Caring for a Premature Baby: Feeding

How often should I feed my baby?

Feeding patterns differ between babies and vary from day to day. Before discharge from your NICU (Newborn Intensive Care Unit), the nurses can give you an idea of your baby's feeding pattern. Most preemies feed every 2 1/2 - 4 hours. Look for cues that your baby is hungry. Premature babies do not always cry, but may move around and become restless if it has been 2-3 hours since they last ate. Often the doctor will want you to awaken your baby if it has been longer than 4 or 5 hours since the last feed. Discuss this with your doctor.

How much should I feed my baby?

A baby who weighs about 4 1/2 lbs. usually needs 12-15 ounces of formula or milk per day. A good way to see if your baby is getting enough to eat is to observe how many wet diapers he/she has in a 24 hour period. Your baby should have 6-8 wet diapers every day. Most formula fed baby's will be taking 2-3 ounces every 3-4 hours when discharged from the hospital. If your baby is finishing the feeding in a shorter time and still acting hungry offer an extra ounce or two. A breast feeding baby will usually increase its feeding time by sucking longer or wanting to eat more often. This builds up the mothers milk supply. Sometimes this means that your baby will want to eat every 2 hours until your supply will meet his/her demands. Your doctor will check your baby's weight at each visit and let you know if the weight gain is appropriate.

When will my baby gain weight?

Almost all babies lose weight before they begin to gain weight. This weight loss typically is 5-15% of the baby's birth weight. Much of the weight loss is loss of water because the baby is no longer surrounded by fluid. Sometimes very sick babies gain weight the first few days. This is not real weight gain; it is retention of water. As the baby's condition improves, the baby will lose weight. Usually a baby does not regain his/her birth weight until two or more weeks of age.

Our baby will be getting formula, what should we know about it?

There are three forms of formula: powdered, concentrate, and ready to feed. The nutritional content of the three preparations of formula are the same. Most formula found in stores has 20 calories per ounce. Your doctor will want you to use 20 calorie, unless she/he has specifically told you to use a higher calorie. It is very important to use only what the doctor has ordered. Higher calorie formulas containing 24 or 27 calories per ounce, need to be ordered and can be very expensive. Here are recipes for mixing formula from powder or concentrate.

Powdered formula

least expensive to buy.
try using warm water and mixing it in a blender to help dissolve formula.
with measuring scoop in the can:
to make 20-calorie-per-ounce formula: 1 scoop powder + 2 ounces of water.
to make 24-calorie-per-ounce formula: 3 scoops powder + 5 ounces of water
once the can is opened the powder must be used within 1 month.

Concentrated formula

most convenient to use.
to make 20-calorie-per-ounce formula: 1 ounce concentrate + 1 ounce water.
to make 24-calorie-per-ounce formula: 3 ounces concentrate + 2 ounces water.
to make 27-calorie-per-ounce formula: 13 1/2 ounces concentrate + 6 1/2 ounces of water.
should be sealed and kept in the refrigerator, once the can is opened.
should be used within 48 hours.

Never add more water than what is called for in the preparation. Follow the directions correctly.

How do I take care of the bottles and other equipment when using formula?

Bottles, nipples, measuring cups, containers, brushes and any other equipment used for feeding should be washed in hot, soapy water and then rinsed in hot, running water. Glass or metal pieces can be washed in the dishwasher.

Should I plan to breast or bottle feed my baby?

Just because your baby is premature does not mean s/he must have formula. In fact, there are many advantages to mother's breast milk over formula. These advantages include:

Fewer infections
Less risk for Necrotizing Enterocolitis (NEC)
Better tolerance of feeds
Less risk of allergy
Enhanced development

Early breast milk, called colostrum, is especially rich in antibodies and cells that help fight infection. Babies who are too young to suckle at the breast can get your milk in their tube feedings. Even if you planned to bottle feed or cannot breast feed long term, you might consider providing breast milk for your preemie while s/he is in the hospital. It is something special that only you can do for your baby.

I can't or don't wish to breast feed. Will I be hurting my baby?

Babies can and do develop normally when fed only formula. Although encouraged, breast feeding is a personal choice. You and your baby can still benefit from close skin to skin contact.

When can my baby nipple or breast feed?

