Revised
Research Proves Mother's Milk Is Best For The Preterm
Since the later part of the 1980's more preterm infants of low gestational age and birth weight are surviving. There is no argument that advances in technology increased preterm survival rates. Since 1989, the major discoveries of specialized nutritional and immunological components in human milk have spawned enthusiasm for its use in the preterm infant. As research continues, we have become acutely aware that the milk from preterm mothers is significantly different from that of mothers who deliver at term. The composition of human milk also changes in relation to how prematurely the infant was born.
According to Lawrence and Lawrence, "Neonatologists have not reached a consensus on the real goals of feeding for the premature (443)." The use of serial ultrasound studies have given neonatology more well defined perimeters for normal intrauterine growth. How that growth is supported once the infant is born prematurely is not universal. Lucas feels that it is unnatural to keep any baby from oral feedings, regardless of gestational age. The fetus starts swallowing amniotic fluid very early in gestation. At term the baby may be swallowing "up to 500 ml per day [of amniotic fluid] which actually provides as much as 3 grams of protein per day," and may help the gut mature. (Lawrence and Lawrence 444)
Human milk feeding, even in small quantities, for the very low birth weight (VLBW) infants, provides benefits that we are only beginning to understand. Preterm mothers' milk contains amino acids and fat blends that aid physical growth. Breastmilk components have overlapping or interdependent functions. The fat globules in preterm milk are smaller thus aiding in their absorption directly from the immature gut. Premature infants lack the enzymes and bile salts need for digestion of fats. However, they absorb 95% of the fats in human milk compared with 83-85% of artificial milks. The fat composition is very different in artificially created formulas as well. The breastmilk itself contains factors that aid in digestion and absorption. The long chain fatty acids are required for adequate neurological growth. These fats are precursors to the hormones required for infant growth. (Hamosh 485-486)
It appears that there is an unknown biological mechanism in mothers
who deliver prematurely that increases the concentration of anti
microbial agents (sIgA, Lactoferrin and lysozyme), anti-inflammatory
factors and immuno modulators. (Goldman et al 495, 498) These
immunological components are vitally important for the VLBW infant
to prevent nosocomial infections, sepsis, Necrotizing Enterocolitis
(NEC), bacterial and viral infections.
The care that a premature infant requires interferes with breastfeeding. Premature infants may not be well enough at birth for enteral
or oral feedings. The decision of when and how much human milk
to give to preterm infants is best left to Neonatologists. Helping
the mother maintain her milk supply for her infant is pivotal
to premature feeding management.
A lactation support system needs to be involved from the time of admission. The NICU should have a written policy delineating who is responsible for the initial breastfeeding contact with the mother. Timing for teaching and early management is crucial. Even if the mother had not planned to breastfeed, most are willing to pump for at least as long as her baby is hospitalized. The mother easily realizes that only she can provide this vital fluid for her baby. For the mother who is seriously ill or unable to pump her own milk for her baby banked human milk is an option.
Early Pumping Is Paramount When Breastfeeding Is Delayed
The mother's milk supply is critical to successful nursing. If
the baby is ill and feeding will be delayed for longer than 24
hours, mother should begin pumping her breasts immediately. It
is crucial to have the mother begin pumping within the first 24-48
hours after delivery to take advantage of the normal physiological
changes after birth (Riordan and Auerbach 456-455). If the breasts
are not stimulated, prolactin levels will fall by 50% within the
first five days after giving birth and will drop to non pregnant
levels within seven days (Riordan and Auerbach 99).
The hospital should have several commercial hospital grade electric breast pumps available for these cases. Small manual or electric pumps are not sufficient for establishing a milk supply. Instruct the mother to pump her breasts at regular intervals of every two or three hours around the clock, until the infant can nurse directly at the breast. This imitates, as closely as possible, what a normal breastfeeding pattern would be. Essentially, mother's body must be convinced that there is an infant to feed. Very early pumping is for stimulation purposes only. It is important to tell the mother that no one expects her to obtain large volumes of milk initially. Babies can obtain colostrum easily from the breast because they strip the milk from the sinuses but colostrum does not pump out well. Most mothers obtain only a drop or two of colostrum for up to three days after birth. If she is told that there won't be much milk with the pump, she will be encouraged by any small amount produced. What is important is the regular stimulation of the breasts to enhance the process of lactogenesis and to bring in a full milk supply. For the mother of the sick newborn, it is better to have mother over produce milk then to under produce. An abundant milk supply will assist in the baby's transition to breastfeedings.
