It was a shock for both Petrina and Mike to have their baby a full three months before they’d expected him; Petrina, who likes to be in control of everything, was particularly disturbed. It was difficult for her to sit by her new baby so impersonally enclosed in an incubator, unable to hold and, most of all, to breastfeed him, something she longed to do.

Maintaining a supply: I explained to Petrina that although no feeding is straightforward for premature babies, breast milk is especially beneficial for them, as it provides protection against infections in the first few risky weeks of life. Benjamin had to be fed intravenously for several days and then gradually through a stomach tube because he had not had time to develop rooting and sucking reflexes. Petrina expressed her milk from day one and stored it so that it could be used to feed Benjamin when the stomach tube was in place. She remained adamant that she wanted to breastfeed Benjamin when she could eventually take him home, and as soon as he could be released from the incubator for short periods, the nurses encouraged Petrina to put him on the breast. I reminded her that breast milk is produced in response to demand. If it’s not removed by a nursing infant, it must be expressed; otherwise production stops. This mean Petrina had to express milk to keep up production until Benjamin was able to breastfeed regularly.

Learning to express: Expressing milk for a premature baby is difficult because all the natural cues for milk let-down are missing: hearing the baby’s hungry cry, lifting him up, putting his mouth to the breast. To master the technique of expressing milk, Petrina needed great persistence and support from Mike; often she felt like giving up. Her breasts become engorged on day three and she could hardly bear to massage them. She explained her problems to the head pediatric nurse in the hospital nursery, who arranged for nurses to help and encourage her to take off milk every two hours (as a very small baby would) and to store it hygienically. Petrina continued to express milk during the night, every four to six hours. By the second week, she’d become quite expert and was asked to teach other mothers how to express. Now she was feeling useful and competent, her fears about her baby started to wane.

Bonding with a premature baby: One of Petrina’s main concerns was that Benjamin wouldn’t bond to her and Mike because he couldn’t hear their voices and couldn’t smell their skin or enjoy their hugs. The hospital staff, however, showed them how they could put their clean hands into the incubator to stroke and caress Benjamin gently. Within a week Benjamin was showing signs of loving this contact and responded by wriggling when they touched him. Quite naturally they would talk to him as they did this, and during the second week they saw his eyes flicker in recognition at the sound of their voices. They thought of this as their first conversation and continued to babble to him happily during their time together. The hospital staff encouraged both parents to spend as much time as possible with Benjamin, and to help feed and change him as their confidence grew.

Coping with the demands: Two and a half weeks after Benjamin’s birth, Petrina experienced a crisis. The shock of the premature birth, the anxiety of the first few days, and the loss of sleep because of expressing at night were all having their effect, and she felt that she had no emotional resources left. When one of the nurses found her sobbing, she realized immediately that Petrina herself needed some tender loving care. She suggested that Petrina talk to Mike about her feelings. Mike had thought that Petrina was totally absorbed with Benjamin, but was only too willing for them to have some time alone together each day for hugging and sharing. Petrina also started to talk some time for herself – to have her hair done, for instance – and to spoil herself now and then with nutritious treats like strawberries out of season or a salad with fresh baby greens. She drank lots of mineral water to keep herself healthy for breastfeeding.

Preparing to go home: Before Benjamin was ready to leave the hospital, the staff established him on breast milk from a bottle so that he learned to suck well before ha was put on to the breast. In the last week before he was due to go home, was taking five feedings out of eight from Petrina’s breast so she got Benjamin used to the breast in the reassuring environment of the unit. When Benjamin was 38 weeks old, and weighed 5 pounds 8 ounces (2.5 kilograms) – ten weeks after he was born – Petrina and Mike took him home and felt like a real family for the first time. At home, Petrina had to continue expressing so that she always had enough milk if Benjamin even showed signs of being hungry after a feeding. A week later, Benjamin weighted in at 5 pounds 12 ounces (2.6 kilograms) and was thriving. However, I explained to Petrina that she must think of him as if he were still in her womb; he wasn’t two months old, but 39 weeks, and she shouldn’t expect him to catch up completely with full-term babies of his age till hw was two years old.

An untreated blocked duct or mastitis can result in a breast abscess. You may feel feverish, and you may have a shiny red patch on your breast that is exquisitely tender. Your doctor should prescribe antibiotics; if this fails, the abscess will have to be drained surgically, but you may be able to continue breastfeeding even if you need this minor operation – ask your doctor’s advice.

If a blocked duct is not treated, it can lead to an acute infection, known as mastitis. The breast will be inflamed and a red patch will appear on the outside, as with a blocked duct. If you can, you should continue to breastfeed because you need to empty the breast. However, you may find nursing too painful. In any case, consult your doctor, who may prescribe antibiotics.

Tight clothing or engorgement can cause a blocked milk duct, resulting in a hard red patch on the outside of the breast. You can prevent this by encouraging your baby to feed often and empty your breasts, and by making sure your bra fits properly. If you do get a blocked duct, offer the affected breast first.

Toward the end of the first week, before breastfeeding has become fully established, your breasts may become overfull and painful and quite hard to the touch. If this happens, your baby won’t be able to latch on successfully. Make sure you wear a good bra to minimize discomfort, and gently express some milk before feeding to relieve the fullness. Having warm baths will also help relieve the discomfort by promoting milk flow.

If sore nipples are not looked after properly, they may become cracked. If this happens, you will feel a shooting pain as your baby suckles. You should keep the nipples dry with breast pads or clean tissues, and stop feeding from the affected breast until it has healed. Express the milk by hand instead; it can be fed to your baby by bottle or from a cup with a spout.

If you are confined to bed, you can express milk so that your partner can feed the baby when you are not feeling up to it. If you are too ill even to express your milk, then your baby can be given formula by bottle or by spoon and, although she may not like this at first, she will take the milk as she becomes hungrier.

If you have to go into the hospital you can still breastfeed. You should inform the nursing staff that this is what you intend to do so that they can make the necessary arrangements – for example, someone will have to be available to lift and change your baby if you are too tired or ill to do so. If you are having an operation, though, you will not be able to breastfeed afterward because of the anesthetic – you will be too groggy, and, more importantly, the drugs you have been given will have passed into your milk. If you know you will be having an operation, try to express and freeze your milk so your baby can be bottlefed until you have recovered. It will take up to ten days for your milk to return; your baby should suck as often as she wishes in the meantime.

Care of the breasts The daily hygiene of your breasts and nipples is very important. You should cleanse them every day with water or baby lotion (not soap, which defats the skin and can aggravate a sore or cracked nipple), and gently pat them dry. Dry them gently after feeding. Wear your bra all the time, as you will need lots of support, but leave the front flaps down with your nipples open to the air. You may like to use a moisturizing cream on your nipples or, if they become sore, an antiseptic spray.

Once your milk flow is established, the milk may leak out quite a bit. You can use breast pads or clean cloth handkerchiefs inside your bra to soak it up. Change them frequently for cleanliness. A plastic breast shell with a reservoir will help keep your nipples dry and catch leaks of milk, which can be frozen or refrigerated in a clean bottle. Wash and sterilize the shell before reusing.