Feeding Your Premature Baby in the NICU

For a preemie, feeding can be a big challenge to overcome while in the neonatal intensive care unit (NICU). Some premature babies don't have the strength or coordination to breastfeed or bottle-feed successfully, and that can hamper their growth.

However, preemies can overcome their feeding challenges with a little help. By understanding why your baby is having trouble, learning some simple techniques, and knowing who to turn to for extra guidance, you can get your preemie on track to steadily growing and gaining weight.

Preemie Feeding Challenges

Although it comes easily to most full-term babies, learning to eat tends to be a challenge for preemies, at least early on. Because they were born early, their muscles, nervous system, and other body parts key to feeding are not fully developed. As a result, taking in and digesting adequate amounts of milk is hard, if not impossible, when many preemies are first born. An estimated 43% of newborns up to 5 months old have problems feeding due to the following issues.

Lack of Sucking Skills

Premature babies sometimes aren't born with mature sucking skills. In order to drink milk from a bottle or breast, babies need to have a suck that is coordinated and doesn't interfere with regular breathing patterns.

Babies who don't coordinate sucking, swallowing, and breathing well can be difficult to feed. They may start off well, sucking and swallowing with gusto. Suddenly, though, they may realize that it's time to breathe, and they aren't quite sure how. They may choke and gag on their milk or stop breathing entirely until the feeding is paused.

Lack of Overall Strength

Sucking and swallowing milk takes a lot of strength, and babies need to develop the muscles in their tongue and jaw to do this well. Gaining strength often happens as premature babies get more practice, but until then, you may notice your baby nodding off just a few minutes into a feeding session. A preemie without a mature suck and swallow will quickly become exhausted during a feeding—each feeding session is quite a workout.

Immature Digestive System

Preemies have an immature gastrointestinal (GI) tract, which means that even when they are able to take in milk, they might not get the nutrients they need from it. They are also more likely to experience GERD or acid reflux, which means they may spit up a large amount of the milk before they can digest it. Their stomachs are also less proficient than full-term babies' at breaking down milk proteins and absorbing amino acids, two important nutrients that aid growth and development.

Sometimes, preemies develop necrotizing enterocolitis (NEC). This condition is rare but more common in premature babies than full-term babies. In NEC, intestinal tissue becomes injured, inflamed, or otherwise damaged, leading to gaps in the intestinal wall through which dangerous bacteria can enter your baby's bloodstream.

Medical Conditions

Preemies are at risk for other conditions that can make it hard for them to breastfeed or bottle-feed in regular intervals. These conditions may include:

• Extremely low body-fat that requires them to stay in an incubator (or isolette) for a certain number of hours per day to stay warm
• Breathing troubles that necessitate being hooked up to a ventilator or continued positive airway pressure (CPAP) machine
• Jaundice, a sign of underdeveloped liver function characterized by yellow skin, which can cause a baby to be extra-fussy and feed poorly

Premature Baby Feeding Methods

There are many different ways that babies are commonly fed in the NICU, and the method chosen usually depends on their gestational age and whether they have any other medical conditions that are hampering feeding. Some of these feeding methods may be combined with another as your baby matures:

• Breastfeeding: Even though they might have trouble early on, many preemies get the hang of nursing while still in the NICU.
• Bottle-feeding: You can pump breast milk or use formula in a bottle for your baby. Sometimes, even if a baby is able to breastfeed, a doctor might recommend feeding your baby breast milk or formula from a bottle so you can see exactly how much milk your baby is taking in.
• Feeding tube: A feeding tube gives your baby nutrients they can’t get from breast or bottle-feeding. They might need a gastronomy tube, that feeds directly into your baby's stomach; a nasogastric tube, that goes through your baby's nose into their stomach; or an orogastric tube, which is inserted into your baby’s mouth into their stomach. Babies on feeding tubes are often given a pacifier to strengthen their mouth muscles and practice their sucking skills.
• Intravenous line (IV): Usually used for the smallest and sickest babies, an IV line for feeding supplies your baby fluids and nutrients directly into their bloodstream.