The frequency and duration of milk expression directly correlates to the amount of milk produced (Schandler and Hurst 480). The mother should pump every two or three hours to mimic a baby's natural feeding pattern. This also takes advantage of the increased vascularity in the breasts and the high prolactin level following birth. Pumping at least once during the nighttime is vital in the first few weeks to maintain milk supply. The best results are obtained with double electric pump system because simultaneous breast stimulation elevates serum prolactin levels (Neifert and Seacat, Milk Yield and Prol. Rise). Continued use of a commercial, hospital grade electric pump increases compliance with the pumping schedule, and is better at maintaining milk supply. The mother should begin pumping with the pump set on low to medium pressure. Mother should increase the pressure to comfort for maximum effectiveness. She should double pump for approximately 10-15 minutes and for an additional minute after all the milk droplets stop flowing. Increasing the suction does not necessarily increase the amount of milk mother is able to obtain. Tell the mother that pumping should not be painful. If mother reports pain with pumpings, a pump session should be observed paying attention to: nipple placement centered in the flange, nipple pinching (larger flanges are available for the mother with large nipples), suction level and duration of pumping.
Praise the mother's pumping efforts. Assure her that all her milk will be used for her baby. Always use positive reinforcement. Be aware of subtle inferences that could be misconstrued by the mother that the amount of milk pumped is not enough for the baby.
Lactation support includes realizing that the mother of a preterm infant has multiple stressors that will interfere with milk production. "Stressors include feelings of guilt or failure from the inability to carry to term; detachment and helplessness; lack of control; parental role alteration; anxieties related to the infant's appearance and behaviors; problems with staff communication; and the sights and sounds of the intensive care unit (Schandler and Hurst 480)." Every effort should be made to decrease those stressors. Fatigue is also a factor in low milk production. If the mother's supply falls off, she should be asked about her diet, fluid intake, sleep and rest habits.
Enhancing Human Milk for Enteral Feedings
Protocols for pumping and saving milk vary by hospital. Some hospitals
require that all equipment is sterile at every pumping. The suggestions in the table below are based upon the recommendations
of hospitals in my location. Your hospital may have different
policies. Mother should be given a written instruction sheet for
collection, storage and transportation of her milk.
Pumping Instructions for the Mother with a Hospitalized Infant
| 1. Always wash your hands before pumping. Use clean (sterile*) equipment. Find a comfortable position and have something to drink within reach. |
| 2. Use the pump every two to three hours daytime. Every three to four hours at night. You should try to pump at least once at night. You should have 8-10 pumping sessions in a 24 hour period. |
| 3 a: Single pump: Pump for five minutes then switch to the opposite breast, pump for five minutes then switch to the opposite breast, go back and forth every 5-10 minutes until flow slows or stops. Single pimping can take 20 to 30 minutes per session. |
| 3 b: Double pump is the best option for establishing and maintaining a good milk supply: 15-20 minutes then one-half to one minute after flow slows or stops. |
| 4. Use breast massage and/or warm moist packs to breasts before pumping to encourage let-down reflex. (A picture of the baby, or something the baby has recently worn or a recording of the baby's cries or listening to soft music can help with the let-down). |
| 5. Rinse the parts of the pump that came in contact with your milk in cold water immediately after use. Then wash pump in hot soapy water and rinse well in very hot water. |
| 6. Sterilize once a day (after each use*). Boil for ten minutes in a full pot of distilled water. Boil hard plastic parts only. Do not boil tubing. Do not let pot go dry: parts will melt. Store in a clean area. |
| 7. Label each container with baby's name date and time pumped. Store milk in sterile air tight containers. |
| 8. Your container of milk should be rapidly cooled immediately after pumping. If you are not freezing your milk refrigerate the bottle of breastmilk in a container of ice in the refrigerator.* |
| 9. Keep the pumped milk cold during transport to the hospital. |
| 10. Do not combine the milk from several pumpings. Keep each pumping in a separate container. |
| 11. Your body must become trained to the pump, don't become discouraged if you get less than a few drops at first. |
| * Depends on hospital policy. |
Most authorities agree that human milk should be stored in sterile glass or polypropylene containers. Some breast pump manufacturers also sell 60 ml bottles specifically designed to avoid loss of components or leaching of plasticizers. 50 ml plastic centrifuge tubes have also been suggested for storage (Lawrence and Lawrence 683). Plastic nurser bags are not appropriate because there is loss of immune components and a higher risk for contamination and breakage. Milk from several pumpings should not be mixed. If the milk is to be used within 24 hours then mother can refrigerate the milk and bring it to the hospital in a cooler. If it is to be used later than 24 hours after pumping the milk should be frozen and kept frozen during transport. When using pumped milk for infant feedings a system of confirming proper identification (similar to using 2 RN's to check blood before transfusion) should be used to prevent errors.
Even the smallest amounts of colostrum should be saved for the baby. Drops of colostrum can be placed on the infant's tongue even if baby is getting tube feedings. Nurses should try to feed breastmilk to the baby in the order that it was pumped to assist in the development of the infant gut.
