Breastfeeding the premature
and the sick baby
Jack Newman, MD, FRCPC
In retrospect, it has become
obvious that incubator care is a
large factor in the difficulty
establishing breastfeeding in
premature and sick babies
So we need to ask the question…

Is incubator care the only way, or even the
best way, to take care of premature and sick
babies?
Early skin to skin care vs. incubator
care

Bergman NJ, Linley LL, Fawcus SR.
Randomized controlled trial of skin-to-skin
contact from birth versus conventional
incubator for physiological stabilization in
1200-2199 gram newborns. Acta Paediatr
2004;93:779-785
Two groups


1.
2.
All babies were put skin to skin with the
mother after birth
After the five minute Apgar, if the baby
was stable (monitored continuously), the
baby was randomly assigned to
Skin to skin care (SCC) for 6 hours
Transferred to incubator and “usual” care
Protocol






All babies had an IV line placed with glucose
running at 4.17 mg/kg/min
All had an orogastric tube placed
All were started on theophylline by orogastric tube
Oxygen given if required
If the baby was well, breastfeeding attempted at 50
min, 3 hours and 5 hours
After 6 hours, all babies given routine care
Parameters


1.
2.
3.
4.
5.
All babies were continuously monitored
The following situations were considered
“exceeding parameters” (see later slide)
Skin temperature below 35.5°C for two
consecutive recordings
Heart rate <100 or >180 for two consecutive
recordings
Apnea >20 seconds
O2 saturation <87% despite support
Blood glucose <2.6 mmol/l confirmed by lab
SCRIP score
Kangaroo Mother Care
Kangaroo Mother Care




If medical condition allows:
Infant, wearing a diaper only, is placed
between mother’s breasts, with head in
“sniffing position”
Maintains baby’s physiological functions at
least as well as, and often better than
incubator care
Facilitates breastfeeding
Kangaroo Mother Care
1.
2.
3.
4.
5.
6.
Fewer apneas and bradycardias
Less frequent and less severe desaturation
Oxygenation improved (even if not desaturated,
allowing lower concentrations of inspired
oxygen)
Body temperature maintained
Earlier discharge from hospital
Improved arousal regulation and stress reactivity
Kangaroo Mother Care
7.
8.
9.
10.
11.
12.
Infants cry less and cry is not of distress type
Provides analgesic effects during painful
procedures
Less stress in baby (shown by decreased ß
endorphin and cortisol release)
Positive effects seem to be maintained after
contact ended
Better parent-child relationship
Greater likelihood of full breastfeeding in
hospital and at discharge
Gas exchange



Föhe K, Kropf S, Avenarius S. Skin to skin
contact improves gas exchange in premature
infants. J Perinatology 2000;5:311-15
53 preterm infants <1800 g in a prospective
study, during incubator care (60 min), skin
to skin contact (90 min)
All babies on oxygen, 5 still being ventilated
More References



Cattaneo A, Davanzo R, Worku B, et al. Kangaroo
Mother Care for low birthweight infants: A
randomized control trial in different settings. Acta
Pædiatr 1998;87:976-85
Törnhage C-J, Sturge E, Lindberg T, Serenius F.
First week Kangaroo Care in sick very preterm
infants. Acta Pædiatr 1999;88:1402-4
Johnston CC, Stevens B, Pinelli J et al. Kangaroo
Care is effective in diminishing pain response in
preterm neonates. Arch Pediatr Adolesc Med
2003;157:1084-8
More References


Feldman R, Weller A, Sirota L, Edelman AI. Skinto-skin contact (Kangaroo Care) promotes selfregulation in premature nfants: sleep-wake
cyclicity, arousal modulation and sustained
exploration. Develop Psychol 2002;38:194-7
Charpak N, Ruiz-Peláez JG, et al. A randomized
controlled trial of Kangaroo Mother Care: Results
of followup to 1 year corrected age. Pediatrics
2001;108:1072-9
More References


Ohgi S, Fukuda M, Moriuchi H, et al. comparison
of kangaroo care and standard care: Behvioral
organization, development and temperament in
healthy low birth weight infants through 1 year. J
Perinatology 2002;22:374-9
Furman L, Minich N, Hack M. Correlates of
lactation in mothers of very low birth weight
infants. Pediatrics 2002;109(4)
www.pediatrics.org/cgi/content/full/109/4/e57
WHO document on KMC (2003)



http://whqlibdoc.who.int/publications/200
3/9241590351.pdf
All the references you could want
Includes practical information for
implementation of Kangaroo Mother Care
Breastmilk and breastfeeding
Breastmilk and breastfeeding
“We are dealing with a question of life and
death
 “You should be happy your baby is
surviving; breastfeeding is a minor issue”
saving the baby’s life and helping the
mother with breastfeeding are not mutually
exclusive
 Nor should they be

