A document about breastfeeding for preterm infants discusses several topics: 1. The mother's feelings after delivery of a preterm infant, which can include shock, doubt in her abilities, and stages of grief. Providing support is important. 2. The advantages of breastfeeding a preterm baby, such as better digestion, protection from infection, and improved development. The baby's own mother's milk is most beneficial. 3. Ways to help the mother bond with her preterm baby, including kangaroo care, involvement in care, and spending time together. The document provides guidance on feeding very low and low birth weight preterm infants, determining readiness for breastfeeding, and

1. Breastfeeding for Preterm
Infants
DR. Varsha Atul Shah

2. Breastfeeding for Preterm
Infants
• Mother’s feelings
• Advantages of breastfeeding a premature baby
• Building a relationship between mother and baby
• LBW Premie (BW >1500g)
• VLBW Premie (BW <1500g)
• Determining baby’s readiness to breastfeed
• The first nursings
• Use of nipple shield

3. THE MOTHER’S FEELINGS

4. The Mother’s Feelings
Mother’s Feelings
• May be in shock, making it difficult
for her to remember information.
• May doubt her ability to breastfeed.
What we can do
• Patience is needed. Give a
written information to which she
can refer.
• Reassurance and
encouragement.
• Explain what she needs to know
at this stage – importance of
beginning frequent milk
expression.
• Keep information brief and to the
point.
• Be available to talk on a regular
basis as circumstances change
and she begins to come to terms
with her situation.

5. The Mother’s Feelings
Mother’s feelings
• May pass through the stages of grief,
including shock, denial, anger,
bargaining, depression and finally
acceptance.
– She may feel overwhelmed.
– She may feel as though her body has
failed her and her baby.
– She may feel anger, guilt and depression.
– Her questions may center around finding
reasons for the baby’s problems.
– She and her husband may blame
themselves or each other while searching
for a reason why the birth occurred early.
– Their anger may be directed at the
hospital staff or the doctor.
– May have feelings of helplessness, loss of
control and isolation.
– She may have crying bouts and develop
physical symptoms eg, insomnia, eating
problems or fatigue.
What we can do
• Recognize that strong feelings are
normal, if the mother feels so
overwhelmed, encourage her to
seek the help of a psychiatrist.
• The mother and father may be in
different stages of grief at the same
time, impairing their ability to
communicate with and comfort each
other.
• Give mother positive reinforcement
and suggest specific ways she can
keep in touch with her baby.
• Suggest a support group – may
benefit from spending time with
others going through the same
experiences.

6. What can influence mother’s
breastfeeding choices?
Mothers who choose to
breastfeed
• Deciding to breastfeed is a
healthy reaction to feelings of
guilt and helplessness.
• Breastfeeding increases her
feelings of being in control and
gives her tangible way to
“make it up to her baby” and
lessen her feelings of guilt.
Mothers who choose not
to breastfeed
• The emotional commitment to
their baby makes them feel
more vulnerable.
• May be afraid to become too
attached to their baby in case
he dies.
• May decide not to breastfeed
or postpone expressing her
milk until her baby’s condition
stabilizes.

7. If a mother has mixed or negative
feelings about breastfeeding?
• Baby receives the greatest benefit from his mother’s milk
during his 1st few weeks and that the mother could
approach it as a temporary commitment.
• Assure her that if decides to quit after a week or two, her
milk will already have given her baby valuable protection
from infection.
• It is much easier to stop expressing milk after two weeks
than it is to start expressing them.
“Say this in a caring way with respect that the
decision rests with the mother.”

8. ADVANTAGES OF BREASTFEEDING A
PREMATURE BABY

9. Breastfeeding advantages over
formula• Easier to digest and better tolerated by the premature baby.
– Proteins in human milk are more completely broken down and better
absorbed.
– Tube feeding tends to be established earlier and with fewer problems.
• Contains lipase – helps baby digest milk fat more efficiently.
• Anti-infective and anti-inflammatory agents to protect from
potentially serious bacterial infections.
– Premature baby’s immune system is immature, he is at greater risk of
developing a variety of infections and is less able to cope with them
should they occur.
• Better vision in premies – due to the types and ratios of fatty acids in
human milk that are absent in formula.
• Higher intelligence and improved motor development.
– Breastfed premies scored an ave of 8.3 points higher on IQ tests than
formula-fed premies
– Dose-related
• An array of hormones and enzymes in human milk including various
growth factors have been found to be important to the maturation of
the baby’s brainstem.
• Breastfeeding brings the mother and her baby closer.

