If your infant is small and premature or very sick at birth, the initial feedings will begin slowly with tiny amounts. The premature bowel is very fragile and about the thickness of tissue paper, so we must be cautious. Infants who are very sick may have less bowel motility and may have a bowel that is also recovering from the stresses of delivery. As the feeding volume increases the intravenous volumes are decreased. If your child is very premature or very ill he/she will received total parenteral nutrition (TPN). The goal is to nourish your infant, providing the essential nutrients. We want your infant to begin to gain weight after the brief initial weight loss (all babies lose weight in the first few days of life). If your infant is small and tolerating feedings, human milk fortifier maybe added to your milk to optimize growth. It increases protein, calcium, phosphorus, mineral, and caloric contents to meet the requirements for growth. If your infant is not receiving human milk, a cow’s milk based premature formula will be used.
When feeding newborn infants mother’s milk is the gold standard. It supplies the very best nutrition and gastrointestinal protection for all infants. We want to encourage all mothers, who are able, to breast feed their infants. We want to support mothers in this endeavor every way possible. If your infant is very small and sick he/she maybe eating small amounts initially. These feedings are given by gavage, which means the feeds are given through a soft plastic tube which extends from the mouth to the stomach. Your infant in addition will received IV nutrition containing all the essential nutrients. We would like to encourage you to use an electric breast pump as soon as you are able and ask you to pump at regular intervals (every 3 hours), saving even the smallest amount of milk (colostrum) obtained. It is often a few days before your milk supply comes in. If your infant is not ready to eat immediately, we will ask you to label and freeze your milk. We will use it when your infant is ready to eat. If you are obtaining only small amounts this can often be used for your infant’s oral cares even if he/she is not being fed initially. If your infant is very premature, ready to eat and your milk has not come in with your consent we will use screened, pasteurized human donor milk from the Indiana Mother’s Milk Bank.
Research has demonstrated that human milk is very advantageous, to all infants, but especially the smallest infants. There appears to be a protective effect on the very fragile preterm gastrointestinal tract. If for some reason screen pasteurized human milk is not available we will use cow’s milk based formulas appropriate for your infant’s age and gestation until your milk is in. Your milk will always be our first choice when it is available.
Kangaroo Care is when a parent holds their infant “skin to skin” with the infant snuggled on the parent’s chest and covered with warm blankets. The infant remains on the monitors so he/she can be easily evaluated. Most infants when stable appear to enjoy this contact, as do their parents. Nursing staff using their clinical assessment and judgment will determine when your infant can safely practice Kangaroo Care. Certain central lines may pose a risk and they should be discontinued before performing Kangaroo Care. All infants appear to benefit from this care. If a mother is providing her milk, kangaroo care may help stimulate more milk production.
Gavage and Nippling
When infants are very premature they have immature suck/swallow/breath coordination. Nipple feeding is dangerous before the full development of this reflex, due to a risk of aspiration of milk into their lungs. Infants are fed directly into their stomachs with a soft pliable tube placed through the nose or mouth. This is called gavage feeding.
The amount of time your infant requires gavage feeding varies depending on the development of the nippling reflex and your infant’s stamina. NICU nurses are trained to read a baby’s cues and do not force infants to continue after they are exhausted. When an infant is not up to nippling all of the feeds, gavage feeding delivers additional calories and protein that your infant needs to continue growing at an in utero rate. This is a period of rapid brain growth and providing nutrients to support this growth is very important.
All infants have their own nippling time table. Your infant will be given the opportunity to nipple when nursing assessment indicates it is safe. Be patient feeding will improve as your infant matures and recovers.
At time of discharge it is important that your infant eat very well for many days with no need for coaxing or encouragement. We want your infant to be consistently eating enough so that he/she is growing and developing appropriately. This ensures that your infant will make a successful transition to home.
Latching and Nursing
Sick or premature infants whose mothers are planning to breast feed often start with kangaroo care. For an infant to nipple feed he/she must be able to coordinate the suck, swallow, and breathing reflexes.
Infants often start going to breast a few times a day in order to learn to latch to his/her mother’s breast when they are beginning to feed orally (both breast and bottle). Feeding coordination often begins to appear at 33-34 weeks corrected gestation. When first latching to the breast, infants will get very little or no milk. The goal is for the infant to practice the unique action of latching, while continuing to receive supplemental milk. A breast shield maybe helpful as the small premature infant begins to latch, this will gradually allow the transition to occur from bottle to breast feeding.
To facilitate the latch, it is important to chose a time when your baby is awake, alert and acting hungry. The goal is to do this for short periods of time consistently. Small or sick infants do not have the power or stamina to obtain a full feeding from their mother’s breast. Since nursing volumes may be small, infants are given additional mothers milk from a bottle or gavage tube so that they receive adequate nutrients while he/she is growing stronger and more mature. The intent is for your infant to continue to grow at in utero rates optimizing his/her brain growth and development. Nipple feeding can be very inconsistent in sick or premature infants. Some feedings may be totally nippled and other require all or partial gavage. Stamina with feeding comes with maturation and recovery from illness. In order to be ready for discharge your infant must be nippling all feedings well for a number of days and be taking adequate volumes by nipple, allowing him/her to gain weight appropriately. At discharge preterm infants need to supplement breast feeding with mother’s milk in a bottle, since they are not strong or mature enough to obtain a full feeding from the breast. Lactation consultants are available upon request, if you need help please do not hesitate to ask.
