Breastfeeding the preterm infant

INTRODUCTION — 

Human milk is recognized as the optimal feeding for all infants because of its proven health benefits to infants and their mothers [1-3]. Human milk is particularly beneficial for preterm infants because of its protective effects against several comorbidities including necrotizing enterocolitis and late-onset sepsis. (See "Infant benefits of breastfeeding" and "Human milk feeding and fortification of human milk for premature infants", section on 'Benefits of mother's milk'.)

Direct breastfeeding of the premature infant, including strategies to address the challenges unique to the infant-mother pair, will be reviewed here. Other topics with related information are:

●(See "Human milk feeding and fortification of human milk for premature infants".)

●(See "Approach to enteral nutrition in the premature infant".) – Focuses on enteral feeds in the neonatal intensive care unit (NICU).

●(See "Breast milk expression for the preterm infant".)

●(See "Growth and feeding issues in the neonatal intensive care unit graduate".) – Focuses on feeding after NICU discharge.

In this topic review, we use the term "mother" to refer to the lactating person and "breastfeeding" to refer to feeding an infant at the breast or chest. However, we recognize that not all lactating people may identify as mothers.

PARENTAL COUNSELING AND SUPPORT — 

For families expected to deliver preterm, education about human milk feeding and direct breastfeeding can begin in the prenatal time period and extend through the neonatal intensive care unit (NICU) hospitalization (see "Breast milk expression for the preterm infant"). With regard to direct breastfeeding, mothers can be educated in the following:

●As a result of the infant's immature sucking ability, direct breastfeeding will be delayed after birth. Development of oral feeding skills takes time; it may be days to weeks before the infant is able to suck effectively and get enough milk to meet their needs. The timing is largely dependent on the infant's gestational age at birth and complexity of their NICU course.

●While the infant is developing early oral feeding skills, they can engage in "nonnutritive suckling" (suckling with little or no milk transfer). This promotes mother-infant bonding and ongoing lactation.

●Most premature infants will need some feedings with multinutrient fortifiers to meet their unique nutritional needs. This means that mothers need to express milk with a pump so that fortifier can be added and fed to the infant via nasogastric tube or bottle. In most cases, as the infant grows and matures, fortified feedings can be decreased over time and direct breastfeeding can increase, according to the mother's lactation goals.

DIRECT BREASTFEEDING FOR PRETERM INFANTS — 

Earlier gestational age at the time of first direct breastfeeding and more frequent breastfeeding episodes when preterm infants are gaining oral feeding skills are associated with longer duration of lactation [4-7].

Initiation of breastfeeding for the preterm infant (born <34 weeks gestation) involves the following steps:

●Assess readiness to feed based on oral behaviors and skills

●Initiate breastfeeding with guidance from a nurse or other clinician with training in lactation support to compensate for the infant's immaturity

●Support breastfeeding while also taking additional measures as needed to ensure adequate nutrition and growth

Readiness — There are no universally established criteria for when oral feedings for preterm infants should be started, and neonatal intensive care units (NICUs) utilize different protocols for initiating oral feeds. Most NICUs focus on using the infant's cues for feeding readiness as a key factor in determining timing [4,8,9].

For infants receiving positive pressure ventilation support (ie, noninvasive positive pressure ventilation or high-flow nasal canula), we generally avoid oral feedings because some studies show that such infants have risk of silent aspiration [10].

Gestational age — The earliest gestational age (based on postmenstrual weeks) at which preterm infants can successfully take oral feedings via breast or artificial nipple is variable. Many preterm infants can begin oral feedings at the breast as early as 31 to 33 corrected gestational weeks [4-7]. Suckling is similar to that of term infants, except that it occurs in shorter bursts. Some infants can take a portion of their feeds orally at an earlier age.

Oral behaviors — Postmenstrual age is an unreliable marker of infant oral feeding ability [11]. Oral behaviors, such as nonnutritive sucking and rooting, appear to be better indicators of readiness to feed. These behaviors may be present in some infants as early as 28 weeks postmenstrual age. For example, in a study of 71 singleton preterm infants (born between 27 to 36 weeks postmenstrual age), rooting, areolar grasp, and latch were observed at 28 weeks postmenstrual age and nutritive sucking at 31 weeks postmenstrual age [12].

