Breastmilk and breastfeeding are the optimum form of nutrition for preterm babies. The successful transition from nasogastric feeds to full breastfeeding requires individualised assessment and care planning for each baby. The purpose of this guideline is to assist clinicians to facilitate this transition by utilising a baby led approach.

Babies transitioning from nasogastric feeding to breastfeeding (and their mothers) receive individualised, evidence based care by all involved staff.

Non-nutritive sucking: Uncoordinated sucking without swallowing milk, usually at a rate of 2-3 sucks per second. NNS enhances maturation of feeding skills, improves the transition to breastfeeding, and is associated with longer breastfeeding duration and decreased length of stay. It is soothing and assists in the attainment of the quiet alert state.

Nutritive sucking:  Rhythmic sucking and swallowing, usually at a rate of about 1 suck per second and a suck swallow ratio of 1, 2 or 3:1. Nutritive sucking is a natural progression from NNS as oral motor behaviours develop and suck / swallow coordination matures. This may be seen from as early as 28 weeks gestation and as the baby matures, the ability to coordinate sucking, swallowing, and breathing improves.

Kangaroo Care (KC) This is a method of caring for babies involving early, frequent and prolonged skin-to-skin contact (SSC) between the parents (usually the mother) and their baby. KC is known to increase the successful establishment of breastfeeding. It also promotes mother/infant and father/infant bonding, improves physiological stability and enhances development of the baby.

Abbreviations

NNS - Non-Nutritive Sucking

SCN - Special Care Nursery

SSC - Skin-to-Skin Contact

LBW - Low Birth Weight

BHS - Ballarat Health Services

BF - Breastfeed/Breastfeeding

All midwifery, nursing and medical staff providing care to babies within the scope of this guideline have the responsibility to utilise this guideline to provide evidence based care.

This guideline relates primarily to preterm babies in SCN but may also be relevant to unwell babies in SCN and the paediatric unit, babies on the postnatal ward or those receiving care as an outpatient.

This guideline will facilitate evidenced based care but should not replace individualised assessment of each mother/baby.

Guideline and principles of care

The following evidence based practices have been found to enhance the successful transition to full breastfeeding for preterm babies:

1. Establish & maintain adequate maternal breastmilk supply

2. Facilitate early and frequent skin-to-skin contact, breast contact and non-nutritive sucking.

3. Provide frequent breastfeeding opportunities when the baby demonstrates readiness to feed.

4. Give developmentally supportive care, including minimising negative oral stimuli.

5. Transition to cue-based, semi demand / baby led feeding

6. Encourage extended maternal presence and parental participation in care and discharge planning.

 1. Establish & maintain adequate maternal breastmilk supply - Low breastmilk supply is the number one reason why mothers of preterm or sick babies cease breastfeeding.

• Refer to BHS CPG0186 Breastfeeding-expressing, storing and feeding for guidance on effective expressing for mothers of preterm babies

• Provide parents with information on breast pump hire both in SCN and the community (pamphlet "Hospital-Grade Electric Breast pump Hire).

• Provide parents with consumer information booklet "Breastfeeding and Expressing in Challenging Circumstances".

• Aim for abundance. An adequate breastmilk supply is 600 -1000mls in 24 hours by 2 weeks for singletons and 1000-2000mls in 24 hours for multiples.

• Review expressing frequency/technique and offer a Lactation Consultant referral to mothers expressing <500mls in 24 hours at 2 weeks, <1000mls for multiples.

2. Facilitate early and frequent skin-to-skin contact, breast contact and non-nutritive sucking (NNS)

• Skin-to-skin contact (Kangaroo Care) enhances the development of feeding capabilities and positively influences the transition to breastfeeding. Refer to CPG0217 Kangaroo Care.

• Initiate breast contact and non nutritive sucking (NNS) when the the baby is stable, regardless of weight and gestational age.

• Allow spontaneous NNS at the breast during kangaroo care. Do not pressure the baby to attach or suck at the breast.

• If spontaneous nutritive sucking occurs, allow to continue as long as baby does not show signs of stress.

• Tasting and smelling breastmilk provides important sensory stimulation for the preterm baby and may enhance the development of effective feeding behaviours.