10. Preterm milk vs Donor human
milk
Preterm milk
• Mother’s own preterm
milk can be given fresh to
her baby.
• Contains more antibodies
than term milk.
• Higher in certain nutrients
eg, protein, sodium, iron
and chloride.
Donor milk
• Donor milk must be
pasteurized, which kills
the live cells that fight
infection.

11.  “All preterm infants should receive human milk, with pasteurized
donor milk rather then premature formula, the preferred alternative if
a mother is unable to provide adequate volume.”
 Evidence:
 Decreased rates of late-onset sepsis, NEC, ROP.
 Fewer re-hospitalizations in the first year of life.
 Improved neurodevelopmental outcomes.
 Lower rates of metabolic syndrome, lower blood pressure, lower LDL
levels, less insulin and leptin resistance when they reach adolescence.
 Decreased NEC – most compelling evidence
 Dose response effect of human milk feeding (for each 10ml/kg/d increase
in human milk in the diet there is a 5% reduction in hospital readmission
rate).

12. Changes in milk composition
over time

13. BUILDING A RELATIONSHIP
BETWEEN MOTHER AND HER
PREMATURE BABY

14. “It is more challenging for the mother of a premie to
form an emotional bond with her baby”

15. Reasons..
• Mothers feel more
vulnerable to even greater
trauma if her baby should
die.
• Mother may find her baby’s
appearance upsetting.
• Mother’s inability to touch or
hold her baby will affect her
feelings towards him.
• A premature baby may not
be able to respond.

16. Ways to help mother feel closer to
her baby..
• Encourage mother to help with her baby’s care.
• Watch her baby’s cues so that he doesn’t become
overstimulated.
• Spend as much time as she can with her baby.
• Other suggestions..
– Name the baby and use the name when talking to him and about
him.
– Change and feed baby whenever possible.
– Ask questions and let staff know what she thinks and how she
feels.
– Leave a photo of the family in the baby’s incubator.
– Take pictures of the baby to keep a record of his progress.
– Keep a record of the baby’s changes to make small
improvements more obvious.

17. Kangaroo Care
• Gives premies warmth, physiological
stability, good sleep and comfort
through skin-to-skin contact.
• Provides opportunities for early
breastfeeding.
• Mothers who give kangaroo care
tends to breastfeed longer and more
frequently.
• Mothers feels more confident about
caring for their babies in the hospital
and about bringing their babies
home than mothers whose babies
received conventional care.
• Increases mothers’ milk volume

18. LOW BIRTH WEIGHT PREEMIE
BW >1500g

19. Low Birth Weight Premie (BW
>1500g)
• Usually born at >30 weeks gestation
• If healthy – the larger premature baby may be able to
breastfeed within the 1st hour or 2 of birth.
– May have a weak suck
– Watch for feeding cues
• If ill or not yet ready – many considerations will be the
same as for the tiny premie.
– Extended hospitalization
– Long-term milk expression
– When to begin breastfeeding
• Larger premature babies tend to grow well on their
mother’s milk without the need for vitamins or mineral
supplements.

20. VERY LOW BIRTH WEIGHT
PREEMIE
BW <1500g

21. Feeding Methods and Options
 At first, the baby may be fed thru IV or by NG/OG tube.
– Place the baby skin-to-skin at the mother’s breast during feeding.
• Colostrum and mature milk are better tolerated than formula
– Contains growth modulators – help premie’s digestive system adjust to
oral feeding.
• Mother’s own fresh milk is better than frozen or donor milk
– Higher anti-infective properties and nutrients (eg, nitrogen, protein
nitrogen, Na, Cl, Fe, fatty acid)
– Changes over time in keeping with baby’s needs which changes as he
grows.
• When human milk is in short supply or unavailable, special preemie
formula can be used.
• May need to be fortified to meet all the baby’s nutritional needs.
– Calcium, phosphorus, protein, Na and vitamins.

22. Human milk fortification
1. Lacto-engineering
 Ideal
 Human milk is processed and specific components added to
EBM eg,
 Human milk protein culled from banked human milk
 Add extra high-fat hind milk to EBM
2. Human milk fortifiers
 Derived from cow’s milk.
 Powdered fortifiers – used when there is enough human milk to
provide necessary volume.
 Liquid fortifiers – can be used to increase the volume of human
milk feeding if in short supply.

