Challenges of late preterm infants
This isn't a typical educational blog post. This is the raw, truthful reality of my experience with a late preterm baby, because I'm hoping my experience and subsequent education will help someone else.
When I delivered my first-born, at 35 weeks and 6 days I had never heard the term "late preterm", even throughout nursing school. Even when I left the hospital with this 5lb 14 oz baby, I did not understand what it meant.
All the nurses said, "He doesn't look preterm". "You must have had your dates wrong."
Late. Preterm. Infant. What does that even mean?
Late preterm infants (born between 34 and 36.6 weeks) are more at risk for several morbidities such as
jaundice
temperature instability
low blood sugar
feeding challenges
respiratory distress
poor breastfeeding rates
Often times these late preterm infants are the great pretenders. They are often a similar weight as their term infant counterparts. They generally spend the same time on the postpartum floor after delivery and go home with unsuspecting parents.
I was one of those unsuspecting parents.
When my first baby was born, the nurse told me I had 12 hours for my milk to "come in" and then we would need to supplement. Sure enough, at the 12-hour mark we began supplementing with donor milk. I was told to attempt to breastfeed my very sleepy baby, then finger feed donor milk and finally pump after every feed.
I had NO idea why I was pumping. I had no idea that it was atypical for babies to be so sleepy, to not have hunger cues, to sleep through feedings, to have low energy and low stamina when feeding. Sure, I knew that the pump was to get milk out, but all I had were a few drops, so I stopped pumping because it obviously wasn't working. I didn't know I should be pumping to stimulate milk production. I defrosted donor milk and finger-fed my baby every hour and a half. He never latched in the hospital, and I BEGGED to be taught how to bottle feed. We went home with a bag of tubes, syringes, nipple shields and pump parts but no plan on how to feed our sleepy baby.
And my milk didn't come in until day 5.
I'll spare you the remainder of the details and just say my breastfeeding experience with my firstborn was not the "natural, beautiful" experience the insurance-created "breastfeeding education" said it would be.
During my years working as a mother/baby nurse and now with my lactation clients, I see, time and time again, parents with late preterm infants struggling with breastfeeding. No one ever mentions the challenges of these babes.
Late preterm babies (LPI) are not the same as term infants.
Or even preterm infants.
Remember how I said LPI's are the great pretenders? They usually skate by in the first few days, avoiding all the excitement of the NICU and all the interventions that go along with being premature.
Late preterm babies account for up to 70% of preterm births, but there is still limited education for parents about what this actually means and how to support breast/chest feeding with this group. LPI's have a lower incidence of initiation of breastfeeding and shorter duration.
What should you know about late preterm infants?
Late preterm may not have as much brown fat at term infants.
Their buccal (cheek) fat pads may not be developed.
These babies are still supposed to be developing in utero, so they are often sleepier, have fewer awake periods and need more stimulation to stay awake.
How does this relate to breastfeeding? Let's break it down.
Brown adipose tissue (aka brown fat) uses lipids (protein) and glucose (sugar) to create energy in order to keep the body warm. If there is not adequate brown fat, the body will use protein stores and glucose from other sources in the body. If an infant does not have enough brown fat, they will be more at risk for calorie and glucose deficit. This can result in greater than normal weight loss, energy loss, and low blood sugars (which has its own problems). These babies need frequent feeding, skin to skin (hello temperature and blood sugar regulation1) and to be kept warm.
Have you ever looked at the cheeks of a preterm infant vs term infant and noticed the chubby, round cheeks of a term babe? While it's super adorable, it's also aids in ability to feed. The fat in infants' cheeks actually helps stabilize the nipple in the mouth and maintain the negative pressure inside the mouth that stimulates milk transfer. Early babies often have lower tone in their cheeks, less fat and therefore need more help with maintaining a latch. They tire easily and often need more assistance with breastfeeding.
3. Preterm infants are very sleepy. They can be difficult to keep awake during feeds, have low stamina and strength when breastfeeding, not show hunger cues and then miss feeds all together. Which again, puts them at risk for low blood sugar, weight loss, calorie deficit, jaundice, poor breastfeeding...see where I am going with this?
* Photo of my late preterm baby on the left and my term (8lb 12 ounce) baby on the right*
How can we (healthcare and lactation consultants) help parents of late preterm infants.
Educate
Parents and support partners should be made aware of the potential issues related to feeding late preterm infants. The age-old adage "what they don't know won't hurt them" does not work in healthcare! Parents should know WHY these babies might need extra help or more frequent feedings or monitoring. You wouldn't tell a parent their child has diabetes and then not tell them what to look for, so why would we do that with infants? Give all the information, even the scary stuff.
Empower and Plan
Empower parents by giving them all of the information and then giving them OPTIONS on how they want to proceed. We want adherence, not compliance. Decision making should be a mutual task. Develop a feeding plan that the parents are comfortable with, come up with a back-up plan and allow them time to ask questions, change the plan and veto what they do not like.
Support
Once parents are discharged from the hospital, there is little support. If someone is discharged with a specific feeding plan, there should be a follow-up appointment scheduled to see if that plan worked, if it needs to be adjusted or if it can be discontinued. There should also be a checklist for parents (beyond the standard "Return to your doctor if..." warning) so they can identify normal vs. abnormal and knwo when to return for help. Sending them home with a bag of supplies, no feeding plan and no guidance on weaning from the plan is setting them up for failure and frustration.
That's great, but what should I do about my late preterm baby!?
A few things you can do right after delivery are:
Uninterrupted skin to skin. This helps baby regulate body temperature, helps with blood sugar, allows for the natural instincts of nursing to kick in, helps keep them calm and promotes milk production. (WOW!)
Breastfeed within the first 60 minutes. Studies show that uninterrupted skin to skin and feeding within 60 minutes positively impacts the overall duration of breastfeeding. Your baby is also no longer receiving continuous glucose, nutrition and hydration from the placenta so the longer they go without feeding, the more likely they will become hypoglycemic (low blood sugar). Remember the brown fat and glucose?
Hand express! Hand expression helps stimulate the hormones that are responsible for milk production. Hand expression in combination with breastfeeding also helps increase your overall supply of breastmilk than breastfeeding alone. Because many preterm infants have difficulty latching and/or staying awake to feed, hand expression can be used to remove colostrum to given via spoon/cup/syringe if baby is unable to effectively feed. Colostrum is thick and available only in small amounts, so hand expression is better at removing the colostrum than a pump.
Things you may have to do to support your late preterm infant:
Pump to stimulate and protect milk supply if baby is unable to latch or is inefficient at removing milk from the breast.
Use an alternate feeding device (such as a spoon, cup, syringe, bottle or SNS device) until baby is strong and coordinated enough to feed on their own.
Wake your baby frequently and uses frequent stimuli to keep baby actively feeding.
Work with a lactation consultant to develop a feeding plan including supplementation as needed AND weaning from any devices or supplementation.
Late preterm infants can be tricky; however, I strongly believe that when parents are informed, empowered and supported, they are set up to better care for their infant and care succeed in meeting their feeding goals while also being mindful to the challenges they may face along the way.
Did you have a late preterm infant, and did you feel informed about what that meant?