Breastfeeding forms a unique relation between mother and infant. The arrival of an infant prematurely who is in the neonatal intensive care unit (NICU), poses unique feeding challenges that need to be considered on an individual basis, for the mother and the infant. Given the health benefits that mother’s milk has, breastfeeding is recommended as the normal and unequalled method for feeding infants, especially premature ones. According to studies by Medela India, premature infants who receive mother’s milk during their stay in the NICU have a reduced risk of nosocomial infection, sepsis, necrotising enterocolitis, chronic lung disease, retinopathy of prematurity, developmental and neurocognitive delay, and rehospitalisation after NICU discharge.
Breastfeeding doesn’t always come naturally. Most mothers who provide human milk for their infants in the NICU rely on breast pump instead of a healthy breastfeeding infant for the initiation and maintenance of lactation.
The mothers of infants in the NICU are at a greater risk for insufficient milk when compared with mothers with healthy breastfeeding infants. The reasons could be due to delayed onset of lactation and low milk volume. Majority of mothers are unprepared for the premature delivery and the whole situation can be overwhelming and stressful.
There is a need to assist them in anticipating, managing, and overcoming these barriers- from the mechanics of latch to reassurance about milk supply. Majority of barriers take place in the first few days postpartum and in the hospital, which lead to further barriers in the later day’s eventually precluding breastfeeding.
Common barriers that mothers face during the postpartum period of premature birth are:
Lactational: Breast milk supply
The most commonly reported barrier by mothers is of insufficient milk supply in the first few days due to their premature stage of breast development.
Mothers experience difficulties with latch, as clinically preterm infants show difficulty maintaining a latch to the breast, apply weak vacuums and often fall asleep on their mother’s breast itself, which further cause nipple pain. This is a unique scenario that prevents their breastfeeding. This barrier is commonly experienced by most mothers. Majority of babies develop the latch, suck and swallow reflex by 32-34 weeks of gestation, thereby further delaying the process.
Separation from infant
Many mothers encounter unexpected separation from their infants in the hospital after delivery, such as NICU stays for infants with health concerns. Separation interferes with the initiation and establishment of breastfeeding and increases the likelihood of complications that could lead to mothers experiencing significant stress, anxiety and lack of sleep. In some instances, babies may be transferred to another higher center for lack of local resources and this could mean separation for even longer time.
Lack of proper knowledge
A major barrier to the initiation and maintenance of lactation in mothers whose infants are in the NICU is the inconsistent information that they receive regarding the importance of human milk for their infants, strategies to pump and store their expressed milk, specific guidelines for transferring the infants to feeding at the breast, and combining pumping and feeding during the late NICU hospitalisation and after discharge.
These problems further lead to barriers that mothers face in the late days of postpartum. Once the initial stage barriers get resolved, mothers themselves tend to find ways to solve other barriers such as general inconvenience, family responsibility, maternal exhaustion, baby rejection and perceived benefits of formula.
Family support and tips of feeding preemies that new mother must know
Awareness of breast feeding and advantages should be started as early as antenatal period. Majority of preterm deliveries happen without adequate warning and therefore mothers are disadvantaged. The doctors and nurses should help mothers’ express milk as soon as she is able to, soon after birth. The babies could be given the advantage of early tropic breast feeds or even mouth painting with colostrum, which is known to be very beneficial. This first milk would enable the babies to colonise with friendly bacteria, enhance the gut integrity and provide the much-needed immunity.
Breastfeeding a premature baby requires an enormous amount of patience. Chances are, the babies feeding skills haven't fully developed yet. This means the preemie will need to be slow fed, or she may feed too fast and spit up or develop a feeding aversion. A popular method to start the breastfeeding process is Kangaroo Care, a method that involves skin-to-skin contact. This is shown to enhance greater bonding between mother and baby, regulate the baby’s heart rate and temperature and also enhance the milk production.
To heighten the chance of successful breastfeeding, mothers should start pumping immediately after birth and make sure to pump regularly from both the breasts every 2-3 hourly. The milk can be pumped until the breast is empty of milk, including the hind milk that is high in milk fat and essential to the baby’s nutritional needs.
Pumping is all the more important in mothers dealing with lactational issues and mothers should be encouraged to use the breast pumps as it significantly improves the initiation of lactation after preterm birth.
Mothers can use nipple shields to facilitate milk transfer. An ultrathin silicone nipple shield has been shown to compensate for problems related to latch in infants in the NICU by creating the nipple shape and facilitating the transfer of milk to the infant. Most mothers need to use the shield until their premature infants achieve approximately term, corrected age and are gaining weight well on exclusive feeds at breast. Nipple shield is also shown to be beneficial in those mothers with flat or inverted nipples.
It cannot be emphasised more that families and spouse should play a major role in providing support, both skill- and relation-based. They should be provided with information which strengthens their belief in the benefit and feasibility of breastfeeding initiation and observe the factors that modulate breastfeeding outcome in premature infants. It is important to support mothers to continue breastfeeding beyond the first few weeks, and for a change in cultural attitudes, while ensuring that it doesn’t dictate to mothers that they must breastfeed or suggest that they are a failure if they don’t. For the working mothers the employers must be supportive and understand the need for extended maternity leaves in case of preterm delivery in order to continue breastfeeding for longer periods.
As a new mother one will receive a lot of advice on what and how to feed your premature baby, but one thing to remember is to do what is comfortable for oneself and one’s baby.
*Disclaimer: The article has been contributed by Dr Prathap Chandra, lead neonatologist, Motherhood hospital, Bangalore. The opinions expressed in the article are the personal opinions of the author. The facts and views appearing in this article do not reflect the views of Deccan Chronicle and Deccan Chronicle does not assume any responsibility and liability for the same.