A baby born between 34+0 weeks and 36+6 weeks gestation is defined as a late preterm baby. A baby born between 37+0 weeks and 38+6 weeks is defined as an early term baby.
For babies who are born at this time, establishing breastfeeding can be quite difficult. They are often well enough to remain on the postnatal ward with their mothers, which is great as they do not have to go to special care. But as such they often get treated the same as a full term baby and are left to “demand feed”.
The problem is that these babies often do not “demand” enough and prefer to sleep, although I prefer the term “cue-based feeding” or “baby-led feeding”. They are often too sleepy for the mother to be able to follow their lead completely. And if they do not feed enough, they get even sleepier and harder to rouse to feed. Also a lot of slightly early babies are not physically strong enough or coordinated enough to fully breastfeed, often until around due date or even a bit after. They have a few sucks, take on a little milk, and then fall asleep before they have had their fill.
This can lead to real problems! Babies can lose weight, or jaundice can set in. Mum’s milk supply may not be stimulated enough, or she may lose her hard-earned milk supply if she was pumping in NICU. After a week or two it is decided the babies need supplementing, but the lack of breast milk may mean they need to use formula.
These problems are also experienced by parents of more premature babies as they are often discharged around what would have been 36-37 weeks gestation with minimal breastfeeding support. They are often given the chance to “room in” for a couple of days to practise feeding and looking after their baby or babies full time, and this is often the first time the breastfeeding mother is allowed to follow her babies’ lead.
These families need lots of support. They need good quality face-to-face breastfeeding support after discharge. They need to be shown the subtle cues their baby makes to show that they need a feed; stirring, mouth opening, turning head from side to side, and the later cues including stretching, moving arms and legs, trying to bring hand to mouth. Crying and agitation are late cues. (Maria Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. Dr Tena Fry said in her interview with Maria Biancuzzo: “If a baby’s eyes are open they should be offered food”. Parents also ned to be supported to understand when their baby is not cueing frequently enough. We would suggest not to let a baby of this gestation go longer than 3 hours from the start of each feed to ensure they have a minimum of 8 feeds in 24 hours.
Parents should also be shown how to ensure the babies are latching on well to feed. And tandem feeding positions can be discussed to help with the intensity of breastfeeding new baby twins. Also breast compressions are a very useful tool to help transfer a bit more milk to the babies during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end of the feed. Sometimes a baby of this gestation may have trouble latching directly on to the breast. Babies who are a little early sometimes latch better and feed more efficiently when using nipple shields. Close attention should be paid to milk weight gain and nappy output if shields are used as they can inhibit milk transfer.
Parents may need support with continuing to pump for top ups if the babies are not ready to fully breastfeed. And they need to be shown how to tell that their baby is developmentally ready and feeding efficiently enough to move away from 3 hourly feeds and on to baby-led, cue-based feeding. The problem is each baby is different. Some will be ready to fully breastfeed at 36 weeks, others at 42 weeks, and everything in between. But mums often continue to supplement and schedule far longer than they need to. We would normally look for each baby to be putting on weight as expected, generally waking themselves for feeds before the 3 hour schedule, and having a good proportion of “active feeding” during a breastfeed. Then if mum is pumping for top ups this can be gradually phased out. They will be safe to move on to baby-led feeding. If parents are using formula to top up this can be gradually phased out. See our guide here
Ideally each family would be guided by somebody highly qualified such as an IBCLC or experienced breastfeeding counsellor. This is a scenario that deserves specialist breastfeeding support in the home on discharge from hospital, to ensure they can maximise the breast milk intake of their babies.
This survey was designed to find out whether UK families
with babies in special care who were born before 34 weeks gestation were asked
for consent before their babies were offered cows’ milk based infant formula
top ups or cows’ milk based fortifier and whether the risks were discussed. The
motivation behind this study was a reply on a Facebook post from a mother who
lost one of her premature twins to NEC (Necrotising enterocolitis) after he was
given cows’ milk based fortifier without her consent. She is quite certain that
the fortifier had something to do with the baby developing this deadly disease,
although there is little formal research to this back this up. However, there
is quite extensive research into the risks of developing NEC when babies are
fed with cows’ milk based infant formula. More studies into the risks of cow’s
milk based fortifier are desperately needed to ensure parents can make an
informed choice. One study found no significant risk of NEC whereas another
found there was an increased risk. Studies are summarised here: https://bestbets.org/bets/bet.php?id=2309
Fortifiers are made from processed cows’ milk protein with
added nutritional supplements. It is often offered to premature babies as
studies have shown that breast milk alone does not contain enough of the
energy, protein, vitamins, minerals and salts needed by rapidly growing
premature infants. There seems less risk of fortifier triggering CMPA (Cows’
Milk Protein Allergy) due to the proteins being hydrolysed.
