When babies arrive early…
The challenges of being born prematurely (before 37 weeks of pregnancy) are fairly well known. Depending on just how premature they are, these babies are often cared for in Neonatal Intensive Care Units (NICUs), where they have a team of specialists overseeing them. They may remain there for weeks; growing, developing and learning.
What about babies who are born early, but not early enough to need NICU care? These babies are either called “late preterm” or “early term”, depending on the gestation they were born at. At birth, they’re often cared for on a regular postpartum unit, where they don’t have the same NICU level of care. I affectionately call these babies “Early Birds.” (Credit to the great, Christine Staricka 🤩)
Although they may be just a few weeks away from being full-term, Early Birds lack a whole lotta development and need to be watched very closely.
Feeding Challenges
Coordination
In utero, the suck reflex begins to take root at about 32 weeks and is fully developed around 36 weeks. For a baby born at 36 weeks, although the suck reflex may be fully developed, the baby may need practice in order to get really good at coordinating sucking alongside swallowing and breathing.
Sleepiness
Early Birds tend to be quite sleepy, which means they may feed less often and for shorter periods. They may have the energy to latch and suck a few times, but may soon stop and fall asleep on the breast. They also may be very inconsistent with feeds; some feeds may be fairly good, and others may be quite ineffective.
Less Fat
You know how babies tend to gain a bunch of weight in the last few weeks of pregnancy? Yeah, Early Birds miss out on that. Those cute chubby cheeks are more than just adorable. Without them, it’s harder to form a seal around a nipple (human or artificial.) Without a strong seal, it’s hard to extract milk from a breast or bottle.
Less effective feeding leads to a vicious cycle, where less food leads to more sleepiness, and the sleepiness leads to even less feeding. Babies can quickly get into trouble putting on weight. In addition, less effective feeding also puts them more at risk for trouble with:
maintaining their body temperature (hypothermia)
regulating their blood sugar (hypoglycemia)
high levels of bilirubin (jaundice)
As these complications develop, Early Birds become even less efficient at feeding, as now their little bodies are prioritizing basic functions, and can no longer prioritize feeding.
Given the more fragile state for these infants, what can parents do to keep them out of trouble?
Intervene Early
We don’t want to wait for Early Birds to tell us they’re in trouble. Instead, we want to be proactive by:
Keeping them in skin to skin contact (SSC) as much as possible. SSC is great for all babies, regardless of gestational age, but it’s especially important for Early Birds. Parents can take turns holding the baby on their bare chests, covered by layers of blankets to hold the heat in. This will keep the baby warm, as well as keeping stress levels down, allowing the baby to hold onto glucose longer.
Scheduling feeds. While I advocate for “on-demand” feedings for full-term infants, Early Birds cannot be relied on to demand anything. I encourage parents to set an alarm for every 2 hours to wake the baby for feeding. Feeding in between these times should also be done anytime the baby is showing interest or simply waking up.
Supplementing. Early Birds are not usually great breastfeeders right away; many won’t be good at it until they’re close to their due date. While they’re learning to breastfeed, they’ll need to be fed a bit extra. That can be with the parent’s own milk, donor milk or formula. The device (bottle, cup, syringe, etc) that parents use to give this supplement should be their choice, and pros and cons of each should be presented so they can make an informed decision.
Expressing milk regularly. This accomplishes 2 goals; obtaining a supplement for the baby and increasing future milk production. Hand expression works well in the early days when there’s colostrum. Early pumping is helpful, as it will stimulate demand for milk while the baby is spending most of their day sleeping and not nursing.
Getting help with breastfeeding. Being supported by a lactation consultant starting on day 1 will help the parents understand how to manage all the feeding and the pumping while also getting some rest.
Using breast compressions to help baby get more at the breast. When baby is sucking, the parent gently squeezes the breast to help move more milk. When the baby stops sucking, the parent releases the hold. With breast compressions, not only is the baby better fed, but more milk is made for next time (demand drives supply).
Delaying the first bath. Getting washed and removing the layer of protective vernix will put Early Birds at increased risk of hypothermia.
Here’s a plan that works well for many families:
Hand express after each feeding attempt. Parents can start this in the first few hours after delivery. Whatever is expressed can be collected for the baby.
Start pumping. Depending on how well the Early Bird is breastfeeding, pumping should be considered by day 2 in order increase demand for milk production. A good place to start would be 4-8 pumping sessions per day, depending on how breastfeeding is going. This will help to build strong milk production, so that once the baby is a great breastfeeder, they can get all that they need from the breast!
Give extra in addition to breastfeeding. Supplementation can be given by oral syringe, cup, spoon or bottle. Drops can be fed to the baby from a finger. A great option for some is a supplemental feeding system (pictured below), which allows extra to be given while the baby is breastfeeding. The amount that’s given will depend on their age, and how much they are getting at the breast. A lactation consultant can help the parent make an individualized plan. If a bottle is being used, I recommend a slow flow nipple that is gradually tapered and using a paced bottle technique.
More Sustainable Triple Feeding
Triple feeding is when parents are breastfeeding, pumping and feeding extra milk or formula to their baby. Often parents are told to do this around the clock in order to build milk production while making sure the baby is getting what they need.
Triple feeding quickly becomes unsustainable for most parents. Why is this?
😴 It’s exhausting and takes a toll of physical and mental health.
😴 It’s very time consuming and leaves very little time for enjoying the baby, caring for yourself and sleeping.
😴 It’s a recipe for burnout and early ending of breastfeeding.
The reality is that until an Early Bird is a good breastfeeder (remember, this may not happen until they reach their due date), we need to keep the milk supply going. This is often accomplished with frequent pumping around the clock. The baby will also have to be fed frequently in order to grow and develop well.
Where we have some leeway is with breastfeeding. It may seem weird for a lactation consultant to tell parents to breastfeed less, but in this case, it actually works quite well.
For most Early Birds, what makes them better at breastfeeding is time. Attempting to breastfeed 10 times a day is just not necessary, and makes the whole feeding experience take extra long. Early Birds get better at breastfeeding as they grow and develop.
Instead of frequent breastfeeding attempts, my recommendation is for parents to pick just 4 times a day to work on breastfeeding.
The ideal times are when the parent and baby are at their best. As you might expect, 2:00 AM is generally not an ideal time to work on new skills.
Here’s a way to make triple feeding more sustainable:
⭐️ Feed your baby and pump milk at least 8 times per day. Keep in mind that babies often need to be fed more frequently than that. Parents can pump while feeding the baby a bottle in order to accomplish more in less time.
⭐️ Work on breastfeeding about 4 times a day, around the same time as the feeding and pumping. This will give the parent and baby opportunities to practice and get more comfortable.
As the baby starts “waking up” and breastfeeding better, the parent may begin to reduce supplementation and pumping can begin to decrease. Again, working with a lactation consultant who can guide the family through this - getting regular weights on baby and adjusting the plan - can make a huge difference.
Language Matters
How we talk to and about our babies is important. I sometimes hear providers and parents calling babies “lazy”, when what the babies are actually telling us is that they need help.
An Early Bird may not be developmentally ready to effectively breastfeed 10 times per day yet. That’s normal.
We can shift our mindset by having a better understanding about the infant’s neurological development in the last few weeks of pregnancy. The brain growth that occurs as the baby approaches their due date helps them to become better feeders. They’re not lazy - they’re just not ready to do it.
Just as we wouldn’t expect a 6 month old to be walking yet, we can’t expect a 36 week old baby to be great at breastfeeding. With time and patience, however, they’ll get there. For parents, having support along the way will make all the difference.