Donor Breast Milk
Considerable research has confirmed multiple advantages of feeding infants human milk (see resources section for documentation). Our NICU has been fortunate to obtain a supply of frozen, screened, pasteurized Human Donor milk for the smallest and sickest of our patients from the Indiana Mother’s MilkBank (IMMB).
For additional information concerning the treatment and safety of IMMB donor breast milk please visit the website for the Indiana Mother’s Milk Bank
If You Are Not Breast Feeding
Breast feeding is encouraged whenever possible. We realize that some mothers are unable to breast feed for a variety of reasons. If you are not breast feeding, and your infant is less than 32 weeks, donor human milk will be available on a limited basis. If your infant is greater than 34 weeks, we will use the best commercially available formula that is appropriate for your infant’s needs. These formulas are specially developed to support balanced growth for infants with a variety of problems in addition to prematurity and are the result of years of research.
Infants born early often have extremely irregular breathing resulting in a slowed heart rate and a fall in oxygen levels in the blood. This is a result of an immature respiratory control center and is called apnea. Apnea in premature infants frequently doesn’t start on the first day of life, but may appear on a subsequent day. Mild apnea is monitored closely with cardiorespiratory monitors and infants are stimulated when necessary to encourage them to breath. More severe apnea spells maybe treated with nasal CPAP, or high flow nasal cannula, and/or caffeine.
Infants cannot go home from the hospital while they are having significant apnea, bradycardia, or desaturation spells. Apnea of prematurity resolves with brain maturation and spells will resolve as infants approach term. It is often frustrating for parents when infants have apnea spells, but these can be life threatening events and need careful monitoring.
Respiratory Distress is one of the main reasons infants are admitted to the NICU. There are many causes for newborn infants to have respiratory distress. Your infant’s neonatologist/NNP will discuss the most likely cause of your infant’s distress. Common types of support or treatment for infants with respiratory problems include the ventilator (breathing machine), Nasal Continuous Positive Pressure (NCPAP), High Flow Nasal Cannula, and supplemental oxygen. We will follow blood gases, oxygen saturations and Chest X-Rays when indicated. If your infant is having respiratory distress your doctor/NNP will discuss the diagnosis and treatment with you.
Jaundice is the yellow skin color often seen in newborn infants, and is caused by elevated levels of bilirubin in the infant’s blood stream. Jaundice has many causes in the newborn period. Sick and premature infants are more at risk of experiencing the toxicities of jaundice, so they are often treated at lower levels. Mildly elevated bilirubin levels are often seen in term, healthy infants and may or may not need to be treated. Elevated levels of bilirubin are a concern, because bilirubin may cross into the infant brain, potentially causing seizures, mental retardation, and hearing loss. For this reason it is important to follow bilirubin levels and treat when appropriate. Your infant’s physician/NNP will take into account your infant’s gestational age (weeks of age since conception), illness, reason for elevation, and postnatal age before deciding whether and when to treat. Elevated bilirubin is most often treated with light therapy or phototherapy. The goal is to keep the values well below the toxic level.
Suspected infection is often a reason for admission to the NICU. Infections maybe passed from mother to infant in the labor and birth process. While an infant is in the uterus he/she is protected by the mother’s mucus plug and the membranes surrounding the infant holding in the amniotic fluid. When these barriers are no longer present, the infant inside becomes more susceptible to acquiring an infection. Bacteria from the birth canal may cause infection in the infant. When a woman is pregnant, both she and her infant have suppressed immune systems. This means they are both susceptible to becoming ill from infection during the delivery process. When a mother has a fever during labor this may be a sign of serious infection in the mother and infant. In addition when an infant is born and has distress with difficulty transitioning to extrauterine life, infection must be suspected. Prolonged or premature rupture of membranes puts both mother and infant at risk of serious, life threatening illness. Immune suppression puts all infants at higher risk for infections in the newborn period. Infants have few ways to indicate to us when they are sick. Infants who demonstrate signs or symptoms which suggest to the medical staff an infection maybe present, will have cultures drawn and will be treated with antibiotics, until an infection is either confirmed or ruled out.
Sick newborn infants both term and preterm may have multiple health problems after birth. Your infant is unique and may not experience all of the potential problems. Your physician and NNP will discuss your infant’s problems with you. We are anxious for you to understand the health problems your infant is having and how we are treating them. If you have questions or concerns we encourage you to talk with your infant’s nurse, NNP, and doctor.
For more information and reading on common concerns please visit our resources page for additional reading.