By Terri Bailey, CRNP, IBCLC

You’re excitedly awaiting the birth of your baby. You know you want to breastfeed. Then the unexpected happens. Your baby has to go to the neonatal intensive care unit (NICU).

Possibilities include; prematurity, respiratory problems, infections or low blood sugar. It is common for parents of infants who are admitted to the NICU to experience feelings of anger, disbelief, sadness, shock, denial and panic.

Now what do you do?

Stand by your decision to breastfeed, which is one of the only things that you can do for your baby that no one else can. Breastmilk is easier to digest than formula. Colostrum produced during the first few days sticks to the infant’s intestines and protects it from bacteria that can cause infection. Substances in breastmilk help the premature infant’s GI system to mature. Living white blood cells in the breastmilk help to decrease the risk of infections, specifically one called necrotizing enterocolitis, which is an infection that can cause parts of the intestine to die. This infection is most common in premature infants. Breastmilk contains antibodies, which are living substances made by the mother’s body when she is exposed to germs in the environment that can help protect your infant from illness.

What You Need to Know About Premature Infants

Premature infants have a weak suck, have difficulty coordinating their suck, swallowing and breathing and tire easily. Lower muscle tone and sucking pressures make it more difficult to draw the nipple and areola into the mouth. Rooting, which is turning toward the cheek that is touched, is usually seen around 32 weeks gestation. Coordination of suck, swallowing and breathing is seen between 32 to 35 weeks gestation. From 32-34 weeks gestation, some infants may be able to direct breastfeed once or twice/day. Premature infants do not wake up on their own to eat until closer to full term. They can fool you sometimes. It may look like they are sucking well at the breast but do not do a good job at transferring milk from the breast.

Expressing Breastmilk for Your Premature/Sick Infant

Begin pumping as soon as possible after the birth of your infant, preferably within 6 hours or sooner. Use the hospital’s double electric breastpump every 3-4 hours for 15 to 20 minutes. This frequency will help to establish and maintain an adequate breastmilk supply. Be sure to wash your hands before pumping. No special care is needed for your breasts other than routine showering/bathing. Use a new double breastpump kit with the correct flange size. Wash your breastpump parts in hot soapy water after each pumping. Rinse well and air dry upside down on a clean towel.

Don’t become discouraged if you are unable to express colostrum or only get a few drops initially. The key is to continue to pump regularly. Try not to worry about how much breastmilk you are able to pump. Each mother is different. Any amount of breastmilk will benefit your infant. Use the breastmilk containers that the hospital gives you to collect your breastmilk. Preferred containers are hard-sided with airtight lids. Be sure to mark the date and time on the container along with your infant’s name and medical record number. Some hospitals will give you printed labels with this information on it. Most containers are made so that you can pump directly into them.

When your infant starts feedings, it will be in small amounts to make sure that it is tolerated. Start storing your breastmilk in smaller quantities, so that minimal amounts are wasted when it is defrosted. Arrange to rent a hospital grade double electric breastpump to use when you are discharged from the hospital. We rent this in our office. Call for pricing. Fresh breastmilk is preferred, so once your infant is receiving breastmilk and you will be visiting daily, the NICU nurses will use this. Fresh breastmilk should be refrigerated immediately within 1 hour. For premature infants, fresh breastmilk can be kept in the refrigerator for 48 hours. If not used within 48 hours, it should be placed in the freezer. Thawed breastmilk should be used within 24 hours. Transport your breastmilk to the hospital in a cooler with an ice pack.

Helpful Information Not Related to Breastfeeding

You probably will not be able to hold your infant immediately. How premature/sick your infant is will determine how soon you will be able to hold him/her. There are things that you can do other than holding your infant. Ask your infant’s nurse if you can place your finger in your infant’s hand. Gently cradling your infant’s head and feet with your hands can help make your infant feel more secure. Once your infant’s condition is stable, little things like taking the temperature and changing the diaper can help you feel more confident. NICU nurses will cluster your infant’s care, so that he/she can have optimal rest to help with growth and development. The nurses ask that you try to schedule your visits around the time that they are providing care and feedings, if you would like to participate in your infant’s care. Premature infants are very sensitive to being over stimulated by sound and light because of their immature nervous systems. Most NICU’s have dimmed lights and covers on the incubators.

Kangaroo care, in which your infant is clothed only in a diaper and hat and is held skin to skin with you, is another way to bond with your infant. It is helpful to wear a shirt that buttons down in the front so that it can be used to cover your infant along with a blanket. A hospital gown can also be used. Participating in kangaroo care before pumping has been shown in some cases to increase breastmilk supply. Kangaroo care has also been shown to help with transitioning to the breast.

Colostrum, your first breastmilk can be used to provide oral care for your infant. Initially your infant will be fed your breastmilk through a feeding tube that goes from the nose or mouth into the stomach. Ask your infant’s nurse if you can do kangaroo care while your infant is receiving his/her feeding through the feeding tube. If your infant is very premature, your breastmilk will be fortified with human milk fortified that has extra nutrients to help your infant achieve better weight gain. As your infant gains weight, the amount of fortifier will be decreased.

Pacifier use for the premature infant helps with better digestion and absorption of nutrients. Use during tube feedings has been associated with improved growth. When your premature infant is first put to the breast, he/she may not latch and breastfeed. Practice, practice for the both of you to become comfortable. When he/she latches and begins to suck, it may seem like they are sucking, but initially there may be minimal transfer of milk from the breast. As your infant matures and stamina improves, they will become better at breastfeeding.

Do not hesitate to go to your infant’s nurse with questions and be sure to ask for help from her and the lactation consultant. Establishing and maintaining an adequate breastmilk supply will require motivation and patience. The key to success is early and frequent pumping. Your infant will be able to fully breastfeed as he/she gets closer to term. As you watch your infant grow, pat your self on the back. You have done a great job making sure that he/she has the breastmilk that they need.

Terri Bailey retired from Kids Plus and the BFC in December 2022. She is a certified, licensed pediatric nurse practitioner, an IBCLC and former NICU nurse.