When babies are born prematurely their sucking is not well coordinated with their breathing. This suck-swallow-breathe pattern usually becomes coordinated enough to safely breast or bottle feed at about 34 weeks of gestation. However, there are big differences among babies. Some are ready at 32 weeks; others are not ready at 36 weeks. Nurses can often tell when a baby is getting close to this time by how a baby acts during a tube feeding. Your baby's doctors and nurses will determine when to start. At first your baby will have only one or two feeds a day that are not by tube. This will gradually increase as the baby gets used to the extra work of feeding. Because nipple and breast feeding requires more work, babies who have had severe respiratory problems may be slower to start and slower to advance on feedings. Before your baby is ready to feed by breast or bottle, s/he may enjoy sucking. A pacifier may be used to encourage sucking. When the baby is being tube fed, s/he may like to suck on a pacifier or the breast that is empty of milk. This is called non-nutritive sucking. Sucking on the empty breast or nuzzling the breast during tube feeding can be combined with kangaroo care. This helps the mother with milk production and readies the baby for future breast feeding. In addition, babies stay warm while held.

Will my baby be able to nurse even though he/she has been taking the bottle at the hospital?

Most nurseries encourage the mothers to pump their breasts while their baby is in the hospital. The nurses will work with you and your baby once your baby is able to begin the process of sucking, swallowing and breathing.

Premature babies may take days or weeks to learn how to nurse. It is important to remember to be patient and try not to become discouraged if you have chosen to breast feed. There are times when this transition is not entirely successful; it is important to not feel guilty.

How will my body know to produce milk early?

After delivery, hormones change rapidly, signaling to your breast to begin making milk. With stimulation by the baby's sucking (or by the breast pump) the breasts will continue to make milk. The more stimulation the more milk the breasts make.

When should I start pumping?

It is best to start as soon after delivery as you can, within the first 6 hours is best, but definitely within the first 24 hours. Early pumping is very important for establishing a milk supply. Even if your baby is very sick and not being fed, you need to pump your breast regularly so there will be milk when your baby is ready. Electric breast pumps are the best. Ask your nurse or a lactation consultant for assistance in learning to use one and in preparing to rent one when you are out of the hospital.

How often should I pump?

You should pump at least five times a day and for a total time of at least 100 minutes a day. Ideally increase this to 8 to 12 times a day for 10 minutes per side. Frequent pumping signals your body to keep making milk. At first you may get very little milk, sometimes just a few drops. But, it is important to save all that you get of this early milk for your baby. About the third day your breasts will become full and swollen. This is your milk coming in. At this time your milk supply will increase. With frequent pumping you will produce more than your baby can use, but don't decrease the amount of pumping. It is important to build a good supply early.

My baby is sick and not eating. What do I do with my milk?

Pumped milk can be frozen for later use. Unless told otherwise, the milk from an entire pumping should be pooled and then divided into containers for freezing. The nutrients of milk are not changed by freezing, but frozen milk does not protect against infection. Your baby's doctor may want to use fresh milk when the baby starts to feed. Fresh milk is milk that has not been frozen, but it can be refrigerated for 24-48 hours. Ask you baby's nurse about the guidelines for your nursery.

Will my milk provide my baby with all the things that s/he needs to grow?

Milk from mothers who deliver early is different from milk from mothers who deliver on time. It has more protein, sodium, calcium and some other nutrients. Even so, it not as rich in some of these things as what the baby would receive from the placenta if s/he were not born early. Some preemies grow well on their mother's milk alone. Others, especially very small or sick preemies, cannot handle the amount of milk that it would take to get all the calories and nutrients that they need. The same is true of formula - preemie formulas are richer in these things than regular formulas. Your baby's doctor may decide to enrich your milk to provide your baby with more calories and/or minerals. There are many ways to do this:

Adding specific nutrients to the milk such as fat, protein or sugars.
Mixing your milk with preemie formula. This is common if your baby needs more milk than you can currently supply.
Human milk fortifiers. These are powders or liquids added to your milk before it is given to the baby.
Giving more "hind" milk to the baby. This is the last portion of milk pumped from the breast. It is richest in fat and calories.

As the baby gets older and no longer needs to be tube fed, his/her need for extra nutrients and calories also decreases. So, by the time the baby can completely breast feed, usually breast milk supplies all the calories that s/he needs. Your baby may still need additional vitamins and iron