Feeding Issues

Feeding Issues


Feeding as all of us know is a major milestone in your premature babies development. We are focusing a section of the site on feeding because it's an area that there can be problematic for parents and our babies. Our aim to to try support parents in whateverfeeding choice they want for their baby, whether its your expressed breastmilk, donated breastmilk, breastfeeding or bottle feeding with formula.

As we are a parent focus group, we have a number of parents sharing their experience of expressing, breastfeeding and bottle feeding. We also have a number of very relevant links to help support parents who want to try breastfeed their baby and have some articles from members of the medical profession who actively encourage and support mothers to breastfeed their premature babies.

If you are going to hire a hospital grade breast pump, please check out our section on expressing, as we have lists of where you can hire them. Medicare and Neurotech have kindly agreed to give parents of premature babies in Ireland a discount when hiring a breast pump. Please quote Irish Premature Babies when hiring your breast pump.

Dianne Maroney, has graciously given us at Irish Premature Babies her very helpful insights as a mum of a prem and a NICU nurse with the following very good articles on feeding issues.

Feeding Issues in the NICU

By Dianne I. Maroney RN

Holding and feeding your premature infant should be one of the most precious moments you spend with your baby. Feeding is a symbol of parenting, an opportunity to make your child feel good and one where you can communicate with your child. But when a child is born premature, having these intimate feeding times can be challenging. Learning to suck, swallow, and coordinate breathing while eating is a major milestone for any infant, but for a premature infant whose brain function and muscle strength is immature, it can be even more difficult. Typically a preemie is not developmentally ready to suck until 24 weeks, suck and swallow at 28 weeks, and coordinate both sucking and swallowing until 32-34 weeks. If there are any medical complications such as lung disease or reflux, these abilities can be delayed even further. Preemie parents are often surprised at the difficulty in getting their child to eat and many times they feel lost as to how to help their infants.

The most important part of the feeding process parents can participate in to help their preemie is to learn their infant’s behavior. Preemies will give certain cues as to when they are ready to eat such as being quiet and alert with their eyes open. They may not be ready to eat if they are sleepy and turning their heads away. Your preemie’s nurse can help you recognize your preemie’s special cues. Also, it’s easy as parents to get locked in to worrying only about how much your infant consumes at each feeding, especially when those are the messages you get from the nurse or doctor. However, it’s also important to understand that when you are feeding your preemie, you are forming a relationship that will affect your child in many ways. Feeding supports a child through developmental milestones and helps with important growth, but it also gives your preemie positive attitudes about him or herself and the world around him. It’s critical that you understand your role in forming a feeding relationship with your child and keep the relationship around feeding a positive and supportive one.



Feeding Issues after the NICU



By Dianne I. Maroney, RN



A premature infant has come into the world with a different beginning. In his first few weeks or months he often faces many challenging obstacles that can take weeks, months, or even years to overcome. Learning to coordinating sucking, swallowing, and breathing is one of those important first obstacles. Accomplishing the difficult task of taking solids is next, and then taking solids with a variety of textures. There are many types of problems that can develop when a preemieattempts to learn these otherwise basic skills for many different reasons. A preemie may not be able to consume enough calories to gain weight because of his size or strength, he may not be able to swallow properly, feed himself adequately, he may take too long to eat, choke, gag, or vomit easily, and/or he may become very picky about what types of food heeats because of the texture of the food. Many of these problems are fairly common in former preemies. Some common cause might be: negative stimulation from the tubes, tastes, smells, etc. while in the NICU can teach a preemie that it’s unpleasant to have anything in or near his mouth; he may have some development differences that alter the way the muscles in his mouth work; and/or he may have some neurological problems that affect his ability to eat. Some feeding problems are directly related to medical problems such as Gastroesophageal Reflux.

There are some things parents can do to help their former preemies when they are at risk for developing feeding problems. First, it is very important to take away any painful or negative stimulation around the baby’s mouth, stomach,or intestines. For example, if your preemie has reflux, it’s extremely important that the reflux is under control and not causing any further pain that can be associated with eating. Second, concentrate on the feeding relationship between you and your baby (or child). So often, parents learn in the NICU that feeding is all about how much a preemie can consume at each feeding. Although the amount they consume is important, what’s equally important is the positive feeling a baby gets around feedings. Parents learn to parent through feeding their baby and babies learn about life initially through feeding. So concentrate as much as possible to keep the feelings around feeding time encouraging, relaxed, and fun (which may be very hard when things aren’t going well). Lastly, it’s important to support your preemie’s delays or problems with outside help. He may need an occupational therapist or speech/language pathologist to help him learn and develop appropriately. Ask your pediatrician or your local county early education programs about finding a therapist if you need one.

Because your preemie has had a different beginning he may need extra time to heal and grow. He may reflect this by having difficultly with eating. Be patient and support him nutritionally, physically, and psychologically so in time he candevelop typical eating habits and you both can enjoy mealtimes together. 
The Charity are running the expressing/breastfeeding course on the 8th of June 2013. Location to be announced.
Nicola O' Byrne will be running the workshop for the charity again.

Ten Tips to help express your breast milk for your premature baby.

1.      Colostrum. The first milk you produce after giving birth is called colostrum. This milk can be expressed by hand. Colostrum is very beneficial for your preterm baby as it contains immune boosting properties. Colostrum is produced in very small quantities but it is still extremely beneficial for your baby. A medical profession will show you how to hand express your colostrum.

2.     Early Expressing. To help establish and maintain a good milk supply, you should try to start expressing as soon after you give birth. The earlier you start expressing the better for your milk supply. When your breasts start to feel fuller, you will need to start using a breast pump.

3.     Double Pump. A double pump is the most effective in establishing your milk supply. The double pump helps to stimulate the release of the milk making hormone prolactin. Double pumping also reduces the amount of time that is spent expressing.

4.     8/10 times a day. For most women it is recommended to express at least 8/10 times in a 24 hour period with at least one overnight expression. For mothers of twins, it is recommended to express at least 10 times within a 24 hour period.

5.     Supply and demand basis. Frequent expressing gives a message to your breasts to make more milk for your baby. Breast milk is produced on a supply and demand basis. The more you express the more milk you make.

6.     Length of time to express. It will probably take between 25 and 30 minutes in total. If using a double pump kit then it will normally take about 15 minutes. The important thing is to express one side until the flow slows to drips and then switch to the other side and repeat. If you are expressing because your supply is low, switch back to the first side again. Switching back and forth, expressing each side 2 or 3 times will increase your supply over time. This is sometimes called switch pumping /expressing. Using “breast compression” to help drain your breasts will speed up the process as well as increase the amount you obtain. Breast compression means squeezing your breast gently (squeeze where the breasts meet the ribs, with your fingers on one side and thumb on the other) while expressing.   

7.     Night expressing. You have to pump at least once during the night. The hormone Prolactin produces breast milk and more prolactin is produced at night, so expressing at night is especially helpful for keeping up the milk supply. Have a picture or item of clothing belonging to your baby to hold when pumping

8.     Kangaroo Care. Kangaroo care is when you hold your baby is held skin to skin with you. The hormones that are released when you hold your baby close can help increase your milk supply. If your baby is too sick for kangaroo care, talk to the NICU staff about pumping beside your baby. Pumping next to your baby will make the most of your mothering hormones to increase your pumped milk supply.

9.     Dwindling supply. If you find that your milk supply never established very well or it is dwindling. There are a number of natural remedies or over the counter medications that you can try. If you contact a professional lactation specialist in your hospital or privately to help work with you. A list of contact details are supplied on this leaflet.

Donor Milk. There is a milk bank in Ireland that donates breast milk for premature babies while in the NICU if you are unable to express any milk.  Please ask the neonatal staff about donor milk.

Ten Facts about breast milk and expressing

1.      Expressing milk/ breastfeeding is beneficial to mothers, it lowers the risk of breast & ovarian cancer, uses up to 500 calories each day and is less risk of bone thinning in later life. 

2.      Breast milk provides health benefits for your baby, it helps to protect your baby from infections and diseases. It helps to lower the likelihood of NEC (necrotising enterocolitis) decrease the likelihood of type 2 diabetes, eczema & asthma. Some studies have also shown the babies fed breast milk have higher IQ’s in contrast to formula fed babies

3.      If you are stressed you will pump less. Try to relax as much as you can, rest and eat healthy and drink plenty of fluids.

4.      One recent study showed that the mothers of hospitalized babies who listened to relaxation or soothing music while pumping had an increased pumping output.

5.      If you wake up each morning and your breasts feel full, then you are sleeping too long through the night, this fullness can actually diminish your milk production.

6.      Mothers of premature babies frequently take a longer time to go from a few drops to an ounce or more at a pumping. This condition is referred to as a delayed onset of lactation, and is related more to pregnancy complications-such as bed rest, medications for high blood pressure and premature labour, and Caesarean deliveries-rather than to premature birth itself.

7.      Mothers of premature babies produce breast milk that is slightly different in composition, at least for the first several weeks, and this difference is designed to meet your baby’s particular needs. The premature milk is higher in protein and minerals, such as salt, and contains different types of fat that they can more easily digest and absorb.

8.      Breast massage during pumping sessions has been proven to dramatically increase milk supply. Massage breasts before you pump and while you're pumping for maximum benefit.

9.      Breast milk is easier to digest than formula and avoids exposing your baby’s immature intestinal lining to the cow’s milk proteins found in premature infant formula.

10.  The last droplets of milk released during pumping contain very high levels of fat, which provides most of the calories in your milk. If you stop pumping after 10 or 15 minutes while your milk is still flowing, your baby may not receive these valuable fat calories. you should use the pump until your milk has stopped flowing for at least 1-2 minutes

 

 

 

 

 

 

Expressing

Before you hire a breast pump we recommend that you contact your Public Health Nurse first to see if they can provide you with a breast pump. It has come to our attention that in some areas of Ireland, the Public Health Nurse can provide a mum with a breast pump. We are in the process of contacting the HSE and will report back as soon as possible.When expressing you can either buy a breast pump or hire a hospital grade type. We have included some guidance as to where you can hire a breast pump in Ireland and we are delighted to announce that both Medicare & Neurotech have kindly agreed to give our parents a discount when hiring a breast pump from them. In light of this kind offer we would recommend that parents avail of this opportunity. On behalf of Irish Premature Babies we would like to thank both these companies for wanting to help parents who have premature babies in Ireland. See the following links for contact details:

Medicare 12.5% discount on breast pump rentals
Neurotech 10% discount on all breast pump rentals
Price's Medical Centre

We have a very good article 'Expressing Milk for your Premature Baby' by Paula P. Meier.

