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 breastfeeding
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
1. Promote, support, and sustain breastfeeding in the late
preterm infant.
2. Maintain optimal health of the infant and mother.
Purpose
1. Allow the late preterm infant to breastfeed and/or
breastmilk feed to the greatest extent possible.
2. Heighten awareness of difficulties that late preterm infants
and their mothers may experience with breastfeeding.
3. Offer strategies to anticipate, identify promptly, and
manage breastfeeding problems that the late preterm
infant and mother may experience in the inpatient and
outpatient settings.
4. Prevent medical problems such as dehydration, hypoglycemia,
hyperbilirubinemia, and failure to thrive in
the late preterm infant.
5. Maintain awareness of mothers’ needs, understanding
of current plans, and ability to cope.
Definition
At 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
panel of experts assembled by National Institute of Child
Health and Human Development designated infants born
between 340/7 to 366/7 weeks of gestation as late preterm to
emphasize the fact they are really ‘‘preterm’’ and not ‘‘almost
term’’ and establish a uniform designation for this group of
infants.1 This definition, however, includes infants born 1
week more premature (340/7–346/7 weeks) than the previous
Academy of Breastfeeding Medicine protocol for the ‘‘nearterm
infant’’ that encompassed infants born at 350/7 weeks to
366/7 weeks. In addition, infants born at 370/7–376/7 weeks
may be at risk for breastfeeding problems and associated
risks, and, therefore, the following guidelines may be applicable
to these infants as well.2
Background
The advantages of breastmilk feeding for premature infants
are even greater than those for term infants; however, a large
body of literature in the past 5 years documents the increased
risk of morbidity and even mortality of the late preterm infant
often related to feeding problems, especially when there is
inadequate support of breastfeeding.3–11 Establishing breastfeeding
in the late preterm infant is frequently more problematic
than in the full-term infant. Because of their
immaturity, late preterm infants may be sleepier and have less
stamina and more difficulty with latch, suck, and swallow
than a full-term infant. The sleepiness and inability to suck
vigorously may be misinterpreted as sepsis, leading to unnecessary
separation and treatment. Alternatively, the late
preterm infant may appear deceptively vigorous at first
glance. Physically, large newborns are often mistaken for
being more developmentally mature than their actual gestational
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.
The late preterm breastfeeding infant has more difficulty
maintaining body temperature, increased vulnerability to
infection, greater delays in bilirubin excretion, and more respiratory
instability than the full-term infant. Consequently
they are at greater risk for hypothermia, hypoglycemia, excessive
weight loss, dehydration, slow weight gain, failure to
thrive, prolonged artificial milk supplementation, exaggerated
jaundice, kernicterus, dehydration, fever secondary to
*This protocol was previously titled ‘‘Breastfeeding the Near-Term Infant (35 to 37 Weeks Gestation).’’
BREASTFEEDING MEDICINE
Volume 6, Number 3, 2011
ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2011.9990
151
dehydration, sepsis, apnea, re-hospitalization, and breastfeeding
failure. Furthermore, mothers of late preterm infants
are more likely to deliver multiples or have a medical condition
such as diabetes, pregnancy-induced hypertension,
chorioamnionitis, or a cesarean-section delivery that may affect
the success of breastfeeding.9 Late preterm infants are also
more likely to be separated from their mother for evaluation
and treatment of medical problems. Late preterm infants may
be discharged home after successful transition to the extrauterine
environment, but before lactogenesis II is fully established
and before problems with latch and milk transfer can be
discovered and then adequately addressed. Parental education
and timely outpatient follow-up by a provider knowledgeable
in breastfeeding are crucial in the proper
management of breastfeeding for these mother–infant dyads.
All infants, including late preterm infants, have a greater
chance of exclusive breastfeeding in hospitals that adhere to
the Ten Steps to Successful Breastfeeding. To this end, practitioners
should become knowledgeable in the Ten Steps and
work with the administration in their maternity hospitals to
uphold the guidelines set forth in the Ten Steps.12
Given the known increased risk of medical problems of the
late preterm as compared with the term infant, close observation
and monitoring are required, especially in the first 12–
24 hours after birth when the risk of inadequate adaptation to
extrauterine life is highest. Each delivery service must determine
where and how this can best be accomplished while
supporting the mother-infant dyad and breastfeeding. Keep
in mind infants born at 340/7 to 346/7 weeks have a 50% risk
for morbidity during the birth hospitalization.9 Some acute
problems encountered in the late preterm infant can be
managed on the postpartum floor, but there are times when
an infant should be transferred to a higher level of care for
appropriate care and monitoring.
