A preterm is a baby born prematurely before 37 weeks of pregnancy but the earlier a baby is born, more are the problems expected with each of its immature body organs. Delivering such babies at an appropriate facility, giving steroid treatment to the mother during pregnancy, delayed cord clamping, early respiratory support and starting early nutrition are some of the key interventions that have made it possible to save babies as premature as 25 weeks.

In an interview with HT Lifestyle, Dr Ganga Anand (PT) Obstetrics and Gynaecology - Paediatrics and Neonatology at Daffodils by Artemis in Gurugram, said, “Welcoming a preterm baby into the world can indeed be a very challenging journey, but breastfeeding provides a powerful opportunity for mothers to nurture their babies and build a strong emotional bond with them. Feeding a preterm baby requires more time and effort and patience and persistence is the key. Early initiation is the key and breastfeeding must be started as soon as possible after birth, even if your baby is in the neonatal intensive care unit (NICU). Kangaroo care, where you hold your baby skin-to-skin, can help in promoting bonding and breastfeeding. In the beginning, you might need to pump your breast milk since preterm babies might not be able to latch immediately. Colostrum, the nutrient-rich first milk, is very crucial for your baby's health and overall development.”

She added, “As your baby grows stronger, try transitioning from pumping to direct breastfeeding. Consult an expert who will guide you on optimal positioning and techniques to support your baby's latch. It is important for new moms to maximise skin-to-skin contact as much as possible. This practice not only encourages breastfeeding but also helps in promoting emotional bonding and helps regulate your baby's body temperature and heartbeat. Preterm babies might have a smaller stomach capacity and therefore are needed to be fed more frequently. Establish a feeding schedule with the guidance of your pediatric expert, to ensure that your baby gets the necessary nutrients. Regular weight checks help in ensuring that your baby is receiving adequate nourishment. Besides all this, mothers should focus on having a nutrient-rich diet that supports your milk production. Hydration, balanced meals, and appropriate supplements can help meet your baby's nutritional requirements.”

Kavita Singh, Lactation Expert and Physiotherapist, revealed, “Feeding a preterm baby is a journey with different stages and many challenges. Babies born this early won't be able to coordinate suck, swallow and breathe. In the beginning, your baby will receive very small amounts of milk because their digestive system is not ready yet. New mothers can ensure a continuous supply of milk by pumping as it helps to stimulate the breast and helps to produce more milk for the baby. As your baby gets more stable, the first step is to get them used to being at the breast. Mothers should also practice kangaroo care or skin-to-skin, which can happen early on and as the baby gets a little older, they can start to do what's called nonnutritive sucking (NNS) and that's just getting the baby to an empty breast. Ideally, pumping should be done every two to three hours, a minimum of eight times daily, and at least once at night. With continued pumping, the milk supply will start to increase. Mothers can also do hand expression to get the milk out by massaging and compressing the breast. And especially for colostrum, which is quite thick, it can be helpful to get that milk out. It is also important to get the right support once the baby starts latching on the breast actively and lactation counsellor can help. Learning the right techniques and oro-motor exercises can help to build a good breastfeeding relationship with the premiee.”

Breast milk: The elixir of life

The importance of breast milk for a human baby cannot be over-emphasised. Dr Mahesh Hiranandani, MD (PGI), Senior Consultant Paediatrician and Neonatologist at Cloudnine Group of Hospitals in Chandigarh, shared, “It is easily digestible and contains all essential nutrients (for optimum growth), anti-infective substances (for protection against infection from birth), hormones, and growth factors (to regulate metabolism). For decades all scientific bodies, including the WHO have recommended the ‘Golden Hour’ advantage of providing mothers milk to all babies, of any size and any gestation, within the first hour of their birth.”

The smaller the baby, more enriched the nutrition required

Dr Mahesh Hiranandani revealed, “If the baby is very small or premature it may not be possible to provide breast milk directly by breastfeeding and thus, they require alternative feeding methods, both in the hospital and at home. Premature milk is higher in proteins, minerals and fats which ensure optimum ‘Catch up’ physical growth and brain development.”

