Feeding behavior in newborns is linked to so many things:  How rough the
birth was, if there was any subtle injury to the baby, the health of the
dyad, the social pressures, etc.  Certainly,  gestational age is a huge and
often underappreciated issue. I just assume the pre-term infant will be a
temporarily weak feeder and manage these cases with a great deal of
anticipatory guidance.  It continues to surprise me how often these 35 and
36 weekers are released home with the expectation that they will behave like
a term infant.

If a baby falls into the category of the baby who is "just a little early"
there are well-documented statitstical increases in their risk for poor
breastfeeding behavior.  Part of the reason that this is so is because their
facial structures are not well-developed and their body tone (including
facial tone)is low.

 They have thin cheeks with few fat deposits.  To assess for this, observe
for the presence of deep creases under the eyes. Put one finger inside the
mouth and thumb on the cheek and give a little squeeze.  In these
under-cooked babies you can feel your fingers touch. Term babies have a
thicker pad in the cheeks and you can literally feel it as you squeeze.  Why
is a lack of fat pads of interest to us as breastfeeding experts?  Well, if
the cheeks are thin, they further destabilize the facial tone.  This may
affect lip seal.  If lip seal is affected the baby is going to lose suction
frequently during feeding.  This will make feeding more effortful.

 As the work of feeding increases for a small, immature baby, there is
greater risk for feeding-related fatigue.  The baby may feed ok for a few
min. but will tire quickly and cease feeding before really getting full.
Teach parents to watch for when the baby's eyes close.  If this happens
almost immed. as baby goes to breast, then baby is very likely doing almost
no nutritive sucking (NS).  Count jaw excursions, grade the type of jaw
excusions (big, wide and slow are NS; short, shallow and fluttery indicate
NNS.)  Listen for swallows, etc.  When in doubt, do an intake check on a
capable scale.  It is impt to assess whether baby is doing any real feeding
or just sleeping with a nipple in their mouth.

As these infants consistently fail to access much more than the first
letdown, they start to hibernate to save energy.  They become harder and
harder to rouse.  Their weight drops;  fatigue and energy deficits increase,
and they become less and less capable of reversing the downward cycle under
their own steam.  They tend to leave so much residual milk in the breast
that there is a build-up of FIL and a subsequent down-regulation of milk
supply.  If helpers don't anticipate this risk and start insurance pumping
during Week 1, moms often will calibrate at a low level of milk production
that later will be difficult to reverse.  A viscious cycle of underfeeding,
understimulation and hunger-related infant frustration will ensure.  As
mothers observe how their baby is faltering, their confidence in
breastfeeding diminishes right along with their milk supplies because no one
has explained that the prematurity of the baby is interfering in the
normally robust process they were expecting.

The 3 rules apply.

1.  Feed the baby.
Use whatever alternative method the parent prefers, but teach (with return
demonstration) how to deliver the milk with pacing techniques so the baby's
immature respiratory system isn't overwhelmed by too-rapidly delivered
fluids (creating the risk of aversive feeding reactions that someone will
have to solve later.)

2. Protect the milk supply.
What happens on Day 2 is critical to weight loss and to when and to what
extent the milk "comes in".  (refs cited below.)  If you are managing a
pre-term infant younger than 38 weeks, anticipate that breastfeeding won't
become robust until the baby nears term. Let parents know this.  They get
scared thinking baby will always be this hard to breastfeed. Counsel the
mother to pump to compensate for the baby's inability to access milk
adequately and to stimulate supply adequately.  If baby surprises you with
more feeding ability than you expected, you can always ramp down the
intervention.

3 Keep something happening at the breast.
 Lots of skin-to-skin helps the supply and helps baby develop in a lower
stress extrauterine environment.  Using the breast as a pacifier AFTER
feeding by alternative method helps maintain the baby's orientation to the
breast.  This is where you want him/her to end up at the final stage of the
intervention. I like to give the breast when the baby is full (or at least
not too frantically hungry) so that the baby doesn't always associate the
breast with frustration and hunger.  You can switch the order of when you
offer the breast as the situation improves and baby is stronger.  Encourage
lots of practice feeding, but emphasize that supplementation is temporarily
necessary.  Don't say discouraging things like:  "The shield is bad and all
these bottles will prevent your baby from ever nursing, so get rid of them
asap."  You get rid of the interventions when they are no longer necessary,
not according to some dogma.  Plant positive post-hypnotic suggestions such
as:  "Pre-term babies are the easiest of all to transition back to breast
even if they've had lots of alternative feeding PROVIDING the mom's milk
supply is robust."  This, in my experience, is true.

  Then stick around by phone to help the mom with info and support as she
transitions off the intervention.

Refs:

Cernadas J, Noceda G, Barrera L, Martinez A, et al:  Maternal and Perinatal
Factors Influencing the Duration of Exclusive Breastfeeding During the First
6 Months of Life, J Hum Lact 2003; 19(2):136-144.



Hall R, Mercer A, Teasley S, et al:  A breast-feeding assessment score to
evaluate the risk for cessation of breast-feeding by 7 to 10 days of age, J
Pediatr 2002; 141:659-64.


Kramer M, Demissie K, Yang H, Platt R, et al:  The Contribution of Mild- and
Moderate Preterm Birth to Infant Mortality, JAMA 2000, 284:843-849.



Palmer,MM: Identification and management of the transitional suck pattern in
premature infants, J Perinat Neonatal Nurs 1993, 7(1):66-75.



Ramsey,M and Gisel,E:  Neonatal Sucking and Maternal Feeding Practices, Dev
Med and Child Neurol 1996, 38:34-47.





Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
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