By: Lisa Stellwagen, MD, FAAP & Margaret G. Parker, MD, FAAP
Babies born prematurely often face unique health challenges. Those weighing under 3 pounds 5 ounces at birth, considered very low birth weight, are even more fragile. Feeding them breast milk offers critical benefits, especially when the milk comes from their mother.
The American Academy of Pediatrics (AAP) recommends that these tiny premature babies be fed mother's own milk whenever possible. Here's why.
Benefits of mother's milk for tiny premature babies
The perfect nutritional match
After a premature birth, your body knows exactly what your baby needs. Your breast milk is especially high in protein, fat and milk sugar to help baby get growing. But the magic of mother's own milk lies also in the immune factors and biology of her milk. It is packed with infection fighting power, antibodies, brain building fats, probiotic bacteria, immune and stem cells and much more.
Protection from complications
The breast milk mothers make has many factors to help fight infections in the blood and in the intestines. This includes a serious and sudden illness called
necrotizing enterocolitis (NEC).
What is NEC and how can breast milk help prevent it?
NEC can weaken and damage the lining of immature intestines. Babies who get sick with NEC can lose bowel tissue and have lifelong complications related to digestion. For some babies, it can be life threatening.
Mother's own milk is the very best way known to reduce the risk of NEC (though nothing is 100% protective). There are many other benefits of mother's milk, including reducing the risk of lung problems, eye problems, feeding struggles and slow development. Babies who receive mother's milk often go home sooner and are less likely to be readmitted to the hospital after discharge from the NICU.
Family support in providing breast milk
Many families of premature babies wonder what their role is in the complicated and busy NICU. Providing lifesaving milk for their child is something nobody but mothers can do, but supportive partners and family members are the key to success. In this video, learn how everyone can work together to help these fragile babies get the best start:
Feeding small babies
Premature babies need help to feed
Premature babies have been swallowing and digesting amniotic fluid before they are born, and their intestines are ready to digest milk. But their sucking, swallowing, and breathing coordination is immature at first. These babies are all fed with a thin, soft plastic tube that passes through their nose or mouth into their stomach.
The nurses feed babies small amounts of milk at first, and then day by day baby is fed more milk and starts to gain weight. This is why mothers must express their milk at first. Feeding directly at the breast will happen later when baby has become stronger and more mature.
Colostrum is liquid gold
The first milk produced after delivery, called colostrum, is packed with immune factors and it is
critically important for baby to receive this milk. Colostrum starts with little drops of golden yellow milk that is low in fat, but high in protein and antibodies. Most NICUs recommend that small drops of colostrum be placed in the baby's mouth to jump start their immune system even before the first feeding.
Over the course of the first week, each day the amount of milk mothers make increases. It starts off as yellow and becomes whiter because it has more fat in it. The calories increase as the fat gets higher and babies will start to gain weight. Helping babies grow with mother's own milk is a very important step to the best outcomes and preventing complications in the NICU.
What to know about breast milk fortifiers
Tiny babies have extreme nutrition requirements and will need some boosters (fortifiers) added to mother's milk for brain, body and bone health. Your NICU team will explain how and when fortifiers will be mixed with your milk and how long this will be needed. All very low birth weight babies will need fortification in the NICU to grow; however, around the time of NICU discharge or in the weeks after the baby goes home, the fortifiers can often be stopped.
Learning how to pump
The NICU team will show you how to use a breast pump and help arrange a pump for you at home. There are a few very important things to know—and advocating for your family by asking for help to get started soon after delivery and being comfortable and confident before you go home is critical to success! NICU nurses, doctors, and special breastfeeding lactation consultants are great sources of information and help for you in this journey of making milk.
5 key pumping tips
Pump within 6-8 hours after delivery
Pump 5-6 times a day (every 3-4 hours and at least once in the middle of the night) or even more often once your breasts begin to fill up with milk
Get help if you have any pain or discomfort (it should NOT hurt to pump)
Long stretches without pumping can shut down your
milk supply, so be sure you keep up a regular schedule of milk expression. Get your family and support network involved to help you keep up with pumping! This is hard work, but the payoff will be your baby's improved health outcomes and the future ability to nurse your baby if you desire.
Be sure you have a comfortable, electric, double pump to go home with before you are discharged from the hospital. The NICU and lactation staff will help you obtain the pump and give you containers and labels. They'll also provide information about
milk storage and bringing your milk in from home.
