By Marianne Neifert, M.D., Author of Great Expectations: The Essential Guide to Breastfeeding
Until recently, babies born a few weeks early — between 34 and 36 weeks gestation — were referred to as near term infants. However, the designation, near term, implies that an infant is almost term or almost fully mature, and the misnomer has often caused health professionals and parents to underestimate the medical risks in this large, vulnerable population of infants. Recently, the American Academy of Pediatrics has recommended that infants born at 34, 35, or 36 weeks gestation be referred to as late-preterm infants to emphasize that these babies are physiologically immature and have special health care needs compared to full term infants (born between 37 to 41 weeks). In addition, the mothers of late-preterm infants are more likely to have medical complications themselves, such as gestational diabetes, high blood pressure, or C-section delivery.
The Rising Incidence of Late-Preterm Births
The proportion of all U.S. births that are late preterm has increased over the past 15 years. Late-preterm infants now comprise over 9% of all births, and account for more than 70% of all preterm births (<37 weeks gestation), representing nearly 400,000 babies each year. Although the reason for the increase in late-preterm deliveries is not well understood, one explanation is the increased use of fertility treatments, which has lead to a rise in pregnancies with twins and higher multiples. Half of all twins and 90% of all triplets are born preterm. Other possible contributors to the rise in late-preterm births include the rise in cesarean section births (now 30% of all deliveries), the need to deliver some infants early due to medical complications, and more pregnancies occurring among women at an older age. In addition, performing elective labor inductions or elective cesarean sections for no clear medical or obstetrical reason sometimes leads to the unintentional delivery of a late-preterm infant. Both expectant mothers and obstetricians need to know the importance of avoiding late-preterm delivery unless it is medically necessary. Medical Complications among Late-Preterm Infants Because many late-preterm babies are the size of infants born at full term, health care professionals may not always give these at-risk infants the special treatment and careful screening they deserve. Instead, hospital personnel and parents tend to treat these apparently healthy infants as if they were developmentally mature. Late-preterm infants have been called imposter babies because many of these "slightly early" newborns masquerade as full-term infants, appearing to need no special care after birth and being discharged as early as term babies. Yet, babies born even a few weeks early have an increased risk of medical complications after birth and may require a longer hospital stay than full-term infants. Late-preterm infants are more likely to develop low blood sugar, severe jaundice, breathing difficulties, and infections; to have difficulty maintaining their body temperature; and to experience feeding problems and excessive weight loss after birth. Late-preterm infants also are more likely to be re-admitted to the hospital in the early weeks of life for medical complications, including newborn jaundice, breastfeeding difficulties, dehydration, and possible infections. The brain and nervous system are among the last systems to mature during fetal development, and some studies show that late-preterm infants have a higher risk of developmental and behavioral problems compared to full-term babies. Late-preterm infants also have a higher rate of birth defects and an increased risk of sudden infant death syndrome. For all these reasons, late-preterm infants require close monitoring, evaluation, and follow-up after birth. Breastfeeding Challenges among Late-Preterm Infants The initiation of successful breastfeeding can be especially challenging for smaller, developmentally immature, late-preterm infants. These babies often have trouble latching on to the breast correctly and may be unable to breastfeed effectively at first because of their lower muscle tone and tendency to tire easily. Inadequate breastfeeding increases a newborn's risk for severe jaundice and excessive weight loss. Providing your baby with skin-to-skin contact immediately after birth and as often as possible while you are rooming-in will help promote infant feeding behaviors and successful breastfeeding. Your hospital lactation consultant can offer valuable assistance with your breastfeeding technique during your hospital stay. Sometimes, using an ultra-thin, soft silicone nipple shield can help your late-preterm baby latch on and stay attached to your breast. Ask to be referred for extra help with breastfeeding after discharge, since it often takes several weeks for a late-preterm infant to be able to breastfeed effectively. Late-preterm infants seldom are able to drain their mother's breasts well at first. Ineffective breastfeeding not only increases a baby's risk of medical complications, a mother's milk supply can rapidly decrease if her baby removes little milk. If you deliver a late-preterm infant, you can help assure that you bring in and maintain an abundant milk supply by using an effective electric breast pump to express the extra milk your infant leaves behind after breastfeeding. Removing the milk remaining after your baby nurses is known as "insurance pumping" or "prevention pumping" because it helps keep your milk supply generous until your infant is big enough and mature enough to drain your breasts well on her own. Having an abundant milk supply also helps your immature, smaller, less-vigorous baby obtain more milk when she attempts to breastfeed because she can "drink from a fire hydrant" instead of having to work hard to get enough milk. Furthermore, the extra milk you remove with the pump makes the ideal supplement if your baby temporarily requires supplemental feedings. Your surplus pumped milk can be stored for later use (in the refrigerator for 3-5 days; in a separate door freezer for at least 3 months; in a deep freezer for at least 6 months). After you go home from the hospital, arrange to have your baby followed closely and weighed often to monitor her progress with breastfeeding. Her first pediatric visit should occur 24-48 hours after discharge. A lactation consultant or your baby's doctor periodically can weigh your baby (identically clothed) before and after breastfeeding to measure how much milk she drinks and monitor her progress with breastfeeding. As your baby matures and gains weight rapidly and becomes able to breastfeed effectively, you gradually can decrease your pumping regimen. Your extra investment of time and effort to safeguard breastfeeding in the early weeks after your baby's birth will pay off in a thriving infant and a plentiful milk supply that will set the stage for a long-term successful breastfeeding experience.