  • Express drops of breast milk onto the baby's lips, allowing the baby to lick and taste.

  • Use expressed breastmilk (EBM) on a cotton stick for mouth care and on pacifiers during NNS.

  • Place drops of EBM on the lips during kangaroo care and nasogastric feeds.

• Place a cotton stick/cotton ball soaked in EBM 1-2cms from baby's nose several times a day during gavage feeding and just before any breastfeeds. This has been shown to improve sucking effectiveness and decrease time taken to transition from NGT to breastfeeding. If mothers milk supply is low a breast pad worn by the mother may also be used.

• With parental permission allow NNS on pacifier during nasogastric feeds.

3. Provide frequent breastfeeding opportunities when the baby demonstrates readiness to feed.

3.1 Assessing Readiness to breastfeed

Breast contact and breastfeeding should be initiated without limitations when the baby is medically stable and exhibiting signs of readiness to suck regardless of gestational age and weight.

Individualise assessment of readiness to feed and base decisions on this rather than taking a generalised approach. All babies differ.

Signs of readiness to suck may include:

• exhibiting rooting reflex, gaping, mouthing, swallowing own saliva,

• sucking on feeding tube or fighting feeding tube,

• bringing hand to mouth, sucking on fingers, fist, pacifier, licking lips,

• awake and alert at feed times or demanding feeds before scheduled time,

• Note: crying is a late sign of hunger and may result in uncoordinated sucking and fatigue, even in a term baby.

 3.2 Introducing breastfeeds

INTRODUCTORY SUCK FEEDS ARE TO BE AT THE BREAST ONLY. Bottle feeds are NOT to be introduced at this stage (refer to bottle feeds for breastfed babies, section 14 below)

• Offer breastfeeds whenever baby displays feeding cues and mother is present regardless of scheduled feeding times.

• Offer alternate breasts to promote feeding from both sides

• Provide education to the mother regarding early learning stages of breastfeeding, such as licking, nuzzling, attaching to the breast for a few short sucks and falling asleep easily.

• Document outcome of feeds as per the Breastfeeding Codes on MR/450.0 Infant Care Chart

 3.3 Positioning and attachment for preterm babies

• Use supportive positioning such as transitional and football hold; this helps to compensate for weak neck and jaw musculature and a heavy head in relation to body weight.

• The Dancer Hand technique may help to prevent the baby slipping off the breast during pauses in sucking.  Using her free hand, the mother supports her breast and the baby's chin. The chin is supported in the curve of the mothers hand between thumb and first finger. When the baby pauses during breastfeeding, the support from the mothers hand helps keep the lower jaw from falling away from the breast.

• The breast may need to be supported throughout the entire feed with the cupped hand or a rolled cloth.

4. Use developmentally supportive care

• Observe for appropriate state behaviour, stability or stress cues. The quiet alert state is the most conducive to successful breastfeeding. In the quiet alert state the baby has:

  • wide bright eyes, focused gaze, dilated pupils, attention focused on stimulus

  • regular respirations and heart rate

  • rhythmic sucking

  • reaching or grasping, hand to mouth movements,

• Allow feeds to continue as long as the baby shows signs of stability.

• Ensure baby is safe for oral feeds and look for signs of aspiration which may include coughing, choking, change in respiratory rate, increase in work of breathing, change in colour or decrease in oxygen saturation

• If a baby exhibits signs of stress while breastfeeding, remove from the breast, provide skin to skin contact and allow the baby to re-organise before offering the breast again.

• Be aware that the baby may not feed well after events such blood sampling or medical examination and KC will assist the baby to re-organise and rest.

• Stress signs during feeding may include:

  • colour change, mottled skin,

  • cough, splutter or gag

  • desaturation or increased oxygen requirements,

  • change in state of alertness,

  • tachycardia or bradycardia,

  • arching, stiffening, finger splaying, fussing and crying,

• If the baby does not return to the quiet alert state, the feed should be given by nasogastric tube while the baby is held skin to skin against the breast.