A few mums have kindly offered to share their experience.
My story of expressing
Deirdre’s Story



Breast Pump Rental

Medicare

Medicare has kindly agreed to give parents of premature babies in Ireland a 12.5% discount on breast pump rentals. Please quote our organisation Irish Premature Babies with their sales staff when renting your breast pump. Medicare also provides an extensive range of breastfeeding and baby accessories, as well as respiratory monitors. For further information, check out the link to their website www.medicare.ie

You can call into their retail store.

Medicare Health & Living Ltd
Glencormack Business Park
Kilmacanogue
Co. Wicklow

The opening hours are:
Monday to Friday : 9.00am to 5.30pm
Saturday: 10.00am to 4.00pm

Ring them for a delivery at 01-2014900 or email them at info@medicare.ie

Neurotech

Neurotech has kindly agreed to give a 10% discount on all breast pump rentals for parents who have preterm babies in Ireland, please quote Irish Premature Babies to get your discount.

Neurotech are based in Galway and deliver nationwide to your home. They don't charge for delivery and they can also arrange a collection service from your home when you return your pump (standard fee applicable for this) Contact their freephone number for more details.

www.neurotech.ie

Freephone: 1800511511

You can also call into or ring the following chemists for neurotech breast pumps.

Moores Chemist, 
Unit 2,
McGoverns Corner,
Cork Street,
Dublin 8.
Tel :(01) 4542981

Hawkes Road Pharmacy,
Bishopstown,
Cork.
Tel : 021 4348331

Mulligans Pharmacy,
Waterford.
Tel: 051 820200

Prices Medical Centre is based in Dublin and will deliver nationwide.

Prices Medical Centre,
26, Clare Street,
Dublin 2,

Tel (01) 6761899

Expressing Milk for your Premature Baby

By Paula P. Meier, RN, DNSc, FAAN, Rush-Presbyterian St. Luke's,Medical Center.

Mothers' milk provides important health benefits for premature infants, so whether you've decided to express milk for a short time or to breastfeed for several months, your milk is an important part of your baby's treatment plan. Many people think that giving birth prematurely limits a mother's ability to make enough milk, but this is not true. The extra stress, discomfort, and fatigue that go along with the birth of a premature baby can cause a slow start with milk production. In the first few days after giving birth, mothers may make just drops of milk each time they use the breast pump, so it is easy to get discouraged. Remember, these drops are like a medicine for your baby, because they provide protection from infection. And this slow start usually gives way to an adequate milk supply by the fifth or sixth day after birth. Answers to the following common questions will help you get started with milk expression for your premature baby.

What Type of Breast Pump Should I Use?

Studies have evaluated the different kinds of breast pumps available to new mothers. The findings show that mothers who are expressing milk for premature babies should use a hospital-grade electric breast pump-ideally with a double collection kit, so that both breasts can be emptied at the same time. This type of pump is the most effective in stimulating release of the milk-making hormone, prolactin, which results in the greatest amount of milk. Mothers sometimes report that they have received a battery-operated or a less-powerful electric pump as a "baby shower" gift, and want to use it to express milk for their premature baby. While this type of pump is suitable for a mother who uses it only once or twice a day and breastfeeds a full-term baby the rest of the time, it does not provide enough stimulation to establish and maintain a good milk supply for a mother who is pumping for a premature baby. If you have received one of these pumps as a gift, you will be able to use it later-after your baby comes home and is feeding.well from the breast. But, in the first few weeks after premature delivery, you should plan to rent a hospital-grade electric pump.

How Often Should I Use the Pump?

During your first week or two of milk expression you should use the pump as frequently as 8-10 times daily-about as often as a healthy, full-term baby would feed at the breast in the early days after birth. The purpose of this frequent pumping is to stimulate prolactin during the time that your body is beginning to make milk in plentiful amounts. While you may get only drops of milk at first, frequent pumping is important in building an abundant, long-lasting milk supply. You may not see the results of your pumping immediately, but your efforts should pay off toward the end of the first week of milk expression. Do not set a clock to wake up at night to pump. However, if you wake up on your own-as many mothers do-an extra night-time pumping may help boost your milk supply. You may want to call the nursery, check in on your baby, and use the pump before going back to sleep.

How Long Should a Pumping Last?

In the first few days after birth, most mothers express very small amounts of milk-from a few drops to a few teaspoons-at each pumping. During this time, a pumping session should last from 10-15 minutes, which is enough time to stimulate the release of prolactin. However, after the milk has "come in" several days later, and you produce more than half an ounce at each expression, you should use the pump until your milk has stopped flowing for at least 1-2 minutes. The last droplets of milk released during pumping contain very high levels of fat, which provides most of the calories in your milk. If you stop pumping after 10 or 15 minutes while your milk is still flowing, your baby may not receive these valuable fat calories. Also, your breasts need to be emptied as much as possible--meaning that milk flow has stopped-otherwise your body thinks that the milk left in the breasts isn't needed, and less will be produced. A few mothers say that the milk never "stops" flowing while they pump. As a general rule, you should not pump for more than 30 minutes, even if milk continues to flow. Also, if you pump for this long at each milk expression, you do not need to pump as frequently as a mother who can express her breasts in less time.


What is a "Normal" Amount of Milk?

Nearly all mothers of premature babies worry about whether they are producing a "normal" amount of milk. Many things affect the amount of milk a mother produces-especially in the first few days after giving birth. A mother of a full-term breastfeeding baby produces only about an ounce of milk during the first 24 hours after birth, but by the 3rd or 4th day is making several times that amount. Mothers of prematures frequently take a longer time to go from a few drops to an ounce or more at a pumping. This condition is referred to as a delayed onset of lactation, and is related more to pregnancy complications-such as bedrest, medications for high blood pressure and premature labor, and Cesarean deliveries-rather than to premature birth itself. No one knows exactly why this is the case, but researchers think that the milk-making hormones or tissues in the breast may be affected temporarily by these complications and medications. A slower onset of milk production does not necessarily mean that a mother will not make enough milk for her baby-only that it may take her a few extra days in the beginning to catch up with mothers who have had uncomplicated deliveries. Ideally, by the end of the second week of pumping, you'll be producing at least 500 ml (about two cups) of milk each day. This is the amount of milk that your baby will need at the time of hospital discharge. Thereafter, you will want to maintain or even increase this amount so that you have enough milk to feed your baby after discharge hospital discharge.


Can I Do Anything to Increase My Milk Supply?

Fatigue, pain, and stress-all of which are common among mothers of prematures-cause the body to release a substance that interferes with prolactin. While it may be difficult for you to overcome all of these barriers, most of these do diminish or become more manageable over time. Some things have been shown to increase the milk supply. First, try to spend as much time in the nursery with your baby as possible during these early days, if that is where you are the most relaxed. Family members often feel that mothers should stay at home and rest after giving birth prematurely, but mothers report that being separated from their babies causes even greater stress. When you are in the nursery, request a comfortable chair, and use the breast pump at your baby's bedside where you can see and touch your baby. When you are not in the nursery, pump where you can see your baby's picture. If your baby's condition permits, ask to hold your baby in Kangaroo--or skin-to-skin-Care. Don't be afraid to take pain medications that your doctor has prescribed. These medications can be used safely with breastfeeding, and pain relief is important to milk production. In some instances, prescription medications may be used to stimulate prolactin and increase the milk supply. Typically these medications are used after the second week of lactation, and require a prescription from your obstetrical care provider.

©Rush-Presbyterian St. Luke's Medical Center
Rush Mothers' Milk Club
Special Care Nursery
Used under permission.

Written by Paula P. Meier, R.N., DNSc, FAAN, Rush-Presbyterian St. Luke's Medical Center.

Permission granted to distribute for non-commercial purposes

For additional questions and for help in transitioning your baby to the breast when the baby is ready, talk to your doctor, the NICU nurse at your hospital, and your IBCLC lactation consultant. For help in in finding a breastpump rental location or breastfeeding professional where you live, visit www.medelabreastfeedingus.com . You can e-mail the Medela online nurse lactation consultant, Kathleen Bruce, BSN IBCLC with any breastfeeding questions, askthelc@medela.com.

My story of expressing

My daughter was born 8 weeks premature. For her age she was a healthy weight of 2kgs, but to us she was tiny!
While I hadn’t given it a lot of thought, my intention was always to breastfeed. That’s what nature intended – so how hard could it be?

The day after she was born, a lovely nurse called Jade came along with the hospital pump. She showed me how to use the machine and so the process began. We started off slow, 10 minutes each breast every four hours and working up to 20 minutes each breast. A day later nothing had come!

The paeds nurse in ICU kept asking me for milk, even though at this point, as my daughter’s stomach was swollen they had her on an IV and wouldn’t be feeding her until they confirmed her stomach was okay. So back I’d go and hook myself up to the machine, hypnothised by the rhythmic chug chug chug of the machine, willing for a drop of milk or colostrum to appear in the plastic container.

Halleluiah! On the second day, a few drops, and I mean a few appeared! I made my way to the nurses’ station for their help to get this precious fluid in to the little bottles ICU had given. Well the nurse, obviously humouring me, got a syringe and tried to suck up literally 4 drops of milk! And proudly up I went to ICU with my produce! It was labeled and put in the freezer! And 4 days later this was my daughter’s first meal! They started tube feeding her very slowly at 2mls a feed.

Thankfully the milk started coming in faster and I kept up the routine of pumping every 4 hours around the clock. My right breast seemed to produce twice as much as the left, but I was getting about 40 mls every 4 hours so I thought I’d plenty so once I got to the 40mls I’d stop. I wish a nurse would have told me then to keep going! In the hospital I felt like my care and the babies care were very separated as she was in ICU. I believe if she'd been in the ward with me, that the one nurse would have been looking after us both and I think it would have been easier. For me, this was definitely a gap in the system.

When I left the hospital, I purchased the Medula Swing and kept pumping away. Before we knew it, our little one was up to 30/40 and then 50mls a feed. I struggled to keep up with her demand. It seemed no matter how much I expressed I could get no more then 40ml a go. It was difficult to fit in pumping too. I’d pump first thing in the morning, and then travel to the hospital with my baby’s breakfast! After I fed her that I’d go to the pump room and express her lunch! Once again before I’d leave I’d express, but it seemed I couldn’t provide enough for her and she was supplemented with formula. I felt deflated. I was exhausted and stressed and my supply just didn’t seem to increase. I spoke to the nurse and my mam, and both convinced me it that the baby getting 7 EBM feeds and 1 formula feed a day was still great. When the baby started with the bottle to get her suck reflex to work, we saw great results. Again I tried to get her to latch on, but she wasn’t interested. In my hurry to get her home, I left her to her bottles. I do regret not spending more time getting her to latch on, as it’s such an added effort to express and then feed a baby, especially at 4am!

When our daughter came home, I decided to hire out a hospital grade pump for a couple of months. It was great because it meant I spent less time pumping, but my supply didn’t increase much. I kept going until she was 14 weeks old. At this point she was doing great and I decided to stop expressing as I was exhausted.
I'm happy to have been able to provide expressed milk for my daughter at the beginning of her life, yes I would have loved to have kept going but thankfully today she is a happy healthy one year old and absolutely thriving.

