The premature baby: everything you need to know

Welcome to the world of the premature baby! Although it may feel overwhelming, it is important to remember that the vast majority of premature babies grow and develop normally. At Happymami, our team of midwives understands the emotions and challenges that come with a premature birth.

That is why we have put together this post based on the latest scientific evidence to help you navigate this situation. From the problems a premature baby may face to breastfeeding and bottle-feeding, we cover everything you need to know about your premature baby. We are here to support you!

When is a baby considered premature?

A baby is considered premature when they are born before 37 completed weeks of gestation. Generally, a full-term pregnancy lasts around 40 weeks from the first day of the mother's last period. Premature babies can be born at any time from the first weeks of the third trimester to the end of it. There are different categories of prematurity, based on the length of gestation:

• Moderate premature: born between 32 and 36 completed weeks of gestation.
• Late premature: born between 34 weeks of pregnancy and 36 weeks and 6 completed days of gestation.
• Very premature: born between week 28 of pregnancy and 31 completed weeks of gestation.
• Extremely premature: born before 28 completed weeks of gestation.

Premature baby at 36 weeks

When you have a premature baby born at 36 weeks, breastfeeding can present unique challenges, but it also offers important benefits. Breast milk provides essential nutrients and antibodies that are crucial for the development and strengthening of the premature baby's immune system. What is more, closeness and skin-to-skin contact during breastfeeding can promote an emotional bond and improve the baby's thermal and cardiac stability. It is essential to have the support of healthcare professionals and to use the right techniques to make feeding easier, ensuring that the premature baby gets the best possible start in life.

What happens to a premature baby?

Premature babies can face a series of challenges and complications due to their immaturity and low birth weight. Some of the problems they may experience include:

1. Breathing problems: premature babies often have difficulty breathing because their lungs are not fully developed.
2. Feeding and digestive problems: premature babies may have difficulty sucking and swallowing, which can lead to nutrition and growth problems.
3. Immune problems: premature babies have a less developed immune system, which makes them more susceptible to infections and illness.
4. Neurological development problems: premature babies may be at greater risk of intellectual disabilities, delayed motor development and other neurological problems.
5. Temperature problems: premature babies struggle to maintain their body temperature, which can lead to hypothermia or hyperthermia.

It is important to point out that not all premature babies face these problems, and some may have a short hospital stay and develop normally in the long term. However, it is essential that premature babies receive specialised medical care and intensive care to minimise the risks associated with their prematurity and ensure their health and wellbeing.

What is corrected age and how is it calculated?

Corrected age is a measure used to estimate the development of premature babies in relation to babies born at term. Because premature babies are born early, their neurological and physical development may be delayed compared with babies born at term of the same age. Corrected age is calculated by subtracting the number of weeks of prematurity from the baby's chronological age (age since birth).

For example, if a baby is born at 32 weeks of gestation and has been alive for 6 weeks, their corrected age would be 0 weeks (6 weeks of chronological age – 6 weeks of prematurity = 0 weeks of corrected age). This means that their neurological and physical development is being measured as if they were 0 weeks old, which is considered the gestational age corresponding to 32 weeks of gestation.

Corrected age is used to help doctors and parents assess the development of the premature baby in relation to their gestational age and determine whether additional interventions or specialist follow-up are needed.

When do you stop calculating corrected age?

Corrected age is used to assess the development of premature babies until they reach a chronological age of 2 or 3 years, depending on the specific recommendations of each country and medical centre. After this period, babies are considered “corrected” and are expected to be up to date with the developmental milestones for their chronological age.

Bear in mind that corrected age is a useful tool for assessing the development of premature babies, but it is not an accurate measure of a child's future development. Children can experience a wide range of developmental outcomes, even if they are born prematurely and have a corrected age, and never forget that every child develops at their own pace.

Therefore, it is recommended that premature babies receive ongoing follow-up from a specialist medical team, who can provide the care and attention they need to maximise their long-term health and wellbeing.

What happens with breastfeeding in the case of premature babies?

Breastfeeding is a highly recommended practice for all babies, as it has been proven to have numerous health benefits for both the baby and the mother. In the case of premature babies, these benefits are even more crucial. However, producing breast milk and feeding premature babies present unique challenges that can be difficult to overcome without the right support.

So, establishing an adequate milk supply is more difficult for mothers who have given birth prematurely, and various factors are associated with a lower likelihood of breast milk being used to feed the premature baby.

Baby born at 28 weeks of pregnancy

• Extreme prematurity: Breast milk production decreases with gestational age. Milk production is particularly reduced in mothers of extremely premature babies (gestational age <28 weeks).
  
