Feeding Tips for Premature Babies: Ensuring Healthy Growth

How often should I feed my preemie baby?

Babies’ feeding patterns differ and vary from day to day. Before discharge from your NICU (Newborn Intensive Care Unit), the nurses will give you an idea of how often, and how much, your baby will eat. Most preemies feed every 2.5 - 4 hours.

Look for cues that your baby is hungry. Premature babies don’t always cry but may move around and get restless it’s been 2 - 3 hours since they last ate. You’ll be advised to wake your baby if it’s 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 feedings take no more than 25 - 30 minutes. Bottling for more than 30 minutes than your baby is taking in and can greatly affect weight gain.

If your baby frequently needs more than 25 - 30 minutes to eat, consider increasing the flow of their nipple to the next level. You can also talk to your physician about an outpatient feeding evaluation to assess your baby’s bottling skills and identify additional recommendations.

Parents of premature babies often have concerns about their baby's weight gain, and it's a critical aspect of a preemie's development. "Fast" weight gain isn't always the goal. Rather, it's about healthy, consistent weight gain to help them catch up and thrive.

When will my preemie baby gain weight?

Almost all babies lose weight before they gain weight. This weight loss is typically 5-15% of the baby's birth weight. Much of the weight loss is water weight, because the baby is no longer surrounded by fluid. Sometimes, very sick babies gain weight the first few days. This isn’t real weight gain. It’s water retention. As the baby's condition improves, they’ll lose weight. Usually, a baby won’t 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 4.5 lbs. needs 12-15 ounces of formula or breastmilk per day. A good way to see if your baby is getting enough to eat is to observe how many wet diapers they have in a 24-hour period. Six to eight wet diapers is the norm. Most formula fed babies take 2-3 ounces every 3-4 hours when discharged from the hospital.

If your baby finishes feeding in a shorter time and still acts hungry, offer an extra ounce or two. A breast-feeding baby increases their feeding time by sucking longer or wanting to eat more often. This builds up the mother’s milk supply. Sometimes this means your baby will want to eat every two hours, or until your supply meets his/her demands.

If you’re still unsure about how much your preemie should eat based on their demand, or lack of interest in feeding, talk to your doctor. They’ll check your baby's weight at each visit and let you know if their 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 is the same in each. Most preemie babies should have 20 calories per ounce, unless your care team specifically told you to use a higher calorie. Higher calorie formulas, 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 they must have formula. In fact, there are many advantages to mother's breast milk over formula, such as:

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

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 can’t breast feed long term, consider providing breast milk for your preemie while they’re in the hospital.

However, babies can and do develop normally when fed only formula. Although encouraged, breast feeding is a personal choice.

Why is skin to skin important?

Skin to skin is beneficial and important for your baby even when you’re home. Not only does it help with bonding, it allows your baby to conserve their energy and focus on 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 other nutrients. Even so, it’s not as rich in some of these things as what the baby would receive from the placenta if s/he weren’t born early. Some preemies grow well on their mother's milk alone. Others, especially very small or sick preemies, can’t handle the amount of milk it would take to get all the calories and nutrients they need. The same is true of formula. Preemie formulas are richer in these items 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, including:

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

As the baby gets older and no longer needs to be tube fed, his/her need for extra nutrients and calories also decreases. By the time your baby can completely breast feed, breast milk usually supplies all the calories they need. Your baby may require need additional vitamins and iron though.

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’re weaned off. This is 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—and 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. Alternate feeding your baby in your right and left arm to help them develop their visual motor skills.

You won’t always have to use an elevated side-lying position to feed your baby if they aren’t on oxygen. After your baby is home for 1-2 weeks and/or has turned their full-term age, try to hold your baby in a cradle hold position when feeding.

This is done before you need to change the flow of their nipple. You can start with the cradle hold one to two times daily and then increase slowly as they’re doing well during all of the feeds.

If you’re 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, consider returning 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 isn’t 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 aren’t ready at 36 weeks. Nurses can often tell when a baby is getting close to this time by how they act 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 aren’t 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’ve had severe respiratory problems may be slower to start and 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’s 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 your baby learning how to self calm.

It’s important to continue to use a pacifier that’s 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 your baby is eight 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 helps to pair the pacifier with a small tag blanket or stuffed animal 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 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’s important to be patient and try not to become discouraged if you have chosen to breast feed. There are times when this transition isn’t entirely successful. Don’t be hard on yourself as breastfeeding can be difficult and doesn’t work, or isn’t right, for everyone.

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 continue to make milk. The more stimulation the more milk the breasts make.

When should I start pumping?

It’s best to start as soon after delivery as you can. Within the first six hours is best but definitely within the first 24 hours. Early pumping is important for establishing a milk supply. Even if your baby is very sick and not being fed, 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 on how to use one when you’re 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’s important to save all that you get of this early milk for your baby. By 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’ll produce more than your baby can use, but don't decrease the amount of pumping. It’s 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 aren’t changed by freezing, but frozen milk doesn’t protect against infection. Your baby's doctor may want to use fresh milk when the baby starts to feed. Fresh milk is milk that hasn’t 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’s time to work on drinking skills, we recommend using an open cup and straw. Sippy cups aren’t recommended for preemie babies as they promote a drinking pattern that’s 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 healthcare 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. We’re here to support you every step of the way.

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