Holding and feeding your baby
Skin-to-skin or kangaroo care
Families can help their tiny baby adjust to life outside the mother's body by holding baby close in direct contact with parent's skin. This helps settle baby down, regulates their temperature and breathing, and has been shown to improve growth and mothers' milk supply. Try and hold your baby frequently and throughout the NICU stay.
When can I start breastfeeding my premature baby?
Most mothers who have been expressing milk for many weeks are eager to put baby to breast. Babies differ on how quickly they mature, and the NICU staff will help tell you when the time is right. NICU nurses are feeding experts! NICU feeding specialists are also very helpful in learning how to breastfeed or bottle feed a tiny baby and help baby take everything by mouth as they get ready to go home. Lactation nurses too can help parents learn the art of breastfeeding over the NICU stay
Alternatives to your milk
Most tiny babies will need other types of milk, either before mother's milk comes in, or if she has any times when her milk is not enough for baby. There are several alternatives, and your NICU team will discuss them with you and make recommendations about what is best for your baby. As a reminder, there is nothing that prevents NEC 100% of the time.
Donor human milk
The American Academy of Pediatrics recommends pasteurized
donor human milk if mother's own milk is not available or plentiful enough for baby. Donor milk reduces the chance of baby getting sick with NEC, and is a great substitute for mothers' own milk; still, it doesn't have all the same benefits as mother's own milk.
Donor human milk comes from mothers that have donated their extra milk not needed by their child. NICUs obtain donor milk from registered milk banks that operate like blood banks (but for milk). They carefully screen donors, process and test milk and provide it for the times mothers' own milk is not available. In North America, all donor milk is pasteurized – heated - to remove cells, bacteria and viruses to prevent any infections. The NICU will have information for you on donor milk and may ask you to approve that recommendation or sign a consent form.
Commercial premature infant formula
Commercial premature infant formula made from cow's milk is another option if additional milk is needed. It's designed to provide the nutrients needed for premature infants. However, this formula does not provide the same level of protection against NEC that mother's own milk or donor milk can provide.
This is because commercial premature infant formula does not have the immune protection or
biologic components of human milk. Some families may still prefer to use commercial premature milk formula, and the NICU will discuss the risks, benefits and alternatives with you. You may be asked to sign a consent form.
Getting ready to leave the hospital
Many hospitals allow parents to stay overnight with their babies, especially on the nights right before taking a baby home. This gives you the chance to tune in to your infant's round-the-clock hunger cues and rhythms and eases the transition from hospital to home.
Continue your skin-to-skin care (both parents!), and work on doing all of baby's feedings like you will at home. The lactation nurses will help you decide when and how to reduce your pumping as baby gains strength at the breast (if you wish to breastfeed). Learn more in this video:
Self-care for parents
Caring for a premature or ill newborn is very challenging whether in the hospital or after you take baby home. Don't blame yourself if things don't go as expected. Some key tips:
Get as much rest and TLC as you can. Stay hydrated and make sure you get balanced nutrition, which supports milk production and your own recovery.
Accept help from family or friends for household tasks so you can focus on feeding and recovery. Fellow parents often have good practical advice when it comes to caring for a preemie. Tap into this wisdom bank by joining a local group for parents of preemies.
Make sure your partner and family fully understand the health advantages of mother's own milk for your little one. The emotional and practical support they offer will go a long way in helping you meet your goals.
If you are interested in finding out more, read the AAP's clinical report, "Promoting Human Milk and Breastfeeding for Very Low Birthweight Infants."
More information
About Dr. Stellwagen
 Lisa Stellwagen MD, FAAP, is a pediatrician, professor emerita of pediatrics at the University of California, San Diego, School of Medicine, and Medical Director of the University of California Health Milk Bank. Dr. Stellwagen is a member of the AAP Section on Breastfeeding and President of the Human Milk Banking Association of North America. She has been deeply engaged in the education of health care workers and families about the importance of breastmilk to reach optimal health outcomes for mother and child. She has worked locally and nationally on breastfeeding promotion and removing barriers for families to provide mother's own milk or obtain pasteurized donor milk for vulnerable and premature infants.
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About Dr. Parker
 Meg Parker, MD, MPH, FAAP, a member of the American Academy of Pediatrics Committee of Fetus and Newborn, is a Professor of Pediatrics and Academic Chief of Neonatology at UMass Memorial Medical Center. Dr. Parker is a neonatal health services researcher and holds several federal and foundation grants in the area of social disparities in preterm birth outcomes; she has a particular interest in safe sleep and breastfeeding. Dr. Parker has led multi-site NICU quality improvements focused on breastfeeding and family engagement in the NICU setting. She applies a health equity lens to her local and multi-site quality improvement projects.
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