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 parents, 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”. Babies that were born premature are often discharged home at this gestation and so frequently have similar problems. 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 premature babies are fed responsively.
The problem is that these babies often do not “demand” enough and prefer to sleep. They are often too sleepy 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 take enough milk from the breast when they do wake to feed. 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 difficulties! Babies can lose too much weight, or jaundice can set in. The parent’s milk supply may not be stimulated enough, or they may lose their hard-earned milk supply if they were pumping in NICU. After a week or two of responsive feeding when the babies just are not ready, it is often decided they need supplementing, but because the baby has not been feeding effectively, supply is often low and they may need to use formula. And so the top up trap begins. These families need lots of support. They need good quality face-to-face breastfeeding support after discharge.
In the first 48 hours, parents of late preterm and early term babies should be encouraged to hand express after each feed. This will give them extra colostrum to give the baby, and also it will help prime the prolactin sites to stimulate a full milk supply. The colostrum can be given if baby is too sleepy and hard to rouse. A shot of colostrum boosts blood sugar and should give the baby energy to feed. Or it can be used after a feed if the baby last latched on but only fed for a short period. Colostrum can be given by syringe straight into the mouth or by finger feeding, or by spoon.
Once the parent’s milk begins to come in they could also add some pumping sessions if the baby is struggling to take enough milk. This supplement could be given by syringe, finger feeding, spoon, cup or a paced bottle.
This guide developed by Queen Charlotte’s Neonatal Unit, can be used to decide if the baby needs to be topped up. Most late preterm and early term babies fall into sections D, E or hopefully F! A full top up means a full feed, often using the calculation 150ml x baby’s weight in kg divided by the number of feeds in 24 hours. A half top up would be around half this number.
The “active feeding” part of this diagram from UNICEF is the main area of the feed we should be focussing on. This is where the majority of the milk is taken by the baby. This can be maximised by using breast compressions. They can be a useful tool to help the baby transfer more milk during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end, so extending their active feeding time.
Parents should 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. (Marie Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. If a baby’s eyes are open they should be offered the breast! If their baby has not woken themselves by 3 hours from the start of the last feed, they should be encouraged to wake and feed. Once the baby begins to consistently beat the parent to this wake up, this is a sign they can move to responsive feeding. Most babies refer to feed more frequently than 3 hourly once they are full term, although they may have one or two longer stretched, especially after some cluster feeding.
Parents should also be shown how to ensure the babies are latching on well to feed. A baby of this gestation is often smaller, with a small mouth. An optimal latch is necessary for an efficient feed. Breast shaping can help to get a little more breast tissue into baby’s mouth. The C hold can be used when baby is upright or lying on their back and so their mouth is horizontal. The U hold can be used when baby is on their side and so baby’s mouth is more vertical.
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 weight gain and nappy output if shields are used as they can sometimes inhibit milk transfer. Once the babies are feeding well with a shield, support can be given to feed without them.
Parents may need support with continuing to pump for top ups if the babies are not ready to fully breastfeed. It is an incredibly intense routine and should only be a short term intervention. The baby should begin to become more alert and stronger and more coordinated quite quickly.
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. Parents often continue to supplement and schedule feeds far longer than they need to. Once the baby has adequate weight gain, generally waking themselves for feeds before the 3 hour schedule, and having a good proportion of “active feeding” during a breastfeed then they can be fed responsively and expressing gradually phased out. If parents are using formula to top up this can be gradually phased out. See my 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.
Kathryn Stagg IBCLC, updated June 2021
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