Providing Breastmilk for

Premature and Ill

Newborn Infant

Rosalina D Roeslani
Neonatology Division, Child Health
Departement,CiptoMangunkusumo Hospital - University of
Indonesia
Objective

◎ What happen to breastmilk if mother

delivered to soon or the newborn get ill?
◎ How to provide breastmilk to premature
infant?
◉ Mother own milk:
● how to encourage mother?
● How to increase breast milk production?
◉ Donor milk
Introduction: Breastmilk as an Ideal Nutrition for Preterm Infants
Introduction: Breastmilk as an Ideal Nutrition for Preterm Infants
Introduction: Breast Development During
Pregnancy & Lactation
 Preterm delivery
Effect of Preterm Birth and Antenatal
Corticosteroid Treatment on Lactogenesis
2 in Women - Journal of American
Academy of Pediatrics
Preterm
Antenatal corticosteroid
Effect of Preterm
Effect of Preterm Birth and Antenatal Birth and Ill Infants
on Lactogenesis
Corticosteroid Treatment on Lactogenesis 2 in
Women - Journal of American Academy of
Pediatrics

Delayed
Stress & maternal illness development
lactogenesis II
Recognizing and Treating Delayed or Failed
Lactogenesis II – Journal of Midwifery &
Ill Neonate Women’s Health

Unscheduled
Operation/SC
Recognizing and Treating Delayed or Failed
Lactogenesis II – Journal of Midwifery &
Women’s Health
Delayed Lactogenesis II

◎ Definition
○ The onset of copious milk production > 72 hrs post
partum
◎ Prevalens of 22-31%
Hypoplastic breast
50 mothers,
preterm infant
GA < 34 wk
 Preventing
Delayed
Lactogenesis II
Milk Volume was significantly associated
with frequency of expression ( > 6
expression/24 h)

Mothers who intended to breastfeed > 6

mo significantly have greater breastmilk
volume on the first 3 days postpartum
Time of Lactogenesis II – early vs
delayed breast milk expression
group: 80,4 vs 136,8 hrs, p 0,03
Lactagogue
◎ Antenatal education about colostrum and the
benefits of early initiation of breastfeeding.
◎ Initiate breastfeeding within an hour of birth:
2624/2835 mothers (including twins and
triplets).
◎ Only 211 mothers could not initiate
breastfeeding within an hour
◎ Between January to December 2015, we
observed that the breast-feeding initiation
within 1st hour of birth was at 80,56%.
◎ From the period January 2016 to December
2017, our success grew up to 96,7%.

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◎ In 2016  Cochrane 46 randomized
◎ Eight of the trials including Cesarean and six of the trials included late preterm
infants (> 35 weeks gestation).
◎ Mothers who had skin to skin care with their babies were 24% more likely to still
be breastfeeding at 1-4 months after giving birth compare to mothers who
received routine hospital care.
◎ Breastfeed their infants longer (± 64 days).
◎ The rate of exclusive breastfeeding (6 weeks – 6 months) after the
birth  50% more likely to exclusively breastfeed.
◎ Babies held skin to skin with their mothers were 32% more likely
to breastfeed successfully during their first feed and they had
higher blood glucose > 10mg/dl.

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Milk Donor
Management of Milk Donor
Microbiology
◎ Bacterial Culture before and after
pasteurization

◎ Don’t use it if the bacterial culture result:

○ pre-pasteurization bacteria count ≥ 105 CFU / mL
○ post-pasteurization bacteria count ≥ 10 CFU / mL
Guideline for
Expressing
Breastmilk
 Milk Volume Enhancing Strategies:
Achieving Sufficient Milk Volume

◎ Express breastmilk with hand for 10-15 minutes than continue

express breastmilk with pump (double pump) for 10-15 minutes
◎ If mother prefers to use single pump  express about 5-7
minutes on each breast and repeat in addition
◎ Double pumping may increase milk volume at each expression
(>18%/more)
◎ Use correct size breast shield/flange (medium/24mm,
large/27mm, extra large/30mm). Wrong size breast shield/flange
can reduce milk flow and milk volume as well as cause
pain/damage to the nipple/areola
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 Milk Volume Enhancing Strategies:“Hands on”
Expressing/Pumping

◎ Advise the mother to gently massage both her breasts for 1-2 minutes
before using her pump

◎ Use the double pump for 10 minutes while gently massaging any areas of
fullness at the same time

◎ Take off the pump and gently massage the breasts again for 1-2 minutes
◎ Hand express or single express/pump and massage the breast for 4-7
minutes on each breast again
Milk Volume Enhancing Strategies: Prolonging
Skin to Skin Care

◎ Increases milk volume and the

breastfeeding ability of the baby

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Milk Volume Enhancing Strategies: Enhancing
Oxytocin

◎ Advise the mother to take daily photos / video

of her baby to look at, use relaxation
techniques/music while she expresses at
home as this can encourage a milk ejection
◎ Encourage the mother to smell an item of the
baby’s clothing before and during expression
as this can encourage a milk ejection
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Milk volume for Women Exclusively Expressing

◎ Aim for approximately 400 ml/24 hours by day 4-7

postpartum
◎ Aim for approximately 750 ml/24 hours by day 7-14
and beyond
◎ Milk supply is considered low if it is ≤ 500 ml/24
hours by day 7-14 and beyond
10 Steps for Promoting and Protecting Breastfeeding for
Vulnerable Infants

1. Informed decision
2. Establishment and maintenance of milk supply
3. Breast milk management
4. Feeding of breast milk
5. Skin to skin care (SSC)
6. Nonnutritive sucking at the breast
7. Transition to breast
8. Measuring milk transfer
9. Preparation for discharge
10. Appropiate follow up
 CiptoMangunkusumo Hospital Protocol based on
EBM for Enhancing Breastmilk Production

1. Antenatal education (2 times)

2. Postpartum education & expressing colostrum in 1 hour.
3. Expressing breastmilk and emptying the breast 6-8 times/day
4. Express breastmilk using electrical pump (hospital base)
 CiptoMangunkusumo Hospital Protocol based on
EBM for Enhancing Breastmilk Production

5. Early Initiation of Breastfeeding & Kangaroo Mother Care if

possible.
6. Milk donors on the first week of life if mother breastmilk is
not out yet.
7. Galactagogue for special condition.
Conclusion

1. Breastmilk is the ideal nutrition for premature

and Ill infant, so it’s very important to establish
and maintain the milk supply especially mother
own milk
2. EBM showed to decrease delayed lactogenesis
II we should :
○ Initiating breastfeeding wit in 1 hours of age (express
breastmilk)
○ The frequency to emptying the breast is > 6 time perday
Conclusion

○ Manipulation by breast massage & electrical pump

could increase milk production
○ Some time galactagogue is useful

3. Donor milk help to provide breastmilk for preterm

and ill neonate in the first week of life.

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