Deirdre’s Story

(Lack of support for breastfeeding is not just something parents of prems encounter. Deirde has kindly shared her experience of how she managed to express for 19 months for her son)

I have always been very pro-breastfeeding and always knew that if I ever had children that I would breastfeed. Right through my pregnancy with my son Gearoid I never ever thought that I would have any problems. When Gearoid was born, after a long tough birth I was taken aback when he wouldn’t latch.

The midwife didn’t try to help me and just told me to try again later. We were landed on the postnatal ward and my husband was asked to leave as it was in the middle of the night. Gearoid started crying, I tried and tried to latch him all night and couldn’t get him to latch. I rang the bell a few times and each time a midwife came, looked annoyed, turned off the bell and said she would come to me when she had a chance, she never did, and she wasn’t too busy to help as I could hear her laughing and chatting with other staff down the corridor. 
By the time morning came Gearoid was in such distress, he was disturbing the other babies, he was hungry, I was exhausted as it was my third night without sleep and I asked for a bottle of formula, it arrived straight away- no problems getting help there!

I cried bitter tears giving it to him, but he was much happier. All that day I asked for help and didn’t get it- in fairness the staff that day were very busy. At 5pm and after a few more bottles of formula the female doctor who delivered Gearoid came to see me. I told her that I was getting no support with BF Gearoid, that I was fine, but exhausted, and wanted to go home. She granted my early discharge. I rang my husband and asked him to collect us.

On the way home we stopped at an all night chemist, where a bought the only pump they had- a hand pump, and a steriliser and bottles. That night I tried latching Gearoid, and pumping- neither successful. The next day I rang a friend in New York, who recommended a double electric pump- I went out and got it. Oh the absolute relief when I was able to express colostrum. Gearoid got his last formula bottle at 2 days old and got a colostrum bottle that evening. He never received formula again. Despite seeing a lactation consultant I was not successful in getting him to latch and I exclusively expressed for him for 19 months. He is the light of my life and I still feel very sad that I could not breastfeed him in the normal natural way, but I did my best. I often look of photos of me smiling with him in that hospital, but beneath that smile was a very worried and unhappy first time mom.

My very special daughter Eilis was born in February this year, and I prepared well by attending breastfeeding classes before the birth and making sure I got some support in the hospital. My husband also posted on the breastfeeding board with my questions from the maternity bed and that was a huge help. My daughter is now 12 months and I love love love breastfeeding her. We have had a few stumbling blocks along the way, but nothing that I couldn’t handle. It’s such an amazing magical experience- every feed is pure magic. I can’t explain it. The health benefits are brilliant obviously, but so is the experience. I’d get pregnant again just to BF!

How I exclusively expressed:

This is for anyone who is currently exclusively pumping.

I managed to pump exclusively for son for 19 months and never used formula, apart from the first few feeds. Gearoid simply wouldn’t latch. He had severe reflux and I got very little post natal BF support, a combination of both I think meant that we weren’t able to BF.

My daughter is currently on a nursing strike, she's 12 months and I am exclusively pumping for her too now, though hopefully she'll decide to like her mams boobs again, we have had the most wonderful 11 months of BF ever! I live in hope.

My knowledge in a nutshell:

Until baby is 6 weeks they take around 15 oz a day, after this from 19-30 oz a day, but every baby is different. Baby will take less if premature.

Until baby is 12 weeks you should express every 2-3 hours at least and for 15-20 minutes, to a total of 8-12 pumps in 24 hours. Also one pump should be overnight, although I stopped that once DS started sleeping through the night. Once your supply is established at around 12 weeks you can slowly reduce the number of times you express so long as you are still producing enough milk.

Express if possible into a feeding bottle for convenience and then store in the fridge (keeps for 3-4 days in the back of the fridge*). Keep the stock rotated so that you use the oldest milk first. Heat, in a cup of warm water, only to take the cold out of the milk as if you overheat it you destroy some of the antibodies. With a premature baby the general rule of thumb is to sterilise for each pumping session till term age- but this will depend on your paediatricians’ approval. With your paediatrician’s approval, at term age you can wash pump parts, in the dishwasher if you can to save even more effort, sterilise and between pumps store the parts in a freezer bag in the fridge. Any traces of milk then stays fresh there. They are fine then for around 12 -24 hours- this saves so much time and work.

Finally you need a good professional grade double electric pump - I found the medela pump in style great, the ameda Lactina is a fab pump too and cheaper than the pump in style advanced. Shop around - the prices of the above vary hugely. Several companies also rent professional grade pumps, from 75e-100e a month - so it works out cheaper to buy one of the above if you intend to exclusively pump for a while. PHNs quite often will lend a pump.

Kellymom.com has a good pumping message board. 
This link though was invaluable to me at the time:
http://www.messageboards.ivillage.com/iv-ppexcluspump
it’s a message board especially for exclusive pumpers and the advice is fab!

I got most of this info over the months of pumping from kellymom.com and the above ivillage forums so it’s all fine!

Also if you find you are not producing enough porridge, fenugreek tablets from the health food store, fennel tea, non alcoholic beer, and Motilium tablets are all very good for supply. Motilium is recognised as being very safe to use, but again get your paediatrician's approval. You can get more information on this by looking up domperidone on Kellymom.com.

I strongly recommend though that you see a lactation consultant or go to a BF support group, esp. if you want to attempt BF directly- you might get your baby latched and it would make life a lot easier. Go to www.friendsof breastfeeding.ie for lists of local support.

*please check with a phn or lactation specialist on the current recommendations in relation to storage of expressed milk for preterm babies.

Breastfeeding

Irish Premature Babies just recently ran an workshop on Breastfeeding & expressing for the premature baby. The course was paid for by the charity and open to the public and medical professionals. Nicola O' Byrne from breastfeeding support ran the course for us. Due to the success of the course we will be running it again in a few months. We are in the middle of setting up breastfeeding buddies so parents can talk to other mums who have successfully breastfeed or expressed for their preterm baby. We are also working on producing a booklet on breastfeeding.

If you have any expressing or breastfeeding problems and would like to talk to either an experienced mother or a professional lactational consultant, please contact the helpline and we will put you in touch with somebody. Our charity works with the help of a wonderful lactation specialist who has ample experience of helping prem mums. If you are not in a position to finance this, we will try to cover the costs of one visit and some follow up phone calls. 

Tips for Breastfeeding Your Premature Baby

By Azza Ahmed, DNS, RN, IBCLC, CPNP

Bringing Your Premature or Ill Breastfeeding Baby Home 

By Kathleen S. Kuhn, RN, BSN, IBCLC, and Megen J. Kuhn, RN, BSN 

Real mums' stories


Two mums have kindly shared their experience of getting their premature baby to breastfeed. We hope it will help any mums who are in a position to consider breastfeeding their baby.

Debra's experience of breastfeeding her son.

My failure & success at breastfeeding my premature babies


Information sheet - Breastfeeding your premature baby

Justine Diamond & Anne Casey courtesy of www.preemie-l.org have produced an informative and helpful sheet called "Breastfeeding your premature baby"

Article - Early attainment of breastfeeding competence in very preterm infants

The article "Early attainment of breastfeeding competence in very preterm infants" by KH Nyqvist of the Department of Women's and Children's Health, Uppsala University, Sweden is available. It explores the development of breastfeeding capacity in very preterm infants, as an immature sucking behaviour is often mentioned as a barrier in the establishment of breastfeeding. 

Tips for Breastfeeding Your Premature Baby

By Azza Ahmed, DNS, RN, IBCLC, CPNP 

Your(“premie”) baby. Breastfeeding a premie baby takes time and patience. It may be easier if you know why your baby acts the way he does. 

When will my premature baby be ready for breastfeeding?

Your premie is ready to breastfeed when he can suck, swallow, and breathe on his own. Your premie will have a good heart beat,easy breathing, and good skin color. Babies have 6 different ways of acting,from deep sleep to crying.

1. Deep sleep: No eye movement, no bodymovement, steady breathing

2. Light sleep: Some eye and body movement 3. Drowsy: Heavy eyelids that open andclose, some body movement

4. Quiet alert: Wide open eyes that look around. Breastfeeding may work best when your baby is “quiet alert”

5. Active alert: Eyes open, more body move- ment, fussing

6. Crying: Awake and upset

Watch your premie when he is just waking up (drowsy). When your baby is “quiet alert” and ready to breastfeed, he might:

1. Smack his lips

2. Stick out his tongue

3. Put his hands up to his mouth.

How do I know that my baby is getting enough milk?

While your baby is in the hospital, you can weigh him before and after breastfeeding

to see how much he drank. After your baby is 1 week old, look for:

1. A gain of about 1/2 to 1 ounce (14 to 28

grams) every day at 34 to 36 weeks.

2. Six or more wet diapers each day

3. Three or more poopy diapers each day

How will I know my baby is good at breastfeeding?

Lots of practice will help your premie learn how to breastfeed.

1. He will start out sucking 1 or 2 times, then stop to rest.

2. He may need to practice over many feeds to get strong and use a nice pattern to suck,

swallow, and breathe.

3. Babies love to practice!

Good sucking means your baby can keep sucking for more than 10 seconds before pausing. Some premies may be home before they can suck well. Good sucking may not happen in the hospital.

Look for:

1. A wide-open mouth as big as a yawn. Baby’s mouth will take in all of your nipple

and some of the darker colored areola.

2. A good sucking rhythm with 1 suck per second.

3. Baby swallows milk after every 1 or 2 sucks.

4. Baby stays on the breast.

5. Baby can suck and swallow several times in a row before he stops to rest.

How do I know my baby is drinking milk?

You may see milk at the corners of the baby’s mouth.

You may hear him swallow.

You can feel tugging when he sucks. The tug should feel like the breast pump.

How will I know if my babyis having a problem?

Watch your baby when you breastfeed. If your baby shows any of these Signs of stress, stop the feedingand give him a break.

Breathing fast

Hiccupping or coughing

Gagging or choking

Spreading his fingers

Fussing

Arching his back

Looking away from you or staring into space

If you think your baby is not getting enoughto eat, ask your health care provider or lactation consultant.


Bringing Your Premature or Ill Breastfeeding Baby Home

By Kathleen S. Kuhn, RN, BSN, IBCLC, and Megen J. Kuhn, RN, BSN


If your baby is born premature or ill they , he may start life in the the neonatal intensive care unit (NICU) of your hospital. He may stay only a day or two, or he may stay a few weeks or even months. Until he is able to breastfeed well, you will be expressing and storing milk. Once your baby starts to breastfeed, you will want to do it often. This will give him a lot of practice before going home. You will also want to continue to express your milk after each feed while your baby is learning to breastfeed. The lactation consultant will help you to know when you can stop expressing milk.

