Getting ready to breastfeed your high-risk baby

Breastfeeding has important health benefits for your baby. It also helps the two of you bond. The benefits are even higher for babies who are born high-risk. Babies in the neonatal intensive care unit (NICU) need a mother's breastmilk to help support their immune systems, improve their digestion, and decrease the risk of a serious condition called NEC (necrotizing enterocolitis). If you are expecting a high-risk baby, providing your child with breastmilk is something only you can do. This makes you an important member of their healthcare team. Below are some suggestions for how you can get ready to make enough milk for your high-risk baby:

• If possible, start pumping or hand expressing within 60 minutes of delivering your high-risk infant if you are unable to nurse in that first hour. Evidence shows that this can help make more milk than if you start later.

• Use breast massage and warm your breasts before you pump.

• Start expressing milk by hand. Then use a pump as needed, to get your milk started.

• Listen to relaxing music as you pump. Evidence has shown that this can help women to make more milk, possibly by reducing stress.

When milk production is delayed or not enough

You may have a delay in the time when your milk comes in after the birth of a high-risk baby. Also, it's not abnormal to have a decrease in the amount being pumped after several weeks. A decrease may be gradual. Or it may occur suddenly.

Don't wait to get help if milk production is ever a concern. The sooner you get help, the better. Ask a certified lactation consultant, your baby's nurse, healthcare provider, or a breastfeeding support leader to help you figure out what might be affecting milk production if:

• You aren't making a daily total of at least 17 ounces of milk by 7 to 10 days after birth.

• You begin obtaining less and less milk each day for 3 or 4 days in a row.

• The daily total dips below 12 or 13 ounces for more than 2 or 3 days in a row.

• Your breasts are firm, sore, or red. And you are unable to remove milk to soften them. Or you develop a fever, body aches, or chills.

Possible causes for delayed or low milk production

Are you pumping often enough?

Not pumping often enough or not fully emptying your breasts is the most common reason milk is delayed or not enough milk is made. A review of the number and length of pumping sessions should always be the first thing you do if you are ever concerned about milk production.

It's easy to fall into the habit of letting more and more time pass between pumping sessions when recovering from birth and visiting your baby in the NICU. Also, a mother may at first get more milk quickly when several hours pass between pumping sessions. Without frequent and effective milk removal, the breasts soon get the message to slow milk production. Within a day or two, a mother who pumps less and less often will start making less milk overall per day. This is true even if at first the amount of milk per session seems high.

Equipment checks

If your breast pumping routine doesn't seem to be the problem, it may be the breast pump you are using. Many mothers find that a hospital-grade, double electric pump works best when pumping for a high-risk infant. Some women find that hand (manual), battery-operated, or smaller electric breast pumps are not effective at establishing and maintaining a milk supply for a high-risk baby. If you don't have a hospital-grade pump, you can sometimes rent one from a local hospital, lactation consultant, or mother's group. Once you have your pump, pay attention to how well it is working. If you think that the pump isn't working correctly, call the rental station or manufacturer. It is also important to make sure that the part of the breast pump touching your breast (the flange) is fitted correctly. This will help you to remove milk effectively. A lactation consultant can assist in making sure your flanges fit correctly.

Adding strategies

These strategies may also help increase your milk production:

• Don't forget to use breast massage and warm your breasts before you pump.

• If you are pumping, consider adding in some hand expression, especially at the beginning and end of the pumping session. You can do this while the pump is still on and it will help to empty your breasts.

• Don't forget to relax. Listening to relaxing music has been shown to help women to make more milk, possibly by reducing stress.

Maternal factors for delayed or not enough milk production

A delay when milk "comes in"

Occasionally, a mother has a health condition that may temporarily delay the large increase in milk production often seen between 3 to 5 days after birth. In these cases, large amounts of milk are not seen until 7 to 14 days after giving birth. If this happens to you, don't feel discouraged. Keep pumping.

It can be hard to keep pumping at least 8 times in 24 hours (for more than 100 total minutes) when getting only drops of milk with each session. But it's very important to keep expressing milk frequently. This kind of delay doesn't mean a mother will have trouble making enough milk once the milk does "come in." Often, she has plenty of milk as long as she has been pumping often enough.

Some conditions, or treatments, that may possibly delay milk include:

• Stress

• Cesarean section delivery

• Heavy postpartum bleeding

• Maternal obesity

• Infection or illness with fever

• Diabetes

• Thyroid conditions or polycystic ovary syndrome

• Strict or prolonged bed rest during pregnancy

Not enough milk

Rarely, a delay in the time when milk "comes in" turns into an ongoing problem of low milk production. Some of the conditions linked to a delay may also have an ongoing effect on milk production, including increased stress, severe postpartum bleeding, leftover placental fragments, and thyroid conditions. If a mother has ever had a breast surgery that cut some of the nerves, milk-making tissue, or milk ducts, she may have trouble making enough milk to fully feed her baby.

Other factors can also lead to low milk production. These include:

• Maternal smoking

• Some medicines and herbal preparations

• Hormonal birth control, especially any containing estrogen. However, some mothers report a drop in milk production after taking a progestin-only contraceptive during the first 4 to 8 weeks after birth. Talk with your healthcare provider for more information.

If you still have trouble making enough milk and your pump is working correctly, consider the following:

• Increase the frequency of milk expression to 9 to 12 pumping sessions. You can also increase the time of each pumping session. Do this for a few days.

• Begin or increase the amount of skin-to-skin contact you have with your baby during NICU visits.

• Ask your healthcare provider or a certified lactation consultant to review your health history with you. This can help you learn if there may be a health condition, treatment, or medicine that is changing your milk production.

• Ask your provider or a certified lactation consultant about medicines or herbal preparations that may increase milk production. 

• Think positive. Insufficient milk production often can be reversed. But any milk you produce, even drops, is valuable for your baby.

Overproduction of milk

Some mothers consistently make much more than 25 to 27 ounces of milk in 24 hours. Their freezers are overflowing with containers of expressed breast milk. When mothers are making a lot more milk than even a full-term baby or twins could handle, some find they can drop 1 or 2 daily pumping sessions. It is important for these mothers to keep pumping for 100 minutes in 24 hours. These mothers can often achieve this in fewer sessions of pumping. If the daily amount pumped ever drops below 25 ounces (750 ml) for 24 hours, add another pumping session.

Making too much milk is often not a problem, so there is no reason to interfere with a successful plan for milk expression unless it is hard to maintain. If you are "overproducing" and thinking about changing your pumping routine, it is advised that you:

• Discuss your situation with a certified lactation consultant or your baby's healthcare provider and nurses before making any changes.

• Don't make changes if you are pumping for multiple children (twins, triplets, or more). 

• Watch the volume of your milk closely and have a clear plan to increase your pumping frequency or duration if your milk supply decreases. 

• If you truly don't need the extra milk, think about donating it to other mothers in need.

Most mothers would much rather make more than their baby needs than discover they are no longer making enough. If the amount you are making is causing you discomfort or pain, talk with a certified lactation consultant or your healthcare provider.