Breast Feeding the Premature Infant


Reviewed & Updated by Lynley Nichols
Clinical Guidelines Back Newborn Services Home Page
Preparing for Breastfeeding Kangaroo Care Assessing Readiness to Feed/
Establishing Breastfeeding
Breastfeeding Code
The Sleepy Infant Nipple Shields Other Related Documents

Preparing for Breastfeeding

Follow the steps below to prepare a preterm infant for breastfeeding.

Please Note: The preferred method of transitioning an infant to breastfeeding in Newborn Services is by nasogastric tube.

  1. The infant should be offered the breast when showing cues (if the mother is available) regardless of the feed time. If the infant is consistently not showing cues to feed spontaneously refer to Newborn Services RBP: The Sleepy Infant.
  2. Observe baby’s response at the breast and explain to the mother initial attempts at the breast may only involve licking, or latching and mouthing only.
  3. Baby should be held on alternative breasts to promote feeding from both sides.
  4. Frequent breastfeeding opportunities will enhance the maturation of the infants feeding skills.
  5. For the breastfed preterm infant, supplementary feeds should ideally be given by nasogastric tube or alternative feeding methods discussed with the mother.
  6. Nasogastric tube feed baby while having skin-to-skin contact with the mother, or being held at the breast. Refer Newborn Services RBP: Non-oral Feeding.
  7. Bottles should not be offered to preterm infants whose mothers wish to breastfeed unless:
  8. Document outcome and management plan in infants Care Plan.
  • Kliethermes, P., Cross, M., Lanese, M., Hohnson, K., & Simon, S. (1999). Transitioning preterm infants with nasogastric tube supplementation: Increased likelihood of breastfeeding. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 28(3), 264-273.

Kangaroo Care

Refer to newborn service: Kangaroo Care Protocol

Assessing Readiness to feed / establishing breastfeeding

Follow the steps below to assess readiness of the preterm infant to breastfeed, and assist establishing breastfeeding.

Breastfeeding is a normal physiological behaviour even for preterm infants. Early and frequent feeding opportunities will enhance the infant’s ability to successfully breastfeed.

Please note: Readiness to feed is determined by infant’s feeding cues. Readiness to breastfeed is not determined by age, gestation, weight or ability to take oral feeds by alternative methods. Some well preterm infants may have the ability to initiate breastfeeding as early as 28-30 weeks gestation. Infants at this gestation should be cardio-respiratory stable and mothers may need to express prior to offering the breast.

  1. Observe for cues of readiness to suck, i.e. mouthing, rooting, gaping, brings hand to mouth. Note. Crying is a late sign of hunger and may result in uncoordinated sucking and fatigue, even in a term newborn.
  2. Offer breast when baby shows cues for sucking.
  3. Refer to NWH RBP: Healthy Term Baby: Establishing Breastfeeding as same principles apply.
  4. Ensure correct positioning and attachment occurs. See NWH RBP: Positioning and Attachment as same principles apply
  5. Assess breastfeeding outcome. See Newborn Services RBP: Breastfeeding Score as a guide to baby’s progress and guidelines to supplementation. Not all infants will require supplementation.
  6. If the infant is unable to effectively breastfeed – refer to the following Newborn Services RBP
  7. No restrictions should be placed on the infant’s opportunities at the breast unless there is a justified medical reason.
  8. Document outcome and management plan in infants Care Plan.
  • Hedburg Nyqvist, K., Sjödén, P-O., Ewald, U. (1999), The development of preterm infants breastfeeding behavior. Early Human Development, 55, 247-264.
  • Nygivst, KH. (2008) Early attainment of breastfeeding competence in very preterm infants. Acta Paediatricia, 97(6), 776-781

Breastfeeding Code

The following ‘Breastfeeding Code” is a guide only. Please take into account maternal milk volume, milk ejection reflex and medical condition of the infant when assessing a breastfeed.

Follow the steps below to make a breastfeeding assessment of a preterm/sick or newborn infant and to determine how much supplement will be given.

  1. Use the following scale to score and document the infants breastfeeding ability and whether a supplement/top-up is required:
  2. Depending on assessment and scoring:
  3. Do not supplement the infant who scores an E if the mother is available for another breastfeed.  Consider not supplementing then infant who scores a D if the mother is available for another breastfeed. The infant may wake sooner for the next feed.
  4. If nasogastric feed is indicated it is preferable to provide the opportunity for infant to have skin-to-skin contact or nuzzling at the breast. See Assessing Readiness to Feed/Establishing Breastfeeding

Note: All infants have different sucking patterns and pauses therefore timing a breastfeed does not provide an accurate assessment.

