After 35 years of caring for premies, I would just 
like to comment about the "exhaustion" issue. 
 It isn't breastfeeding that stresses premies - 
it's eating --period...and a lot of other things including 
the overstimulation of handling, too much light, 
too much noise, painful procedures, 
poor positioning, etc. etc. 
Paula Meier's study showed quite clearly
that premies do better and have fewer
stress cues with breastfeeding than
with bottle feeding, but, depending on the
degree of prematurity, both are difficult.
It's a lot like asking a 9 month old baby to
walk - some can do it, but most can't.  We 
are pushing these babies to get them to eat
before they may be ready.

Developmentally, the baby is not supposed
to have to coordinate suck,swallow and breathe at
 28 or 30 weeks gestational age.  He/she is
 supposed to be floating in water,
 practicing a little while still attached
to a placenta which does all the real feeding,
excreting, breathing, etc.

Everything is unfinished - gastric system, lungs,
immune system, brain, eyes, kidneys - you
name it....but at birth, even when that
birth is premature, everything tries to work.
What we do in an intensive care nursery is
support those immature systems and try
to keep the baby physiologically stable
until maturity takes place.  It isn't easy.  That's
why they call it "intensive care."

Babies can suck very early, but to coordinate
suck/swallow/breathe requires a fair amount of
maturity.  Not all mothers have nice, easy MER's.  
Some have Niagara Falls letdowns, while others
take forever to let down even with massage.  It 
requires patience and skill to help a premie learn
to breastfeed.  When they hit about 35 - 36 weeks
gestational age, it is like somebody turns on the
switch  and the baby says "OH!  THAT is what
I am supposed to do," and begins to breastfeed. 
Some require 40 - 42 weeks to do well, depending 
a lot on how sick they were.

Like the analogy of the 9 month-old - some can do it
sooner than others.  It is a very individual thing and is
sometimes related to the mother's anatomy and
lactation physiology as much as to the baby's
capability and health status.

What we don't want to do is allow the baby to 
burn so many calories trying to eat that he
loses weight.  Call it "exhaustion", call it "stress"
call it "developmental immaturity' or whatever.
The point is, getting a premie to breast is a 
lot different than getting a full-term baby to
breast, and the infant's responses are quite
different.
Hope this helps.
Deanne RN  IBCLC
NICU

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