The premature baby



The word “premature” covers a lot of ground
What may be true about the 26 week gestation
baby, weighing 600 grams, being ventilated for
weeks, may not be true of the 33 week gestation
baby, weighing 1600 grams, who is otherwise well
The latter has more in common with a full term
baby than he does with that 26 week gestation
premature baby
They both need breastmilk
But the methods of feeding them, the need
for fortification, the approaches are very
different
 Each baby needs to be treated as an
individual
 The “one size fits all” approach to feeding
premature babies is inappropriate

Generalizing from the NICU



Unfortunately, much of how we approach feeding
the premature comes from NICU’s, neonatologists
and pædiatric nutritionists who deal with that 26
week gestation premature baby, but never see a
healthy 33 week gestation baby
In fact, most premature babies fall into the latter
group
they are relatively mature and larger, often have
only minor medical problems, and are in hospital
essentially for “nutritional support”
Let’s not generalize



We cannot take what may be appropriate for that
26 week gestation baby in a NICU as a basis for
the nutrition of the bigger premature babies found
in nurseries in most community hospitals
For example, if the mother is pumping enough
milk, most babies of 33 or more weeks gestation do
not need “fortification”
Different approaches are necessary for this group
Confession
I did 6 months in a tertiary NICU as part of
my training
 But most of my experience in feeding
premature babies comes from my
experience with prematures in Africa
 babies who did not make it on oxygen alone,
didn’t make it
 this is a different situation from NICU

Still, this allows some perspective
on the question of feeding
premature babies
Why breastmilk for the premature?

1.
2.
3.
4.
5.
6.

Breastmilk provides:
Protection against infection
Protection against NEC
Appropriate lipid profile (PUFA’s)
Better cognitive development
Better visual development
A role for the mother in the care of her baby
this is very important
Breastfeeding and sepsis

Rønnestad A, et al. Late onset septicemia in a
Norwegian national cohort of extremely premature
babies receiving very early full human milk
feedings. Pediatrics 2005;215:e262-e268
Cumulative proportions of infants initiated on enteral feeding
(black bars) and established on FEF with human milk (gray
bars), according to age, among extremely premature infants in
Norway, 1999-2000
Survival free from LOS according to week of establishment of
FEF with human milk among extremely premature infants in
Norway, 1999-2000
RR of future LOS if FEF with human milk is not established
within a given age (in days) among extremely premature
infants in Norway, 1999-2000
Why breastmilk for the premature?

And, for the same reasons that breastmilk is
best for the full term baby
 Premature babies don’t need breastmilk less
they need it more!
Alternatives to breastmilk?




There is lack of evidence for safety, superiority or
even equality of the alternatives (preterm formulas
and fortifiers) in the long term
Unlike drugs, the formula companies do not have
to prove they are safe, never mind useful
We should be careful about using them routinely
They should be used as drugs, if necessary, but not
if not necessary
Apparent deficiencies of breastmilk





Not enough protein to support the growth of the
premature baby
Most of the protein in breastmilk is not even
absorbed (don’t tell anyone)
Insufficient calcium, phosphorus and vitamin D
for bone mineralization
Insufficient calories for intrauterine growth rate
Intolerance of some tiny premature babies to
lactose
Intrauterine growth rate







Besides being intellectually satisfying, is there any proof
that a baby is better off growing at intrauterine growth
rates?
How did we establish this “standard”?
The physiologic situation is completely different for a baby
outside the uterus
Are there suggestions that more is not necessarily better?
Yes
There are advantages to exclusive breastfeeding (or
breastmilk feeding) that go beyond growth rate
A balance which is best for the baby needs to be struck
Advantages to exclusive
breastmilk feeding?


Lipid profile in adolescents
Singhal A, Cole TJ, Lucas A. Breastmilk
feeding and lipoprotein profile in
adolescents born preterm: follow-up of a
prospective randomised study. Lancet
2004;363:1571-8
Results




“The ratio of LDL to HDL cholesterol was significantly
lower in adolescents who had been randomised to bank
breastmilk compared with those who received preterm
formula”
“CRP concentration was also significantly lower in
adolescents randomised to banked breastmilk compared
with preterm formula”
CRP=C reactive protein, a marker for atherosclerosis
“As expected, early weight gain was significantly greater in
infants randomised to nutrient-enriched preterm formula
than in those randomised to banked breastmilk”
Is more weight gain necessarily better?

“As expected, early weight gain was
significantly greater in infants randomised
to nutrient-enriched preterm formula than in
those randomised to banked breastmilk”
The more breastmilk a baby got, the lower his
LDL to HDL ratio (better profile)
Different study, same cohort


Effects on blood pressure
Singhal A, Cole TJ, Lucas A. Early nutrition
in preterm infants and later blood pressure:
two cohorts after randomised trials. Lancet
2001;357:413-9
And there’s more
1.
2.
3.
Singhal A, Cole TJ, Fewtrell M, et al. Is slower early
growth beneficial for long term cardiovascular health?
Circulation 2004;109:1108-13
Singhal A, Fewtrell M, Cole TJ, Lucas A. Low nutrient
intake and early growth for later insulin resistance in
adolescents born preterm. The Lancet 2003;361 (March
29):1089-97
Singhal A, Farooqi IS, O’Rahilly S et al. Early nutrition
and leptin cencentrations in later life. Am J Clin Nutr
2002;75: 993-9
Osteopænia, fractures etc.