Nonnutritive sucking/early suckling at breast — As soon as early indicators of readiness are noted, early suckling at the breast and nonnutritive sucking (eg, sucking on a pacifier) should be encouraged. Early and regular sucking attempts may enhance the transition from tube feeding to oral feeding by promoting maturation of oral feeding behaviors [13-17]. In addition, early suckling promotes maternal-infant bonding, may promote milk production by stimulating the nipple, and provides an opportunity to observe the infant's behavior and track developing oral skills as an indication of readiness for oral feeding. (See "Breast milk expression for the preterm infant", section on 'Suckling to provide tactile nipple stimulation'.)

Suckling at the breast is an optimal form of early sucking for preterm infants [18]. This is a form of nutritive suckling since some milk transfer occurs even when the mother has expressed her milk before the feeding attempt. For initial attempts suckling, the infant should be placed at the breast after the mother expresses milk. Although the infant should be held close to the breast, no attempt should be made to "position" the infant's mouth and gums over the nipple and areola. Instead, licking and suckling on the nipple tip is all that is expected during the initial sessions. When the mother is not available, nonnutritive suckling on a pacifier is appropriate. Providing small drops of colostrum or breast milk on the pacifier can enhance the infant's oral skills and also helps them to associate the taste and smell of the mother's milk with the positive oral experience.

Initiation of breastfeeding — When the preterm infant is deemed ready to begin oral feedings (eg, ability to locate and latch on to the breast), breastfeeding may be initiated directly. The breastfeeding technique is similar to that for term infants, but the mother requires specialized instruction and support from a nurse or other clinician with training in lactation support, including:

●Feeding cues – The parent(s) should learn to recognize the infant's feeding readiness cues (eg, drowsy/alert, rooting, hand to mouth) and signs to pause or stop feeding (eg, decreased tone, gagging, avoidance behaviors).

●Positioning – The cross-cradle (sitting) or clutch (football) positions are often best for preterm infants because they provide support to the head and neck (figure 1). These positions give the mother more control in placing the baby in an optimal position and maintaining the alignment of the infant's torso at the breast.

●Achieving an effective latch and milk transfer – Preterm infants tend to have low sucking pressure and immature suckling patterns, which present challenges for the infant to maintain an effective and sustained latch to the breast. Strategies to manage these issues include optimizing breastfeeding technique and positioning and/or use of a nipple shield. In some cases, milk ejection can compensate for marginally effective suckling because some infants can still consume an adequate quantity of milk during breastfeeding if the mother has a copious milk volume that flows readily. However, the latch and milk transfer will generally improve as the infant matures. (See 'Problems with milk transfer' below.)

High rates of milk flow may interfere with breastfeeding by less mature infants because their suck-swallow-breathe coordination is not fully developed. To assess for this issue, the clinician should evaluate the mother's milk supply and milk ejection reflex in addition to the infant's clinical status. This information will help guide the strategies for successful and safe breastfeeding.

If high milk flow rate is interfering with breastfeeding, the mother can reduce the milk flow rate by fully or partially expressing milk before each feeding session [14,19]. The reduced milk flow allows the infant to feed without a need for mature suck-swallow-breathe coordination or prolonged closure of the airway for swallowing. As the infant matures and develops a more mature sucking pattern, they will be able handle a greater milk flow rate and the mother will no longer need to express milk prior to the feeding.

Assessment of milk intake — In the initial stages of breastfeeding the preterm infant, clinical assessment of feeding behaviors, including observation of swallowing activity, may not be a reliable tool for measuring milk transfer [20-22]. Milk intake is best assessed by weighing the infant before and after breastfeeding. Benefits of test weighing were demonstrated in a comparison study of two NICUs, in which exclusive breastfeeding was attained at an earlier postmenstrual age in a NICU that used test weighing to measure milk intake compared with a NICU that used clinical observation to estimate milk intake [23].

