 40 to 44 weeks’ postmenstrual age (PMA).
For the preterm infant, slipping off the nipple repeatedly during a feeding is common because infants are unable to sustain the suction pressures required (approximately −50 mm Hg) to maintain an effective latch position at the breast.
Even stronger suction pressures are used to transfer milk from the breast to the infant during breast-feeding.
Sleep-wake cycles
Sleep-wake-feeding regulation is immature in preterm infants first learning to breast-feed, so most demonstrate erratic waking, falling asleep early in the feeding, and appearing satiated after consuming only a few milliliters of milk.
Cues of satiety that are useful for healthy breast-fed infants do not apply indiscriminately to preterm infants.
Eating
Intake is expected to be minimal when infants first start feedings at the breast, but increases with infant maturity, maternal comfort with positioning, and learned timing of breast-feedings, so they begin immediately after the infant awakens.
Box 12-1 shows a sample feeding management strategy for a preterm infant who is transitioning to oral feedings during the late NICU hospitalization.
Individualized maturity
Getting enough milk at the breast is not a matter of learning and practice, but rather one of maturity on the part of the infant.
Standardized “one-size-fits-all” guidelines to manage inadequate intake during breast-feeding are not evidence based because some preterm infants demonstrate mature suction pressures at 34 weeks, whereas others reach 44 weeks before these pressures become effective with respect to milk removal at the breast.
Box 12–1 Transitioning to Cue-Based Breast-Feedings in the Late NICU Hospitalization
When the infant consumes approximately 50% of the daily prescribed feeding volume orally (versus by nasogastric tube), write the order for cue-based (demand feedings) as follows:
Change feedings from every 3 hours to a modified cue-based schedule.
Order a minimum intake for either an 8-hour (for infants who are thought to consume smaller versus larger volumes) or 12-hour interval.
Example: Feed on cue with a minimum intake of 125 mL every 8 hours; or
Feed on cue with a minimum intake of 180 mL every 12 hours.
Infant feeds on cue and consumes ad libitum volumes.
On cue means when the infant awakens, prior to sustained crying. It may be as little as 30 to 60 minutes after the last feeding.
The infant should feed ad libitum, but should not be forced or coaxed into consuming more milk than he or she can while maintaining physiologic stability. Finishing a bottle is not the priority.
There should be no more than 1- to 5-hour sleep stretch during a 24-hour interval.
If the infant does not consume the minimum prescribed volume over the 8- or 12-hour interval, the remainder can be fed by gavage at the end of the interval.
If the infant requires additional milk at the end of intervals for 48 hours, he or she should be placed back onto a scheduled 3-hour feeding.
For feedings at breast
Follow the above guidelines, with the following additions:
The mother performs test weights for feedings at the breast so that milk intake can be tallied into the 8- or 12-hour interval.
If the infant consumes very small volumes at breast and the mother is present for an 8-hour interval, the 8-hour minimum should be divided into a 4-hour minimum so that the infant does not underconsume for an extended period.
If the infant consumes an adequate volume of milk by bottle when the mother is not present, the additional milk can be given by bottle rather than by nasogastric tube.
The care provider uses these measures of milk intake during the late NICU hospitalization to determine how to individualize instructions for breast-feeding after NICU discharge.
Test weighing
Scales
Accurate scales (BabyWeigh, Medela, McHenry, IL) for performing test weights are available for inhospital use or may be rented for in-home use by mothers.
Measurements in the NICU
Measuring milk intake during breast-feeding is easily done by test weighing, wherein the clothed infant is weighed before and after the breast-feeding in exactly the same conditions (eg, diaper, clothing, blanket pacifier, etc) for both weights.
Test weighing has been studied in both preterm and term populations, and is extremely accurate and reliable when electronic scales and appropriate weighing techniques are used.
Additional studies in NICU populations have demonstrated that the use of observed clinical indices such as duration of the feed, milk in the mouth, number of swallows, etc, are not accurate indicators of milk intake.