Bone demineralization is often cited as a reason to
use fortifiers
And there does appear to be a benefit to giving
extra calcium and phosphorus to prevent
osteopænia in very small premature babies
But of course, it is not necessary to give cow’s milk
(from which fortifiers are made) in order to give
extra calcium and phosphorus
Calcium and phosphorus can be added to
breastmilk without using fortifiers, based on
individual evaluation of biochemical factors
One long term study



Bishop NJ, Dahlenburg SL, Fewtrell MS, et al.
Early diet of preterm infants and bone
mineralization at age five years. Acta Pædiatr
1996;85:230-6
Compared banked donor milk vs preterm formula
as a supplement to mother’s breast milk in 54
children aged five years
“Increasing human milk intake was strongly
positively associated with later bone mineral
content.”
Implications?

“…a period of mineral deprivation in the
newborn period is good for long term bone
mineralization! This would represent
another example of programming. It could
represent the action of other factors within
breastmilk, such as growth factors”¹

¹Ryan S. Bone mineralization in Preterm Infants. Nutrition.
1998;14:745-747
Let’s look at how feeding of the
premature baby is often undertaken
Case study







Twins girls born at 33 weeks gestation
Normal delivery
Mother breastfed a previous child 7 months
without problems
MH born at 2.02 kg (4lb 7oz),VH born at 1.6 kg
(3lb 8oz)
They are relatively big babies
No medical problems at all in hospital
The twins in hospital 5 weeks total, 3 weeks in one,
then 2 weeks in another hospital
Feeding in hospital
Intravenous for first 4 days
 Formula started early, nasogastric feedings
at first
 Bottles started within the first week
 Breastfeeding only attempted after several
weeks (mother not sure exactly when)
 Pumping started in hospital but mother not
sure when (not within first days)

What’s wrong with that?





The mother should have started expressing
immediately (but it was not encouraged)
No kangaroo mother care
The babies could have been tried on the breast as
soon as it was obvious they were stable (<24 hours
in this case)
Cup feeding would have been preferable to bottles
and even to ng feedings
Formula was not necessary in the first days
On discharge from hospital
Mother was essentially bottle feeding both
babies, with babies taking the breast a little
on the left, refusing the right side completely
 Each feeding consisted of approximately 60
ml (2oz) of formula with 30 ml (1oz) of
expressed milk

First visit to our clinic
The babies are 83 days old
 MH weighs 3.35 kg (7lb 6oz)
 birthweight was 2.02 kg (4lb 7oz)
=weight gain 16 g/day, well below intrauterine
growth rate
 VH weighs 3.25 kg (7lb 2oz)
 birthweight was 1.6 kg (3lb 8oz)
=weight gain 20 g/day, better but still below
intrauterine growth rate

Intra-uterine growth rate

The “experts” say that premature babies
need to grow at intra-uterine growth rates of
12 to 16 grams/kg/day

Nutrient needs and feeding of premature
babies. Statement of the Canadian
Paediatric Society, 1995
Intra-uterine growth rate
Therefore, when they left the hospital,
according to this standard:
 MH should have weighed 2.85 kg (6lb 6oz)
 VH should have weighed 2.27 kg (5lb even)
 This is using the lower 12 g/kg/day and not
even taking into consideration the
increasing weight with time

What does this mean?




1.
2.
If they had, in fact, grown at 12 g/kg/day:
MH would have gained only 140 g (5oz) since
discharge from the hospital 5 weeks before
VH 710 g (llb 9oz) in the same time
So two possibilities:
They didn’t grow at intra-uterine growth rates in
hospital (which is the likely answer, despite all
the fortifier and preterm formula they received)
They didn’t grow well since leaving hospital
despite being mostly formula fed, and shouldn’t
we be concerned about that?
What does this mean?
As long as babies are formula fed, we don’t
seem to worry too about intrauterine growth
rate
 We probably believe that we’re doing the
best that can be done
 because formula is the best
 If the babies were strictly breastfed or
breastmilk fed:
 We have to do something!

