Breastfeeding and the NICU
When I learned I was pregnant with my second child, I knew I wanted to breastfeed and I knew I wanted to take the time to enjoy it. With my first, I was struck by how difficult it was for me to sit still! The transition from a busy, independent, working New Yorker, to an existence of being pinned to a chair every couple of hours, for a good half hour (or more!) at a time, came as somewhat of a shock. I wanted to enjoy it, and eventually I did, but the first few months were really rough. The bonding grew and grew rather than being a given, as I had anticipated. This time I knew how fleeting those first few months would be, how precious those moments together would be. I looked forward to relishing in the time away from daily activities, and imagined the serenity of gazing at my beautiful baby while providing her with nature’s “liquid gold”. Little did I know that, once again, my expectations would have nothing to do with my reality.
My daughter was born 3 months too soon. I spent a weekend in the late summer not being able to feel her little kicks and wiggles inside me. As much as friends tried to comfort me, saying it was probably nothing – that I was probably just distracted or she was sleeping during the day – I knew something was very wrong.
The following Monday I went to get checked by my midwife and she immediately sent me to the hospital. I had twice as much fluid as I should, and my baby’s heartbeat was barely detectable. After a high level ultra sound that showed the blood flowing the wrong direction through her umbilical cord, my baby girl was taken out of my body and into the bright operating room lights, surrounded by doctors, nurses, and then the beeping machines of a neonatal intensive care unit (NICU). She was just over 2 lbs and she was very sick.
My heart felt like it was ripped out of my body too that day. I was terrified, angry, sad, anxious, full of hope, full of adrenaline, and about to be full of milk. The first thing I asked the nurse in the recovery room was, “Will I still be able to feed her? Where’s the pump?”. Within hours of my daughter’s arrival, I was not lying peacefully with her on my chest, basking in the breastfeeding couple’s bliss, but busy awkwardly pumping colostrum, praying I could help to save her life. After only having laid eyes on her tiny being for a brief moment, I knew the next time I would see her she would be hooked to many machines and breathing apparatuses, in an incubator and out of my reach. But I was determined to stick to my breastfeeding plan. More determined than ever since I knew that breast milk was the best thing for her premature body, and one of the only ways I could help her when I felt so painfully helpless. I was determined, even though the odds were against us and our journey would look nothing like the one I had imagined. I was determined even though my time spent away from daily activities would not be time spent breastfeeding, but time hooked to a pump.
My daughter did not actually receive any of my colostrum or my milk until several weeks after her birth, as she could only tolerate i.v. nutrients. When she could finally tolerate milk, it was given through a feeding tube for over 4 months. I wasn’t able to begin putting her to the breast in tandum with the feeding tube for almost 2 months, but in the end, after 6 whole months in the NICU, she came home exclusively breastfeeding. She managed to survive a myriad of life threatening complications, and my dreams of rocking her to sleep and feeding her in the way that felt most natural to me, miraculously came true. We both worked very hard to get to that point, but it happened.
It doesn’t matter if you suddenly find yourself facing 3 hours, 3 days, 3 months or more riding the NICU roller coaster. If you don’t want to let go of your plan to breastfeed, you don’t have to. If you didn’t expect to breastfeed but wish to provide your fragile infant with the potent benefits of human milk, you can. If you are unable to produce milk, even with lactation support, and wish your baby to receive human milk’s advantages, you have options.
No matter what anyone says, no matter how many people voice their doubts, breastfeeding or providing human milk for a severely premature infant is entirely possible, and can have huge benefits for both baby and mother.
It is important to be armed with some important facts and the knowledge that anything is possible.
A mother’s milk is more like medicine than food, as it improves a premature infant’s health and development in many ways. One of the most important benefits being protection against necrotizing enterocolitis (NEC), a painful disease of the bowels which is the #2 killer of preemies and the #10 killer of all babies worldwide. Babies who are fed exclusively human milk have a lowered risk of NEC by a whopping 79%. Human milk also reduces the risk of retinopathy of prematurity (ROP) which can cause blindness, developmental and neurocognitive delays, DNA damage, and re-hospitalization after NICU discharge. Additionally, it contains stem cells, which have the potential to impact a wide variety of health outcomes over the course of a child’s life.
Despite decades of trying, researchers have failed to come up with a milk substitute that mimics the antibody activity, and anti-infective and anti-inflammatory effects that human milk provides. It’s well documented that artificially feeding any baby increases their relative risk of death. A premature infant is even more susceptible to this risk due to the immaturity of every one of her bodily systems. Unfortunately formula fed preemies have longer hospitalizations, twice as many episodes of inadequate oxygenation as those who received breast milk, and higher blood pressure. Despite these findings, formula is still the widely accepted way to feed babies in the NICU. It is part of the hospital culture, and it is not based in scientific evidence. The good news is, even if a mother is able to supplement formula feeds with some breast milk, it can greatly improve her preemie’s health.
