Challenges with breastfeeding in the NICU
Challenges for the preterm infant
Safe and successful oral feeding requires not only appropriate sucking, swallowing and breathing, but also the coordination of these three functions in order to minimise adverse episodes of apnoea, bradycardia, oxygen desaturation and aspiration.
For preterm infants, a combination of issues affects their ability to safely feed, including hypotonia (low muscle tone), neurological and gastrointestinal immaturity and underlying medical complications such as gastro-oesophageal reflux and chronic respiratory disease. Together these issues make it difficult for the hospitalised infant to create and maintain the vacuum required for breastfeeding and also to coordinate swallowing and breathing safely.
Birth defects such as cleft lip and palate can limit an infant’s ability to breastfeed even further.
Challenges for the mother
Preterm birth interrupts the mother’s breast development and she must subsequently adapt to lactation earlier than expected. Mothers of preterm infants, especially extremely low-birth-weight infants, experience both physiological and emotional difficulties, which adversely affect breastfeeding success.
When the infant cannot go to the breast, or cannot effectively remove milk from the breast, the mother requires assistance to initiate and maintain a sufficient milk supply.
The stress associated with maternal-infant separation, in addition to inadequate breast stimulation, can interfere with the establishment of breastfeeding and increase the likelihood of complications. For many mothers of preterm infants, this means they must initially rely on the support of healthcare professionals and a breast pump to express milk for their infant. If their milk supply is low, they may also need to rely temporarily on donor milk.
Circumstances that prevent breastfeeding
Other challenges include situations where the expressed milk requires fortification before it is fed to the infant and where the mother is taking medication that makes direct breastfeeding unsafe. Sometimes the mother’s milk requires treatment, such as pasteurisation, preventing breastfeeding altogether. In some cases, the mother may be unable to be present at the hospital for every feed throughout the day.
When infants are unable to feed at the breast, the principal goal is to provide human milk to these infants while developing their natural oral feeding skills to facilitate exclusive breastfeeding as early as possible.
McGuire, W., Henderson, G., & Fowlie, P.W. Feeding the preterm infant. BMJ 329, 1227–1230 (2004).
Barlow, S.M. Oral and respiratory control for preterm feeding. Curr Opin Otolaryngol Head Neck Surg 17, 179–186 (2009).
Bertoncelli, N. et al. Oral feeding competences of healthy preterm infants: A review. Int Pediatr 2012, (2012).
Meier, P. Bottle- and breast-feeding: Effects on transcutaneous oxygen pressure and temperature in preterm infants. Nurs Res 37, 36–41 (1998).
Lau, C., Smith, E.O., & Schanler, R.J. Coordination of suck-swallow and swallow respiration in preterm infants. Acta Paediatr 92, 721 (2003).
Delaney, A.L. & Arvedson, J.C. Development of swallowing and feeding: Prenatal through first year of life. Dev Disabil Res Rev 14, 105–117 (2008).
Mizuno, K., Ueda, A., Kani, K., & Kawamura, H. Feeding behaviour of infants with cleft lip and palate. Acta Paediatr 91, 1227–1232 (2002).
Reid, J., Reilly, S., & Kilpatrick, N. Sucking performance of babies with cleft conditions. Cleft Palate Craniofac J 44, 312–320 (2007).
Cregan, M., De Mello, T., Kershaw, D., McDougall, K., & Hartmann, P.E. Initiation of lactation in women after preterm delivery. Acta Obstet Gynecol Scand 81, 870–877 (2002).
Meier, P.P. & Engstrom, J.L. Evidencebased practices to promote exclusive feeding of human milk in very low-birthweight infants. NeoReviews 18, c467– c477 (2007).
Lau, C. Effects of stress on lactation. Pediatr Clin North Am 48, 221–234 (2001).
Chatterton, R.T., Jr. et al. Relation of plasma oxytocin and prolactin concentrations to milk production in mothers of preterm infants: Influence of stress. J Clin Endocrinol Metab 85, 3661–3668 (2000).
Dewey, K.G. Maternal and fetal stress are associated with impaired lactogenesis in humans. J Nutr 131, 3012S-3015S (2001).
Newton,M. & Newton,N. The let-down reflex in human lactation. J Pediatr 33, 698–704 (1948).
Schanler R.J., Lau, C., Hurst, N.M., & Smith, E.O. Randomized trial of donor human milk versus preterm formula as substitutes for mothers’ own milk in the feeding of extremely premature infants. Pediatrics 116, 400–406 (2005).
Schanler,R.J. The use of human milk for premature infants. Pediatr Clin North Am 48, 207–219 (2001).
Hale, T.W. Medications and Mothers’ Milk (Hale Publishing, Plano TX, 2014).
Hamprecht, K. et al. Cytomegalovirus (CMV) inactivation in breast milk: Reassessment of pasteurization and freeze-thawing. Pediatr Res 56, 529–535 (2004).
Meier, P.P., Engstrom, J.L., Patel, J.L., Jegier, B.J., & Bruns, N.E. Improving the use of human milk during and after the NICU stay. Clin Perinatol 37, 217–245 (2010).
