Premature babies have extra nutritional needs. It is very important that they get the best possible nutrition to support them as they continue to develop outside the womb. Breast milk is the ideal nutrition, but babies born early may not be able to breastfeed directly. This leaflet explores some of the ways in which premature babies are fed in the early weeks.
How are premature babies fed?
This all depends on how premature your baby is, and on whether they have other medical problems or not. It will also change and evolve as they grow older, just as it does for babies who were not born early.
Breast milk has many advantages over other methods of feeding, but in some situations it may not be possible to feed your baby breast milk, or your baby may need extra supplements to breast milk.
Sucking, swallowing and breathing at the same time is something all babies have to learn, and those babies who are very small or very premature may not yet have the strength or coordination to manage this. Broadly speaking, babies born earlier than 34 weeks of pregnancy are likely not to be able to breastfeed or feed from a bottle directly, and may need to have breast milk or formula milk through a tube passing into their tummy via their nose or mouth. Extremely early, small or sick babies may need to be fed via a tube going into the vein at first.
The experts on your special care baby unit (SCBU), neonatal unit or neonatal intensive care unit (NICU) will explain the feeding options for your baby. This will change over time, and the experts will advise and help you. You will also get advice and support once you are discharged from hospital to help you as you continue to feed and then wean your baby.
Some of the ways in which premature babies may be fed are briefly explained below.
Breastfeeding premature babies
If it is possible, breast milk is the best possible feed for any newborn baby. Breast milk contains substances which help protect your baby from infection and it also has many long-term health advantages for both baby and mum. These include reducing your baby's risk of severe eczema, obesity, diabetes, cot death (sudden infant death) and reducing the breastfeeding mother's chances of breast cancer, ovarian cancer and diabetes. For premature babies specifically, breastfeeding also reduces the risk of a serious gut problem called necrotising enterocolitis.
Babies born after the age of 34 to 36 weeks are usually able to breastfeed, and babies born earlier than this should be able to once they reach this sort of age. For those babies who are too tiny or too young to be capable of breastfeeding directly, consider expressing your breast milk. This can then be fed to your baby through a tube or saved for later.
The staff looking after your baby can help you learn to express milk. It can be done by hand or with a breast pump. It allows you to be involved in giving your baby the best possible start. At first only a small amount of a thicker milk called colostrum will be produced, but over time you will find you are producing more milk, especially if you express regularly and frequently.
Supplementing breast milk
Premature babies may need more energy and may have different nutrition needs than babies born at term. So for some premature babies in addition to breast milk, one or more of the following may be needed:
- Extra vitamins, minerals and protein (in a breast milk fortifier or as separate supplements).
- Formula milk specifically for premature babies.
- Donor-expressed milk.
- Extra nutrients through a tube into the vein.
When breast milk fortifier is used, your baby will have regular blood tests to check that the levels of salts, minerals, etc, are exactly right to keep them healthy. Usually these blood samples are taken by pricking the baby's heel or back of the hand.
Premature baby formula milk
The experts looking after your baby in the neonatal unit will advise on which is the best premature baby formula for your baby, the amount needed and when this should be changed. It will depend on how early your baby was and on how much the baby weighs. Premature baby formula has extra nutrients to cover the extra demand. Usually it is first given by tube through the nose or mouth, but later by bottle once your baby is able to suck and swallow. Quantities will be calculated and changed as your baby gets bigger. When your baby uses a bottle, it is very important to sterilise it correctly. Premature babies are particularly at risk of infections, so this is extra-important. Your specialist staff on the neonatal unit will show you how this is done.
There are several premature baby formula milks available in the UK, including SMA® PRO Gold Prem, Nutriprem 1® and Hydrolysed Nutriprem®. Depending on the health and growth of your baby, in time these can be changed to normal formula milks. Some babies may need special milks and close monitoring if allergy is an issue. Getting the quantity of feeds and the rate of change right is important for the health of your baby, and your specialists will advise you.
