When your baby is in NICU trying to building a breastfeeding relationship can be challenging. In my last blog we looked at ways to support families in NICU to get breastfeeding of to a good start.
After supporting a mother in the early days to build and maintain a good supply of milk it may be weeks before breastfeeding attempted and many more weeks before breastfeeding can be established. So when is it the right time for attempting to place a premature baby to the breast?
In order to breastfeed a baby needs to be able to co-ordinate not only the ability to suck and swallow, but also the ability to co-ordinate sucking and swallowing with breathing. A baby’s sucking ability may be present from around 28 weeks’ gestation however sucks will often be irregular and the baby will tire easily. At first the baby may show a suck/swallow pattern but will only take breaths when baby the pauses in feeding. As the baby becomes older and stronger sucks become more co-ordinated with swallowing and then breathing. It is this co-ordination of suck, swallow, breathing that is essential for good milk transfer. Most premature babies will start to co-ordinate these around 32–36 weeks gestation, and so this is an ideal time to try transitioning baby to the breast provided baby is tolerating NG tube feeds and is showing signs of swallowing and non-nutritive sucking sometimes on hands or a dummy. It is also important of course that baby is physically stable with stable respirations.( usually over 70 bpm) As soon as the baby is extubated time at the mothers breast can be started. Continuous Positive Airway Pressure (CPAP) is not a problem for non-nutritive sucking or trying baby to the breast.
This is where previous skin to skin really benefits both mother and baby. Time doing skin to skin will enable baby to develop instinctive reflexes such as rooting and mouthing. It also allows a mother to gain confidence in handling her baby which will help greatly when it comes time to try breastfeeding.
So how can a premature baby be encouraged to suck at the breast?
One way is by allowing the baby time at the breast to attempt sucking, it may help to do this after a mother has recently expressed so her breast is softer. At first the baby may only lick the nipple this is fine as it will also help stimulate the hormones for milk production. At its mothers breast the baby is warm and comfortable which is important to help both relax, hand expressing a little milk onto the nipple allows the baby to smell, lap or lick milk. It is possible to then tube feed the baby at the same time so that a connection is made between being at the breast, sucking and the taste of milk with getting a full tummy.
As the baby develops stronger sucking and good co-ordination is observed with swallowing and breathing then progression to breastfeeds can begin.
It is important that a mother is supported to position and attach her baby at the breast. Positions such as biological nurturing is often very beneficial as the baby will be use to being in a similar position from skin to skin. It is important that a premature baby’s head is supported as the neck muscles are weaker than those of a full term baby. This should be done in a way that still enables movement of the head but provides stability. A cushion can be an aid if placed under the baby’s bottom or moms arm to help with the weight but should not be used to rest baby on as this prevents movement of the baby’s head and also will make the mother go to her baby instead of bringing the baby to her. Once a mother is feeling confident with attaching her baby to her breast breastfeeds can be increased.
If a baby is struggling to latch especially if instead of cup feeds baby has been having some bottle feeds, it can sometimes be helpful to use nipple shields. Nipple shields are available for premature babies and the mother should be given support to use the correctly.
Trying to transition from NG tube feeds or cup feeds to breastfeeding can be a real challenge for the mother and staff. Often babies in NICU will be on a strict feeding plan of set hours and amounts of milk. When a baby breastfeeds it isn’t possible to be certain regarding the amounts of milk the baby is effectively removing from the breast. This can be difficult for the mother as she will be use to her baby being on strict amounts for feeds, she may worry how much milk her baby is getting and may feel unsure in her ability to breastfeed her baby. It is important that staff provide encouragement, support and help build confidence in her breastfeeding. Explaining to a mother that it will take time to build up breastfeeds is also important, premature babies will tire easily and may feed well at one feed but may struggle the next time. This is normal and will take time and patience. Teaching breast compressions will enable a mother to help her premature baby to effectively take more milk. It can be easy for a mother to become discouraged and feel like her baby is not transitioning well to breastfeeding. Kindness and reassurance goes along way in helping support a family while baby matures and learns this new skill.