The Sleepy Infant

Follow the steps below as guidelines for gently waking and breastfeeding a sleepy infant

  1. Guiding principle is to feed according to the infants cue’s and the mothers availability.
    Note: That premature infants may have limited behavioural cues that may be subtle. Feeding sessions may occur at any time after the last feed and should not be based on when the next NG feed is due. It may be better to wake the baby after 1 1/2 to 2 hours after last feed than wait 4 or 5 hours as the baby may be even more difficult to wake then.
  2. Observe for subtle feeding cues, and then follow the steps below.
  3. Unwrap infant and allow to self stimulate while in the cot for a few minutes. If no response move to next step.
  4. Undress infant and place infant in skin-to-skin contact with his mother for as long as needed. If no response move to next step.
  5. Provide gentle massage over body, back and front. If no response move to next step.
  6. Drop some EBM onto the infant’s lips. If no response move to next step.
  7. Encourage some non-nutritive sucking. If still no response repeat from step 3.
  8. Infants may show signs of fatigue or ‘shut-down’ from over-stimulation. If this occurs revert to skin-to-skin contact to allow the infant to recover and then start again, or give feed via NGT.

Nipple Shields

There is scientific evidence to suggest that nipples shields may be of benefit for premature infants who have difficulty maintaining a correct latch. Nipple shields may also be useful for infants who fatigue quickly while feeding (e.g. cardiac or chronic lung disease infants). It is expected that nipple shield use will be limited to the prescription of a Lactation Consultant or Senior Nurse who has fully assessed the problem and detailed the risks and benefits to the mother. Nipple shields have not been shown to be beneficial for mothers with sore or cracked nipples and they are not recommended for this purpose. The use of nipple shields for flat and inverted is also controversial and needs assessment by a Lactation Consultant.

Cautions re use: Nipple shield use has been reported to decrease milk production, exacerbate sore nipples, contribute to mastitis and create difficulties re-latching baby onto the mother’s nipples. The longer the infant is on a nipple shield, the harder it will be to wean off. It is expected that the infant will be weaned off the nipple shield within two weeks of established breastfeeding.

Follow the steps below to ensure breastfeeding is maintained with appropriate use of nipple shields.

  1. Identify the problem, and document reason for use of nipple shield and management plan.
  2. Ensure appropriate size nipple shield is used. This will depend on nipple size and size of infant. Only one nipple shield is to be given to a mother. These are not recycled between mothers.
  3. Teach gentle hand expressing and provide some colostrum/EBM in the nipple shield to encourage baby to start suckling.
  4. Ensure baby opens mouth wide and teach mother to aim the nipple shield towards the roof of baby’s mouth.
  5. Bring baby onto the breast quickly with the lips flanged and located well onto the flat base of the shield over the underlying areola.
  6. Show the mother how to gently hand massage the breast to encourage milk flow while baby starts to suck.
  7. Observe for
  8. Supervise feeds to ensure adequate/effective sucking.
  9. Record outcome of nipple shield use.
  10. Mother should be encouraged to express after feeds regardless of how well the infant fed with the nipple shield.
  11. Provide ongoing opportunities for baby to attempt breastfeeding without the nipple shield. This should occur prior to every feed.
  12. Begin a feed with the nipple shield until the mother’s nipple has protruded and the milk let-down, then remove the shield and latch baby directly onto the breast. Repeat several times if baby fusses.
  13. Review continued use of nipple shield to ensure correct use and attempts to wean off.
  14. Document management plan.
  15. Ensure follow-up Neonatal Homecare, LMC, Lactation Consultant. 
Associated RBP
  • Disinfection of Feeding Equipment
  • Brigham M., Mother’s reports of the outcome of nipple shield use. Journal of Human Lactation, 12(4) 96.
  • Mier. P., Brown, L.,Hurst, N., Spatz, D., Engstrom, J., Borucki, L., & Krouse, A. (2000). Nipple shields for preterm infants: Effect on milk transfer and duration of breastfeeding. Journal of Human Lactation, 16(2), 106-114.