What You Need to Know Now About Feeding A Premature Baby

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By Linda Folden Palmer

I highly recommend that all pregnant mothers become informed about premature infant care. There’s no time to become informed if a premature birth happens to you, and your choices will have huge consequences on the survival and long-term health of your baby. If you’re not informed, medicalization can win out and your baby may lose out – so please do take time to think about the possibilities of preemie care today.

Premature infants present a very special and delicate nutritional case. They are designed to be fed totally processed nutrients in mother’s blood through the umbilical cord; their digestive systems are not well developed, and some may be too weak to suck. Many are given various feeds through tubes, bottles or through needles directly into their veins, even though in other countries all but the tiniest of these infants have been successfully fed by using mother’s milk exclusively.

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Preemies are certainly the most vulnerable of babies, as well, and the immune protection provided by breast milk is of utmost value. Their best survival is strongly linked to the earliest and greatest amounts of breast milk possible, even though this is often not encouraged in many neonatal units.

Mother’s milk is best
When infants are too tiny or weak for breastfeeding, mothers can express their milk for spoon or cup feeding or for tube feeding if necessary. Artificial nipple (bottle) feeding should not be used in infants intended for breastfeeding because it has been shown to reduce the success of the infants’ continued breastfeeding by nearly two-thirds (known as nipple confusion). Not only does the opioid reward of food intake and sucking help to bond infants to artificial nipples instead of to their mothers’ breasts, but the latching technique, sucking pattern and use of tongue and mouth muscles are very different between bottle nipples and real nipples.

The tiniest infants are generally fed intravenous sugar, fats and protein pieces but can take some breast milk by mouth even on day one. Although seldom practiced in the United States, these infants should be fed on nothing but breast milk as soon as possible — within a few weeks at most.

Nearly all kinds of infections are significantly elevated when premature infants are fed artificial formulas instead of breast milk, including urinary tract infections and diarrheal diseases.

Among the tiniest preemies, there are 45% more serious infections in those exclusively fed formula. While the difference in mortality between low birthweight infants fed breast milk versus formula is not as great as the difference seen between term infant feedings, those not receiving breast milk still have a 26% to 37% greater death rate.

The statistical benefits of breast milk in these studies are reduced by some of the various types of breast milk used (stored, pasteurized, term milk) and the various forms of supplementation or fortification of breast milk. The highest benefit is from fresh premature colostrum and breast milk from the infant’s own mother, although this is not always possible.

Special benefits for preemies
It has been found that the preemie’s ability to break down fats from mother’s milk is twice as efficient as from formula. Of course, other nutrients are more available in mother’s milk as well. Many studies on breastfeeding preterm and low birth-weight babies complain that the nutrients in breast milk are lower than in chemically derived milks, and breastfed preemies sometimes gain weight more slowly during their stay in the hospital. However, follow-up studies to age 2 or 3 show there is no difference in the size between naturally or artificially fed babies.

Additionally, studies suggest the breastfed preemie’s growth rate is similar to that inside the uterus. In fact, the bone mineral content is greater in childhood follow-ups in direct proportion to the amount of human milk received. The growth of head circumference, an indicator of brain development, is not lower during premature hospitalization in infants fed human milk, even when the breastfed infant weighs less.

Preterm infants who are fed breast milk grow up with higher intelligence scores, and other neurological development parameters are better as well. Long-term immune development is superior in those who receive breast milk. Breastmilk-fed preterm and low-weight infants have higher survival rates, lower illness rates, stronger bones (eventually), greater intelligence and superior neurological development; hence, weight gain comparisons are not highly relevant.

The advantages of warm, affectionate care
A big difference in the health of tiny hospitalized infants can be induced by caring for them via kangaroo care and other nurturing measures.

Standard care for Western preemies is to remain in incubators for their first weeks of extra-uterine life. Self-regulation of body temperature is very inadequate in preemies. Temperature, oxygen and infection regulation are the chief purposes of incubators. Of course, breast milk regulates infection, too. It has been found that for all newborns, even very premature infants, placing them skin-to-skin on the chest of the mother or father provides superior temperature regulation to that of an incubator.

