WHO Guidelines: Supporting Mothers to Initiate and Maintain Breastfeeding for Small and Preterm Newborns

WHO Guidelines: Supporting Mothers to Initiate and Maintain Breastfeeding for Small and Preterm Newborns

Breastfeeding is a cornerstone of infant health, but it presents unique challenges for mothers of small, sick, or preterm infants. Several studies have shown lower breastfeeding rates for preterm infants compared with term infants. Small, sick, and/or preterm infants are at higher risk of not establishing exclusive breastfeeding due to both their own physiological limitations and unsupportive clinical environments (144, 216, 217). Establishing and maintaining lactation is often the biggest challenge for successful breastfeeding in the neonatal ward.

The WHO Quality of Care Framework (220) emphasizes patient-centered care, including respect, emotional support, physical comfort, clear communication, continuity, care coordination, family involvement, and access to care. These principles are especially critical when managing care for small, sick, and/or preterm newborns.

Barriers to Breastfeeding for Mothers of Preterm Infants

Mothers who rely on hand expression or breast pumps face predictable barriers to initiating and maintaining lactation (145). For mothers of preterm infants, additional challenges include:

• Immature suckling patterns in the infant.
• Delayed lactogenesis II (secretory activation).
• Inadequate breast emptying during milk expression.
• An inadequate milk ejection reflex, often due to stress.

The volume of milk produced by a mother who must express her milk is the strongest determinant of the exclusivity and duration of breastfeeding for preterm and ill infants. Establishing a milk supply is a time-sensitive process that requires frequent and thorough emptying of the breasts as soon as possible (14, 141, 221–225). To maintain milk availability, mothers and healthcare professionals must understand the transition from endocrine to autocrine regulation of milk volume and the importance of achieving a milk volume of at least 500 mL/day within the first 14 days after birth . It is often difficult for mothers with initially low milk volumes to increase their supply after the first two weeks (145).

Special Attention for Late Preterm Infants

Late preterm infants (born between 34 and 37 gestational weeks) require special breastfeeding attention, as their ability to breastfeed may be overestimated. This can lead to complications such as hyperbilirubinemia, hypoglycemia, and dehydration, whether they are rooming-in with their mother or in the neonatal ward (226–228). Mothers of these infants need extra assistance in establishing and maintaining their milk supply, as the infant may not be able to successfully breastfeed alone.

Clinical Guidance for Breastfeeding Assistance

1. Early Support in the Neonatal Ward

Mothers of small, sick, and/or preterm infants admitted to the neonatal ward should receive breastfeeding assistance as soon as feasible after the infant’s admission.

• Positioning: Breastfeeding positioning for preterm and ill infants may differ significantly and will evolve over the course of the neonatal stay. Support can be hands-off or hands-on, depending on the mother’s cultural preferences, needs, or specific requests. Small and preterm infants often require additional head and neck support, as well as easy visibility of the latch and infant’s face to assess safety and milk transfer.

• Correct Attachment: Achieving proper attachment can be challenging for small, sick, and preterm infants. Both the mother and infant should be taught and observed frequently until they are comfortable with the latch.

• Standardized Assessments: Routine use of standardized breastfeeding assessments, such as the Infant Breastfeeding Assessment Tool (IBFAT) (230), Mother-Baby Assessment (MBA) (231), LATCH (232), or the UNICEF b-r-e-a-s-t tool (233), is recommended. Non-nutritive breastfeeding has been shown to increase milk supply and the duration of breastfeeding post-discharge (234).

2. Milk Expression

Establishing a full milk supply is especially challenging for mothers of small, sick, and/or preterm neonates. Therefore, mothers should receive appropriate assistance with milk expression within the first one to three hours after delivery—or as soon as possible if the mother is unstable (235).

• Frequency of Expression: Mothers should be encouraged to breastfeed or express milk at least 7–8 times every 24 hours, including at least once at night, to establish and maintain their milk supply. Expressions need not be regularly spaced, but care must be taken to thoroughly empty the breasts each time to avoid milk stasis and inhibit lactation.

• Psychological Factors: The average expressed milk yield without let-down is less than 4% of available milk (236, 237). Psychological inhibitors of the neuro-endocrine let-down reflex—such as fear, pain, and embarrassment—can compromise milk yield. Expressing at the infant’s bedside or using positive stimuli, such as seeing, hearing, or touching the infant during skin-to-skin care, can increase milk yield (238).

• Hygienic Practices: All mothers should be taught hygienic hand expression. Frequent hand expression (more than five times per day) combined with electric pumping in the first three postpartum days can significantly increase milk supply by day 14 through more thorough breast emptying and increased caloric content of the milk (239, 240). If electric double-pumping is unavailable, manual pumps can be used.

3. Monitoring Milk Supply

While milk volumes vary, typical goal amounts  of milk to be expressed daily are outlined below:

If a mother intends to use a breast pump, she should be taught how to use it safely and appropriately and how to clean all parts thoroughly. During the first two weeks, neonatal staff should assess the mother’s technique and troubleshoot any issues, such as pain or improper breast flange size. Periodic assessments should continue thereafter.

4. Record Keeping and Remediation

Mothers should be encouraged to keep a record of expressed milk to identify early opportunities for remediation if milk volume falters. Neonatal staff should monitor ongoing milk volumes and refer mothers for specialized lactation assessment and care if volumes fall short of anticipatory guidance goals.

5. Milk Storage and Hygiene

Any clean, dry, glass or food-grade/BPA-free hard plastic container with a secure lid may be used for milk collection and storage. In high-income countries, sterile storage containers provided by the hospital are recommended for critically ill NICU patients (242). A nipple/teat should not be used as a lid. Careful attention should be paid to hand hygiene when expressing and handling human milk. Best practice documents for expressing, storing, and handling human milk are available from human milk banks worldwide (242) and other expert sources (243, 244).

Support for Establishing and Maintaining Milk Supply

Specific guidance for establishing and maintaining a milk supply is essential for mothers to ensure adequate milk for infant growth and development. Consistent information regarding the initiation and maintenance of a milk supply is critical for mothers dependent on milk expression for small, sick, and/or preterm infants.

An information packet and educational support group can help ensure mothers receive and retain the necessary information (245). Coordination and collaboration between the mother’s and infant’s healthcare teams ensure consistent messaging.

Mothers experiencing difficulties in establishing or maintaining a milk supply may require focused, individualized support. Proactive interventions to achieve a milk volume of ≥ 500 mL/day by day 14 postpartum are especially important in the first two weeks after birth (145).

Assessing Milk Transfer

Clinical assessment of milk transfer is unreliable in preterm infants (246). Test weighing, conducted according to standard protocols, appears to be a valid measure of intake at the breast and can determine the need for supplementation (247, 248). Mothers can be taught to perform accurate test weights.

Conclusion

Supporting mothers of small, sick, and preterm infants requires a comprehensive, compassionate approach that addresses both physiological and environmental barriers to breastfeeding. By implementing evidence-based practices and fostering supportive clinical environments, we can improve breastfeeding outcomes and ensure better health for vulnerable newborns.