  Extremely premature babies are often unable to breastfeed effectively for some time after birth, which forces their mothers to establish and maintain their milk production by hand expressing or with a pump.
• Delay in starting breastfeeding (for example, more than six hours after birth)
• Irregular and infrequent emptying of the breast, especially in very premature infants (gestational age <34 weeks)
• Increased mother-infant separation.
• Less skin-to-skin contact.
• Other factors are maternal fatigue and stress, the young age of the mother and the mother's low annual income.

Relying on your team of midwives and nurses will help you overcome these obstacles. Also, bear in mind that if you have a premature baby who cannot breastfeed effectively for at least six weeks after birth (postpartum), it will be advisable to express and maintain your milk production with a breast pump.

Which milk is best for a premature baby?

The best milk for a premature baby is breast milk, but this question is very normal. And it is because in many cases mothers who give birth to their premature baby have not yet made a definitive decision about whether to breastfeed their baby. What is more, you may not yet have the information you need to make an informed decision.

It is also normal that most mothers, after receiving information about the benefits of breast milk for their premature babies, decide to feed their babies with breast milk, being prepared to express milk for at least one or two weeks until the premature baby can feed directly at the breast.

Bear in mind that after you decide to offer breastfeeding to your premature baby, as soon as a bottle is used to give your breast milk, we should avoid generic bottles and opt for a custom-designed Happymami bottle. This way we will avoid the confusion factor for your baby and help them learn what mum's breast feels like, so that when they have the strength to be put to the breast, establishing your breastfeeding will be easier.

Benefits of breast milk for a premature baby

Feeding with breast milk is particularly beneficial for premature infants, as it offers a series of important advantages for their health. On the one hand, breast milk provides protection against infections and necrotising enterocolitis, improves tolerance of enteral feeding and reduces the length of hospital stay. On the other hand, there is evidence that breast milk can also protect against severe retinopathy of prematurity and improve neurodevelopment. In addition, further health benefits have been identified in relation to other types of formula.

Which breast pump should you use with a premature baby?

The best breast pump for a mum with a premature baby will depend on her specific situation and needs. If the mother depends entirely on expressing milk to start and maintain her production, we recommend an electric hospital-grade breast pump. These pumps are programmed with suction patterns that imitate the baby during breastfeeding, which results in greater milk production in less expressing time.

For greater efficiency when expressing milk, simultaneous expression from both breasts (double pumping) is recommended during the first two weeks after birth. Double pumping stimulates more milk ejections and produces a greater volume of milk with a higher energy content than sequential or single pumping.

It is important that mothers use the maximum vacuum they feel comfortable with, as it has been shown to improve milk flow rate and milk production compared with vacuum pressures above this comfort threshold.

A hospital-grade double pump can be hired from hospitals, pharmacies, lactation consultants and home health agencies. Alternatively, a single-user (personal) double breast pump can be used, and the Elvie Pump is recommended.

For mothers who do not have access to an electric breast pump, hand expressing can be a good option, although it takes longer. In general, we recommend that mothers speak to a breastfeeding professional to determine which is the best breast pump for their individual needs and to get guidance on how often and for how long to express milk in their particular situation

The best bottle for a premature baby

There are currently good bottles on the market, but if your decision is to feed your premature baby with your breast milk and then continue breastfeeding, the best option is to avoid generic bottles and offer your baby a custom-designed Happymami bottle.

The fundamental reason is that when a premature baby is able to suck on their own and no longer needs the nasogastric tube, they will probably be given a generic bottle when they are fed inside the incubator. And once the baby gains more strength or their situation is more stable and we can take them out of the incubator, they need to learn what the stimulation of the palate that mum's breast will produce feels like, in order to feed directly from the breast.

If I have been using a generic bottle different from mum's breast, this learning process to establish breastfeeding will probably be much more difficult and complex.

How much should a premature newborn eat?

The success of breastfeeding a premature baby depends largely on the mother's ability to produce enough milk to meet the needs of her premature baby at the time of hospital discharge. Fortunately, most mothers of premature babies, even those born extremely prematurely (with a gestational age <28 weeks), can produce enough breast milk through a combination of mechanical and hand expression and ongoing breastfeeding support.

Bottle feeds for a premature baby

Generally, premature babies need around 150-170 ml/kg of milk a day (300-500 ml a day for a 3 kg baby), although some may need up to 200 mL/kg. Larger premature babies and those who will be fed exclusively on breast milk after discharge may need volumes above this range.

Bear in mind that mothers of premature babies who produce less than around 350 ml of milk a day between days 10 and 14 postpartum are at risk of producing insufficient milk to feed their premature babies at the time of discharge, and should focus their efforts on increasing production.

Expressing breast milk for a premature baby

Mothers of premature infants who are born at a gestational age of less than 34 weeks often face difficulties breastfeeding due to the baby's immaturity. For this reason, it is common for them to need to express breast milk after birth in order to feed their baby properly.

