What is a “late preterm” baby?
Late preterm babies are usually defined as those born between 34 and 36 weeks gestation. Because these babies are often well – most don’t need to spend time in Special Care – and because they look like full-term babies (just a bit smaller), it’s often assumed that they will breastfeed easily from the start.
Babies born before 37 weeks gestation are treated as premature. Most late preterm babies do very well when they are born and, if they don’t need extra support with breathing, will usually stay with you. Your baby’s doctor will want your baby monitored closely over the next few days to ensure his temperature is fine, his blood sugars are in the normal range, he doesn’t need treatment for jaundice and that he is feeding well.
The following information may also be helpful if your baby was born at “early term” (37-39 weeks) but was small for gestational age, especially if under 2500g.
Small babies – those born early and/or small for their gestational age – can be tricky to feed at first, and it’s helpful to be aware of this. They are sometimes known as “the Great Pretenders”, because they may spend a lot of time looking like they are feeding, but are not actually taking much milk! This is because, even when well positioned and deeply attached at the breast, and encouraged to feed as often and long as they want, they often just don’t have enough energy yet to take what they need from the breast. If they could, they would!
Giving birth early
Giving birth to your baby early, especially if you weren’t expecting it, can be a shock. You might feel worried about looking after a small, early baby, and confused about what to expect, even if you’ve had a baby before. Doctors may be more involved in your baby’s care than if they had been born at term, and you might feel as if others are making decisions about your baby’s care which can be difficult to understand. Knowing about the special challenges of feeding these babies can help you to make sense of what is going on. Staff may be important partners in your baby’s care, but you, as the parents, are the most important people to your baby, so don’t be afraid to ask questions and make your wishes and feelings known.
Some families know their baby or babies will be born early. You may have a condition which means it will be safer to give birth earlier, and have opted for an early induction of labour or a caesarean birth. Sometimes a placental problem is identified or the baby isn’t growing well and an early delivery may be the best option.
Antenatal expression of colostrum
Increasingly, mothers who know in advance that their babies will be born early are choosing to hand express colostrum (first milk) before their baby is born. Your body makes colostrum from as early as 16 weeks of pregnancy and with a little practice, you can learn to express (gently squeeze out) some of it, to keep until your baby needs it. It is usually recommended to start doing this at 36 weeks, but if you know that your baby is going to be born before this, you can discuss with your healthcare team whether it might be helpful in your situation, and if so, when to start.
Colostrum is usually yellow or orange in colour and known as “liquid gold” because it is so valuable for protecting your baby from infection and kick-starting his immature immune system. Any farmer will tell you that baby animals who get their mother’s colostrum do better than those who don’t! Expressed drops of colostrum can be frozen at home and brought into hospital at the time of birth. As well as having colostrum on hand should your baby need it, expressing before birth helps you get to know your breasts and to practise hand expression, so if you are separated from your baby, or she is slow to get going with breastfeeding, you will have a head start on expressing colostrum after birth.
You can find more information about expressing antenatally here: https://www.laleche.org.uk/antenatal-expression-of-colostrum/ and https://www.laleche.org.uk/hand-expression-of-breastmilk/
Skin to skin contact
Holding your baby “skin to skin” (dressed just in a nappy, against your bare skin) has many benefits for all babies, but even more for late preterm babies. Ask hospital staff to help you and your baby enjoy skin to skin contact as soon as possible after birth; you will soon become confident about how to get yourself and your baby comfortable. The warmth of your body will help your baby stay warm and she will be calm and relaxed, saving her energy for feeding. Late premature babies are usually sleepy and you may only get a short “window” of alertness before she falls asleep again. While your baby is held against your chest you will get to know her and notice her subtle feeding cues as she moves about, bobbing her head, licking her lips. You can gently help her move towards your breast and perhaps express some drops of colostrum onto your nipples for her to lick off. She may latch on and have a little suckle. Exploring your body and your breasts is an important part of your baby’s learning to breastfeed. If she isn’t quite ready to begin breastfeeding yet, there’s no rush to make her start. If your baby can breastfeed at all, even if she isn’t getting many calories from feeding yet, it can still be comforting and provide pain relief. You may be able to feed her through medical procedures such as having a cannula put in – your medical team may be surprised how little your baby cries, if you work with them to find ways of doing this!
Encouraging your baby to feed
Having a late preterm baby can be frustrating at times. Although she might look like a slightly smaller version of a full-term baby, you can see that her prematurity affects the way she breastfeeds. Because she is immature, it is normal for her feeds to be sleepy and short, and for you to need to encourage her to wake and feed.
