Transitioning to direct feeding at breast – Transition to at-breast feeding interventions

Offering NICU infants opportunities to receive stimuli during non-nutritive suckling at the breast, helps them progress from enteral feeding to breastfeeding. Effective milk transfer during breastfeeding is the ultimate goal of lactation interventions, so accurate measures of milk transfer must be set in place to ensure this is achieved.

NICU baby being made familiar with feeding at breast

What is transitioning to direct feeding at breast?

Transitioning to direct feeding at breast is defined as the progression from enteral feeding to effective milk transfer directly from the breast.

Many NICU infants are unable to directly breastfeed at birth due to gestational age, immaturity, associated neonatal morbidities, and medical conditions.

The transition from enteral feed starts early with skin-to-skin care with the mother, and provides the infant with opportunities for1-3 

  • Non-nutritive sucking (NNS)
  • Oral sensory stimuli at the breast
  • Progression towards nutritive-sucking (NS)
  • Gradual learning of the sucking dynamics of breastfeeding

Why is transitioning to direct feeding at breast important?

Positive breastfeeding experiences in the NICU are foundational to continued success after discharge.4

Premature infants who have their first oral feeding experience directly at the breast have longer durations of breast milk feedings while in the NICU.5

NNS at the breast improves transition to breastfeeding for nutritive purposes and is associated with longer breastfeeding duration.2 Monitoring at-breast experiences (NNS and NS) and milk transfer volumes enables

  • mothers to observe their infant feeding cues and initiate at-breast feeds
  • accurate evaluation of milk transfer through pre and post breastfeed test weighing.6,7

These practices support the progression to exclusive direct feeding at the breast.

For further information, watch 'Test weighing of breastfeeding premature and medically complex infants' by Barbara Haase PhD, MSN, CPNP-PC, IBCLC.

How to optimise transitioning to direct feeding at breast

Effectively initiate and track mother’s milk supply to assess coming to volume (daily volumes ≥500 ml/day)

  • Support regular NNS and the progression to NS as soon as physiologically appropriate
  • Document NNS and NS events as standard practice
  • Support skin-to-skin care with the mother for >1 hour duration each time
  • Endorse test-weighing as a validated measure of milk transfer volumes during at-breast feeding to:
    • Record actual milk volume ingested when breastfeeding
    • Tailor supplementation in accordance to milk intake
    • Support transition of the NICU infant to full breastfeeds before discharge
    • Empower and reassure mothers to be confident with breastfeeding skills and meeting their infant’s nutritional needs
    • Provide individual post-discharge planning to support mothers who may need to continue expressing  to maintain supply.

How to monitor transitioning to direct feeding at breast

Collect data on frequency of non-nutritive sucking and quality of nutritive sucking (milk volume transfer).

Carry out monthly monitoring and evaluation of the data to measure

  • Percentage of infants performing their first oral feed at the breast.
  • Percentage of at-breast feeds that have milk transfer validated by test-weighing.
  • Percentage of infants breastfed ≥ once per day for 7 days prior to discharge, and ≥ 6 times daily for 48 hours prior to discharge.

Audit records on a monthly basis to review progress, identify and address challenges to improve transitioning to direct feeding at breast


1 Meier PP et al. Evidence-based methods that promote human milk feeding of preterm infants: An expert review. Clin Perinatol. 2017; 44(1):1–22.

2 Narayanan I et al. Sucking on the 'emptied' breast: non-nutritive sucking with a difference. Arch Dis Child. 1991; 66(2):241–244.

3 Spatz DL. Innovations in the provision of human milk and breastfeeding for infants requiring intensive care. J Obstet Gynecol Neonatal Nurs. 2012; 41(1):138–143.

4 Briere C-E et al. Direct-breastfeeding in the neonatal intensive care unit and breastfeeding duration for premature infants. Appl Nurs Res. 2016; 32:47–51.

5 Pineda R. Direct breast-feeding in the neonatal intensive care unit: is it important? J Perinatol. 2011; 31(8):540–545.

6 Haase B et al. The development of an accurate test weighing technique for preterm and high-risk hospitalized infants. Breastfeed Med. 2009; 4(3):151–156.

7 Hurst NM et al. Mothers performing in-home measurement of milk intake during breastfeeding of their preterm infants: maternal reactions and feeding outcomes. J Hum Lact. 2004; 20(2):178–187.