Breastfeeding the Premature Infant

From Delivery to Discharge

CEAC 0055 March 2013

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Table of Contents

What are the benefits of breast milk? 3

How do you pump your breast milk? 4

How do you know when to pump? 5

How much milk should you be pumping? 5

How do you store your breast milk? 6

How long is your breast milk good for? 6

Why is it better to start giving your breast milk sooner? 7

What is Kangaroo Care? 8

How do you put your baby to breast? 9

How do you get started? 10

What are good positions to breastfeed your baby? 11

How do you get your baby to latch well? 13

What are some things you may see with your baby in NICU? 14

How will you continue to breastfeed once you go home? 15

How can you take care of yourself with a new baby? 16

Who can I contact for help? 17

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“Breastfeeding is something

only you can do!”

Congratulations on the birth of your baby! You have welcomed your bundle of joy into the world sooner than expected. Your new baby will need to spend some time in the Neonatal Intensive Care Unit (NICU). The NICU has special equipment and staff who work around the clock to provide your baby the best care possible. You may be feeling overwhelmed or scared. These are common feelings to have when your baby is in NICU. You are not alone, the nurses and staff are there to help you. Just being there for your baby is important. Deciding to provide your baby with breast milk is a gift only you can give your premature baby. This booklet will provide you with information on how to breast feed your preterm baby.

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What are the benefits of breast milk? The nutrition in the breast milk you produce will change based on what your baby needs. Colostrum: • is the first milk your body makes. It can be quite thick and yellow or gold in colour • helps to fight infection • is produced for up 5 days after the birth of your baby • is a natural laxative. It is important the first milk your baby gets is colostrum. The breast milk you produce when your baby is born premature is higher in: • protein • minerals • fats • vitamins

Giving breast milk is the best way to feed your baby and improves health, growth, and development.

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How do you pump your breast milk? While your baby is in NICU, you will need to express your breast milk with the help of a breast pump.

Breast milk production is based on supply and demand.

Be aware that your body may not produce breast milk for a pump quite the same as you would for a breastfeeding baby. There are things you can do to help such as:

• pumping at baby’s bedside when possible • thinking of your baby while pumping • relaxing while pumping by listening to music • having your partner give you a back massage. The NICU at the Regina General Hospital uses the Medela Symphony hospital grade double electric pump. These pumps are equipped with a Preemie+ program that is designed to help establish and maintain a milk supply for mothers who are pump dependent while their babies are in the NICU. To use the Preemie+1.0 program: • Press the on/off button on the pump to turn it on. • Press the let down button within 10 seconds. • If you do not press the let down button to start the Preemie+ program, the standard

program will start. • The Preemie+ program will last 15 minutes, and cycles back and forth between 2

different phases of expression. • Use the pump until your baby is 5 days old or until you have pumped 20 mL, for 3

pumpings in a row.

Above material is used with permission of Medela, Inc.,Mississauga, Ont. Canada

© 2011 Medela, Inc.

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How do you know when to pump? Pump: • As soon as possible, ideally in the first 6 hours after the birth of your baby. • Try for 8 times in a 24 hour period. • For no longer than 15 minutes each side. • If you choose to take a break at night to sleep do not go longer than 5 hours without

pumping. If you do this ensure you still pump at least 8 times in a 24 hour period. This may mean you pump every 2 to 3 hours in the daytime.

Stop pumping if you have pain or bleeding and talk to your nurse. Pumping may be uncomfortable at first, but should not be painful. There are things that can be changed such as a larger breast shield or suction strength. How much milk should you be pumping? After the first week the amount of milk you should pump in a 24 hour period for a single baby is: Ideal: 750 to 1000 mL Borderline: 350 to 500 mL Low: less than 350 mL • In the first few days you may only pump drops or teaspoons. That’s OK. • You will need to pump more for multiple babies. Ask your baby’s nurse for a pumping log to help you keep track of your supply. If you are worried that you do not have enough milk, talk about your concerns with your baby’s nurse, doctor, or your own doctor. There are many simple things that can be done to increase milk production. It is better to deal with these concerns early before they become a problem.

