Breastfeeding the preterm infant
- Steven A Abrams, MD
Steven A Abrams, MD
- Section Editor — Neonatology
- Professor, Department of Pediatrics
- Dell Medical School at the University of Texas at Austin
- Nancy M Hurst, PhD, RN, IBCLC
Nancy M Hurst, PhD, RN, IBCLC
- Assistant Professor
- Baylor College of Medicine
Human milk is recognized as the optimal feeding for all infants because of its proven health benefits to infants and their mothers. The World Health organization (WHO), the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), and the United States Preventive Services Task Force all recommend breastfeeding for the first six months of life [1-5]. (See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)
However, mothers of vulnerable infants, such as preterm infants, encounter a variety of unique breastfeeding barriers and challenges that result in a decreased rate of breastfeeding in preterm compared with term infants [5,6]. As an example, in Massachusetts, breastfeeding initiation rates were 77, 70, and 63 percent in term infants, infants born between 32 and 36 weeks gestation, and those born between 24 and 31 weeks, respectively . These results emphasize the need to address the breastfeeding barriers in the maternal-preterm infant dyad, especially as the benefits of human milk are well-established in these infants. (See "Human milk feeding and fortification of human milk for premature infants", section on 'Advantages of human milk'.)
Breastfeeding the premature infant, including strategies to address the challenges unique to the infant-mother pair, will be reviewed here. The nutritional composition of human milk, fortification of human milk for premature infants, and approach to enteral feeds in the preterm infant are discussed separately. (See "Nutritional composition of human milk and preterm formula for the premature infant" and "Human milk feeding and fortification of human milk for premature infants" and "Approach to enteral nutrition in the premature infant".)
There is strong evidence that a combination of prenatal and postnatal educational and support interventions improve breastfeeding rates for all new parents, which is discussed separately. (See "Breastfeeding: Parental education and support".)
In the neonatal intensive care unit (NICU), further educational efforts are needed to address the specific breastfeeding needs of parents with preterm infants. In most cases, mothers who deliver prematurely have not made a final decision on whether to breastfeed their infant and may not have the necessary information to make an informed decision. Clinical staff should discuss the benefits of human milk, including the long-term effects of exclusive breastfeeding. In most cases, mothers opt to feed their infant breast milk, and are willing to express when they learn about the benefits of human milk .
- Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129:e827.
- World Health Organization. Global Strategy for Infant and Young Child Feeding (2003). www.who.int/nutrition/publications/infantfeeding/en/index.html (Accessed on April 10, 2009).
- U.S. Preventive Services Task Force. Primary care interventions to promote breastfeeding: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2008; 149:560.
- Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects. Obstet Gynecol 2007; 109:479.
- Merewood A, Brooks D, Bauchner H, et al. Maternal birthplace and breastfeeding initiation among term and preterm infants: a statewide assessment for Massachusetts. Pediatrics 2006; 118:e1048.
- Donath SM, Amir LH. Effect of gestation on initiation and duration of breastfeeding. Arch Dis Child Fetal Neonatal Ed 2008; 93:F448.
- Meier PP. Breastfeeding in the special care nursery. Prematures and infants with medical problems. Pediatr Clin North Am 2001; 48:425.
- Lee HC, Gould JB. Factors influencing breast milk versus formula feeding at discharge for very low birth weight infants in California. J Pediatr 2009; 155:657.
- Hoban R, Bigger H, Patel AL, et al. Goals for Human Milk Feeding in Mothers of Very Low Birth Weight Infants: How Do Goals Change and Are They Achieved During the NICU Hospitalization? Breastfeed Med 2015; 10:305.
- Kirchner L, Jeitler V, Waldhör T, et al. Long hospitalization is the most important risk factor for early weaning from breast milk in premature babies. Acta Paediatr 2009; 98:981.
- Fugate K, Hernandez I, Ashmeade T, et al. Improving Human Milk and Breastfeeding Practices in the NICU. J Obstet Gynecol Neonatal Nurs 2015; 44:426.
- Dodrill P, Donovan T, Cleghorn G, et al. Attainment of early feeding milestones in preterm neonates. J Perinatol 2008; 28:549.
- Medoff-Cooper B. Multi-system approach to the assessment of successful feeding. Acta Paediatr 2000; 89:393.
- Nyqvist KH. Early attainment of breastfeeding competence in very preterm infants. Acta Paediatr 2008; 97:776.
- Maastrup R, Hansen BM, Kronborg H, et al. Breastfeeding progression in preterm infants is influenced by factors in infants, mothers and clinical practice: the results of a national cohort study with high breastfeeding initiation rates. PLoS One 2014; 9:e108208.
- Nyqvist KH, Sjödén PO, Ewald U. The development of preterm infants' breastfeeding behavior. Early Hum Dev 1999; 55:247.
- Hedberg Nyqvist K, Ewald U. Infant and maternal factors in the development of breastfeeding behaviour and breastfeeding outcome in preterm infants. Acta Paediatr 1999; 88:1194.
- Simpson C, Schanler RJ, Lau C. Early introduction of oral feeding in preterm infants. Pediatrics 2002; 110:517.
- Lau C, Kusnierczyk I. Quantitative evaluation of infant's nonnutritive and nutritive sucking. Dysphagia 2001; 16:58.
- Pickler RH, Best AM, Reyna BA, et al. Predictors of nutritive sucking in preterm infants. J Perinatol 2006; 26:693.
- Fucile S, Gisel E, Lau C. Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. J Pediatr 2002; 141:230.
