BREASTFEEDING MEDICINE

Volume 6, Number 3, 2011 ABM Protocol

ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2011.9990

ABM Clinical Protocol #10: Breastfeeding

the Late Preterm Infant (340/7 to 366/7 Weeks Gestation)
(First Revision June 2011)*

The Academy of Breastfeeding Medicine

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 breast-
feeding 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. These guidelines are not
intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Goals term infant’’ that encompassed infants born at 350/7 weeks to

366/7 weeks. In addition, infants born at 370/7–376/7 weeks
1. Promote, support, and sustain breastfeeding in the late
may be at risk for breastfeeding problems and associated
preterm infant.
risks, and, therefore, the following guidelines may be appli-
2. Maintain optimal health of the infant and mother.
cable to these infants as well.2

Purpose Background
The advantages of breastmilk feeding for premature infants
1. Allow the late preterm infant to breastfeed and/or
are even greater than those for term infants; however, a large
breastmilk feed to the greatest extent possible.
body of literature in the past 5 years documents the increased
2. Heighten awareness of difficulties that late preterm infants
risk of morbidity and even mortality of the late preterm infant
and their mothers may experience with breastfeeding.
often related to feeding problems, especially when there is
3. Offer strategies to anticipate, identify promptly, and
inadequate support of breastfeeding.3–11 Establishing breast-
manage breastfeeding problems that the late preterm
feeding in the late preterm infant is frequently more prob-
infant and mother may experience in the inpatient and
lematic than in the full-term infant. Because of their
outpatient settings.
immaturity, late preterm infants may be sleepier and have less
4. Prevent medical problems such as dehydration, hypo-
stamina and more difficulty with latch, suck, and swallow
glycemia, hyperbilirubinemia, and failure to thrive in
than a full-term infant. The sleepiness and inability to suck
the late preterm infant.
vigorously may be misinterpreted as sepsis, leading to un-
5. Maintain awareness of mothers’ needs, understanding
necessary separation and treatment. Alternatively, the late
of current plans, and ability to cope.
preterm infant may appear deceptively vigorous at first
glance. Physically, large newborns are often mistaken for
Definition
being more developmentally mature than their actual gesta-

A t the time this protocol was first written ‘‘near-term’’

infant was commonly used to describe infants born in the
few weeks before the 37th week of gestation. In July 2005 a
tional age and as a result receive less attention than they need.
For example, the 3.8-kg baby born at 40 weeks was 3.0 kg at 36
weeks of gestation.
panel of experts assembled by National Institute of Child The late preterm breastfeeding infant has more difficulty
Health and Human Development designated infants born maintaining body temperature, increased vulnerability to
between 340/7 to 366/7 weeks of gestation as late preterm to infection, greater delays in bilirubin excretion, and more re-
emphasize the fact they are really ‘‘preterm’’ and not ‘‘almost spiratory instability than the full-term infant. Consequently
term’’ and establish a uniform designation for this group of they are at greater risk for hypothermia, hypoglycemia, ex-
infants.1 This definition, however, includes infants born 1 cessive weight loss, dehydration, slow weight gain, failure to
week more premature (340/7–346/7 weeks) than the previous thrive, prolonged artificial milk supplementation, exagger-
Academy of Breastfeeding Medicine protocol for the ‘‘near- ated jaundice, kernicterus, dehydration, fever secondary to

*This protocol was previously titled ‘‘Breastfeeding the Near-Term Infant (35 to 37 Weeks Gestation).’’