In the early months, most babies need to feed at least 8-12 times in 24 hours, with at least 5-20 minutes of active sucking per breast (deep sucks, with swallows after every 1-2 sucks for most of the feed). If your baby is too sleepy to do this much feeding yet, or if there are any signs that your baby might not be getting enough milk (fewer dirty nappies, more weight loss or slower weight gain than expected), it’s important to act quickly to keep your baby safely fed and to protect your milk supply. You can read more about how to tell if your baby is getting enough milk at https://www.laleche.org.uk/is-my-baby-getting-enough-milk/ and https://www.laleche.org.uk/whats-in-a-nappy/
Some babies need extra milk at first
In the very early days, before your milk supply increases rapidly, and if she isn’t feeding vigorously yet, she may need more milk than the small quantities of colostrum you can express at this time. Depending on the hospital, there may be donor milk available or your baby’s doctor may suggest infant formula for a short time until your milk supply increases. In the early days and weeks after birth it is important to remove as much milk from your breasts as possible, as often as you can, to give your body a strong signal to make plenty of milk later. Staff will support you to hand express at first (usually for about 3-4 days) and then to use a breast pump. Make sure you know where and how you can rent or buy a breast pump for when you get home.
You can read more about how to use extra milk (expressed milk, donor milk or formula) to support breastfeeding here: https://www.laleche.org.uk/formula-supplements/
Growing into breastfeeding
As the days go by and she gets closer to her due date, you will notice your baby getting better at breastfeeding. His feeds are longer, his sucking feels stronger, he wakes by himself and tells you when he is hungry. You will start to find that he doesn’t want so much extra milk (and you may be able to express less), because he is taking more milk at the breast now. Keep closely in touch with your midwife or health visitor to ensure that as he takes less extra milk, he continues to grow well. It’s really tempting to stop expressing as soon as your baby is feeding better, but it’s wise to be cautious at this stage, and to reduce expressing and extra milk feeds gradually, while keeping a close eye on your baby’s nappies and growth.
Recent research has suggested that some late preterm babies drink more milk when using a silicone nipple shield. The firm shield seems to help the baby with a weak suck to grasp and remove milk more effectively from the breast. Not all late preterm babies will need a nipple shield, but they may be worth considering after day 4 or 5 if your baby is still very sleepy at the breast and their suck seems weak. You can find more information here: https://www.laleche.org.uk/nipple-shields/. You can talk to your midwife, health visitor or breastfeeding supporter about whether this is a suitable option for you and your baby.
Hard-wired to breastfeed
Parents sometimes worry that if their baby isn’t breastfeeding at all yet, or is breastfeeding but needs to use tools such as shields or bottles as well, that they will forget how to breastfeed. You can be reassured that babies are strongly “hard-wired” to breastfeed, and will keep on trying for at least 8-12 weeks after birth. You will notice that when your awake baby is placed face-down on your body, she starts to move herself around, as if she is looking for something. If anything touches her head, she will turn towards it. She may smack her lips and suck her hands. These are all feeding behaviours which are going to be useful to her in the months to come, and they won’t disappear for many weeks. Getting breastfeeding going matters but is it also very important to get your milk supply going! In the meantime, spending lots of time holding your baby skin to skin gives her lots of time to practise her feeding behaviours and to enjoy being near the breast.
Balancing expressing and breastfeeding
If your early baby is spending a lot of time at the breast, it can feel as if there aren’t enough hours in the day to express milk. Babies who aren’t feeding efficiently may spend most of their at-breast time sucking lightly (short, “fluttery” sucks, all the same length, with little or no swallowing) and complain when they are taken off the breast. Despite a lot of time spent “breastfeeding”, they don’t do as many dirty nappies as expected, or grow normally. When this happens, it’s important to know what needs to be done first, so you can spend your time effectively. Removing milk efficiently from your breasts, to feed your baby and build your milk supply, is the first priority. If your baby isn’t yet strong enough to do this himself, you may need to limit his time at the breast for now, to free up enough time to express milk. Once you have a good milk supply, your baby has plenty of time to learn to breastfeed well when he is ready.
Milk supply usually reaches its peak level within the first month after birth, with most of this increase occurring in the first couple of weeks. After this time, it tends to become more difficult to increase supply, and many mothers find it hard or even impossible to get more milk after about 4-6 weeks, however hard they work at it. This is why it’s so important to start expressing early and often, if your goal is for your baby to be fully breastfed when he is ready.
Some women do manage to get a significant supply increase later than this, though – you never know what you can do until you try! If you’ve had a slow start with your milk supply, and are wondering if you can increase it, find good local breastfeeding support as soon as possible.
Here are some tips on maximising your milk supply.
