Breastfeeding premature and sick newborns

• Optimal nutrition for the newborn

• Easy to digest, and adapted to the newborn’s immature digestive system

• Protects the baby against infections (respiratory infections, gastrointestinal infections, and urinary tract infections)

• Promotes the development of the baby’s own immune system

• Long-term health benefits: helps protect the child against certain autoimmune diseases

• Health benefits for the mother: reduces the risk of breast cancer

• Provides closeness and is a way to communicate with the baby

• Economical

• Environmentally friendly

• Practical and simple when it works

When your baby is sick or born prematurely and is admitted to the neonatal intensive care unit, you may not have the opportunity to breastfeed at the beginning. The start of breastfeeding and breast milk production often takes place during an emotionally overwhelming time.

After birth, breast milk production begins whether or not the baby is placed at the breast. However, if the breast is not stimulated and emptied, milk production will stop. When you and your baby are separated, you must pump or hand express your breast milk. To ensure good milk production, you need to stimulate the breast as soon as possible after birth – preferably within the first hour, and no later than within 6 hours. The breast should then be stimulated every 2–3 hours.

• Early and frequent skin-to-skin contact with your baby is the start of breastfeeding.

• Early stimulation of the breast is very important for later milk supply.

Milk Production

During pregnancy, hormones prepare the breasts to produce milk. Most women notice that their breasts become larger. This is because the milk ducts, milk glands, and blood vessels are hormonally stimulated. Breast milk is produced in the breast and stored in small milk glands. Nutrients in the milk are transferred from the mother’s blood to the milk through a network of tiny blood vessels.

Breast milk production depends on the interaction between the hormones prolactin and oxytocin:

• Prolactin stimulates milk production. The concentration of prolactin in the mother’s blood increases each time the breast is stimulated.

• Oxytocin causes the muscle cells around the milk glands to contract. This is known as the let-down reflex. Oxytocin is released when the nipple is stimulated.

Prolactin levels are high in the first period after birth. More prolactin is released during sleep. You may notice that there is more milk at night and in the morning. Frequent stimulation of the breast leads to higher prolactin levels and increased milk production.

When you hold your baby skin to skin, place the baby at the breast, hand express, or use a breast pump, your body is stimulated to produce breast milk. The more the baby feeds or you pump, the more milk you produce. When milk production begins, the breasts will often feel sore and tight. You can read more about breast engorgement on helsenorge.no.

Milk production occurs continuously, and it is not physiologically possible to completely “empty” a breast. About one hour after breastfeeding or pumping, approximately 40 % of the milk has been produced again, and after 2 hours about 75 %.

Colostrum

During the first days after birth, your breasts produce colostrum. Colostrum is rich in proteins, hormones, growth factors, and antibodies. It protects your baby from infection and stimulates the maturation of the intestines. This is why it is especially important that sick and premature babies receive breast milk. Even a few drops of milk are important for your baby. Bring every valuable drop to your child.

The Let-Down Reflex

For milk to flow, the let-down reflex must be triggered. A baby that is eager to suck is the best stimulation to start the reflex and get the milk flowing.

At the beginning, you can help by gently rolling the nipple between your fingers (remember clean hands) so that it becomes erect, and by stroking the breast with light circular movements toward the nipple before pumping or placing the baby at the breast. You can also place a warm cloth on the breast for a few minutes.

Once breastfeeding is established, you usually do not need to do this – the let-down reflex will start automatically when you place the baby at the breast. You may also notice that milk begins to drip simply by thinking about your baby.

If you have difficulty triggering the let-down reflex, it may be helpful to use a nasal spray containing oxytocin.

Signs That the Baby Wants to Suck

The baby may:

• search for the breast

• open the mouth widely

• move the lips

• extend the tongue

• turn the head

Crying is a late sign of hunger. When your baby is sick or born prematurely, these signals may be less obvious. Instead, the signs may include:

• eyelashes “vibrating”

• slight body movements

• facial grimaces

• lip movements

Measures to Promote the Sucking Reflex

Sometimes it may be necessary to stimulate and strengthen the baby’s sucking reflex.

