Help! My baby can't breastfeed.

Many pregnant women daydream about holding and feeding their newborn babies. But this dream doesn't always come true when a baby is born prematurely and whisked off to an intensive care nursery equipped with special equipment, doctors and nurses.

In such circumstances, parents typically experience mourning reactions similar to those occurring with a death of a child. Even if the parents are assured that the baby is in good condition, they may feel grief over the loss of their "dream baby." Parents often feel a sense of loss at being unable to perform even routine care like feeding, bathing and diapering their infant.

First steps toward breastfeeding

The mother of a preterm infant can actively contribute to the recovery, growth and development of her child by expressing (pumping) breast milk and bringing it to the hospital. The breast milk is frozen until the premature baby is able to receive oral feedings.

Due to an immature digestive system, weak or absent suck reflex, breathing difficulties and/or other medical problems, a premature infant usually receives fluids and nutrition intravenously or through gavage tube-feedings. Intravenous feedings, also called total parenteral nutrition," are given through an infant's veins, bypassing the digestive system completely. Gavage tube-feedings are given through a temporary feeding tube that is threaded into one nostril or the mouth, down the throat and esophagus, and into the stomach. Breast milk is usually tube-fed to a premature infant until he or she is able to to suckle adequate amounts at the breast. Normally, an infant begin suckling when he or she has reached a gestational age of 32 to 34 weeks. However, the transition to total breastfeeding is not usually complete until a gestational age of 40 weeks (the infant's original due date).

Mothers who express breast milk can give a preterm infant special benefits the child can get from no other source. * Human milk is easy to digest The preterm infant with an immature digestive, system can derive maximum caloric benefits from breast milk feedings. * The protein, breast milk of mothers who deliver preterm babies is higher in the first four to six weeks of lactation. This makes it the optimum feeding choice for preterm infants, who require a higher-protein diet. * Human milk contains enzymes and hormones that are particularly important to the maturation of the digestive system and nervous system. * Human milk contains defenses against infection. Antibodies in breast milk give the premature baby's immune system protection from serious bacterial infections, and respiratory viruses.

Lactation consultants, health professionals with special training and experience in breastfeeding, work with ICN staff to provide support to mothers who are pumping and/or breastfeeding. These professionals teach the correct use of electric breast pumps and procedures for handling, storing and transporting expressed breast milk. They also provide tips on maintaining breast-milk production, caring for themselves and stimulating infants to suck. Finally, lactation consultants can provide support during the transition to breastfeeding and assess infants' suckling progress.

Electric breast pumps can be rented from hospitals, durable medical equipment suppliers, private-practice lactation consultants or some WIC agencies (Women, Infants and Children - WIC - is is a government program that provides vouchers for the purchase of certain foods). Breast pumps can also be rented directly from manufacturers. (from $1 to $2.50 a day). Some ICNs have funds available (often through the Children's Miracle Network) to cover rental fees when insurance coverage is denied. The use of a breast pump is usually required until an infant reaches what would have been his or her due date, and longer if there are other medical problems.

As soon as the baby is medically stable, parents are encouraged to engage in a tecnique known as "kangaroo care, or "kangaroo holding," which involves holding the diapered baby upright, skin-to-skin on dad's chest or between mom's breasts. This stimulates the infant's warm, pre-birth environment as he or she feels the parent's rhythmic breathing and hears his or her heartbeat and voice. When this technique is used regularly, premature babies show a number of benefits, including improved heart rate and breathing pattern, decreased crying, longer quiet sleep periods (important in conserving calories for growth), more rapid weight gain and faster transition to breastfeeding. Kangaroo also stimulates the mother's breastmilk production.

During visits to the ICN, parents are also encouraged to train their baby to suckle by encouraging the infant to suck on a finger. The suck-training technique involves stroking the infants cheeks, lips and palate (roof of the mouth) to stimulate a sucking response. The parent can also use a finger to exert gentle pressure downward and forward on the tongue; this helps the infant develop the tongue coordination that will be needed later for breastfeeding.

Alternative feeding methods

Hospitals have started teaching parents how to gavage tube-feed their preterm infants, allowing infants to be discharged earlier. Their parents tube-feed them at home while they make the transition to breastfeeding, bottle-feeding feeding or an alternative feeding method. The average duration of at-home tube-feeding is two weeks.

As an infants gag reflex improves, it becomes more difficult to thread a feeding tube down his or her throat, and parents are understandably anxious to discontinue this feeding method. They can do so once an infant can take adequate nourishment orally - by breastfeeding, bottle-feeding or alternative feeding method. However, because the transition to total breastfeeding takes time, infants who have started breastfeeding are likely to need supplemental feedings for several weeks. Bottle-feeding may seem the most logical and convenient type of supplementation; however, for the infant, bottle-feeding and breastfeeding are very different experiences. Differences include nipple texture and length, as well as the mechanisms the infant must use in suckling and swallowing. Switching an infant back and forth is likely to lead to "nipple confusion" - or even a preference for the bottle - prolonging the transition time and leading to frustration for both parent and child.

Fortunately, alternative feeding methods including cup-feeding, spoon-feeding, finger-feeding and supplemental nursing systems allow infants to receive supplemental breastmilk or special formulas by tube while suckling at the breast. If a baby is having difficulty latching onto the breast, cup-feeding or finger-feeding would be the alternative methods of choice. If the baby can latch onto the breast, a supplemental nursing system would be preferred. To prevent aspiration (breathing of fluid into wind pipe or lungs during feedings), parents must be trained in the use of these methods and the infant must have a sufficiently strong gag reflex. * Cup-feeding teaches an infant to bring his tongue down and forward (part of the normal tongue movement needed for breastfeeding). It also allows the infant to pace his feedings, allowing time to swallow. During cup-feedings, the infant is swaddled in a blanket and placed in an upright sitting position. The cup is placed against the infants lower jaw or lip, so the infant can use his tongue to lap up milk like a kitten. For older infants, the lower rim of the cup rests against the upper lip, and the child's tongue remains below the cup. When the cup is angled so liquid touches the baby's lips, he will sip and swallow at his own pace. * Spoon-feeding is similar to cup-feeding, but uses a small medicine spoon or the soft, pliable Medela Cup Feeder, which has a control valve and self-refilling reservoir that maintains a steady supply of liquid at its lip. * Finger-feeding uses the gavage feeding tube or supplemental nursing system (see below) taped to the parents finger instead of to the breast. Alternatively, a periodontal syringe (plastic syringe with a tapered, curved tip) or soft, plastic eyedropper may be used. Finger-feeding combines nourishment with exercises that train the infant to later accept and compress the nipple properly - keeping his tongue down, forward and cupped. When the baby draws the parents finger into his mouth, he also takes the tube, syringe or eyedropper. When the baby sucks properly, he will be "rewarded", by drawing liquid into his mouth. An eye dropper is especially useful for an infant who tends to chew rather than suck on the parent's finger because it allows parents to "reward", sucking attempts by squeezing the eyedropper bulb to release a few drops of liquid. Eventually, the infant will begin sucking the liquid out of the eyedropper on his own. * Supplemental nursing systems allow an infant to simultaneously nurse at the breast while receiving supplemental feeding through one or two soft tubes taped next to the mothers nipple and attached to a bottle or bag hung around her neck. When the baby takes the nipple into his mouth, he also takes the tube. Breastfeeding then proceeds normally. Supplemental nursing systems are made by Medela and Lact-Aid. The tubing and syringe from a gavage tube-feeding set can also be used for this purpose.