Transition to the Breast
Infant's Need for Additional Supplements
Assessing Breastfeeding Success
- Breastfeeding at the breast may be very challenging for mothers and very low birth
weight (VLBW) infants. Many infants who
initially receive their mother's milk are not successful in the transition to feeding at
the breast. All mothers of preterm infants who breastfeed need support encouragement, and
knowledgeable help and advice.
- The problems associated with breastfeeding at the breast for VLBW infants are more
likely to be due to feeding limitations of the infant rather than maternal milk production.
- Advice that may be helpful to mothers of full-term infants may not be especially helpful
to mothers of VLBW infants, and standard counseling by lay support group members or
untrained health professionals may not work well.
- See section on "what parents tell us about
breastfeeding" and references by Meier and Brown,
Kavanaugh et al, Hill et al
(1994), and Hill et al (1997). For more information
about this experience from the family's point of view.
Hospital to Home
Mothers who plan to breastfeed need to express milk for a
prolonged time until the infant is ready to nipple at the breast. Even when the baby
starts to go to breast, milk expression should be continued to maintain the milk supply.
By the time of discharge it is often recommended that the mother pump enough to build up a
milk supply that is 50% greater than her baby will need. Most infants complete the
transition to complete nipple feeding after discharge from the hospital. For these
infants, it is often the case that the mother needs to continue expressing milk and that
the infant continues to receive some supplemental feedings.
The practice of feeding infants on a set schedule in the
hospital may not prepare a mother for more typical breastfeeding behavior. If possible,
more frequent nursing and/or rooming-in periods before discharge to home should be
Follow-up plans at discharge
Consultation with the same
lactation specialist prior to discharge, and shortly after discharge may facilitate
transition to home. It is sometimes recommended that the infant be weighed at the primary
care provider's office on the way home and again at 24 to 72 hours after discharge.
Frequent weights should be obtained until the weight-gain pattern is satisfactory. Incremental growth assessment will be a useful tool for
close monitoring. Plans for test weighing may be appropriate;
in which case families may need help obtaining an accurate scale before discharge.
Transition to the Breast
The transition to full breastfeeding involves three major issues:
Maternal milk supply depends
primarily on regular breast emptying provided by either the breast pump or the infant. If
the mother perceives that her milk supply is limited, the solution is to increase the time
spent pumping or the number of pumping episodes each day. Double pumps that allow
expression of milk from both breasts at the same time may increase prolactin levels and
enhance milk production. If the milk supply does not improve within three days, the mother
should be referred to a lactation specialist for a more thorough evaluation.
Maternal Let Down
The post discharge period is
usually found to be stressful for families of VLBW infants. Anxiety, stress, and fatigue
may interfere with maternal let down reflexes. Families may need to implement plans to
reduce these factors for the breastfeeding mother as much as possible. Often, lack of let
down is also related to the infant's weak and immature suck.
Infant's Feeding Skills and
There are several reasons that a VLBW infant's feeding skills and abilities
may be limited. Assessment of these skills and abilities should be routine in both
breastfeeding and bottle feeding infants. Feeding difficulties and skills are covered in
the section on assessment of feeding skills.
Need for Additional Supplements
Vitamins and Minerals
The breastfed VLBW infant will need vitamin and mineral
supplements. See section on supplementation recommendations.
Additional Energy, Protein, Carbohydrate, and Fat:
- When needed? When a mother's milk supply is low, or an infant's feeding skills or
endurance for feeding are inadequate to sustain growth, supplements may be needed.
Supplementation is a frequent occurrence in this population. The common advice offered to
families of full-term infants about avoiding supplements in the first weeks at home is not
safe advice for high risk infants.
- What to offer? Supplements may be expressed breastmilk, expressed breastmilk that
has been fortified to increase energy and nutrients, standard infant formula, or
concentrated formula. Human milk fortifiers (Enfamil Human Milk Fortifier
and Similac Human Milk Fortifier) are designed for gaining and growing premature infants in the
hospital. Because these two products contain high levels of vitamins A and D these
products should not be continued at the point where the vitamin D intake exceeds recommendations. This will occur at different weights depending on the content of the product. Please
see section on increasing formula concentration for more
information about energy content of potential additions to breastmilk and concentrating
formulas for additional feedings.
- How to deliver? Supplements may be delivered with additional bottle feedings,
offering the bottle after breastfeeding, or a supplemental
nursing system. An abstract suggests that Supplemental nursing systems may not work well for feeding preterm infants (Meier P. Pediatric Clinics of North America - Neonatology, #2344, 5/13/1999.) Although cup feeding is used in some settings, this method has not been shown to be an efficient feeding method for preterm infants. The choice of method will vary
based on maternal/infant needs, preferences, and the infant's feeding skills.
- When to deliver? If an infant is unable to sustain prolonged nippling due to
respiratory or energy reserve limitations, offering a bottle immediately post feed may not
be successful. In planning methods of supplementation it is useful to remember that
frequency of nippling at breast enhances milk supply and should be incorporated in the
In the long run, growth is the best indicator of breastfeeding success
During an individual feeding
Assessment of feeding effectiveness may be
difficult during early breastfeedings in the VLBW infant. In older infants, signs of
effective breastfeeding include rhythmic sustained suckling, audible swallow, softening of
the maternal breast and maternal signs of milk ejection.
The American Academy of Pediatrics has endorsed the WHO/UNICEF Ten Steps to Successful Breastfeeding guidelines (AAP Committee on Breastfeeding, 2012).
Infants should have more than 5 wet diapers a day. Super-absorbant
disposable diapers invalidate this method of assessing breastfeeding success.
Test weights for breastfed infants
gain may be a valuable assessment tool. Meier et al. (1994)
recommends a program of test weighing in the home for 2 to 3 weeks after discharge for
some infants. The basic steps of test weighing are as follows:
- Before hospital discharge, family obtains an accurate infant scale that can weigh in
grams for home.
- A minimum daily milk intake is prescribed in milliliters at the time of hospital
discharge. This is usually determined by an infant's energy intake and growth pattern in
- Family and health care providers make plans for appropriate supplement choice if it is
- After discharge family keeps records of pre and post test weights for each feeding. If
diapers are not changed between weights, a somewhat accurate indication of the amount of
liquid that was ingested can be made.
- At the end of a set period of time, say 6 to 8 hours, the infant's actual intake is
compared with the prescribed volume.
- If the infant consumes less than the prescribed amount, a supplementary bottle feeding,
preferably of expressed breast milk, is given as needed to make up the deficit.
- The plan for weights and supplemental feedings is frequently reviewed by a breastfeeding
specialist and or the primary care provider.
- When the infant has shown that he or she can gain weight steadily, the frequency of test
weights may be reduced. Daily weights may be recommended for a few weeks to assure
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Page reviewed: March 24, 2015