- Foster JP, Psaila K, Patterson T. Non-nutritive sucking for increasing physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev 2016; 10:CD001071.
- Blaymore Bier JA, Ferguson AE, Morales Y, et al. Breastfeeding infants who were extremely low birth weight. Pediatrics 1997; 100:E3.
- Meier P. Bottle- and breast-feeding: effects on transcutaneous oxygen pressure and temperature in preterm infants. Nurs Res 1988; 37:36.
- Meier P, Anderson GC. Responses of small preterm infants to bottle- and breast-feeding. MCN Am J Matern Child Nurs 1987; 12:97.
- Berger I, Weintraub V, Dollberg S, et al. Energy expenditure for breastfeeding and bottle-feeding preterm infants. Pediatrics 2009; 124:e1149.
- Pineda R. Direct breast-feeding in the neonatal intensive care unit: is it important? J Perinatol 2011; 31:540.
- Lau C, Sheena HR, Shulman RJ, Schanler RJ. Oral feeding in low birth weight infants. J Pediatr 1997; 130:561.
- Kavanaugh K, Mead L, Meier P, Mangurten HH. Getting enough: mothers' concerns about breastfeeding a preterm infant after discharge. J Obstet Gynecol Neonatal Nurs 1995; 24:23.
- Meier PP, Engstrom JL, Fleming BA, et al. Estimating milk intake of hospitalized preterm infants who breastfeed. J Hum Lact 1996; 12:21.
- Scanlon KS, Alexander MP, Serdula MK, et al. Assessment of infant feeding: the validity of measuring milk intake. Nutr Rev 2002; 60:235.
- Haase B, Barreira J, Murphy PK, et al. The development of an accurate test weighing technique for preterm and high-risk hospitalized infants. Breastfeed Med 2009; 4:151.
- Funkquist EL, Tuvemo T, Jonsson B, et al. Influence of test weighing before/after nursing on breastfeeding in preterm infants. Adv Neonatal Care 2010; 10:33.
- Meier PP, Brown LP, Hurst NM, et al. Nipple shields for preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact 2000; 16:106.
- Clum D, Primomo J. Use of a silicone nipple shield with premature infants. J Hum Lact 1996; 12:287.
- Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database Syst Rev 2016; :CD005092.
- Shaker CS. Cue-based feeding in the NICU: using the infant's communication as a guide. Neonatal Netw 2013; 32:404.
- Shaker CS. Cue-based co-regulated feeding in the neonatal intensive care unit: supporting parents in learning to feed their preterm infant. Newborn and Infant Nursing Reviews 2013; :51.
- Watson J, McGuire W. Responsive versus scheduled feeding for preterm infants. Cochrane Database Syst Rev 2015; :CD005255.
- Mizuno K, Kani K. Sipping/lapping is a safe alternative feeding method to suckling for preterm infants. Acta Paediatr 2005; 94:574.
- Yilmaz G, Caylan N, Karacan CD, et al. Effect of cup feeding and bottle feeding on breastfeeding in late preterm infants: a randomized controlled study. J Hum Lact 2014; 30:174.
- Abouelfettoh AM, Dowling DA, Dabash SA, et al. Cup versus bottle feeding for hospitalized late preterm infants in Egypt: a quasi-experimental study. Int Breastfeed J 2008; 3:27.
- Collins CT, Ryan P, Crowther CA, et al. Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ 2004; 329:193.
- Collins CT, Gillis J, McPhee AJ, et al. Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Database Syst Rev 2016; 10:CD005252.
- American Academy of Pediatrics. Nutritional needs of the preterm infant. In: Pediatric Nutrition Handbook, 7th ed, Kleinman RE, Greer FR (Eds), American Academy of Pediatrics, Elk Grove Village 2014. p.83.
- Hill PD, Ledbetter RJ, Kavanaugh KL. Breastfeeding patterns of low-birth-weight infants after hospital discharge. J Obstet Gynecol Neonatal Nurs 1997; 26:189.
- Lawrence RA. Breastfeeding support benefits very low-birth-weight infants. Arch Pediatr Adolesc Med 2001; 155:543.
- Meerlo-Habing ZE, Kosters-Boes EA, Klip H, Brand PL. Early discharge with tube feeding at home for preterm infants is associated with longer duration of breast feeding. Arch Dis Child Fetal Neonatal Ed 2009; 94:F294.
- Meier P, Patel AL, Wright K, Engstrom JL. Management of breastfeeding during and after the maternity hospitalization for late preterm infants. Clin Perinatol 2013; 40:689.
- Hackman NM, Alligood-Percoco N, Martin A, et al. Reduced Breastfeeding Rates in Firstborn Late Preterm and Early Term Infants. Breastfeed Med 2016; 11:119.
- Meier PP, Engstrom JL, Crichton CL, et al. A new scale for in-home test-weighing for mothers of preterm and high risk infants. J Hum Lact 1994; 10:163.
- Hurst NM, Meier PP, Engstrom JL, Myatt A. Mothers performing in-home measurement of milk intake during breastfeeding of their preterm infants: maternal reactions and feeding outcomes. J Hum Lact 2004; 20:178.
- PARENTAL SUPPORT
- PRETERM INFANTS BELOW 34 WEEKS GESTATION
- - Nonnutritive sucking
- - Position
- Assessment of milk intake
- Test weighing
- Inadequate milk intake
- - Milk production
- - Milk transfer
- Transition to full breastfeeding
- - Modified demand-feeding schedule
- - Supplementation
- Discharge planning
- LATE PRETERM INFANTS
- Discharge planning
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS