7.1 Late preterm; Non-latching
The 'late preterm' baby
Infants born 34 weeks 0 days to 36 weeks 6 days gestational age are categorised as 'late preterm'. 1
Late preterm infants with no significant respiratory problems or other problems of prematurity are often cared for on the postnatal ward, with the temptation to treat them as you would a term baby. Called 'the great pretenders', these infants may present with subtle immaturity that requires a trained eye to detect, and proactive management to prevent subsequent problems.
Some problems these infants may encounter:
- respiratory instability and interrupted lung development 2 3 4
- poor ability to clear normal lung fluid (particularly if delivered by elective, pre-labour caesarean section)
- increased incidence of apnoea
- little respiratory reserve
- temperature instability 3
- less glycogen and brown fat stores available to protect against hypoglycaemia 2 5
- reduced ability to conjugate and excrete bilirubin, increasing need for phototherapy to treat jaundice 2 3
- neurological immaturity 2
- poor state regulation - may go from hyper-alert to deep sleep without intervening stages
- easily overstimulated, then exhausted - may fall asleep before full breastfeed taken
- lower tone
- reduced immunological competence. 2 3 6 Keeping mother and infant together reduces risk of nosocomial infections.
- poor breastfeeding establishment and increased breastfeeding-associated rehospitalisations 6 7 8 9
- higher mortality throughout infancy 6 10
- higher incidence of mental and physical developmental delay at 24 months 3 11

Don't be complacent
These babies are NOT term babies. They may initially appear to cope well but exhibit decreasing stamina and ability after several days - watch them closely!
Remember: Late preterm = Great Pretenders
Postpartum care
Initial treatment should be no different from any other infant:
- Skin-to-skin contact immediately after birth - initial resuscitation, drying and observations occuring on mother's chest
- Leave in skin-to-skin contact until after the first breastfeed
Skin-to-skin care will provide
- optimal physiological stability
- temperature stability
- improved oxygen saturation and gas exchange
- enhanced immune protection (colonization with mother's normal flora; maternal antibody development targeted to baby's needs)
- decreased crying
- increased opportunities to breastfeed
- improved breastmilk production
- enhanced maternal-infant bonding
- longer exclusive and total breastfeeding
- Delay all routine procedures (eg. vit K injection, eye prophylaxis, hepatitis B vaccine, weighing) until baby stable, settled and after first breastfeed as these procedures increase crying, depleting metabolic reserves and disrupting breastfeeding behaviours. Most can be carried out while skin-to-skin with mother if hospital routine is not flexible.
The first 12 - 24 hours
- Close observation of the infant should continue for at least the first 12 - 24 hours. Each institution will have their own protocol, however the mother should never be excluded. Skin-to-skin care with the mother is still the best way to stabilize and protect the infant and should be overtly encouraged, even if the infant is in the NICU for observation.
- Encourage 24-hour rooming-in. Stable, healthy babies can stay with the mother even while receiving intravenous therapy or phototherapy.
Discharge planning
- Develop a feeding plan in conjunction with the mother. Ensure she understands the plan and the rationale behind it.
- Provide this plan to her in written format after discussion, and send a copy to her outpatient health care provider.
- It will include
- response to early feeding cues,
- frequency of feeding for her infant,
- signs of good milk transfer while sucking,
- how to increase milk transfer if indicated (breast compression and massage),
- how to increase milk production if indicated (hand expressing and hands-on pumping),
- expected urine and stool output.
- how and when to supplement if this has already been initiated.
- Book a follow-up appointment for 24 - 48 hours after discharge for reassessment of baby and feeding plan.
Lactation Management
The importance of breastfeeding for a preterm infant is even more significant than for full term infants. Yet it is the very nature of the immaturity of the preterm and late preterm that creates breastfeeding challenges. Poor stamina, low tone, difficulty with latch and suck all contribute. 9 12 13 14

Use skilled resources
The lactation consultant will also be able to teach you any additional clinical skills required should you be unsure of any of them.
Ensure the mother knows not only how to implement the following, but also why it is important.
- use skin-to-skin care and biological nurturing postioning extensively (maintaining physiological stability, stimulating neonatal feeding reflexes).
- respond immediately to early feeding cues, leaving nappy/diaper changing until after feeding (due to baby's low energy reserves).
- hand express colostrum then use hands-on pumping when milk is 'in' after every breastfeeding attempt initially (ensure adequate stimulation of milk supply).
- breastfeed 2 - 3 hourly (small frequent feeds easier on small stomach capacity reducing overdistension; increased sleepiness causes baby to not wake to feed as often as needed).
- and, of course, to seek immediate medical review for any of the 3 danger signals that all mothers are taught before discharge home: ie
- urine output less than normal
- increasing jaundice
- painful or damaged nipples
Additional skills you may need:
- how to teach hands-on pumping, and knowledge of its effect
- how to teach body and jaw support during breastfeeding for an infant with hypotonia
- how to teach breast compression and massage
- the use of some lactation aids, eg a nipple shield or an at-breast tube feeding device (eg SNS)

Workbook Activity 7.1
Complete Activity 7.1 in your workbook.

Hands-on Pumping

What signs of late prematurity are evident in this 35wk gestation infant?
What should I remember?

- Late preterm is not full term even if appearing to be well.
- The signs and symptoms that indicate baby's condition and progress.
- How skin-to-skin care affects this group of infants.
- Breastfeeding management which minimises energy usage, enhances milk transfer and protects milk supply.
Self-test quiz
The Non-latching Baby
There are many reasons for a newborn not to latch or latch poorly and breastfeed ineffectively. The following have been associated with sub-optimal breastfeeding behaviors on Day 3 postpartum:15
- condition at birth compromised (trauma, intrapartum drugs, resuscitation required)
- pacifier/dummy use
- flat or inverted nipples
- breastfeeding delayed for up to 48 hours, and
- primiparous mothers.
It has been demonstrated that forcing the baby to the breast can abolish the rooting reflex and disturb placement of the tongue. A healthy baby should have the opportunity of showing hunger and optimal reflexes, and attach to its mother's breast by itself. 16
Read this short article that describes the detrimental effects of a hand placed on the back of the baby's head during latching.
Your first responsibility
A newborn who shows no inclination to breastfeed is abnormal until proven otherwise.
The most important concern when a baby is not exhibiting this expected reflex is to rule out infant morbidity. Observe the infant's vital signs and organize a pediatric review if any abnormality is detected. Conditions such as unexpected respiratory distress syndrome, Group B strep infection, sepsis, hypoglycaemia, etc may first present as a baby not exhibiting the normal feeding reflexes.
We also know that it could be as a result of intrapartum drugs or the birthing experience, and the baby just needs more time, but don't assume that until you have eliminated the more sinister causes.
Principles of management
The aim of your plan is to:
- protect the baby: this not only means to ensure the physical well-being of the infant (nutrition and warmth), but includes protecting the baby from unnecessary supplementation before it is indicated.
- protect the lactation: until such time as baby is suckling well
- treat the mother with sensitivity; emotionally she may be feeling guilty or rejected by her infant.
The Action Plan
Re-establish skin-to-skin care on mother's chest if this had been interrupted. This baby should have A LOT of time in this position. Encourage the mother to adopt the laid back position of Biological Nurturing to stimulate pre-feeding behaviours.
Teach the mother about the early feeding cues, ie. wriggling, mouthing, bringing hand to mouth, rooting. Ensure she knows to facilitate feeding immediately the baby shows these cues
Smear the areola with breastmilk (the smell of the breast guides the baby towards it). Trickle small amounts of breastmilk into the corner of the infant's mouth as he lies near the breast.
Avoid stressful events/procedures and handle the baby with care ie. don't force the baby to the breast or hold the infant's head in an attempt to hasten latching.
From 0 to 24 hours old
- continue to observe the baby's vital signs regularly and observe for symptoms of hypoglycemia (blood testing not indicated if asymptomatic). Initiate pediatric review if outside the range of normal.
- reassure the mother and be patient
- hand express breastmilk each time baby tries unsuccessfully to breastfeed. Finger-feed, spoon feed or slowly trickle the tiny volumes into the corner of the baby's mouth from a syringe if the baby is swallowing OK.
- hand expressing should have commenced within 6 hours of birthing (preferably earlier) and regularly at least 3 hourly thereafter (up to 5 hour break overnight). 17 While the baby's condition should not deteriorate due to lack of feeding in this first 24 hours, giving the baby the expressed milk makes common sense.
From 24 to 48 hours old
- continue in skin-to-skin care
- continue regular observations of vital signs and for signs of hypoglycemia.
- attempt to rouse and interest baby in breastfeeding every 3 hours.
If unsuccessful: -
Feed the baby! with the expressed breastmilk.
Average breastmilk volume intake in the second 24 hours is 5 - 15ml per feed with a 24 hour total volume of 84ml. This should be your goal.
- cup, finger or spoon feed 18 the breastmilk to the baby. 19 Giving more than 2 supplements using a bottle can lead to discontinuation of exclusive, and any, breastfeeding. 20
- continue regular hand expressing or pumping at least 8 times per 24 hours.
- refer mother and baby to a Lactation Consultant for evaluation.
From 48 to 72 hours old
- Continue all strategies as above
- Average total volume of breastmilk taken is 400ml (13.5oz) per day, or about 15 - 30ml/feed - depending on the volume the mother is able to express each time.
From Day 5
- Secretory activation (lactogenesis II) should have occurred by now
- Continue all strategies as above
- The breast may need to be softened by expressing a little milk prior to attempting to latch21
- Average daily volume of breastmilk consumed from Day 5 is ~700ml (~24oz). Some babies may settle and thrive on less, some may require more.
(The recommended daily volumes are taken from the average volume taken at the breast by the well, full-term baby. Refer to the table in topic 6.2 .)
Note: Never underestimate the significance of skin-to-skin contact to trigger instinctive reflexes and enhance recovery.