During the late NICU hospitalization, the information provided by measuring milk intake is only part of an assessment that will help individualize a management strategy to use during the late NICU hospitalization and early postdischarge period.
The neonatologist can explain the total number of milliliters of HM that the infant requires in a day, and/or break this number into 8- or 12-hour minimum volume feedings, as per Box 12-1. Thus, the mother starts implementing these guidelines during the late NICU hospital stay, and continues them with a rental scale during the first weeks after discharge.
Measurements in the home
Mothers should be shown how to measure milk intake using test weights prior to NICU discharge so that they can perform this procedure independently during and after the NICU hospitalization.
In-home measurement of milk intake with test weights has been studied and found to be extremely acceptable by mothers, who perform the technique accurately and use the information to make informed decisions about providing extra pumped milk by bottle.
In contrast to common myths, in-home measurement of milk intake does not make mothers nervous or stressed, nor do they give more bottle supplements of expressed milk than do mothers who do not perform test weights.
In addition to measuring milk intake during breast-feeding, mothers can also continue a daily or twice weekly weight check in the home with these scales, which weigh to the nearest 2 g. With appropriate teaching, mothers can measure a nude weight in the infant, share weight gain patterns with the pediatrician office by phone or e-mail, and perhaps avoid taking the infant to the pediatrician office for only a weight check.
Maternal stress of weighing baby
While it is widely assumed that test weighing is stressful to mothers, several published studies have demonstrated that mothers of NICU infants seek the information provided by test weights because this information helps them determine specifically how much extra milk to give over the course of a day.
Similarly, the data reveal that mothers are not just “fixated on numbers” as a function of their infants having been in the NICU.
Test weights are an effective tool in helping mothers achieve their goal of exclusive or mostly feeding at the breast.
Transition to home
Mothers who plan to provide HM for their infants after the NICU hospitalization—especially those who want to feed at the breast as much as possible—have three basic concerns about making the transition from NICU to home: volume, technique, and pumping.
Volume
First, mothers want to know if their babies are getting enough milk during a breast-feeding session, or whether they need to provide extra milk, and if so—how do they combine feeds at breast and bottle?
At the time of NICU discharge, very, moderate, or late preterm infants seldom consume an adequate volume of milk during exclusive breast-feedings over the course of the day, even when the mother is able to remove an abundant volume of milk with the breast pump.
Lactation specialists and skilled nurses should perform assessments during the NICU hospitalization, including measurement of milk intake during breast-feeding, so that the discharging care provider can work with the family to develop an individualized plan for continued breast-feeding.
Use of test weighing ensures adequate volume intake.
Technique
Second, mothers want to know about specific techniques to help them facilitate milk intake in their babies during breast-feeding.
NICU infants, especially those born preterm, frequently do not consume as much milk from the breast as they do from the bottle as discharge approaches. Several temporary strategies exist to help them consume as much milk as possible during breast-feeding.
Timing
First, the feeding should begin as soon as possible after the infant awakens, rather than employing techniques, such as a diaper change, that shorten the infant’s wakeful period.
Parents can be guided to feed the infant at breast, change the diaper when the infant falls asleep, and return the infant to the breast if the diaper change wakens the baby a second time.
Positioning
Second, breast-feeding positions that support the infant’s head, neck, and shoulders are more effective at achieving and maintaining an effective latch position than are positions suited to a term infant without suction deficits.
Mothers should be told that the preterm infant’s head is heavy in relation to the weak neck muscles, and the special breast-feeding positions (Figure 12-1) help to compensate for this difference in head weight and neck muscle strength.
As the infant’s suction strength improves, these positions will no longer be necessary.
Nipple shield
Finally, many preterm and some term NICU infants benefit from the temporary use of an ultrathin nipple shield until the suction pressures mature sufficiently to create the nipple shape and transfer sufficient quantities of milk.
The nipple shield allows the infant to maximize milk transfer at the breast using limited suction pressure, and is recommended for some or all breast-feedings until the infant’s suction pressures have matured sufficiently to extract milk effectively and efficiently.