Test weighing — The most reliable and accurate measurement of milk intake is test weighing based on the difference in weight before and after a feed, using a precise electronic scale that can weigh to the nearest 2 g [24]. Such devices usually automatically calculate milk intake from the prefeed and postfeed weights and can be rented for home use after discharge [25]. This approach has been demonstrated to measure milk intake accurately for term and preterm infants [26].

Milk intake, as measured by test weighing, can be used to modify feeding plans to ensure optimal growth. As an example, if test weighing after a breastfeeding session indicates that the infant has taken less milk than the goal, the remaining volume can be fed by gavage tube or bottle. This strategy is particularly useful during the early phases of transitioning to direct breastfeeding.

Insufficient milk intake, as demonstrated by test weighing, is usually due to immature feeding skills leading to poor milk transfer. However, in some cases, inadequate milk production can contribute to poor milk intake. This issue that can be identified by reviewing the mother's milk expression schedule and pumped milk volumes, which also allows for timely intervention to support milk production. (See "Breast milk expression for the preterm infant", section on 'Specific measures to optimize milk production'.)

Problems with milk transfer — Insufficient milk transfer during direct breastfeeding is defined as the inability of the infant to ingest an adequate milk volume (as indicated by test weighing) when the mother's milk supply is known to be adequate (as indicated by daily expressed milk volumes).

The main causes of insufficient milk transfer are:

●Immature infant suckling – Suckling immaturity is the most common cause of ineffective milk transfer in preterm infants [11,20,21]. These infants tend to generate low suction pressures during suckling and use short, irregular sucking bursts that may result in poor milk transfer and ineffective oral feeding [27]. The median age for achieving sufficient milk transfer for adequate growth is approximately 35 weeks postmenstrual age [9]. Some preterm infants achieve this milestone as early as 32 weeks postmenstrual age, although this is uncommon.

●Failure to trigger the milk ejection reflex – Another relatively common cause of insufficient milk transfer is difficulty eliciting the milk ejection reflex during early breastfeeding attempts. This problem may be related to antecedent use of a mechanical breast pump, which exerts higher suction pressure than the infant and conditions the breast to the higher suction pressure. Hand expression/breast massage and/or briefly pumping to stimulate milk ejection just prior to the breastfeed is an effective strategy. As the infant's sucking pattern matures, this problem should improve as breastfeeding progresses (usually as the infant nears term age).

●Difficulty sustaining latch – Because of their weak sucking pressures (-2.5 to -15 mmHg), premature infants may have difficulty maintaining attachment to the breast [19]. This issue can be addressed by using a thin-walled nipple shield, which facilitates sustained breast attachment [28,29]. After the infant begins to suck, a vacuum is created in the shield chamber and the negative pressure facilitates milk transfer. This results in an accumulation of milk within the shield chamber when the infant pauses between sucking episodes. When the infant resumes suckling, the pooled milk flows despite the low pressure generated by the infant.

The efficacy of a nipple shield intervention was illustrated in a study of 34 preterm infants, in which use of a nipple shield resulted in greater milk transfer compared with the previous feeding without a shield (18.4 versus 3.9 mL) [28]. The infant's tongue movement pattern is not altered by use of a nipple shield [27].

Mothers generally like the nipple shield because it often is associated with the first breastfeeding experience in which the infant remains awake, sucks eagerly, and consumes measurable volumes of milk. Data are somewhat conflicting regarding the effects of continued nipple shield use. One study found no effect on age at which exclusive breastfeeding was achieved in one analysis [4], another reported a negative effect on this milestone in another analysis (49 percent achieving exclusive breastfeeding with a nipple shield and 66 percent without) [30], and another found positive effects of continued use of the nipple shield after hospital discharge on duration of breastfeeding [28]. In the absence of definitive data, it is reasonable to individualize the use of a nipple shield and to encourage the mother to try breastfeeding with and without the nipple shield as the infant matures. Prolonged used of a nipple shield should be managed by a clinician with advanced training in lactation to assess for impact on milk supply.