In the hospital, before your baby goes home

Ask the staff about your baby’s feeding routine when you go home.

Try to be at the hospital as much as you can so you can breastfeed often.

The more your baby practices, the faster he will learn to feed without any help or extra milk.

After your baby goes home

He may continue to need extra milk until he learns to breastfeed well.

Continue to feed your baby the same way he fed in the hospital for the first few days

at home. Make feeding changes slowly. Continue expressing your milk after feedings.

Continue to hold your baby skin to skin often

Gradually make feeding changes

For example: If your baby is breastfeeding 3 times per day and fed another way 5 times

per day, your first change might be to breastfeed 4 times per day and another way 4 times per day.

Continue to slowly increase the number of times your baby breastfeeds.

Gradually reduce the number of times you give expressed breast milk.

If your baby has been breastfeeding at each feeding and is also taking some extra milk

with each feed, slowly reduce the amount of extra milk you give after the feed.

Gradually decrease your pumping

Keep pumping until your baby is no longer given any extra milk.

Try to pump often enough so you can give the baby your milk when he needs extra milk.

Your baby’s doctor or lactation consultant will help you to slowly reduce the number of times you pump each day.

You can stop 1 or 2 of your pumps at first. Then, after a few days, you can stop another 1 or 2 pumps.

Do not keep dropping the number of times you pump if you feel engorged (breasts feel hard and painful) at any time.

It is important not to stop pumping all at once.

As you cut out pumps, continue to get your baby weighed weekly.

Your baby should keep gaining weight well before you stop pumping.

Continue to change the feedings slowly. Make changes only if your baby has enough wet or soiled diapers and is growing well.

Your baby should have at least 5 or 6 sopping wet diapers each day.

Your baby should make at least as many poops each day as when he was in the hospital.

Your baby’s doctor or nurse will tell you if the baby is growing well.

If your baby is growing well, that means he is getting enough milk.

Follow up care:

Take your baby to his doctor or nurse for all his appointments.

Remind your baby’s nurse or doctor that you are working toward full breastfeeding.

Your baby may need to be weighed often to be sure he is feeding well.

Call your lactation consultant anytime you are concerned about breastfeeding.

Signs your baby may not be getting enough milk:

Your baby will not wake up to feed.

Your baby will not stop crying.

Your baby is not making enough wet or poopy diapers.

Call your baby’s doctor right away if he has any of these signs. 

Debra's experience of breastfeeding her son.

I'm not Irish, I'm Canadian (Though I do have Irish roots, my great grandfather came from Dublin) Anyways, I can understand the stress and worry of breastfeeding with a preemie. My second son came early at just over 34 weeks. They never knew why, as until then all had been uneventful. One weekend, the week before he came, I was feeling very unwell (but didn't worry that much, as I'd been unwell almost the whole pregnancy), and as I was on all fours, suddenly I felt a small pop..and I knew what it was. I went in to have the fluids tested, they said nope it's not amniotic, but I knew it was, and went back the day insisting they test gain. This time, it did test positive. Due to being very, very strongly strep b+, they induced me (I cringed when they said it, but had done my research and knew it was safer that way, especially since the waters had been broken for close to 48 hours at that time...)

Anyways, lo and behold, my little Alex was born seven hours later, 5 lb 4oz. He was whisked away to be taken care of immediately, and I tried to sleep (had him at 8 pm ish). The next morning, I was told he'd been put on CPAP, but had pulled it out. They laughed and said that was a good sign...and while he was in NICU one of the nurses said, oh, he's got a little temper! And the funny thing is he still does (he's now just turned four).

So, all in all he did quite well. He had no trouble with breathing or maintaining his body temp, just had to stay to in NICU to learn the suck/swallow/breathe and also to make sure he gained weight. In the weight dept, he didn't do all that well...but once I got him home, he gained better (though in all honesty, he's a real lightweight, STILL, he's about 5-10% for weight but 50% for height, so a real string bean). I remember them (the doctors going around from baby to baby with their clipboards and notes) giving me a bit of the third degree and asking questions about me breastfeeding etc, and I finally said, I breastfed my first son to 18 months and he was in the 90% for weight...they backed off after that ;)

I did a lot of kangaroo care with him, and went to the hospital twice a day for nursing when he started to be able to (hubby went once a day too, to do kangaroo care and to visit). The first latch he ever did, was so good that one of the nurses asked for permission to show another new nurse what a good latch looked like. I was very lucky that he took to breastfeeding like a duck to water. Had he not, I was still very determined. I was told that, when I got him home, I should increase his feedings from bottle to breast over about the span of two weeks. It was looking like he preferred breast to bottle even in NICU (one of the nurses commented on it), and sure enough, he took about five days before he was on breast only.

I feel very blessed to have had the prior breast feeding experience to give me confidence. It can be difficult enough to learn how to breastfeed a full term child (my first child, born full term, and I went through a LOT during the first six months, I hung on but at times it was so overwhelming and challenging I would cry). It's THAT much more daunting to learn to breastfeeding a preemie!
BUT - it can be done.

First, you need to make sure you surround yourself with plenty of positive support.
If you are determined to make it work, and at give it your best shot, having someone trying to pressure you to just give in and give formula isn't good. If you can be paired up with a preemie mom who is breastfeeding that would be terrific. Secondly, do your research! Know where to go for advice (many family doctors are NOT up to date on breastfeeding and will often just say to switch to formula rather than help overcome obstacles that can be overcome). Third, be careful with bottles! There are other ways that baby can be fed that will help avoid nipple confusion/preference. I was lucky that my baby liked the breast over the bottle and I hadn't really thought about nipple confusion (Though, it was a challenge later when he flat out refused bottles when I had a five day hospital stint due to pancreatitis and then a gallbladder surgery... but we figured it out...).

Dr. Jack Newman has been known to respond to emails within 24 hours...if you're in need of help, try that. It's by email, but sometimes it can help allay worries, or clue you into something that no one told you about. And, really important, keep up your supply! I started pumping before I went to sleep that first night, and had the nurses wake me over night so that I could pump. Yes, it's a pain to wake up, but if the full term baby were hungry, you'd be feeding baby anyways...sleep deprivation comes with the territory, as we all know. 
I found the Medela Symphony worked really well for me, whereas other pumps had not (I make LOTS of milk but struggle with pumping...but I actually got a good supply of frozen milk, which ended up not being used as baby hated bottles).Drink well, eat well, rest as much as you can (HAHHAAA...I know, baby in NICU, who gets to rest??? But accept any offers of help, etc, or ask if you need to, in regards to other things, like cooking, cleaning, watching other children etc).Remember that milk comes in (mature milk) at differing rates. Give it a chance. You might be one of the women that takes a little longer, and that colostrum will do your baby a LOT of good!

It's absolutely a case of needing to teach yourself where to go for help/advice, and also educating yourself well.

That said, if you give it your all, and you only bf for five months, three months, or three weeks...don't beat yourself up. We do the best we can with what we know. And some breast milk is better than no breast milk. It's a really tough time when your baby is in NICU. I cried a lot, and he never had any real setbacks/problems! It's just emotionally difficult.

Do your best to give your baby your breast milk, as it is absolutely the best for him/her (I ended up breastfeeding Alex to around 19 months or so)...but don't harbour guilt if you did all you could and it didn't work.

My failure & success at breastfeeding my premature babies.

I had my first preterm baby at 30 weeks. He came home from hospital a bottle fed baby on bottles of expressed milk. I wanted to try get my son to breastfeed but I had no idea how to do it. I contacted several of the usual suspects and asked for some advice and most were unsure how best to get a preterm nipple confused baby to breastfeed. I was advised to contact a lactation specialist to get some help and I had arranged an appointment with one. However, events changed and my son was admitted into hospital seriously ill and fighting for his life. Unable to do anything for him, I thought at least I could continue pumping and give him some breast milk to help him. However under the stress of the situation and I know I was not eating, sleeping or drinking properly, my previously good milk supply started to dwindle and I had no idea how to rectify the problem and there was no one around to help me as I was staying in the hospital all the time. When my son recovered and was allowed home, he was close to six months and my milk supply was almost non-existent and I had to supplement some of his feeds. I finished expressing at six months and within a week or so, my freezer supply was gone. It was almost a relief to finish, it was so frustrating pumping tiny bits of milk, it made me feel so inadequate and I felt I had let down my son all over again, the first time I let him down. I failed to carry him to term and now I could not feed him the way I had wanted. I would have liked to either express longer or get him to breastfeed but neither worked out through a lack of knowledge or the right support.


When pregnant again, I decided to spend some time reading up on breastfeeding and expressing. I found the internet a brilliant source of information. It was only through research that I realised that I never got the advice, support or the correct information about expressing or breastfeeding and this, in conjunction with a very stressful situation, ended my hopes of ever breastfeeding and of expressing. I was determined to give myself the choice to choose the method of feeding I wanted for my baby whether it was a full term or another preterm. It ended up I went into labour at 31 weeks so it was another preterm. Only this time, while I was sent to HDU, my husband went to the NICU and told the staff to put a sign on the incubator that no bottles were to be given. The baby was doing really well and was tube fed for a while. I was allowed to hold him on day six and every day after that I did kangaroo care and put him to my breast. Most days he did nothing at the breast but the odd day, he gave me a little lick. The time came for him to be introduced to an independent method of feeding and in most cases this starts with the bottle in Ireland. I was really nervous of introducing a bottle because I had already come home with a nipple confused premature baby and really did not want to go down that route again. I tried to explain my fears to staff to the NICU and sadly on the whole it was not met with much empathy. In the end after a very tearful conversation with a doctor and senior nurse, I gave in and reluctantly agreed for the sake of son to allow him to be bottle fed. Without the NICU staff I would not have my two beautiful sons and for that I will eternally grateful, and I have met some amazing people in the medical profession, but I feel that many women like myself are being let down and not getting the right support in relation to breastfeeding. When you have a term baby, you see your baby first, you wash them first, you change their nappy first, you cuddle them first and you choose how to feed them, when you have a preterm baby, all your “firsts” are taken away and all you have is feeding and for me breastfeeding is the one thing that only I could do as my baby’s mammy.
When I brought my son home, he was bottle fed just like his brother, but I was absolutely adamant that I was going to get this one breastfed.