151
152 ABM PROTOCOL

dehydration, sepsis, apnea, re-hospitalization, and breast- c. Assess breastfeeding daily on the postpartum floor or
feeding failure. Furthermore, mothers of late preterm infants special care nursery.
are more likely to deliver multiples or have a medical condi- d. Assess breastfeeding issues carefully in the outpa-
tion such as diabetes, pregnancy-induced hypertension, tient setting.
chorioamnionitis, or a cesarean-section delivery that may af-
3. Provide timely lactation support in the inpatient and
fect the success of breastfeeding.9 Late preterm infants are also
outpatient setting.
more likely to be separated from their mother for evaluation
4. Avoid or minimize separation of mother and infant:
and treatment of medical problems. Late preterm infants may
be discharged home after successful transition to the extra- a. In the postpartum period, including immediately
uterine environment, but before lactogenesis II is fully estab- postpartum.
lished and before problems with latch and milk transfer can be b. In cases in which either mother or infant is hospi-
discovered and then adequately addressed. Parental educa- talized for medical reasons.
tion and timely outpatient follow-up by a provider knowl-
5. Prevent and promptly recognize frequently encoun-
edgeable in breastfeeding are crucial in the proper
tered problems in breastfed late preterm infants:
management of breastfeeding for these mother–infant dyads.
All infants, including late preterm infants, have a greater a. Hypoglycemia
chance of exclusive breastfeeding in hospitals that adhere to b. Hypothermia
the Ten Steps to Successful Breastfeeding. To this end, prac- c. Hyperbilirubinemia
titioners should become knowledgeable in the Ten Steps and d. Dehydration or excessive weight loss
work with the administration in their maternity hospitals to e. Failure to thrive
uphold the guidelines set forth in the Ten Steps.12
6. Educate:
Given the known increased risk of medical problems of the
late preterm as compared with the term infant, close obser- a. Educate staff and care providers in an ongoing man-
vation and monitoring are required, especially in the first 12– ner on issues specific to breastfeeding the late preterm
24 hours after birth when the risk of inadequate adaptation to infant in the inpatient and outpatient settings.
extrauterine life is highest. Each delivery service must deter- b. Educate parents about breastfeeding the late preterm
mine where and how this can best be accomplished while infant.
supporting the mother-infant dyad and breastfeeding. Keep c. Train one (or two) outpatient office support person
in mind infants born at 340/7 to 346/7 weeks have a 50% risk (R.N. or lactation educator) in:
for morbidity during the birth hospitalization.9 Some acute
i. breastfeeding support, assessment, basic breast-
problems encountered in the late preterm infant can be
feeding problem solving, and late preterm.
managed on the postpartum floor, but there are times when
ii. breastfeeding issues.
an infant should be transferred to a higher level of care for
appropriate care and monitoring. 7. Discharge/follow-up:
The late preterm infant’s condition requires timely evalu-
a. Develop criteria for discharge readiness.
ation after discharge. Just as many hospitals are becoming
b. Establish a post-discharge feeding plan.
breastfeeding friendly, the outpatient office or clinic needs to
c. Facilitate timely and frequent outpatient follow-up to
be not only supportive of the breastfeeding mother, but also
assure effective breastfeeding after discharge.
able to assist mothers with uncomplicated problems or
d. Monitor carefully once the mother and late preterm
questions related to breastfeeding. It is essential to be able to
infant are outpatients.
refer mothers and infants in a timely manner to a trained
lactation professional for more complicated breastfeeding 8. Monitor care of the late preterm infant through quality
problems. A lactation referral should be viewed with the same improvement projects (in- and outpatient settings).
medical urgency as any other acute medical referral.
Inpatient: Implementation of Principles of Care
Principles of Care
Quality of evidence for each recommendation, as defined in
1. Communicate optimally: the U.S. Preventive Services Task Force guideline, is noted in
a. Develop pathway and order set for breastfeeding the parentheses.*
late preterm infant. These principles are guidelines for optimum care of the late
b. Communicate the discharge feeding plan clearly to preterm infant. Each provider and newborn unit should use
the family and primary health provider. these recommendations as applicable to their institution and
c. Facilitate communication among physician, nurses, practice.
and lactation consultants in the inpatient and out- 1. Initial steps:
patient settings.
d. Avoid conflicting advice to mother and family about a. Communicate the feeding plan through a prewritten
the feeding plan. late preterm order set that can be easily modified.14
(III)
2. Assess/reassess:
a. Assess gestational age objectively and associated risk
factors. *Levels of Evidence (I, II-1, II-2, II-3, and III) are based on the U.S.
b. Observe closely for signs of physiologic instability. Preventive Services Task Force ‘‘Quality of Evidence.’’13
ABM PROTOCOL 153

