By nature of their prematurity and underdevelopment of all body systems at birth, extremely low birthweight (ELBW) infants (<1,000 g) are unable to obtain their total nutrition from any source of oral or gavage feeding for weeks or months after birth. In my opinion, they should be given the opportunity to reap the benefits of receiving their mothers' milk. Mothers of ELBW infants should be provided with information, resources, and support to eventually exclusively breastfeed their infants, if that is what they desire.

The nutritional, gastrointestinal, immunological, neurodevelopmental, and psychological benefits of breast milk to premature infants have been well documented in the literature (Callen & Pinelli, 2005). Many NICUs are currently encouraging mothers of ELBW infants to express their milk so that it can be given to their infants when gavage feedings are initiated.

Challenges and barriers to breastfeeding ELBW infants have been documented, and they generally include (1) establishing and maintaining an adequate milk supply without the normal stimuli of the infant feeding at the breast, (2) transitioning from gavage feedings to breastfeeding, and (3) measuring milk transfer (Spatz, 2004). Establishing and maintaining an adequate milk supply is critical to the process that will eventually allow a mother to breastfeed her ELBW infant (Spatz). This is possible if lactation is established 6-12 hours after birth, hospital-grade electric breast pumps are used, and the mother keeps a log of her breast milk production, with daily assessment and intervention by the infant's nurse (Spatz).

Transitioning to breastfeeding can be a natural progression from gavage feedings. The bottle never needs to be introduced. In the past, it was common for NICU nurses and physicians to inform families that feeding from the breast is more difficult than feeding from a bottle and that attempts at breastfeeding should be delayed for the preemie until the infant is tolerating bottle-feedings (somewhere between 33 and 34 weeks' postconceptual age). Furthermore, some nurses argued that allowing the premature infant to feed mainly from the breast would delay discharge. Now we know that no research supports these theories or even shows that premature infants need to be successfully fed by bottle before they can begin breastfeeding attempts (Spatz, 2006). There is, however, evidence to show that premature infants are physiologically more stable, with fewer episodes of apneas and bradycardias during breastfeeding as opposed to bottle-feeding (Callen & Pinelli, 2005). Because kangaroo care has been shown to increase mothers' milk supply, improve infant growth, significantly decrease length of hospital stay, and increase breastfeeding duration, mothers should be encouraged to practice kangaroo care during gavage feedings, progress to nonnutritive sucking, then to nutritive sucking, which can occur as early as 30 weeks' gestation (Callen & Pinelli; Spatz).

Mothers may worry that their infants are not getting enough during breastfeeding, but milk transfer can be assessed by weighing the infants immediately before and after a breastfeeding session, then complementing the feeding by gavage. Nipple shields also can be used to enhance the transfer of milk. A supplemental nursing device may help to ensure adequate milk volume transfer during each breastfeeding session until an infant's suck becomes stronger (Spatz, 2004). Spatz encourages mothers to spend at least 8 consecutive hours a day, for as many days as possible, breastfeeding their infants on demand, with subsequent evaluation of the process and the development of discharge feeding plans. Follow-up at home by experienced healthcare professionals who are knowledgeable about breastfeeding premature infants is essential to achieving a positive outcome (Spatz, 2006).

Mothers of ELBW infants should have the opportunity to eventually exclusively breastfeed their infants if this is what they desire. To achieve this goal, the NICU healthcare team should discard old myths and use evidence-based research to provide sound information and support to these families. With knowledge, commitment, and patience on the part of all, this can be safely accomplished.

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