Amanda Wilde (Host): This is LIFE Cast, a podcast from Infirmary Health. I'm Amanda Wilde, your host. My guest is neonatologist, Dr. Nathan Knutson, And we are discussing breastfeeding for premature babies. Dr. Knutson, welcome and thank you for being here.

Dr. Nathan Knutson: Well, thank you so much for having me.

Host: So, explain this to me. Premature babies are often, I imagine, nourished through a tube initially that I think of a premature baby as being in a respirator. Can you explain really who these individuals really are?

Dr. Nathan Knutson: Many times premature babies are fed through a tube initially. There's a couple reasons why that might be. Sometimes they're on respiratory support that precludes them from feeding by mouth. Sometimes their gestational age, they're just not mature enough, usually under 33, 34 weeks. So, we feed them via a tube until they're showing some signs of readiness in feeding by mouth.

Host: And when you see those signs, do you then try to transition to breastfeeding?

Dr. Nathan Knutson: Yeah. We do really encourage breastfeeding early. It's a very important thing for the mothers and for the babies, both psychologically and in preparation for full feeding by mouth. So, we will try and, many times, reserve the first feed by mouth to be a breastfeed, especially if the moms are engaged in that.

Host: And when you're transitioning babies from tube feeding to breastfeeding, what are the strategies you use to support that transition?

Dr. Nathan Knutson: We have mothers try to do the first feed by breastfeeding. And then, we will kind of pay attention to the cues. It's really important that, during that particular time, that the families enable the mother to be there regularly to participate in this. Usually, the first few days we're not feeding every feed by mouth, but maybe a couple a day for short attempts. And then, we'll have mothers pump ahead of time to just get the letdown started. So, it's a little easier for the babies to get the milk out of the breast. Sometimes they have been fed by a bottle. And although we use slower flow nipples on the bottle, they can get a little frustrated with getting the milk out of the breast initially.

Host: So, you're talking about a gradual transition, the short attempts, pumping, making it easier for the baby to get to the breast milk. What about the milk supply of mothers of preterm or medically fragile infants during the early weeks. How are you supporting mothers in milk supply?

Dr. Nathan Knutson: So, we have excellent lactation consultants that usually visit the mom within the first, 24-48 hours. Get the mom to begin pumping, if they're not able to feed by mouth. it is really a good idea to use in the hospital hospital grade double electric pump. So, that helps to extract the milk a lot better than a manual pump or things like that. So, early on, we get them pumping about eight times a day or about every three hours. So, they'll do this through the night. There have been studies that show that are early pumping in this manner definitely increases your milk supply at two weeks. So really, if they are having any difficulty, it's usually the regular pumping that really gets that going. So, they really have to be diligent with that. So, that's kind of where we focus.

Now, some mothers with anxiety and maybe pain, we really want to get them in a comfortable state to where they can pump in a relaxed manner. And it's usually a last resort that we will have them see their obstetrician for some medicine to help them produce milk. So, those are the types of strategies that we use early.

Host: It does sound like it can be daunting for parents. What advice do you give parents of a preterm baby who struggle with breastfeeding or are intimidated by the process?

Dr. Nathan Knutson: Yeah, the mother-baby dyad, everyone is unique. Everybody in the situation, including the physicians, the nurse practitioners, the nurses, the lactation consultants, the mothers, and the mother's extended family all bring their own psychology to this. And so, you kind of have to figure out each particular one, what works best for them. They may not always be able to be at the hospital, just impressing upon them how it's important to be there. But each person has their own struggles or their own situation that may not make that possible to be there on a routine basis, or some of them are very engaged and have the ability to be there regularly. We try to recognize that and not beat them over the head with doing these kind of things. But also, at the same time, the breast milk for premature babies is extremely important. It decreases infection. We call it liquid gold. So, it is that balance between recognizing their personal psychology, but also trying to make it hit home that it is definitely something important to do. And it's not an easy thing to do. We start out with that as well.

We can do donor breast milk in situations where they're unable to produce or early on to just bridge as they're getting their milk supply in. But mother's own milk is unprocessed and it has all the good antibodies and all the things that really help a baby to do well long-term.

Host: Another aspect of breastfeeding is completely physical, and there's this term called kangaroo care. Maybe you can explain that and how that affects breastfeeding success.

Dr. Nathan Knutson: Yes. We encourage mothers, even before the breastfeeding, and this helps with producing breast milk as well. It is really a core part of neonatology to get mothers and fathers holding the baby early if they're stable enough. It stabilizes their temperature. There's that psychological bonding. It helps the mother really produce those bonding hormones that are helpful in increasing, milk supply and those kind of things. And a lot of times, we'll even say for the mothers to pump in front of the baby.

So, I did read not too long ago that even kangaroo the mother can help prevent infections in the baby, because if the baby's exposed to something and the mother's exposed to it, the breast milk will change within less than an hour to provide immune defenses for the baby. So, it is extremely good thing to be done, that bonding. A lot of times if mothers weren't thinking that they were going to breastfeed, putting a baby on their chest and watching them really try to breastfeed without mother being even engaged in that, a lot of them will decide that it's an important thing to do at that point.

Host: So, that really close skin-to-skin contact or kangaroo care affects breastfeeding success. And also, as you're pointing to long-term outcomes for the infants involved, right?

Dr. Nathan Knutson: You know, holding a baby close like that, they've shown it increases IQ. It has so many effects psychologically on the baby. You're not just leaving them in the incubator without anybody holding them. And that human physical touch is extremely important.

Host: I think you've touched on this, but is there anything you want to add to how clinicians, people on your side promote breastfeeding while supporting sometimes overwhelmed parents or those facing barriers?

Dr. Nathan Knutson: I think sometimes it's hard for us to recognize, because there's so many people that come in and out of the situation, what things have been addressed and what things haven't, and trying to attempt to decrease the brow beading, understanding it's nice to get a little bit of a history with how the feeds are going before we just enter the room and just have a conversation off the cuff. Many of these conversations may have already been had.

But really, what I want them to understand is everybody, the nurses, the lactation consultants, the practitioners, everybody in the situation, we're all on the same team of trying to get the baby to the point of going home and the successful breastfeeding or, if not breastfeeding, milk pumping and milk availability from the mother to the baby. Those are our goals.

And really, I think this team approach and trying to recognize hopefully they speak up when they have some issues that we love to troubleshoot and help them through these kinds of things in a nonjudgmental way.

Host: Well, Dr. Knutson, thank you for providing support for families with premature babies in their breastfeeding journey. This was a really informative conversation.

Dr. Nathan Knutson: You're welcome. I love doing this. I love the interaction with the families and just watching all these babies grow up as time goes on. I've been doing this for over 20 years now, and it's amazing to see it all.

Host: So, you've seen babies that grow into adults.

Dr. Nathan Knutson: I've seen babies graduate high school.

Host: Well, may you see many more graduations in the future.

Dr. Nathan Knutson: I appreciate that.

Host: That was neonatologist Dr. Nathan Knutson. For more information, go to infirmaryhealth.org. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. Thanks for listening to LIFE Cast, a podcast from Infirmary Health.