- Use your breasts as much as you can. More milk out = more milk made. This is the main “rule” of milk supply, and much more important than any other factors, such as your diet, fluid intake, health or how unwell or tired you are (though of course you will feel better if you take good care of these things too!) Milk removal doesn’t have to be done regularly (with equal time gaps between), just as often as you can. While your baby is still small and tires quickly, it is likely that a breast pump is more effective than your baby at removing milk, so if you want to maximise your supply, it makes sense to prioritise expressinging. Aim to express at least 8-12 times in 24 hours. Expressing doesn’t need to be regular; do it whenever is convenient for you, even if this means expressing several times close together (babies often feed like this too!) Try not to allow more than about 6 hours to go by without removing milk, though, since this causes your hormone levels to fall. The number of times per day you express is more important than the total time you express for, so if you only have a few minutes, it’s still worth it. You can of course use any time left over for breastfeeding as much as you like! Some mothers find that lining up 8-12 treats (e.g. chocolates or biscuits) each morning, and eating one each time they express, helps them to track how many times they are expressing, as well as rewarding them for doing it! If you have a competitive streak, you might enjoy aiming each day to beat how much milk you expressed yesterday!
- Maximise efficiency at the breast. If there is any question about your baby’s effectiveness at the breast, skilled face to face breastfeeding support can help a lot. Often, a bit of adjustment to how your baby comes to the breast can help to make the most of the time that he is feeding. A slightly deeper attachment can make a big difference (and to your comfort as well, if you’ve had any pain or nipple damage). However, even with comfortable, deep attachment, a small or early baby tends not to have enough energy to remove all the milk they need, so just waiting until he grows a bit is likely to help a lot with his efficiency! In the meantime, switch nursing and breast compressions, both described here: https://www.laleche.org.uk/my-baby-needs-more-milk/ during feeds can help him to get more milk out in a shorter time. Switching sides keeps the baby interested – flow is faster on the “new” side – and compressions do some of the work for him. As your milk supply increases, breastfeeding is going to become easier for your baby – he won’t have to work so hard to get milk out – another great reason to invest effort in milk expression at this stage!
- Use the most effective pump. For most women, this is a double electric “hospital grade” pump of the kind used in Special Care units, or the next size down. Smaller (single electrics, or manual) pumps are designed for casual use, perhaps once or twice a day, rather than the big job of establishing a milk supply for a baby who can’t yet feed effectively. Hospital grade pumps can be hired; your local LLL Leader may know of any pump agents in your area, or you can arrange hire online.
- Use “hands on pumping”. This is the most efficient technique that we know of, for getting the most milk in the shortest time. How much you use your hands is probably even more important than what kind of pump you use, and whether you pump one or both breasts at a time. “Double pumping” (both breasts at once) can be faster and more efficient, but some women find that it feels “too much” and prefer to express one breast at a time, using their hands to massage while they express. You can find some great pumping ideas to try here: https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html. Hand expressing as much as you can after pumping is probably the most important tip – the better you can drain the breast, the faster it will make milk. A full hands-on expression session takes around 15-20 minutes, but it’s still worth expressing even if you don’t have more than a few minutes.
- Finish at the breast. Breastfeeding experts differ about exactly how to time formula or expressed milk supplements, but some say that the least helpful way to give them is always to offer them after breastfeeding. This encourages dissatisfaction at the breast, and tends to undermine your confidence. Supplements can either be given as a completely separate feed (not offering the breast at all), or in the middle of a breastfeed. As long as the baby gets the right amount of milk in each 24 hour period, it really doesn’t matter exactly how it’s timed! The goal is to finish on the breast as often as possible. It’s much nicer for your baby to feed off to sleep on the breast rather than the bottle, and for you to see him rolling off the breast looking full and happy! Even if he isn’t breastfeeding at all yet, you can let him end his feed of expressed milk or formula milk with his cheek pillowed on your breast as he falls asleep. A baby who enjoys being at the breast, and associates it with feeling satisfied, comfortable and happy, will be eager to breastfeed as soon as he is ready.
