Breastfeeding the premature baby: Part 2

Premature babies cannot start going to the breast until 34 weeks gestation?

This is simply not true. Experience and evidence (see references at bottom) from Scandinavia clearly show that babies can go to the breast well before 30 weeks gestation and as early as 27 weeks gestation.  Not only can they go to the breast and latch on, but also, they actually can be getting milk from the breast by 28 to 30 weeks gestation, 4 or more weeks before in North America, they are even “allowed” to go to the breast.

In North America and elsewhere in the world, we believe, because it’s true, that babies born at 24 weeks gestation and even earlier can be kept alive and leave hospital in reasonably good shape, but we just cannot believe a baby can go to the breast before 34 weeks gestation.  How can that be?

Well, saving a baby of 24 weeks gestation is “high tech” and we really believe in “high tech”.  It proves humans are above the other animals, and neonatologists , oh, they are superior beings, not quite gods, but just below, at the level of archangels, perhaps.  But breastfeeding is “low tech”, so “who cares?”, “not interesting” and therefore breastfeeding is generally ignored (though breastmilk, which was a long time ignored as inferior, is now back in fashion), and what we believed about premature babies and breastfeeding 50 years ago, well, no point in looking any further, it’s all the same, doesn’t change. In fact, we believed that breastmilk was “low tech”, (after all, made by women, so… must I say more?).

Help with breastfeeding

And then we started to find out more: that breastmilk made by the mother of a premature baby was tailor made for the needs of the premature, different than the milk of a mother of a baby born at term; we learned that breastmilk contains all sorts of very important compounds we never suspected even existed even just a few years ago: for example, lysozyme (an enzyme, not so new actually, that attacks bacteria and kills them by destroying their cell wall), mucins, stem cells, lactadherin, bifidus factor, milk fat globule membranes, human milk oligosaccharides and many others.  And probably many others are yet to be discovered.  And so, breastmilk became high tech and worthy of interest, especially by formula companies who realized the marketing potential immediately.  But breastfeeding? Still “low tech” and is believed, wrongly, not worth thinking about. After all, breastmilk in a bottle is just as good as breastfeeding, the baby is actually getting milk from the breast. So why bother our heads about making sure the baby breastfeeds?

Oh, yes, we forgot. Premature babies “need” “fortified” breastmilk, so we cannot have the mothers breastfeed.  “High tech” wins over “low tech” again.  But do babies all need “fortified” breastmilk?  More about this in Part 3.

But where does such an idea come from that a baby must be at least 34 weeks gestation before he can breastfeed? It is thought that bottle fed babies started on bottles before about 34 weeks gestation will have apneas (breathing stopped) and bradycardias (slow heart rate) as a result of bottle feeding.  And we all know that bottle feeding is just like breastfeeding, breastfeeding using a softer bottle. NOT. No, the bottle is not just like breastfeeding, but we seem to believe it is. Thus, if babies younger than 34 weeks gestation have apneas and bradycardias while drinking from a bottle, they would likely have them while drinking from the breast.  NOT true.

Breastfeeding is not bottle feeding and breastfeeding is not even feeding breastmilk from a bottle. Unlike what many neonatologists believe, breastfeeding does not take more energy than bottle feeding and does not tire the baby out or cause the baby or that babies fall asleep at the breast because they are “lazy”. That is an error based on the observation that babies tend to fall asleep at the breast even though when they come off the breast they show they are still hungry. But they don’t fall asleep because they are tired or that breastfeeding takes up a lot of energy.  They fall asleep because babies respond to the flow of milk from the breast.  If the flow of milk is slow, the baby tends to fall asleep at the breast.  And why does the milk flow slow down? Because, in most NICUs, we do not teach mothers how to latch babies on, and we don’t teach them the simple useful “trick” of breast compression.

It is generally said in lactation consultant “circles” that babies do or do not transfer milk well.  So, for example, “The baby is not gaining weight well because he is not transferring milk well.”  Well, in fact, babies don’t transfer milk.  Mothers transfer milk.