The late preterm infant’s condition requires timely evaluation
after discharge. Just as many hospitals are becoming
breastfeeding friendly, the outpatient office or clinic needs to
be not only supportive of the breastfeeding mother, but also
able to assist mothers with uncomplicated problems or
questions related to breastfeeding. It is essential to be able to
refer mothers and infants in a timely manner to a trained
lactation professional for more complicated breastfeeding
problems.Alactation referral should be viewed with the same
medical urgency as any other acute medical referral.
Principles of Care
1. Communicate optimally:
a. Develop pathway and order set for breastfeeding the
late preterm infant.
b. Communicate the discharge feeding plan clearly to
the family and primary health provider.
c. Facilitate communication among physician, nurses,
and lactation consultants in the inpatient and outpatient
settings.
d. Avoid conflicting advice to mother and family about
the feeding plan.
2. Assess/reassess:
a. Assess gestational age objectively and associated risk
factors.
b. Observe closely for signs of physiologic instability.
c. Assess breastfeeding daily on the postpartum floor or
special care nursery.
d. Assess breastfeeding issues carefully in the outpatient
setting.
3. Provide timely lactation support in the inpatient and
outpatient setting.
4. Avoid or minimize separation of mother and infant:
a. In the postpartum period, including immediately
postpartum.
b. In cases in which either mother or infant is hospitalized
for medical reasons.
5. Prevent and promptly recognize frequently encountered
problems in breastfed late preterm infants:
a. Hypoglycemia
b. Hypothermia
c. Hyperbilirubinemia
d. Dehydration or excessive weight loss
e. Failure to thrive
6. Educate:
a. Educate staff and care providers in an ongoing manner
on issues specific to breastfeeding the late preterm
infant in the inpatient and outpatient settings.
b. Educate parents about breastfeeding the late preterm
infant.
c. Train one (or two) outpatient office support person
(R.N. or lactation educator) in:
i. breastfeeding support, assessment, basic breastfeeding
problem solving, and late preterm.
ii. breastfeeding issues.
7. Discharge/follow-up:
a. Develop criteria for discharge readiness.
b. Establish a post-discharge feeding plan.
c. Facilitate timely and frequent outpatient follow-up to
assure effective breastfeeding after discharge.
d. Monitor carefully once the mother and late preterm
infant are outpatients.
8. Monitor care of the late preterm infant through quality
improvement projects (in- and outpatient settings).
Inpatient: Implementation of Principles of Care
Quality of evidence for each recommendation, as defined in
the U.S. Preventive Services Task Force guideline, is noted in
parentheses.*
These principles are guidelines for optimum care of the late
preterm infant. Each provider and newborn unit should use
these recommendations as applicable to their institution and
practice.
1. Initial steps:
a. Communicate the feeding plan through a prewritten
late preterm order set that can be easily modified.14
(III)
*Levels of Evidence (I, II-1, II-2, II-3, and III) are based on the U.S.
Preventive Services Task Force ‘‘Quality of Evidence.’’13
152 ABM PROTOCOL
b. Encourage immediate and extended skin-to-skin
contact to improve postpartum stabilization of heart
rate, respiratory effort, temperature control, metabolic
stability, and early breastfeeding.15 (I)
c. Assess gestational age by obstetrical estimate and
Ballard/Dubowitz scoring.16 (III)
d. Observe the infant closely for 12–24 hours to rule
out physiologic instability (e.g., hypothermia, apnea,
tachypnea, oxygen desaturation, hypoglycemia,
poor feeding). As noted in the Background of
this protocol, each delivery service must determine
where and how this can best be accomplished while
supporting the mother–infant dyad and breastfeeding.
(III)
e. Encourage rooming-in 24 hours a day and frequent,
extended periods of skin-to-skin contact. If the infant
is physiologically stable and healthy, allow the infant
to remain with the mother while receiving intravenous
antibiotics or phototherapy.17 (III)
f. Allow free access to the breast, encouraging initiation
of breastfeeding within 1 hour after birth.18 (II-2)
g. Encourage breastfeeding ad libitum and on demand.