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How do you store your breast milk? The milk that you have pumped can be saved and brought to the hospital to be fed to your baby. When you pump at the hospital there are bottles for you to use. For home use you will need to buy specially made breast milk storage bags. Ask your nurse how much you should begin saving in each bag. This will change as your baby begins to eat more. Remember to label the breast milk with: • your baby’s last name • the date and time that you pumped. Please number the first 25 bottles of milk you pump, to ensure your baby gets the colostrum first. How long is your breast milk good for? In the NICU we prefer to give fresh breast milk if possible. If it is frozen and thawed it will be used for a 48 hour period. Try not to put too much in each bottle because if your baby is not feeding enough we may have to throw some out. Once your baby goes home, breast milk can be stored: • 5 to 8 days in the refrigerator • 3 to 4 months in the freezer compartment of a refrigerator • 6 months or more in a chest type freezer. If you are away from the hospital and want to bring the milk into the NICU, you must keep the milk cold. Milk can be kept cold by placing it in a cooler with cold packs. How do you thaw your breast milk? • Thaw your breast milk by putting the container in warm water. Make sure to gently

swirl it to mix it. • Do not thaw breast milk in the microwave. • Milk heats unevenly in a microwave oven. Your baby could get burned if the milk is

too hot. Microwaving can damage the proteins and infection fighting properties of the milk.

• Thawed breast milk should be used immediately or be refrigerated. • Thawed unused milk should be thrown out after 24 hours. • Do not refreeze thawed milk.

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Why is it better to start giving your breast milk sooner? The nurses and doctors in NICU may want to give your baby your breast milk in the first couple of days of life, by using drops of it on a Q-tip® to clean his mouth. The benefits of using breast milk for mouth care are: • helps to develop your baby’s sense of taste and smell • keeps the mouth clean and healthy, to lower the risk of infection • keeps the lips soft and moist • is comforting to your baby • fights infection. Even giving your baby drops through mouth care can help fight a

number of infections. It is important to start pumping within 6 hours of the birth of your baby, and to try to pump 8 times in a 24 hour period. Remember even drops of your milk can be used.

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What is Kangaroo Care? Kangaroo care is a way for you to bond with your new baby. Kangaroo care is also called skin to skin care. You get to hold your baby in a diaper against your bare chest. The nurses can help you get set up and can put a hat and blankets over your baby to help keep him warm. Kangaroo care is important for you and your baby because:

• it can help your milk come in and keep up your supply • your baby already knows your voice, scent, and rhythm of your breathing and will

enjoy that feeling of closeness with you. • it can help you learn to handle your new baby, especially if your baby has been sick

during the stay in NICU. • it helps your baby gain weight • your baby may need less oxygen and breathe easier • your baby may be less fussy and have a more restful sleep • being skin to skin with you will help baby control own body temperature. As soon as your baby is medically stable this is something you can start enjoying on a daily basis. Please ask your baby’s nurse if it is a good day to do kangaroo care.

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How do you put your baby to breast?

Breastfeeding will: • help form a bond with your baby • stimulate milk production and increase milk supply • give your baby an opportunity to learn how to feed from your breast. The first time you put your baby to breast can be a very exciting time, but it can also be stressful. Try to think of the first few times you offer your baby your breast as practice time. Your baby may not get any milk and that’s okay. Remember that every feed will be different and that is perfectly normal. Premature babies cannot suck, swallow and breathe all at the same time until about 34 weeks. Your nurse or doctor will help you decide when your baby is ready to try breastfeeding. The first times you put your baby to breast may be after you have pumped. This is called non-nutritive sucking and will help make it easier for your baby to learn to latch on.

Latching on is getting your baby to position mouth correctly on the breast.

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How do you get started? Position yourself in a comfortable position, using the recliner found at your baby’s bedside. Make sure that when you nurse at home you have a comfortable place to breastfeed. The more comfortable you are during a feed, the easer it will be for you to have a “let down”.

