Breastfeeding a Preterm Infant after NICU Discharge: Reflections on Ryan's Story
Paula P. Meier, RN, DNSC,
Associate Director for Clinical Research: Section of Neonatology,
and NICU Lactation Program,
Director: Rush-Presbyterian St. Luke's Medical Center,
Professor: Rush College of Nursing, Chicago, IL
Linda P. Brown, RN, PHD,
FAAN, Professor and Chair: Division of Health Care of Women and Childbearing Families,
University of Pennsylvania, Philadelphia, PA
from Breastfeeding Abstracts, August 1997, Volume 17, Number 1, pp. 3-4.
"Ryan Can Nurse Today," published in La Leche League International's publication for mothers, NEW BEGINNINGS,1 captures the essence of studies that address breastfeeding a preterm infant during the early postdischarge period. In this article, Ryan's mother described the support and assistance she received from health professionals during her preterm infant's stay in the neonatal intensive care unit (NICU), and detailed the challenges to persevering with breastfeeding after Ryan's discharge. The words of Ryan's mother "personalize" the results from studies that focus on breastfeeding for mothers and their preterm infants during this brief, but physically and emotionally intense, period of time. These study results show that mothers are concerned about their preterm infants "getting enough" milk from exclusive breastfeeding2-6 and that these concerns are real, in that preterm infants are at risk for underconsumption of milk by exclusive breastfeeding until they reach approximately term, corrected age.2, 7-12
The purpose of this review is to highlight the differences between term and preterm infants with respect to breastfeeding management and to describe research-based interventions to facilitate breastfeeding for preterm infants and mothers during the early post-discharge period. Preterm infants are not small term babies. In the United States preterm infants are usually discharged from the NICU before their expected birth dates, so they are still "immature" during the early weeks at home.14 Typically, these babies weigh between four and five pounds, which is approximately half to two-thirds the body weight of a healthy, term newborn. In comparison to term infants, preterm infants have a large body-surface-area-to-weight ratio and higher metabolic demands to support temperature regulation and rapid growth. In combination, these factors mean that preterm infants have greater fluid and caloric requirements per pound of body weight than do healthy, term infants.15 As such, a preterm infant is more susceptible to the effects of even temporary underconsumption of milk and can become dehydrated much more quickly than a healthy, term infant. Feeding behaviors also differ for preterm infants, especially with respect to the regulation of sleep and eating. Preterm infants may not have developed sufficient state control to respond predictably to hunger until they reach approximately term, corrected age.2 Ryan's mother provided an excellent example of this when she wrote; "He was not able to 'demand' a feeding until he was about seven weeks old, and would sleep eight hours, and still not be interested in nursing when he awoke." Similarly, preterm infants can demonstrate signs of satiation post-feed (e.g., falling asleep, refusing the breast) when little or no milk has been consumed.7,8 These immature behaviors cannot be corrected by waking the preterm infant to feed more frequently (>8 times daily), because sustained sleep periods are necessary for the secretion of growth hormone, which is crucial for adequate growth.
These physiologic and behavioral differences mean that breastfeeding strategies commonly used for term, healthy infants will often be ineffective (and possibly unsafe) for preterm infants.12, 16, 17 In particular, unmonitored "demand" feedings and/or frequent sleep interruption are not appropriate for preterm infants, because of the risk for dehydration and slow weight gain.
Getting enough: Term and preterm infant differences
The international literature suggests that preterm infants are at risk for underconsumption of milk with exclusive breastfeeding until they reach approximately term, corrected age.2, 7-12 In contrast to mothers of healthy term infants, mothers of preterm infants seldom cite insufficient milk as a reason for their babies’ not taking an adequate volume of milk at breast.6 Mothers of preterm infants often produce two to three times as much milk as their babies need, which they can express effectively with a breast pump, but they report that their babies do not take all the milk that is available to them. Typically, mothers describe immature feeding behaviors, such as not waking to feed, falling asleep early in the feeding, and slipping off the nipple before a steady milk flow can be sustained. These suggest to them that their infants are not getting enough.2, 4, 14 Studies suggest that these behaviors are the norm for preterm infants, and they are gradually replaced with more mature behaviors as the infants approach their expected due dates.2, 9, 14 Although these maturationally dependent feeding behaviors cannot be corrected, several breastfeeding strategies can be used to compensate for them. Milk transfer is dependent upon infant suckling, maternal milk supply, and milk ejection, so a preterm infant with an immature suck can still “get enough” if the mother has extra milk and it flows easily.14 Research-based interventions for getting enough include: maintaining an abundant maternal milk supply, breastfeeding in positions that support and direct the infant’s head, and the temporary use of breastfeeding aids, such as infant scales for measurement of milk intake.12, 13 Although strategies for increasing the milk supply may facilitate milk transfer, they do not correct infant feeding behaviors that are maturationally dependent. Thus, extra pumping and galactogogues may increase milk volume, but do not correct the underlying problem of infants’ immaturity in extracting milk from the breast.