- Use feeding tools in ways that support breastfeeding. There are lots of ways to give your baby extra milk, if she needs it. Hospital staff may suggest that you feed extra milk by cup, or by nasogastric (NG) tube. Sometimes, bottles are the most convenient way of giving extra milk. Babies are hardwired to breastfeed, and once the underlying feeding issues have been addressed (or they have matured a bit more), they will usually happily begin or continue breastfeeding, whether or not they’ve needed alternative feeding methods. Having said that, there are ways of using feeding tools that are more, and less, supportive of breastfeeding. However you choose to give extra milk, feed carefully and slowly, paying attention to your baby’s signals, to keep feeding calm for your baby and encourage behaviours that are useful at the breast. You can read more about cup-feeding, “paced” bottle feeding, side-lying bottle-feeding and other ways of giving extra milk here: https://www.laleche.org.uk/bottles-and-other-tools/
- Consider domperidone. This is a prescription-only drug which has a side effect of increasing the levels of the hormone prolactin in your bloodstream. It isn’t magic, but there is good evidence that for some women domperidone can help to boost milk supply, when combined with intensive milk removal as described above. If your GP is not familiar with its use for this purpose (and it isn’t licensed for this use, so your GP needs to be willing to take responsibility for prescribing it), these are useful resources to share: Breastfeeding Network – domperidone factsheet and UKMi – “Drug Treatment of Inadequate Lactation”.
- Get support from other mothers who value what you are trying to do. Any LLL group will welcome a mother who is working on her milk supply, and the other mothers will highly value the effort you are putting in. We warmly welcome anyone who is interested in breastfeeding or providing her own milk for her baby, whether or not she is currently breastfeeding – please don’t feel awkward about giving extra milk at a LLL meeting. Many LLL groups are on Facebook too – it can be a great way to connect with other mothers whose babies have been born early, and who have overcome their early feeding challenges.
How much milk do I need to make?
It might help to know that a week-old full-term baby takes about 500ml in 24 hours, rising to an average of 750ml in 24 hours by 2-4 weeks after birth and staying at this level until the baby starts eating other foods, around 6 months. Although every baby is different, with some babies needing more and some less milk than this, it can be helpful to have a rough idea in mind of how much milk to aim for when you’re expressing. Even if your small baby doesn’t need this much milk yet, if your goal is to feed her only on your milk, it makes sense to aim for a full supply, so that you will have plenty of milk for her as she grows.
Although formula instructions suggest increasing the amount in line with the baby’s weight (feeding a certain number of ml per kg of baby weight), human milk supply doesn’t work like this – the daily amount stays the same from about 1-6 months, and this is probably a better guide. If you can get to a full milk supply by the end of the first month, you’ll be making as much milk as your baby will ever need!
Babies often go through a “catch up” phase of drinking large volumes of milk and growing fast, until they catch up with their natural size. You can tell when this happens, because their growth curve settles on one of the “centile lines” on the chart in the red book. It is important to work closely with your health visiting team during this stage. You will probably want to weigh your baby at least once a week until you and your healthcare team are confident that your baby is feeding well.
If your baby has needed some formula supplements, you can find information on how to use and perhaps reduce them here: https://www.laleche.org.uk/formula-supplements/ This is an art rather than a science, and it’s important to work with your local healthcare team and local feeding supporters with the skills and experience to work with late preterm babies.
Early/small babies just need a little more time and support
With time, and patience, this special group of babies can breastfeed beautifully – they just need some extra help at first, when they aren’t yet able to do all the work of feeding by themselves. Knowing what to expect, being prepared for the extra investment of effort, and finding good breastfeeding support will help you to reach your breastfeeding goals.
- If you know your baby will be born early, consider expressing colostrum antenatally. This gives you a headstart with feeding your baby and learning how to express milk by hand.
- Keep your baby close. Holding your baby against your skin will keep him calm and happy, encourage him to feed, save his energy for feeding and help you to notice the small signs that he wants to feed (like smacking his lips and sucking his hands). It’s the best way to get to know and enjoy each other.
- Keep your baby fed. Early/small babies might not ask to feed as often as they need to, and often tire quickly when feeding. Your baby needs to be fed at least 8-12 times in 24 hours. Short, frequent feeds usually work best. Encourage him to feed whenever he shows interest. Watch your baby’s nappies and growth carefully to make sure he is getting enough milk. Some babies may need extra milk (expressed mother’s milk, donor breastmilk or formula milk) at first.
- Keep your milk flowing. Milk supply usually reaches its peak level (around 750ml in 24 hours on average) within 4 weeks of birth. Removing milk frequently in the early days and weeks gives your body a strong signal to make more milk. If your baby can’t take all she needs at the breast yet, express your milk with a pump and/or your hands, as often as you can, to keep your baby fed and ensure a good milk supply for when she is ready to breastfeed.
- Keep your goal in mind. Early/small babies will grow into breastfeeding, with time and patience. Their path might be more complicated, and involve more people, tools and time than a full-term baby. Get the support you need while you do some of the work of feeding for your baby, until she can do it all for herself!
Written by Jayne Joyce, Ann Davison & Emily Tammam
Photos courtesy of Naomi Cotton, Becca Map, Roisin Keenan and Laura Loasby