Infant formula, also processed cows’ milk, is often offered
to babies where the mum is struggling to meet the required amounts of pumped
breast milk, or if baby is struggling to gain weight on solely breast milk then
high calorie formula can be used to help. A significant
association between early neonatal exposure to cow’s milk formula feeding and
subsequent development of CMPA/CMPI has been documented. https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1399-3038.1994.tb00352.x
The survey was an anonymous exploratory study and shared on
the “Breastfeeding Twins and Triplets UK” Facebook group and the “Parents of Preemies
UK” Facebook groups. Those who took part were free to choose to participate and
were aware anonymous quotes may be used. 191 parents responded, 131 had
singletons, 54 had twins, 6 had triplets, so that equals 257 babies in total.
Gestation in weeks
26+0 – 27+6
28+0 – 29+6
30+0 – 31+6
32+0 – 33+6
During their time in NICU these babies were given the
Just breast milk
This is how the rate of supplementation varied for different
(gestation in wks)
Before your baby/ies were given formula or fortifier was
consent sought and were risks explained?
No consent sought
Consent sought/no risks discussed
Consent sought/few risks discussed
Consent sought/full risks discussed
Was donor milk discussed and consent sought?
As this survey covered from very early babies up to 34 week
gestation one would imagine that the majority of time donor milk was not
offered was for the later babies. However on further analysis, 50% of the
babies less than 26 weeks, nearly 65% of babies between 26 and 28 weeks and
over 60% of babies around 60% of 28-32 week babies were not offered access to
I was also interested by the difference in numbers where
consent was sought between formula/fortifier and donor milk. Perhaps donor milk
is deemed far more risky than formula and fortifier? In reality, I am not sure
this is the case.
Here are some quotes from the survey:
I was very clear that I wanted to breastfeed only but they asked me to
consent to formula in case it was needed before I managed to harvest colostrum.
No discussion about the risks of formula or the importance of breast milk. If I
hadn’t been aware already I might not have understood the benefits of breast
milk for premature babies.
Both my babies were prem. I had to fight to give my son my milk. They gave
him formula without my consent. With my daughter I actually had a NICU nurse
tell me that I would fail at breastfeeding and shouldn’t even bother trying! It
broke my heart.
I felt pressured into giving
fortifier by the dietitian even though the nurses informed me that they didn’t
like to give it to babies, none of them would give me enough info as to why as
they didn’t want to be seen as disagreeing with another member of staff (the
dietitian) All my boys now have CMPA and I’m wondering if there’s a link.
I wish more units allowed donor
milk – it’s so important.
When I had my 26 weeker I expressed for a while and one day I came in and
my milk was getting something put in and all I was told it was fortifier he
needed it and that was it.
Twin one was given formula on day one as nurses said he needed feeding,
went on to solely breastmilk about day three then on to fortified breast milk
shortly after. Twin two was given breast milk until he was on full feeds then
given fortifier on day 9. Day 10 twin 2 became very ill with NEC and died
Was NEC (Necrotising enterocolitis) discussed with you?
NEC was only discussed with 30% of the families. Again maybe
this low figure was due to the older age range, but on further analysis NEC was
discussed only with between 30-40% of parents with babies born in the higher
risk zones of 26-32 weeks gestation, rising to 50% of families with babies of
less than 26 weeks gestation.
Although the risks of fortifier are still unclear, consent
should always be sought and use discussed before babies are given it. The risks
of giving formula are much more apparent; increased risk of NEC and development
of CMPA and yet still it seems that consent is not always sought before it is
given to babies. For 31% of the babies on this survey, consent was not sought.
This needs to change.
“He’s just feeding for comfort” is a comment us breastfeeding supporters hear a lot.
And why not? Anyone who has breastfed will soon come to realise that breastfeeding is about far more than just food. Yes its handy that this act of liquid love is also optimally designed to grow and nourish our babies, but there is far more to it than that.
Of course babies ask to breastfeed when they’re hungry. And they’re hungry a lot! But they may also be thirsty and just want a quick drink, especially in hot weather. Or their bodies and brains may be in a fast period of growth which needs to be fuelled.
They may also ask to feed if they’re feeling cold, if they want a cuddle, if they’ve missed you, if they’re feeling lonely, or tired, or poorly, or scared. Or if they are in pain. All of these reasons are just as valid as hunger.
Breastfeeding your baby whenever they ask, ensures not only that they receive enough nutrition but that their physical and emotional needs are met as well.