Within a day of coming home, I had hired a lactation specialist to work with us. She recommended we try nipple shields first, to make it easier for him to feed as he was only 35 weeks. We tried him on the nipple shields for almost every feed first but he got so tired he practically stopped feeding at all, so we amended it to alternate feeds, one feed at the breast using a nipple shield followed by a bottle feed. It was a little time consuming as after the” feed” on the nipple shield I ended up giving him top ups in the bottle and then had to express. He just seemed to show no interest and all he wanted to do was sleep. I tried every trick I could think of to keep him awake to feed but if he wanted to sleep that was it. He had problems with jaundice since he was born and still had, so this did not help matters at all. I was getting a bit frustrated but I had a very supportive husband, public health nurse and lactation specialist who helped me when I felt like throwing the pump & nipple shields out the window. A few more weeks followed like this and we decided to try a SNS system of feeding. In theory I loved what this machine could do but it was not for me. I found it a bit messy and the tubes kept falling out. It was around week 14 now and despite all our best efforts, breastfeeding was not happening. I was thinking of just expressing full time because I was wore out, my milk supply had dropped but thankfully I went on to motilium and it resumed within a few shorts days. My lactation specialist came over for a visit and as usual we tried to breastfeed. But this time, it was different, he opened his mouth wide enough so she could latch him on and miraculously he breastfed for the first time. I could not believe it, I was delighted, it was short lived as he refused for the next feed but he took it the feed after that. We started off it one or two breastfeeds a day, sometimes followed by a top up. Gradually over a period of about two weeks, he breastfed more than bottle fed, the tops were gone and he was gaining good weight. Still had to continue doing some expressing until he learnt to breastfeed more proficiently. When he eventually made the transition to full breastfeeding, it would take him an hour for each feed but as he got stronger, his feeding time reduced. I eventually managed to get him away from the set feeds and he was feeding on demand. He is almost a year now and we are both still enjoying breastfeeding and I am so glad I stuck with it even though I felt like stopping a few times. It’s so easy and I took great delight in sending back my pump. It took me a while but his jaundice was an issue and if my son learnt to breastfeed and if you have the right support and advice it can really makes the difference. I am glad, thanks to the support I received, that I got to breastfeed my prem.


Breastfeeding your premature baby

by Justine Diamond and Anne Casey

For most new mothers, breastfeeding is something you expect to happen as a natural result of childbirth. When a baby arrives prematurely, you are suddenly thrust into a critical life and death situation. Your baby will be rushed off to intensive care to be hooked up to breathing tubes, IVs and monitors. You may not be able to touch or hold her. The baby's immediate care seems to eclipse every other concern and thought you may have had. So now you may ask, with some concern "Can I still breastfeed my baby?"

Yes, you can. There are many good reasons for supplying your baby with breastmilk. It is something that only you can do, and it enables you to take a more active role in the baby's care. The breastmilk of mothers who deliver prematurely is ideally suited to the special needs of the premature baby. Colostrum and breastmilk contain white blood cells, antibodies and other valuable immune properties that may help a premature baby resist infection. Recent studies have shown that breast milk may improve the neurological development of premature infants.

It isn't easy. Supply can be very difficult to build up and maintain. You'll need to use a breastpump until your baby is mature enough for direct breastfeeding, and sometimes for longer. Here are some basic questions and answers to help get you started while your baby is still in hospital:

1. When can my premature baby begin to breastfeed?

If your baby is stable and relatively well, breastfeeding can be gradually introduced from about 32-33 weeks. Before this stage, expressed breastmilk can be given to your baby via a gavage tube, and baby's interest in breastfeeding encouraged by the skin-to-skin contact of kangaroo care.

2. How do I get started?

You'll need to begin expressing by the day after your baby's birth, and even earlier if possible. Some mothers prefer to begin with hand expressing. A nurse or lactation counsellor should show you the proper way to express either by hand or with a breastpump. Once your milk has come in, you'll need to begin using a good breastpump. The pump may feel uncomfortable at first, so try to use a low setting. In time, you will be able to increase the speed and the suction setting of the pump.

3. How often and for how long do I need to express?

For the first day or two, before your milk comes in, you'll should pump for about 5 minutes every three hours during the day, and once during the night. Once your milk comes in (no matter how small the amount produced), you should try to express at least 6-8 times in each 24 hour period, for as long as it takes to completely empty your breasts. You'll need to rent or buy a hospital grade electric breastpump to use at home. 
Frequent pumping can be difficult to manage with a sick baby but will help to build and maintain your supply. If your baby is in hospital for a long time, you may decide that it would be better for you to sleep through the night, but try to never go longer than 8 hours without expressing. When you know your baby will soon be coming home, you can begin begin expressing during the night again.

4. What is the best way to store and freeze/thaw milk?

Some hospitals don't allow the use of frozen milk. Your NICU will be able to guide you on their practices and procedures, however these general guidelines should help:

Containers used for collection or storage of breastmilk should be clean and sterile. Most hospitals supply sterile containers or bottles, or small bottles of sterile water (discard water) which can be used to store breastmilk. Small plastic bags or disposable bottle liners (double bag) can be used to freeze milk. Some of the breastpump manufacturers make bags specifically for the purpose of storing milk though these can be expensive.

You need to label each collection with your name and the date, as the oldest milk will be used first. It is safest to refrigerate or freeze milk promptly after pumping. Fresh milk can be refrigerated and transported on ice to the NICU. Many NICUs have a refrigerator or freezer where you can store your milk. Make sure that you don't overfill any bag of milk that will be frozen as the milk will expand in the freezing process.

Storage times: Recommendations provided by The Nursing Mothers Association of Australia 
Fresh milk(6 hours at room temperature), refrigerator (3-4 days, at the back of the fridge where it is coldest), freezer compartment of your refrigerator (2 weeks), if the refrigerator has a separate door (3 months), deep freezer (6-12 months).

Frozen milk : if thawed in the fridge but not warmed (4 hours or less at room temperature), thawed in the fridge (24 hours but don't refreeze), thawed in warm water (only for the duration of the feed, or back in the fridge for a maximum of 4 hours).

To defrost: Thaw under warm running water or in a tepid water bath. Do not use hot water, as this can destroy some of the milk's benefits. Do not thaw by leaving on the counter for a long period of time (the refrigerator is O.K. though). Do not microwave breastmilk to heat it or thaw it. Breast milk also separates, so gently swirl to remix

5. Is there anything I can do to increase my supply?

Maintaining a breastmilk supply without a nursing infant is very difficult. Here are some suggestions from Preemie-L mothers:

A. Fluids and rest
The stress and fatigue that come with having a premature baby can be counter-productive to your milk supply. A good diet and plenty of fluids are essential, and need to be planned for as best you can. If you find your supply is dwindling despite your best efforts, try to spend a day or two in bed, getting up only to eat and express.

B. Increase frequency of pumping
Most women find that frequent shorter pumping sessions work better than longer ones spaced further apart, for example, 10 minutes every three hours rather than 20 minutes every four hours. You need to experiment and find out what works and what is practical for you. If your baby is still in the hospital, you may not have the opportunity to express freqently.

C. Herbal and Medicinal preparations
There are various herbal remedies that are popular and worth trying (but not all at once!). These include brewer's yeast, fenugreek tea or capsules, blessed thistle (also called milk thistle) and mother's milk tea (a U.S. product). These are usually available at health food stores. A Guinness stout in the evening is also a popular remedy, at the very least it is nutritious and will help you sleep.

There are also medicines which can help your let-down such as Metoclopraminde, available as Reglan in the U.S.A. and as Maxalon or Pramin in Australia and England. The lactation consultant at your hospital can advise you on these. They aren't suitable or effective for everyone.

D. Expressing techniques 
Many Preemie-L mothers have found that warm compresses and breast massage prior to pumping helped them to relax, and that this in turn resulted in a higher yield of milk. Stopping several times during pumping to reposition the pump cones can sometimes help. Alternating hand expression with machine pumping during a session may also provide a greater yield. If you are not using a double pump, this is something you should consider.

E. Have your breastpump checked
This is so obvious that many times it is overlooked. Make sure that your pump is working correctly and that the suction is correct and the gaskets are all tight. If there is a problem, you can usually return the pump or get new attachments.

F. Supplemental Nursing System [SNS] (only if you are actually Nursing) 
A supplemental nursing system may help increase your supply because it allows your breasts to be stimulated while the baby is fed either expressed breast milk or formula. There are two widely available models the Lact_aid Nursing Trainer and the Medela Supplemental Nursing System. A SNS consists of a bag or bottle that hangs around your neck and is filled with formula or expressed milk. Thin tubes taped to your breasts with surgical tape deliver milk to the infant as he sucks. They can be fiddly to use but some mothers have found them to be a good solution for low supply.

6. What can I do if my baby fails to thrive?

If your baby fails to gain weight, it may be recommended that you supplement your nursing with formula or your milk may be enhanced with a fortifier. This does not mean that you have failed, and it does not necessarily mean that you must give up your efforts to breastfeed your baby.

7. Can I supplement breastfeeding with bottles?

If your milk supply remains low, you can continue to breastfeed with supplements of formula or EBM. Supplemental feedings can be given by bottle, supplemental nurser, cup or by one of the special feeding devices. Depending on the health of your baby, your neonatolgist may prescribe a higher calorie formula, or have a breastmilk fortifier added to your expressed milk. Remember that any milk you can supply, no matter how little, is a precious gift, one that only you are able to provide.

8. What can I do if my baby is unable suck well?

Some premature babies never learn to suck well, even though they may be growing and developing in other ways. You can continue to provide breastmilk for your baby by expressing and giving EBM in bottles. A good routine is to feed your baby EBM from a bottle, and then express for the next feed while your baby is close-by. It sounds awkward but it's actually nice (and time-saving) to combine feeding and expressing this way rather than separating the two activities.

9. Will my baby suffer if I give up trying to breastfeed?

No, your baby won't suffer if you are unable to provide breastmilk. Sometimes, even with the best of intentions and the best of efforts, supply just does not increase. It happens more frequently than the books and the lactation specialists would have you believe, and it is NOT an indication of failure. Milk supply is not a simple equation, especially with a premature baby. The stress of having a premature baby, your own physical condition as a result of the birth all come into play as well as how quickly you are able to actually nurse, and how soon after the birth you are given access to a pump.

While it is possible to build a supply through exclusive pumping, it is very difficult, and most women will experience a decrease in their supply after about 6 weeks of exclusive pumping. Sometimes this can be overcome, and sometimes it cannot.

10. Is there anything husbands can do to help?

For mothers struggling with the demands of pumping, a husband's support is very important. Husbands can help by encouraging rest, shopping for food and cooking, providing companionship during the endless breastpump sessions, offering backrubs, borrowing magazines and videos to help make the time spent expressing more tolerable.

And remember to praise. Expressing milk for months on end can feel like a thankless task. Husbands who nurture their wives through this long and demanding process are helping to provide their premature babies with a unique gift of love.

Sometimes it becomes clear that breastfeeding isn't working out. This can be devastating for a mother who has always hoped to breastfeed, and the love and support of a husband can be a great comfort.

