As a mom who has experienced the NICU with twins at different stages of development—and as someone who works in the lactation field and deeply understands the value of breastfeeding—there are things I wish I had known before stepping into the NICU, even with the knowledge I already had.
First and foremost, understand that feeding a premature baby in the NICU is entirely different from feeding a full-term baby. It’s crucial to listen to the NICU team and their recommendations for your baby just as much as you communicate your own goals. The medical team is not there to be a barrier to breastfeeding but rather to support both your baby’s health and your feeding journey.
That being said, here’s what I would tell any mom preparing for a NICU stay who wants to leave with a breastfeeding baby.
Prepare Before Delivery
If you know that your baby is going to spend time in the NICU for whatever reason, spend some time educating yourself on the NICU environment, prenatal lactation care, and writing out your goals. It does not take much to get overwhelmed in the NICU (in addition to being newly postpartum), so you must prepare for your breastfeeding journey before the baby arrives!
- Talk to other moms who have been through the NICU.
- Meet with NICU unit directors to hear how they support breastfeeding.
- Meet with an IBCLC prenatally to game plan your lactation journey.
It is crucial to stimulate your breast tissue (using a hospital grade pump) within one hour of delivery, as research shows this can have the most significant impact on your milk supply. If you are coming out of a C-section, you may be “out of it,” so have a support person ready to help you with this and remind you of its importance. The hospital has pumps ready and available for your use, but you will have to ask for it and initiate the process.
Communicate (and Re-Communicate) Your Goals to Your Baby’s Medical Team
If I learned anything in the NICU, it is that you have to communicate your goals repeatedly to your medical team. Being persistent (but gentle) is key.
- Express that you want to start breastfeeding as soon as possible.
- Ask about any protocols that might affect that—such as introducing a bottle, using nipple shields, or starting with pumping and providing breastmilk via NG tube.
- Don’t be afraid to communicate that you want to establish breastfeeding before introducing a bottle.
It’s common in the NICU to hear, “A bottle will get you to discharge sooner,” but know there is no clinical backing behind that statement. Bottles are often easier for staff to use as they provide a visual of how much volume your baby is taking, but they do not mean you get to go home faster! NICU staff often introduce bottles because they are perceived as “easier” for preterm infants. However, successful feeding is not just about volume intake—it’s about coordination of sucking, swallowing, and breathing. Some preterm babies may initially transfer more milk from a bottle, but that doesn’t mean they are truly feeding efficiently. Direct breastfeeding encourages muscle development, sensory integration, and self-regulation, all of which contribute to long-term feeding success. Discharge criteria involve multiple factors, including weight gain, respiratory stability, and feeding endurance. While a bottle-fed baby may take in volume quickly, this doesn’t always translate to better feeding overall. The belief that bottle-feeding speeds up NICU discharge is not evidence-based. Instead, a baby’s feeding efficiency, endurance, and overall stability determine readiness for discharge. Encouraging breastfeeding when possible supports not just the NICU stay, but also long-term feeding success and development.
If volume intake is a concern for your infant who is learning to breastfeed but you are not ready to introduce a bottle, suggest doing a weighted feed at every feed. Your NICU nurse can help you with this by request.
If your baby requires bottles for fortified feeds, be adamant about working with the dietitian team to develop a game plan that includes breastfeeding. There is almost always a workaround, such as:
– 4 breastfeeds/day and 4 bottles/day
– 5 breastfeeds/day and 3 bottles/day
– Even if your baby is on 8 bottles/day due to needing a higher volume of fortified milk, suggest practicing latching once daily (minimum) to maintain those muscles. If your flow is a concern, you can always ask your team about scheduling your pump right before you latch, as not to overwhelm your baby.
The NICU team knows medicine best, but you know your baby best. You have full authority (and responsibility) to actively participate in your baby’s medical team. Be clear in your communication and attend rounds to ask the team questions and reinstate your feeding goals.
- Ask the NICU dietitian team to provide feeding regimen options in writing.
- With terms like “milliliters, grams, and ounces” being used frequently, having written options helps you diligently choose what is best for your baby.
Push for Skin-to-Skin Often
This is key. If your baby is physiologically stable enough to tolerate movement, hold your baby skin-to-skin as much as possible.
- Every NICU has different policies regarding kangaroo care, depending on the acuity of the infant.
- Even if your baby is too premature to begin oral feeds, skin-to-skin is crucial in supporting the breastfeeding relationship as it promotes oxytocin, the hormone responsible for making milk.
- If your baby is mature enough for oral feeds, start by offering the breast at least once daily, even if they don’t transfer anything. Transfer is not an indication of eventual success in the NICU.
- If your baby is not mature enough for oral feeds, have them nuzzle on your chest skin-to-skin while fed via an NG tube.
One key to helping a preterm baby learn to breastfeed is by not ignoring their feeding cues. You will have to advocate for flexibility in the NICU with this, but if your baby is cueing, reward them by putting them to the breast, even just for nuzzling or gavage feeding.
Depending on if your baby is in an isolate or open bassinet, you may need a NICU nurse to assist you with getting your baby ready to hold. Do not feel guilty or like a bother for asking them multiple times daily to hold your baby! This fear alone keeps many moms from doing adequate amounts of skin-to-skin. Nurses are often more than willing to help facilitate that relationship between you and your baby.
Remember, Breastfeeding in the NICU is Not a Linear Journey
Oftentimes, the dance of NICU is two steps forward and one step back, and the same goes for learning to breastfeed in the NICU. An infant’s suck, swallow, breathe reflex does not develop until around 32/34 weeks gestation, so depending upon the gestational age of your baby, their body is either still learning this reflex or just starting to learn it!
- Swallowing is a complex behavior that requires the use of more than 30 muscles and nerves.
- While feeding may seem like the easiest milestone to hit in NICU compared to weaning from respiratory support, isolates, etc., it’s often the most complex milestone to achieve.
- Some days, your baby may take all their feeds via breast, and the next, they may only take 4 feeds via breast and the other 4 via NG. This is normal, as premature babies are still building the stamina to suck, swallow, and breathe.
Continue to be consistent in skin-to-skin and offering the breast to your baby, even if they just nuzzle while they are fed via NG tube. Give yourself grace, and remember that the nature of NICU is two steps forward, one step back. You will feel like your life is about numbers, monitors, machines, etc., but your number one goal in NICU is building relationship.
Breastfeeding a preemie baby is a long game and will more than likely come with progress and setbacks, but it is more than possible to leave the NICU with a breastfeeding baby!