23. Foremilk and Hindmilk

24. Feeding Methods and Options
• If weight gain is a concern, assess milk production.
– Give more high-fat hindmilk – express at least 10-15 minutes per
breast, longer if the flow continues at a steady rate.
– Continuous feeding system – greater milk fat losses.
– Intermittent feeding – orienting the syringe in an upright position
decrease fat losses from 48% to 8%.
• A mother who thinks her milk may not be meeting her baby’s
needs may be depressed.
– Needs reassurance and support.
• Her milk is better for her baby than any type of formula.
• The need for supplementation is temporary.
• Infant formula must be also supplemented with extra nutrients to meet a
premie’s special physical needs.
– Help her to communicate her feelings and goals to staff.

25. 1. Before expressing milk, mothers wash their hands thoroughly, giving special attention to
fingernails and nail beds.
2. An electric breast pump with automatic cycling be used. Hand expression, manual,
battery, or small electric pumps are considered inadequate for most mothers to establish
and maintain a good milk supply, esp when they must pump for a long time.
3. Each mother use her own collection kit.
4. All parts of the collection kit that touch the milk be cleaned after each use with hot soapy
water, thoroughly rinsed, then placed on a clean towel, covered with another clean towel,
and allowed to air dry. Washing is a dishwasher is also acceptable.
5. In areas where water is contaminated, boiled or bottled water be used for cleaning pump
kits.
6. The expressed milk be labeled with the date, the baby’s name, the baby’s hospital ID, any
illnesses in the family, and any medication(s) the mother is taking.
7. Milk is stor eight ounces should not be used.
8. Colostrum and early milk may be “layered” – a mother may chill and add milk to the same
container from different pumpings in order to get a full feeding.
9. Storage containers be hard-sided and made of glass, polycarbonate (clear, hard plastic)
or polypropylene (cloudy, hard plastic) with solid caps that provide an airtight seal.

26. The challenges of expressing
milk..• Most mothers do not get much milk during the first few days.
– Use 1ml or 5ml syringe to measure the milk expressed may help mother feel
better.
• Mother may become discouraged if not able to express large quantities of
milk immediately.
– Assure the mother that no amount is too small to save for the baby.
• If there is a concern about bacteria levels in the EBM.
• The KEY to establishing and maintaining a full milk supply over time while
expressing is to express milk early and often, express long enough to drain
the breast and stick to a daily routine.
– Begin ASAP, ideally within 6 hours of birth.
– 10-15min/breast at least 8-10x/day.
– Pump at least once during her normal sleeping hours.
– Pump long enough (2 minutes after the last drop of milk or for 30 minutes
whichever comes first).
• Using an effective breast pump is critical to establishing good milk
production.
– Double-pumping cuts the time spent in half and increases milk supply more

27. How do you know if mother is
expressing enough milk?
• By Day 10
– Ideal:
>750ml/day or
90-
120ml/pumping
– Borderline: 350 –
500ml/day
– Low: <350ml/day

29. Ways to keep milk supply
• Holding and touching her baby may help the mother express
more milk.
• Mother-to-mother support groups and encouragement from
health care providers can be critical in establishing good milk
supply and in motivating a mother to continue in her effort to
provide milk for her baby.
• Other strategies to boost milk supply:
– Plan “frequency days” – at 2-3wks, 6wks & 3mo.
– Express longer – pump until 2min after the last drop or for 30min
whichever comes first.
– Consider medicinal herbals – eg, herbal teas, fenugreek with or
without blessed thistle.
– Consider prescription medicines – eg, domperidone,
metoclopramide

30. When baby is going through a
crisis..
• It is normal for a mother’s milk supply to
temporarily decrease.
– Assure her that the decrease in supply is
temporary and will increase again as baby’s
condition improves.
– Talk to another mother of a premature baby
who has gone through a similar experience.
– If appropriate, arrange a more skin-to-skin
contact with her baby before milk expression
as this may enhance milk let-down.

31. DETERMINING A BABY’S
READINESS TO BREASTFEED

32. “Breastfeeding is less stressful than bottlefeeding.”

33. When a premie is ready..
• If the baby is ready to be fed by mouth, breastfeeding is
less stressful than bottle-feeding.
– Common assumptions include:
• Breastfeeding is too stressful for babies weighing <1500g.
• Babies cannot coordinate sucking and swallowing enough to
breastfeed until they reach 34-35 wks gestation.
• Babies must be able to bottle-feed before they can breastfeed,
because breastfeeding is more “difficult”.
– Premies’ ability to effectively breastfeed by gestation. (Nyqvist
1999)
• 28 weeks – root and grasp
• 30.6 weeks – some nutritive sucking
• 36 weeks – exclusively breastfeed

34. When a premie is ready..
• Practice at completely or partially drained breast.
– 30-32 week babies
– Fluid-restricted babies due to other medical problems

35. When a premie is ready..
• Go directly from tube feeding to the breast –
without giving bottles.
– Babies who were supplemented as needed by
NGT feeding were 4.5x more likely to be
breastfeeding at hospital discharge and >9x likely
to be exclusively breastfed than babies
supplemented by bottle. (Kleithremes 1999)
• If feeding went well, no supplement was given.
• If breastfed only fairly (latch-on but didn’t keep up the sucking
rhythm for very long & few swallows were heard) – baby
received half of the usual feeding via NGT.
• If rooted or licked the breast but did not latch on or suck
– he received a full feeding via NGT.

36. When a premie is ready..
• Cup-feeding rather than bottle feeding
– Breast-refusal from early use of artificial nipples is rare in
most East African hospitals because bottles were never
used. (Newman, 1990)
– Lang 1994
• Babies could successfully feed by cup as young as 30 wks
gestation.
• More babies who received supplements by cup were fully
breastfeeding at hospital discharge than those who received
supplements by bottle (81% vs 63%).
• During cup-feeding, premies maintain satisfactory HR, breathing
and SpO2 levels.
• Gives baby more control over milk intake than bottle-feeding
and involves tongue movements that are important for
successful breastfeeding.
• “Lapping” involves extending the tongue over the lower gum, is
important for effective breastfeeding, but babies who sip from
the cup does not learn the same tongue movements.

37. When a premie is ready to
breastfeed..• Cup-feeding
– Concerns:
• Amount of milk taken and
amount of spillage (up to
38.5%).
• Risks of aspiration.
– Technique is critical.
• Baby should be upright.
• The liquid is just high
enough so that the baby
can sip or lap it in, but not
so high that it is poured
into his mouth.

38. When a premie is ready..
• A variation on the
cup, feeding vessel
called a “paladai”.
– Low bowl with a spout,
shaped like "Alladin’s
Lamp”.
– Milk is poured into the
baby’s mouth through
its spout.
– No reported cases of
aspiration.
– Less spillage than cup.

39. When a premie is ready..
• Evaluate individually for readiness to
breastfeed.
– Baby’s overall condition.
– How well the baby tolerates milk fed by gavage.
– Baby’s ability to coordinate sucking, swallowing
and breathing.
– Whether the baby can maintain his body
temperature outside incubator.
• In some hospitals, premature babies are
breastfed without the use of bottles.
– US, parts of Africa and India, England

40. When a preemie is ready..
• If the mother choose to use a bottle, find ways to make
the transition to breastfeeding easier.
– Bottle with long nipple
– Softer nipple
– Baby should be well supported during feedings.
• Bottle feeding in a breastfeeding position.
• Sitting baby in a supported upright position.
– Latch the baby onto the bottle as she would the breast.
• Touching the baby’s lips with the nipple and waiting until he
opens wide.
• Allow the baby to draw the bottle nipple well into his mouth
rather than pushing it in.
• Avoid latching the baby onto the tip of the rubber nipple with a
tightly closed mouth.

41. When a preemie is ready..
• Feed on cues (on demand) rather than a fixed feeding
schedule.
– Saunders 1991
• Compared 2 groups of stable premies weighing ≥1550g (1
group cue-based feeding, 1 group fixed feeding schedule).
• Babies on cue-based feeding feed well, no problems with
overfeeding, same weight gain as babies fed on schedule
despite taking less milk and took longer rest periods.
• Cue-based fed babies were discharged earlier and it allowed
parents to learn their babies’ hunger cues before discharge
making the first weeks at home easier.
• Knowing how much milk baby receives while
breastfeeding can be important – use of special
electronic scale.
– Olympic’s SMART scale, Medela’s Baby Weigh scale

42. THE FIRST NURSINGS

43. Setting the Scene..
• Depending on gestational age, early feedings may take
time and patience.
– May take several breastfeeding sessions before the baby nurses
well.
– Baby may simply lick or mouth the nipple at first.
– Many premies start by sucking in short burst and fall asleep
quickly.
– Assure the mother that it is alright if baby does not receive much
milk in these early nursing.
• Support and realistic expectation help early
feedings to go more smoothly.
– A lactation consultant can be with her the first time
she puts the baby to the breast.

