A baby born at younger than 36 weeks is considered premature. A baby born at 38 weeks or later is considered full term.
But what about the baby born from 36 weeks to 37 weeks, six days gestation? A baby born in this window is considered a “late preterm infant” or LPI or, as I like to call them, baby birds.
LPIs are tricky. They almost always look and seem to act like full term babies, just smaller. They can usually maintain their body temperature as well as a full termer and breathe like a full termer, at least well enough to not need 24 hour care in the NICU. LPIs seem to eat well, too. They root and latch and suck.
The problem with LPIs is what you can’t see. Yes, they can maintain their temperature and breathing, but it requires a lot more work and energy to do so–energy that should be saved for eating and growing. Yes, they root and suck, but their sucks are uncoordinated and weaker than full term babies’ and they often don’t have enough energy to do the hard work of completing a feeding.
Late Preterm Infants often don’t have the energy or sucking strength to eat enough or stimulate a healthy milk supply.
It is a mistake to trust a late preterm baby to carry the full burden of breastfeeding. No, they don’t need NICU care, but they do need extra special care. After all, they could have stayed in the womb an additional four to six weeks and had an umbilical cord to do all of their work! Why do we expect them to come out of the womb and do all the work of eating and growing on their own?
Furthermore, it is unfair and sometimes harmful to treat a late preterm infant like a full term infant. They shouldn’t be undressed to keep them awake; they don’t have enough fat to keep them warm and thus end up wasting energy. They shouldn’t be awoken every one-and-a-half to two hours to feed. Interrupting sleep cycles can exhaust the little energy stores they have. Ideally, LPIs should be getting an uninterrupted two to three hours of sleep between feedings. However, LPIs should go no longer than four hours without eating until the pediatrician gives the go ahead to go longer.
These little babies are working damn hard to eat and grow like they should. So, please don’t call these babies lazy. They are trying their hardest and they simply don’t have the extra energy to work hard as a full term baby does.
So how do we best care for the late preterm breastfed baby? Easy—we follow the same rules that we follow with every baby, we just assume that the late preterm baby will be more likely to need us to feed him and protect his supply than his full term counterpart.
The sooner we fatten up this little baby bird, the sooner he will have the energy to take over and breastfeed on his own. Instead of making him fight his way through the early weeks of his life that could have been in the belly, why not help him out?
As you have heard me preach time and time again:
- Feed the Baby
- Protect the Milk Supply
I will add here: Maintain Balance
- Seek Help
Feed the Late Preterm Baby
Assume that your late preterm baby isn’t eating as much from the breast as he should be until he proves otherwise. Sure, he latches on and seems to suck, but he may only drink for a few minutes, if at all. The late preterm infant is notorious for non-nutritively sucking on the breast, not effectively drinking from the breast. Take him off the breast and he may cry or he may just fall asleep, seemingly full but in actuality just too tired to tell you otherwise.
So, feed him.
If at the two- to three-hour mark he is showing signs of hunger and eagerness to eat, let him nurse on the breast and then give him some “easy milk.”
If he seems pretty sleepy and isn’t showing much energy or stamina to feed, it is okay to skip direct breastfeeding and go straight to the bottle. We want baby bird to get an easy feed, especially when he just doesn’t seem to have the spunk to do it himself.
After or in place of breastfeeding, offer him a supplement of your own milk if you have it or formula if you don’t. Follow these top-off guidelines:
Help him nurse directly from the breast with the use of a nipple shield. (But, Katie, isn’t this baby going to get nipple confused?! Maybe, maybe not, but don’t worry. He will still get back on the breast when he is good and ready).
Nipple shields can be really helpful for near-term babies. Because they have less cheek fat, they often have too much intra-oral space to create a strong enough suction to drain the breast. A properly fitted nipple shield can help decrease the intra-oral space and increase the strength of the baby’s suck.
However, nipple shields for the preterm baby are often misfitted. The shield should be fitted for mom’s nipple first and foremost. This is almost always (for mom) and very rarely (for LPI) a size 24mm. Remember, just like a pump flange, the nipple needs freedom to extend up to 1.5 times its length with every suck to properly release milk. If you are comfortable pumping in a 24mm pumping flange (the one that comes with the pump) or perhaps even a larger flange, you should not be using a 20mm (small) nipple shield. Nipple shields are often misfitted, even by professionals. A 24mm may seem too big for your little baby’s mouth, but that simply means he isn’t ready to feed at the breast. He needs to grow. A smaller shield may seem like a better fit for baby’s mouth, but if it is pinching off mom’s nipple, it is going to cause nipple trauma and prevent milk from flowing. Not worth it.