Cup feeding is a good alternative when an infant is unable to suckle.
© A.Hunt, IBCLC
Some general tips
For example:
- flat, inverted or non-protractile nipples
- try pulling the nipple out with gentle suction from a pump, or the mother may be able to evert the nipple or make it more erect by stimulation
- shape the breast for the baby and hold that shape until the baby is well-established suckling
- a thin silicone nipple shield may be useful, though milk transfer is very poor prior to secretory activation
- baby attempts to latch but has uncoordinated latch
- skin-to-skin and biological nurturing facilitating normal reflexes
- avoid all use of artificial nipples (teats/dummies/pacifiers)
- encourage baby to suck well on finger, rewarding good sucking action with expressed breastmilk
- slip finger out and breast into mouth when baby establishes good sucking pattern
- sleepy baby (usually as a result of intrapartum medications or birth trauma)
- attempt to wake for feeds
- give expressed breastmilk via finger feeding to ensure baby has sufficient calories for energy (sleepy babies will often still suck on a finger while too drowsy to latch to breast)
- patience - s/he will become more alert eventually
- physical issues (eg torticollis, fractured clavicle, ankyloglossia, facial asymmetry, cleft palate, etc)
- refer to specialists for treatment; refer to lactation consultant for feeding plan
- concentrate on establishing a good breastmilk supply

Does your Unit have a policy on the non-latching baby?
Review the policy. Is it current, using up-to-date research to support the recommendations? If not, form a small group to research the topic then draft a policy that you present to your colleagues (midwifery, nursing and medical). Ensure all staff are familiar with the policy to avoid conflicting information and management strategies.