Let down is a reflex which allows your milk to flow freely. Your nurse can help you determine which will be the best position to use to begin breastfeeding your premature infant (cradle, cross cradle, football hold). Once you are home and comfortable with breastfeeding you may want to learn how to breastfeed lying down. To help to get into a good, relaxed position try:

• pillows behind your lower back and shoulders • a pillow under your arm supporting baby • a recliner or footstool to elevate your legs • a relaxing environment. (music, books, TV, lights)

Make sure your baby is awake and alert prior to latching. In the NICU your baby will be weighed before and after breastfeeding. This will give you and your nurses an idea of how much your baby ate. If your baby is still sleepy you may:

• Hold the baby in an upright position. Pat your baby gently on the back to try to get baby to burp.

• Open the blanket to cool your baby off a little. If your baby gets too warm and comfortable your baby will want to sleep instead of eat.

• Change your baby’s diaper.

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What are good positions to breastfeed your baby? Cross Cradle Hold This gives more support and control of your baby’s head. Your nurse may have you get started in this position and move you into the cradle hold.

Cradle Hold Ideal for full term infants/older infants and moms who are comfortable breastfeeding.

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Football (clutch) Hold This is a good to use when you are just learning to breastfeed and when your baby is very small. The football hold is useful if you have large breasts, have flat or sore nipples, or if you have had a caesaran section (c-section). This is the hold some moms of twins use. Try out different positions. This will help to empty different areas of your breast.

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How do you get your baby to latch well? Latch is when your baby’s mouth is in good position around the nipple. When getting your baby to latch: • Your baby should be well supported with baby’s ear, shoulder and hip in a straight line.

Your baby should be looking straight ahead, not to the side, up or down. • Your baby should be “tummy to tummy” with you. • Bring him to the breast, not the breast to baby. • It may help baby to latch if you hand express some colostrum/breastmilk onto your

nipple beforehand. • Tickle your baby’s lower lip with your nipple. • Aim your nipple at the roof of his mouth while bringing baby to your breast. Try to get

your baby to latch when his mouth is open at its widest. You will know if baby is latched and sucking properly if: • Lips are curled outward • There is a tight seal between his lip and the areola (the dark area of the breast

surrounding the nipple) • Your baby is latched onto a good portion of the areola surrounding the nipple, not just

the nipple. • Your baby’s tongue is “down” (not stuck on the roof of the mouth). • Your baby’s ears wiggle with each suck • You can hear and see baby swallowing. • There is no (or little) milk leaking from the corners of baby’s mouth. • There are no clicking sounds when baby sucks.

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What are some things you may see with your baby in NICU? Jaundice Jaundice is the yellowish colour of the skin that occurs in the first few days of life in many newborns. This is caused by too much bilirubin in the blood. Bilirubin is made when red blood cells are broken down. Babies remove bilirubin when they pass stool. Sometimes the liver cannot get rid of the bilirubin to be removed through the stool and it then builds up in the body, causing the skin and eyes to turn yellowish. One way to treat this is with a phototherapy light. Sometimes it can take days to go away. It is important during this time that baby spends as much time as possible under the lights. This can be hard for a breastfeeding mother. Feel free to spend as much time as possible with your baby. Nasogastric Feeds (NG feeds or Tube feeds) Premature babies are sleepier and have less energy than babies born at term. They can not coordinate sucking, swallowing and breathing. This makes it hard to feed. Your baby may need a special tube that goes from nose to stomach to help with feeding. You can still breastfeed while your baby has a tube in the nose. Nipple shields You may need to use a nipple shield to feed your premature baby for a variety of reasons. They can be used for babies who have a hard time latching on, and are offered at no charge for NICU babies. Together with your nurse you can decide if you need one and which size is best for you and your baby. They can be ‘weaned’ off at a later date when baby is stronger at breastfeeding. Supplementation Your baby may require the use of a preterm formula or human milk fortifier while in NICU. Preterm formula and human milk fortifier provide additional calories, protein, essential fatty acids, vitamins, and minerals that preterm babies need for best growth and development. A preterm formula may be used for the period of time prior to your milk coming in. Human milk fortifier is added to your breast milk. Preterm formula and human milk formula, in addition to your breast milk, improve baby’s growth, bone strength, and the development of all organs such as the brain, eyes, lungs, and heart.