As I will explain in just a moment, late pre-term babies should be cared for under the supervision of an IBCLC. She should be able to make sure your nipple shield is the right size and is working effectively.
Protect the Late Preterm Baby’s Milk Supply
Again, I don’t trust late pre-term infants. I don’t trust them to tell us whether or not they have had enough to eat and I don’t trust them to protect your milk supply. Furthermore, mothers who deliver before full term are at a higher risk for low milk supply. So, let’s do some of the hard work for the baby bird. Pumping after some nursing sessions will drain your breasts more thoroughly than the baby can. This will promote a more abundant milk supply so that when baby is ready to take over and nurse, his full milk supply will be there for him.
Ideally, your breasts will have eight good breast stimulations per 24 hours. A good stimulation in this case is a nursing session followed by a pumping session or a pumping session alone. Until proved otherwise, nursing a late preterm infant without pumping after is not considered a “good stimulation.”
There are a lot folks out there who will say that a baby is always better than a pump. My response is that a good breastfeeder may be better than a pump. Late preterm babies are not good nursers. Not until they prove to us that they are.
I’m sorry! I am not trying to be mean to the little baby born a little too early. In fact, I am trying to be nice to him and help a baby out!!
Maintain Balance when caring for the Late Preterm Infant
You may hear the recommendation to “triple feed” every two hours around the clock. Triple feeding is first breastfeeding, then supplementing baby with a bottle, then pumping. In a world where there are more than 24 hours in a day and a mother is an octopus who needs no sleep and has round the clock assistance, this may be a realistic plan. In real life, this is something no woman can or should be asked to do. Yes, she will need to triple feed at times. She will need to triple feed when she is “practicing” breastfeeding at those times when baby is awake and alert. During these practice feeds, time at the breast should be about 30 minutes total since there is still a bottle-feeding and pumping session to follow.
Remember the goal is eight good stimulations in 24 hours. That leaves room for creative thinking. For instance, mom may opt to triple feed for 12 hours of the day and exclusively pump and bottlefeed overnight. Mom may even be able to sneak in a much needed four to five hour stretch of sleep overnight while a helper bottlefeeds baby at the two- to three-hour mark (in another room where mom isn’t awoken). It is okay. Your boobs can handle one or two four- to five-hour stretches. Just be sure you clump together your pumping sessions for the remainder of the 24 hours to earn a total of at least eight.
Remember that you are going to be at this for quite a few weeks until your baby is ready to take over and do all this extra work on his own. It is a marathon, not a sprint. If you go too hard too fast in the beginning with triple feeding, you will crash hard.
Seek Help Specialized for the Late Preterm Baby
You need a team as you navigate the early weeks and possibly months of breastfeeding a late pre-term infant. You need a great pediatrician and a great IBCLC who understand that late pre-term infants are not small full-term infants. They have special needs and need special care. A good IBCLC who understands these needs will help you find a plan that is sustainable for the long term, a plan that does not drive you and your partner crazy with exhaustion or leave your late preterm infant susceptible to unnecessary stress and medical complications such as jaundice, dehydration, or readmission to the hospital.
A note to the mother of a late preterm infant:
The mama of the LPI is fragile, just like her baby. She was taken by surprise by this delivery. She wasn’t ready. She may feel responsible for not carrying this baby inside of her longer.
It has been my experience that these mamas will do anything and everything asked of them to breastfeed this baby.
So here is what I say to you, mama of the baby bird born a little too soon:
It is not your fault that your baby came before he was “supposed to.” It is not your job to toil extra hard to make up for the fact that this little baby came a little too soon. Your self-sacrifice is not penance for the sins that were not yours to begin with.
So, yes, be extra protective of your little baby. Protect him from stress and cold. Protect him from germs. Make life easy for him, make eating easy for him, and carry a little more of that load upon yourself. Do the hard work for him until he is big and strong enough to do it himself.
Because he will be able to do it by himself very soon, when he is strong and ready.
But you must take care of yourself, too, mama. You must pace yourself, drink plenty, eat well, and rest. You must seek the help of a caring and skilled IBCLC and the solace of a welcoming and nonjudgmental support group.
Before you know it, your little baby bird will be flying all on his own.