b. Encourage immediate and extended skin-to-skin i. If there is evidence of ineffective milk transfer, teach
contact to improve postpartum stabilization of heart the mother to use breast compressions while the
rate, respiratory effort, temperature control, meta- infant suckles19 (III) and consider the use of an ul-
bolic stability, and early breastfeeding.15 (I) trathin silicone nipple shield.30–32 (II-2) The use of
c. Assess gestational age by obstetrical estimate and nipple shields is becoming more common for this
Ballard/Dubowitz scoring.16 (III) group of infants and can be helpful. If a nipple
d. Observe the infant closely for 12–24 hours to rule shield is used, the mother and baby should be fol-
out physiologic instability (e.g., hypothermia, ap- lowed closely by a trained lactation consultant or
nea, tachypnea, oxygen desaturation, hypoglyce- knowledgeable healthcare professional. (III)
mia, poor feeding). As noted in the Background of ii. Pre- and post-feeding weights may be helpful to
this protocol, each delivery service must determine assess milk transfer especially once lactogenesis II
where and how this can best be accomplished while has occurred.33–36 (II-2)
supporting the mother–infant dyad and breast- iii. The infant may need to be supplemented after
feeding. (III) breastfeeding with small quantities (5–10 mL per
e. Encourage rooming-in 24 hours a day and frequent, feeding on day 1, 10–30 mL per feeding thereafter)
extended periods of skin-to-skin contact. If the infant of the mother’s expressed breastmilk, donor human
is physiologically stable and healthy, allow the infant milk, or formula.14,20 Mothers may supplement
to remain with the mother while receiving intrave- using a supplemental nursing device at the breast,
nous antibiotics or phototherapy.17 (III) cup feeds, finger feeds, syringe feeds, or bottle de-
f. Allow free access to the breast, encouraging initiation pending on the clinical situation and the mother’s
of breastfeeding within 1 hour after birth.18 (II-2) preference.20 Cup feedings have demonstrated
g. Encourage breastfeeding ad libitum and on demand. safety in preterm infants, although intake is less and
Sometimes it may be necessary to wake the baby if duration of feeding is longer compared with bottle
he or she does not indicate hunger cues, which is not feeds.37–39 There is, however, little evidence about
unusual in the late preterm infant.19 The infant the safety or efficacy of other alternative feeding
should be breastfed (or breastmilk fed) eight to 12 methods or their effect on breastfeeding. When
times per 24-hour period. A mother may need to cleanliness is suboptimal, cup feeding may be the
express her milk and give it to the baby using al- best choice.40 (I, II-1, II-2, II-3, III)
ternative feeding methods if the baby is not able to iv. If supplementing, the mother should pump or
effectively breastfeed.19,20 ( III) express milk after breastfeeding, six to eight times
