Babies in the neonatal intensive care unit (NICU) face many unique struggles based on their conditions, but almost all of them share one challenge: feeding. Babies with complex medical conditions may struggle with breastfeeding or bottle-feeding because they don't have the necessary skills, or their condition or medical equipment interfere.

If you have a baby in the NICU, it might take a little longer to get them to feed, and in some cases, babies aren’t able to feed orally. However, with the help of NICU lactation consultants, therapists and qualified nurses, many babies with complex medical conditions can breastfeed in the NICU successfully.

What to know about breastfeeding in the NICU

The American Academy of Pediatrics and the American Academy of Family Physicians agree that breast milk is the ideal form of nutrition for infants, especially those with serious illnesses.

For that reason, we recommend parents breastfeed their babies if they’re able. However, we recognize that even under the best circumstances, breastfeeding can be challenging — and in the NICU, those challenges grow. But with proper support, this difficult task can become more manageable.

For many infants in the NICU, the main challenge is simple: They don’t yet know how to feed orally. Babies born prematurely often lack the instinct and physical development for breastfeeding. But if NICU babies can’t breastfeed in their early days due to medical needs, learning to feed later can be even more difficult.

Every baby is different, but many premature babies begin oral feeding between 32 and 34 weeks’ gestation. Your care team will guide you based on your baby’s readiness.

How does skin-to-skin contact influence breastfeeding?

Skin-to-skin contact (often called kangaroo care in the NICU) has many benefits, including reducing stress, regulating breathing and temperature, enhancing bonding and encouraging early feeding cues. 

When you hold your baby close, they may show subtle signs of feeding readiness, such as turning toward a breast or rooting. NICU nurses and lactation consultants can help you recognize and respond to these feeding cues for breastfeeding.

What are infant feeding cues?

Cues that your baby is hungry can include:

• Moving their head to look for the breast
• Lip smacking
• Opening and closing their mouth
• Moving hands to their mouth

If your baby doesn’t show these signs, don’t get discouraged. If your baby is showing these signs, they may be ready to breastfeed, even briefly. You can express a little milk to guide them. Some babies may nuzzle rather than latch, and that’s OK. Others may latch but only suckle lightly. The goal is to get your baby familiar with breastfeeding.

Along with lactation consultants, occupational and speech therapists can help your baby build the skills for breastfeeding. They help NICU babies develop the coordination to suck, swallow and breathe effectively — key skills for cue-based feeding and breastfeeding success.

Follow your baby’s feeding cues

If your baby responds well to early feedings, you can slowly increase breastfeeding with the help of your care team. Keep in mind that premature infants lose energy quickly. Signs of nutritive sucking (stronger, rhythmic sucking) show that they’re feeding effectively, while short, fast sucking may be non-nutritive.

After feeding, a “milk-drunk” look — calm and sleepy — is a good sign that they’re full. Teaching your baby to breastfeed in the NICU may be a slow process, but it’s an essential step toward going home.

How can I breastfeed with medical equipment in the NICU?

Some babies require medical equipment that can complicate the process of breastfeeding. These might include:

• NG tube (nasogastric tube)
• G-tube (gastronomy tube)
• Ventilator

These devices support nutrition and breathing but may limit breastfeeding temporarily. Babies on a ventilator or other equipment to help them breathe often can’t breastfeed. In these cases, feeding the baby through a tube may be necessary.

Therapists can still help your baby practice oral feeding with a pacifier or small sips of milk. You can bond by holding your baby during tube feedings and swabbing your baby’s mouth with fresh pumped breast milk when breastfeeding isn’t yet possible. Once babies transition to lower oxygen support, such as a nasal cannula (a thin plastic tube), they may safely begin breastfeeding.

Tongue-tied babies and breastfeeding challenges

Tongue-tie, or ankyloglossia, is a condition where the tissue under a baby’s tongue limits their tongue’s movement. Tongue-tie is often harmless and most often goes away on it’s own, but it’s important to know that it can  interfere with breastfeeding success.

Signs your baby might have a tongue-tie:

• Difficulty latching or staying latched
• Poor milk transfer
• Clicking sounds while nursing
• Restlessness or hunger after feeding
• Slow weight gain

You may also experience:

• Sore nipples
• Painful breastfeeding
• Low breast milk supply
• Engorged breasts

Tongue-tie surgery and breastfeeding support

If tongue-tie disrupts breastfeeding, your care team may try a couple solutions:

Position changes to encourage latching: Your nurses and lactation consultants can suggest solutions based on what your baby is doing.

Tongue-tie surgery: This is a quick, low-risk procedure called frenotomy. NICU doctors would likely only suggest this if a position change does not help. During the procedure, your child’s doctor will clip the tissue that connects the bottom of your baby’s tongue to the floor of their mouth to allow the tongue to move more freely. This procedure doesn’t require anesthesia and only hurts your baby for a moment, if at all. It’s best to perform this procedure before an infant turns 1 month old.

What the research says about tongue-tie

Research on tongue-tie is still evolving. Studies show:

• Fewer than 50% of tongue-tied babies struggle to nurse.
• Many babies referred for surgery improved with non-surgical support...
• This tissue can stretch over time, improving feeding without surgery.

Breastfeeding when you go home from the NICU

When your baby can feed independently and gain weight, you’re likely ready to leave the NICU. At home, your goal is to keep breastfeeding consistent and support your breast milk supply.

It is normal for stress, fatigue and ongoing medical needs to reduce milk supply. Here’s how to support lactation:

• Rest whenever possible.
• Stay hydrated — drink fluids every time you feed or pump.
• Eat well — lean protein, vegetables, fruits and whole grains.
• Pump often and in between feedings if you’re able.

Even if you’re not producing a large amount of milk, don’t be discouraged. Some parents choose to supplement breastfeeding with formula or donated milk, and that’s OK. Your baby’s health and growth come first.

Feeding at home with medical equipment

Some babies may go home with an NG tube or G-tube. They can still breastfeed, and you can supplement feedings through the tube afterward or overnight. If breastfeeding isn’t yet safe due to swallowing concerns, your care team may recommend feeding exclusively through the tube. During those times, hold your baby, offer a pacifier and keep mealtimes interactive to build feeding associations.

Bottle-feeding in the NICU

You may choose to bottle-feed breast milk or formula in the NICU due to:

• Difficulty latching
• Personal preference
• Limited milk supply
• Medical needs requiring fortified breast milk
• Dairy protein allergies

NICU nurses and feeding therapists will help you find the tactics that work best for your baby. General tips for bottle-feeding:

• Hold your baby side-lying with head slightly elevated, similar to a breastfeeding position.
• Feed your baby every 2 to 4 hours based on care team recommendations.
• Burp your baby after every 1 to 2 ounces of milk.
• Avoid introducing different types of bottles and nipples to your baby. Stay with the type of bottle and nipple your baby used during their NICU stay.

Maintaining a pumping routine (often 8 to 10 sessions per day) can be exhausting. Freezing breast milk for future use can be helpful. You can save freshly pumped breast milk for 6 months. If pumping becomes stressful, ask your care team about formula or donated milk options. Parenting a newborn with complex medical conditions is demanding — give yourself grace and prioritize your well-being.