Like Ryan’s mother in the story, mothers of preterm infants are acutely vulnerable with respect to their infants’ getting enough–not because they have become accustomed to “numbers” in the NICU, but because their concerns are real. Mothers of preterm infants usually elect to complement at-breast feedings with expressed milk “just to be sure” the babies consume an adequate volume.2 Routine complementation establishes an undesirable feeding pattern for the infant, because it is seldom individualized to the amount just consumed at the breast. Additionally, it involves so much extra work for mothers that they become exhausted; each feeding involves at-breast feeding, pumping, and a bottle (or some alternative) complement.2-6
Measuring milk intake in the home
Studies have demonstrated that mothers of preterm infants cannot use clinical indices of intake, such as audible swallowing and changes in breast fullness pre-and post-feed, accurately until infants are home for at least two to three weeks.2, 7 Thus, these women don’t know whether their babies consumed an adequate amount of milk from the breast at a particular feeding. The difference in the use of these clinical indices by mothers of term and preterm infants is beyond the scope of this review, but has been detailed in published research.7, 8
In-home measurement of at-breast intake by test-weighing can prevent the sequelae of low milk consumption while promoting and sustaining the breastfeeding relationship. Test-weighing involves weighing the clothed infant before and after the feeding under exactly the same conditions; the weight gain (in grams) is equal to the volume of milk consumed (in cc’s).18 In one study, mothers demonstrated the ability to perform test weights very accurately when using an electronic scale available for short term in-home rental.7 The scale is portable, operates on household current or with batteries, and automatically calculates milk intake from the pre-and post-feed weights. A large study is currently underway to examine the effect of in-home test-weighing on several breastfeeding outcomes including: infant weight gain, transition to complete breastfeeding, and maternal concerns about infant intake.19
However, in the interim, it is important to acknowledge that no clinical trials have suggested that in-home test weights are burdensome or anxiety- provoking for mothers. In contrast, the preliminary results from a separate study suggest that mothers find the information from test weights to be reassuring, in that they know whether a complement is needed.20 Ryan’s mother echoed the words of many mothers from published studies when she wrote; “If I had known at the time that Ryan was still gaining weight, I would not have been so quick to supplement.”
Individualized complementation schedules
Use of in-home test-weighing gives mothers the technology and information that they need in order to make informed choices about complementation, while preventing dehydration and slow weight gain in their preterm infants. Guidelines for in-home test-weighing have been published, 13, 14 and are summarized briefly as follows. At NICU discharge, the baby’s doctor discusses with the mother the minimum amount of milk her baby should consume each day (not every 3-4 hours); this volume can be further divided into 6-hour or 12-hour volumes to ensure adequate hydration. Then mothers can measure intake at each feeding, and maintain a milk intake record, such as the one that was developed for use with the electronic scale.21 With advice and guidance from professionals and/or another experienced mother, these women can decide how they would like to complement breastfeeding.
For example, a mother might decide with her baby’s doctor that she will measure intake at each breastfeeding and will complement breastfeedings after a 6-hour or 8-hour period of demand feeding. If her baby needed 100 cc’s of milk over this period, but consumed only 80, the mother could provide the extra 20 cc’s as a complement. This approach meets everyone’s needs: the mother will not feel so vulnerable with respect to infant intake; the infant is given the opportunity to "demand;" and the health care provider can feel comfortable knowing that a minimum volume of milk will be consumed. The mother should implement the plan while the infant is still in the hospital, so she becomes comfortable with test-weights, recognizing hunger cues, and deciding when and how to provide complements.
In most instances, mothers will need the scales for two to three weeks at home. At first, they will perform test-weights at every feeding, then occasional test-weights, and finally a nude daily weight to measure weight gain patterns, rather than milk intake. Many pediatricians defer a first return visit until one week post-NICU discharge, if they know daily in-home nude weights are being measured by the parents.13, 14
Giving mothers a choice
Lactation consultants and health care providers who work primarily with healthy, term infants may feel that the use of special breastfeeding positions, and technology such as test-weights, is unnecessary and interferes with the naturalness of breastfeeding. However, it is important to maintain a perspective that includes information from the research literature and the preferences of mothers of preterm infants. These women are accustomed to the highly complex environment of the NICU, so that the use of equipment to facilitate breastfeeding is not instinctively “unnatural”—it is simply how breastfeeding will work for them. It has been argued that if inadequate infant intake is confirmed by test-weighing, the mother will be disappointed and discouraged.7, 8 Similarly, some breastfeeding proponents feel that in lieu of in-home test-weighing, a mother can take her preterm infant to the doctor or lactation consultant for a “weight check” several times during the first week at home, so that she is not burdened with an unnatural breastfeeding accessory. This approach has led to some clinicians’ request that infant scales be available to mothers only by prescription. Such an approach implies that mothers are not capable of making appropriate choices about managing breastfeeding for their preterm infants. In contrast, Ryan’s mother’s story and the research literature suggest that mothers need only the information, assistance, and support for their individual breastfeeding situation in order to make informed choices for themselves and their infants. Then breastfeeding can be the empowering experience for these women that it is for mothers of healthy, term infants.