5. Transition to cue-based, semi-demand/baby-led feeding

5.1 Assessing milk transfer during breastfeeds and the need for top up feeds.

Accurate assessment of breastfeeds is important in determining the need for top ups and for planning subsequent breastfeeds.

Signs of milk transfer include:

• the baby is well attached and the whole jaw moves rhythmically as the baby sucks,

• swallowing is seen and sometimes heard,

• the mother may feel a let down or a drawing sensation,

• the baby appears satisfied after the feed (not to be confused with fatigue).

Other points to consider in assessing milk intake include:

• all babies have different sucking patterns, therefore timing a breastfeed may not provide an accurate assessment of milk transfer

• the mothers milk supply and flow; a good supply and flow will more likely result in better milk transfer

• gestation, corrected age, weight, medical issues

• assessment of weight gains and output over a 48 hour period

Following each breastfeeding attempt assess the need for a top up:

• Use "A guide to top-ups after breastfeeds for preterm and unwell babies" (Appendix 1) to assess the need for and amount of a top up.

• If unsure about whether to top up or not, and mother is available for the next feed, consider withholding top up. The baby may wake sooner for another feed.

• Top up feeds should preferably be given by nasogastric tube or finger feed until breastfeeding is well established (see use of bottles below).

• Give top up feeds while baby is still held at the breast if mother is still present.

5.2 Increasing the number of breastfeeds

Ongoing assessment of the baby's responses before, during and after feeding and consideration of the baby's medical condition are necessary to provide individualised planning for each baby.

• Breastfeeds may begin with 1-2 per day and increase as determined by individual assessment.  At all times be guided by each baby's own feeding cues, feeding effectiveness and developmental stability.

• Babies with chronic lung disease, neurological or cardiac disease may require a slower progression of breastfeeds than well preterm babies.

• When the baby is having 2-3 breastfeeds per day consider alternating breastfeeds and nasogastric feeds, or two nasogastric feeds : 1 breastfeed.

• Document and communicate feeding progression and plans at each handover.

5.3 Moving to baby led feeding/semi demand feeding

Documented feed plans and parental involvement are vital in successfully transitioning from scheduled to baby led feeds. Individual assessment and a multidisciplinary approach should determine when this may occur rather than gestation alone.

When baby is ready to progress from 3 hourly feeds consider rooming in for a couple of nights to offer baby led/semi demand feeding over 24-48 hour period. If rooming in facilities are unavailable or mother is not able to stay overnight baby led/semi demand feeding may occur during the day while the mother is present. The baby may be nasogastric tube fed when mother is not present, using a pacifier with parental permission if the baby wishes to suck.

The baby may be ready for baby led/semi-demand breastfeeding if they:

• Are medically stable with no concerns regarding hypoglycaemia

• > 34 weeks, gaining weight and tolerating 3/24 feeds

• Able to wake spontaneously for feeds, are alert and regularly demonstrating hunger cues

• Able to attach and suck well at the breast at least 3-4 times per day

• The mother is available for extended periods during the day and/or rooming in facilities are available for night feeds.

Baby led/semi demand feeding:

• Observe for signs of readiness to feed and offer breastfeeds when the baby exhibits quiet alert state and feeding cues regardless of length of time since last feed or when the next feed is due. 

• Allow baby to have unrestricted baby-led, cue based access to the breast while mother present but ensure at least 8 feeds per 24 hours - use white board to track 8 feeds each 24 hours.

• Allow one 4 hour gap overnight if baby has fed well during the day and there are no concerns about weight gains and output

• Offer top-ups if required as per "A guide to top-ups after breastfeeds for preterm and unwell babies" (Appendix 1)

• If baby is not ready to feed by 3 hours, allow to sleep for another 30 minutes

• If baby is not ready to feed by 3.5 hours the following may bring the baby to a quiet alert state:

  • Soak cotton buds in expressed breastmilk and place near babys nose,

  • Skin to skin and breast contact, NNS at the breast or on a pacifier,

  • A taste of EBM from the breast, spoon, cup syringe.