h. Show the mother techniques to facilitate effective per 24 hours, until the baby is breastfeeding well to
latch with careful attention to adequate support of establish and maintain her milk supply.11,20 Use of
the jaw and head.21 (III) a hospital-grade electric pump is recommended.
Milk production may be increased by hand mas-
2. Ongoing care:
sage of the breasts while pumping.41 (II-3)
a. Communicate daily changes in feeding plan either
h. Avoid thermal stress by using skin-to-skin (i.e.,
directly or with use of written bedside tool such as a
kangaroo) care15 (I) as much as possible or by double
crib card.14 (III)
wrapping if necessary and by dressing the baby in a
b. Evaluate desirably, within 24 hours of delivery, for-
shirt and hat. Consider intermittent use of an incu-
mally by a lactation consultant or other certified
bator to maintain normothermia.14,19 (III)
health professional with expertise in lactation man-
agement of the late preterm infant.14 (III) 3. Discharge planning:
c. Assess and document breastfeeding at least twice
daily by two different providers using a standard- a. Assess readiness for discharge, including physiologic
ized tool (e.g., LATCH Score,22 IBFAT,23 Mother/ stability and adequate intake exclusively at breast, or
Baby Assessment Tool24). (II-3) with supplemental feedings.42 (II-2) The physiologi-
d. Educate the mother about breastfeeding her late cally stable late preterm infant should be able to
preterm infant (e.g., position, latch, duration, early maintain body temperature for at least 24 hours in an
feeding cues, breast compressions, etc.)17,19 (III) open crib and have a normal respiratory rate, and
e. Monitor vital signs, weight change, stool and urine weight should be no more than 7% below birth
output, and milk transfer.11,25 (III) weight. Adequate intake should be documented by
f. Monitor for frequently occurring problems (e.g., hy- feeding volume or an improving pattern of infant
poglycemia, hypothermia, poor feeding, hyperbilir- weight (e.g., stable or increasing).14 (II-2) Twenty-
ubinemia).26–28 The late preterm infant should be four-hour test weights, with a scale designed for
followed closely with a low threshold for checking adequate precision may be useful to assess intake.39
bilirubin levels and have a routine discharge bilirubin (II-3)
determination plotted on a Bhutani curve according b. Develop a discharge feeding plan. Consider milk
to age in hours.2,29 (III) intake (mL/kg/day), method of feeding (breast,
g. Avoid excessive weight loss or dehydration. Losses bottle, supplemental device, etc.), and type of feed-
greater than 3% of birth weight by 24 hours of age or ing (i.e., breastmilk, donor human milk, or formu-
greater than 7% by day 3 merit further evaluation la).14 If supplementing, determine method most
and monitoring.14,19 (III) acceptable to mother for use after discharge.20 (III)
154 ABM PROTOCOL