Of course it can be a huge challenge for staff too as feeding schedules will change and more time will need to be spent with mother and baby offering help, support and reassurance, something that is difficult when there are so many babies requiring care. Careful assessment of feeds will be needed and staff may not feel adequately trained to do this. Trying to move to responsive feeding may also mean changes in care routines, expressing times and doctors rounds!
It will take time, patience and perseverance.
Another challenge that may arise is a premature baby may not exhibit feeding cues and so responsive breastfeeding will take time to establish. After being on a feeding plan of NG tube feeds, hourly then two hourly then three hourly the premature baby has never really been hungry. Communicating for food has not be necessary. At first trying to stir baby to put to the breast can take some doing, especially if the hours before have involved tests or cares that may have tired baby. It is important while baby is transitioning that feeds do not get too far behind schedule, so attempting to place baby to the breast can be attempted for a time but if baby is showing no signs of latching then a tube or cup feed should be done and baby tried again later. As baby becomes stronger and breastfeeding progresses feeding schedules should be relaxed and baby allowed to feed responsively, the mother looking for her babies feeding cues. In order for responsive feeding to be successful a mother needs to be with her baby as much as possible, offering as much time at the breast as possible. For this to be possible may be hard on a family especially if there are other children at home to care for and so support and practical help will be needed to support mother and baby. Some NICU have flats where mother and baby can stay together for 24/48 hours prior to discharge to fully establish breastfeeding and to assess feeding.
Its not just baby that can find transitioning to breastfeeding hard. One challenge can be issues with the mothers milk ejection. From the birth of her baby a mother has become use to hand expression or expression of her milk via a pump. Sometimes when her baby is put to the breast there can be a delay in her let down of milk reflex. Support can be offered to help this by either first hand expressing or using her pump to stimulate her let down before placing baby to the breast or she can pump the other breast while feeding her baby till her milk lets down.
Another challenge for mothers is the logistics of the transition. For weeks she will have been in a schedule of expressing every three hours. Now she will also be putting her baby to the breast. She may wonder about how many times she now needs to express and if she should reduce expressions. Its important that a mother continues to express until her baby has fully established breastfeeding. At first when baby is taking only a few sucks, licks, expressing 2/3 hourly should continue. As feeding progresses a mother can reduce expressions as her baby increases feeds. If her baby goes to the breast and effectively takes a full feed then a mother may chose to not express or express what is left in her breast to store or hand express the other side. Careful assessments of breastfeeds by staff is important to determine feeding is progressing well before expressing can be reduced.
If a mother is mixed feeding or topping up breastfeeds with formula it is important that she is given information on how to maintain her supply, the use of bottles and teats, how to make up feeds safely and to slowly reduce top ups should she wish to do so.
How can a mother be supported to know her baby is feeding well both in hospital but more importantly on discharge?
Support must be given to build confidence in a mothers ability to provide for her baby. Going home can be scary and so having information she can draw up on to help her feel more confident with feeding is important. Good support from qualified staff is important and should include.
- Showing a mother signs to look for that her baby is latched well to the breast.
- Explaining the three stages of sucking her baby will do at the breast and how to know if her baby is accessing a full feed.
- Nappies, urine and stools of appropriate amounts.
- Number of feeds in 24 hours.
- What to do if her baby becomes reluctant to feed.
- Where she can access support in community.
- How to mixed feed, make up bottles and store EBM safely and correctly at home.
Providing support will empower a mother and thus help breastfeeding become established. Signposting to local support groups with qualified support can help encourage and maintain her breastfeeding journey.
Yes having a baby in NICU is challenging especially when it comes to feeding. However with the right help and support the challenges can be overcome and a successful breastfeeding journey is possible. The joy that a mother feels when she first puts her baby to the breast is one of the many magical and scary moments in NICU. Yes it will take time, yes it will take patience and perseverance and yes there will be some tears along the way. But having the privilege to support families on this amazing journey is truly a gift and what a gift we can give in helping a mother to feed her beautiful baby.