Tube feeding of premature babies
If premature babies are unable to feed from the breast or bottle, they are fed via a tube. A nasogastric tube goes in through the nose, delivering the feed down to the baby's tummy (stomach). An oro-gastric tube goes in to the tummy through the baby's mouth. The feed may consist of expressed breast milk, fortified breast milk or formula milk. Most babies born before 35 weeks of pregnancy will need feeding in this way at first.
When your baby is being tube-fed, you may still be able to try 'kangaroo care', which is skin-to-skin contact between you and your baby. This helps the bonding and closeness between you and your baby, and helps with early breastfeeding. If your baby is placed close to your breast when being tube-fed, once ready to breastfeed he or she may start trying to lick or suck the breast.
Total parenteral nutrition
Total parenteral nutrition (TPN) is used in very premature or very sick babies. All the nutrition the baby needs is given by a tube into a vein, sometimes through the belly button (umbilicus) into the vein there. This is used when the baby's guts are not developed enough to deal with the feeds passing through them, or if the baby is very sick or has a condition of the guts called necrotising enterocolitis. Once the baby's guts are more developed or settled, then tube-feeding can gradually replace TPN.
Feeding problems in premature babies
Feeding more than one baby
If you are having twins or triplets or more then they are more likely to be born early. The feeding principles are all exactly the same, but the logistics can be more challenging! It is still possible to breastfeed more than one baby as the breasts produce milk on demand, so theoretically can produce milk for as many babies as you have. Some mothers are able to breastfeed two babies at the same time; others prefer to have more of a rota system going. Again, your breastfeeding advisor will help you as you establish a system, and learn to breastfeed, and your specialist team on the neonatal unit will advise if your babies need extra nutrition in any way.
Premature babies may be more likely to get colic in the early weeks. A baby with colic is more unsettled, crying more than most babies. This is thought to be because they have a tummy ache, but it is not known for sure. Health professionals will determine whether there is any other cause other than colic for the crying, particularly in premature babies who are more at risk of various medical conditions. If colic is thought to be the cause, there are various strategies you could try to help settle your baby. See the separate leaflet called Colic in Babies and Infants.
Reflux is a common condition which is more common in premature babies. After feeds, some of the milk makes its way back up from the stomach into the gullet. The baby may or may not bring the milk back up (vomit) and seems to be uncomfortable after feeding. It may affect weight gain, and the baby may seem unsettled and cry a lot. See the separate leaflet called Childhood Gastro-oesophageal Reflux for more information.
Weaning your premature baby
Weaning is the time when you start to add foods other than milk to your baby's diet. 'Solid' foods are started as mushy foods - baby rice, pureed fruits and vegetables, etc. There is no single time when it is right to wean a premature baby, because each individual baby's situation is different. The timing is likely to be around 4 to 6 months after the date when your baby should have been born if he or she hadn't been born early. In your individual case, you will probably make the decision to start weaning, taking into account:
- Your baby's past medical history and how early he or she was born.
- Advice from the medical specialists if your baby is still under specialist care.
- Advice from your health visitor.
- Signs that your baby is ready to start weaning. Read about these in the separate leaflet called Baby-led Weaning.
Further reading and references
Victora CG, Bahl R, Barros AJ, et al; Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016 Jan 30387(10017):475-90. doi: 10.1016/S0140-6736(15)01024-7.
The Baby Friendly Initiative; UNICEF UK
Dutta S, Singh B, Chessell L, et al; Guidelines for feeding very low birth weight infants. Nutrients. 2015 Jan 87(1):423-42. doi: 10.3390/nu7010423.
Agostoni C, Buonocore G, Carnielli VP, et al; Enteral nutrient supply for preterm infants: commentary from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2010 Jan50(1):85-91. doi: 10.1097/MPG.0b013e3181adaee0.
Conde-Agudelo A, Diaz-Rossello JL; Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2016 Aug 23(8):CD002771. doi: 10.1002/14651858.CD002771.pub4.
Moore ER, Bergman N, Anderson GC, et al; Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016 Nov 2511:CD003519. doi: 10.1002/14651858.CD003519.pub4.