Sometimes it may be necessary to wake the baby if
he or she does not indicate hunger cues, which is not
unusual in the late preterm infant.19 The infant
should be breastfed (or breastmilk fed) eight to 12
times per 24-hour period. A mother may need to
express her milk and give it to the baby using alternative
feeding methods if the baby is not able to
effectively breastfeed.19,20 ( III)
h. Show the mother techniques to facilitate effective
latch with careful attention to adequate support of
the jaw and head.21 (III)
2. Ongoing care:
a. Communicate daily changes in feeding plan either
directly or with use of written bedside tool such as a
crib card.14 (III)
b. Evaluate desirably, within 24 hours of delivery, formally
by a lactation consultant or other certified
health professional with expertise in lactation management
of the late preterm infant.14 (III)
c. Assess and document breastfeeding at least twice
daily by two different providers using a standardized
tool (e.g., LATCH Score,22 IBFAT,23 Mother/
Baby Assessment Tool24). (II-3)
d. Educate the mother about breastfeeding her late
preterm infant (e.g., position, latch, duration, early
feeding cues, breast compressions, etc.)17,19 (III)
e. Monitor vital signs, weight change, stool and urine
output, and milk transfer.11,25 (III)
f. Monitor for frequently occurring problems (e.g., hypoglycemia,
hypothermia, poor feeding, hyperbilirubinemia).
26–28 The late preterm infant should be
followed closely with a low threshold for checking
bilirubin levels and have a routine discharge bilirubin
determination plotted on a Bhutani curve according
to age in hours.2,29 (III)
g. Avoid excessive weight loss or dehydration. Losses
greater than 3% of birth weight by 24 hours of age or
greater than 7% by day 3 merit further evaluation
and monitoring.14,19 (III)
i. If there is evidence of ineffective milk transfer, teach
the mother to use breast compressions while the
infant suckles19 (III) and consider the use of an ultrathin
silicone nipple shield.30–32 (II-2) The use of
nipple shields is becoming more common for this
group of infants and can be helpful. If a nipple
shield is used, the mother and baby should be followed
closely by a trained lactation consultant or
knowledgeable healthcare professional. (III)
ii. Pre- and post-feeding weights may be helpful to
assess milk transfer especially once lactogenesis II
has occurred.33–36 (II-2)
iii. The infant may need to be supplemented after
breastfeeding with small quantities (5–10mL per
feeding on day 1, 10–30mL per feeding thereafter)
of the mother’s expressed breastmilk, donor human
milk, or formula.14,20 Mothers may supplement
using a supplemental nursing device at the breast,
cup feeds, finger feeds, syringe feeds, or bottle depending
on the clinical situation and the mother’s
preference.20 Cup feedings have demonstrated
safety in preterm infants, although intake is less and
duration of feeding is longer compared with bottle
feeds.37–39 There is, however, little evidence about
the safety or efficacy of other alternative feeding
methods or their effect on breastfeeding. When
cleanliness is suboptimal, cup feeding may be the
best choice.40 (I, II-1, II-2, II-3, III)
iv. If supplementing, the mother should pump or
express milk after breastfeeding, six to eight times
per 24 hours, until the baby is breastfeeding well to
establish and maintain her milk supply.11,20 Use of
a hospital-grade electric pump is recommended.
Milk production may be increased by hand massage
of the breasts while pumping.41 (II-3)
h. Avoid thermal stress by using skin-to-skin (i.e.,
kangaroo) care15 (I) as much as possible or by double
wrapping if necessary and by dressing the baby in a
shirt and hat. Consider intermittent use of an incubator
to maintain normothermia.14,19 (III)
3. Discharge planning:
a. Assess readiness for discharge, including physiologic
stability and adequate intake exclusively at breast, or
with supplemental feedings.42 (II-2) The physiologically
stable late preterm infant should be able to
maintain body temperature for at least 24 hours in an
open crib and have a normal respiratory rate, and
weight should be no more than 7% below birth
weight. Adequate intake should be documented by
feeding volume or an improving pattern of infant
weight (e.g., stable or increasing).14 (II-2) Twentyfour-
hour test weights, with a scale designed for
adequate precision may be useful to assess intake.39
(II-3)
b. Develop a discharge feeding plan. Consider milk
intake (mL/kg/day), method of feeding (breast,
bottle, supplemental device, etc.), and type of feeding
(i.e., breastmilk, donor human milk, or formula).
