Q&A: Bottles, Supplementation and Late Preterm Infants

Tawny asks:

My twin boys were born at 35 weeks and are doing great except for the nursing. In the hospital we finger fed with a syringe and feed them a combo of my expressed milk and donated milk. As the amount they were supposed to eat increased the hospital suggested using a bottle as they said it was important for them to be getting as much food as possible to put on weight. Our routine was to get them to latch, feed them with a bottle or syringe and then pump. Now we are home and I desperately want to breastfeed them exclusively but I am afraid that they have already developed a preference for the bottle. They don’t latch for very long and get frustrated easily, as do I. I know I should be patient and not expect too much but I just don’t know what to do. Any advice? Thanks so much.

Congratulations on your new babies! And how exciting to have them home!

Babies born at 35 weeks are considered “Late Preterm Infants” – they’re not too tiny and often don’t require much (if any) extra hospital or NICU time, but they’re still very sleepy and need a lot of encouragement to eat.  It’s pretty typical hospital protocol for late preterm infants to involve breastfeeding, supplementing (at breast, if possible), and pumping to stimulate milk production, just as you’re doing.  This process, known as “triple feeding” works to stimulate milk production while ensuring that the babies get enough to eat so they can grow!  It’s also exhausting!  If triple feeding needs to continue for more than a week or so, parents are often advised to supplement using bottles rather than using a supplemental nurser at breast (or by finger)  because the tubes and syringes are quite a production and parents often want to get more efficient with their time management so mom (and dad) can get some rest.  Plus, babies can get tired out when breastfeeding and we want to be sure that they don’t burn more calories nursing than they are taking in.

While you’re in this combination feeding phase — and it is just a phase — here are some tips for balancing breastfeeding and supplementing:

1. When bottle feeding, use a slow flow nipple and practice paced bottle feeding.  It’s easy for a baby to chomp on a bottle and elicit a fast flow of milk, but this flow can overwhelm them.  Build in breaks when you’re feeding by bottle to give the babies a chance to catch their breath, and to keep them in practice for the slightly slower pace of breastfeeding.  To do paced feeding, hold the bottle in a more horizontal position relative to the baby’s mouth, and watch the baby for signs they may need a break. Tip the bottle down slightly to encourage the babies to pause for a moment before resuming their bottle feeding. (More tips for paced bottle feeding [pdf].)
2. Continue offering the breast!  It may seem like the babies are developing a preference to the faster flow of the bottle, and you may need to work with them to transition to feeding exclusively at the breast once they are stronger and your supply is well established.  Until then, keep breastfeeding as part of the feeding routine.  Many moms begin their feeding sessions at the breast, then follow with a bottle.  You can also reverse this order – offering the bottle first to satiate the babies’ immediate hunger, and following with the breast once they are less frantic. This may help the babies (and you) get more comfortable with the breastfeeding without getting as frustrated.  (This has been dubbed the “finish at the breast” method of supplementation. [pdf])
3. When the babies are at the breast, consider using breast compressions to increase milk flow to the babies. Breast compressions and breast massage can increase milk flow to the babies, giving them a bit of a boost while they’re getting the hang of sucking.
4. Tandem nursing is wonderful for breast stimulation (and time management!) but in the early days it may be easier to feed the babies one at a time so you can focus on the basics – establishing a comfortable position, getting a deep latch, and helping the babies transfer milk.
5. If the babies are still having trouble latching, you may benefit from a visit by a Lactation Consultant who can help assess the babies’ latch, weigh them before and after a feeding to determine how well they’re transferring milk at the breast, and help you develop a plan to meet your breastfeeding goals.

What do you say, moms? How did you help your babies transition to breastfeeding after using bottles? What other tips do you have for establishing breastfeeding in the early days?

Additional Resources:

• Going Home with your Late Preterm Infant [pdf] (Contemporary Pediatrics)
• Breastfeeding the Near Term Infant [pdf] (Eyla Boies, MD – San Diego County Breastfeeding Coalition)