July 2019 Newsletter: Breastfeeding a Premature Baby

By Agnes Nemes-Chow, BMSG Volunteer
Photo credits: Agnes-Nemes Chow

Agnes is a stay-at-home mother of seven children aged between 2.5 months and 11 years. Originally from Hungary, Agnes married a Singaporean and has been living in Singapore for 16 years. She and her family stayed briefly in Australia prior to 2011, and returned to Singapore in January that year when she unexpectedly gave birth to a premature baby. The following is her story on how she was thrown into the waters of breastfeeding a premature baby back then.

Agnes’ son was born at 33 weeks gestation and had to stay in the Neonatal Intensive Care Unit (NICU) for three weeks.

How it All Began

When we moved back from Australia to Singapore in January 2011, I was then expecting our third child and I didn’t realise that the place where we were living in then was a dengue cluster. I was feeling unwell for a few weeks during my second trimester but I just assumed they were pregnancy symptoms. I only casually mentioned to my gynaecologist that the General Practitioner (GP) I had been seeing had suspected I had dengue. During a growth scan later on, they found that my baby was too small for his gestational age but there was nothing we could do about it at that time. A few days later, at 33 weeks, I went into labour and gave birth to a baby weighing only 1.6 kg baby, but thankfully, he was healthy baby. Our son had to stay in the NICU for almost three weeks till he was able to be fed expressed milk from a bottle.

Initiating Breastfeeding

Agnes (masked) with her baby at the NICU doing kangaroo care. Agnes and her husband spent many days and nights at the NICU to ensure that they were able to feed their baby expressed breastmilk before he could attempt to latch.

I had experience in breastfeeding full-term babies but I had no idea about breastfeeding a premature baby. After birth, my baby was taken to the Neonatal Intensive Care Unit (NICU) straight away so I had no chance to breastfeed him. I was wheeled to the maternity ward and I could only see my baby later at night. There was a very kind nurse, who taught me how to express colostrum into a syringe so I kept doing that and it was encouraging to see that after 1-2 mls at the beginning, I could express more and more subsequently.

My baby only took 2 ml of milk for his first feed, but that was all that was needed then. He was fed through a feeding tube. After I was discharged, I was very determined to express as much milk as I could for my baby and we delivered the milk to the hospital every day, sometimes twice a day. In the NICU, the doctors told me that it was very important, especially for a premature baby, to receive breastmilk instead of formula so that he receives all the antibodies to fight infections.

In the NICU, the doctors told me that it was very important, especially for a premature baby, to receive breastmilk instead of formula so that he receives all the antibodies to fight infections.

Conflicting Advice

Some of the doctors also encouraged me to keep trying to breastfeed, so I did. Others told me that such small babies may not end up breastfeeding so the advice was conflicting. My baby never seemed to show any interest in breastfeeding in the initial days when I tried to feed him and I didn’t receive any practical help from the medical personnel. I think the problem was that I was unsure about when he had already been given EBM so when I was allowed to hold him, he was not hungry. The main concern was for him to gain weight and we were told that he could be discharged when he reached two kilograms and was able to drink from a bottle.

Agnes’ son (middle) continued to thrive into a healthy baby and was able to eventually fully direct latch.

The Importance of Support

When he was transferred to the nursery, I asked if it was possible for me to try breastfeeding and they allowed me to try. I made sure that I was there for many hours so that I didn’t miss the feeding times this time around. My baby’s weight was already 2 kilos then but his mouth was still tiny and he struggled to latch and got tired and fell asleep very easily. My husband was my greatest support at that time. He wanted me to spend as much time in the hospital as possible so that I could keep trying to breastfeed my baby. He thought it was the critical time to establish breastfeeding and he was right!

Agnes’ 3rd child (middle) happy with his siblings!

Going Home!

After 3 weeks in the hospital, we finally got to bring our baby home! The older two children were 3.5 years and 20 months old then. I had to continue expressing milk at home. My routine was to wake my baby up (as he tended to sleep throughout the whole day), breastfeed, give expressed milk from a bottle and then pump for each feed. It was very tiring for me and my older kids were especially needy as I was previously away from them so much when I had to go to the hospital. When my 1.5 years old son, who could already drink from a cup, saw the bottle, he also asked me to give him milk from a bottle! It was total chaos at home those days.  At that stage, my baby was only taking a small amount through direct latch and drank a good amount from the bottle. As the days passed, I noticed he was drinking less and less from the bottle and that was a sign to me that he was able to get more from the breast. After about two weeks, when he wasn’t really drinking much from the bottle anymore, I did away with it and we just continued with direct latch. Finally, my life got easier!

Agnes’ son is now a bubbly and healthy 8 year old!

Advice for Parents

From my experience, I believe that it is important to inform the hospital staff that you want to breastfeed your baby and to coordinate the feeding times so that the baby is hungry enough at the time you want to try latching baby. Even if the baby seems too small and weak to feed, through skin-to-skin contact (kangaroo care), the baby can be encouraged to be near the breast. Mums must make sure they express milk at least every three hours, not only to provide milk for the baby but also to establish a good supply so that when the baby can direct latch, there will be plenty of milk available. It is important to spend as much time as possible in the hospital to give kangaroo care to the baby and to keep on trying to breastfeed. It’s a good idea, too, to also ask for help from a lactation consultant.

Breastfeeding a premature baby is very challenging but with good support and perseverance, it is definitely possible. It’s important to start to direct latch the baby as soon as possible and not to give up even if it doesn’t work at the beginning. They will grow and get stronger faster and will be able to latch eventually. If the baby is discharged on bottle-feeding, it’s important to always latch the baby first for each feed and only give expressed milk as a top-up. This way, the bottle can be removed after a while and the baby can be directly breastfed.