11. When should I wean my baby? 

The simple answer to this is when you are ready. It may be when the baby is several months old (or younger) or several years old. As your baby grows, breastfeeding continues to be a source of comfort as much as nutrition. This is part of a unique relationship which can continue as long as you and your child enjoy it, regardless of the amount of milk provided.

Recommended books:

Neifert, Marianne, Dr. Mom's guide to breastfeeding Penguin Group, 1998. Excellent information on breastfeeding high risk infants. A good source for information on increasing supply. One of the only books to address the emotional concerns of not being able to supply an adequate amount of milk.

Eiger, Marvin S, and Olds, Sally Wendkos The complete book of breastfeeding Workman Publishing,1987. Excellent section on expressing and storing milk.

Expressings - Thoughts and advice on breastfeeding from The Early Edition newsletter

Getting started with pumping (moo) 
Increasing your supply
Where to get help
Transition to nursing at the breast in NICU
Transition to nursing at home 
Selected Websites:

Breastfeeding your premature baby This is a very helpful and informative page taken from the For Parents of Preemies web site.

The emotional side of breastfeeding a preemie by Preemie-L member Kerry Bone. 
The more technical side of breastfeeding a preemie by Preemie-L member Kerry Bone.

Breastfeeding a premature baby supplied by Ameda/Egnell, a company that makes hospital grade pumps.

Breastpumps and breastfeeding solutions the home page of Medala, who make breastpumps and other nursing aids.

Pumping moms listserve provides information and support for breastfeeding mothers who are working, or who have premature babies.

Organisations like LaLeche League and Nursing Mothers' Association of Australia (NMAA) provide breastfeeding support, breastpump and SNS hire, regular social meetings and special information booklets (breastfeeding preemies, building supply, returning to work and so on).

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Disclaimer: The writings and opinions contained in this FAQ are simply that, and are in no way meant to be considered as medical advice, nor are they meant to replace any medical advice. Always discuss concerns with your doctor. 
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This document is copyright to Preemie-L. It may be reproduced in any format so long as it is reproduced in its entirety, including the contact link to the Preemie-L home page at www.preemie-l.org
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Expert Advice on Feeding

The Baby Friendly Hospital Initiative in Ireland have produced an article on why "Preterm infants need mothers’ milk".

The Baby Friendly Hospital Initiative (BFHI) is a global campaign by the World Health Organisation and the United Nations Children's Fund (UNICEF) which recognises that implementing best practice in the maternity service is crucial to the success of programmes to promote breastfeeding. You can find more information on their website http://www.ihph.ie/babyfriendlyinitiative/

Irish Premature Babies greatly appreciate Dr. Jack Newman & Dr. Nils Bergman for allowing us to share their expert experience and research with us on our website.

Breastfeeding the Premature Baby by Dr. Jack Newman

Research by Dr. Nils Bergman, Overview - Physiology and Research of KMC

Breastfeeding the Premature Baby by Dr. Jack Newman

Introduction

Mothers too often have preventable problems with breastfeeding. Many hospital routines make it difficult for mothers and babies to breastfeed successfully. When the baby is born prematurely, mothers have even more difficulty with breastfeeding, and this is unfortunate because premature babies need breastmilk and breastfeeding even more than healthy full term babies. The reason for mothers not getting the help they need is that many of the “techniques” used to save the lives of premature babies were developed during the 1960’s and 1970’s when breastmilk, never mind breastfeeding, really wasn’t a priority in neonatal intensive care units (NICU’s). Unfortunately, despite much about what we have learned since that time about how to help mothers and babies to breastfeed, NICU’s seem to be, in general, with some exceptions of course, resistant to change the way babies should be fed. Even worse, some techniques have been adopted that make the situation even more difficult.

Some Myths About Premature Babies and Breastfeeding

1. Premature babies need to be in incubators
Actually premature babies, even very small ones, often do better skin to skin with the mother (or father) than they do in incubators. Evidence shows that premature babies (and term babies too for that matter) are more stable metabolically when they are skin to skin with the mother. Their breathing may be more stable and less distressed, their blood pressures are more normal, they maintain their blood sugars better and their skin temperatures better in Kangaroo Mother Care (skin to skin care for most of the day) than they do in incubators. Furthermore, mothers and babies in Kangaroo Mother Care will more likely produce more milk, she will get the baby to the breast earlier and the baby will breastfeed better. A document from the WHO discusses this at length with many references. Please show this document to your baby’s doctor(s). You can get it at the website http://www.who.int/reproductive-health/publications/kmc/text.pdf free of charge.

2. Premature babies all need fortifiers
Actually, most don’t. If the mother is expressing enough milk, babies over about 1500 grams (usually about 32 weeks gestation babies weigh this much, though there are exceptions) can grow just fine with breastmilk only, perhaps with the addition of vitamin D or phosphorus, maybe.

The real problem behind this “need” for fortifiers is that it has become a gospel, carved in stone, for many NICU policies that babies must grow at the same rate outside the mother as they would have had they not been born so early. But there is no good evidence to prove that, whereas there is evidence that babies who grow faster than the premature baby on breastmilk has problems later in life with higher levels of “bad” cholesterol, higher blood pressure, insulin resistance (which may be an early finding of type 2 diabetes) and overweight. These studies were done in premature babies given a) just breastmilk b) breastmilk plus banked breastmilk or c) breastmilk plus preterm formula. The babies who got the preterm formula did grow faster and bigger but there was a price.

How can the baby be fed without using fortifiers? Well, first of all, some babies will need fortifiers, true: really tiny babies and babies whose mothers are not able to express enough milk. However, fortifiers are now being made from human milk (breastmilk) but admittedly they are not easily available yet and are very expensive as well. There is no reason fortifiers need be made from cow’s milk. However, most premature babies don’t need fortifiers because most premature babies are “big” premature babies.

• Many NICU’s have a rule that babies can receive only a certain amount of liquid a day. This is usually kept at about 150 to 180 ml/kg/day, sometimes less. If the baby also has an intravenous, the fluid given orally is cut down even more. This restriction of fluid makes sense, for example, if the baby is on a ventilator to help him breathe because too much fluid may cause him to go into heart failure and prevent his coming off the ventilator. So, restriction of fluid, plus the “baby must grow as if he were still in the uterus” results in the “need” for fortifier.

One way avoiding the need for fortifiers in some premature babies, I learned when I worked with premature babies in Africa, was to give them more breastmilk than what is ‘allowed’ in NICU’s. True, these babies were not like babies in NICU’s in affluent countries; they were bigger, not as sick and needed not more than a little oxygen to survive. But, as a believer at that time in “the baby must grow as if he were still inside the mother”, I increased the amounts of milk the baby received well above the 150 to 180 ml/kg/day, sometimes up to 300 ml/kg/day and the babies did fine and grew well. So as not to give the baby too much milk at one time, the milk was dripped into the baby’s stomach continuously, a few drops at a time.

• There may be a need for additions to the breastmilk, depending on the baby’s levels in the blood. It is possible to add vitamin D, phosphorus, calcium, even human protein (albumin) and human milk fat (from a breastmilk bank) to the baby’s milk without using fortifiers. If the baby doesn’t need fortifiers, then fortifiers actually should be considered diluters since they decrease the concentration of all those elements that make breastmilk special and unique.

3. Premature babies cannot go to the breast until they are at 34 weeks gestation
This is simply not true. Work in NICU’s friendly to breastfeeding, especially in Sweden, have shown that babies can start taking the breast even by 28 weeks gestation and many are able to latch on and drink milk from the breast by 30 weeks gestation. Indeed, some babies have gotten to full breastfeeding by 32 weeks gestation. This means breastfeeding, not receiving breastmilk in a bottle or tube in the stomach. With Kangaroo Mother Care and early access to the breast, it can be done elsewhere as well.

Of course, every baby is different and some babies may take longer depending on whether they were sick with respiratory problems or other issues, but waiting until the baby is 34 weeks gestation before trying the baby on the breast is using the bottle-fed baby as the model for infant feeding.

See the following articles or refer your doctor to them:
Nyqvist K. The development of preterm infants’ breastfeeding behavior. Early Human Development; 1999;55:247–264
Nyqvist K. Early attainment of breastfeeding competence in very preterm infants, Acta Pædiatrica 2008;97:776–781

4. Mothers of premature babies need to use nipple shields to get their babies latched on well and getting milk well
This is certainly not true most of the time from my experience in Africa (actually, we never used nipple shields in Africa) and the experience of the NICU’s in other countries such as Sweden. The second article by Nyqvist had babies born as small as 26 weeks gestation and up to 31 weeks gestation and only a small minority ever used a nipple shield. Yet, unlike what happens generally in North American NICU’s from which very few babies leave the hospital breastfeeding (at best they are getting breastmilk in the bottle and frequently the mother is not putting the baby to the breast), almost all the babies actually left the hospital breastfeeding.

The key is to take time to get the baby to take the breast well. This does take extra time compared to using a nipple shield with the mother, but in the long run the result is worth it. Nipple shields eventually lead to a decrease in the milk supply which makes getting off the nipple shield very difficult (see the information sheet The Baby Who Does Not Yet Latch On).

The way to get the premature baby latched on is not essentially different from the baby who was born at term. See the information sheet When Latching and the video clips at the website nbci.ca. These video clips do not show premature babies but the principles of a good latch are the same.

5. Premature babies need to learn to take a bottle which teaches them how to suck
Well, I don’t know what to say about this. It’s just not true. Premature babies can learn to suck without getting bottles as shown, once again, from experience elsewhere in the world. Too often, mothers and babies are hurried out of hospital with the “advice” that the baby will be discharged earlier if he starts taking a bottle. This is not a way to help the mother and baby. In any case it would not be true that the baby needs a bottle to learn. Kangaroo Mother Care and getting the baby to the breast before the “magic” 34 weeks gestation would do a lot to avoid this situation. Furthermore, as different muscles are used when bottle-feeding vs. breastfeeding, bottle-feeding ‘teaches’ baby poor sucking skills and these can sometimes be extremely difficult to ‘unteach’.

6. Premature babies get tired at the breast
This is believed to be true because babies, not only premature babies, tend to fall asleep at the breast when the flow of milk is slow especially in the first few weeks. The baby is given a bottle and because the flow of milk is rapid, the baby wakes up and sucks forcefully. The false conclusion? The baby tired out at the breast because it’s hard work and the bottle is easier.

Premature babies often do not latch on well, partly because we teach latching on so poorly. With a good latch, the use of breast compression and, if necessary, using a lactation aid at the breast to supplement if necessary, the baby will get good flow and not fall asleep at the breast. Get that flow increased and you will see that breastfeeding is neither difficult for the baby nor tiring for him.

7. Test weighing (weighing the baby before and after a feeding) is a good way of knowing how much milk the baby got at a feeding
Test weighing presupposes that we know what a breastfed baby is supposed to get. How can we know since the rules that say a baby of this weight and this age should get x amount of milk are based on babies fed formula by bottle? And how can we say how much the baby would have gotten if he had been well latched on, with the mother using compression, especially if the breastfeeding is limited to a particular time or schedule like 10 or 20 minutes (because of the concern that the baby will tire out)?