c. Make an appointment for follow-up 1–2 days after ii. Increasing the frequency of breastfeeds.
discharge to recheck weight, feeding adequacy, and iii. Supplementing (preferably with expressed breast-
jaundice.17 (II-2) milk) after suckling or increasing the amount of
d. Communicate discharge-feeding plan to mother and supplement.
pediatric outpatient provider. Written communica- iv. Instituting or increasing frequency of pumping or
tion is preferred. (III) manual expression. Consider referral to a lactation
specialist. (III)
Outpatient: Implementation of Principles of Care
b. For infants with latch difficulties, the baby’s mouth
1. Initial visit: should be examined for anatomical abnormalities
a. The first outpatient office or home health visit should (e.g., ankyloglossia [tongue-tie], cleft palate), and a
digital suck exam should be performed. The moth-
occur 1 or 2 days after discharge.17 (II-2)
er’s nipples and breast should be examined for
b. Review and place relevant information from the in-
plugged ducts, mastitis, engorgement, fullness of the
patient maternal and infant records, including pre-
breast, and nipple trauma. The infant should be ob-
natal, perinatal, infant, and feeding history (e.g.,
served breastfeeding to examine the latch, suck,
need for supplement in the hospital, problems with
swallow. A referral to a trained professional lactation
latch, need for phototherapy, etc.), in the outpatient
specialist or in the case of ankyloglossia a referral to
chart. Gestational age and birth weight should be
a healthcare provider trained in frenotomy may be
noted prominently.25 (III)
indicated.11,44–46 (I, II-2, III)
c. Review of breastfeeding since discharge by the phy-
sician needs to be very specific regarding frequency, c. The jaundiced late preterm infant poses more of a
problem when considering management of hyperbi-
approximate duration of feedings, and how the baby
is being fed (e.g., at the breast, expressed breastmilk lirubinemia. All risk factors should be determined,
with supplemental device such as supplemental and if the principal factor is lack of milk, the primary
nursing system, finger feeds, or bottle with artificial treatment is to provide more milk to the baby, pref-
nipple). Information about stool and urine output, erably through improved breastfeeding or expressed
color of stools, baby’s state (e.g., crying, not satisfied breastmilk supplementation. If home or institution-
after a feed, sleepy and difficult to keep awake at the based phototherapy is indicated, breastmilk produc-
breast during a feed, etc.) should be obtained. If tion and intake should not be compromised.2,47 If the
the parents have a written feeding record, it should mother’s own milk or donor milk is not available,
be reviewed.11 (III) small amounts of cow’s milk-based formulas can be
d. Examine the infant, including an accurate weight used.47 Hydrolyzed casein formulas should be con-
without clothes and calculation of percentage change sidered for this purpose, as there is evidence that
in weight from birth, change in weight from dis- they are more effective in lowering serum bilirubin
than standard infant formula.48 (II, III)
charge, state of alertness, and hydration. Assess for
jaundice with transcutaneous bilirubin screening d. Consider the use of a galactogogue (a medicine or
device and/or serum bilirubin determination if in- herb that increases breastmilk supply) in mothers
dicated.11 (III) who have a documented low breastmilk supply and
e. Assess the mother’s breast for nipple shape, pain and for whom other efforts to increase milk production
trauma, engorgement, and mastitis. The mother’s have failed.49,50 (II-2, III)
emotional status and degree of fatigue should be e. The mother’s ability to cope and manage the feeding
considered, especially when considering supple- plan should be evaluated. If the mother is not coping
mental feeding routines. Whenever possible, observe well, work with her to find help and or modify the
the baby feeding at the breast, evaluating the latch, feeding plan to something that is more manageable.20
(III)
suck, and swallow.11 (III)
3. Follow-up:
2. Problem solving:
a. Babies who are not gaining well and for whom ad-
a. Poor weight gain (<20 g/day) is most likely the result
justments are being made to the feeding plan may
of inadequate intake. Median daily weight gain of a
need a visit 2–4 days after each adjustment. A home
healthy newborn is 28–34 g/day.43 The healthcare
health provider preferably trained in medical evalu-
provider must determine whether the problem is in-
ation of the newborn and in lactation support, who
sufficient breastmilk production, inability of the infant
reports the weight to the primary care provider,
to transfer enough milk, or a combination of both. The
could make this visit. (III)
infant who is getting enough breastmilk should have
b. All infants, including late preterm breastfed infants,
at least six voids and four sizable yellow seedy stools
should receive vitamin K shortly after birth51 (II-3)
daily by day 4, have lost no more than 7% of birth
and vitamin D supplementation (400 IU/day) be-
weight, and be satisfied after 20–30 minutes of nurs-
ginning in the first few days of life as recommended
ing.11 The following strategies may be helpful:
by the American Academy of Pediatrics.52 (II-3) Late
i. Shortening duration of breastfeeds if the late pre- preterm breastfed infants are at risk for iron defi-
term infant is not satisfied after approximately 30 ciency as their iron stores are less than that of the
minutes. full-term infant.53 (I) The American Academy of Pe-
ABM PROTOCOL 155