14 If supplementing, determine method most
acceptable to mother for use after discharge.20 (III)
ABM PROTOCOL 153
c. Make an appointment for follow-up 1–2 days after
discharge to recheck weight, feeding adequacy, and
jaundice.17 (II-2)
d. Communicate discharge-feeding plan to mother and
pediatric outpatient provider. Written communication
is preferred. (III)
Outpatient: Implementation of Principles of Care
1. Initial visit:
a. The first outpatient office or home health visit should
occur 1 or 2 days after discharge.17 (II-2)
b. Review and place relevant information from the inpatient
maternal and infant records, including prenatal,
perinatal, infant, and feeding history (e.g.,
need for supplement in the hospital, problems with
latch, need for phototherapy, etc.), in the outpatient
chart. Gestational age and birth weight should be
noted prominently.25 (III)
c. Review of breastfeeding since discharge by the physician
needs to be very specific regarding frequency,
approximate duration of feedings, and how the baby
is being fed (e.g., at the breast, expressed breastmilk
with supplemental device such as supplemental
nursing system, finger feeds, or bottle with artificial
nipple). Information about stool and urine output,
color of stools, baby’s state (e.g., crying, not satisfied
after a feed, sleepy and difficult to keep awake at the
breast during a feed, etc.) should be obtained. If
the parents have a written feeding record, it should
be reviewed.11 (III)
d. Examine the infant, including an accurate weight
without clothes and calculation of percentage change
in weight from birth, change in weight from discharge,
state of alertness, and hydration. Assess for
jaundice with transcutaneous bilirubin screening
device and/or serum bilirubin determination if indicated.
11 (III)
e. Assess the mother’s breast for nipple shape, pain and
trauma, engorgement, and mastitis. The mother’s
emotional status and degree of fatigue should be
considered, especially when considering supplemental
feeding routines. Whenever possible, observe
the baby feeding at the breast, evaluating the latch,
suck, and swallow.11 (III)
2. Problem solving:
a. Poor weight gain (<20g/day) is most likely the result
of inadequate intake. Median daily weight gain of a
healthy newborn is 28–34 g/day.43 The healthcare
provider must determine whether the problem is insufficient
breastmilk production, inability of the infant
to transfer enough milk, or a combination of both. The
infant who is getting enough breastmilk should have
at least six voids and four sizable yellow seedy stools
daily by day 4, have lost no more than 7% of birth
weight, and be satisfied after 20–30 minutes of nursing.
11 The following strategies may be helpful:
i. Shortening duration of breastfeeds if the late preterm
infant is not satisfied after approximately 30
minutes.
ii. Increasing the frequency of breastfeeds.
iii. Supplementing (preferably with expressed breastmilk)
after suckling or increasing the amount of
supplement.
iv. Instituting or increasing frequency of pumping or
manual expression. Consider referral to a lactation
specialist. (III)
b. For infants with latch difficulties, the baby’s mouth
should be examined for anatomical abnormalities
(e.g., ankyloglossia [tongue-tie], cleft palate), and a
digital suck exam should be performed. The mother’s
nipples and breast should be examined for
plugged ducts, mastitis, engorgement, fullness of the
breast, and nipple trauma. The infant should be observed
breastfeeding to examine the latch, suck,
swallow. A referral to a trained professional lactation
specialist or in the case of ankyloglossia a referral to
a healthcare provider trained in frenotomy may be
indicated.11,44–46 (I, II-2, III)
c. The jaundiced late preterm infant poses more of a
problem when considering management of hyperbilirubinemia.
All risk factors should be determined,
and if the principal factor is lack of milk, the primary
treatment is to provide more milk to the baby, preferably
through improved breastfeeding or expressed
breastmilk supplementation. If home or institutionbased
phototherapy is indicated, breastmilk production
and intake should not be compromised.2,47 If the
mother’s own milk or donor milk is not available,
small amounts of cow’s milk-based formulas can be
used.47 Hydrolyzed casein formulas should be considered
for this purpose, as there is evidence that
they are more effective in lowering serum bilirubin
than standard infant formula.48 (II, III)
d. Consider the use of a galactogogue (a medicine or
herb that increases breastmilk supply) in mothers
who have a documented low breastmilk supply and
for whom other efforts to increase milk production
have failed.49,50 (II-2, III)
e. The mother’s ability to cope and manage the feeding
plan should be evaluated. If the mother is not coping
well, work with her to find help and or modify the
feeding plan to something that is more manageable.20
(III)
3. Follow-up:
a. Babies who are not gaining well and for whom adjustments
are being made to the feeding plan may
need a visit 2–4 days after each adjustment. A home