After 4 visits to our clinic over 3 weeks
MH weighs 4.02 kg (8lb 14.5oz)
 Increase of 530 g (1lb 3oz)
 VH weighs 3.81 kg
 Increase of 460 g (1lb even)
 They are getting 120 cc/day (about 4oz) of
supplemental formula a day or
±60cc/baby/day
 Both are breastfeeding beautifully

Let’s look at the weights






Did they gain enough, on almost exclusive
breastfeeding?
MH gained: 530/21=25 g/day
VH gained: 460/21=22 g/day
At this age (12 weeks of age), it’s just fine!
Do we really truly need to check weight gain/day?
Nobody seemed to be worried that the weight gain
was not up to intra-uterine rates when they were
being supplemented with formula, were they?
After 5 weeks of help in our clinic, with
the mother obviously very determined,
babies are exclusively breastfeeding and
gaining weight well
Known deficiencies of artificial
feedings






No protection against infection
No trophic factors
epidermal growth factor, nerve growth factor,
insulin-like growth factor etc, etc
Long chained polyunsaturated fatty acids
(PUFA’s) are likely not added in proper amounts
Bioavailability of many elements poor or much
reduced
Interaction of elements does not occur
Breastmilk made to measure
Fortifiers



Because of the insufficiencies of each, then the use
of fortifiers is the “ideal” solution?
Benefits of both, right?
No, because fortifiers dilute the benefits of
breastmilk alone


They may be helpful or even necessary, but in the
case of liquid fortifier, dilute breastmilk or in the
case of powder, makes it hyperosmolar
Always necessary? No!
Overcoming “deficiencies” of
breastmilk




Feed more!
a healthy, unstressed premature may tolerate
a lot more than a sick, tiny one
we had no option in Africa; babies could get
breastmilk only; I was convinced by the
“intrauterine growth rate” argument
so we gave them more, and when the roof
didn’t cave in we gave even more
How much more?






Usually it is said that premature babies can take only up to
180 to 200 cc/kg/day fluid
This total includes IV fluid, so that enteral feeds are
correspondingly reduced
In some NICU’s, the “rule” is even less
In an NICU this may make sense since the babies are sick
and some may go into heart failure with more fluid,
especially if they are on ventilators
but the well premature baby can take more, especially if
given by continuous ng feeding
We gave 300+ cc/kg/day with no trouble except
occasionally babies would get diarrhea
Continuous drip





It has been said this isn’t as good as intermittent
feedings, because of greater loss of fat
Others studies suggest the oppositeless fat loss
with continuous flow
But if the syringe is tip upwards, we lose less fat
Ultrasound homogenization can decrease fat loss
as well
In utero the baby gets continuous flow
Continuous feeding better?


Dslina A, Christensson K, Alfredsson L, et
al. Continous feeding promotes
gastroentestinal tolerance and growth in
very low birth weight infants. J Pediatr
2005;147:43-49
“In VLBW infants, continous feeding seems
to be better than intermittent feeding with
regard to gastrointestinal tolerance and
growth”
Lecithin to decrease fat loss


Chan M, Nohara M, et al. Lecithin
decreases human milk fat loss during enteral
pumping. J Ped Gastroenerol Nutr
2003;36:613-15
Adding 1 g of soy lecithin to 50 ml of human
milk decreased fat loss from 58% (±13%) to
2% (±2%)
Overcoming “deficiencies”






Use hindmilk (more fat, faster growth)
Use fresh milk immediately after pumped
In Africa, we found that when mothers had to
leave, and refrigerated milk was used, babies grew
less well (but then this may be due to less KMC)
Add calcium, vitamin D and phosphorus without
using fortifiers
Use commercial lactase to incubate with expressed
milk
Kangaroo mother care
Need more weight gain?





If the mother is producing sufficient milk, why not
centrifuge some of the mother’s milk, skim off the
fat, and add it to the baby’s feedings?
Easy to do
We did it in Africa, with no equipment except a
centrifuge
Actually you can just let the breastmilk stand and
the fat rises to the top
Being done in some NICU’s in the US
Individualize care





The approach is different depending on the baby
bigger babies (>1500 g) usually do not need
fortification
“dilution” would be the appropriate word in this
case
a healthy baby, even small, presents fewer issues
than a sick one
this does not mean a sick baby should not get
breastmilk
Human milk banking





Why do “fortifiers” need to be made with cow’s
milk?
The technology is there (after all we make
“fortifiers” from cow’s milk) to make fortifiers
from human milk
This has been done and it is being done, and it is
conceivable that individual items can be ordered
up
baby needs more proteinphone the milk bank to
get human milk protein
baby needs to gain moreget human milk fat
Human milk banking



Human milk banking also affords us the luxury of
getting human milk into the baby from the very
first days, if the mother’s supply does not yet allow
getting significant amounts
Early feeding is now felt to be best for most
premature babies
Usually a small amount of human milk is much
better than large amounts of formula (preterm or
otherwise)
Getting breastmilk





First of all you need to get the milk
Milk from a breastmilk bank is one option
Some mothers have no intention of breastfeeding,
but they should be approached
“This is the one thing you can do for your baby
that nobody else can”
“You will be providing the best medicine there is
for your premature baby. Won’t you help us help
him?”
Early feeds





Colostrum should be provided as soon as possible
Even drops may be beneficial, by “priming” the
baby’s gut and giving protective SIgA
Drops can be tolerated even by the tiniest baby
and even drops protect
Many premature babies have IV lines up, so there
is no rush to get fluids into them
Small amounts of colostrum are perfectly
acceptable, and safer than early introduction of
foreign proteins
From the Canadian Paediatric
Society



