Transitioning to Breastfeeding In the NICU

Irene Murphy Zoppi, RN, MSN, IBCLC / August 2019


The value of human milk for all infants is no longer a debate. Empirical evidence supports the practice of providing human milk regardless of infants’ gestational age.

Due to immaturity, the premature infant may not be able to direct breastfeed, and may need to first receive human milk enterally. Depending on the infant’s gestational age and morbidities, it may be an extended period before the infant is able to receive oral feeds and direct breastfeed. In addition, the transition to breastfeeding can be slow, as poor oral motor skills and inefficient feeding are common among premature infants.1

NICU clinicians may wonder when it is appropriate for mothers to initiate at-breast feedings, and what practical strategies they can employ that will best assist mothers with breastfeeding their infants. Mothers will probably have multiple questions as well, and express anxiety about putting their infants to breast for the first time.

Providing a well-communicated plan of care for staff and mothers may reduce some of these concerns. The following offers a review of researched strategies that facilitate the transition to breastfeeding.

Colostral Oral Care

In the first days of life, premature infants should receive oral colostral care with expressed colostrum. This provides infants the opportunity to both taste and smell their mothers’ own breast milk and supports sustained, longer term breastfeeding. Research also demonstrates infants are more likely to tolerate oral breast milk feeds earlier following regular oral colostral care.2

Skin-to-skin care (SSC)

SSC is a recognized standard of care for infants within the NICU. In addition to the many physiologic benefits of improved gas exchange, heart rate, and decreased periods of apnea, the most substantial evidence of benefit from SSC is for breastfeeding. Individual randomized controlled trials and a systematic review have shown that intermittent SSC is associated with longer and more exclusive breastfeeding and higher volumes of expressed milk3,4 and should be encouraged as an initial step in the transition to breastfeeding. 

Nonnutritive Sucking

Nonnutritive sucking at the breast improves transition to breastfeeding and has been linked with longer breastfeeding duration.5 It should be initiated after the infant has been extubated, and coincide with gavage feedings. The mother should be instructed to first empty her breast just prior to the feeding, position her infant skin-to-skin at the breast, and manually express drops of breast milk onto the infant’s lips. The infant can taste breast milk and become familiar with the breast while being gavage fed.

There is no precise gestational age that infants can begin nonnutritive sucking at the breast. Researchers in Sweden have shown that infants as young as 29 weeks postmenstrual age have obvious rooting behavior, efficient areolar grasp, repeated short sucking bursts, and demonstrate repeated swallowing from 31 weeks.6

NICU Breastfeeding

With increasing episodes of nonnutritive sucking at the breast, improved latch and removal of quantities of breast milk, premature infants can begin transitioning to direct breastfeeding.  There is no need to ‘test’ feeding behaviors by introducing bottle feeding prior to direct breastfeeding. 

Research has shown premature infants who had their first oral feeding experience directly at the breast with their mother had longer and more sustained durations of breast milk feedings while in the NICU. In addition, the first oral feeding, as a direct breastfeeding experience, was found to be associated with a higher likelihood of infants receiving breast milk at discharge than for infants who receive breast milk in a bottle yet never experience direct breastfeeding.7

Nipple Shield Use in the NICU

Nipple shields have been shown to increase the volume of milk transferred, and extend breastfeeding in the preterm population. Nipple shields help to compensate for inadequate sucking pressures premature infants exhibit by concentrating negative pressures in the tip of the shield.8 They should be used early in the breastfeeding process and continue to be used until the infant is able to fully breastfeed. Weaning from the nipple shield can then begin but this typically occurs in the post-discharge period.

Measuring Breast Milk Transfer

The use of a scale specific for measuring breast milk transfer is a useful tool in the NICU as it empirically quantifies the amount of milk the infant ingests. Mothers should be taught how to perform ‘test weights’, as research has indicated confirming milk transfer reduces anxiety about the amounts of breast milk their infants transfer and that mothers enjoy this aspect of providing care to their infants.9,10 Test weighing should continue until effective breastfeeding is demonstrated at all feeds.

Bedside clinicians play an instrumental role in helping to provide a positive breastfeeding experience for mothers and their premature infants. Mothers may feel apprehensive about what to initially expect and how their infants will respond to breastfeeding attempts. They will need guidance, support and direct supervision during these initial early feeding attempts on how to properly position the infant and facilitating latch.

A well-developed care plan providing careful explanation and direction to mothers will increase their confidence and motivation to continue to direct breastfeeding. The commitment and hard work of mothers to breastfeed their premature infants is admirable and needs to be applauded by the NICU team.

What successes have you experienced in your NICU when assisting mothers transition their infants in breastfeeding?

  1. McGrath JM, Braescu AV. State of the science: feeding readiness in the preterm infant. J Perinat Neonatal Nurs 2004; 18(4): 353–368.
  2. Snyder R, Herdt A, Mejias-Cepeda N, Ladino J, Crowley K, Levy P. Early provision of oropharyngeal colostrum leads to sustained breast milk feedings in preterm infants. Pediatrics & Neonatology. 2017; 58(6):534-540.
  3. Hake-Brooks SJ, Anderson GC. Kangaroo care and breastfeeding of mother-preterm infant dyads 0-18 months: a randomized, controlled trial. Neonatal Netw. 2008;27(3):151–159.
  4. Renfrew MJ, Craig D, Dyson L, et al. . Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis. Health Technol Assess. 2009;13(40):1–146.
  5. Narayanan I, Mehta R, Choudhury DK, Jain BK. Sucking on the “emptied” breast: non-nutritive sucking with a difference. Arch Dis Child. 1991;66:241– 244.
  6. Nyqvist KH. Early attainment of breastfeeding competence in very preterm infants. Acta Paediatr. 2008; 97(6):776-81.
  7. Pineda R. Direct breast-feeding in the neonatal intensive care unit: is it important? J Perinatol. 2011;31(8):540-545. 
  8. Meier PP, Brown LP, Hurst NM, et al. Nipple shields from preterm infants: effect on milk transfer and duration of breastfeeding. J Hum Lact. 2000; 16:106– 114.
  9. Hurst N, Meier PP, Engstrom JL, et al. Mothers performing in-home measurement of milk intake during breastfeeding for their preterm infants: effects on breastfeeding outcomes at 1, 2, and 4 week post NICU discharge. Pediatr Res.1999;45:125A
  10. Meier PP, Engstrom JL, Fleming BA, Streeter PL, Lawrence PB. Estimating milk intake of hospitalized preterm infants who breastfeed. J Hum Lact. 1996; 12(1):21-6.


About the Author

Irene joined Medela in 1999 as a clinician for the Breastfeeding Division. She currently serves as a Clinical Education Specialist focusing on Advocacy Outreach. In this role, she acts as a vital resource for groups assisting breastfeeding mothers and infants. She has been frequently interviewed on radio and online regarding breastfeeding issues for mothers and clinicians.

Irene spent many years caring for new families in antenatal, labor and delivery, postpartum and NICU settings and was involved in direct patient care and family-based education. Irene has extensive experience teaching in a variety of nursing education programs.  She produced a video presentation on nursing students’ involvement in Community Health Nursing for the National League of Nursing.