health provider preferably trained in medical evaluation
of the newborn and in lactation support, who
reports the weight to the primary care provider,
could make this visit. (III)
b. All infants, including late preterm breastfed infants,
should receive vitamin K shortly after birth51 (II-3)
and vitamin D supplementation (400 IU/day) beginning
in the first few days of life as recommended
by the American Academy of Pediatrics.52 (II-3) Late
preterm breastfed infants are at risk for iron deficiency
as their iron stores are less than that of the
full-term infant.53 (I) The American Academy of Pe-
154 ABM PROTOCOL
diatrics Committee on Nutrition recommends 2 mg/
kg/day of elemental iron for all preterm infants from
1 to 12 months of age. The late preterm breastfed
infant will, therefore, need 2 mg/kg/day of iron
supplementation until consuming 2 mg/kg/day
through complementary feeds or weaned to ironfortified
formula. Screening for iron deficiency and
iron deficiency anemia at 6 months with hemoglobin,
serum ferritin, and C-reactive protein or reticulocyte
hemoglobin is recommended.53 (I)
c. The late preterm infant should have weekly weight
checks until 40 weeks postconceptual age or until he
or she is thriving. Weight gain should average 20–
30 g/day, and length and head circumference should
each increase by an average of 0.5 cm/week.43 (III)
Recommendations for Future Research
Future research is needed to establish the best methods for
monitoring the late preterm infant in the first 24 hours of life
for physiologic instability while optimizing mother–infant
interactions and specifically initiation of breastfeeding. Currently
newborn units must decide where and how this should
be done. There is no uniform approach to this issue. Additional
areas of research should focus on:
1. the best methods for assessing breastfeeding
2. supplementing the late preterm infant
3. appropriate use of nipple shields
4. appropriate feeding plans
5. establishing discharge readiness
6. establishing appropriate guidelines for certified lactation
consultation in the in- and outpatient area
7. establish outpatient care guidelines to support lactation
while avoiding medical problems (i.e., hyperbilirubinemia
and hypernatremic dehydration).
Outcomes measures for future research should include
breastfeeding duration and exclusivity in addition to other
parameters appropriate for the subject of investigation.
Acknowledgments
This work was supported in part by a grant from the Maternal
and Child Health Bureau, U.S. Department of Health
and Human Services.
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Pediatrics 2008;122:e188–e194.
46. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: Assessment,
incidence, and effect of frenuloplasty on the breastfeeding
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47. Academy of Breastfeeding Medicine Protocol Committee.
ABM Protocol #22: Guidelines for management of jaundice
in the breastfeeding infant equal to or greater than 35 weeks’
gestation. Breastfeed Med 2010;5:87–93.
48. Gourley GR, Kreamer B, Cohnen M, et al. Neonatal jaundice
and diet. Arch Pediatr Adolesc Med 1999;153:184–188.
49. Gabay MP. Galactogogues: Medications that induce lactation.
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50. Academy of Breastfeeding Medicine Protocol Committee.
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augmenting the rate of maternal milk secretion, first revision
January 2011. Breastfeed Med 2011;6:41–49.
51. American Academy of Pediatrics Vitamin K Ad Hoc Task
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ABM protocols expire 5 years from the date of publication.
Evidence-based revisions are made within 5 years or sooner if
there are significant changes in the evidence.
Academy of Breastfeeding Medicine Protocol Committee
Maya Bunik, M.D., MSPH, FABM
Caroline J. Chantry, M.D., FABM
Cynthia R. Howard, M.D., MPH, FABM
Ruth A. Lawrence, M.D., FABM
Kathleen A. Marinelli, M.D., FABM, Committee Chairperson
Larry Noble, M.D., FABM, Translations Chairperson
Nancy G. Powers, M.D., FABM
Julie Scott Taylor, M.D., M.Sc., FABM
Contributors
Eyla G. Boies, M.D., FAAP
Yvonne E. Vaucher, M.D., M.P.H.
For correspondence: abm@bfmed.org
Appendix
Baby-Friendly Hospital Initiative steps for successful
breastfeeding
1. Have a written breastfeeding policy.
2. Train all healthcare staff in the skills necessary to implement
the policy.
3. All mothers should be informed of the benefits of
breastfeeding.
4. Help mothers initiate breastfeedingwithin 1 hour of birth.
5. Show mothers how to breastfeed and how to maintain
lactation, even if they are be separated from their infant.
6. Give newborn infants no food or drink other than
breastmilk, unless medically indicated.
7. Practice rooming-in, allowing mothers and infants to
remain together, 24 hours a day if medically stable.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers to breastfeeding
infants.
10. Foster the establishment of breastfeeding support
groups and refer mothers to them, on discharge from
the hospital or clinic.
156 ABM PROTOCOL
