Written by Dr. Meg Parker, Associate Professor of Pediatrics at Boston Medical Center, Boston University School of Medicine
In the NICU, mother’s breast milk is medicine for very premature infants. Mother’s breast milk has a multitude of nutritional and immune properties that protect against many devastating infections, including necrotizing enterocolitis (NEC). When mothers understand the benefits of their milk to their very premature infants, they are often highly motivated to make breast milk for their babies. Unfortunately, many mothers are unable to reach their goals to provide exclusive, or nearly exclusive, breast milk for their babies during the NICU stay. This is because mothers of premature infants face many unique challenges to making breast milk. One reason is that mature breast milk production is delayed because of preterm birth, cesarean section delivery, or medical problems, like preeclampsia and diabetes. When mother’s own milk is not available, pasteurized donor milk is the next best option.
Mothers in the NICU often have to depend on a breast pump to make their milk for weeks or months, since their babies are not developmentally ready to nurse at the breast. This requires frequent pumping, repeatedly, which can be extremely difficult. Frequent pumping is challenging because mothers have a lot of important competing tasks and priorities at home, spend a lot of time traveling to/from the NICU, and often have to go back to work. Mothers may find using a mechanical pump to be less emotionally fulfilling than feeding their baby directly at the breast, which can make it even more difficult to continue to pump for weeks or months. Fortunately, there are some well-known practices that mothers of very premature infants can do to maximize their milk production. NICUs that support and encourage mothers in these practices can make a BIG impact.
#1: Get the right pump
There are literally hundreds of breast pumps on the market. Mothers that are exclusively pumping need very powerful pumps that completely empty the breasts of milk at each pumping session. Most hospitals have “hospital grade” pumps for this purpose; the most common brands are the Medela Symphony or Ameda Elite. These pumps are ideal for maximizing milk production while infants are still hospitalized. Hospital-grade pumps can be rented for home use and some hospitals have pump loaner programs. Hospital staff should explain how the pumps and the pump supplies work to mothers before they go home. Mothers should also learn the techniques of hand-expression of breastmilk. Click here and here for resources on hand expression.
#2: Start expressing milk within 6 hours after birth
In order to kick-start milk production, it is important to start expressing milk as soon as possible after birth. Mothers can first start making milk with the pump or with hand expression. The first milk that is produced is yellow, comes in tiny drops, and is called “colostrum.” This colostrum contains important immune properties and can be delivered directly into the infants’ mouth. The earlier milk production starts, the better for mothers to maximize their milk production into the future.
#3: Express milk every 3 to 4 hours to keep up your milk supply
Mature milk, which is white in color, begins to be expressed about 3 to 7 days after birth. Frequent pumping is most important in the first two weeks after birth to promote maximal amounts of milk that can be continued for weeks after birth. A well-established goal is to produce at least 500 ml of milk per day by 2 weeks after birth. It can be hard to pump this frequently. It is helpful for partners, family, friends, and the NICU care team to offer their encouragement.
#4: Hold your baby skin-to-skin
When mothers hold their undressed baby on their bare chest (known as Kangaroo Care or skin-to-skin care) it offers many benefits to both the baby and mother, including maximizing milk production. Skin-to-skin care can make the infants’ breathing and heart rate more stable, keep babies warm, and promote bonding. There is no limit to the amount of time mothers can do skin-to-skin care. Infants with CPAP or ventilators can also do skin-to-skin care with some help from the NICU team. Skin-to-skin care releases hormones which help make more breast milk.
#5: Try direct breastfeeding
When infants are mature enough to start sucking, they can begin feeding directly at the breast. Mothers that practice more direct breastfeeding in the hospital have longer duration of milk production after discharge home. Many infants can begin feeding at the breast as early as 31 to 33 weeks corrected age. In the beginning, infants usually aren’t strong enough to suck much milk, but as they get stronger, they will be able to drink more milk, over time.
Making breast milk for a very premature infant in the NICU is incredibly challenging! Any amount a mother makes is special and beneficial. Mothers should reach out to their NICU staff for help at any time. We are very proud of how hard NICU mothers work to make milk for their babies!
To view the NEC Society’s webinars on Human Milk, please click here.
To view educational videos on the importance of human milk in the NICU, please click here.