• When you stimulate the baby’s grasp reflex, you also stimulate the sucking reflex. Let the baby hold your finger while feeding.

• Keep the baby’s hips flexed. Resistance under the feet and bent knees help strengthen the sucking reflex.

• Drip breast milk into the baby’s mouth. When the baby tastes the milk, it will begin to suck and swallow.

• Place the baby in a reclined breastfeeding position. In this position, the baby’s natural reflexes are stimulated.

Breastfeeding Frequency

It is not expected that a baby who has been sick will immediately latch and begin to suck the first time it is placed at the breast. Do not force it. Let the baby take the time it needs and keep the baby skin-to-skin as much as possible.

Closeness stimulates the hormones that increase milk production and helps you learn to interpret your baby’s signals.

Read more about breastfeeding frequency at helsenorge.no.

No breastfeeding position is more correct than another. Try different positions and find the one that works best for you and your baby.

Laid-Back Breastfeeding Position

Lie in a reclined position (about 45°) in a chair or bed with good support for your head and body. Place the baby on top of you, tummy to tummy – across your body, lengthwise, or at an angle, depending on what feels most comfortable for you. The baby’s soles should press against a firm surface.

This position stimulates the baby’s natural reflexes to latch onto the breast. It is also a good position if you have sore nipples.

Side-Lying Position

Lie on your side with your legs slightly bent, with a pillow under your head and possibly between your knees. The baby lies on their side facing you, close to your body.

You can bring the breast closer to the baby by rolling slightly forward toward the baby. The baby’s head and back can be supported with a rolled-up baby blanket or a small pillow.

Modified Cradle Hold (Head in the Hand)

Support the baby’s neck, shoulders, and back with the hand opposite the breast being used (for example, the left hand when the baby is feeding from the right breast). This leaves your other hand free to support and shape the breast.

This position is well suited for premature babies and newborns with limited head control, and it also allows you to clearly see the baby’s mouth.

Classic Cradle Hold

The baby lies on their side with their tummy against your tummy. The head rests in the middle of your forearm. The baby’s lower arm wraps around your waist.

Support the baby’s head and back with your forearm, and hold the baby’s bottom or legs with the other hand. This position works best when the baby is 2–4 months old, has good head control, and can latch on well independently.

Football Hold (Under-the-Arm Position / Twin Position)

Support the baby’s neck, shoulders, and back with your palm and forearm. The baby’s feet point backward under your arm. Do not press the baby’s head into the breast; instead, support it lightly with your hand. This allows the baby to keep the breast in their mouth even when taking a pause from sucking.

Your other hand can be used to hold the breast. You can also gently stroke the breast to help the milk flow more easily. This position is well suited for premature babies and newborns with limited head control.

Breastfeeding Twins

Breastfeed one baby at a time or both at the same time? It is often helpful to breastfeed each baby separately during the first few days to manage the most common beginner challenges. This allows you to focus on one baby at a time.

Later, you can feed both babies simultaneously. This is practical and time-saving, but it requires that at least one of the babies is easy to wake and flexible with feeding times. When one baby wakes up, you wake the other as well.

If one of the babies has difficulty feeding, the weaker sibling can sometimes benefit from the let-down reflex already being stimulated when the other baby begins to feed.

To maintain breast milk production, you should pump about every 3 hours (about every 4 hours at night). Double pumping is recommended – it saves time and supports better milk production.

Remember good hand hygiene.

How to Pump

• Start the Medela Symphony pump by pressing the left button.

• Symphony pumps have two different programs; see the user manual for details.

• Start with the lowest suction level, and increase the vacuum using the middle dial until milk begins to flow, but without causing pain.

• For proper suction, both the breast and the pump shield must be dry.

• Sit upright, preferably leaning slightly forward, and keep the bottle pointing straight downward.

• Hold the breast shield against the breast with your thumb and index finger.

• Pump for at least 15 minutes. You can gently massage or stroke the breast during pumping.

If double pumping:

• When the milk flow slows down, pump each breast separately for 3 minutes while massaging.

• Alternatively, take a short break halfway through, massage both breasts, and then continue pumping.