Collection, storage and transport of milk for a preterm baby

Dr Mahesh Hiranandani advised, “Breast milk expression should be initiated as soon as possible after birth to provide the preterm baby with colostrum often called the first immunisation of a baby, since it is enriched with live immune cells and antibodies. Collecting milk for a preterm baby can be challenging. However, with a little effort, most mothers can provide their baby with the best possible start in life. Premature babies are often separated from their mothers for a variable period, which makes feeding their mother’s milk to them an unphysiological process.”

Highlighting that most hospitals have a policy to encourage mothers to express milk manually or through a manual or electric breast pump, readily available commercially and in all hospital nurseries, he explained, “The milk is collected in a sterile cup for immediate use or in clean and closed stainless steel or glass containers for later use and transported to the nursery in a cool box. It can be refrigerated to use within 24 hours and even frozen to use up to 6 months. It is essential to express breast milk completely every 2 to 3 hours to provide an adequate milk supply and prevent breast engorgement. The application of a hot compress helps in milk expression by softening the breasts and dilating the milk ducts. In case of pain due to engorgement, mothers can use a mild analgesic, like paracetamol, before expression. To maintain a good milk supply, mothers are encouraged to provide kangaroo care (naked skin-to-skin contact) that not only enhances milk letdown, but also helps in better weight gains of babies.”

Feeding process inside Neonatal ICU

• Premature babies have small stomachs, so they can only handle small amounts of food at a time. Hence, they are initially given 1-2 ml of expressed breast milk/donor human milk per feed and this amount is gradually increased over 5 to 7 days to reach full feed.
• Premature babies do not have any energy stores, and hence are given measured quantities of feeds and intravenous fluids to maintain their sugars in normal ranges. Feed intolerance leading to vomiting and abdominal distension is common due to immaturity of the digestive system.
• Once on full feeds, they are provided supplements (Vit D, Calcium, Iron & Vitamins) which kickstart the process of weight gain and catch-up growth.
• The entire process is slow with many turbulent events, hence the need for support and guidance of the naïve parents by an empathetic health care team. Transitioning from tube feed to spoon feeds, some babies may take longer to coordinate the suck-swallow reflex, which develops by 34 weeks. Patience is the key to tide over this anxious period.
• At 34 weeks maturity and an approximate weight of 1400 grams, babies may be allowed to feed on an empty breast (non-nutritive sucking) to check on their suck-swallow-breathe abilities and stimulate the process of milk let-down. Direct breastfeeding can be started only after the baby has developed a robust suck and swallow reflex and weighs more than 1700 grams.

Is there anything that can improve the milk supply?

Dr Mahesh Hiranandani suggested some tips to improve the milk supply:

• Adequate liquid intake of 4-5 litres/day (All healthy nutritious liquids)
• A balanced diet of grains, pulses, vegetables, fruits, milk & poultry
• Avoid excess sugars, spices, fatty foods & alcohol
• Adequate sleep as and when possible.
• Avoid too many visitors (Mother & Baby need privacy for feeding)
• Iron, Calcium, Vitamin D & zinc supplements to be taken for 6 months
• Bond with the baby by talking, holding, singing

Avoid the temptation to bottle feed at all costs!

Dr Mahesh Hiranandani asserted, “It is crucial to avoid using a bottle for giving expressed breast milk to newborn babies, especially in the first month of life as it may lead to nipple confusion, as the techniques of sucking at the breast and bottle are very different, the latter being easier and quicker. The babies thus prefer to feed from the bottle than the breast and may refuse breastfeeding later. This leads to failure of breastfeeding, despite an adequate milk supply. In addition, the risk of getting diarrhoea and other infections is higher in infants who are bottle-fed.”

He concluded, “Once breastfeeding is initiated, it may be attempted for short periods on an empty breast and slowly graduate to feeding from a full breast. Allowing the baby to lick on milk applied to the nipple may aid in latching to the breast. Ensure that the nostrils are not obstructed by the breast during feeding and experiment with different positions for nursing till the one most comfortable for the baby and mother is identified. Most preterm babies are fed every 2 to 3 hours till they reach a weight of 2.5 kgs when they can be shifted to demand feeding. It is important to ensure that the baby is alert, awake, and calm while feeding. Breast milk is the best gift you can give your baby. It is a gift of love, health, and happiness.”