Workbook Activity 7.2
Complete Activity 7.2 in your workbook.
Breast refusal in the older baby
Babies may be fussy at the breast and refuse to breastfeed for a period of time. Before 12 months of age this is rarely due to the infant choosing to wean.
Determine that it actually is breast refusal. Mothers sometimes misinterpret an older baby's quicker more efficient feeding, or a decreased need for breastmilk when complementary foods are introduced, as breast refusal. During very hot weather baby may not feed during the heat of the day, but will feed well in the evening or during the night. Other reasons may be pain, forceful MER/low supply, flavour changes and sucking confusion.
Management strategies for the older baby
- Record a comprehensive history, including specifics on breastfeeding behavior and urine and stool output prior to this episode. Record the change in behavior and baby's current output.
- Do an assessment of the baby including weight, length, head circumference, attainment of appropriate developmental milestones, observation of alertness and general health. If there are signs of delayed growth or ill health, refer the baby to a doctor.
- Observe a breastfeed, or attempted breastfeed. (Review Topic 5.2 Assessing Breastfeeding)
-
If refusal persists for more than one or two missed feeds
- the mother should express her milk to maintain her milk supply
- use the expressed milk or donor breastmilk to feed baby, preferably using a cup
- use donor breastmilk or artificial infant formula if baby refuses the breastmilk
- a medical review of the baby is indicated if baby won't feed at all

Detective work is needed!
This is a distressing time for the mother, who may be feeling variously angry, rejected, worried, disappointed and bewildered. Good counseling skills will help you to empathize with the mother and work together through a comprehensive history-taking to find a reason for the baby's behaviour. If you can determine the cause you can then direct your management strategies more effectively.
General guidelines include:
- patience; avoid trying to force the baby to breastfeed or displaying anxiety or anger during attempts
- encourage lots of skin-to-skin time in bed together or sharing a bath. Don't expect the baby to breastfeed ... but it just might happen
- observe the environment - avoid distractions such as other children, toys, television, etc. Choose a dimly lit room and play some relaxation music.
- attempt breastfeeding when baby is nearly asleep or just beginning to wake up
- offer the breast instead of pacifier/dummy, and when infant starts thumb sucking
- suggest baby be cup fed rather than bottle fed when separated from the mother
- suggest the use of a tube feeding device at the breast instead of bottles if supplements were being given
- give written instructions and supervise the mother using alternative feeding methods until she feels confident doing it herself.
What should I remember?

- Protect the baby. Protect the lactation. Support the mother.
- Be a detective to determine possible cause of non-latch or refusal.
- Know the protocol to follow for a non-latching infant in the first 24 hrs after birth and for each day until secretory activation.
- Encourage patience.
Self-test quiz
Give your response
Notes
- # Engle WA (2006) A recommendation for the definition of "late preterm" (near-term) and the birth weight-gestational age classification system.
- # Hughes A et al. (2014) Late preterm birth is associated with short-term morbidity but not with adverse neurodevelopmental and physical outcomes at 1 year.
- # Baumert M et al. (2011) [Late preterm infants--complications during the early period of adaptation].
- # Resch B et al. (2011) Are late preterm infants as susceptible to RSV infection as full term infants?
- # AAp Committee on Fetus and Newborn (2011) Postnatal glucose homeostasis in lat preterm and term infants
- # Machado LC Júnior et al. (2014) Late prematurity: a systematic review.
- # Radtke JV (2011) The paradox of breastfeeding-associated morbidity among late preterm infants.
- # Vessière-Varigny M et al. (2010) [Breastfeeding in a population of preterm infants: a prospective study in a university-affiliated hospital].
- # Cleaveland K (2010) Feeding challenges in the late preterm infant.
- # Tomashek KM et al. (2007) Differences in mortality between late-preterm and term singleton infants in the United States, 1995-2002.
- # Woythaler MA et al. (2011) Late preterm infants have worse 24-month neurodevelopmental outcomes than term infants.
- # Meier P et al. (2013) Management of breastfeeding during and after the maternity hospitalization for late preterm infants.
- # Ahmed AH (2010) Role of the pediatric nurse practitioner in promoting breastfeeding for late preterm infants in primary care settings.
- # Walker M (2008) Breastfeeding the late preterm infant.
- # Dewey K (2003) Guiding Principles for Complementary Feeding of the Breastfed Child
- # Widstrom AM et al. (1993) The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle
- # Furman L et al. (2002) Correlates of lactation in mothers of very low birth weight infants
- # Kumar A et al. (2010) Spoon feeding results in early hospital discharge of low birth weight babies.
- # Morton J et al. (2013) Five steps to improve bedside breastfeeding care.
- # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
- # Cotterman J (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement