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.
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