Breastfeeding the Late Preterm and Early Term Infants
Publication Date: January 1, 2016
Last Updated: March 14, 2022
Recommendations
Implementation of principles of care: inpatient
Initial steps
Develop and communicate in writing to hospital staff a standard feeding plan for late preterm infants that can be easily implemented and modified as needed. (IV)
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Facilitate extended skin-to-skin contact immediately after birth when the mother is alert to improve postpartum stabilization of heart rate, respiratory effort, temperature control, blood glucose, metabolic stability, and early breastfeeding. ()
(IV, I, and llA)
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Determine gestational age by obstetrical estimate and Ballard/modified Dubowitz scoring. (III)
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Observe the infant closely for 12–24 hours after birth to rule out physiologic instability (e.g., hypothermia, apnea, tachypnea, oxygen desaturation, hypoglycemia, poor feeding). Where the infant is observed will depend on the local conditions, facilities and staffing available, and how the mother–infant dyad can be supported to breastfeed. Close observation must be continued during skin-to-skin care, breastfeeding, and rooming-in. ()
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Encourage rooming-in 24 hours a day, with frequent extended periods of skin-to-skin contact when the mother is awake. If the infant is physiologically stable and healthy, allow the infant to remain with the mother while receiving intravenous antibiotics or phototherapy. ()
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Allow free access to the breast, encouraging initiation of breastfeeding within 1 hour after birth. ()
(l, IIA)
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If the mother and infant are separated, the mother should begin hand expression of colostrum within the first hour of birth and at~3 hourly intervals. Some, but not all, studies demonstrate that hand expression is as good or better than breast pump expression in establishing milk supply immediately after birth. (IB)
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Even if the mother and infant are not separated, many of these infants will not effectively suckle when first offered the breast, so consider hand expression and feeding expressed colostrum to the infant with a spoon, dropper, or other device after the first attempted breastfeed. (III)
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Encourage breastfeeding ad libitum and on demand. It may be necessary to wake the infant if he or she does not indicate hunger cues within 4 hours of the previous feed, which is not unusual in the late preterm infant. (IV)
The infant should be breastfed (or breast milk fed) 8–12 times per 24-hour period. Instruct and help initiate milk expression by pump or hand in mothers whose infant is smaller, sleepier, or unable to successfully latch in the first 24 hours. These infants, especially if they have intrauterine growth retardation (IUGR), may need supplemental feeds (preferably of expressed breast milk) for low blood glucose levels, or excessive weight loss.
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Show the mother techniques to facilitate effective latch with careful attention to adequate support of the jaw and head. (IV)
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Ongoing care
Communicate any changes in the feeding plan to parents and hospital staff directly and/or in writing as appropriate depending on the local procedures and protocols. ()
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Evaluate breastfeeding, preferably within 24 hours of birth, by a lactation consultant or other healthcare professional with expertise in lactation management of late preterm and early term infants.
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Assess and document breastfeeding at least twice daily by two different healthcare professionals, preferably by using a standardized tool (e.g., LATCH Score, IBFAT, Mother/Baby Assessment Tool). (III)
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Educate the mother about breastfeeding her late preterm infant (e.g., position, latch, duration of feeds, early feeding cues, breast compressions, etc.). Provide written information as well as oral instruction about breastfeeding the late preterm infant. ()
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Monitor vital signs every 6–8 hours, weight change, stool and urine output, and milk transfer. ()
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Monitor for frequently occurring problems (e.g., hypoglycemia, hypothermia, poor feeding, hyperbilirubinemia). (IA)
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Late preterm and early term infants should be followed closely with a low threshold for checking bilirubin levels. Many healthcare facilities determine bilirubin levels and plot them on an appropriate curve according to age in hours (e.g., Bhutani chart) before the infant is discharged. ()
(lV, lll, and lV)
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Some infants may need to be transferred to a higher level of care for medically appropriate management and monitoring.
Avoid excessive weight loss or dehydration. Losses greater than 3% of birth weight by 24 hours of age or greater than 7% by day 3 merit evaluation and may require further monitoring and adjustment of medical and breastfeeding support. ()
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If there is evidence of ineffective milk transfer, breast compressions while the infant suckles may be helpful, and the use of an ultrathin silicone nipple shield could be considered.
(lll, IV)
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If a nipple shield is used, the mother and infant should be followed closely by a lactation consultant or a knowledgeable healthcare professional until the nipple shield is no longer needed. (IV)
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Consider pre- and post-feeding test weights daily or after some (but not all) breastfeeds to assess the quantity of milk transferred. Infants are weighed immediately before the feed on an electronic scale with accuracy at minimum ±5 g, and then reweighed immediately after the feed under the exact same circumstances. ()
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Avoid hypothermia by using skin-to-skin contact, that is, kangaroo care as much as possible when the mother is awake or by double wrapping if necessary and dressing the baby in a shirt and hat or cap. Intermittent use of an incubator may be required to maintain normothermia. ()
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Discharge planning
Assess readiness for discharge, including physiologic stability and intake exclusively at breast, or with supplemental feedings. (IV)
The physiologically stable late preterm infant should be able to maintain body temperature for at least 24 hours without assistance and have a normal respiratory rate. Preferably, weight should be no more than 7% below birth weight, although all aspects of the mother/infant dyad should be taken into account. Adequate intake should be documented by feeding volume (e.g., test weights) or infant weight (e.g., stable or increasing).
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Develop a discharge-feeding plan. Consider method of feeding (breast, cup, supplemental device, bottle etc.), type of feeding (i.e., breast milk, donor human milk, or infant formula), and volume of milk intake (mL/kg/ day), especially if being supplemented. If required, determine the most practical and acceptable method of supplementation for the mother. ()
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Communicate the discharge-feeding plan to mother and the healthcare professional/s involved in following up the infant. Written communication is preferable. ()
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When breast milk transfer is low, it may be appropriate to send the mother home with a scale to do test weights to confirm milk transfer during breastfeeds, or arrange for the infant to have frequent weight checks.12 Parents should also be asked to monitor and record urine and stool output. ()
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Ongoing care
Implementation of principles of care: outpatient or community follow-up
Initial visit
Although timing of the length of hospital stay may vary, late preterm and early term infants require close followup in the early postpartum period and the first follow-up appointment or home health visit should normally occur 1 or 2 days after hospital discharge. (IV)
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Relevant information, including prenatal, perinatal, infant, and feeding history (e.g., need for supplement in the hospital, problems with latch, need for phototherapy, etc.), should be recorded. Gestational age and birth weight should be specifically noted. Electronic medical record templates with breastfeeding-specific queries are useful in recording this information. ()
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Review feeding since discharge with specific attention to frequency and approximate duration of feeding at the breast and if needed, method and type (expressed breast milk, infant formula) of supplementation. Obtain information about stool and urine output, color of stools, and the infant’s behavior (e.g., crying, not satisfied after a feed, sleepy and difficult to keep awake at the breast during a feed, etc.). If the parents have a written feeding record, it should be reviewed. (IV)
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Examine the infant, noting state of alertness and hydration. Obtain an accurate infant weight without clothing. Calculate percentage change in weight from birth and change in weight from discharge. Assess for jaundice, preferably with a transcutaneous bilirubin screening device and/or serum bilirubin determination if indicated. ()
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Assess the mother’s breasts for nipple shape, pain, trauma, engorgement, and mastitis. The mother’s emotional state and degree of fatigue should be taken into account, especially when considering supplemental feeding routines. Whenever possible, observe the baby feeding at the breast, evaluating the latch, suck, and swallow. ()
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Review the mother’s goals and expectations regarding breastfeeding her late preterm or early term infant. She may need encouragement and education regarding the process of transitioning from expressing and giving supplemental feeds to exclusive breastfeeding. Mothers should be cautioned not to taper expressing sessions too rapidly to ensure the maintenance of a generous milk supply that will allow for more effective milk transfer. ()
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Review with the parents where their infant is sleeping and educate about safe sleeping practices. Asking, ‘‘where did you and your baby sleep last night?’’ may give a more accurate picture of actual sleeping practice. ()
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Problem solving
Poor weight gain (<20 g/day) is almost always the result of inadequate milk intake. The median daily weight gain of a healthy newborn is 28–34 g/day. (IV)
The healthcare provider must determine whether the problem is insufficient milk production, inability of the infant to transfer sufficient milk, or a combination of both. The infant who is getting enough breast milk should have at least six voids and three to four sizable yellow seedy stools daily by day 4, be satisfied after 20–40 minutes of breastfeeding, and have an age appropriate weight loss/ gain. Although a 10% weight loss may be acceptable in the larger, healthy late preterm or early term infant who is effectively breastfeeding and whose mother is achieving secretory activation, in many situations a maximum of 7% weight loss is more appropriate for the smaller and/or IUGR infant. The following strategies may be helpful to increase weight gain:
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- The infant should be observed breastfeeding with attention to the latch, suck, and swallow. Test weights may be useful to evaluate the quantity of milk transferred.
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- Increase the frequency of breastfeeds.
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- Start supplementing (preferably with expressed breast milk or donor human milk) after breastfeeding or increase the amount of supplement already being given.
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- Offer the supplement if the infant is awake and not satisfied after ~30–40 minutes at the breast. Additional time suckling may tire the infant without significantly increasing intake. Newborns need to rest between feeds rather than suckling continuously.
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- Institute or increase frequency of expressing (hand or pump), especially after a breastfeed if the breasts are not well drained. If already using a breast pump appropriately, switch to a more effective type (e.g., hand to mechanical, mechanical to hand, or a more efficient mechanical pump). Expressing more than six times a day may not be feasible for many mothers once their infant is home, whereas expressing eight or more times a day may be necessary to maximize milk removal.
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- Explore ways for the mother to relax while expressing: Arrange for help with other chores and to get more sleep.
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- In conjunction with the mother, consider the use of a galactogogue (a medicine or herb to increase her milk supply) if there is documented low breast milk supply and for whom other efforts to increase milk production have failed (see ABM Clinical Protocol #9).
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- Consider referral to a lactation consultant or breastfeeding medicine specialist.
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Triple feeding regimens (breastfeeding, followed by supplementation and then expressing) for every feed are effective, but they may not be sustainable for some mothers, especially if they have limited support at home. The mother’s ability to cope and manage breastfeeding and expressing must be taken into account when devising a feeding plan. (IV)
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For infants with difficulties in latching, the infant’s mouth should be examined for anatomical abnormalities (e.g., ankyloglossia [tongue-tie], cleft palate), and it may be helpful for a digital suck examination to be performed by a suitably trained healthcare professional. The mother’s nipples and breasts should be examined to assess breast development, anatomic configuration, plugged or blocked ducts, mastitis, engorgement, nipple trauma, or postfeeding nipple compression. A referral to a lactation consultant or breastfeeding medicine specialist or in the case of ankyloglossia, referral to a healthcare professional trained in frenotomy may be indicated. (III)
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Jaundice and hyperbilirubinemia are more common in late preterm and early term infants. Although all risk factors should be considered, if the principal causative factor is lack of milk, the primary treatment is to provide more milk to the infant, preferably through improved breastfeeding or supplementation with expressed breast milk or donor milk. If home or hospital-based phototherapy is indicated, breast milk production and intake should not be compromised. (IV)
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If the mother’s own milk or donor milk is not available, small amounts of cow’s milk-based infant formula should be used. Hydrolyzed casein formulas may be considered for this purpose, as there is evidence that these formulas are more effective in lowering serum bilirubin than standard infant formula. (IIB)
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Ongoing care
Infants who are not gaining weight well and for whom adjustments are being made to the feeding plan must be evaluated by a suitably trained healthcare professional frequently (e.g., daily or every 2–3 days depending on the situation) after each feeding adjustment either in the clinic or in the office or by a home healthcare provider with feedback to the primary care provider. (III)
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The late preterm infant should have weekly weight checks until 40 weeks of post-conceptual age or until he or she is thriving. Weight gain should average 20–30 g/ day, and length and head circumference should each increase by an average of 0.5 cm/week. ()
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Breastfed late preterm infants are at increased risk for iron deficiency and iron deficiency anemia compared with term infants, and routine iron supplementation is recommended. ()
(lV, lll, and lB)
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Late preterm infants are also more likely to sleep in unsafe situations as compared with term infants, thus adding to the established increased risk of sudden infant death syndrome (SIDS) in preterm infants. Therefore, regular inquiry into sleep position and location is also warranted. ()
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The diagnosis of late preterm birth should remain on the primary care giver’s problem list for several years, as these children are at increased risk for pulmonary and mild neurodevelopmental problems. ()
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Multiples
Multiple gestations (twins, triplets etc.) more often result in preterm or late preterm birth. The issues of having enough breast milk for two or more infants and feeding two at the breast are more challenging than when managing a singleton dyad. ()
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Supplemental feeds are more frequently required. Consider donor human milk if available, at least in the first few weeks of life, if the mother is not producing enough milk. ()
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Help the mother of multiples in managing her time. This includes how best to use the help of family, friends, and even hiring help. ()
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The mother of late preterm twins will usually not be able to feed them in tandem until they are older and are each effectively feeding at the breast alone due to their immaturity and need for more help with positioning, latch, and continued attention during a feed. ()
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Some mothers will never produce enough milk to exclusively breastfeed more than one infant, and those infants will need supplementation with donor human milk or infant formula. ()
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Recommendation Grading
Overview
Title
Breastfeeding the Late Preterm and Early Term Infants
Authoring Organization
Academy of Breastfeeding Medicine
Publication Month/Year
January 1, 2016
Last Updated Month/Year
June 9, 2022
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
Assist the late preterm and early term infant to breastfeed and/or breast milk feed to the greatest extent possible. Heighten awareness of difficulties that late preterm and early term infants and their mothers may experience with breastfeeding. Offer strategies to anticipate, identify promptly, and manage breastfeeding problems that the late preterm and early term infant and their mothers may experience in the inpatient and outpatient settings. Prevent problems such as dehydration, hypoglycemia, hyperbilirubinemia, hospital readmission, and failure to thrive in the late preterm and early term infant.
Inclusion Criteria
Female, Male, Adult, Infant
Health Care Settings
Ambulatory, Outpatient
Intended Users
Dietician nutritionist, counselor, nurse, nurse practitioner, physician, physician assistant
Scope
Counseling, Prevention, Management
Diseases/Conditions (MeSH)
D001942 - Breast Feeding, D007225 - Infant Food, D007228 - Infant Nutrition Disorders, D007234 - Infant, Premature
Keywords
Breastfeeding, late preterm, early term, infant nutrition, lactation support
Supplemental Methodology Resources
Methodology
Number of Source Documents
63
Literature Search Start Date
January 1, 1990
Literature Search End Date
December 31, 2016
Description of External Review Process
Yes. The draft protocol is peer reviewed by individuals outside of contributing author/expert panel, including specific review for international applicability. The Protocol Committee's sub-group of international experts recommends appropriate international reviewers. The Chair and/or protocol resource person institutes and facilitates this process. Reviews are submitted to the committee Chair and resource person. The contributing author/expert panel and/or designated members of protocol committee work to amend the protocol as needed.
The draft protocol is submitted to the Academy of Breastfeeding Medicine (ABM) Board for review and approval. Comments for revision will be accepted for three weeks following submission. The Chair, resource person and protocol contributor(s) amend the protocol as needed. Following all revisions, the protocol has the final review by original contributor(s) to make final suggestions and ascertain whether to maintain contributing authorship.
The final protocol is submitted to the Board of Directors of ABM for approval. A two-thirds majority of Board members' positive vote is required for final approval.
Specialties Involved
Endocrinology, Obstetrics And Gynecology, Pediatrics, Neonatology And Perinatology, Pediatric Endocrinology, Pediatrics, Pediatrics
Description of Systematic Review
Yes. Expert Consensus from systematic reviews with evidence tables.
Description of Search Strategy
Yes. The panel lowered the age for inclusion in the Late Preterm category by one week to include the infant born 346/7 - 346/7 weeks in the LPI category. Much of the new literature documents the increased vulnerability of these infants. There is little strong evidence for managing the late preterm infant, therefore, we have occasionally drawn on studies using more preterm infants or even full-term infants in the management section. The obstetrical literature has had a number of articles examining the increasing incidence of late preterm births and current obstetrical practice. We have therefore included some of these articles.
Description of Evidence Analysis Methods
General Methods
An initial search of relevant published articles written in English in the past 21 years in the fields of medicine, psychiatry, psychology, and basic biological science is undertaken for a particular topic. Once the articles are gathered, the papers are evaluated for scientific accuracy and significance.
Specific Methods
The search was conducted using PubMed. In addition, a search of the original references and literature searches (from the previous version) were used to look for additional supportive articles. The time frame for the literature search was January 1995 to December 2016. The inclusion criteria used for the searched were: humans, review articles, primary research articles, and English. The specific search terms used were: breastfeeding, primary care, physician, pediatrician, obstetrician, family physician.
Description of Evidence Grading
U.S. Preventative Services Taskforce Recommendations. An expert panel is identified and appointed to develop a draft protocol using evidence-based methodology. An annotated bibliography (literature review), including salient gaps in the literature, is submitted by the expert panel to the Protocol Committee.