Measures of important energy conservation (oxygen consumption) in these infants are excellent as well. Designed especially for small and preterm babies, “kangaroo care” advocates dressing infants in only a diaper and placing them upright inside the mother’s clothing, in between her breasts.

Here, they can feed or attempt to suckle at will and can enjoy the comfort and gentle stimulation of continued contact with mother — her warmth, sounds and odor. Almost no crying is heard this way, compared to the long pulses of “separation distress calls” normally found in the nursery.

This method of care has become standard in Scandinavian countries (where the infant death rate is half that of the United States) and has been adopted in other European countries for several hours per day. In 1979 in the United States, researchers demonstrated significant improvement in the recovery of newborns when affectionate treatment was given to them on cue.

Not yet ready for allowing the mother in, nurses in the study provided this treatment. Newborns were rocked, cuddled and provided with verbal and visual stimulation and were allowed to suck on a pacifier as much as desired. In comparison to standard care infants, these babies demonstrated superior temperature regulation and respiratory rates; far fewer heart murmurs were detected, fewer sucking and swallowing difficulties were seen and almost no crying was found.

More than 25 years later, some health care practitioners and hospitals in the United States are finally starting to seriously consider this kind of care.

Kangaroo care decreases newborn deaths, and these infants gain twice as much weight per day as standard incubator babies. Kangaroo care also results in more sleep, good oxygen saturation, less agitation, many fewer episodes of apnea (no breathing) and more stable heart rates. A 1999 U.S. school of nursing study confirmed all these findings and reported that kangaroo care would be beneficial for newborns, beginning in the delivery room.

This care can also be used with preterm infants who require tube-feeding; it even accelerates production of a hormone that stimulates secretion of digestive enzymes. Even babies on respirators can benefit from kangaroo care. Hospital stays are much shorter for preemies who receive this kind of attention. This early skin-to-skin care has also been shown to significantly improve mother’s milk volume, a common challenge with preterm births, and it improves mother’s attachment and maternal behaviors.

Oxygenation, temperature control and respiration are all superior when these infants are directly breastfed. Additionally, they have fewer sucking and swallowing problems, they tolerate their oral feedings earlier and their breast milk feedings are greater when received directly at the breast or in another nurturing manner.

When these measures are added, weight gain is faster than for those in standard care. Thus, although a small infant fed breast milk through a tube will have a higher chance of healthy survival than one fed formula by tube, any infant who is fed directly at the breast or who is otherwise fed breast milk with warm body contact and affectionate care will have the best chance for success.

Unfortunately, kangaroo care and exclusive breastfeeding are almost never seen in U.S. neonatal intensive care units (NICUs). Breastfeeding at any level is not always encouraged and sometimes not even allowed. I heard of a mother who was laughed out of the NICU when carrying in one or two tiny ounces of her first colostrum, which is actually “liquid gold.”

I must emphasize that infant mortality rates (up to age 1 year) in the United States are higher than in 41 other industrialized and developing nations who record and report statistics. The restricted availability of premature feeding formulas and supplies, incubators and other equipment in less affluent nations causes premature infants to be more often held and breastfed — hence, they more often survive.

Additionally, it has been shown that early discharge of low-weight infants (at 4 pounds or less), leads to faster weight increases as well as longer breastfeeding with no decline in health or survival rates. In the Philippines, where an infant born at home will generally stay at home regardless of birth weight, low birthweight infants were breastfed far longer when born at home than when born in hospitals.

How to improve outcomes
Mothers of underdeveloped infants need to be proactive in order to improve outcomes for their children. Mothers have to be as close as possible to their preemies from the very start to encourage milk production. Just hearing the infant cry will help to promote milk production. When some kind of breastfeeding attempt is made within the first six hours after birth, prolactin levels are much higher than when the first attempts are three days later.

Mothers need to take measures to maintain elevated prolactin levels. If breastfeeding attempts are infrequent or weak, the possibilities include kangaroo care, maintaining nearness to the infant, hearing and responding emotionally to baby’s cries, having the infant attempt to suck or at least nuzzle and regularly attempting to manually express or pump milk (which is beneficial even though only drops may come the first days).

Every time the infant receives food other than mother’s milk, mother’s milk production is impaired. Thus, she should express milk each time such a feeding occurs. It’s important for mother to pump regularly during this period anyway to store milk up that can be given when baby is ready for it and mother is not present.

As mentioned before, many kinds of breast milk are fed to low-weight infants. Pooled donor milk, which is a collection of stored milk from multiple donor mothers, can be of two types: from mothers of term infants or from mothers of premature infants. Mother’s milk after a premature birth is much higher in certain nutrients, and studies show superior growth and head circumference in low-weight infants fed milk from preterm baby mothers.

Important fat absorption is greater when pooled milk is not sterilized. Growth is shown to be even better when mother’s own milk is used, rather than pooled milk, likely because it is fresher and unprocessed, naturally customized to the maturity of the infant and because mother’s exposure to the infant allows her to create customized antibodies in response to the microbes in the infant’s body and environment.

Researchers have just discovered (to their admitted surprise) that when preemies are being bottle-fed or spoon fed, these infants, when allowed, quickly become able to self-regulate their caloric intake when fed in response to hunger and to satisfaction. There are many confirmed advantages to on-cue feeding, especially less frustration and better digestion. There is also less energy expenditure from crying while waiting for feeding. This point is very important in the weak, tiny preemie. In all likelihood baby knows best, yet scheduled feeding of prescribed dosages continues to be the norm in hospitals, likely because they are easier to monitor in this kind of setting.

Fortifying mother’s milk?
Attempts to fortify human milk for preemies are very common. Calcium and phosphorous are often added to improve early bone mineralization. Protein is added in an attempt to increase growth rates. Other vitamins and minerals are often added as well. It all sounds great, but there are many problems associated with fortification.

One study analyzed the feeding of a high-protein formula that contained three times the protein of human milk, comparing this feed to mother’s milk in low-weight babies. The growth rates were similar, but the high-protein infants had high levels of toxins from protein breakdown in their blood (urea and creatinine).

Additionally, two amino acids (components of protein), phenylalanine and tyrosine, were found to be too high in the formula-fed infants’ blood. In excessive amounts, these hinder nervous system development. Another study viewed protein utilization in a formula with extra cow’s milk protein added, compared with human milk with extra human milk protein added. The human protein fortified infants gained more weight and had better protein balance.

Most breast milk fortification contains cow’s milk proteins. These are not desirable with breast milk or in preemie formulas (although they are in nearly all formulas). A few of the problems with these dairy proteins are the high incidence of bovine protein intolerance associated with intestinal inflammation, bleeding and diarrhea; the slow breakdown of these large proteins in the tiny system, preventing additional formula feedings as early as they are needed for optimal caloric intake; and the increased risk of developing childhood diabetes — the risk being greater the earlier cow’s milk proteins are introduced.

It has been shown that breast milk fortified with any cow’s milk products, including nearly any preemie or infant formula or milk fortification powder, reduces the immune protective properties of mother’s milk. A higher rate of infection is seen in infants fed fortified breast milk versus those fed only human milk. The immune protection from mothers can be reduced by fortification in part because E. Coli bacterial growth in the intestine increases, which mother’s milk alone hinders.

This bacterial flora sets the stage for other more-dangerous bacterial colonizations and many diarrheal illnesses; similar to that seen in fully formula-fed infants. Various researchers are interested in supplementing elements such as sodium, phosphorous, calcium and vitamins to the breastfed preemie.

These can all be provided without dairy products. Iron supplements will block much of breast milk’s infection protection and is not needed in most cases. Low iron stores in the infant should not be a reason to risk supplementing iron, with its known influence on increased threat of illness.

Only proven anemia should prompt low-dose iron fortification. Vitamins shouldn’t be harmful in low quantities according to the research to date, and vitamin D may enhance bone building when neither breast milk-providing mother nor infant is obtaining much sun exposure.

In a German study, half of the preterm infants receiving medium or high levels of calcium supplementation were found to have dangerous calcification in their kidneys, and many suffered abdominal distension as well. We have already seen that breastfed preemies eventually show very good bone mineralization with no supplementation.