44. Cross-cradle (Transitional hold)
• Position herself comfortably with enough support behind.
• Hold baby with the arm opposite the breast at which he will feed. Support the baby at breast
height so that his head, neck and hips are supported in a straight line.
• With the hand holding the baby’s head, suggest the mother position her palm on baby’s
upper back, supporting the baby’s head with thumb and fingers behind the ears.
• Use same-side hand to support the breast and use the “U-hold” so that her elbow is in a
comfortable position.
• Position the baby’s nose at the level of nipple and adjust the baby’s position just to the right
of the L breast with his head tilted slightly back, so that when he is pulled on by his
shoulders, he latches on to the breast chin first.
• Move the baby gently toward and away from the breast,
tapping his lips lightly with the breast and wait until he opens
wide, like a yawn.
• As he open his mouth, pull him on the breast chin first. (Bring
the baby to the breast, not the breast to the baby)
• Apply gentle pressure on the baby’s shoulders throughout the
feeding using thumb and index finger to support his head and
prevent him from turning away. This gentle pressure also helps
the baby keep more of the areola in his mouth, which
minimizes soreness and maximizes the amount of milk he will
be able to get.

45. Football (Clutch hold)
• Using her L hand, position her palm on baby’s upper back,
supporting the baby’s head with thumb and fingers behind the ears
to avoid triggering the rooting reflex. Avoid putting hand or fingers on
the back of baby’s head, as most babies react by arching back when
their heads are pushed to the breast.
• Tuck the baby’s body under her L arm on
her L side, so baby is far enough under the
breast so that he doesn’t have to bend his
neck to latch on. The baby should not have
to stretch or turn his head to reach the
mother’s nipple.
• Use a pillow or two under the baby and
under her forearm to bring the baby up to
the level of the nipple.
• Use her R hand to support the L breast
using the “C-hold”.

46. Putting the baby to breast..
• Need practice and encouragement to open wide
– like a yawn – and latch on well to the breast.

47. Putting the baby to breast..
• If the baby has trouble staying on the breast, he
may need more support. The mother also may need
to support her breast throughout the feeding.

48. Putting the baby to breast..
• Breast compression in combination with good
latch-on may help keep a premie active at the
breast.

49. Putting the baby to breast..
• Switching back and forth from breast to breast
may be too tiring for a tiny premie.
– Baby nurse well from only one breast.
– Watch for baby’s cues to avoid overtiring or stressing
him.
• An overheated baby may suck less vigorously.
• He may need extra time to get the milk flowing.
– Evaluate individually.
– May take a little extra time at the breast to stimulate
his mother’s let-down reflex.

50. USE OF NIPPLE SHIELDS

51. Nipple shields
• Helps to latch on and
take more milk.
• Babies are able to suck
for longer bursts and stay
awake longer.
• Compensates for the
weak suction.
– Maintains the position of
the breast in the optimal
part of the baby’s mouth.

52. Thin silicone nipple shields
• Must have good fit
– Length:
• Too long – cause baby to gag.
• For most premies 2-2.5kg – shorter nipple shields will be the
best fit.
• <1.3kg – even a short nipple may be too big, baby’s mouth may
need to grow more before he is ready.
• Ideal teat length:
– Measure baby’s mouth by letting baby suck on clean finger, pad side
up.
– Allow finger to go to baby’s palate where the soft and hard palate meet.
– Mark with pen where the baby’s lips close.
– Range 1.9 – 3.1cm
– Nipple shield range in size 1.9 – 6.4cm
– Width:
• Wide enough to accommodate mother’s nipple.

53. 2 Styles of nipple shields
Circular nipple shield
• Complete circle of soft
silicone with a firmer tip that
protrudes like a nipple.
Contact nipple shield
• Has a soft brim with a cut-out
area.
• Cut-out area – where the
baby’s nose is placed during
breastfeeding.

54. Latching on to the shield..
• Baby needs to open wide and
latch on to the softer brim
surrounding the firmer tip of the
shield to extend back far enough.
• If baby latched on shallowly to the
firm tip of the shield, it will not go
into the back of his mouth and
trigger effective sucking.
• If can see any part of the firmer tip
of the shield while the baby
nurses, the baby needs to be
removed from the breast and
latched on again.