Nutrient needs and feeding of premature babies
1995
“During the transition period, when growth is
variable and infants are metabolically unstable, all
infants, regardless of birth weight, should receive a
combination of parenteral and enteral nutrition.”
“Expressed preterm-mother’s milk, without
fortification, is the first choice for enteral feeding
during this period.”
Priming the gut






The baby is much more likely to tolerate oral
feedings earlier
Trophic factors (epidermal growth factor is present
in high concentrations in colostrum) help the gut
mature
growth of villae and digestive enzymes
promote gut “closure”
increase absorption of nutrients
improve gut motility
Sending a message
Even a drop or two of colostrum can be used
for mouth care of the ventilated baby, even
mixed with some water
 Giving the few drops to the baby sends a
very strong message
 even a few drops of breastmilk are important
and good
 Treat the milk as if it were precious!
 Because it is

What if no IV is necessary?




Small amounts of fluids may be adequate
colostrum in drops for a day or two
if mother not yet producing, and more calories
neededhow about banked milk?
IV should be seriously considered to avoid
formulas in the first days, so as not to lose the
advantage of the baby’s getting only breastmilk
orally during this most important time
Starting out expressing
Start as soon as possible after the baby’s
birth
 The sooner one starts, the more milk the
mother is likely to produce, and the sooner
the baby has colostrum available to him
 The mother has more practice
 Hand expression is often easier when
quantities are small

Hand expressing in the NICU
Pumping milk





Use double setup electric pump if possible
less time involved than single
more milk
results in higher prolactin levels
most mothers prefer double setup
How frequently?




Mother should express as much as
reasonable
eight times a day for about 20 minutes/side?
compression can be used as well towards
end of pumping (increases milk supply, gets
more milk)
don’t forget hand expression!
Support for the mother
It can be extremely difficult
 She needs support in hospital
 all health professionals should be expected
to convey the message of the importance of
breastmilk
 there will be rough moments
 She needs support outside hospital
 La Leche League, outside LC

Handling milk
Best to use fresh pumped milk given to the
baby immediately after pumping
 Refrigerated better than frozen
 The more you handle milk, the more you
lose beneficial factors
 but remember, even if you lose some SIgA,
for example, there is no SIgA in formula
 Glass and hard plastic presently the
preferred containers

Cytomegalovirus




There was considerable concern with mothers who
were carriers for cytomegalovirus a few years ago
The worry was that the tiny premature baby could
get seriously ill from virus in the milk
The virus is killed by freezing, so freezing of milk
was recommended before giving the thawed milk
to the baby if the mother was positive for IgG
antibodies to the virus in her blood
This is no longer felt to be a concern
Cytomegalovirus and prematures


Pædiatr Child Health, volume 11, no 8,
October 2006; page 490 (Statement from the
Canadian Pædiatric Society)
“…recent studies suggest that the relative
incidence and severity of CMV disease
in…premature infants are low…providing
further support for fresh breastmilk feeding
even if the mother is CMV positive.”
What about breastfeeding?




As one mother said to me about a Toronto
hospital where she gave birth to two
premature babies a few years apart,
“They’ve changed
“They now believe in breastmilk and are
urging me to express my milk,
“but I don’t think they believe yet in
breastfeeding”
When to start at the breast?





As soon as the baby is stable
babies can start nuzzling the breast very early
let them learn to take the breast
if you wait until they can “coordinate suck and
swallow”, you will have lost much valuable time
Kangaroo care, mother and baby (or father and
baby) skin to skin as much as possible is ideal
Pholosong Hospital, South Africa
31 weeks, 3 days old, and
breastfeeding
Note latch
When can the baby start
breastfeeding?




Nyqvist KH, Sjö P-O, Ewald U. The
development of preterm infants’
breastfeeding behaviour. Early Hum Dev.
1999;55:247-264
71 singleton (26.7-35.9 weeks gestation)
studied prospectively
Mothers made most of the observations,
with help from experienced observers
4321 records of infants’ behaviour
When can the baby start?




“Irrespective of postmenstrual age, the infants
responded by rooting and sucking on the first
contact with the breast”
“Efficient rooting, areolar grasp and latching on
were observed at 28 weeks”
“Nutritive sucking appeared from 30.6 weeks”
“Sixty-seven (out of 71) infants were breastfed at
discharge. Fifty-seven of them established full
breastfeeding at a mean postmenstrual age of 36.0
weeks (33.4-40.0)”
Bottle feeding mentality again

“Restrictions in breastfeeding policies for preterm
infants are commonly based on studies of bottle
feeding, where it has been established that infants
with immature cardio-respiratory control show a
less coordinated suck-swallow-breathe pattern,
resulting in apnea, hypoxia and bradycardia”
From Kersten Nyqvist
(email sent August 16, 2004)