But the notion that it is the baby who “transfers milk” leads to the false conclusion that breastfeeding is hard work, that the baby has to use up a lot of energy in order to suck milk out of the breast. And this is even more so for a premature baby who has “undeveloped cheek muscles”.  Babies use their cheek muscles to pull milk out of the breast??? But none of the previous statements is true.  Babies respond to milk flow.  If milk flow is rapid and consistent, the baby usually stays awake and drinks the milk. If milk flow slows, the baby stops drinking and may only “nibble”. And the flow of milk slows quickly because in most NICUs mothers are not taught good latching on  and are not taught breast compression


Video 1.The mother in this video is using breast compression to increase the flow of milk to the baby who is only a few days old.

So, premature babies in North America cannot start breastfeeding until 34 weeks gestation, while at least some premature babies in Scandinavia can start at 27 weeks gestation. That makes no sense at all.  And it is “obvious”, also, that feeding at the breast should not be “too long”, thus tiring the baby out.

Another obvious, but incorrect conclusion, is that babies need to be fed or supplemented by bottle, as everyone seems to believe that the bottle is less tiring.  But that is believed only because we are used to the bottle.  Supplementation can be done at the breast with a lactation aid which is the best way, but also by open cup.

Video 2. Using a lactation aid to supplement a baby. Note that the baby falls asleep when the flow of milk slows but wakes up and sucks vigorously when the flow of milk, given by lactation aid at the breast, increases. The baby was not tired and fell asleep; the flow of milk was slow and the baby fell asleep because the flow of milk was slow.  When the flow increased, the baby woke up.

Here are a few articles showing that babies can start going to the breast well before 34 weeks gestation. The comments below the reference are exact quotes from the article.

Blaymore JA, Ferguson AE, Morales Y, Liebling JA, Oh W, Vohr BR. Breastfeeding Infants Who Were Extremely Low Birth Weight. Pediatrics 1997;100(6).

“Results. The infants demonstrated a higher oxygen saturation and a higher temperature during breastfeeding than during bottle feeding, and were less likely to desaturate to <90% oxygen during breastfeeding. Mean weight gain was greater during bottle feeding than during breastfeeding (31 vs 9 g).

Conclusions. Breastfeeding the ELBW infant is desirable from a standpoint of improved physiologic responses, but such practice requires breastfeeding support and possible supplementation to optimize weight gain.”

Hedberg Nyqvist K, Ewald U. Infant and maternal factors in the development of breastfeeding behaviour and breastfeeding outcome in preterm infants. Acta Pædiatr 1999;88:1194-203

“In conclusion, low gestational age at birth was associated with early emergence of efficient breastfeeding behaviour and a high incidence of full breastfeeding.”

Nyqvist KH, Sjödén P-O, Ewald U. The development of preterm infants’ breastfeeding behavior. Early Human Development 1999;55:247-264

“Irrespective of PMA (post menstrual 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, and repeated bursts of >10 sucks and maximum bursts of >30 sucks at 32 weeks. Nutritive sucking appeared from 30.6 weeks. Sixty-seven infants were breastfed at discharge. Fifty-seven of them established full breastfeeding at a mean PMA of 36.0 weeks (33.4–40.0 weeks). Their early sucking behavior is interpreted as the result of learning, enhanced by contingent stimuli. We therefore suggest that guidelines for initiation of breastfeeding in preterm infants should be based on cardiorespiratory stability, irrespective of current maturity, age or weight.”

Nyqvist KH, Early attainment of breastfeeding competence in very preterm infants. Acta Pædiatrica 2008;97:776-781

“Very preterm infants have the capacity for early development of oral motor competence that it sufficient for establishment of full breastfeeding at a low postmenstrual age.”

Need breastfeeding help in Toronto and area? Make an appointment with International Breastfeeding Centre

Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018, 2020