You should pump for at least 120 minutes per day in total. It is better to pump often for shorter periods than rarely for long periods. We recommend pumping so that the daily milk volume reaches about 500–1000 ml per day.

You may reduce pumping if you produce much more milk than your baby needs, but only if your supply is clearly abundant. If you notice the amount decreasing, you should increase pumping again. Remember that your baby will need more breast milk as they grow.

Breast Shield

Make sure you use the correct breast shield size on the pump bottle. Choose the size based on the nipple, not the breast.

• The entire nipple should fit into the tunnel.
• The nipple should not turn pale during pumping.
• Pumping should not cause pain or discomfort.

Choose the Correct Size

The nipple remains centered in the breast shield, and the areola (the darker area around the nipple) moves slightly but is not pulled into the tunnel with each suction cycle.

Breast Shield Too Small

The nipple is not pulled properly into the tunnel, and it may rub against the tunnel walls. There is very little or no movement in the areola during pumping.

Breast Shield Too Large

The nipple does not reach the tunnel walls, and the areola is pulled into the tunnel during pumping.

Learning hand expression can be very useful – it is gentler on the breasts and just as effective as pumping once you have learned the technique.

If your baby is not ready to breastfeed, you can hand express milk during the first 2 days. Colostrum is thick and comes in small amounts, but every drop is precious for your baby. After 2–3 days, it is recommended to use an electric breast pump.

It is not harmful to stimulate the breast even if you are sick, have high blood pressure, or an infection. The hormones released can help you relax and may even help lower blood pressure.

How to Hand Express

1. Wash your hands thoroughly before expressing milk. Warm hands are helpful.

2. Prepare a container to collect the milk.

3. Stimulate the let-down reflex by gently massaging the breast and rolling the nipples between your fingers. Think about your baby; you can also look at a picture of your baby if they are not with you.

4. Place your thumb on the top of the breast at the edge of the areola (the dark area around the nipple) and your index finger on the bottom in the same position. Support the breast with the other fingers.

5. Press gently toward the chest wall, then compress over the milk ducts and release so the ducts refill. Use a rolling press-compress-release motion. Move your fingers around the entire areola.

6. Hand express for about 3–5 minutes on one breast, then repeat on the other breast. Repeat both sides once more. Fingers should not slide on the skin –dry them if they get wet.

7. Hold the container under the nipple to collect the drops. Draw the milk into a syringe, cap it, and label with your name, date, and time.

Do not take a break during the procedure. If you do, you must stimulate the let-down reflex again before continuing.

• The baby’s chin should touch your breast, the head slightly tilted back, and the nose pointing toward the nipple.

• The baby should have a wide open mouth, which is important to get enough breast tissue into the mouth. You can stimulate the baby to open wide by gently stroking around the mouth with your finger or the nipple, and by expressing a few drops of milk.

• The baby’s tongue should be under the nipple, and the nipple should reach far back into the baby’s mouth, up to the soft palate. Some babies raise their tongue to the palate when placed at the breast—make sure the tongue stays down.

• When the baby is latched, the mouth should be open, no pursed lips, and the lower lip should be slightly turned outward. More of the areola should be visible above the upper lip than below the lower lip.

• The baby’s ear, shoulder, and hip should be in a straight line.

• The baby’s jaw movements should be rhythmic and visible all the way back to the ear. Watch and listen to see if the baby is sucking and swallowing.

• When the baby releases the breast, the nipple should remain round and pointing in the same direction as the breast.

Sore and Cracked Nipples

Breastfeeding should not be painful, though mild soreness can occur at the start. Sore breasts are usually prevented by using a good latch technique.

The most common cause of sore and cracked nipples is an incorrect latch, where the baby does not open the mouth wide enough and does not get enough breast tissue into the mouth. Remember: the baby should latch onto the areola, not the nipple.

Ask staff for help if you are unsure whether the baby is latching correctly.

Cracks or open sores can sometimes cause minor bleeding during breastfeeding or pumping. This is not harmful to your baby, but good hand hygiene is important to avoid infection.

Read more about sore and cracked nipples at helsenorge.no.