…the postmenstrual age (PMA, corresponding to
GA after birth) when preterm infants in the
Uppsala NICU reach full breastfeeding has been
decreasing gradually, with an increasing number
of 34- and 33-weekers being discharged with full
breastfeeding
We also see some 32-weekers fully breastfed, and
recently one baby attained full breastfeeding at a
PMA of 31 weeks and 6 days (GA verified by
ultrasound)
Another personal communication
from Kersten Nyqvist (July 2006)

Feeding premature babies by the clock
delays transition to full breastfeeding
More from Dr. Nyqvist


1.
2.
3.
4.
Early attainment of breastfeeding competence in
very preterm infants. Acta Paediatr 2008;97:776781
A study of 15 babies born at 26-31 weeks
gestation
Five babies were able to latch on by 29 weeks
gestation
Kangaroo Mother Care was routine
Bottles are not given unless mothers insist
Only 4 of the 15 premature babies ever used a
nipple shield
And…
5.
6.
7.
8.
One baby achieved exclusive breastfeeding at 32
weeks gestation
Fortifiers were not used routinely and only 7
received any
Full breastfeeding was achieved at a median of
35 weeks gestation
The 26 week gestation baby left hospital
exclusively breastfeeding
And…
9.
10.
Twelve of the 15 mothers achieved exclusive
breastfeeding in hospital
Note that breastfeeding means feeding at the
breast, not “breastmilk feeding”
28 weeks gestation, two weeks
old, latched on, getting milk
28 weeks and breastfeeding
Consider this
Apparently in some or many Scandinavian
NICU’s, mothers are encouraged not only to
touch their babies, but also to hold them
skin to skin, and also to lick their skin all
over
 Why on earth?
 Think of the common causes of sepsis in
premature babies

Positioning, latching on
This is no less important for the premature
baby than in the full term
 A good latch allows the baby to get milk
better from the breast
 this teaches the baby to suckle properly
 babies learn to breastfeed by breastfeeding
 A good latch helps prevents nipple soreness

Good position, good latch
Nipple points to roof of mouth
Two errors?
Two errors?
1.
2.
Nipple is pointing to the lower lip, not
upper lip (or the mother has moved baby
too much to her left side)
Mother is squeezing nipple to put it into
the baby’s mouth
Better
Well latched on
34 weeks, not badly latched on
31 weeks, drinking beautifully
A few contentious points





Do premature babies need nipple shields?
Maybe some, but give them a chance to latch on
without them
What’s the rush?
If we did more skin to skin care (Kangaroo Mother
Care), we would have babies latching on better and
earlier
If we didn’t feed premature babies by schedules,
we would also not need nipple shields
A few contentious points





Are test weighings so important?
Do you really believe they tell you anything?
What if you get a negative test weight?
Why not just follow the baby’s weight from
day to day?
Observe the baby at the breast!
Study on test weighings


Savenije O E M, Brand P L P. Accuracy and
precision of test weighing to assess milk intake in
newborn infants. Arch Dis Child Fetal Neonataol
Ed 2006;91:F330-F332
“Test weighing is an imprecise method for
assessing milk intake; overestimation and
underestimation of up to 30 ml are possible,
probably caused by the use of insensitive scales…”
A few contentious points?




Do premature babies fall asleep at the breast
because the are tired?
Or because the flow of milk is slow? Right!
Just as with a full term baby!
Get the flow going, and they will keep awake
just as they would on a bottle
How to prevent slow flow?
1.
2.

3.
4.
5.

Best latch possible
Teach the mother how to know the baby is
getting milk
See websites www.nbci.ca
Use compression when the baby doesn’t actually
drink
Switch sides as the flow slows
Use a lactation aid to supplement
preferably expressed milk
Lactation aid


Use only after baby has nursed both sides and only
after the baby no longer actually drinks
Is the best way to supplement because babies learn
to breastfeed by breastfeeding



Even if there is no such thing as nipple confusion,
lactation aid still best
baby continues to get milk from breast
there is more to breastfeeding than breastmilk
Show video clip: insertion of
lactation aid
Does nipple confusion exist?


Mizuno K, Ueda A. Changes in sucking
performance from nonnutritive sucking to
nutritive sucking during breast- and bottlefeeding Pediatr Res 2006;59:728-31
“It is evident from the results of this study
that bottle feeding is a completely different
feeding method regardless of attempts to
make bottle feeding more closely resemble
breastfeeding”
Does nipple confusion exist?


Gomes CF, Trezza EMC, Murade ECM,
Padovani CR. Surface electromyography of
facial muscles during natural and artificial
feeding of infants J Pediatr (Rio J)
2006;82(2):103-9
Essentially, the study shows that different
muscles are involved in breastfeeding than
in bottle feeding
Lactation aid in place
Inserting tube-1
Inserting tube-2
Inserting tube-3
Inserting tube-4
Cup feeding
Best used when mother isn’t present
 Used to avoid a bottle
 Some people say that if used correctly, helps
the baby to learn to breastfeed because he
must stick out tongue to drink from cup
 In any case it is easy, and better than bottle

Cup feeding
Cup feeding
Cup feeding
Show video of cup feeding
Finger feeding
Used essentially to help a reluctant baby to
take the breast
 It calms him, gets him suckling properly
 After a few seconds to a minute or two of
finger feeding, try the baby on the breast
 If mother not there, cup feeding is better,
there is no reason to use finger feeding

Finger feeding
Positioning of tube for FF
Positioning of tube for FF
So what about the “older” premature
baby (35-37 weeks)?









