A Preemie Needs His Mother

by Jane A. Morton, M. D.

Before the birth of a baby, the placenta is primarily responsible for providing the fetus with nutrition and protective factors. After birth, the breasts assume these roles. In contrast to a healthy term baby, the tenuous nutritional stores and the immature systems of the premature baby make him particularly vulnerable. His own mother's milk is uniquely designed to protect, nourish, and stimulate his growth. The protective properties of each mother's milk is unique, and the milk a mother produces after delivering prematurely is different from the milk she would produce had she delivered at term. No formula, or even the milk from another mother, can enhance the development of his brain, intestines, and immune systems as his own mother's.

The last thing any pregnant woman expects or wants is to deliver a very premature baby. While it is understandable to feel overwhelmed as the baby is whisked away down the halls to the high-tech intensive care nursery, in many ways, a preemie needs his mother the most. Her job of protecting, nurturing, and nourishing her baby becomes even more important now.

There is a fragile and critical short window of time in the first several days after birth when the breasts are most sensitive to frequent and effective pumping, which will ensure a generous and flexible milk supply. Providing this new mother with the inspiration and information she needs to immediately begin the invaluable and demanding job of initiating her milk production can make an enormous difference. Even if a third of a 2.2 pound (1 kilo) preemie's diet is breast milk, he will leave the hospital, on the average, 15 days earlier and far healthier than the exclusively formula fed baby.

Premature Infants in the United States

Birth weight is one of the most important predictors of infant mortality. Despite impressive improvements in the care of premature babies, the United States has been unsuccessful in reducing the number of preterm deliveries. In 1997, 65 percent of all infant death occurred to the 7.5 percent of infants born with low birth weight. Compared to the heavier babies (over 2500 grams or 5.5 pounds), the risk of infant death is five times higher for infants weighing 1500-2499 grams, and 92 times higher for infants born at or under 1500 grams.

The rise in the multiple birth rate has dramatically influenced the rate of prematurity. Twins, triplets, and other higher-order multiples now account for nearly three percent of all births. Since 1980, twin deliveries have risen 52 percent and higher multiple births have escalated by 404 percent. Two related trends, older age at childbearing and increased use of assisted reproductive technologies, have had a heavy impact on the multiple birth rate. Half of all twins and the great majority of triplets are born early, accounting in part for the increasing rate of prematurity.

Advantages of Breast Milk

In a soon to be released video designed to help new mothers of preemies keep their babies breast milk fed, Dr. David Stevenson, Director of Neonatology at Stanford University, states simply, "Good nutrition is the way out of the intensive care nursery, and breast milk is the ideal food". Although we only appreciate the tip of the iceberg of advantages provided by breast milk, we recognize the protective benefits on the preemie's immune system, gastrointestinal system, and brain. The impressive decrease in the incidence of sepsis, an infection in the blood stream, and necrotizing enterocolitis, a devastating inflammatory disease of the intestines, primarily account for the earlier discharge of preemies fed human milk.

Data also suggest that skin-to-skin contact, more common in the breastfed baby, may be an important factor in promoting the benefits of human milk. So called "kangaroo care" enhances the mother's capacity to synthesize specific factors that protect against the pathogenic bacteria prevalent within the hospital. The intimacy of this type of care, when the mother actually "wears" her preemie against her chest, has numerous benefits for both mother and baby, with improved milk production and infant weight gain being only two of them.

Even when controlling for socio-economic and educational status of the parent, as well as illness severity, "ex-preemies" who have been breast milk fed score significantly higher on verbal performance and other tests by eight years of age. The improved visual function and reduction in retinal disease of prematurity in breastfed babies, add further support to the positive association between human milk and the neuro-developmental outcome of premature infants.

What Are The Hurdles?

With research strongly supporting the numerous advantages of breast milk for the premature infant, one might question why only a small minority of preemies leave the hospital exclusively breastfed. There are several reasons. First, mothers frequently feel overwhelmed, ill, intimidated, guilty or depressed after delivering prematurely. Good research shows that the delay between initiating pumping and infrequent pumping are the two strongest contributors to the common problem of insufficient milk production. While literally every drop counts, the demands of pumping eight to twelve times a day from the first day takes enormous commitment. How to pump and integrate pumping into one's daytime and nighttime routines for the weeks ahead can be facilitated if experienced members of the medical staff provide mothers with support and practical information. Frequently, however, there is too little verbal support from physicians for the heroic efforts of these mothers, with most of the physician's focus being the health status of their patients.

The Learning Curve

Breastfeeding is a learned behavior for every baby, no matter what his size or age. Initially, a preemie is fed by a small gavage tube from his mouth to his intestines. Drip by drip, he receives the innumerable benefits from this "liquid gold", without even tasting it. By holding him skin-to-skin, he learns his mother's touch and smell, and he begins rubbing his face against her. Later, he will begin licking and mouthing, and finally he will receive the first taste of the sweet drips of breast milk she expresses on his lips. Usually, it takes weeks before he learns the process of coordinating sucking, swallowing, and breathing. A baby learns the rhythm of nursing more easily if the flow of his mother's milk is very generous.

Mothers of preemies need to learn special techniques to help their babies transition from gavage feeding to breastfeeding. Compared to the term baby, the preemie's head is proportionately larger and heavier. As his neck muscles are weak, head control is typically poor in these tiny babies. Therefore, his mother needs to learn techniques that support and guide the infant's head to her breast. Another difference from the term baby is the small mouth of a preemie. As the size and shape of women's nipples and breasts vary, some mothers will need to contour the breast to comfortably fit the baby's mouth. By using her hands to support and shape the breast and synchronously express milk, she can assist her baby with latch on and initiation of milk flow.

During these weeks, both the mother and the baby learn the "dance" of breastfeeding. Step by step, ounce by ounce, the preemie becomes stronger. This gift is only one a mother can give.

References:
1. Guyer B, et al. "Annual summary of vital statistics-1998". Pediatrics, 1999;104:1229-1246.

2. Hay WW, Lucas A, et al. "Workshop summary: Nutrition of the extremely low birth weight infant". Pediatrics, 1999;104:1360-1367.

3. Hill PD. "Effects of pumping style on milk production in mothers of non-nursing preterm infants". Journal of Human Lactation, 1999;15(3):209-216.

4. Schanler RJ, Shulman RJ, Lau C. "Feeding strategies for premature infants: Beneficial outcomes of feeding fortified human milk versus pre-term formula". Pediatrics, 1999;103:1150-1157.

5. Schanler RJ, Hurst NM, Lau C. "The use of human milk and breastfeeding in premature infants". Clinics in Perinatology, 1999;26(2):379-398.