diatrics Committee on Nutrition recommends 2 mg/ 6. Bird TM, Bronstein JM, Hall RW, et al. Late preterm infants:
kg/day of elemental iron for all preterm infants from Birth outcomes and health care utilization in the first year.
1 to 12 months of age. The late preterm breastfed Pediatrics 2010;126:e311–319.
infant will, therefore, need 2 mg/kg/day of iron 7. Dimitriou G, Fouzas S, Georgakis V, et al. Determinants of
supplementation until consuming 2 mg/kg/day morbidity in late preterm infants. Early Hum Dev 2010;86:587–
through complementary feeds or weaned to iron- 591.
fortified formula. Screening for iron deficiency and 8. Kitsommart R, Janes M, Mahajan V, et al. Outcomes of late-
iron deficiency anemia at 6 months with hemoglobin, preterm infants: a retrospective, single-center, Canadian
serum ferritin, and C-reactive protein or reticulocyte study. Clin Pediatr (Phila) 2009;48:844–850.
9. Shapiro-Mendoza CK, Tomashek KM, Kotelchuck M, et al.
hemoglobin is recommended.53 (I)
Effect of late-preterm birth and maternal medical conditions
c. The late preterm infant should have weekly weight
on newborn morbidity risk. Pediatrics 2008;121:e223–e232.
checks until 40 weeks postconceptual age or until he
10. Wang ML, Dorer DJ, Fleming MP, et al. Clinical outcomes of
or she is thriving. Weight gain should average 20– near-term infants. Pediatrics 2004;114:372–376.
30 g/day, and length and head circumference should 11. Neifert MR. Prevention of breastfeeding tragedies. Pediatr
each increase by an average of 0.5 cm/week.43 (III) Clin North Am 2001;48:273–297.
12. Academy of Breastfeeding Medicine Protocol Committee.
Recommendations for Future Research ABM Clinical Protocol #7: Model breastfeeding policy (re-
Future research is needed to establish the best methods for vision 2010). Breastfeed Med 2010;5:173–177.
monitoring the late preterm infant in the first 24 hours of life 13. Appendix A Task Force Ratings. www.ncbi.nlm.nih.gov/
books/NBK15430 (accessed April 12, 2011).
for physiologic instability while optimizing mother–infant
14. Hubbard E, Stellwagen L, Wolf A. The late preterm infant: A
interactions and specifically initiation of breastfeeding. Cur-
little baby with big needs. Contemp Pediatr November 1, 2007.
rently newborn units must decide where and how this should
www.modernmedicine.com/modernmedicine/Features/
be done. There is no uniform approach to this issue. Addi-
The-late-preterm-infant-A-little-baby-with-big-nee/Article
tional areas of research should focus on: Standard/Article/detail/472738 or spinprogram.ucsd.edu/
1. the best methods for assessing breastfeeding Documents/ContemporaryPediatricsThelatepreterminfant_
2. supplementing the late preterm infant AlittlebabywithbigneedsCME.pdf (accessed April 12, 2011).
3. appropriate use of nipple shields 15. Moore ER, Anderson GC, Bergman N. Early skin-to-skin
4. appropriate feeding plans contact for mothers and their healthy newborn infants. Co-
chrane Database Syst Rev 2007;3:CD003519.
5. establishing discharge readiness
16. Ballard JL, Khoury JC, Wedig K, et al. New Ballard Score,
6. establishing appropriate guidelines for certified lacta-
expanded to include extremely premature infants. J Pediatr
tion consultation in the in- and outpatient area
1991;119:3:417–423.
7. establish outpatient care guidelines to support lactation
17. Gartner LM, Morton J, Lawrence RA, et al. Breastfeeding
while avoiding medical problems (i.e., hyperbilir- and the use of human milk. Pediatrics 2005;115:496–506.
ubinemia and hypernatremic dehydration). 18. Righard L, Alade MO. Effect of delivery room routines on
Outcomes measures for future research should include success of first breast-feed. Lancet 1990;336:1105–1107.
breastfeeding duration and exclusivity in addition to other 19. Walker M. Breastfeeding the late preterm infant. J Obstet
parameters appropriate for the subject of investigation. Gynecol Neonatal Nurs 2008;37:692–701.
20. Academy of Breastfeeding Medicine Protocol Committee.
Acknowledgments ABM Protocol #3: Hospital guidelines for the use of sup-
plementary feedings in the healthy term breastfed neonate,
This work was supported in part by a grant from the Ma- revised 2009. Breastfeed Med 2009;4:175–182.
ternal and Child Health Bureau, U.S. Department of Health 21. Thomas J, Marinelli KA, Hennessy M, et al. ABM Clinical
and Human Services. Protocol #16: Breastfeeding the hypotonic infant. Breastfeed
Med 2007;2:112–118.
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diatrics 2008;122:1119–1126. 1. Have a written breastfeeding policy.
43. Grummer-Strawn LM, Reinold C, Krebs NF. Use of World 2. Train all healthcare staff in the skills necessary to im-
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45. Geddes DT, Langton DB, Gollow I, et al. Frenulotomy for
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46. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: Assessment, remain together, 24 hours a day if medically stable.
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