When the Baby Refuses to Suck

If your baby struggles to latch and only cries at the breast, feeding can feel like a constant struggle. To avoid stress, try these tips:

• Take your time and let the baby nuzzle and lick the nipple. Express a few drops of milk for taste.

• Offer the breast as soon as the baby wakes, as hungry babies can get impatient quickly.

• Check that the diaper is dry and clean and that the baby is not too warm. Remove layers if necessary.

• Use the laid-back breastfeeding position to stimulate the baby’s neonatal reflexes and help them start again.

• Keep the baby skin-to-skin; familiar sounds like your voice and heartbeat create calm and security.

• Take a break and give milk via cup or syringe if needed—staff can show you how.

When the Baby Cannot Latch Due to Engorgement

Sometimes milk-filled breasts can make latching difficult. You can soften the breast or nipple by hand expressing or pumping a little milk before attempting to feed.

Flat or Inverted Nipples

• Most nipples that appear inverted can be pulled out by rolling or gently rubbing between your fingers.

• You can also use a breast pump to help draw them out.

• The area around the nipple must be stretchable for the baby to latch properly. Express a little milk if the breasts are engorged.

• With regular feeding, nipple elasticity will improve over time. In rare cases of completely inverted nipples, a breast shield may be necessary.

Blocked Milk Ducts

Blocked ducts often present as tender, slightly firm areas on the breast, sometimes with redness. If untreated, they can develop into mastitis (breast infection).

Tips for blocked ducts:

• Do not massage the breast, as this can damage tissue and worsen inflammation.

• Continue feeding as usual, based on the baby’s demand. No need to feed more often than normal.

• Ensure a good latch.

• Offer the affected breast first.

• Reduce swelling and pain with cool compresses for 10–20 minutes between feedings.

• Some find warm compresses before feeding help with milk flow.

• If the baby feeds less frequently or weakly, hand express or pump the same amount the baby would normally consume.

• Stimulate the let-down reflex if the breast is very tender – standing in the shower or lying in the bathtub may help.

• Some blockages take several days to resolve. If the lump does not reduce after 1–3 days of frequent feeding/pumping, consult a doctor – it could be an abscess.

• Do not try to stop milk flow from the other breast by pressing on it.

• If blockages are due to a poor let-down reflex, oxytocin nasal spray may help.

• Vary breastfeeding positions to fully drain the breast.

If you notice your milk supply decreasing or your baby suddenly needs more milk (so-called growth spurt days), there are ways to boost production. These days can be challenging, so rest whenever you can and consider limiting visitors.

• Keep your baby skin-to-skin as much as possible.

• Pump immediately after skin-to-skin or breastfeeding.

• Do something enjoyable while pumping, such as reading a book or listening to music.

• Drinking a warm beverage like herbal tea or nursing tea may help, but limit to 1–2 cups per day.

• Some mothers find acupuncture or certain medications helpful – ask hospital staff for advice.

Intensive Pumping to Increase Milk Supply

1. Increase feeding/pumping frequency to every 2 hours during the day (less often at night).

   • If your baby cannot feed this often, hand express or pump to stimulate the breasts at least 10 times a day for 2–3 days.

2. Pump for 15–20 minutes each session.

3. Double pump both breasts simultaneously.

The effect of increased stimulation is usually seen within a few days, but for some mothers, it may take up to a week.

If pumping every 2 hours does not increase supply, you can try power pumping.

Power Pumping

1. Pump for 20 minutes to “empty” the breasts.

2. Take a 10-minute break, then pump for 10 minutes.

3. Repeat as needed to complete 1 hour of power pumping.

4. Feed or pump normally for the rest of the day.

Power pumping for 1 hour can be repeated daily until your desired milk volume is achieved.

A breast shield is made of silicone and shaped like a nipple, designed to fit over your nipple during breastfeeding.

Disadvantages of Using a Breast Shield

• It creates a barrier between the baby and your skin, which can reduce stimulation of the let-down reflex, affect the latch, and prevent the breast from being fully emptied.

• Because of this, you may need to pump 1–2 times a day after breastfeeding to maintain milk production.