Another study suggests that bone mineralization in breastfed preemies is as high as in formula-fed preemies by just a few months after birth, but the concern continues about the light bone mineral content early on for breastfed low birthweight infants. While it seems a little backwards to use formula-fed infants as the gold standard, comparisons to intra-uterine growth are used as well.

Breastfed preemies may lag behind formula-fed in this arena. Possibly a very low level of calcium and phosphorous supplementation to the breastfed preemie is a good choice. If protein fortification is desired, it should come from a human or possibly soy source. Much more research is needed in this area.

IV feedings for preemies
There has been a dangerous but preventable finding in regards to the tiny newborn who is receiving nutrition parenterally — that is, not by mouth but directly into the bloodstream. This feeding is known as TPN, or “total parenteral nutrition.” It seems that vitamin E, which is typically a beneficial anti-oxidant, can actually become a harmful oxidant, a pro-oxidant, when exposed to light, especially phototherapy lights, throughout the day. This causes the fats in the parenteral formula to quickly become rancid. This infusion of rancid fats into the bloodstream of preemies, which are toxic and can even be cancer-causing, may add to the many difficulties encountered in these tiny infants. This oxidization can be prevented by covering the liquid with aluminum foil or by adding vitamin C to the solution at time of use, although this is not always practiced.

TPN solutions can be lifesaving when they are truly needed, but these formulas are far from perfect nutrition and are not yet truly safe. Liver damage is very common in tiny infants receiving TPN. Although this damage is generally reversible in adults, it can be more permanent in infants and can lead to lifelong illness or early death. Finally, this liquid sits for long periods in plastic bags and tubing, allowing dangerous leaching of the plasticizing chemicals BPA (if PC plastic) or DEHP (if PVC plastic) into the IV fluid.

Oral feeding of breast milk is tolerated much sooner than formula by mouth. Moreover, early introduction of formula increases the chance an infant will develop life-threatening necrotizing enterocolitis. This condition is rarely seen in infants receiving no formula by mouth, even if they received parenteral nutrition. Human milk proteins and lipids are more easily absorbed than formula components, and human milk speeds the maturation of the digestive system. Hence, feeding breast milk to infants on intravenous feeding will reduce the total amount of parenteral solution needed, reducing possible negative consequences.

Robbing antioxidants
Oxygen therapy (direct or through an incubator) causes many harmful oxidizing reactions in infants. This creates toxicity and predisposes them to cancer. Furthermore, this oxidation uses up the infant’s supply of antioxidants, including selenium and vitamin E. Low levels of selenium and vitamin E predispose an infant to more infections. Supplementing these elements as well as vitamins A and C may help to reduce this, but the infant’s ability to absorb these is limited. When these supplements are added to mother’s milk, they are absorbed more readily than with formula. In addition, kangaroo care can provide superior oxygenation, reducing the need for artificial oxygen supplementation.

Regardless of oxygen therapy, parenteral nutrition preemies develop very low selenium levels within weeks. Selenium levels decline in formula-fed infants as well. This decline is likely due to oxidative breakdown in these feeds as well as other stresses caused by the feeds and feeding methods. Supplementation does not adequately compensate. On the other hand, those fed mainly breast milk maintain healthy selenium levels (except with the highest levels of oxygen therapy).

For full references, see Baby Matters: What Your Doctor May Not Tell You About Caring for Your Baby. For a list of the article resources, see bottom of page.

© Linda Folden Palmer

Dr. Linda Folden Palmer consults and lectures on natural infant health, optimal child nutrition and attachment parenting. After running a successful chiropractic practice focused on nutrition and women’s health for more than a decade, Linda’s life became transformed eight years ago by the birth of her son. Her research into his particular health challenges led her to write Baby Matters: What Your Doctor May Not Tell You About Caring for Your Baby. Extensively documented, this healthy parenting bookpresents the scientific evidence behind attachment parenting practices, supporting baby’s immune system, preventing colic and sparing drug usage. You can visit Linda’s web site at www.babyreference.com.

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