Meeting the Challenges of Breast-Feeding in the NICU

by Deborah L. Davis, Ph.D. & Mara Tesler Stein, Psy.D

I breast-fed my older [term] son with no problems. I know what it takes -- and believe me, trying to breast-fed a baby who isn't there is pretty difficult. Add to that the fact that your two daughters are still in the hospital and you don't know when or if they will be coming home soon. Now that's a task. ~~Rosa

The NICU is not the place to get a great start, everything else about the preemie experience, you don't have a lot of choices, do you? Preemies have weaker, sometimes less coordinated sucks; they tire easily; they distract easily (which I thought was more difficult that the tiring); and it's so hard with the tension, hormones, and milk-engorged breasts. ~~Sheila

I really wanted to breast-feed her right away. I did keep up the pumping and did eventually get to breast-feed, but they convinced me that bottles were better to start. I really feel bad to this day for letting them take charge because I know now this is not so. Still, who was I to know? They were the professionals. ~~Linda

Lenore & AdamUnfortunately, while your preemie is hospitalized, you may not always receive effective guidance and support in your attempts to breast-feed. Sometimes, despite the health care team's encouraging you to supply breast milk, your baby is given formula. Or the staff's decision to bottle-feed your breast milk to your baby may make you feel that they are more interested in your breast milk than in helping you master breast-feeding. Your desire to breast-feed or the pace that you had imagined for feeding your baby might not match the staff's routines.

When you're trying to assert some control as a parent, it can be frustrating to have to negotiate all of this with your baby's medical team. And sometimes, you and your baby simply will not be able to breast-feed. This can be a tremendous blow if you had had your heart set on breast-feeding exclusively.

The next day I was desperate to pump some more milk for my son, but the nurse on duty wouldn't help me. She said okay and then never showed up, so I kept calling her to help. Finally she told me that she was waiting for the lactation specialist to come in at 10 am. I was mad and shot her a dirty look. I don't think she realized how important it was to me to get some more milk to my son. I am still mad about it four months later. I was also mad at the NICU people who fed my son formula because they didn't have any of my milk. Didn't they realize that I had plenty of it but that I just couldn't get it to them? Why didn't they come get my milk -- I was only a few corridors away? If my milk is so much better than formula, then why???? The more I think about it, the madder I get!! ~~Ruby

Trying to breast-feed her turned out to be quite traumatic for both of us. She would latch on but, after thirty seconds or so, would become exhausted and fall asleep. The nurses would weigh her before and after our breast-feeding sessions and more often than not, she would have lost weight. I was very disheartened. I reasoned that breast-feeding her would be an opportunity to make up for our lost bonding experience, but it only proved to be very distressing for both of us. I tried to get her to breast-feed for six weeks once she was home, but I finally had to give up. At that point she was "hooked" on the bottle, and I couldn't get her to change her mind. I do wish the NICU nurses had told me that once she took the bottle it might be hard for me to switch to the breast. ~~Rebekah

Even if you end up succeeding in breast-feeding, the process can be quite trying and drawn out. Because preemies often take a long time to learn to coordinate sucking, swallowing, and breathing, breast-feeding can require a lot of patience. Your baby may take two steps forward and then one step back. Do keep in mind that most term babies don't learn to nurse until they are around forty weeks' gestation. Try to give your preemie credit for accomplishing as much as he or she does. Comfort yourself by imagining a future in which you and your baby have mastered nursing. Envision it. Allow yourself to hope for it. Then do what you can to try to make it happen.

I was absolutely determined to breast-feed my preemie (not knowing at the time how difficult such a thing is!). I arranged special permission with the NICU staff to be able to breast-feed him every time he was bottle-fed, supposedly to try to keep him used to both. He didn't have any trouble latching on to me, though. Well, sometimes he did seem to have trouble, as if he was frustrated and didn't want to latch on. And I'd get all discouraged and depressed. And, of course, the staff didn't really care about making sure I breast-fed the same number of times as he bottle-fed -- it was all up to me to push for it to happen. But I kept trying (stubborn mom that I am!). Lots of ups and downs, but we were exclusively breast-feeding by a few days after his due date. Patient stubbornness goes a long way, I think! ~~Sandy

Here are some suggestions for tackling the challenge of breast-feeding in the NICU (some of these apply to establishing breast-feeding after home-coming as well):

  • Discuss feeding options with your baby's nursing and medical staff. If you very much want to breast-feed, discuss ways to increase your breast-feeding practice without compromising your baby's progress.

  • Seek out support for and information about breast-feeding preemies. Talk to other breast-feeding mothers of preemies. If you are not satisfied with the lactation support provided by the NICU, don't hesitate to look for another lactation consultant: a nurse, midwife, or doula (a woman who gives emotional encouragement and physical assistance to a new mother) can also be a good source of support. There is plenty of information available in print and on the Internet. See the resources in Appendix C for some suggestions. (Chapter 6 also contains lots of information on the advantages, the mechanics, establishing and enhancing your milk supply, and overcoming physical challenges to breast-feeding.)

  • Recognize that you and your baby form a unique breast-feeding partnership. Whether her baby is term or a preemie, every mother has to do a certain amount of figuring out what works best. For instance, if your baby has trouble latching on to your nipple, you might try using your pump's suction to draw out your nipple before putting your baby to your breast. If your baby is overwhelmed by your milk spurting out at the beginning of the feeding, you might pump just enough milk to decrease the pressure or volume so that your baby can keep up with the flow without swallowing so much air or choking. Look for answers that work for both of you. Problems don't indicate failure -- they only indicate a need for solutions.