55. Breastfeeding for Sick Term
Infants

56. Breastfeeding for Sick Term
Infants
• When baby is acutely ill
– Neonatal hypoglycemia
– Vomiting
– Reflux
– Diarrhea
– Cold or ear infection
• When baby has chronic illness or physical limitations
– Cardiac problems
– Cleft lip &/or cleft palate
– Down syndrome
– The neurologically impaired baby

57. “When baby is ill..”

58. When baby is ill..
• Human milk offers important benefits.
– It is easy to digest.
– Provides immunities to help fight sickness.
– Offers a familiar taste in unfamiliar surroundings.
– The sucking and closeness will be a source of comfort.
• If baby loses interest in nursing.
– The mother may need to express her milk for her own comfort, to
keep up her milk supply and to provide milk for her baby.
• A lethargic baby can be given his mother’s milk in other
ways eg, tube feeding.

59. When baby is ill
Common Condition What to do
Neonatal
hypoglycemia
• In most cases, frequent nursing is all that is needed.
• Treatment of documented hypoglycemia should not
be withheld in the exclusively breastfeed baby.
Vomiting • For some babies, it is not unusual to spit up after
nursing.
• Regular projectile vomiting could be a sign of pyloric
stenosis.
• In rare cases, vomiting may be a symptom of
metabolic disorder that precludes breastfeeding.
• If baby is ill and vomiting, he will benefit from
continuing to breastfeed. Ice chips may help.
• The danger is dehydration, know the signs and how
to prevent it.
• Temporary weaning is not beneficial.
Cold / Ear infection • If refuses to nurse, use cup/spoon/dropper.

60. When baby is ill
Common Condition What to do
Reflux (GER) • Simple strategies eg, feeding position at 30-
40°angle, small frequent feedings.
• Rule out allergy or cow’s milk protein sensitivity.
• Common advice to “thicken feeds”.
• Switching from human milk to formula not advocated
– human milk empty from the stomach 2x as quickly
as formula.
Diarrhea • Baby will almost always benefit by continuing to
breastfeed.
• Maximize the amount of hind milk her baby receive
at the breast.
• May indicate the baby is sensitive to a food or
medication mother is passing into her milk.
• The danger is dehydration, know the signs and how
to prevent it.
• Temporary weaning is not beneficial.

61. WHEN BABY HAS CHRONIC
ILLNESS OR PHYSICAL
LIMITATION..
“The parents may need to go through a grieving process of giving
up the baby they imagined in order to accept the baby in their
arms”

62. The Mother’s Feelings
Mother’s feelings
• Parents of baby with special
needs may be coping with
feelings of disappointment,
anger, helplessness and guilt.
• If breastfeeding is not going
well,
– Mother may blame herself and
believe that the difficulties
reflect on her inability to care for
her special child.
– Blame her child’s physical
disorder for normal infant
behavior (eg, fussiness).
What we can do
• When offering information and
options, it may need to be repeated
several times before she can use it.
Written information may be more
helpful.
• Listen and acknowledge her feelings.
• Encourage her to take it one day at a
time, pay close attention to her
baby’s cues as she tries to find ways
that work for them.
• Focus on the normal aspects of the
baby.
– Focusing on the normal can help the
mother see her child as a baby first and
a baby with a physical problem second.
• Refer to an appropriate support
group.

63. Congenital heart disease
• Usually gain weight very slowly even if receiving enough
nourishment.
• Breastfeeding is less stressful and more energy-efficient than bottle
feeding.
– More energy-efficient heart rhythms, lower HR and expended less
energy. (Zeskind 1992)
– Shorter hospital stay and gain more weight. (Combs and Marino 1993)
• Some babies can be breastfeed exclusively, others may need to be
supplemented.
– Additional hind milk can provide the baby with more calories.
– Supplement by nursing supplementer or other methods (eg, cup, spoon,
bottle, eyedropper, feeding syringe).
• If supplementing causes the mother to question the value of her milk
or her milk supply, assure her that these are not the problem.
– Babies with weak or uncoordinated suck improves with medication.

64. Cleft Lip and/or Cleft Palate
• One of the most common birth defects.
• May occur together or separately.
– 1/3 cleft lip only
– 1/3 cleft palate only
– 1/3 both cleft lip & palate
• Cleft Palate
– Cleft of soft palate
– Cleft of both soft and hard palate
– Cleft of hard palate only (rare)
• Muscle of soft palate are used for swallowing – a large cleft of soft
palate can have major effect on the baby’s ability to feed.
• “Submucosal cleft” – an opening of muscle or bone beneath the
intact skin.
– May not affect feeding – unlike other types of cleft palate, the baby is
able to seal off the mouth and generate suction.