Jan 2018 – The start of 2018 saw me setting up in private practice after finally qualifying as an International Board Certified Lactation Consultant. Such an exciting time. It’s been such a difficult journey but finally I had qualified. Next I built the first incarnation of this website, got all my forms together, found insurance, registered my business with Lactation Consultants of Great Britain “Find an IBCLC” so that local mums could find me. It started slowly with a couple of home visits in Harrow and Uxbridge.
I also began my role as Regional Coordinator for the East for The Association of Breastfeeding Mothers. My role is to support the volunteer Breastfeeding Counsellors with their National Breastfeeding Helpline duties, and the Trainee Breastfeeding Counsellors with their training. I also organise supervision and study days. I have been a Breastfeeding Counsellor with the ABM for several years now, taking calls on the National Breastfeeding Helpline and volunteering locally. Its a wonderful organisation and I am so proud to be part of the Central Committee.
Feb 2018 – Continued with a few home visits. Also I was very proud to host a “Supporting Breastfeeding Multiples” webinar for the National Breastfeeding Helpline. The technology worked and I had lots of lovely feedback about the session. I love talking to people about how to support twin and triplet mums to fulfil their breastfeeding goals. It’s the reason I trained as a peer supporter so many years ago when my now teenage twins were just 1 year old; to try to pass forward the amazing support I had received myself. So many people, including many health professionals, believe that it is not possible to exclusively breastfeed more than one baby. But it most definitely is, and with good, knowledgeable support mums can fully breastfeed if that’s what they wish to do.
Mar 2018 – This month saw a big surge in home visits mainly due to the weather I think! Its so lovely to be able to support a new baby and mother to breastfeed in their own home without the need to battle the elements. This is me dressed for the snow walking to my home visit as it was too dangerous to drive that day.
March also saw the launch of myself and colleague Miriam Feen’s specialist breastfeeding support group, The Lactation Corner. Myself and Miriam have worked together in the past and volunteered together for years so I was very excited about this collaboration. We have a beautiful venue at Eastcote House Gardens with a lovely light room. We have a breastfeeding group there, and also run Introduction to Solids sessions and Preparing to Breastfeed sessions.
April 2018 – This month took me all over the local area, from Harrow to Iver to Denham to Edgware to North London. This IBCLC will travel (I do try to keep it to within half an hour of my house, although I will go a bit further for a twin or triplet mum!)
April also saw my first LCGB conference. What a wonderful experience! The highlight for me was Dr Jen 4 Kids, also known as Dr Jennifer Thomas. Such an inspirational speaker and she blew my mind with further information on breastfeeding and the microbiome. And of course then there was Nancy Mohrbacher! One of my all-time breastfeeding heroes. And amongst all these was my friend and fellow Harrow Peer Supporter Zainab Yate talking about her Breastfeeding Aversion and Agitation project. I was so proud of her and all she has achieved.
May 2018 – May was far more Harrow based which was a relief for my fuel bill! Supported a mum with Insufficient Glandular Tissue to try to breastfeed. Such a heart breaking situation. Unfortunately mums with this condition can struggle to make a full supply of milk for their baby. So we discussed maximising the efficiency of the feed, and we also used a Supplementary Nursing System to give baby some extra milk. Some was donor breast milk and some formula. This is where specialist breastfeeding support really comes into its own. The health professionals who were supporting her just did not have the specialist knowledge to maximise her chances of breastfeeding and couldn’t spend the 2 hours with her which was really needed to get to the bottom of her problems.
I also had my first booking for an antenatal/postnatal package. I love talking to mums about preparing to breastfeed. Gaining knowledge of normal baby behaviour and how to tell if your baby is getting enough is incredibly valuable before baby arrives and before the brain goes to mush!
June 2018 – June is always Conference time for the Association of Breastfeeding Mothers. This was my first conference where I was on the Central Committee. I realised just how much organisation this takes! This year the highlight was a visit from Kimberley Seals Allers who flew in from the USA to talk about her book The Big Let Down. It was a very thought provoking presentation. I highly recommend reading her book.
June also brought my first support session via Skype. Such a useful medium for follow up or general breastfeeding concerns, baby behaviour, returning to work, or other non latch related scenarios.
July 2018 – Home visits continue to be steady. The Lactation Corner have also begun to offer Introduction to Solid Foods sessions. This is a lovely interactive session with evidence based information and lots of myth busting! We either host it at Eastcote House or for a group of mums I one of their houses.
Aug 2018 – I took a few weeks off and travelled round the country a bit seeing relatives. One highlight was trying out Ivan my self-build campervan for the first time. It worked, we fitted myself, my partner and 4 children all sleeping in a campervan!
On my return from our adventures the volume of home visits sky-rocketed over the Bank Holiday weekend and the following week. Again I was travelling far and wide from North London to West London to Uxbridge to Watford supporting mums and babies with latching difficulties.