Transition to full breastfeeding — The timing of the transition to exclusive breastfeeding depends on the mother's personal lactation goals, the infant's feeding ability, and any needs for ongoing fortification due to poor growth. During the NICU stay, the clinical staff and NICU policies can support the transition by encouraging the mother to participate in feeding and other daily care tasks, which enhance maternal self-efficacy and maternal-infant attachment. Teaching parents to recognize feeding cues and coregulate feedings with the infant also helps to improve feeding outcomes [31,32].

Modified demand-feeding schedule

●Rationale – Preterm infants do not demonstrate predictable demand-feeding behaviors until close to term (corrected age) [11,20]. Demand-feeding refers to feeding an infant based on their cues only, rather than at fixed time intervals. A preterm infant may not elicit cues consistently to enable intake of adequate volumes to maintain growth. Therefore, a modified demand-feeding schedule is most appropriate for these infants. This approach requires that the parent be present to recognize infant feeding cues and coregulate feedings in response to these behaviors, while setting a 24-hour minimal milk intake target as a safeguard against slow weight gain and/or dehydration. Limited evidence from a systematic review suggests that modified demand-feeding regimens were associated with an earlier attainment of full oral feedings compared with scheduled feedings [33].

●Implementation – To implement a modified demand-feeding schedule, the 24-hour minimal milk intake is calculated based on the infant's estimated caloric needs. Then, the mother breastfeeds when the infant shows feeding cues (ie, "cue-based" or "on-demand" feeding) and monitors the infant's actual milk intake at each feed using test weighing (see 'Test weighing' above). If the infant does not consume the target volume over the designated interval (typically a 12- or 24-hour period), extra milk is provided during the next interval to ensure adequate caloric intake and prevent dehydration. The extra milk is given by bottle, cup, or nasogastric tube (if in place). (See 'Supplementary feeds' below.)

This method allows the mother to breastfeed on demand during the hours that she is with her infant in the hospital. It also provides the clinician with the necessary information regarding whether the infant can maintain an adequate intake solely by breastfeeding and then modify the infant's feeding regimen in preparation for discharge. In addition, it allows the mother to observe the feeding cues, feeding patterns, and sleep habits of her infant in a controlled environment under the guidance of the NICU staff.

When implementing demand feeding, the mother may pump after each breastfeeding session to maintain her milk supply. Expressing this residual milk is important to ensure continued optimal milk production since the preterm infant is often unable to transfer the available milk in the breasts. In addition, the pumped milk can be stored for use in the supplemental feedings, when needed.

Supplementary feeds

●Indications – During the transition from partial to full breastfeeding, supplemental feedings may be needed for infants with inadequate milk intake, as determined by test weights and by monitoring the infant's overall weight gain. (See 'Test weighing' above.)

●Volume and type of supplement – The feedings should consist of expressed mother's milk whenever possible. Pasteurized human donor milk or preterm formula should be used only if the mother's milk supply is insufficient.

●Technique – Supplemental feeds are generally given by tube or bottle. Cup feeding has also been used in some controlled settings but should generally be limited to late preterm infants and with training of caregivers on appropriate technique to ensure safety and efficiency [34-38].

●Need for fortification – Mother's milk needs fortification to maintain growth for most preterm infants during the hospital period and for some infants with poor growth. Thus, some infants may need to have some feedings with supplemental fortification while they transition to direct breastfeeding. A shared decision-making approach between the infant's caregivers and clinicians should be used to develop a safe feeding plan that will meet the goals of the family while also ensuring adequate growth.

Vitamin D and iron supplements — Vitamin D and iron supplementation are recommended by the American Academy of Pediatrics in preterm infants who are breastfed [39].

●Vitamin D – Supplemental vitamin D (at least 400 international units [10 micrograms] daily) should be given to all human milk-fed infants, beginning during the first month of life and continued until the target intake is supplied by other components of the diet. This can be supplied by a human milk fortifier (which also provides supplemental calcium and phosphorus) or as a separate vitamin D supplement. (See "Management of bone health in preterm infants", section on 'Vitamin D requirements'.)