65. “Breastfeeding and human milk are important to the
health of a baby with a cleft lip and/or palate..”

66. Breastfeeding and Cleft Lip /
Palate
• More normal ear, respiratory and overall health.
– Babies with cleft palate tend to have more ear infection – eustachian tube and muscles of the
palate are not functioning – fluids can accumulate in the middle ear and may become infected.
– Immunities in human milk provide protection against infection.
• Non-irritating fluid.
– Leakage of human milk into a baby’s nose is less irritating to the baby’s mucous membranes than
formula.
• Closeness between mother and baby.
– Cuddling time with skin-to-skin contact is calming and comforting for both mother and baby.
• More normal development of the baby’s mouth and face.
– Muscles becomes stronger and more developed with practice – more normal formation of the
muscles of the face.
– Promotes speech and language development.
• Feeding advantages
– Breast is more flexible than a rubber nipple, allowing it to mold itself to compensate for many
abnormalities in the lip and mouth.
– Baby has more control over the flow of milk and position of the breast in his mouth.
– By positioning the baby above or below the breast, the direction of the milk flow can be changed to
accommodate how fast the milk is flowing, the baby’s individual sucking pattern and the location of
the baby’s defect.
– Allows the baby to suck for comfort as well as for food. When a baby is fed by bottle, there is less
comfort sucking, and babies with cleft defects often find it difficult to use a pacifier.

67. When to start?
• Encourage the mother of a cleft-affected baby to begin
breastfeeding ASAP after birth, trying different nursing
position.
– Start life with the protection from infection provided by
concentrated antibodies in the colostrum.
– Easier for baby to latch on and learn to milk the breast
while the breast is still soft.
• By 3rd-4th day, breast become firmer and fuller and may be more
difficult for her baby to grasp, suckle and stay latched on.
– Early practice will help baby to remember how to nurse if
breastfeeding must be interrupted due to corrective
surgery.
– Facilitates attachment between mother and baby.
• Keeps the mother’s focus on an important and normal task that
require her to interact with her baby.

68. “Tell the mother to expect feedings to be time-
consuming during the first few weeks, no matter how
the baby is fed..”

69. Challenges..• Mother may need to spend
most of her baby’s waking
hours feeding him.
• Whether fed by breast or
bottle, a baby with a cleft lip
and/or palate may take up
to 2-3x longer to feed than
baby without cleft defect.
• Mother will need to try
different strategies to help
make feedings go smoothly
for her and her baby.

70. Cleft lip with intact palate
• Can usually nurse at the breast
even before surgery.
• May be difficult for the baby to
form a seal on the breast.
– Depending on the location and
extent of the cleft, one
breastfeeding position may be
more effective than another.
– Mother can help baby form a
seal and maintain suction by
positioning their nipple to one
side and use their thumb to fill
the space above baby’s upper
lip.
– Mother’s thumb can also be
used to fill the space in babies
with alveolar ridge defect.

71. Cleft Palate
• Usually has difficulty feeding at both breast and bottle. The amount
of difficulty will depend upon the severity and location of the cleft as
well as other factors.
– It is impossible for the baby to seal off his mouth and create suction
typically used to keep the breast (or bottle) in place and pull the milk to
the back of his mouth.
– Any milk the baby receives can flow through the opening in the palate
and into the baby’s nasal cavity, causing choking.
– A wide cleft of the palate may make it difficult to locate an area on the
upper palate that the baby can press the breast or bottle against to
express milk.
• Even with good technique and use of a device exclusive
breastfeeding remain an elusive goal.
– From birth, the mother needs to begin expressing her milk after feedings
in order to ensure adequate milk production.
– Encourage mother to be patient, to experiment to find what works best
for her and her baby and to seek support.

72. "Well-supported, upright nursing
position”

73. Modified football position
– With mother sitting on a bed, have her sit the baby upright facing her at her side,
with his legs along her side and his feet at her back.
– His bottom should be on the bed or a pillow at breast level with pillow behind his
back.
– Mother can support the baby’s back with her upper arm and the base of his head
with her hand.
– Mother may need to support her breast with the C-hold (thumb on top, 4 fingers
underneath well back from the nipple).
– Lean forward until baby latches on, lean back again once baby is nursing to avoid
backache.

74. Straddle position
– Mother sit her baby in her lap
facing her, with his legs
straddling her abdomen.
– If baby is small, it may be
necessary to raise him to
breast level by putting pillows
under him.
– Mother need to tip the baby’s
head back as little as baby
latches on so she can position
him carefully.

