Breastfeeding Late Preterm Babies

La Leche League Israel’s recent breastfeeding conference featured a talk by Dr. Larry Noble, a pediatrician who specializes in Neonatal-Perinatal Medicine. Dr. Noble, who practices in New York City, also serves on the Board of Directors of the Academy of Breastfeeding Medicine.

Dr. Noble brought up an issue that I knew little about: Late preterm (LP) babies. Sure, I knew to ask mothers at how many weeks their babies were born, and that the ones who arrived a little early were more likely to have “disorganized sucking.” But I didn’t realize the extent of the problems. Even more alarming, the number of late preterm babies is increasing every year.

Late pre-term (LP) babies are those born after 34 weeks and before 37 full weeks of gestation. After 37 weeks, a baby is considered full-term. LP babies look normal and may weigh within the normal range. Yet they have underlying issues that affect breastfeeding.

An increase in breastfeeding rates has highlighted the problem. When babies we are typically bottle-fed, the immaturity of late preterm babies wasn’t as noticeable.We are seeing problems both because of the increase in the numbers of these babies, and the increase in mothers who want to breastfeed.

Many mothers of full-term babies have difficulty breastfeeding in the beginning. But while a full-term baby may overcome poor breastfeeding in the first day or two, breastfeeding LP babies are often readmitted to the hospital with jaundice, dehydration, and hypoglycemia.

Why the increase in numbers of late preterm babies?

More late preterm babies have been born in recent years because of increased maternal age at birth, multiples, IVF (in vitro fertilization), cesarean sections, inductions, and the wish to avoid post-term problems (42+ weeks). One reason for the rise in cesarean sections is that the number of VBACs (vaginal birth after cesarean) peaked in the 1980’s and are rarely performed today.

Late preterm babies have three major areas of immaturity, all of which affect breastfeeding:

  • Brain: Brain immaturity may cause difficulty coordinating sucking and swallowing while breastfeeding.
  • Breathing: LP babies have more apnea (breathing interruptions). Breathing must also be coordinated with sucking.
  • Liver: LP babies have higher jaundice levels. In late preterm babies the bilirubin level initially rises at the same rate as full-term babies. After a standard discharge of 36 hours (in the US), the level in a healthy, full-term baby will go down. But levels in a late preterm baby may continue to rise. So unless there is followup, these babies have a high risk for kenicterus, brain damage caused by high bilirubin. Bilirubin binds with feces to exit the body, and if the baby is not getting as much milk as he should because of breastfeeding problems the bilirubin won’t be eliminated.

LP babies have twice the rate of SIDS and need more therapies in early childhood, but by school age they have mostly caught up.

Breastfeeding issues in late preterm babies include immature sucking efficiency, weak sucking pressure, low sucking frequency and inability to generate a milk ejection reflex (MER), immature swallowing, abnormal tongue movement, and breathing abnormalities. LP babies are sleepier. They need frequent, small feedings.

Less fat, thin skin:

LP babies have fewer layers of fat, and thin skin. They have trouble retaining their body temperature. These factors also make them more vulnerable to breastfeeding problems, dehydration, and hypothermia. Dressing warmly with hats and lying on the mother’s stomach are helpful.

A full-term baby has enough fat to overcome a poor feeding or two, but an LP baby may not. LP babies need to be watched carefully and may need additional food. If the baby is not getting enough from the breast, the mother can express her milk and give it to the baby. This will help keep up her supply and prevent infection and risk of disease, as well as ensuring that the baby is growing properly. If expressed milk is not available formula supplements may be necessary.

LPs in the hospital are treated like full-term babies, but they actually need extra supervision and followup. When breastfeeding LP babies are discharged after 36 hours, they have higher rates of readmission than breastfeeding fullterm babies, breastfeeding early preterm babies (small premies), and bottlefed LPs. The mothers of early preterm babies have time in the hospital to learn, and the baby is stable by discharge. This is usually not the case with LP babies.

The breastfed late preterm babies who spent even a few hours in the NICU have a much lower rate of readmission. However, this leads to separation of mothers and babies. Someone in the audience commented that at Tel Hashomer, they have a special NICU for LP babies, and Dr. Noble thought this was an excellent idea.

Mothers of Late Preterm Babies Have Their Own Problems

If you go back to the reasons listed for the increase in LP babies, you will note that the mothers often have their own health issues including diabetes, cesarean sections, hypertension, and multiple births. In ordinary circumstances we could tell mothers of late preterm babies to keep them nearby to nurse frequently. Mothers can express by hand or with a pump to keep up supply and feed the baby until the baby matures. But when the mother is being treated herself, this may be physically impossible. Dr. Noble described how many times a mother would be just about to nurse the baby, when she would be summoned to see her own doctor. Formula may be needed in situations where expressed milk is not available.

What Can Be Done to Help Late Preterm Babies Breastfeed?

Few factors that led to an increase in LP babies can be easily controlled, except perhaps the rates of induction and c-sections. So the numbers are likely to increase.

Consideration of the special needs of LP babies and their mothers may include later discharge, some type of modified NICU for LP babies, avoiding separation of mother and baby, more breastfeeding support and education, and better followup. All new mothers need support. But the mothers (and fathers) of late preterm babies need extra help, guidance and followup to ensure that breastfeeding gets off to a good start without compromising maternal and infant health.

Update: The Academy of Breastfeeding Medicine has produced a protocol for late preterm infants, that you can share with your health care providers.

More Breastfeeding Posts from A Mother in Israel:

Guest Post: Breastfeeding and the Working Mother

Ynet: Screaming Babies Ignored in Maternity Ward

Supply and Demand (Part of the Green Prophet Breastfeeding Series)

Modiin Mom Told to Nurse in Breastfeeding Room

Dr. Jack Newman in Israel: Heroin, Marketing and More

More Breastfeeding Posts

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Comments

  1. My sister gave birth to her 4th child at 28 gestational weeks – a baby girl who weighed 1.25 Kg. She had already breastfed her older 3 – for at least 2 years each and she was determined to breastfeed #4. It was a long painfull story – but after 5 (!!!!) months of pumping the baby was fully breastfed. She did not start actually nursing from the breast until she was the equivalent of 40 gestational weeks. My sister saw every lactation consultant in her state and tried EVERYTHING. But until she reached full term age – she just was unable to suck from the breast.

  2. Shoshana says:

    I was the mom of what you describe as a LP baby in terms of development – it was 38weeks gestation but as an IUGR baby, he was developmentally about 35 weeks.

    In my case, he wound up in the NICU for several days due to sever jaundice requiring a full blood exchange because of blood type incompatabilities.

    I was encouraged to try to pump and then to try to nurse but he simply couldn’t suck initially – we had the apnea spells and the lack of co-ordination you define above. and unfortunately i didn’t get great breastfeeding support services overall – there was no specially trained counsellor at the time in Tsfat hospital to help with babies like this.

    The one thing that saved our nursing was what goes ‘against’ the books but was suggested by one of the NICU nurses – namely nursing with soft plastic nipple shields (no idea of the name). For my son, at least, it was the clear cut answer to nursing and let him suckle for hours to help us build up my milk supply and get nursing off to a start – within 5 weeks, they were gone and nursing continued normally.

    I was very lucky in that i was able to stay in hospital until he was release (yay israeli medical system) – i had 5 days after my c-section and then they had me stay shabbat after since he was in NICU and they wanted me nursing as much as possible. No pressure of separation and i had 24×7 access to him – the same hospital has rooming in so i suppose the full NICU access was good to. (The only time I didn’t have access was during the 8-10 hours of the blood transfer and processing after).

    The other thing that really made nursing work was that it was my first child and i made nursing my full time job. I simply nursed all day and night, every day and night for 2 months. I was nursing for 45 minutes or more at a time every 2 hours or less since he simply had such a small stomach that he needed that frequency. By not being pushed to maintain a schedule, i was able to help him keep up his growth when he would have otherwise struggled. Thankfully i had great support from my Tipat Halav nurse, who had herself nursed a LP baby and who didn’t push anything about scheduling nor supplements but insted was super pro-nursing for the immune system benefits my early baby needed.

    shoshana

  3. why not pump and feed with bottles?

  4. mominisrael says:

    Ariela–5 months is a long time! Thanks for sharing her story.
    Shoshana–I remember being surprised that they let you get away with that. I heard a story about a mother of twins who was threatened to have her babies removed if she didn’t supplement them. I have no idea about the details.
    LoZ–I mentioned the reason toward the end–it’s because the mothers are often physically overwhelmed and have their own problems.

  5. MII:

    i understood you in the post to be referring to mothers that are being treated for their own health problems. i didn’t realize that this characterizes most pre-term mothers.

    or by “physically overwhelmed” did you also just mean that mothers are so busy and don’t have time/energy or can’t otherwise handle pumping?

    ???? ???

  6. that was shavu’ah tov. i guess hebrew doesn’t work on the new blog?

  7. mominisrael says:

    LOZ: I did update the post to be more specific about the pumping option. f course you are right and that is the preferred option.
    I don’t know what percentage of moms have issues that interfere with caring for their baby. Dr. Noble didn’t emphasize pumping. At least it didn’t make it into my notes.

  8. Katherine says:

    posts like this make me even more appreciative of the fact that my baby was born at a full 42 weeks, and at home. Well done to mothers of babies like these who do manage to persevere and breastfeed them – it sounds like a super human effort!

