Feeding Tips for Premature Babies: Ensuring Healthy Growth

How often should I feed my preemie 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 long should my preemie baby eat? 

We recommend that feedings take no more than 25 to 30 minutes. Bottling for more than 30 minutes will burn more calories than they are taking in and can greatly affect weight gain for some babies.

If your baby is frequently needing more than 25 to 30 minutes to eat, you may consider increasing the flow of their nipple to the next level or talk with your physician as your baby may benefit from an outpatient feeding evaluation to assess their bottling skills and determine any additional recommendations that may help your baby with bottling.

When will my preemie 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.

How much should I feed my preemie 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.

How much formula should I give my preemie baby?

There are three types of baby formula: powdered, concentrate and ready to feed. The nutritional content of the three are the same. Most preemie babies should have 20 calories per ounce, unless your care team specifically told you to use a higher calorie. Higher calorie formulas containing 24 or 27 calories per ounce need to be ordered and are typically more expensive. Here are recipes for mixing formula from powder or concentrate.

How do I clean baby 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 preemie 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 baby 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 they are in the hospital. It's something special that only you can do for your 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.

Why is skin to skin important?

Skin to skin continues to be beneficial and important for your baby even when you are home. Not only will it continue to help with bonding, but it will also allow your baby to conserve their energy and allow them to focus on their most important jobs which are growing, developing their brain and eating. Skin to skin is also a great way to prepare for or recover from increased stimulation, travel, physician appointments, vaccinations, etc. 

Will my milk provide my baby with all the things they 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.

Why is an elevated side-lying position important? 

If your baby was discharged home on oxygen, then remaining in elevated side-lying feeding position is recommended until they are weaned off. This is recommended because the respiratory patterns and energy for eating are best supported in this feeding position. When moving to a cradle position, your baby can no longer use their back muscles to breathe. This means they often can breathe as fast or as much as needed.

You may increase the flow of the nipple as needed while remaining in an elevated side-lying position. It's important to alternate feeding your baby in your right and left arms from feeding to feeding to help them develop their visual motor skills.

You will not always have to use an elevated side-lying position to feed your baby if they are not on oxygen. After your baby has been home for 1-2 weeks and/or has turned their full-term age, you can try to hold your baby in a cradle hold position when feeding.

Ideally, you will transition your baby to a cradle hold position before you need to change the flow of their nipple. You can start by doing this one to two times daily and then increase slowly as they are doing well to all of the feeds.

If you are struggling to transition from the elevated side-lying position, talk to your physician.

If your baby becomes sick with a cold or other respiratory illness, it may be beneficial to return to this feeding position to allow your baby to breathe more easily and slow the flow of milk.

When can my preemie 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, they may enjoy sucking. A pacifier can be used to encourage sucking.

When the baby is being tube fed, they 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.

How long will my baby need a pacifier?

Using a pacifier at home can continue to help your baby. Not only does it allow your baby to continue to work on their non-nutritive suck but it also helps your baby with their state regulation and helps organize their body in preparation for eating. The non-nutritive suck started in utero and can be a key to babe learning self-calming.

It is important to continue to use a pacifier that is rounded all the way around and similar in shape to their bottle nipple to optimize their tongue cupping and sucking pattern.

Many parents and caregivers are concerned with using a pacifier at home as it may be difficult to transition your baby away from using the pacifier. We recommend transitioning away from offering a pacifier by the time that your baby is 8 months old. You can transition first to sleeping and/or car time only, with a goal of being done by 10 months of age. It often helps to pair the pacifier with a small tag blanket or stuffed animal that they always get with the pacifier, so when you take away the pacifier, they still have the other item.

Some babies benefit from prolonged use of the pacifier, as sucking is very organizing. Just know that after 10-12 months of age when the pacifier “has a name” and “can be found when missing” it will be harder to take away.

Will my preemie baby be able to nurse even though they were 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.

Should I transition my preemie baby to a sippy cup or straw?

When it is time to work on drinking skills, we recommend working on open cup and straw drinking. Using sippy cups is not recommended for preemie babies as they promote a drinking pattern that is similar to drinking from a bottle rather than using more mature skills.

Sippy cups encourage your child to drink with his head/neck back in extension, which increases aspiration risk. Sippy cups also have no flow control and often lead to coughing/choking spells.

Preemie Care Support with UnityPoint Health

Caring for a premature baby comes with unique challenges, but understanding their specific feeding needs is an important step in ensuring their growth and development. By staying informed and partnering with your health care team, you can navigate this journey with confidence and provide the best care for your little one.

If you have questions or need additional support, don’t hesitate to reach out to your child’s pediatrician or a lactation consultant. Together, we’re here to support you every step of the way.

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