• Always ensure the baby is actually swallowing milk when using a breast shield. Seeing milk in the shield does not always mean milk is reaching the baby’s stomach.

Breast shields come in different sizes, so make sure you select the correct size for your nipple. Turn the shield inside out before placing it on your nipple.

Weaning Off the Breast Shield

It’s important to try breastfeeding without the shield occasionally to see if the baby can feed without it. You can start the feeding with the shield and then remove it once the baby has latched and started feeding.

Sometimes a breast shield can save breastfeeding, as it may be exactly what the baby needs to latch properly. Some babies use a shield throughout the entire breastfeeding period, while others manage to breastfeed without it after a few months.

• Cool or freeze breast milk immediately after pumping.

• If freezing, do so as quickly as possible. Breast milk can be frozen while still warm.

• The refrigerator should be +4 °C or colder.

• When transporting breast milk from home to the neonatal intensive care unit, use a cooler bag or insulated bag to keep it cold.

• Breast milk pumped on the same day can be combined in one bottle, but the fresh milk must be cooled before mixing with previously chilled milk.

• Freshly pumped milk can be poured over already frozen milk, as long as the amount does not exceed the amount already frozen.

Shelf Life

• Fresh breast milk: up to 72 hours (3 days) in the refrigerator.

• Fresh breast milk at room temperature: up to 4 hours.

• Colostrum (first 3 weeks of milk): up to 3 months in the freezer, because it contains high fat content.

• Mature milk (after 3 weeks postpartum): up to 6 months in the freezer.

Thawing

• Frozen breast milk should be thawed in the refrigerator. Once thawed, it is good for 48 hours if the refrigerator is +4 °C or colder. If warmer, shelf life is about 1 day.

• Frozen milk can also be thawed in a cold water bath, but must then be used within 24 hours.

• In an emergency, you can hold the bottom of the container under lukewarm running water, but the milk must be used immediately.

• Heated breast milk should be used right away and never reheated.

Newborns who are separated from their mothers may need a pacifier when the mother is not available.

When the mother is present and the baby is feeding at the breast, there is no medical reason to use a pacifier.

Benefits of a Pacifier

• Soothes pain and discomfort

• Satisfies a natural sucking reflex

• Helps the baby to calm down or fall asleep

When the baby is feeding via a tube, sucking on a pacifier can also stimulate digestion. For babies with weak sucking reflexes, pacifier use can help strengthen the muscles around the mouth and jaw.

Alcohol and other drugs in breast milk can make your baby drowsy.

• Do not drink alcohol during the first 6 weeks after birth.

• Avoid all other drugs while breastfeeding or pumping.

• If you do drink alcohol, limit the amount. After one glass of wine, wait at least 3 hours before breastfeeding.

Smoking and Nicotine

• Nicotine from smoking or snus passes directly into breast milk, with concentrations up to 3 times higher than in your blood.

• Your baby receives nicotine in their blood, and the milk may taste of smoke.

• Nicotine reduces milk production.

If you cannot stop smoking or using snus, it is recommended to breastfeed or pump before smoking. This way, as much time as possible passes before the baby’s next feed.

Research shows that babies of smoking mothers are more likely to develop colic. Smoking and snus are also linked to shorter breastfeeding duration.

Important: Even if you smoke, breast milk is still better than formula.

Melkeveien is a tool that shows the premature baby’s step-by-step journey toward breastfeeding. It highlights the gradual development from initial contact with the breast to exclusive breastfeeding:

1. Skin-to-skin contact – bonding and comfort.

2. Smelling the breast – familiarizing with mother’s scent.

3. Licking and tasting milk – early oral exploration.

4. Searching for, finding, and latching onto the nipple – first attempts at a latch.

5. Sucking and swallowing – initial feeding coordination.

6. Short, repeated feeding sessions – several times a day.

7. More effective sucking, less reliance on cup or tube feeding.

8. Sucking more than received from cup/tube – increasing efficiency.

9. Exclusive breastfeeding – fully feeding at the breast.

This tool helps parents and staff track progress and support the baby’s development toward independent breastfeeding.