The best way to know if a baby is getting milk well from the breast is to watch the baby at the breast. See the video clips at the website nbci.ca.

8. Premature babies need to continue getting fortifiers once they leave hospital
This is a relative new wrinkle in the undermining of breastfeeding the premature baby. Perhaps someone presented a paper at a conference that showed the baby gained better if the fortifiers were continued even after his discharge from hospital. But, again, more is not necessarily better and breastfeeding is more important than more weight gain, which is not necessarily good. See the information on fortifiers above.

Premature babies and their mothers run into breastfeeding problems much more frequently than do babies born at term. But these can be fixed. Get good hands on help as soon as possible. See also the information sheets available at www.drjacknewman.com

When Latching
Protocol To Manage Breastmilk Intake
Sore Nipples
Candida Protocol
Lactation Aid
The Baby Who Does Not Yet Latch On

Research by Dr. Nils Bergman, Overview - Physiology and Research of KMC


• Research on SSC (Skin to Skin Contact)
• Breastfeeding
• Breast Milk and Immaturity
• Neuroscience and Stress

Kangaroo Mother Care (KMC) has been variously defined, but two essential components are skin-to-skin contact (SSC), and breastfeeding (BF). From the biological perspective, in the immediate newborn period of Homo sapiens, skin-to-skin contact represents the correct "habitat", and breastfeeding represents the "niche" or pre-programmed behaviour designed for that habitat.

RESEARCH ON SSC
In the uterine habitat, oxygenation is provided through the placenta and the cord, as well as warmth, nutrition and protection. These are the four basic biological needs. Parturition (birth) represents a "habitat transition". In the new habitat, the basic needs remain the same. Research over the last ten years provides strong support for the contention that newborn itself in the skin-to-skin habitat, not the mother or the health services, provides these basic needs.

Oxygenation has been shown to be improved on SSC, to the extent that KMC is used successfully to treat respiratory distress. The breathing becomes regular and stable, and is coordinated with heart rate. When removed from incubator and placed SSC, oxygen saturation may rise slightly, or the percentage of oxygen provided to maintain good saturation can be lowered.

Heart Rate is increased when placed SSC. Though we can regard this increase as being with the clinically normal range, what is seen is actually a return to the physiologically normal heart rate, the lower rate being due to "protest despair behaviour". Infants removed from incubators and placed SSC show a rise in temperature and a dramatic drop in glucocorticoids, as predicted by the "protest-despair response". Mothers are able to control the infants temperature within a very narrow range, far better than an incubator. To accomplish this, her core temperature can rise to two degrees Centigrade if baby is cold, and fall one degree if baby is hot. Skin-to-skin contact is better than incubator for rewarming hypothermic infants.

Self-attachment refers to the phenomenon that fullterm undrugged infants, left on their mother's chest and undisturbed, will all breastfeed spontaneously within one hour, with no help at all. But this behaviour is dependent on SSC. Mother and infant should NOT be separated. The stimulations the newborn gives the mother during SSC elicit caregiving and protective behaviours from the mother. The baby’s legs kicking on the mother’s abdomen cause the mother’s uterus to contract strongly, preventing post-partum bleeding.

Nutrition is improved, both with respect to the mother’s ability to breastfeed, and with respect to the newborn’s utilisation of the feed. The volume of mother’s milk is greatly increased, and the frequency of feeds provided likewise. Even without the increased milk, with the vagal stimulation the infant receives, the gut is better able to use the milk provided, and grows faster.

Immunity is improved, demonstrable even 6 months later. Prematures seem to have poor immune systems, and are susceptible to allergies, infections and feeding problems in the first year of life. Early SSC dramatically reduces these problems.

Infections are reduced when SSC and exclusive breastfeeding are firmly introduced. Necrotizing enterocolitis (a potentially lethal and very costly disease to treat) has been dramatically reduced in many units following a KMC programme.

In no published paper is a single adverse outcome reported for KMC. Positive effects on the mother are better bonding, healing of emotional problems associated with premature birth, among others.

BREASTFEEDING

Breastfeeding is a behaviour based on hindbrain functions that regulate hormones, autonomic functions and the somatic system. Key to understanding breastfeeding behaviours in the transitional and newborn periods is "state organisation".

State Organisation refers to the ability to control the level of arousal, or of being awake. A scale of state organisation can be described varying from deep sleep to hard crying, each being associated with particular behaviours and conditions. For breastfeeding an infant should be in an awake state, and should thereafter be in quiet sleep for optimal development. KMC has profoundly beneficial effects on the state organisation of newborns.

"Suckling" is the "chewing movement" an infant makes on the nipple. Quite apart from suckling as a means to ingest food, this behaviour has essential effects. Suckling stimulates the back of the palate, and results in intense vagal stimulation, which is vital for the general wellbeing of the baby. Suckling releases hormones similar to morphine in the brain, and gives powerful pain relief to infants. While it was observed that ability to suck on a bottle only started at 34 weeks post-conceptional age, recent research has shown that suckling from the breast is possible at 28 weeks. Suckling is a myographically distinct behaviour from sucking, and research on sucking on bottles of premature infants shows it clearly to be stressful. Premature infants are unable to coordinate their breathing and their swallowing.

BREAST MILK AND IMMATURITY

Compared to that other mammals, human milk is extremely thin in terms of protein, fat and carbohydrate contents. Protein in particular. In olden days, protein was measured in terms of “nitrogen”, the assumption being that the majority of the nitrogen was a constituent of proteins. For a cow, protein nitrogen is 98%. For a human however, it is only 75%, and the non-protein nitrogen (NPN) is full quarter of the content. What human milk lacks in terms of concentration, it makes up for in terms of variety, well over two hundred NPN compounds have been found. These are related to the evolutionary immaturity of the newborn.

NEUROSCIENCE AND STRESS

The primary violation, the worst case scenario, to any newborn is separation from its habitat/mother. This applies to Homo sapiens as fully as to other mammals studied. “Protest-despair” behaviour is a stress reaction, and the hormones related to this have been extensively studied. At high levels, these hormones are intrinsically neurotoxic to the brain, particularly areas of the hindbrain, and any area which may be already a little hypoxic. SSC has been shown to markedly reduce these levels.

http://www.kangaroomothercare.com/

Where to find support

Specific breastfeeding support for preterms

Each of the maternity hospitals has midwives and lactation specialists,they are experienced and qualified to help mums to breastfeed. You could consider making an appointment with the lactation specialist to discuss any issues you have in relation to expressing and breastfeeding. Also before you leave the NICU, find out if your local hospital runs post natal breastfeeding support groups.

http://www.alcireland.ie The association of lactation consultants Ireland. On the site they have a list of accredited lactation specialists who work in private practise. They should be able to help parents of preterm babies in relation to many issues and they will come to your home,which is such an advantage in those early days and especially as it is was almost possible for mums to bring their premature babies out to normal breastfeeding support groups.

www.thebreastway.ie The breastway provides support, information and a very good forum. One section of the forum is “Ask the experts”, it’s moderated by lactation specialists and other medical professionals. They have dealt with issues relating to preterm babies and will respond to any message in a timely manner.

http://www.drjacknewman.com
Dr. Jack Newman provides very relevant information in relation to expressing and breastfeeding premature babies. They also provide online support for parents, which is a great asset. We have included some information about breastfeeding premature babies kindly allowed by Dr. Newman on this site. We have included some information on breastfeeding from Dr.Newman on the site.http://www.drjacknewman.com/breastfeeding-help.asp

http://www.lalecheleagueireland.com 
LLL provides breastfeeding help and information. They hold monthly meeting run by volunteers around the country and have lists of support leaders. We have spoken with LLL and they have informed us that they regularily deal with parents of preterm babies,and have experience helping premature babies to breastfeed or help mums who are expressing. They offer advice over the phone and will call out to see a mum. La leche league international has a very relevant section dedicated to premature babies. Check out the following link http://www.llli.org/NB/NBpremature.html

http://www.kellymom.com/ Kellymom contains very relevant information about expressing and breastfeeding premature babies. It also contains many of Dr.Newmans breastfeeding leaflets. It also has a very good forum for advice.

General breastfeeding support links

www.breastfeeding.ie A breastfeeding support network of services & support in Ireland. This is the HSE breastfeeding website.

www.friendsofbreastfeeding.ie FOB aims to foster a more positive breastfeeding culture in Ireland. Also to raise awareness & provide information about breastfeeding support networks, which is really good. The site also provides a very useful list of breastfeeding friendly establishments. This is a site set up by parents just like Irish Premature Babies.

http://www.cuidiu-ict.ie Cuidiu the Irish Childbirth trust amongst other services provide breast feeding support. They run breastfeeding support groups around the country and have a list of counsellors who offer support as well.

The websites listed here are not under the control of Irish Premature Babies. We are therefore not responsible for the content of these sites and they are provided solely for the convenience of users of this site. 

Bottle Feeding

Two mums have shared their bottle feeding stories:·

Karen's experience of bottle feeding her son

Feeding our little Girl

When Will My Baby Be Ready to Bottle Feed? Usually, premature babies are ready to start bottle feeding between 32 and 36 weeks' gestational age. The healthcare team will be helpful in deciding when your baby is ready to bottle feed.
Bottle Feeding Basics
When?
Some babies wake up for feedings and cry when they are hungry. Other babies will need to feed on a schedule of every 3 to 5 hours. Feeding times should take no longer than 30 minutes.

Where?
Feed your baby in a quiet place and in a position that is comfortable for you and your baby.

Burping?
Babies swallow air when they feed from bottles, and burping helps to get rid of the extra air. Hold your baby upright, either on your lap or shoulder, and gently pat your baby's back for 1 to 3 minutes. Burp your baby in the middle and at the end of each feeding.

Choking?
Your baby may be choking if your baby starts to sputter, hold his/her breath, or have color change (pale or blue). Take the bottle out of your baby's mouth and sit him/her up on your lap and pat his/her back until your baby looks comfortable again.

How Can Parents Help with Bottle Feeding?
Learning to bottle feed takes time and practice. Try these tips:

* Feed in a quiet area

* Provide oral stimulation

* Provide nonnutritive sucking (NNS)

* Provide oral support

* Choose the right bottle nipple for your baby

What Is Oral Stimulation?
* Gently stroke your baby's mouth, cheeks, gums, and tongue with your finger.

* Do this before and/or after feeding times.

What Is Nonnutritive Sucking (NNS)?
* NNS is when your baby sucks on a pacifier or a finger.

* Infants may start NNS as early as 24 weeks' gestational age.

How Do I Provide Oral Support?
* Bundle your baby in a blanket, placing arms and legs close to the baby's body.