75. Dancer Hand Position
• When baby need jaw and chin
support to nurse well.
– Support her breast with the C-
hold (thumb on top, 4 fingers
underneath)
– Slide the hand supporting the
breast forward, supporting the
breast with 3 rather than 4
fingers. Her index finger and
thumb should now be free in
front of her nipple.
– Rotate her hand around the
breast so thumb and index
finger form a “U”.
– Bend her index finger slightly so
it gently holds the baby’s cheek
on one side while the thumb
holds the other cheek. The
baby’s chin rests on the bottom

76. Haberman Feeder (Special Needs
Feeder)
• Feeding device
designed for babies
with feeding
problems.
• Special nipple does
not require suction,
has a slit valve that
allows milk flow to be
controlled so that the
baby is not
overwhelmed with
milk.

77. Palatal Obturator
• A plastic plate that is placed over
the opening in the palate and
shaped to cover it.
• Used before corrective surgery.
– To keep the cleft in the baby’s
hard palate from closing in an
improper way.
– Although it doesn’t allow the baby
to create a vacuum inside his
mouth, it provides a firm surface
on which baby can press breast or
bottle nipple with his tongue
during feedings.
• May be fitted as early as 24hrs
after birth or as late as several
weeks after birth.
• Needs to be replaced as baby’s
mouth grows.
• If breastfeeding, request a
smooth rather than a rough plate
so it will be less irritating to the
nipples.

78. Palatal obturator + Haberman
feeder
• Decreases feeding time to half.
• Marked increase in milk consumption.
• Crying and later speech sound more
normal.
• Reduction in the size of defect.
• Positive effect on the family.
• More normal sucking assists growth and
helps with feeding.

79. Down Syndrome
• Breastfeeding may take longer than usual – low muscle tone (“floppy”) and a weak
suck.
 Muscle tone and sucking will improve with time and practice
• Often placid and sleepy – mother may need to set the pace for feeding
 Frequent feedings throughout the day
 Fully awaken the baby before offering the breast and stimulate him to stay
interested throughout the nursing
 Give lots of touching and attention to stimulate him
 Kangaroo care to provide skin-to-skin contact
• When positioning, keep baby’s body horizontal using pillows as support
• If gulping and choking are a problem, position the neck and throat higher than the
mother’s nipple.
• Tongue may protrude causing difficulty latching on to the breast.
 Try an exercise “pushing the tongue down and out" before putting baby to the
breast.
• May need jaw and chin support
 Provide extra support during nursing by using the “Dancer Hand Position”
• If not nursing effectively and not gaining weight, mother may express her hind milk
and offer it as a supplement

80. “Learning to take one day at a time and to focus on the
baby as a unique individual will help parents cope in the
short and long run...”

81. The Neurologically Impaired
BabyHypertonic babies Hypotonic babies
• Babies who clamp down and clench
their jaws at feedings.
• Gentle rocking before feedings – to
calm and relax baby and decrease
muscle tone enough for the baby to feed
more effectively.
• Side-lying position with baby’s body
resting on a firm, stable surface rather
than on the mother’s arm.
• For baby who is tongue thrusting or has
his tongue retracted – mother to help
him learn more effective tongue
movements on her fingers before
putting him to the breast.
• Use nipple shield with or without nursing
supplementer.
• Weak suck and low muscle tone.
• May breastfeed more effectively if
provided with some extra stimulation
and/or flow at the breast.
 Swaddling and flexing baby at the
hips.
 Feed when breast feels fuller or
firmer.
 Help stabilize his tongue – apply
gentle pressure behind the bony
part of the chin directly under the
floor of the mouth.
 Firmly patting the baby’s lips
before feeding if milk is dribbling
during feeding.
 Apply downward and forward
pressure on the tongue if baby has
protruding tongue.
• Use of nipple shield – babies with
problems latching on and sucking
effectively.

82. Nursing supplementer
• Allows the baby to receive supplements through a tube taped to a
mother’s breast.
• Helps baby learn a more effective sucking pattern because extra
milk baby gets from the supplementer stimulates him to swallow
and consequently suck more effectively.
• As the baby begins to suck more effectively, he automatically takes
more milk from the breast and less from the supplementer.
• Gauge baby’s progress by how much of the supplement is left after
nursing.
• Can be used with a nipple shield to provide both flow and a firmer

83. Thank you!