A Review of the Literature Examining the Benefits and Challenges, Incidence and Duration, and Barriers to Breastfeeding in Preterm Infants

Jennifer Callen, RNC, MSC; Janet Pinelli, RNC, MSCN, DNS


Adv Neonatal Care. 2005;5(2):72-88. 

In This Article

Challenges of Breastfeeding VLBW Infants

Challenges of breastfeeding VLBW infants include the provision of adequate caloric and nutritional intake, establishing and maintaining a milk supply, and transitioning from gavage feeding to breastfeeding. A good milk supply is critical to achieving successful breastfeeding. Mothers of VLBW infants are often required to pump their milk for 2 to 3 months until their infant is physiologically stable enough to attempt nutritive sucking at the breast.[14] Additionally, they may have difficulty maintaining their milk supply due to the protracted hospitalization and separation from their infant.[59] Depending on the physiological and developmental status of the infant, mothers may be stressed and fatigued, further decreasing milk production.[14,59,60]

While human milk is beneficial for preterm infants, the use of human milk as the sole source of nutrients for preterm infants remains controversial. Very-low-birthweight infants fed human milk have slower growth rates and inadequate nutrient and protein intakes to meet their needs.[36,61] Additionally, the calcium and phosphorus content in human milk is not sufficient to meet VLBW infants' growth needs.[62] Prolonged deficiency of these minerals stimulates bone resorption to normalize serum calcium concentrations, placing VLBW infants at risk for osteopenia of prematurity and metabolic bone disease.[62] Specific nutrient limitations of human milk must be enhanced for VLBW infants receiving human milk.

Although fortification of preterm human milk remains controversial, the American Academy of Pediatrics and the Canadian Pediatric Society recommend the use of fortifiers containing protein, minerals, and vitamins to ensure that infants fed preterm human milk receive their estimated nutritional needs.[63—65] Further research regarding the duration and use of human milk fortifiers is necessary to ensure preterm infants are receiving adequate nutrition to optimize growth and development.[48]

Immediately after delivery VLBW infants do not have the capability to directly breastfeed and stimulate maternal milk production due to their immaturity, and weak, ineffective suck.[66] Mothers must begin to establish their milk supply by pumping.

The literature examining the physiology of breastfeeding, as well as controlled clinical studies, support the importance of early pumping in establishing a milk supply. A delay in initiating pumping may result in impaired production.[67,68] Early removal of colostrum from the breast is associated with a better prognosis for successful lactation.[69] In a prospective observational study of 87 mothers who intended to breastfeed their infants (mean GA 28 weeks), 34% were lactating after their infants reached 40 weeks corrected age and only 14% made the transition to breastfeeding.[70] The initiation of pumping before 6 hours postpartum was associated with successful lactation beyond term ( P < 0.02).70 Another randomized, longitudinal study examined milk production in 39 mothers with 50 preterm infants (mean GA 27 weeks).[71] At 9 weeks, 69% of the mothers were lactating, and milk production was inversely correlated ( r = -.385) with the time from birth to initiation of breast pumping.[71]


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