Most babies that require specialized care in the Newborn Intensive Care Unit (NICU) were born prematurely, typically in the 22 to 32-week out of 40-week gestation age range.
A baby born early often requires extra support and can face unique health challenges, one of which includes feeding. A premature baby may experience feeding challenges, because they:
- Have an immature gastrointestinal tract.
- Are not medically stable enough to take regular feedings.
- Require help breathing, or are breathing fast, and are not safe to feed by mouth due to the risk of breathing food into the lungs.
- Don’t have the stamina to take all the nutrition they need by mouth.
“A team of neonatologists, expert nursing staff and health professionals in the NICU at Brigham and Women’s Hospital provide the most advanced care possible to newborns with critical health challenges, including the need for advanced feeding support,” says Terrie Inder, MBCHB, chair of the Department of Pediatric Newborn Medicine at the Brigham.
Medical care before breastfeeding
Many babies in the NICU are initially too small or sick to take a full milk feeding. Thus, medicines and fluids are often given through their veins or arteries. There are several ways a baby may receive fluids and medicines in the NICU, including:
- Intravenous line (IV): Babies may have an IV placed in a hand, foot or the scalp, where veins are easily accessed. Tubing connects the IV to a bag that contains nutritional fluids, which are delivered with a pump.
- Umbilical catheter (UVC or UAC): After the umbilical cord has been cut at birth, the short stump of the cord remains. Because the stump is still connected to the baby’s blood supply and circulatory system, a catheter can be inserted into one of the two arteries or the vein of the umbilical cord. Medicines, nutritional fluids and blood can be delivered through this catheter.
- Peripherally inserted central catheter (PICC) line: A catheter is placed in a deep vein or artery in the baby’s arm or leg and is used to meet a baby’s longer-term nutritional needs through an intravenous line.
“A premature baby may need IV lines or catheters for a short time or several days or weeks, in some cases. Once a baby is well enough to take milk feedings, and is gaining weight, IV lines are usually removed. Sometimes, an IV may be needed to give a baby antibiotics or other medicines even when the baby can be fed normally,” says Dr. Inder.
Your baby’s nutrition
Every baby needs enough calories, protein and fats for adequate growth and development. Fluids, electrolytes and vitamins are also needed for growth, development and proper functioning of the body’s systems.
In the NICU at the Brigham, which is the largest and most state-of-the-art of its kind in Massachusetts, registered dietitians make rounds with medical teams daily to design and oversee nutrition plans for each baby. These plans may include IV nutrition, breast milk and/or formula.
A dietitian measures and evaluates a baby’s growth regularly, including weight, length and head circumference (a measure of brain growth). These measurements are then plotted on a growth chart specific to each baby’s sex and gestational age. The baby’s growth provides valuable information for the dietitian to recommend changes to a feeding plan.
Babies who cannot consume milk require a special preparation called parenteral nutrition (intravenous nutrition). Parenteral nutrition bypasses the normal digestion in the stomach and bowel. It’s a special liquid nutrition mixture delivered into the blood through an intravenous catheter. The mixture contains the nutrients a baby needs until they can take milk feedings. The contents of parenteral nutrition are calculated for each baby. Calories, protein, fats and electrolytes, including sodium, potassium, chloride, magnesium, phosphorus and calcium, are all important components.
The NICU team supports parents and families as they navigate the challenges of having a premature baby in the hospital. There are many support services available to patients and their families, including built in support systems to identify and intervene in the event of any cognitive or emotional difficulties.
“We include parents in all clinical care decisions, including feeding decisions. We want to support families as they face the challenges that can happen when they have a sick baby in the hospital,” says Dr. Inder.
How your baby is fed in the NICU
Gavage or tube feedings
Because premature babies often can’t be fed from the breast or bottle right away, gavage or tube feedings may be needed until the baby learns to feed for themselves. For gavage feedings, a small flexible tube is placed into a baby’s nostril or mouth and passed into the stomach. The tube usually remains in place until the baby is consistently able to feed by mouth. At first, tiny amounts of breastmilk or formula are given through the feeding tube. Because of their small stomach size, smaller babies may be fed using a pump that slowly delivers the milk in small amounts. As a baby grows, they can slowly take larger amounts at each feeding.