Nothing really
The same approach is necessary
An early start, good positioning and latching
No forcing of the baby to the breast
No rush to get him breastfeeding
Avoidance of bottles
Skin to skin contact (most of the day)
Alternative feeding methods if necessary
Discharge with good outside followup
Discharge planning
There is no need to wait for the baby to
breastfeed well, if the mother and baby can
get early, reliable, frequent and
knowledgeable followup, starting within a
day or two of discharge
 Should we intimidate mothers into giving
bottles, so the baby can go home?
 short term gain, for long term pain (mother’s
and baby’s not the staff’s)

Attrition of Breastfeeding In NICU from
Admission to Discharge
80
70
60
BM in
NICU
50
40
BM at
D/C
30
20
10
0
89
90
91
92
93
94
95
96
97
98
99 '00 '01
Attrition of Breastfeeding In NICU from
Admission to Discharge  1500 gms
80
70
60
50
In NICU
At D/C
40
30
20
10
0
89
90
91
92
93
94
95
96
97
98
99
'00 '01
27 weeks gestation
1 year old (8 months corrected)
Still breastfeeding by his mother who
adopted him at birth
Breastfeeding the baby with
congenital heart disease
Why is it important to breastfeed?
For the same reasons as for any baby
 Why do babies with cardiac disease need
breastfeeding (or breastmilk) less?
 They need it more!
 They spend a lot of time in hospital, and
infection rates are not minimal
 Indeed infection is not rarely cause of
complications, prolonged hospitalizations
and death

What obstacles are there?





Same as any mother-baby pair plus:
“Breastfeeding is more difficult than bottle
feeding”
Fluid restriction is “necessary” for the baby
with congestive heart failure
Cardiac disease often associated with other
problems
A baby who has had a cardiac transplant
cannot breastfeed
Is breastfeeding more difficult?
Not according to the data
 Anyone who takes the trouble to watch a
baby breastfeeding at the breast knows this
is not true
 See the video clip: Inserting lactation aid
 Marino BL, O’Brien P, LoRe H. Oxygen
saturations during breast and bottle feeding
in infants with congenital heart disease. J
Pediatr Nurs 1995;10:360-4

Fluid restriction





Fluid requirements can be managed clinically
(daily weights, physical examination, increased use
of diuretics)
Even, if one must, pre and post feeding weights
If truly necessary, though, the mother could:
use a lactation aid with expressed milk while the
baby nurses on a “dry” breast
Still possible to avoid bottle with cup feeding
Associated problems







Babies with cardiac problems often have other
associated problems
Trisomy 21
large tongue, hypotonia
most babies will take the breast
Tracheo-oesophageal fistula (other gi anomalies,
such as gastroschisis)
no need for favourite surgeon formulas
breastmilk is best
Cardiac Transplantation
Will antibodies in the milk increase the risk
of rejection?
 Ridiculous!
 An example of breastmilk is guilty until
proved otherwise, whereas formula is
innocent until proved guilty

Antibodies in various fluids
Do maternal antibodies in
breastmilk cause infant illness?
1.

2.
3.
4.
The predominant immunoglobulin in human
milk is secretory IgA
there is no evidence that secretory IgA is a
pathogenic antibody in autoimmune disease or
rejection
In any case, secretory IgA is not absorbed via the
gastrointestinal tract
There is no evidence that IgG in human milk is
absorbed into the circulation of the infant
IgM also excluded from the infant’s circulatory
system
In rare cases…






It would seem as if white cells in the milk can give
information (via cytokines?) to the baby which has resulted
in an immune response to platelets in baby when the
mother had idiopathic thrombocytopenic purpura, for
example
Has never been reported with cardiac transplantation.
Rare!!
Often gets better after a few weeks
Freezing milk kills white cells
But would these cytokines overcome the powerful
immunosuppressives?
Chylothorax
Not a rare complication of cardiac surgery
 The thoracic duct is nicked, and lymph
drains into the right chest cavity
 Occasionally, a baby without any cardiac
disease is born with chylothorax without any
obvious reason

Usual treatment of chylothorax

Chest tube drainage
+

Low fat diet (to decrease lymph flow in the
thoracic duct)
Low fat diet?
You cannot give an infant a low fat diet; this
will result in poor growth
 So if we give him milk with medium chained
triglycerides, the baby will get fats in the
milk which is not absorbed into the lymph,
but rather directly into the blood stream
 This will decrease the flow of lymph in the
thoracic duct and decrease the drainage into
the chest cavity

Does that mean no breastmilk?
That’s what it meant until some people
started to think about it a little
 People who felt breastfeeding, or at least
breastmilk, was important
 Why give Portagen (formula with medium
chained triglycerides) when we can give
breastmilk?