• If baby is not awake by 4 hours and does not breastfeed, feed by nasogastric tube (4 hourly volume)

• Monitor output and weight gains

Consider returning to 3 hourly feeds if:

• baby is feeding less than 8 times in 24 hours

• output is inadequate

• weight gain is <10gms/kg/day on 2 occasions

• baby is sleepy and frequently requiring 4 hourly gavage feeding.

• baby is tiring and not able to complete feeds

 5.4 The sleepy baby

Observe for subtle feeding cues, and then follow the steps below as guidelines for gently waking and breastfeeding a sleepy baby

• Unwrap baby and allow to self stimulate for a few minutes.

• Undress baby and place in skin-to-skin contact with mother

• Provide gentle massage over the baby's body, back and front.

• Drop some EBM onto the baby's lips or give a small amount of EBM by finger feed

• Some babies may show signs of fatigue or shut-down from over-stimulation. If this occurs give skin-to-skin contact to allow the baby to recover and then start again, or feed by nasogastric tube.

5.5 Use of bottles for breastfed preterm babies key points

Bottles and teats are to be avoided while breastfeeding is being established and should not be offered to breastfed babies less than 34 weeks gestation

• The World Health Organisation Baby Friendly Health Initiative Neonatal Standards recommend that alternatives to bottles should be used at least until breastfeeding is well established for preterm babies

• There is no evidence to support introducing bottles to teach healthy preterm or term babies to suck at the breast.

• Early breastfeeding is less physiologically stressful than is early bottle-feeding. The baby has a greater ability to control the flow of milk during breastfeeding, and has more stable patterns of oxygenation.

• Supplementing babies with nasogastric tubes rather than bottles increases the likelihood of full breastfeeding on discharge, at 3 months and 6 months without prolonging length of stay.

• The use of pacifiers for NNS during nasogastric tube feeds is associated with improved feeding tolerance and increased weight gains for LBW babies and may meet the baby's needs for sucking during the transitional period thereby avoiding the use of bottles.

Possible indications for introduction of bottle feeds

There are some situations where the use bottles and teats may be initiated after discussion between multidisciplinary team members (including a lactation consultant) and parents.

• The baby is effectively breastfeeding at least 4 times per day. Ideally in this situation the mother is encouraged to room in and offer full breastfeeds over a 24 hour period.

• The baby is effectively breastfeeding but is asking for more frequent sucking feeds than the mother can be present for.

• The mother has chosen to provide expressed breastmilk but does not intend to breastfeed or continue lactation.

• There are prolonged difficulties in attainment of effective breastfeeding particularly where there are coexisting medical morbidities such as chronic lung disease, cardiac disease, neurological conditions and parents have requested bottle feeds. 

• Parents have explicitly requested bottle feeds after discussion regarding:

  • individual needs of the baby, the parents wishes and any medical and feeding issues.

  • the possible difficulties and risks associated with bottles and teats

  • the continued use of nasogastric tube feeding and supplementation as an alternative.

  • documentation of the above has been made in the clinical notes and the infant care chart.

 5.6. Use of nipple shields

• A nipple shield may be considered in the following situations:

  • the baby is repeatedly unable to attach and suckle effectively or constantly slips off the breast despite supportive positioning, skilled assistance and assessment of breastfeeding.

  • the mother has very flat, fibrous or inverted nipples making attachment difficult.

  • babies with cardiac disorders or chronic lung disease who may tire easily.

• Before introducing a nipple shield, breastfeeding should be assessed by a midwife or nurse experienced in breastfeeding management or a lactation consultant.

• The mothers milk should be in prior to initiating a nipple shield (usually >60 hrs after birth).

• Assess milk transfer and breast drainage during use: the baby may require supplementation when initially learning to use a nipple shield.

• Document the use of the nipple shield on the infant care chart.

• Parents should be given BHS information pamphlet "Using a Nipple Shield" pamphlet

• Arrange follow up with a Lactation Consultant for mothers of babies who are using a nipple shield on discharge home

5.7 Indications for referral and evaluation by medical officer and multidisciplinary team members including speech pathologist, lactation consultant, developmental therapist, dietician

• Babies > 34 weeks who are not showing signs of readiness to feed.

• Delay or regression of oral feeding skills.

• Inability to achieve and maintain effective attachment despite readiness to feed.