Sept 2018 – My youngest started school. He ran in without a second look. I put this down to him being a seriously high-needs baby and toddler who was, on the whole, responded to as best as I could. He is now so securely attached that nothing phases him at all! The youngest starting school is quite a monumental thing for our family. Now all 4 kids are at school. Not all in the same school, but all in school! This means I have a bit more time to really focus on supporting more mums alongside my other work commitments. Although there still does not seem to be enough hours in the day to do everything.
I also began working at an IBCLC led breastfeeding group in NW London. Its been fantastic to work alongside such passionate and experienced IBCLCs. I’m very lucky to have been given this opportunity.
Oct 2018 – My main focus this month was hosting a National Breastfeeding Helpline Study Day for the East of England. We went to Ely, Cambridgeshire, and lots of BFN and ABM breastfeeding counsellors, trainees and mother supporters came along. Subjects covered were Breastfeeding Premature Babies, Genuine Low Milk Supply, Breastfeeding in Slings, Gentle Night Weaning, and Referral Scenarios presented by me and some of my colleagues. The day seemed to be a great success and we got really good feedback.
Nov 2018 – November turned out to be an incredibly busy month with home visits squeezed into every available slot in the week. I also managed to find the time to attend a Tongue Tie Study Day with Sarah Oakley, IBCLC and Tongue tie Practitioner. Quite a high proportion of the mums I support are having difficulties with breastfeeding due to their baby having a tongue tie. Sometimes we manage to work around it with improved positioning and attachment and ensuring baby is feeding as effectively as possible. But sometimes we decide we need to refer on to a tongue tie practitioner to have the tongue tie divided. This session consolidated the knowledge I had already gained in my IBCLC training on how to assess a tongue tie and its impact on breastfeeding.
And my Facebook support group, Breastfeeding Twins and Triplets UK tipped the 4000 members mark. I’m so proud of that group. Its such a wonderful, empowering and friendly Facebook group. We keep it evidence based and supportive, and me and my fantastic team of admins very rarely have to step in. Its my favourite place on the internet!
Dec 2018 – Breastfeeding support calmed down a little leaving me time to go and watch the film Tigers . This is such an important film from Danis Tanovic based on the true story of former Nestle Pakistan salesman taking on the baby milk industry with the help of IBFAN. I was disappointed to miss it when it was shown a couple of years ago so when the chance came again I jumped at it. There was an added bonus as co-writer and co-producer Andy Paterson was available for a Q&A session afterwards. I have just finished off the year with a couple of home visits.
December also sees me completing a Holistic Sleep Coaching course, just the assignment to go and I will be a qualified Holistic Sleep Coach. The Holistic Sleep Coaching Program focuses on supporting and empowering parents, providing gentle strategies (based on evidence), which never involve leaving babies to cry alone. I am very excited to be able to offer this service in the new year (once I’ve completed the assignment!). Watch this space!
And of course, continuing to offer Specialist Breastfeeding Support. It’s such a privilege to be able to help mums at this important time. Thank you so much to all the families that have invited me into their home.
Thanks Shel Banks IBCLC Lactation Consultant for creating this meme on the mnemonic B.R.A.I.N. used for making decisions. She has made it relatable to medical care for you and your baby
So important to consider when health professionals or others are encouraging interventions that are not in your plan.
Topping up with formula because of poor weight gain is one scenario where this is really useful to use. Asking your midwife/health visitor/paediatrician these questions when formula top ups are being suggested may make them think a bit more about their recommendations. And will mean you can make an informed choice as to whether this is something that needs to be used. My experience of supporting many breastfeeding mums over the years is that often formula is offered as an easy and less time consuming solution than helping a mum to breastfeed more effectively or increase her milk supply. Generally very little thought is given to the consequences.
– increased weight gain
– less risk of health problems related to poor weight gain
– drop in mother’s milk supply
– bottle preference
– baby developing cows milk protein allergy
– changes to the gut microbiome
– damaging maternal confidence in breastfeeding
– specialist breastfeeding support to assess feeding, improve latch and milk transfer
– increasing frequency of feeds
– breast compressions to increase milk transfer
– expressing mother’s milk to offer as a top up
– use of donor milk from milk bank or other trusted donor.
– what is the mother’s gut feeling telling her? Mother’s intuition is often correct.
– what happens if we wait? Sometimes mothers and babies just need time for their feeding to click into place
– sometimes weight gain will continue to be a problem and so an intervention is necessary.
Of course, formula can be life-saving given in the correct circumstances. But it should never be given without good breastfeeding support offered, risks discussed and alternatives considered.