Breastfeeding is a basic survival mechanism for babies, especially the vulnerable pre-term infant. The good news is that babies bornprematurely can breastfeed successfully.

Benefits of breastfeeding for pre-term and low birth weight babies

  • Breastmilk is easier to digest and better tolerated than formula milk by the immature gut of the premature baby.
  • Breastmilk contains antibodies that protect the baby against infections. Research has shown that premsmwho receive formula are 6-9 times more likely to

develop NEC (Necrotizing Entero Colitis) than breastfed prems.

  • Increased intelligence, improved motor development later in life (prems may be slow developers).
  • Brings mother and baby closer together. Improves bonding, especially in a high tech NICU.


A vulnerable pre-term baby admitted into a Neonatal Intensive Care Unit or High Care unit, must be fed 1 to 2ml of its mother’s colostrum to seal off the baby’s gut and to ensure good gut integrity, before the baby starts ingesting hospital resistant organisms, which can lead to infection and sepsis.

This colostrum is NOT A FEED. So even if a baby is kept nil per mouth on the day of admission, he/she needs the colostrum, fed ORALLY, not through a nasogastric tube (otherwise all the good fats cleave to the inside of the nasogastric tube), to seal off the gut. Usually, breastfeeding can be established within the first hour or two after birth if the baby weighs more than 1.5kg (>30 weeks). If the baby weighs less than 1.5kg, breastfeeding depends on the baby’s physical condition.

Finger feeding

Milk formula for pre-term babies and human milk fortifiers should only be used until the mother is producing sufficient quantities of breastmilk. Try not to use a bottle and rather encourage the baby to “practise” at the breast as early as possible, following each session finger feeding, i.e. where the baby suckles on the mother’s small finger, while breastmilk is given slowly via a 5ml syringe into the corner of the baby’s mouth.

This way of feeding works perfectly, as the entire feed required is swallowed. This also stimulates the baby’s suckling reflex, preparing the baby to eventually successfully breastfeed.

Kangaroo Mother Care (KMC) 

Kangaroo Mother Care is the cornerstone of successfully breastfeeding a pre-term baby. Low birth weight and premature babies are nursed skin-to-skin between their mother’s breasts. The baby is dressed in a nappy and a cap and placed in an upright position against the mother’s bare chest, between her breasts and inside her blouse. Both mother and infant are covered with a blanket or jacket. Skin-to-skin care may be intermittent at first but should gradually become continuous and persist until the baby weighs at least 2kg.

The mother should start KMC immediately, irrespective of gestational age or weight. KMC may be practiced continuously or intermittently. If the mother is not in hospital with the baby, the she should practice KMC during every visit least 60 minutes, as this is the length of a sleep cycle for the baby.

Skin-to-skin contact has many benefits for the prem baby:

  • The baby is physiologically more stable (pulse, respiratory rate, saturation) as the baby secretes endorphins with vagal nerve stimulation
  • Continuous skin-to-skin contact ensures energy reserved to grow
  • Improves the mother’s milk volume
  • Promotes bonding between the mother and baby
  • Earlier and exclusive breastfeeding is promoted
  • Better oxygenation
  • Better digestion of feeds
  • Thermoregulation
  • More regular breathing pattern
  • Less acquired hospital infections

Kangaroo nutrition

Babies should be fed their own mother’s milk, either by breastfeeding on demand or by expressed breast milk via nasogastric tube, finger-feeding or cup. Weight is not an accurate measure of ability to breastfeed; maturity is a more important factor. The baby should be allowed to breastfeed freely. Adequate and regular feeding is essential, particularly at night.

Infants under 1.5kg should be fed every hour and infants over 1.5kg every two hours – not three-hourly as most hospital routines suggest. Prem babies have very small stomachs and do much better with smaller feeds, more frequently, rather than large feeds every three hours. With early and continuous skin-to-skin contact, even infants of 30 weeks gestational age are able to breastfeed exclusively. The key is keeping baby in skin-to-skin contact.

The baby may need to be tube-fed at first, however, the mother’s milk can be expressed and fed to the baby via a tube. Research has shown that babies who are fed breastmilk via a tube vomit less than those who are fed formula. It is important that a tube-fed baby also receives oral stimulation by placing the mother’s nipple in the baby’s mouth. The baby should remain in the Kangaroo position while receiving a tube feed and the mother should hold the feeding funnel. The mother may adjust the position of the baby to breastfeed or cup feed. The baby should not be fed in the incubator, crib or cot while the mother is visiting.

A premature baby receiving a tube feed while its mouth is on its mother’s finger.