  9. This is indeed an important issue.
    One of the important things that can help, is that a proper lactation advisor be available to give such information to these mothers as soon as the baby is born, or at any rate while she is still in hospital. I do not think that this is the case yet in many places here in Israel. Even if the advisor is available, she does not work every day, or only goes to see people who ask for her.
    re Lion of Israel, while pumping could be a solution, it is 1. not easy to do, also the bast pumps are not easily available
    2. Some babies fed by bottles, later refuse to nurse, leading to further difficulties.

    • mominisrael says:

      Keren: Yes, while it’s improving there is still a limited amount of lactation services at most hospitals.
      Sometimes babies do get confused by the bottle, but it’s usually temporary.

  10. Speech therapists trained in feeding can also help babies with a weak suck and poor coordination of breathing, sucking and swallowing. It’s worth checking with the kupot about this, but make sure the speech therapist is trained in infant feeding.

  11. mominisrael says:

    Thanks, Baila, for mentioning this option.

  12. Mumtobubs says:

    Lion of Zion asked why mother’s of late preterm babies don’t just pump. There is a wide range of success. I had limited success, but it’s much more complicated than it sounds. I had ICP with my second child. We tried to make it to at least 37 weeks before inducing. But my numbers were escalating and I was becoming jaundiced. I made it to one day short of 37 weeks. He was fine at birth, but my health transitioned from ICP to gall bladder attacks. He lost 18% of his birth weight in short order. In Canada, I was admitted with him to the hospital. Due to my own health complications and his, we were frequently separated. The breast pump would be readily available one day and I’d have to throw a fit the next day. The LC and occupational therapist worked with me as he was failing to take bottles much less breast feed and we were having to tube feed him. He started screaming at breasts and bottles. It took a lot of work, but we got him to at least take a bottle and get out of the hospital. I exclusively pumped for a year. But after my experience, I understand why many women with a later preterm baby wouldn’t simply make pumping work. It was a harrowing experience watching how quickly health your infants health can deteriorate and seemingly fighting to give your breast milk that doesn’t appear to be helping.

  13. Lenora Baldonado says:

    Helpful post. Lucky me I discovered your website by indicent, I saved it so I can locate it next time.

  14. This post was very helpful in understanding that what I experienced after my last baby (for now…) was born is normal, and maybe we actually got away with easier than possible problems.
    I didn’t even know there was a specific term for babies born during these weeks.
    Mine was born at 35 weeks weighing just over 2 kilo so she was concidered OK. She was kept in the hospital only one extra day.
    I was determined to breastfeed her as I did my other five children for over a year each. At first it was awful! She was so weak, she would nurse for three minutes and fall asleep. I was worried her weight would drop below 2 kilos so I nursed her every 20 minutes, day and night. Being my sixth I could tell the difference in the way she sucked. I was tired and weak myself and trying to recover from a traumatic pregnancy but I didn’t give up until she finally started gaining weight.
    She is now ten months old and won’t stop nursing. Oh, and she now weighs close to 10 kilos!

  15. Mumtobubs, thank you for sharing your stories.
    Batya, I’m glad your baby is doing so well now.

  16. I had a less successful experience. My daughter was born at 35 weeks, with an uncomplicated, if unexpected, delivery after an uncomplicated pregnancy. Thank G-d, she was a little over 2 kg and had no health problems. The ward had a specific room for the tiny babies that didn’t need to be in the NICU, which I liked. She is my first, and I had no idea how to breastfeed. When I asked the nurse in the hours after birth to help me, I was told that it would be selfish of me to try to breastfeed because my baby needed nourishment and that was the most important thing. She handed me a bottle and I gave it, 2 hours after birth. I believed her then, and I’m not sure I disagree with the underlying sentiment there a year later, though the tone was unnecessary and she should have helped me. On the advice of a lactation consultant, I started pumping immediately and had no problems with that, getting enough supply to replace the formula within days. My daughter was in for 5 days to track her bilirubin and weight gain, and thank the Israeli medical system, I was able to stay with her. But there was little to no nursing support, even when I asked repeatedly. With the help of a lactation consultant, she was nursing from a silicone shield a few days after discharge, with the intention of weaning her off of it once nursing was well established. But within a couple of weeks, she started occasionally refusing to nurse, and then only nursing while asleep…by 3 months she had stopped eating enough to gain weight. After meeting with 4 different lactation consultants and a speech therapist who specializes in sucking, I gave up and switched to pumping. For a couple of months I was able to pump exclusively, but the supply didn’t keep up and I phased in formula. I stopped pumping completely at 10 months, at which point it was taking 3 pumping sessions to get one feeding. That came out super long. Anyhow, my daughter is thriving and beautiful,but I regret not having been able to nurse successfully.

    • Elisheva, thank you for sharing your story. Those early weeks sound like they were challenging.
      As for the nurse’s comment. I find it frustrating when health practitioners take decisions away from parents.
      While you did struggle and some of your problems were no doubt related to the early delivery, there was no way for the nurse to predict that.

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