Breastfeeding High Risk Infants

There is no "one size fits all" method for achieving effective breastfeeding with a high-risk baby. Every baby and situation is unique. Give your high-risk baby extra time to learn to breastfeed and let the infant set the pace for learning. Learning to breastfeed effectively is a process that may take days or weeks for premature and many other high-risk babies. However, you and your baby can become a breastfeeding team if you are patient, persistent and maintain a healthy perspective.

Be sure to let your doctor and your baby's nurses know that you would like to breastfeed as soon as your baby is ready to begin feeding by mouth. In general, a baby must be able to suck-swallow-breathe in a coordinated way to take food by mouth. Some of the signs that a baby is getting ready to do this include:

• Physical stability. A baby's condition should be stable so the baby can physically handle being held and fed.
• Non-nutritive sucking. A baby first displays rhythmic sucking on a pacifier, feeding tube, etc., in brief bursts of more than one suck per second.
• Gestational age. At about 32 weeks gestation, a baby will begin to display bursts of sucking and around 34 weeks a rhythmic suck-swallow-breathe pattern develops.
• Wakeful state. A baby must remain awake – from drowsy to quiet alert to active – for brief periods in order to feed by mouth.
• Oral reflexes. A baby must be able to tolerate touch to the mouth area and demonstrate the reflexes needed for oral feeding. This includes rooting, sucking, cough and gag reflexes.

Breastfeeding is usually less stressful for a high-risk infant because the baby sets the pace. A baby's heart and respiratory rates, oxygen saturation level and body temperature tend to remain more stable and often improve during breastfeeding. This stability of physical systems means breastfeeding takes less energy and is less work for the high-risk baby. Of course, a baby must actually latch-on and effectively suck to get milk during breastfeeding. This may take time for a baby to learn. When bottle-feeding, milk drips in the baby's mouth and a baby must swallow it, ready or not.

The stages listed below describe a baby's progression to direct breastfeeding. They are meant only as a guideline. Progress varies among high-risk babies. A baby might move quickly from one stage to another or skip a stage altogether. On the other hand, a baby may sometimes seem to get stuck at one stage for a few days or weeks.

• Practice feedings. During the early stages of learning to breastfeed, your high-risk baby may not take in much milk during each feeding. The baby is only practicing the motions. Neither you nor your baby should ever feel any pressure to perform.
• Skin-to-skin contact. A baby is likely to begin rooting or nuzzling at the breast and may latch-on when held skin-to-skin.
• "Empty breast" feeding. A mother may want to pump before skin-to-skin holding sessions once rooting and nuzzling are noted. Then, the baby can latch-on and practice without being overwhelmed by the let-down of lots of milk at once. Being overwhelmed can affect a baby's physical state, and your mental state.
• Progressive non-nutritive sucking sessions. A baby will advance at the breast from latching-on, to sucking in bursts, to occasionally coordinating suck-swallow-breathe. As your baby shows more ability, you will want to see what he or she can do with more milk in the breast. Pump until the let-down flow slows and then offer the breast. This prevents large amounts of milk that often come with let-down from overwhelming the baby, yet leaves plenty of milk in the breast for a feeding.

Adding to Your Breast Milk

Although your milk is the best food for your baby, it may not always completely meet the nutritional needs of high-risk babies, such as very small premature babies or some very sick newborns. Fortunately, fortifying a mother's milk can help to better provide the nutrition your baby needs, while not diminishing the nutritional and anti-infective benefits your baby will gain from receiving breast milk.

Certain nutrients occur at the same levels in premature milk as in-term milk, and the overall calorie count is the same for both. However, breast milk contains lower levels of some nutrients than artificial formulas, nutrients that are beneficial for premature babies. For instance, protein and sodium are at higher levels in premature milk than in mature milk, yet they still are low when compared to the amount in most artificial formulas. Because of the lower levels of these nutrients, the premature baby loses less water. Less water loss helps the premature baby maintain a stable body temperature.

The nutrient levels and the available calories in breast milk are often adequate for older premature babies and for many other high-risk babies. However, lower nutrient levels and the full-term calorie count in breast milk may create problems for the low birthweight baby who weighed 3 pounds, 5 ounces (1,500 grams) or less at birth, or for babies with certain health conditions affecting digestion or the use of nutrients. These babies may not get enough of the minerals, such as calcium, phosphorous, and iron, from their mothers' milk alone. They also may need additional calories.

The most common ways of adding nutrients and calories to a mother’s breast milk for high-risk infants includes:

• Hind milk feeding. When a higher calorie count is the only consideration, you may be asked to pump your milk for several minutes and then stop to change collection bottles. The early milk obtained while pumping is called fore milk and it is higher in other nutrients. The milk collected after the first several minutes is called hind milk and it tends to be higher in calorie-rich fats. Freeze any fore milk for later use if asked to provide hind milk for some feedings. Do not obtain only the hind milk for feedings unless directed to do so by your baby's doctors and nurses.
• Human milk fortifier (HMF). HMF contains several nutrients, especially certain minerals that are needed for proper bone development in low birthweight babies. HMF is added directly to a bottle of your own milk. Usually a powdered version is used when plenty of your own milk is available. Liquid HMF will be used if reduced amounts of your breast milk are available.
• Premature infant formulas. Sometimes, feedings of a mother's milk may be alternated with feedings of a premature infant formula. This may be done if HMF is not considered the best option, or when reduced amounts of your breast milk are available.

For more information on breastfeeding high-risk babies, talk with a certified lactation consultant, your doctor or your baby’s doctor. For more information, please call our Lactation Services at (314) 996-5747.