1. Lucas, J. G. Ryan can nurse today. NEW BEGINNINGS, 1997; 14(2):24-25.
2. Kavanaugh, K., L. Mead, P. Meier, and H. H. Mangurten. Getting enough: Mother's concern about breastfeeding a preterm infant after discharge. J Obstet Gynecol Neonatal Nurs 1995; 24:23-32.
3. Meier, P. P., J. L. Engstrom, H. H. Mangurten et al. Breastfeeding support services in the neonatal intensive-care unit. J Obstet Gynecol Neonatal Nurs 1993; 22:338-47.
4. Hill, P. D., K. S. Hanson, and A. L. Mefford. Mothers of low birthweight infants: breastfeeding patterns and problems. J Hum Lact 1994; 10:169-75.
5. Hill, P. D., R. J. Ledbetter, and K. L. Kavanaugh. Breastfeeding patterns of low birthweight infants at hospital discharge and four weeks after birth. J Obstet Gynecol Neonatal Nurs 1997; 26(2):189-97.
6. Kavanaugh, K. L., P. P. Meier, B. Zimmerman, and L. P. Mead. The rewards outweigh the effort: Breastfeeding outcomes for mothers of preterm infants. J Hum Lact 1996; 13:1.
7. Meier, P. P., J. L. Engstrom, C. Crichton et al. A new scale for in-home weighing for mothers of preterm and high risk infants. J Hum Lact 1994; 10:163-68.
8. Meier, P. P., J. L. Engstrom, B. Fleming et al. Estimating milk intake of hospitalized preterm and high risk infants. J Hum Lact 1996; 12:21-26.
9. Ramasethu, J., L. Jeyaseelan, and C. P. Kirubakaran. Weight gain in exclusively breastfed preterm infants. J Trop Pediatr 1993; 39:152-59.
10. Kaufman, K. J., and L. A. Hall. Influences of the social network on choice and duration of breastfeeding in mothers of preterm infants. Res Nurs Health 1989; 12:661-62.
11. Lefevre, F., and M. Ducharme. Incidence and duration of lactation and lactational performance among mothers of low-birthweight and term infants. Can Med Assoc 1989; 140:1159-64.
12. Meier, P. P., and L. P. Brown. State of the science: Breastfeeding for mothers and low birthweight infants. Nurs Clin North Am 1996; 31:351-65.
13. Meier, P. P., and L. P. Brown. Strategies to assist breastfeeding preterm infants. Rec Adv Pediatr 1997; 15:1137-50.
14. Meier, P. P. Professional Guide to Breastfeeding Premature Infants. Columbus, OH:Ross Laboratories, 1997.
15. Van Aerde, J. Nutrition and metabolism in the high-risk neonate. In Neonatal and Perinatal Medicine: Diseases of the Fetus and Infant, ed. A.A. Fanaroff and R.J. Martin. St. Louis:Mosby Year Book, 1992, pp 478-526.
16. Meier, P. P., and H. H. Mangurten. Breastfeeding the preterm infant. In Breastfeeding and Human Lactation, ed. J. Riordan and K.G. Auerbach. Boston: Jones and Bartlettt, 1993, pp 253-78.
17. Meier, P. P., Caution needed in extrapolating from term to preterm infants (reply to letter to editor). J Hum Lact 1995; 11:91-92.
18. Meier, P. P., T. Y. Lysakowski, J. L. Engstrom et al. The accuracy of test-weighing for preterm infants. J Pediatr Gastroenterol Nutr 1990; 10:62-65.
19. Hurst, N. M. In-home test-weighing for preterm infants. Research grant funded by Medela Inc, August 1996-December 1997.
20. Brown, L. P., P. P. Meier, A. Spitzer et al. Breastfeeding services for low birthweight infants: Outcomes and cost. NINR Grant #R01NR03881, September 1995-June 2000.
21. Meier, P. P. The BabyWeigh Scale from Medela: Parent’s Instructions. McHenry, IL:Medela Inc.
The Authors acknowledge research support for this manuscript from the National Institute for Nursing Research (Grants NR01935 and NR03881), National Institutes of Health.