●Iron – For breastfed preterm or low birth weight infants, iron supplementation (2 to 4 mg/kg/day of elemental iron, maximum 15 mg) is recommended starting at two weeks of age and continued until adequate iron is provided from other sources (eg, from iron-rich complementary foods). For infants who are primarily formula fed, the formula provides sufficient iron. (See "Iron deficiency in infants and children <12 years: Screening, prevention, clinical manifestations, and diagnosis", section on 'Dietary recommendations'.)

Nearing hospital discharge — For discharge planning, milk supply and transfer continue to be the two main issues:

●Milk supply – The most important factor for mothers who will be breastfeeding a preterm infant at home is maintaining a milk supply that exceeds the baby's requirements at discharge [40-42]. An adequate milk supply results in a sufficient milk flow rate that can compensate for the infant's immature suckling. The mother's milk supply can be evaluated periodically over the course of the NICU stay by measuring pumped milk volume and/or infant intake in test weighing. If there is concern that the milk supply may be insufficient, steps should be taken to increase milk production. (See "Breast milk expression for the preterm infant", section on 'Specific measures to optimize milk production'.)

After discharge, mothers will need to continue to express milk after some or most feedings to remove residual milk until their infant is feeding more effectively and consistently at the breast. Although some mothers are anxious to reduce or eliminate the need to pump after discharge, it is important to include these instructions in the postdischarge feeding plan.

●Milk transfer – As discussed above, the use of nipple shields facilitates milk transfer and can be used after discharge in preterm infants who have immature suckling and difficulty in milk transfer. Anticipatory guidance should be provided on how to wean from the nipple shield as breastfeeding progresses. Strategies for weaning from the shield include: (1) beginning the feed with the shield in place and then removing and reattaching the infant to the breast to complete the feed, or (2) beginning the feed without the shield when the infant is more alert and then reapplying the shield toward the end of the feeding. We have found that most preterm infants are often able to wean from the nipple shield when they reach term gestational age. (See 'Problems with milk transfer' above.)

Infants who are unable to take sufficient feeds orally may require some tube feeding after discharge. This requires training of the mother or caregivers to do this safely as well as close monitoring of the infant's progress. In one study, earlier hospital discharge with tube feeding was feasible and was associated with an increased duration of breastfeeding compared with infants who were discharged later, after achieving full oral feeds [43]. (See "Breast milk expression for the preterm infant".)

For infants who have required an enriched diet to achieve adequate growth rates while in the NICU, fortified feeds should generally be continued after hospital discharge. This typically includes those with birth weight <1500 g or declines in weight-for-age Z-scores greater than 1.2 between birth and 36 weeks postmenstrual age. (See "Growth and feeding issues in the neonatal intensive care unit graduate", section on 'Enriched diet'.)

LATE PRETERM INFANTS — 

Late preterm infants (born between 34 weeks and 36 weeks and 6 days gestation) require specific attention for discharge planning and follow-up. Since many of these infants are discharged with their mothers following the maternity hospital stay or a short neonatal intensive care unit (NICU) stay, they may have had only limited clinical lactation support. Therefore, robust discharge and postdischarge planning is necessary to monitor the adequacy of direct breastfeeding progression and maternal milk production [44-47]. (See "Late preterm infants", section on 'Breastfeeding difficulties'.)

In addition to the management routinely used to promote breastfeeding in all infants, interventions during the birth hospitalization that specifically address breastfeeding issues in late premature infants include:

●Feeding assessment – The feeding assessment includes direct observation of the infant's latch to the breast; suck/swallow/breathing patterns; and behavior before, during, and after breastfeeding (see "Initiation of breastfeeding", section on 'Principles of breastfeeding'). Based on these observations, a plan should be developed in collaboration with the mother on the progression of at-breast feedings and the need for extra milk feedings. This may include test weighing procedures as a strategy to use postdischarge to monitor milk transfer and manage extra milk feedings. (See 'Test weighing' above.)

