Breastfeeding Smaller Newborns

Newborns born on the smaller side (under 8 pounds) are some of the snuggliest, sweetest babies out there. However, they present unique challenges when it comes to breastfeeding and require a proactive approach.1,2 In this post, we discuss 3 milk supply related challenges of breastfeeding small (under 8 pounds) or late preterm/early term babies (35-39 weeks) and the strategies that lead to breastfeeding success.
Challenge #1: Sleeping Instead of Eating
Early term babies and newborns under 8 pounds tend to LOVE sleeping even more than they love eating. While this might sound like a good thing, it often causes these babies to sleep through their hunger and therefore not take in enough breastmilk. Letting your small newborn skip feedings because she is sleeping will signal your body to slow down milk production.2 Missed feedings may also slow her growth and perpetuate the sleepy/poor feeding pattern.2 Thankfully, awareness goes a long way in heading off this problem.
Solution: Wake baby every 2-3 hours to nurse.
Until baby is showing consistent feedings cues and growing well, wake her up often enough to equal 8-12 feedings per 24 hours.1 Frequent feeding is crucial to establishing a good milk supply and helping baby grow. In fact, I consider it the #1 key to success. Nurse your baby anytime she shows feeding cues but also wake her to nurse as needed to achieve 8-12 feedings per 24 hours. If baby is sound asleep around the 2 hour mark (since start of last feed), try getting her less comfy by placing her on her back next to you on a flat surface instead of being swaddled or snuggled. Gently move baby's arms and legs and talk to him/her. This allows baby to enter a light sleep stage and start to notice he/she is hungry and hopefully begin to show feeding cues. If baby still isn't beginning to rouse after about 15 minutes, undress her and change her diaper.

Challenge #2: Sleeping While Eating
Because of their love of sleep, little babies are often great imposters at the breast. They latch on, take a few comforting swallows of breastmilk, and then relax into a deep sleep with only gentle, fluttering sucks. 30 minutes later, they are still attached to the breast but have taken in very little breastmilk. After all, the breast is their favorite place to snuggle up for a good nap. So what's the problem? With very small or late preterm babies, they will often fall asleep at the breast before they've filled their tummies. The lure to sleep is just too great! Many a mother has been fooled by this seemingly normal feeding behavior into assuming baby is nursing well until a checkup at the pediatrician shows otherwise.
Solution: Encourage active sucking and swallowing.
Taking an active approach to ensure baby fills her tummy and empties your breasts is important. Pay attention to when baby's sucks change from strong and regular to weak and slow. When this happens you will probably also notice that swallowing is no longer heard and her eyes are closed. If this transition from "active sucking" to passive suckling happens after just a few brief minutes, then try to stimulate baby to suck more vigorously. Gently stroke her skin, tickle her feet and talk to her. Use breast massage and compression to speed milk flow by intermittently pressing on and then releasing the lumpy areas of your breast.1 Once you feel like baby has filled her tummy and emptied your breasts, you can let her sleep at the breast as long as you want.

Challenge #3: Building Milk Supply
Babies born over 7 pounds typically clusterfeed the first week to build mother's milk supply until it reaches 25-30 ounces per day and then they maintain this amount the rest of the year (surprising, isn't it?!).3 This increase doesn't happen nearly as quickly for babies born under 7 pounds. For example, a baby who is 5 pounds at discharge from the hospital will probably take a month to get over 7 pounds and up to mature intake (25-30oz). During the first month, the smaller baby will likely only be taking in about 20oz of breastmilk per day (beginning around day 7 of life). The dilemma is that it becomes harder to increase milk supply after the first few weeks. Our bodies are programmed to reach peak production quite quickly and after that to maintain it. Many mothers of small/preterm babies struggle to build their milk supply in the second month if they did not reach peak production in the first month.
Solution: Pump Twice a Day
If your baby is currently under 7 pounds and exclusively breastfeeding, it may be wise to pump twice a day (or more if your lactation consultant advises) as a buffer for your milk supply.2 This will allow your body to quickly and easily reach full milk production during the first month so that baby can naturally grow into it later. Try a routine of pumping once in the A.M. and once in the P.M.. Pump both breasts immediately after breastfeeding but only for about 10 minutes. This way you are only taking the leftover milk that baby did not drink and not taking milk from his next feeding. Use hands on massage and compression to get out every last drop as shown in the link hereThe quantity you will be able to pump each session could be as little as 1 oz (quite common) or possibly as much as 4 oz (less common). If your baby is growing well right now you can freeze this extra milk for future use. If baby is gaining less than one ounce per day, this pumped milk should be supplemented back to baby.1,2 If you follow this routine until your baby is 7 or 8 pounds, you will have a comfortable stash of breastmilk saved up in your freezer. Better yet, you won't be wrestling with low milk supply when your baby is ready to take in larger feedings at the breast.

References
1 Breastfeeding the Late Preterm and Early Term Baby, Academy of Breastfeeding Medicine Protocol # 10