  • Know that some babies are easily distracted or overwhelmed by external stimuli. Ask if you can feed your baby in a quiet, darkened room. Experiment with different methods of holding your little one, such as wrapping or unwrapping him or her in a blanket.

  • Lenore & AdamIncorporate kangaroo care into your efforts to breast-feed. Research indicates that skin-to-skin contact inspires the instinct to suckle. You might try starting your breast-feeding sessions by placing your baby against your bare chest to rest, relax, and soak up your warmth and nurturing. If your baby starts rooting around on your skin, follow this cue and guide her or him to your nipple. Enjoying and relaxing with your little one is a priority, whatever feeding method you use.

  • Be flexible. You may want your baby to receive only breast milk, but allow yourself to consider supplementing with formula if it's necessary. You may want to exclusively nurse your baby, but let yourself consider bottle-feeding if that seems to be a solution. If you have one baby, make decisions uniquely for that baby -- no matter what your sister or cousin or nurse chose to do with her child and no matter what you did with your earlier babies. If you have multiples, the same principle applies: make choices that are unique for each child -- a good general practice for raising multiples. Being flexible doesn't mean that you've given in. It means that you recognize that the situation is not what you'd anticipated. Adjusting your plans to fit the situation is a wise decision.

  • Allow yourself to mourn your losses. Give yourself permission to experience your feelings -- sadness, frustration, disappointment -- about the options your baby's prematurity has ruled out.

  • See the feeding relationship itself as meaningful for you and your baby. Free yourself from society's definition of successful breast-feeding. For you and your baby, successful breast-feeding may mean that your baby takes a bottle filled with your pumped breast milk. Or it may mean putting your baby to your breast for a bit and then providing a full formula feeding afterward. Don't think in either-or terms. Experiment and adjust. Use the combination of breast milk and formula, bottle-feeding and breast-feeding that works for you and your baby.

  • Recognize that you supply many valuable things to your baby -- not just breast milk. The amount of breast milk you supply and the outcome of your attempts to breast-feed say nothing about your desire to nurture your baby or about your competence as a parent.

  • Persist through the ups and downs of your milk supply. When you are pumping into that clear bottle, you are well aware of variations in your milk supply. If your supply seems to be decreasing, you may simply need to get more rest, drink more water, or pump more frequently to maintain or build up your supply. If your baby takes a turn for the worse, your milk production may diminish overnight, and you may feel too depressed to try to maintain your supply. If your breasts seem unproductive in spite of pumping, you may be tempted to give up -- but try to keep pumping. This is a critical time for you to receive the support you need to keep your breasts primed. As your baby improves, your supply may build up naturally in response, and you can continue to reap the rewards of breast-feeding.

I'm so thankful to the lactation nurses at the hospital because, when Fabian got so sick, my milk production completely stopped. When I was pumping, I think I got two drops out, and they would tell me, every day, to continue pumping, I hated it at the time. It was horrible, but I did stick to it. I had to write how much I pumped on each side, a drop here, a drop there; a quarter of an ounce here, a quarter of an ounce there when things got better. For three weeks, I hardly had anything coming out. But when he got better, suddenly my milk came back in, and I got home, breast-feeding him completely. It was amazing -- to see that he was going to survive and make it, and not being scared for his life, that's when the milk started to get better -- and I'm so thankful for the support. Without them, I would have never been able to keep it going. ~~Gallice

Excerpted from Parenting Your Premature Baby and Child: The Emotional Journey, by Deborah L. Davis, Ph.D. and Mara Tesler Stein, Psy.D. (Fulcrum, 2004), pages 301-305.

Deborah L. Davis, Ph.D. & Mara Tesler Stein, Psy.D. are the authors of Parenting Your Premature Baby and Child: The Emotional Journey, a 2004 National Parenting Publications Awards "Gold Award" winner. They also collaborated on Parent: You and Your Baby in the NICU (2002), as part of the nationwide March of Dimes NICU Project. They've been invited to regularly contribute to Advances in Neonatal Care, a neonatal nursing journal; their first article appears in Spring 2005. They are the founding members of Partners in Perinatal and Pediatric Consulting, which promotes developmentally supportive care for babies and parents, as well as collaboration between families and health care professionals.

Dr. Stein is a clinical psychologist in private practice, specializing in the emotional aspects of coping with crisis and adjustment around pregnancy and parenting. She is regularly invited to lecture and give workshops on these issues throughout the country to conferences of physician and nursing groups, doulas, and lactation consultants. Since 1997, she has been consulting with organizations and providing training to health care providers, guiding their efforts to improve the level of psychological support and developmentally supportive care to families during and subsequent to perinatal crisis.

Dr. Davis is a developmental psychologist, researcher, and writer who specializes in perinatal and neonatal crisis, medical ethics, parental bereavement, parent education, and child development. Dr. Davis is the author of four books for bereaved parents, Empty Cradle, Broken Heart (Fulcrum, 1991; 1996), Loving and Letting Go (Centering, 1993; 2002), Fly Away Home (Centering, 2000) and Stillbirth, Yet Still Born (PILC, 2000). She is also on the Board of the Pregnancy Loss and Infant Death Alliance ( and is regularly invited to write articles for professional periodicals and parent support materials.

Copyright © Deborah Davis & Mara Stein. Permission to publish granted to, LLC.