●Protecting maternal milk production – Mothers of late preterm infants must build their milk production concurrently with breastfeeding initiation and progression, unlike mothers of smaller preterm infants who have established their milk volumes during the NICU stay. One approach to promote milk volume is to use the "triple-feeding" technique during the first two weeks of lactation, which is a critical period for establishing milk production. Triple feeding consists of direct breastfeeding, followed by use of an electric breast pump, then feeding the infant with the expressed breast milk. This technique promotes milk production by maximizing breast stimulation and removing residual milk in the breast. However, this regimen can be exhausting for mothers and is not sustainable as a long-term plan. If the discharge plan includes triple feeding, this strategy should be reevaluated periodically and transitioned to a more practical plan when the infant is ready. As an alternative for mothers who are struggling with time constraints of "triple feeding," the mother may modify this technique by occasionally skipping a direct breastfeed and substituting pumping and bottle feeding. Although this approach is not ideal, it may allow a time-strapped mother to maintain lactation until the baby is more mature and can exclusively feed at the breast.

An alternative plan is to set a target volume for each 12- or 24-hour period and give supplementary feeds if the infant does not breastfeed well. This is similar to the modified demand-feeding approach described above [46]. To promote breast milk production, the mother should pump after a suboptimal breastfeed, if possible. (See 'Modified demand-feeding schedule' above.)

●Facilitative/compensatory strategies to improve breastfeeding – A variety of devices and techniques can be used to improve milk transfer during breastfeeding. These include modifying the infant's position to optimize attachment, using nipple shields to facilitate attachment to the breast and improve milk transfer, and providing at-breast supplementation with supply line feeder to entice latch and continued sucking. (See 'Problems with milk transfer' above.)

●Supplemental feedings – When supplemental feedings are indicated for late preterm infants, the optimal choice is mother's own milk. When the mother's own milk is not available, pasteurized human donor milk or commercial infant formula can be used. Supplemental feeds should be given only to those infants with documented inadequate milk intake (as indicated by test weighing) and/or documented low maternal milk supply. The supplemental feeds should be given in a limited volume and accompanied by lactation support and ongoing breastfeeding and milk expression sessions (to encourage increased milk production). (See "Initiation of breastfeeding", section on 'When and how to supplement with formula'.)

DISCHARGE PLANNING — 

Discharge breastfeeding planning for the preterm infant should take several factors into account:

●Mother's personal lactation goals – Some mothers desire to exclusively breastfeed, some choose to do a combination of expressed milk in bottles and direct breastfeeding, and some may choose a combination of mother's milk (expressed or direct nursing) and formula. These decisions may be influenced by maternal work, family support, and other competing factors. Discharge feeding plans should be made collaboratively with the mother and support people and be tailored to their goals and desires.

●Infant's needs – Assessment of the infant's feeding skills and any needs for ongoing fortification based on growth.

•Mothers should be provided specific guidelines on optimal feeding frequency, number of supplemental feedings if indicated, plans for ongoing use of nipple shields and/or test weighing if desired, and resources for postdischarge breastfeeding support.

•If the infant has not fully transitioned to direct breastfeeding or has marginal intake, recommend a plan for the mother to advance breastfeeding and protect her milk supply (triple feeding or a modified demand-feeding schedule, as described above). This approach ensures adequate intake while reducing the mother's workload and fatigue. (See 'Transition to full breastfeeding' above.)

●Follow-up care:

•Clear communication between hospital and outpatient providers about intended feeding plans that take into account the mother's lactation goals is crucial. This can be done through the discharge summary and/or any other communication tools. It is helpful to provide specific goals and parameters to guide the transition to more breastfeeding and reducing fortification with adequate weight gain.

•The first visit to the outpatient primary care clinician should occur within two days of hospital discharge to assess infant weight and feeding, evaluate for any signs of dehydration, and address any breastfeeding problems. For late preterm infants who are discharged within the first week of life, this initial visit should also be used to check for jaundice.

•For all infants, growth and feeding should be closely monitored for several weeks to months. (See "Growth and feeding issues in the neonatal intensive care unit graduate".)

•If possible, mothers should also be referred to an outpatient lactation specialist who is experienced in the needs of preterm infants.