The more mothers who are educated about the benefits of breast milk for preemies, the better they can can advocate for their babies, and hopefully help to change the system. However, no matter how educated a mother is, when breastfeeding challenges arise such as sore nipples, engorgement, a preemie’s weak latch, and so on, it is not education but practical advice from someone experienced in evidence based care that will help the breastfeeding couple succeed. In a NICU, is can be very difficult to get sound advice. Most NICU nurses simply do not have the training needed to give breastfeeding advice, and they are used to seeing preemies be bottle fed. Keep asking, keep searching until you find someone who has answers. If you are told to wean, or simply give formula in order to simplify the situation, you are not speaking to the right person.
PUMP IT UP
It’s not particularly fun and it’s extremely time consuming, but if you must be separated from your baby, pumping as soon as possible will help to establish your milk supply. Pumping every 2-3 hours (the frequency that a newborn would normally feed) with a hospital grade pump is necessary to stimulate your milk to come in. You can ask your NICU nurse to help you locate pump rentals. It sounds daunting, and it is, but with the right support pumping actually helps many women cope with the emotional trauma of the NICU experience by giving them a routine and a way to help.
Amazingly, some NICUs are afraid to offer mothers of preterm babies lactation support or breast pumps because they don’t want to put pressure on mothers who are already under stress. But most moms who learn what breast milk can do for their babies’ health outcomes are eager to breastfeed or express their milk, and are empowered by contributing to their babies’ care. Well meaning nurses and doctors often discourage pumping around the clock, advising sleep instead. Be aware that due to lack of a breastfeeding education, they probably do not realize that going the entire night without pumping can drastically undermine your efforts to establish a full milk supply. At first, lactation is hormonally controlled, but after several weeks postpartum, this control switches to supply and demand. If a woman has not pumped frequently enough during the first few days and weeks after her baby is born, her supply will begin to decrease at about 6 weeks, when hormone levels change and prolactin levels begin to decrease. When your baby is big enough and strong enough, all the pumping will pay off. You will have the milk supply needed to breastfeed!
If you are unable to continue pumping in the long term, your colostrum alone can have significant and lasting positive outcomes. Even if just a few drops of colostrum come out in the first few hours or days of pumping, do not be discouraged! You are giving your baby a huge gift. Studies have shown that preterm colostrum is the most protective colostrum. It has extremely high concentrations of antibodies, human growth factors, anti-inflammatory and anti-infective properties which coat your baby’s premature intestinal lining. A healthy gut means a strong immune system, which your baby needs more than anything.
Many NICUs have begun swabbing babies’ mouths with drops of colostrum during the first days out of the womb, even when they are too small or sick to begin feeding from the breast, bottle, or feeding tube. Research shows that oral administration of colostrum appears to block attachment of bacteria in the airways, and results in a higher average weight at 36 weeks. There are no known adverse effects of the oral colostrum treatment, even in the smallest and sickest of infants. Ask your doctor or postpartum nurse if your hospital’s NICU has implemented oral colostrum care. If not, freeze it for later, make your voice heard, and encourage them to do so in the future!
Fresh colostrum and milk is always best, but if your baby is not ready to eat, or you cannot deliver fresh milk to the hospital soon enough, you will need to use a freezer. A deep freezer keeps milk usable for 9 months! Your baby’s NICU will give you their specific breast milk storage guidelines, as preemies are more susceptible to bacteria, viruses, and other illness. No matter what, always sterilize your pump kit regularly and use sterile bottles for collection. Most hospitals will provide you with special collection bottles.
Hands free pumping bras are extremely useful, as is a hand pump for when you can’t be home (after your milk supply is established), and microwavable sterilizing bags for pump parts can save a whole lot of time. If you know a family with a baby in the NICU, these are great gifts, as are rides to and from the hospital, sibling care, and drop off meals (organizing is easy through a website like mealtrain.com). All NICU moms, and pumping NICU moms in particular, suffer from exhaustion. Any amount of help getting through each day is a big deal and a blessing.
LEARN FROM THE MARSUPIALS
Kangaroo Care, or skin-to-skin care, is a wonderful way to help your milk come in faster, create more successful breastfeeding episodes, and deepen your bond with your baby even if you are unable to breastfeed. Skin-to-skin contact is proven to raise blood sugar and oxygenation levels, lower the heart rate, develop the brain faster, decrease crying, lengthen deep sleep, create longer periods of alertness, and help mature the autonomic nervous systems of premature infants. Babies who receive kangaroo care are less likely to have apnea spells (a period of not breathing) and are better able to regulate their own body temperatures. During kangaroo care, the baby’s overall growth rate increases due to conservation of energy needed to stay warm, and better ability to sleep.