Pre feeding cue

When a prem baby is ready to feed, it will usually:

  • Lick its lips, and make small mouth movements
  • Turn its head towards the breast
  • Smell the nipple
  • Touch the nipple with its hands
  • Nuzzle

10 Small steps to breastfeeding the pre-term baby

1.Baby must be in skin-to-skin contact.

  1. Baby smells the nipple.
  2. Baby smells the breastmilk.
  3. Baby tastes the breastmilk on the nipple.
  4. Baby will make mouth movements, called the rooting

reflex. (Prems may only sip the milk at first)

  1. Baby must be awake and alert for suckling.
  2. Baby latches on and swallows the milk.
  3. First breastmilk meal. (Steps 1-7 go fast for full-term infants. Prems may need successive alert times).
  1. Baby feeds frequently. (For prems every 60-90 minutes).
  1. Mother and baby are together continuously .Encourage the mother if her baby is doing any of

these steps.

Putting the baby to the breast

  •  Put the baby to the breast when it is in a light sleep state, as seen with rapid eye movements under the eyelids.
  • Hold the baby with its body “tummy to mummy”,supported along the mother’s arm to control head movement.
  • The mother will probably need to support her breast, with four fingers under the breast and her thumb on top (dancer hand position, or C-hold), to help the baby keep the breast in its mouth.
  • To increase milk flow, massage and compress the breast each time the baby pauses between suckling bursts (unless the flow is more than the baby can


Ways the mother can encourage Breastfeeding…

  • Gently rub with fingers in small circles near the outside of the baby’s mouth and cheek area near the jaw line.
  • Using your smallest finger, rub the same area inside the mouth.
  • Massage the soft tissue under the baby’s chin bone to stimulate the muscles used for breastfeeding.
  • Frequent attempts to latch on to the breast are good as they encourage stimulation of necessary sensations for breastfeeding behaviour.

What to expect at feeds

  •  Expect that the baby will pause frequently to rest during the feed. Plan for quiet, unhurried, rather long breastfeeds.
  • Stop feeding attempts if the baby seems too sleepy or fussy. The mother can continue to hold her baby against her breast without trying to initiate suckling. Avoid loud noises, bright lights, stroking, jiggling or talking to the baby during feeding attempts.
  • Expect some gulping and choking; this happens because of the baby’s low muscle tone and uncoordinated suckle. If this interferes with comfortable feeding for the baby, the mother can position her baby so the back of its neck and throat are higher than the breast. If the mother leans back, she can assist in slowing the milk flow to the back of the throat. She can also express some milk before the feed to relieve some of the pressure.

Evaluating the feed

  • Show mothers how to watch and listen for swallowing as a sign that the baby is receiving milk.
  • If the baby can attach to the breast but does not suckle correctly, consider using a tube feeding device at the breast.
  • Expressed hind milk, or the cream portion of breastmilk that has risen to the top of the storage container, can be given to the baby if a higher-calorie feed is needed.

 Kangaroo support

 It is important to keep the mother and baby together if at all possible. However, this will always depend on the context and should be a dynamic process of development and improvement.

Hospitals are so focused on the prem baby, that the mother’s emotional wellbeing is often overlooked.

This is an extremely difficult time for her too as she has been plucked away from her home, family and familiar environment and has to stay in hospital with her baby, sometimes for as long as three months – hospitalised, but not ill.

Helping mothers to build and maintain their milk supply

  • Begin expressing breastmilk as soon as possible or at least within six hours of birth.
  • Hand expression is very effective but an electric pump that pumps both breasts at the same time can save time. Pump for 10-15 minutes at a time, and not only the volume required to feed the baby. Oversupply in milk can be donated to the hospital’s breastmilk donor bank.
  • Express eight to twelve times every 24 hours i.e. every two to three hours.

Kangaroo discharge

This is when the baby is discharged, and the mother continues KMC and exclusive breastfeeding at home.

The mother “wears” her baby from birth up to the first six weeks of the baby’s life.

This is where a KMC wrap or sling comes in very handy. Remember to support the prem baby’s head and neck with the wrap. Premature babies have a respiratory pattern that is called “periodic breathing” where they “forget” to breathe. When a baby is wrapped in front onto the mother, the mother’s exhaled carbon dioxide accumulates inside the wrap around the baby’s face and this CO2 is the baby’s respiratory drive.

Skin-to-skin contact is the key

Early and continuous skin-to-skin contact between the mother and the prem baby is the foundation of successful and exclusive breastfeeding. Prem babies need unrestricted access to the mother’s nipple to “practice, taste, smell, and play with” and eventually, successfully breastfeed. The baby knows the “how to breastfeed” part and it is instinct. The baby’s brain is wired to do it correctly. A caring and patient midwife and neonatal nurse plays an important role in supporting the mother-infant bond to exclusively breastfeed. Breast is best – even for the very small and vulnerable ones.

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