Breastfeeding in the NICU

Having a baby in the NICU is an experience like no other.  In this situation, providing breastmilk can be beneficial to baby in so many ways.  However, this also comes with it’s own set of challenges.  While NICU staff work diligently to promote best practices such as kangaroo care, the inherent separation can present and issue in establishing your breastmilk supply.  There are many factors that can affect the breastfeeding relationship while in the NICU.  The following is an abridged literature review that addresses one aspect of this process.  In some NICUs, the policy states that infants must be bottle-fed before attempting breastfeeding.  This is not a universal practice, and the aim of this literature review is to discover if the first oral feeding will affect overall breastfeeding duration.  Of course this question will lead to more questions – such as, “why do these policies exist to begin with?” Often, it is considered that breastfeeding requires more energy from the premature infant, or that the bottle is safer than breastfeeding.  These are valid considerations and are worthy of exploration for the next literature review.


Direct Breastfeeding as the First Oral Feeding for NICU Patients Receiving Breastmilk

        In infant patients admitted to the NICU who are receiving breast milk does initiating direct breastfeeding for the first oral feed, compared to introducing an artificial bottle nipple for the first oral feed, result in a longer duration of breastfeeding after discharge?

Problem Scope and Significance

        The American Academy of Pediatrics (2012) recognizes that breastmilk is of significant benefit to infants and advises that preterm infants should receive human milk.  Breastmilk for a NICU admitted infant can provide significant protection against a common, yet deadly, disease process, necrotizing enterocolitis (Nolan, 2020).  The impact of breastmilk on necrotizing enterocolitis has been found to be dose-dependent, meaning that the more breastmilk an infant receives, the better protection available (Meinzen-Derr et al., 2009). As neurodevelopment is a special concern in the NICU population, breastmilk is especially important.  Breastmilk has been shown to improve brain white matter development and result in higher IQ scores (Isaacs et al., 2010).

        Despite this clear foundation of evidence, pre-term infants are shown to receive less breastmilk than their term peers (Chiang, Sharma, Nelson, Olson, & Perrine, 2019).  Even when socioeconomic factors were controlled, researchers have found that mothers of preterm infants will breastfeed for shorter periods of time (Flacking, Nyqvist & Ewald, 2007).  In light of this data, the importance of learning the factors that could contribute to a longer duration of breastfeeding for preterm infants admitted to the NICU is evident.

       Many NICU policies specify that an infant will bottlefeed before being permitted to attempt breastfeeding.  There are reasons for these policies, which can be discussed and addressed elsewhere.  This paper will focus on one specific topic, and that is the outcome for infants related to their first oral feeding.

       When the infant is skin to skin with the mother, attempting to latch there is often a moment where the mother will raise her eyes to meet the nurse at the bedside.  She is checking to see if the nurse is looking.  There is often a flash of guilt because she wants to latch her baby but believes that if she does her infant’s discharge will be delayed.  This policy often frustrates the breastfeeding families as well as the nurses providing their care.  Whether or not this practice is beneficial or detrimental to these small patients is a frequent question. It is the opinion of this IBCLC that the introduction of the bottle nipple interferes with breastfeeding duration.

Integration/Synthesis of the Evidence

        The first theme to emerge from these studies was that of more direct breastfeeding in the NICU being related to more direct breastfeeding after discharge.  While the focus of this review is to examine how the first oral feeding affects the duration of breastfeeding, the evidence also showed that more direct breastfeeding, while the infant was in the NICU, was a facilitator of success.  Support and education of direct breastfeeding in the NICU allows the breastfeeding mother to learn this skill while in a structured and safe environment with in-person guidance (Briere, McGrath, Cong, Brownell, & Cusson, 2016).  These researchers found that mothers had more long term success when beginning oral feeds at the breast and continuing those feedings in the supportive hospital environment (Briere, McGrath, Cong, Brownell, & Cusson, 2016). Putting the infant to the breast for the first feeding and continuing to provide direct breastfeeding throughout the NICU stay was found to be an indicator of a greater duration of breastfeeding (Pineda, 2011).  Not only was the first feeding at the breast found to be vital, but it was also the continued practice of feeding at the breast while in the NICU that contributed to successful breastfeeding overall (Pineda, 2011).

       The second theme noted was one of feeding imprinting, a phenomenon initially discussed by Mobbs, Mobbs & Mobbs  (2016).  While only one article used this particular term, it was described in other studies.  A noted hindrance to breastfeeding the NICU infant is the delay in oral feedings whether at the breast or at the bottle.  NICU infants are set apart from their term peers who usually complete an oral feeding within the first hour of life.  Many preterm infants do not have the physical ability to process an oral feeding soon after birth. Therefore, researchers found that the first oral feeding could impact an infant admitted to the NICU in a significant way (Suberi, Morag, Strauss, & Geva, 2018).  Not only did researchers find that direct breastfeeding as the first oral feeding was associated with a longer duration of breastfeeding, they surmised that it was also associated with earlier discharge from the NICU (Suberi, Morag, Strauss, & Geva, 2018).  When infants received their first oral feeding at the breast, one study found that those infants were eight times more likely to continue to receive breast milk through discharge (Casavant, McGrath, Burke, & Briere, 2015).  This study noted that the first oral feeding aided the infant in more successful breastfeeding regardless of gestational age (Casavant, McGrath, Burke, & Briere, 2015).