It is important that your baby is stable before you start, but don’t be afraid to ask your nurses and doctors every day whether your baby is ready for kangaroo care. The benefits are great and lasting, and the sooner you are able to begin, the better. If you are met with resistance, politely offer literature for hospital staff to read. Sometimes they are simply following old protocols and are ill informed as to the extensive research that has been done on kangaroo care. Dr. Susan Ludington, who was instrumental in bringing kangaroo care to the United States, sums it up when she says that for mammals, “Separation is not biologically normal”.
The way to perform kangaroo care is to find a comfortable chair (hopefully they have them in your NICU) and nestle your baby, wearing only a diaper, onto your bare chest for at least 1 hour at a time. The father of the baby can perform kangaroo care too. Use blankets to cover the baby’s back, or close your shirt or sweater around her like a kangaroo pouch. Ask the nurses if they can dim the lights.Take this time to rest quietly, sing or read to your baby, meditate, or use visualization techniques to release stress. It is a perfect time to tune out the sights and sounds of the hospital, and tune into your baby in the moment. Living in the moment is a key to surviving the NICU journey.
As you continue kangaroo care, you can move your baby toward your breast, let her nuzzle your nipple and possibly over the course of days or weeks, find a latch. You can hand express a drop of milk and place it in your baby’s mouth to help her associate the taste and smell of milk with your body, and eventually with eating.
What if you can’t breastfeed or express milk due to low supply, a breast reduction, hormonal imbalances, a mastectomy, or any number of other personal reasons, but still want your baby to receive the benefits of human milk? What if your baby cannot latch when the time comes? Donor milk is an option, and can be life-saving.
Donor milk from milk banks is screened, tested, and pasteurized, with the same rigor as donor blood. It is suitable for use in the NICU, although many NICU directors, parents, and insurance companies lack knowledge of its existence and accessibility. Nine of the top ten NICUs in children’s hospitals around the country are now using it, but it will take a lot of education, and parents demanding new policies, to encourage the other NICUs to follow suit.
Milk from a milk bank can be quite expensive, particularly because there are not enough milk banks and drop-off locations established to keep shipping costs down. Many hospitals think that donor milk is too expensive to use, but the fact is, a tiny preemie may need only a few ounces per day. Since human milk can prevent all kinds of severe medical problems, it is estimated that the amount that hospitals and insurance companies could ultimately save on costly procedures far outweigh the cost of the donor milk.
For more information on how to obtain donor milk, or donate your own milk, contact the Human Milk Banking Association of North America. HMBANA has the support of the AAP (American Academy of Pediatricians), CC (Centers for Disease Control, ACOG (American College of Obstetricians and Gynecologists), and the AAFP (American Academy of Family Physicians).
STAY TRUE TO YOURSELF
Ultimately, what’s best for you is best for your baby. If you take care of yourself and trust your capabilities, you can provide the best care for your child. Once informed and educated about the ways in which you can help your preemie, you can choose your own path and help her to the best of your ability.
If you want to breastfeed or express milk, you should not give up hope. Be tenacious and advocate for yourself and for your baby. If for some reason you cannot breastfeed, express milk, or provide your baby with human milk, you should feel good knowing that you have the next best thing. Formula was specifically created for times when breast milk is unavailable. Although it does not provide the same advantages that breast milk can, it is carefully developed to come as close as possible. It will provide your baby with the nutrients she needs.
Most importantly, always continue to let your baby know that you are there. Visit often, she can feel your presence. Give her the best and most healing gift of all, your love.
Fernando Moya, MD, “Colostrum”, PediatricNutritionCE.org, Oct, 2013 Danielle Rigg and Bettina Forbes, “FAST FACTS: Miracle Milk”, May 6, 2014 Stephanie Casemore, “Pumping For Your Preemie”, Nov 5, 2013
Paula P. Meier, RN, DNSc, FAAN, Janet L. Engstrom, RN, PhD, CNM, WHNP-BC, Aloka L. Patel, MD, Briana J. Jegier, PhD, and Nicholas E. Bruns, BS, “Improving the Use of Human Milk Before and After the NICU Stay”, March 2010
Linda Folden Palmer, DC, “Formula Feeding Doubles Infant Deaths in America”, Feb 1, 2004
Jack Newman, MD and Teresa Pitman, “The Ultimate Breastfeeding Book of Answers”, 2000
H Shoji, T Shimizu, K Shinohara, S Oguchi, S Shiga, Y Yamashiro, “Suppressive Effects of Breast Milk on Oxidative DNA damage in Very Low Birthweight Infants”, March 10, 2003
Case Western Reserve University, “‘Kangaroo care’ offers developmental benefits for premature newborns”, July 10, 2013
Holly Richardson, “Kangaroo Care: Why Does It Work?”, Midwifery Today, 1997