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How will you continue to breastfeed once you go home? Your baby will want to feed frequently because breast milk is so easily digested and the stomach is small. Do not be discouraged if your baby is not getting all feedings by breast. Some premature babies take several weeks to become good at breastfeeding. You can pump your milk and give it in other ways that will be shown to you by your nurses. Make sure that your baby is getting enough to eat by: • nursing every 2 to 3 hours (8 times in 24 hours) • watching for at least 6 wet diapers in 24 hours, and baby should have soft, easily passed

stools. Contact your baby’s doctor or the public health nurse if you have any concerns. How can you take care of yourself with a new baby? Nutrition Vitamin, mineral, and energy needs increase while you are breastfeeding. For example, you will need an extra 450 to 500 calories and an extra 25 g of protein daily to help keep up your milk supply. Weight loss diets are not recommended during this time as they may cause your milk supply to decrease. The foods you choose are important. Follow “Eating Well with Canada’s Food Guide”. Continue to take your prenatal multivitamin and mineral supplement.

Food Calories Protein 1 cup (250 mL) skim milk 100 8

¾ cup (175 mL) full fat yogurt 125 6.5

3 oz. (60 g) low fat cheese 100 12

½ cup (125 mL) 2% cottage cheese 100 15

60 g (2 oz.) steak 100 17

60 g (2 oz.) chicken breast, no skin 100 17

½ cup (125 mL) legumes 130 7

1 large egg 75 6

¼ cup (57.5 mL) almonds 160 12

1 tbsp (15 g) peanut butter 100 4

1 medium fruit 100 0.5

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Fluids: Be sure to drink plenty of fluids as well. A minimum of 6 to 8 glasses of fluid per day (1 glass = 8 oz. or 250 mL) is recommended. Most of your fluids should be water. Caffeine: Caffeine is passed into your breast milk. A high intake of caffeine may make baby irritable and cause sleeping troubles. Limit caffeine to no more than 300 mg daily.

Do whatever you can to make sure you get the rest you need: • Forget the housework for awhile. • Accept offers from friends and family to clean your home, do your laundry or prepare

meals. • Use disposable dishes until things calm down. • Take the phone off the hook and put your feet up while you pump. • Set aside a “call hour” when people can reach you for an update on your baby. • Set up a phone chain and have everyone call a certain member of your family to get the

updates. • Avoid stress and conflict. • Avoid caffeine, smoking, and alcohol. • Establish a new routine, such as going to bed early or sleeping when the baby sleeps.

Food or Beverage Serving Size Amount of Caffeine (mg) Coffee 1 cup (250 mL) 60 to 150 Tea Leaf or bag 40 to 80 Cola 1 ½ cups (375 mL) 35 to 64 Chocolate, dark or semi-sweet 30 g (1 oz.) 19 to 20

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Who can I contact for help? Caring for and learning to breastfeed a premature or ill newborn can be an emotional time for any new mother. It is important to have good support during this time. Once you are at home there are resources in the community many mothers find helpful: Maternity Visiting Program - (306) 766-3700 Public Health Nurse - (306) 766-7733 Breastfeeding Support Centre Wednesdays 1:00 p.m. - 4:00 pm - (306) 766-7533 Fridays 1:00 p.m. - 4:00 p.m. - (306) 766-3700 La Leche League - (306) 584-5600 Four Directions Breastfeeding Support Group Last Wednesday of the month 1:00 p.m.- 3:30 p.m. - (306) 766-7540 Neonatal Intensive Care Unit (306) 766-6161 Special Care Nursery (306) 766-6657 Regina General Hospital 1440 14th Avenue HealthLine - For 24 hour professional health advice and information, call Independent Lactation Consultants

CEAC 0055 March 2013