       The third theme to become apparent was the maternal role in providing breast milk to the preterm infant. While donor human milk is becoming more common in NICUs, these studies focused on breast milk from the infant’s own mother.  In order to directly breastfeed, the role of the mother of the NICU infant must be considered.  Her views and goals on breastfeeding play an integral part in successful breastfeeding.  Support and education of the mother of the NICU infant was an intervention that proved to support a longer duration of breastfeeding (Gianni et al., 2018).  One of the factors that facilitated a positive maternal outlook was found to be direct breastfeeding as the first oral feeding (Gianni et al., 2018).  Direct breastfeeding for the first oral feeding contributed to maternal satisfaction, which in turn contributed to a longer duration of breastfeeding (Gianni, 2018).  In looking at another angle, direct breastfeeding as the first oral feeding was found to be a crucial factor in overall breastfeeding success and duration (Casey, Fucile & Dow, 2018).  Therefore, the researchers found that the education of the mother to prepare for this first feeding at the breast was an important step in the process (Casey, Fucile & Dow, 2018).  Goal setting was also found to be a part of maternal preparation. Mothers who received support and guidance in creating a specific breastfeeding goal were found to be much more likely to successfully breastfeed (Briere, McGrath, Cong, Brownell, & Cusson, 2015).

Critique of the Evidence

        The studies related to this PICO question were similar in method and data collection. Most of these studies were conducted as retroactive studies and examined quantitative data (Pineda, 2011).   They focused on specific NICUs and collected data from chart reviews of NICU patients that met the specified criteria for the studies (Casavant, McGrath, Burke, & Briere, 2015).  Each study focused on NICU infants that were born at an early gestational age and classified as preterm (Briere et al., 2015).  Some studies included surveys of the families of the infants to learn about breastfeeding patterns at specific dates after hospital discharge (Gianni et al., 2018).  Sample sizes were generally on the smaller size, though these were adequate to address this specific patient population (Casey, Fucile & Dow, 2018).  The research questions were clearly stated in the studies examined for this review.

Gaps in the Evidence

         While examining the current research, further questions arise.  This literature review is focused on the first oral feeding and the duration of breastfeeding.  While the duration of breastfeeding is indicative of successful breastfeeding, it is not the only indicator (Briere, et al., 2015).   Future research should examine the percentage of feedings of breastmilk vs. infant formula in relation to oral feedings in the NICU. 

         Although direct breastfeeding is seen as a marker of success, it is not always an encouraging experience for the breastfeeding dyad (Gianni et al., 2018).  If direct breastfeeding is causing nipple pain and damage, or if it is difficult to sustain a latch a mother can feel upset (Lucas et al., 2019). She may be discouraged and decide to reduce pumping breastmilk.  Future research could examine if frustration with direct breastfeeding could lead to a shorter duration of breastfeeding.


         Breastfeeding has been shown to be so important in the health and development of preterm infants (American Academy of Pediatrics, 2012).  Not only does breastfeeding benefit the infant, but the family as well (Louis-Jacques & Stuebe, 2018).  The research reviewed has shown that how an infant receives the first oral feeding of breastmilk can impact the overall duration of breastfeeding for that infant.  While this is a small patient population, the factors relating to their health and development are quite relevant.  Future research delving deeper into this topic would help NICU staff to be more effective and efficient in delivering appropriate care.



American Academy of Pediatrics. (2012) Section on breastfeeding: breastfeeding and the use of human milk. Pediatrics. 129(3).

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         Official Journal of International Lactation Consultant Association, 31(3), 386–392.

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 Casey, L., Fucile, S., & Dow, K. E. (2018). Determinants of successful direct breastfeeding at hospital discharge in high-risk premature infants. Breastfeeding Medicine, 13(5), 346.

 Chiang K., Sharma A., Nelson J., Olson C., Perrine C.  (2019). Receipt of breast milk by gestational age — United States, 2017. Morbidity and Mortality Weekly Report 68(22) 489–493.     


 Flacking R., Nyqvist K., & Ewald U. (2007). Effects of socioeconomic status on breastfeeding duration in mothers of preterm and term infants. European Journal of Public Health,

           17(6), 579–584.

 Gianni, M, Bezze, E, Sannino, P., Baro, M., Roggero, P., Muscolo, S. … Mosca, F. (2018).   Maternal views on facilitators of and barriers to breastfeeding preterm infants.   BMC

           Pediatrics, 18(1), 1-8. 

Isaacs, E., Fischl, B., Quinn, B., Chong, W., Gadian, D., & Lucas, A. (2010).  Impact of breast milk on intelligence quotient, brain size, and white matter development.

          Pediatric Research, 67(4), 357–362.

 Louis-Jacques, A., & Stuebe, A. (2018). Long-term maternal benefits of breastfeeding.  Contemporary OB/GYN, 63(7), 26–29.

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            Controlled Trial. Nursing Research, 68(2), E1–E10.

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           death. Journal of Perinatology, 29(1), 57–62.

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             success. Acta Paediatrica (Oslo, Norway : 1992), 105(1), 24–30.

Nolan, L., Parks, O., & Good, M. (2020). A review of the immunomodulating components of maternal breast milk and protection against necrotizing enterocolitis. Nutrients,

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 Suberi, M., Morag, I., Strauss, T., & Geva, R. (2018). Feeding imprinting: the extreme test case of premature infants born with very low birth weight. Child Development, 89(5), 1553–


 Wambach, K. & Riordan, J.  (2016). Breastfeeding and Human Lactation (5th ed.).  Jones & Bartlett Learning.




Amanda is an RN, IBCLC (lactation consultant) who helps breastfeeding families through classes and home visits in the greater Baton Rouge, La area. Secure virtual visits are available for breastfeeding support no matter the location.  

All information on this website is intended for educational purposes only and should not be construed as medical advice. Magnolia Lactation Consulting encourages all families to have close communication with the medical providers of their choice.

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