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breastfeeding and infant nutrition".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Benefits of breast milk for premature babies (The Basics)" and "Patient education: Deciding to breastfeed (The Basics)" and "Patient education: Breastfeeding (The Basics)" and "Patient education: Pumping and storing breast milk (The Basics)" and "Patient education: Health and nutrition during breastfeeding (The Basics)" and "Patient education: Common breastfeeding problems (The Basics)" and "Patient education: What to expect in the NICU (The Basics)")

●Beyond the Basics topics (see "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)" and "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)" and "Patient education: Common breastfeeding problems (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Approach in preterm infants <34 weeks gestation – Implementation of breastfeeding for preterm infants <34 weeks gestation involves (see 'Direct breastfeeding for preterm infants' above):

•Assessing readiness – Breastfeeding depends on the development of sufficient oral skills for successful milk transfer from the breast. The timing of development of sufficient suckling ability varies among preterm infants. Many infants can begin direct breastfeeding as early as 31 to 33 corrected weeks gestation.

We suggest using the infant's cues (ie, oral behaviors such as nonnutritive sucking [sucking on a pacifier] and rooting) rather than relying on postmenstrual age to determine when breastfeeding can be initiated (Grade 2C). To reduce the risk of silent aspiration, we generally avoid oral feedings for infants on positive pressure ventilation support (ie, noninvasive positive pressure ventilation or high-flow nasal canula). (See 'Readiness' above.)

•Initiating breastfeeding – The technique for breastfeeding a preterm infant is similar to that for term infants, but the mother often requires specialized instruction and support, including how to identify feeding cues and help the infant latch on effectively. In some cases, the preterm infant with poorly developed suck-swallow-breathe coordination can only handle a small volume of milk. As the infant's oral skills mature and their ability to handle greater milk flow rates increases, breastfeeding can be advanced. (See 'Initiation of breastfeeding' above.)

•Assessing milk intake – During the hospitalization, the progression of breastfeeding is monitored by assessing milk intake. The most accurate measurement of milk intake is test weighing (ie, the difference in weight before and after each feeding). (See 'Assessment of milk intake' above.)

•Addressing causes of inadequate milk intake – Insufficient milk intake, as demonstrated by test weighing, is usually due to immature feeding skills leading to poor milk transfer. Management strategies include lactation support, use of a nipple shield to facilitate the latch, and gradual transition to full breastfeeding as the infant matures. However, in some cases, inadequate milk production can contribute to poor milk intake. (See 'Problems with milk transfer' above and "Breast milk expression for the preterm infant", section on 'Specific measures to optimize milk production'.)

•Transition to full breastfeeding – When the infant demonstrates the ability to consume all feeds orally, we suggest a modified demand-feeding schedule rather than scheduled feeding or ad libitum-demand feeding (Grade 2C). In the modified demand-feeding schedule, if the infant does not take the target volume of milk intake via direct breastfeeding, they are given supplementary feeds of breast milk (with or without fortifier) by bottle, cup, or feeding tube. This approach allows mothers to recognize infant feeding cues and coregulate feedings in response to these behaviors, while retaining a safeguard against slow weight gain and/or dehydration. (See 'Transition to full breastfeeding' above.)

●Late preterm neonates (34 through 36 completed weeks gestation) – Although late preterm infants are often able to be fully breastfed, they may experience difficulty in establishing successful breastfeeding because their orobuccal coordination and swallowing mechanisms may not be fully matured, risking maternal milk supply due to inadequate stimulation. These mothers and infants require expert instruction, close observation during the early phases of breastfeeding, and, sometimes, interventions similar to those used for more preterm infants. (See 'Late preterm infants' above.)

●Discharge planning and follow-up – Preterm and late preterm infants who are exclusively breastfed remain at risk for inadequate milk intake until approximately term-corrected age. Care after discharge includes close growth monitoring, continuation of the breastfeeding strategies used in the hospital until an acceptable growth trajectory is reached, and referral to lactation support programs and/or resources if needed. (See 'Discharge planning' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Nancy M Hurst, PhD, RN, IBCLC, who contributed to earlier versions of this topic review.