• Consistent tiring at the breast, sucking poorly with inadequate milk transfer.

• Evidence of stress during breastfeeds, tachypnea or apnea with feeding, increasing oxygen requirements.

• Signs of aspiration which may include coughing, choking, change in respiratory rate, increase in work of breathing, change in colour or decrease in oxygen saturation

• Poor weight gains and inadequate output.

• Suspected gastroesophageal reflux, pain associated with feeding.

• Recommendations following medical or multidisciplinary review should be discussed with parents, documented on the feeding plan, communicated at handover and reviewed daily and at doctors rounds

6. Encourage extended maternal presence and parental participation in care and discharge planning

6.1 Feed planning

• Discuss feeding plans at least daily with the mother /parents and document on the infant care chart

• Encourage the use of white boards to communicate when mother will be offering breastfeeds and kangaroo care

• Encourage the mothers extended presence when moving to baby led feeding. Reassure her that she can offer breastfeeds outside of scheduled times whenever her baby is showing signs of readiness to feed

• Facilitate privacy and comfort during skin to skin contact and breastfeeding by providing comfortable chairs, footstools, pillows, drawing curtains where possible

• If the mother has planned to be present at a particular time for a breastfeed and the baby is hungry earlier than planned, do not feed the baby without contacting the mother first. Phone her to let her know the baby has woken earlier and to see when she is likely to arrive. The mother may elect to come in earlier or direct staff to feed the baby for her if this isnt possible. Soothe baby with pacifier or give a very small amount of EBM while waiting for mother to arrive

• Ensure that the mother is aware of the parent lounge, accommodation and meal options, cafeteria and local food outlets

 6.2 Breastfeeding support

• The mother should be provided with breastfeeding support throughout her baby's stay in SCN. Refer mother to a Lactation Consultant where appropriate

• Give mother copies of relevant BHS information pamphlets appropriate to her need - refer to related documents

• Teach mother independent positioning and attachment skills utilising dolls and breast models and a hands off technique

• Build parental confidence in recognising and responding to feeding cues, recognition of effective breastfeeding and how to tell if her baby is getting enough breastmilk when fully breastfeeding

• Build parental confidence in the use of gentle, developmentally supportive settling skills

6.3 Transition to full breastfeeds and discharge

Preparing for discharge

• Once the baby is breastfeeding well at least 4-5 times per day, consider rooming in to facilitate baby led/semi-demand BF over a 24-48 hour period

• Encourage unrestricted breast access and at least 8-10 breastfeeds in 24 hours.

• Assess feed effectiveness, output and weight.

• Teach parents how to assess feeding effectiveness and the need for top up feeds

• Encourage mother to continue expressing after most breastfeeds (at least 6 in 24 hours)

• Enable and encourage parents to provide most care of the baby with guidance from staff.

• At discharge, if required, provide parents with a written feeding plan & offer a 1 week follow up appointment in the Breastfeeding Support Clinic

Criteria for discharge

• Baby has been able to suck all feeds at the breast (or by a combination of breast and bottle if required) for a period of 48 hours.

• Appropriate weight gain during this period. (weight gain of at least 10gms/kg/day)

• Baby has reached a weight of 2200gm, or at the discretion of medical staff

• Follow up services (e.g. Dom care, MCHN, Allied Health if required) are arranged within 24-48 hours after discharge

Ongoing BF management

• If still expressing at discharge, the mother can gradually reduce the frequency as effective breastfeeding increases. The main principle is to slowly reduce expressing according to feeding progress and the degree of breast comfort, observing for signs of blocked ducts and mastitis. How quickly this happens will vary widely

• As a general rule, many mothers will need to continue expressing 2-4 times a day until the baby is around 3000gm and/or 40 weeks corrected age when feeding becomes more effective

• If the baby is still requiring top-ups after breastfeeds, express as often as required to collect EBM for top-ups

• Refer to a Lactation Consultant where appropriate for a written feeding plan including expressing advice at discharge and/or when baby exclusively breastfeeding

• Ensure mother has contact details for Parent Place, BF support clinic and Australian Breastfeeding Association 24 hour helpline before discharge