What to do?
1.
2.
3.
4.
5.
Mother expresses milk
Milk is centrifuged and fat skimmed off
Fat is replaced by medium chained
triglycerides
It’s not quite breastmilk, but it’s better
than Portagen
Baby is also at lesser risk for infection and
receives most of the other benefits of
breastmilk
And then?
Once the thoracic duct heals, the baby goes
back to breastmilk, and attempts are made
to get the baby breastfeeding
 It may not be easy, as most surgeons and
cardiologists want the chest dry for several
weeks before abandoning the milk with
medium chained triglycerides
 If the baby were fed on a “dry breast” with a
lactation aid?

Making skimmed breast milk

See: www.lalecheleague.org and search for
Chylothorax
Breastfeeding the baby with
cystic fibrosis
Why is it important to breastfeed?







For the same reasons as for any baby
Why do babies with cystic fibrosis need
breastfeeding (or breastmilk) less?
They need it more
They spend a lot of time in hospital, and infection
rates are not minimal
Indeed infection is a common cause of
complications, prolonged hospitalizations and
death
Nutrition is a serious issue for these babies
Breastmilk is best
Breastmilk has lipase
These babies usually do not have good
pancreatic function and are unable to digest
fat well
 But breastmilk contains lipase
 These babies usually do not digest protein
well
 But breastmilk contains proteases

Most babies will need enzymes
These can be given, dissolved in some
expressed milk, by lactation aid
 Sometimes, because they are digestive
enzymes, the mother’s nipples can become
sore
 So use all purpose nipple ointment before
passing enzymes through the tube

Fat excretion studies





Part of the “routine” workup for cystic fibrosis is to
do fat excretion studies
The baby is given milk of which the fat content is
known
His bowel movements are collected for five days
and the amount of fat in the bowel movements is
measured
The amount of fat excreted in the stools is
expressed as a percentage of the total fat ingested
Not every hospital centre is doing this any more
Normal fat excretion
Normally, a baby will not have more than
about 10% of the total fat intake recovered in
the stools
 An older child or adult, no more than 5%
 Babies with cystic fibrosis usually pass
much more than 10% of their fat intake in
the bowel movements

What are the implications?



It means taking the baby off the breast and
feeding by bottle for 5 days
Often they are not even offered the mother’s
milk because the amount of fat in breastmilk
is variable
It means that many babies will then refuse
to breastfeed, having gotten used to the
bottle
Is it necessary to do this?
It helps to decide how much enzyme
replacement the baby will need
 It helps to get research published to know
this figure of % fat excreted
 But enzyme replacement is, in any case, a
bit of a guess, and can be adjusted
 And is it worth depriving the baby of
breastfeeding and breastmilk?

Breastfeeding protects pulmonary
function in children with CF

Colombo C, Costantini D, Zazzeron L, et al.
Benefits of breastfeeding in cystic fibrosis: A
single-centre follow-up survey. Acta Paediatr
2007;96(8):1228-32
Breastfeeding and PKU
Phenylketonuria




A relatively rare inborn error of metabolism,
characterized by the child’s inability to oxidize
phenylalanine to tyrosine
It is caused by the absence of active phenylalanine
hydroxylase in the liver
Up until about 1980’s, it was thought that
breastfeeding was impossible (another example of
bottle feeding mentality)
Then it was shown that breastmilk had less
phenylalanine than formula
Can the baby breastfeed?
A baby with PKU needs some
phenylalanine, but not too much, so
breastfeeding can be encouraged
 How do we make sure the baby with PKU
gets some, but not too much, since the
amount a baby would get from full
breastfeeding is usually too much for him?

First approach at PKU clinic
1.
2.
3.
4.
Mother weighs baby before feeding
Mother feeds baby 10 minutes on each side
Mother reweighs baby after feeding
Mother gives rest of calculated total of
feeding as low phenylalanine containing
formula
Why didn’t it work?
1.
2.

The mother had to take a scale with her
wherever she went
Babies started to refuse the breast. Is
anyone surprised?
Babies usually stopped by 2-3 weeks of age
Another way?
1.
2.
3.
Calculate the approximate quantity of low
phenylalanine formula the baby would
require
Give this amount of formula at the
beginning of the feeding at the breast with
a lactation aid
Allow the baby to finish the feeding on the
breast
Results?
During the first year, breastfeeding
continued much longer
 One baby made it to 18 months of age
 Several made it to 6 months
 One baby who had atypical PKU was able to
be breastfed exclusively
 If you look, you may find a way

Lactation aid
Cup feeding
Finger feeding
Summary
If you believe in the importance of
breastfeeding, both to the mother and the
baby
 and you have imagination and
determination
 and develop the necessary skills,
 even in the most difficult, complex, or
previously untried situations,
 you may find a way!