In this sense, mechanical expression using an electric breast pump has been shown to be the best option for emptying the breasts completely and effectively. Several randomised studies have demonstrated the superiority of this method compared with hand expression for achieving optimal milk extraction.

In addition, if you need to increase your breast milk production, expressing breast milk by hand during the first 48 hours after birth, in addition to mechanical expression, provides extra stimulation of the breast and produces greater volumes of colostrum. What is more, this combination of hand and mechanical expression during the first eight weeks after birth helps to establish sustainable daily milk volumes (>500 ml).

Expressing milk for premature babies in the first days

It is important that mothers who cannot breastfeed their premature baby directly start expressing breast milk as soon as possible, preferably within the first hours after birth. Even if your baby is not yet ready to suck, expressing breast milk early will help you establish an adequate milk production, sufficient to cover your premature baby's needs.

In addition, various studies have shown that starting to express milk between the first three and six hours after birth can result in greater milk volumes in the first, second and eighth weeks postpartum. Therefore, it is advisable to start expressing breast milk early and keep to a regular schedule to help increase and maintain the mother's milk production.

It is important to establish a milk expression routine to guarantee an adequate and sufficient supply of breast milk for your premature baby. During the first two weeks after birth, it is recommended to express breast milk at regular intervals of no more than three hours, even during the night.

Afterwards, it is recommended to express breast milk at least six times a day to maintain an adequate milk supply. This frequency of expression has been linked to greater breast milk volumes during the first six weeks postpartum.

However, it is important to bear in mind that the optimal number of daily milk expressions can vary from one mother to another. It is essential that hospital staff closely monitor the mother's milk production and make the necessary adjustments to the expression schedule to suit the individual needs of the mother and the baby. Ultimately, a well-established and adjusted milk expression routine is key to adequate and sustained breast milk production and healthy growth of the premature baby.

Length of the milk expression session for premature babies

Mothers with premature babies are advised to start expressing breast milk from both breasts at the same time for 15 minutes before lactogenesis II, which is defined as the first of two consecutive expression sessions in which total milk production is greater than 20 ml, generally around the third or fourth day after birth.

After the onset of lactogenesis II, each expression session should continue until only drops are being expressed, with a minimum of 15 minutes. The usual length of an expression session is around 15 to 25 minutes. As breastfeeding becomes fully established, some mothers may find that they need less time to achieve satisfactory emptying of the breast.

Emptying your breast completely is important to stimulate breast milk production and also to maximise the fat content of the expressed breast milk, which increases from the beginning to the end of an expression session. The last drops of milk (hindmilk) have the highest fat and calorie content and contribute disproportionately to your baby's calorie intake.

Massaging your breast during the last minutes of expression can increase emptying of the breast and help you express the hindmilk. This technique will also allow you to locate and drain the alveoli containing residual milk, reducing the chance of blocked ducts and mastitis.

Maximum interval between expressing breast milk

Once breast milk production is established after the first two weeks after birth, some mothers may choose to lengthen the intervals between expressions, especially at night, for comfort. However, it is important to stress that milk should be expressed at least six times a day to ensure adequate milk production.

However, in other mothers, lengthening the intervals between expressions can interfere with milk production, as the response to milk stasis varies from woman to woman. In the case of inadequate or at-risk breast milk production, it can be useful to assess the optimal interval between expressions using different expression schedules to adjust the breastfeeding plan to each mother's individual needs.

Conclusion: the premature baby, everything you need to know

In conclusion, if you have had a premature baby, it is understandable that you feel unsure and worried. However, it is important to remember that every baby is unique and that the vast majority of premature babies develop normally and healthily in the long term.

Empowering yourself with information based on scientific evidence, such as that presented in this article, and trusting the medical team working on your baby's care can make a big difference to the success of caring for your premature baby.

Remember that, although it may seem overwhelming at first, little by little you will see your premature baby mature and grow. With time, and with the right love and care, you will overcome the unique challenges faced by parents of premature babies. You will see your little one overcome obstacles and thrive, reaching important milestones in their development.

At Happymami, we are here to give you the support you need on this journey. Do not hesitate to get in touch with us for answers to any questions or concerns you may have. Together, we can work to guarantee the wellbeing and long-term health of your premature baby, while giving you the peace of mind and confidence you need as a parent.

Bibliography the premature baby, everything you need to know

Steven A Abrams, MDNancy M Hurst, PhD, RN, IBCLC. Breast milk expression for the preterm infant . Uptodate.com. . Available here

Steven A Abrams, MDNancy M Hurst, PhD, RN., IBCLC. Breastfeeding the preterm infant . Uptodate.com. . Available here.