Preemie Feeding Milestones

Unfortunately, there is no definite time period in which premature babies learn to breast- or bottle-feed. Some preemies catch on quickly while others take longer. However, most babies will be able to be weaned from a feeding tube by the following gestational ages:

• 32 to 34 weeks: Most preemies have a mature suck and are able to begin the transition from tube feeding to bottle-feeding or breastfeeding.
• 35 to 38 1/2 weeks: By about a week and a half before your original due date, your baby should be able to suck, swallow, and coordinate eating with breathing enough to take all feedings by mouth.

If your baby was born before 27 weeks, was on a ventilator for a long time, wasn't able to eat for a while due to NEC or another illness, or has chronic respiratory problems, it may take longer for them to learn to eat. Usually, to be considered well enough to be discharged from the NICU, babies must be weaned off feeding tubes and able to breastfeed or bottle-feed successfully.

How to Help Your Premature Baby With Feeding

As your baby is catching up in the NICU, it's important for you and your baby's caregivers to support your baby to learn to feed at their own pace. However, there are things you can do in the NICU that can help your baby thrive:

• Respect cues: Offer the breast or bottle when your baby is awake, sucking on their fist or a pacifier, or rooting for a feeding. Stop the feeding if your baby seems upset or fatigued.
• Refrain from force-feeding: Feeding premature babies should be a positive experience. Forcing a feeding can increase the chances that your baby will develop an oral aversion, a condition where babies don't like anything—including a bottle—in their mouths. Even if there are only a few milliliters left in a bottle, let your baby rest before finishing if they need.
• Use kangaroo care: Research shows that skin-to-skin contact with your preemie—like laying your naked baby on your bare chest—leads to faster newborn weight gain and boosts your milk supply. Skin-to-skin is also beneficial for preemies when done with non-breastfeeding caregivers.

Frequently Asked Questions

How does having a preemie affect breastfeeding?

Your preemie may have trouble breastfeeding right away. Premature babies are often born with less-developed muscles, respiratory systems, and nervous systems than full-term babies, which may make it tricky for them to latch on and coordinate their sucking and breathing patterns.

Why does my premature baby get tired during feeding?

Preemies need more sleep than other babies. In fact, it's normal for preemies to spend 90% of their day asleep! They also have to work extra hard during feeding as their muscles and nervous systems are still developing. As a result, your premature baby might nod off a few minutes into feeding time, but they will gain more stamina as they grow.

How much does a premature baby need to eat to leave the hospital?

There is no set number of ounces or milliliters that your baby must be drinking in order to go home. Rather, most doctors want to see that a preemie is gaining weight steadily and is able to drink from the breast or a bottle (rather than a feeding tube) to be ready for discharge.

When is a feeding tube necessary for a preemie?

Feeding tubes are often necessary for newborn preemies who don't yet have the strength and coordination to successfully feed from the breast or a bottle. Experienced hospital staff will observe your baby, monitor their weight gain in the initial hours and days after birth, and recommend a feeding tube if it seems they need a little help.

When do preemies come off the feeding tube?

Your baby should be able to get all—or at least 75%—of their calories from the breast or bottle to be ready to graduate from a feeding tube. Doctors and nurses will chart your preemie's progress as they practice their oral feeding skills while on a tube and help determine when they're ready to make the transition.

A Word From Verywell

Having a preemie in the NICU can be scary and overwhelming. You desperately want your baby to grow at a healthy pace, but may be unsure whether they're getting the right type and amount of nourishment. Not being able to breastfeed right away might be upsetting, too.

However, NICUs are designed to help babies just like yours thrive, and the staff is there to support both you and your preemie. Work with the doctors and nurses to understand your baby's needs and develop a feeding plan that can optimize their growth and facilitate bonding whenever possible. Progress might come more slowly than you would like, but with these tiny, precious humans, it's important to celebrate little victories.