Challenges with breastfeeding in the NICU

Breastfeeding premature infants in the NICU is particularly challenging. Fragile, vulnerable, medically compromised infants generally cannot go directly to their mothers’ breast and feed effectively after birth. In the NICU setting, breastfeeding is a complex task that requires close attention to the needs of both the mother and her infant.

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

NICU feeding

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.


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