* Hold your baby in a semi-upright position (45-60 degrees).

* Hold your baby's head in your nondominant hand (the hand not holding the bottle).

* Your dominant hand should hold the bottle and give oral support:

* Index finger and thumb on your baby's cheeks give gentle forward and inward support.

* Middle finger supports the chin, lifting it slightly upward to improve the suck on the bottle nipple.

* Make sure this does not cause the baby to get too much milk in his/her mouth.

Which Nipple Should I Use for Feedings?
* Nipples vary in size, shape, firmness, and flow.

* Your nurse and/or feeding specialist can help decide which nipple is best for your baby.

How Do I Know If My Baby Is Not Tolerating the Feed?
Read your baby's "cues." If you see these cues your baby may not be comfortable:

* Fanning of the fingers

* Yawning

* Hiccups

* Choking (coughing, spitting, color changes to pale or blue)

* Head turning

* Gagging

* Biting

* Crying

How Do I Know if The Feeding Is Successful?
Feeding is easier when your baby is developmentally ready. Also, practice makes perfect!!

Enjoy this bonding time, and be patient as your baby learns how to bottle feed.





Figure 1: Oral stimulation, such as stroking the cheek, can be done before and after bottle feeding.
















Figure 2: Stroke the cheeks to wake up your baby for bottle feeding.

 










Figure 3: Nonnutritive sucking on a pacifier improves suckling behaviors.

 










Figure 4: Provide oral support by placing your index finger and thumb on your baby's cheeks, applying gentle inward and forward pressure, and supporting the chin with your third finger.

 





Figure 5: Fanning of the fingers and head turning are cues that your baby is stressed and not tolerating feeding.




 











Karen's experience of bottle feeding her son.

When my son was about 33 weeks, the hospital started to introduce bottles so he could develop his suck swallow reflex. He had been tube fed up to this point. The nurses gave him the first few bottles and then I was encouraged to try bottle feed him.

To be honest, I did not enjoy it at all. He just seemed not to like me feeding him, and I certainly did not have the knack that the nurses had at getting him to open his mouth and suck a little and even holding him correctly was an issue for me as I was afraid I was not doing it correctly. I used to get stressed when the alarms would go off and a nurse would have to come and help me out. Even when my son’s alarms were not going off, other little babies alarms were going off and it would still stop my breath and you could never be sure who it was until you had a scan of the room. There were a couple of times when he had to have oxygen during and after his bottle feeding attempts and this did nothing to help my confidence. I actually started to dread the feeds and used to love when he could be tube fed as it was much calmer and relaxing for both of us. Some of the staff did try to reassure me that feeding can be an issue with premature babies and that it would just take time and practice until he became more proficient at feeding. A couple of times I ran off to the express when I knew he was due a feed so I could avoid it and I actively encouraged my partner to feed him anytime he was there, letting me off the hook.

By around 35 weeks, he was getting a little better at feeding, he still bad days when even the nurses had issues feeding him but I realised I had to make more of an effort to feed him as it dawned on me that I would be his main carer at home and he would be relying on me to feed him and I knew he would be released from the NICU and I would have to cope on my own without a nurse to hand him over when it got a bit difficult.

He came home when he was 36 weeks, and it was a wonderful and yet a very daunting experience, leaving the security of the NICU and wondering if we could cope with this tiny little baby that was ours now. He continued to be very slow at feeding. There were feeds of 30-50 mls that took an hour and a half to get into him. We were still feeding him in the routine of the hospital and between expressing and very long feeds, my time seemed to revolve around feeding him and trying to keep him awake. Over a few days, we picked up a couple of little tips that helped us feed him a little better. To keep him awake, we would have to strip a few of the layers off him. We would change his nappy mid way and always kept a bowl of warm water with cotton wool near so we could freshen him up. On one of his outpatient appointments in the hospital one of the nurses suggested to try feed him a little more upright so his tummy would not fill up so quickly and it was not as cosy as in your elbow. All these little hints, helped and sometimes it just takes time. Over a two or three week period he started to wake up for feeds and became much better at feeding and burping and the volume started to increase.

Over time he definitely improved and was gaining good weight, the only problem was milk supply which, was never great and was not keeping up with his needs so I was supplementing with formula. I managed to keep going until he was four months and then gave up expressing or rather it gave up on me and he moved full time over to formula.

Learning to feed my son was a long process. It was slow and nerve racking at times, but it got easier as he grew and developed and thankfully he had no real issues and is a fantastic feeder now at 18 months.

Feeding our little Girl

Our little girl was born at 33 weeks and was tube fed until approximately week 36. Two days after her birth I was discharged from the hospital and went home assuming I would see my little angel after a day's rest at home. Unfortunately I was much more ill than I thought and I was too weak to see my little girl until she was a week old. During that time I tried to express milk at home using massage and a manual pump and I was getting more and more despondent at the tiny amounts that were coming out. Due to these small amounts my little one was being supplemented with formula. Thankfully a friend told me that there are private breastfeeding consultants that you can call or meet in your house and she told me about an electronic double pump that transformed my flow. So I pumped at home and put the milk in the fridge and then a family member brought the milk in to the hospital for me each day. Also it was recommended that I be given one of her baby gro’s that would have her smell on it and this would help the hormones kick the milk in.

Unfortunately I was readmitted to hospital quite ill on day eight and I asked if the medication I was put on could affect the baby’s milk. What I learned was that drugs can be classified according to their believed impact on the breast milk. At the time I was told there was a rating from one to five given to drugs. However I was told not all drugs were classified. NICU have a copy of the book that lists the ratings. Unfortunately there was no rating for one of the drugs I was put on and this coupled with the difficulties I experienced in getting help expressing in the hospital, meant that the conclusion was drawn that it was safer not to give my little girl my breast milk. Unfortunately I was not told that you can keep expressing your milk if you are on medication that is considered risky, and throw away the milk. This will mean that your supply will not dry up, and then when you come off the medication you can try to reintroduce breast milk if you so wish. I wish I had known this – having to let go of the dream I had of bonding with my little girl through breast feeding was one of the hardest decisions I had to make in NICU.

Our little girl often cried when being tube fed, and later being bottle fed and she would then vomit up some or all of her feed every time. Learning how to turn her when she was gagging was terrifying but after a while it became second nature. A month later on her last day in neonatal, a nurse gave us a leaflet describing what to do and after a while we became confident at turning her. We learned that holding her upright when she was being fed and rubbing her back to wind her after every few ml's made drinking easier for her. We also learned to try out different teats as they have different flow ratings that can suit the different sucking reflexes of the baby. She used to cry an awful lot and arch her back hugely throwing her head back. At the same time her back used to go hard and she wanted to be fed a lot. It turned out that she had gastric reflux from birth which we were told is more common in premmies than full-term babies. Once she was put on medication for it, bottle feeding became totally different - she drank more and left longer times between feeds and was so so so much happier.

An advantage we found to bottle feeding was that any family member could feed her and make her feeds up which can give the mother a chance to get an hour’s rest if unwell and/or totally exhausted, and gives the other family members a chance to bond if the baby had spent time in the NICU. 

Donated breastmilk

Sometimes a mum may be unable to express milk but would still like for her premature baby to have all the benefits of breast milk, the option available for parents is the use of donated breast milk. 
There is one human milk bank in Ireland, located in Co. Fermanagh operated by the Sperrin Lakeland Health & Social Care Trust, it has been in operation since 2000 and supplies and receives breast milk from all over Ireland.
Donor milk is tested pre and post pasteurisation. Each bottle is from an individual donor and is traceable from donor to recipient baby. The milk bank operates in accordance with the UK Association of Milk Bank guidelines.

For further information about receiving or donating breast milk contact a staff member in the NICU, a hospital lactation specialist or the milk bank.
The Human Milk Bank,
Unit 2,
The Cornsheads,
Mill Street,
Irvinestown,
Co.Fermanagh BT94 1GR

Tel: 04868628333 Contact Name: Anne McCrea
Email: TMB.IRVINESTOWN@westerntrust.hscni.net

Website: http://www.ukamb.org/

The Western Health and Social Care Trust have kindly given us kind permission to share their newsletters with Irish Premature Babies. The newsletters are very informative and they have real accounts from parents who received donated milk from Irvinstown.

Newsletter from the trust about the benefits of donated milk- 2008

Newsletter from the Trust about the benefits of donated milk-2009

A mums experience of using donated breast milk for her premature baby Harry.


Harry was born at 26 weeks and 4 days. Here I would like to talk about our experience with the Donor Milk Bank.
I was unable to produce my own milk. After a first few drops that was it. It managed to feed Harry for about a day as he was on such small quantities! 
It took an awful long time to establish Harry on full feeds. From the beginning he could not tolerate anything. They tried a number of different formulas but nothing worked and they would come back as dirty aspirates(coffee grounds) up his feeding tube. 
A friend mentioned the Milk Bank to me as she had donated milk before and would do so again if Harry needed it(she was breat feeding at the time he was born). I had never heard of it but was very interested.
I mentioned it the next day in the hospital (Rotunda) and they immediately set it up. I spoke to the lady who runs it and she ran through their practice and I was happy with using the service. 
They began using the Donor Milk as soon as it arrived. Harry was able to tolerate it for a few days and then would crash, they would stop feeds and start again a few days later. There were a number of reasons why he would have to stop and start, he was just not able for it. The only thing was, he was able to take the Donor Milk for longer periods at a time. They stuck with it as it was milder on his stomach and easier for him to break down. 
They had to stop his feeds on six separate occassions before he was established on full feeds(8 weeks later). Due to this extraordiary amount of time on TPN (Total Parenteral Nutrition), some liver damage was done. It was a relief to know the milk he was getting was gentle on him and not putting any extra pressure on his system. 
When they were fully confident that he was feeding well, they alternated between Donor Milk and Fortified Formula. This was because there was a big concern for him to gain weight. Eventually he was on just formula feeds to speed up his weight gain. 
Considering the fact that feeding was going to be such a huge issue for Harry I was so relieved to find that he could tolerate something and it was the Donor Milk. 
I had moments when I felt guilty that I could not provide milk for him but I didn’t let myself wallow in that as I had to be there 100% for Harry. If there was something I learnt through this experience, it was that if i had no control over some things, I just drew a line and moved on. I needed all my energy for Harry.
Some people asked did I not find it weird that Harry was taking another woman’s milk. It is obviously hard for people to put it into context. Picture your baby at a critical stage in the feeding process, with blood coming up his feeding tube, swollen belly, bowels not working properly...we find something he can begin to tolerate....do I care its from another woman? I am thankful to those women for going to the trouble of donating. It helped Harry out of a bad situation and I am forever grateful. 

Breastfeeding Video's


These video's are courtesy of the UCSDMedicalCenter in San Diego in America.

    
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