Published studies of nipple shield use in preterm and term infants have indicated that infants consume more milk with than without the shield (when it is indicated for milk transfer), that the shield is not “addictive,” in that it can be discontinued, and that it does not negatively impact breast-feeding duration.
There is substantial ideology about not using nipple shields because they are inconsistent with “baby friendly” recommendations, or because they look like a bottle, or because they cause breast-feeding problems. While understandable in the perspective that nipple shields were overused in the past, these ideological concerns are inconsistent with the evidence about NICU infants.
Nipple shield use should begin during the NICU hospitalization when milk intake at the breast becomes important (eg, close to NICU discharge) and if the infant demonstrates sleepy behavior and slipping of the nipple during breast-feedings.
Milk transfer with and without the nipple shield in place can be evaluated with test weights, and test weights can be used to adjust infant positioning and other aspects of the breast-feeding while the nipple shield is in place.
Pumping
Mothers should continue breast pump use after feeding at the breast is begun.
One of the critical periods for maintaining an adequate maternal milk supply coincides with the late NICU hospitalization and the early postdischarge period. While part of this problem can be attributed to the stress that accompanies NICU discharge, much of it is preventable if mothers are given evidence-based information about continued breast pump use until effective and efficient milk removal on the part of the infant is established.
For most mothers, this means that they will need to use the breast pump until their infants reach approximately 40 to 44 weeks’ PMA.
Discontinuing the pump too soon translates into inadequate milk supply and difficulties transitioning to exclusive or mostly HM feedings at the breast.
A key misconception is that mothers of preterm or term NICU infants need to use a breast pump only because they are separated from their infants, and that once the separation ends (eg, NICU discharge), they can feed the infants on cue and discontinue pumping. While this logic may apply to relatively healthy term NICU infants, it is not the case with preterm and sick NICU infants.
Several studies indicate that continued breast pump use is critical to the preterm infant’s ability to gradually consume more milk directly from the breast (with fewer bottle supplements and complements) during the early postdischarge period. Basically, the infant consumes more milk because the breast pump provides the stimulation to mammary tissue that the infant cannot. Thus, the infant can consume larger volumes of milk with weak suction pressures because the milk supply is abundant and flows freely.
The graph in Figure 12-2 illustrates this principle, and should be used as a teaching tool by neonatologists and primary pediatric care providers, so that families have evidence-based information about when preterm infants transition to complete feedings at breast. This graphic reveals that during the first week at home (35.5 to 36.5 weeks’ PMA), preterm infants consumed only about 100 mL of milk directly from the breast each day, while the mother must pump and feed an additional 275 mL by bottle.
In addition to providing extra milk for the infant feedings, use of the breast pump maintained an adequate maternal supply, which would have been impossible had only 100 mL (eg, the infant intake) been removed every day. By the fourth week post-NICU discharge, infants consumed more milk from the breast than from the bottle.
Box 12-2 summarizes a plan to combine breast and bottle feedings in the early postdischarge period for preterm and other NICU infants.
Most NICU mothers report a love-hate relationship with the breast pump and all express a desire to discontinue breast pump use as soon as possible. Additionally, many friends or mother-to-mother support organizations encourage mothers of NICU infants to breast-feed exclusively (and not use a breast pump), because they do not understand that a discharged NICU infant is not just a “small” healthy term infant with respect to milk intake.
The breast pump is usually the last breast-feeding aid to be discontinued because it is the mother’s lifeline to her sustained milk supply.
Most mothers will need to continue to use a breast pump two to three times daily until their infants feed exclusively from the breast and consume adequate volumes of milk consistently without the nipple shield.
Even then, the mothers should discontinue only one pumping every 4 to 5 days, while monitoring the adequacy of infant intake.
The overriding clinical question to keep in mind is whether the infant is getting enough because the pump is doing part of the work of maintaining the mother’s milk supply.
For pumping to cease, the infant should be completely capable of regulating the mother’s milk supply through effective and efficient milk removal.
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