Breast and bottle feedings
Feeding practice from breast or bottle can begin as soon as babies are stable, breathing comfortably and can coordinate sucking, swallowing and breathing. Babies begin to practice feeding by mouth while still being tube fed. Even if the baby shows interest and participates in a feeding, it can be tiring for them.
“It’s important to pay attention to behavioral cues that show tiredness. If you are using a bottle, it can be helpful to help your baby pace feedings. Learning to feed by mouth is a gradual process that can take weeks for premature babies. It’s normal to take only occasional small amounts by bottle or at the breast” says Dr. Inder.
The benefits of breastmilk for your baby
A mother’s milk is the preferred milk for all babies, especially the most premature babies. Breastmilk contains nutrients needed for growth and development. It also contains antibodies from the mother to help protect babies from infection. This protection is important when babies are sick or premature and have higher chances of developing an infection.
Additional benefits of mother’s milk for a premature baby include:
- Reduced risk of necrotizing enterocolitis, a rare but severe intestinal disease that affects preterm infants almost exclusively.
- Improved digestion and gastrointestinal function.
- Improved brain and eye development.
- Improved wellness of the mother and bonding with baby.
“Providing breastmilk for your baby lets you participate in your baby’s healthcare in a crucial way. Because the benefits of mother’s milk are so important to the high-risk newborn, you can do something for your baby that no one else can,” says Dr. Inder.
Babies younger than 28 weeks’ gestation can especially benefit from milk feedings. Very early preterm infants are given trophic feedings in small amounts that help the digestive tract mature and grow. The amount of milk is slowly increased over days to weeks. Once your baby can ingest larger amounts of milk feedings, intravenous fluids and/or parenteral nutrition can be slowly decreased.
Very premature babies need fortifiers added to breastmilk and supplements to meet their increased needs for protein, calcium and phosphorus. Even if your baby can’t breastfeed, you can pump your breastmilk and it can be stored for gavage or nipple feedings. Depending on the amount of milk needed for feedings, donor milk or formula may need to be given temporarily in addition to a baby’s own mother’s milk.
“If a mother has difficulty with milk production, she can supplement with donor milk. Our donor milk comes from Mother’s Milk Bank Northeast in Newton, MA. All milk donors undergo an extensive screening process. The donated milk is pasteurized and monitored to ensure its safety,” says Dr. Inder.
Lactation Services in the Newborn Intensive Care Unit
Certified lactation consultants are nurses or other healthcare providers who are specially trained and certified to help women with breastfeeding. In the NICU, lactation consultants help you and your baby become comfortable nursing.
They can also teach you about pumping and storing breastmilk. Because learning to feed by mouth is a process that can take you and your baby a few weeks, you will likely need to continue expressing milk even after leaving the NICU.
The lactation team at the Brigham are international board-certified professionals, as well as nurses that work closely with families from the time they enter the NICU to through discharge.
Feeding therapy services in the NICU
Feeding therapists are also available throughout the NICU. They work alongside nursing staff to assist babies who are having difficulty learning to feed by mouth. Many premature babies benefit from specialty feeding equipment and strategies to help them feed safely and feeding therapists can assist parents in identifying when these would be helpful.
“Our goal is for babies to feed safely and efficiently. We want babies and their parents to have enjoyable feeding interactions,” says Pamela Dodrill, PhD, CCC-SLP, a senior feeding therapist in the NICU.
The Brigham NICU uses an evidence-based algorithm to guide the transition from tube feeds to oral feeds, which allows parents to see where their baby is in their transition to independent oral feeding and readiness for discharge home. Feeding therapists also attend daily rounds prior to discharge and work closely with parents as they begin to transition home.
“Feeding therapists work together with other members of the NICU team to support parents to learn strategies to help their baby as their baby is learning to eat,” says Dr. Inder.