ABM Clinical Protocol #10: Breastfeeding the Late Preterm (34–36 6/7 Weeks of Gestation) and Early Term Infants (37–38 6/7 Weeks of Gestation), Second Revision 2016

Abstract

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Highlights of New Information Since the 2010 Revision Include

• 1.

  Increased risk for breastfeeding-related problems in the early term infant similar to those of the late preterm infant.

• 2.

  Importance of proactive lactation management strategies for many late preterm infants and some early term infants.

• 3.

  Importance of early expression of colostrum within the first hour after delivery.

• 4.

  Role of hand expression with or without mechanical expression in the initial postpartum hours and days.

• 5.

  Risk for iron insufficiency and iron-deficient anemia in the late preterm breastfed infant.

• 6.

  Increased risk for long-term developmental problems in the late preterm infant.

Purpose

The purpose of this protocol is to:

• 1.

  Assist the late preterm and early term infant to breastfeed and/or breast milk feed to the greatest extent possible.

• 2.

  Heighten awareness of difficulties that late preterm and early term infants and their mothers may experience with breastfeeding.

• 3.

  Offer strategies to anticipate, identify promptly, and manage breastfeeding problems that the late preterm and early term infant and their mothers may experience in the inpatient and outpatient settings.

• 4.

  Prevent problems such as dehydration, hypoglycemia, hyperbilirubinemia, hospital readmission, and failure to thrive in the late preterm and early term infant.

Background

The initial Academy of Breastfeeding Medicine protocol was written for the “near term infant” born from 35 0/7 to 36 6/7 weeks of gestation. In 2005, the National Institute of Child Health and Human Development designated infants born between 340/7 and 366/7 weeks of gestation as late preterm to establish a standard terminology and to emphasize the fact that these infants are really “preterm” and not “almost term.”

Over the past 10 years, a growing body of literature has documented an increased risk of morbidity and mortality in the late preterm infant that is often related to feeding problems, especially when there is inadequate support of breastfeeding. In addition, hospital readmission of these infants within the first 7–10 days after hospital discharge is almost always due to feeding-related problems (hyperbilirubinemia, failure to thrive, hypernatremia, and/or dehydration).

Establishing breastfeeding in the late preterm infant is often more difficult compared with the full-term infant born at ≥39 weeks of gestation. Because of their immaturity, late preterm infants are less alert, have less stamina, and have greater difficulty with latch, suck, and swallow than full-term infants. The sleepiness and inability to suck vigorously may be misinterpreted as sepsis, leading to unnecessary separation, investigation and treatment, as well as poor nutrition. Conversely, some infants appear deceptively vigorous, and physically large preterm newborns (e.g., infants of diabetic mothers) are often mistakenly thought to be more developmentally mature than their actual gestational age. As a result, these infants may receive less attention than they need. Although some infants appear to have a good latch, suck, and swallow, they often do not transfer adequate breast milk volume when checked with test weights.

Late preterm infants are at greater risk for a number of transitional and breastfeeding-related morbidities ( Table 1 ).

Late preterm infants are often separated from their mothers for evaluation and treatment and are discharged home before secretory activation (lactogenesis II) is fully established. Problems with latch and milk transfer are often not identified or adequately addressed. Furthermore, mothers of late preterm and early term infants are more likely to give birth to multiples or have medical conditions such as diabetes, pregnancy-induced hypertension, chorioamnionitis, or a Cesarean-section birth that may adversely affect the onset of lactation and the success of breastfeeding. Parents may go home without adequate knowledge and appropriate expectations regarding establishing breastfeeding.

It is now recognized that some early term infants, born between 37 0/7 and 38 6/7 weeks of gestation, are also at higher risk compared with term infants, born between 39 0/7 and 41 6/7 weeks of gestation, for problems including hyperbilirubinemia, hospital readmission, and reduced breastfeeding initiation and duration. Early term infants, especially when born via elective Cesarean section, are also at increased risk for respiratory problems, Neonatal Intensive Care Unit (NICU) admission, sepsis, and hypoglycemia requiring treatment.

Although term infants have a greater chance of successfully breastfeeding when hospitals adhere to the Ten Steps to Successful Breastfeeding of the Baby Friendly Hospital Initiative, these guidelines alone are insufficient to overcome challenges that late preterm and some early term infants and their mothers face in the immediate postpartum period and after discharge from the hospital. Breastfeeding management of the late preterm and some early term infants requires a paradigm shift from that used with full-term infants, where an effective latch, suck, and swallow is the cornerstone for successful lactation and nutrition for the infant. Recognizing that effective suckling often takes some time to become established, management should ensure the infant is adequately nourished and that the maternal milk supply is developed and protected. Breastfeeding adjuncts (e.g., nipple shields, supplementation, milk expression, breast compressions) are more likely to be required for the late preterm and even some early term dyads.

Given the increased risk of medical problems of the late preterm and early term infants compared with term infants, close observation and monitoring are required, especially in the first 12–24 hours after birth when the risk of inadequate adaptation to extra-uterine life is the highest. Late preterm infants born at 34 0/7 to 34 6/7 weeks of gestation have a 50% risk for morbidity during the birth hospitalization. Transfer to a higher level of care for appropriate care and monitoring may be needed.

Late preterm and early term infants also require timely evaluation soon after hospital discharge. These follow-up services must be able to assist with breastfeeding problems or questions from the first post-discharge visit. For more complicated breastfeeding problems, mothers and infants should be seen by a lactation consultant, a breastfeeding medicine specialist, or a healthcare professional who is experienced with managing lactation issues as soon as possible.

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