To improve the immunological properties in the milk mother should visit the nursery frequently. Theoretically, the mother's exposure to the nursery environment should stimulate her immune system to produce sIgA antibodies for the nosocomial pathogens in the NICU (Schandler and Hurst 478). Another important factor in stimulating the mother's immune responses is skin-to-skin (STS) contact between the mother and her preterm infant. Mother and baby can begin skin-to-skin encounters when the infant is stable. The infant, wearing only a diaper, is placed upright on the mother's naked chest, between her breasts. According to Schanler and Hurst, STS increases milk production and maternal self confidence, assists baby with body temperature regulation; increases the baby's oxygen saturation in the blood stream. Schanler and Hurst also noted there was a decrease in apneic episodes, and bradycardia when the infant was held in this position (481). In addition, the experience is emotionally and physiologically beneficial for both mother and infant.
When human milk is used for enteral feedings, care should be taken to prevent losses of valuable nutrients and immunities. "Milk infusion systems employing a syringes and a pump, where the syringe tip is oriented upright will allow more complete delivery of fat. We found a reduction in the losses of fat from 48% to less than 8% . . . (Schandler and Hurst 479)." Several studies show that expressed mother's milk (EMM) should be given by intermittent bolus rather than continuous infusion (Riordan and Auerbach 461).
For the VLBW premature infant the use of human milk fortifiers is considered a necessity to reach the same nutritional levels as in intrauterine growth. Be aware that mother may view human milk fortifiers as an indication that her milk is weak. The use of such fortifiers should be explained to the mother in detail.
Oral Feeding Options
Once the infant is stable and ready to take oral feedings the
transition from tube feeding to oral feedings can be accomplished
without using a bottle. If the mother is consistently available
for feedings the baby can nurse at the breast and fed with a nasogastric
tube when she is not available. Two techniques that can be used
are described below. It should be noted that the baby's mouth
is very sensitive. Multiple or forceful intrusions into the baby's
mouth can cause the infant to become "orally defensive."
Cup Feeding
Cup feeding has become popular in many hospitals in the United
States. It is almost exclusively used in underdeveloped nations.
The process involves using a small flexible feeding cup. The cup
is placed against the lower lip and then tipped up just enough
so the milk touches the baby's mouth. The baby will "lap" up the
milk with his tongue. Videos detailing the procedure can be ordered
from Ameda-Egnell and Medela.
Finger Feeding
Finger feeding is a technique that is popular among lactation
consultants. A soft feeding tube or the tubes from a feeding tube
device, rest on the feeder's gloved finger. The finger and the
tubes are presented to the infant's lips. Both the tubes and the
finger are gently inserted into the baby's mouth for feeding.
This technique should only be done by trained individuals. The
lactation consultant should instruct all baby's care givers in
the proper method for finger feeding and observe a return demonstration
of the process.
Bottle feeding
Using a bottle is always an option and may be preferred by the
parents over the above options. However mom and baby may have
to overcome artificial nipple preference later on when the baby
goes to the breast. There is no general concensus on which bottle
is best. However most LC's and new moms feel that slow flow, clear,
silicon nipples cause fewer problems with nipple preference. (The
most popular ones are the AVENT, and Munchkins brands) A baby
should be latched on to any artificial nipple in the same manner
as latching on to the breast; nipple deep in the mouth and baby's
mouth wide open on the base of the nipple.
NOTE: All of the above methods can cause a feeding preference
that may need to be overcome at a later date.
Managing the First Breastfeedings for the Preterm Infant
Three things needed for successful breastfeeding in cases of prematurity:
1. Stable baby, able to take oral feedings.
2. Good maternal milk supply.
3. A breastfeeding support person who can work consistently with
the mom and baby while they are learning how to breastfeed.
Since a lactation consultant may not be available for the first breastfeeding, here are some tips for the nurse on how to get the mother and baby started:
Positions for Premature Infants
Premature infants are sometimes difficult to place at the breast
in cradle hold. A modified football hold will help the mother
latch the baby on, especially if the infant has an IV line and
monitor cables.
The latch-on process remains the same except, mother may wish to place her hand in Dancer Hold position. In the full term infant fat pads in the cheeks provide support for the lower jaw. The preterm infant normally has very little subcutaneous fat so the "suck pads" may not be fully developed. The premature infant may need external support for his jaw.
For the first feeding,
Much controversy exists over test weighing before and after feedings
as a measurement of breastmilk intake (1 ml of breastmilk weighs
1 gram). Only the newer sophisticated electronic scales can give
an accurate estimate of the infant's intake at the breast. The
baby can then be complemented with additional EMM (expressed Mother's
Milk) as needed. (Riordan and Auerbach 468) The weight of the
infant before and after feedings should in no way be conveyed
to the mother as a measure of breastfeeding success.
The first feedings are a get acquainted period and not true feedings for nourishment. The number of nonnutritive breastfeedings decrease as the infant matures. During these initial breastfeedings, the infant may not take a measurable amount of milk. Assure the mother this will improve as the baby matures .
The infant should not be discharged "breastfeeding" unless he is feeding very well and there is adequate follow-up. If possible, contact a lactation consultant and arrange an appointment in the lactation clinic immediately after hospital discharge.
Copyright Marie Davis, RN, IBCLC 1999
Revised