Notes for Parents with Premature Infants

  • Ask questions! Don’t be afraid of the medical personnel as they are really there to help you and your baby
  • Offer your baby donor milk such as from the KKH Milk Bank.
  • As soon as baby has been admitted to the nursery and separated from you, ask for a hospital-grade breast pump so that you can start stimulating your breast milk supply! It is recommended that this happens within the first three hours after birth.
  • Hand express colostrum into cups or syringes so that baby can be fed with these precious drops. Colostrum is an extremely potent source of antibodies and no single drop should be wasted!
  • Get help from the hospital lactation nurses and lactation consultants.
  • Kangaroo care and spending lots of time skin-to-skin with your baby helps you reconnect with your baby! Grab every opportunity to bond with your baby! Studies show that skin to skin is a great way to kickstart milk production. Mothers who pump beside their babies tend to yield more milk.

June 2019 Newsletter: Breastfeeding a Baby with Tongue-Tie

By Applie Wan (BMSG Volunteer)

Stay-at-home mum Applie Wan was eager to start breastfeeding when she gave birth to her baby girl. Things seemed to start off rather smoothly on the day of the birth. However, on the second day, her nipples began to crack and breastfeeding grew increasingly painful. This is the story of how Applie figured out that her daughter was tongue-tied and how it affected their breastfeeding journey.

I am a SAHM of a 22-month-old girl. We first knew of the tongue tie when our paediatrician checked our baby in the early morning after she was born. The doctor asked if I experienced any pain while breastfeeding, to which I replied that my nipples were sore but I thought it was all very normal since it had only been a day since we had started breastfeeding. She suggested that we discuss this further with our postpartum doula and see a paediatric dentist for a proper diagnosis. 

Initially, we felt a little discouraged, as we hadn’t expected our baby to have any issues. Having a tie seemed almost like she wasn’t a perfectly healthy baby. Thankfully, our doula assured us that tongue ties are actually quite common and our baby was doing very well. Coincidentally, her child also had a tongue tie and she was able to tell us in depth how it might potentially affect breastfeeding and what our options were. 

It is best to catch a baby’s lip or tongue tie as early as possible. If you have your doubts, see a paediatrician or a paediatric dentist.

On the second day after delivering my baby, my nipples began to crack and breastfeeding started to become really painful. We worked on baby’s position as much as we could to get baby latching as deeply as she could, but the pain continued to persist as I could feel the raw wound on my nipples every time she nursed. We decided to book an appointment to see a paediatric dentist as soon as possible so that we could make the necessary decisions without delay. However, the earliest appointment we got was four days later. 

By the next day, my breasts started to get engorged. My milk had started to come in and shortly after, I started to get fever and chills. Our postpartum doula helped me to hand express and found out that there was pus, which may have been due to the cracked nipples leading to an infection. In addition, even though I had been nursing baby on demand every two to three hours, I ended up with blocked ducts. I started to dread latching her because of the pain and tried to pump instead to give my nipples a break. However, I didn’t yield much as I was still new to pumping so I bit my tongue and persevered to latch baby, even though I was in tears each time.

As our baby also had jaundice, she was very sleepy and had to be woken up to nurse. I also started to research about tongue ties, and found out that tongue-tied babies can also be very sleepy as it takes a lot of energy for them to extract milk from the breasts. Their milk transfer is not as efficient, hence they may fall asleep while suckling due to the effort they take. It dawned on us that our baby was gaining weight very slowly, she rarely pooped and her skin seemed loose and wrinkled.

A paediatric dentist will be able to properly advise you on whether your baby’s tongue and lip ties are severe and require a revision. Comparing your child’s lip or tongue tie with other children’s or guessing just from observation will not be helpful. See a professional instead.

Finally, the day of our appointment with the dentist arrived. We saw Dr Tabitha Chng on the advice of our paediatrician and she diagnosed that our baby had both tongue and lip ties. She also did a thorough evaluation of our breastfeeding journey. By the end of that evaluation, it was clear that the ties were impacting breastfeeding adversely. She went through all the procedures that we could do to resolve the ties before allowing us to make a decision. At that moment, I knew that we needed to proceed with the release if I wanted to continue breastfeeding exclusively so we went ahead with the release on the day itself. Within ten minutes, the procedure was finished and I was able to latch baby immediately to comfort her.

Surprisingly, I felt the difference the moment she latched on. I could feel more of her tongue moving against my breast when previously, I could only feel the tip of her tongue. She was also able to flange out her upper lips more than before. Even though she took some time to relearn how to latch with her newfound tongue mobility, I was immensely relieved that breastfeeding was no longer painful. 

We engaged a lactation consultant to continue working with us to improve her latch over the next few days, and diligently did the stretching exercises that were crucial in preventing the tongue and lip from reattaching. Within a week, my nipples had healed, our nursing sessions were pain-free and I was able to enjoy bonding with my baby much more. She started to gain more weight also. Baby is now 22 months old and is still breastfeeding. I am proud to have come this far!

After the revision, your baby may need to relearn how to latch. It will be best to work with a lactation consultant during this period.

If you suspect that your baby has a tie, I would definitely recommend that you seek a proper diagnosis from a paediatric dentist trained in tongue and lip ties. The dentist can help to evaluate how the tie is affecting breastfeeding. Some parents decide not to do the procedure as their babies are able to breastfeed without much issue despite the tie, so it is important to consider if the benefits of doing the release would outweigh the risks.

A release is also harder to do when the child is older. For example, the procedure may have to be done under general anaesthesia if the child is already very mobile, and the baby also has to relearn how to latch after the revision. Hence, I strongly believe that seeking help and advice as early as possible is very important.