Re: 3hr feedings for a premie?

[Guest guest]

Three hourly feeds are typical for NICU. They never feed (rarely feed) babies oftener than that as they have to sleep and grow as well. I'm amazed he can take that much each time -- that's a lot for a baby of that size. He only needs about 10 to 12 ounces/day to grow --

As long as he is taking between 10 and 16 ounces a day, (7 feeds at 45 ml or 8 feeds at 60 ml) he'll grow. That's why the peds isn't terribly concerned about bringing him in for another weight check (my hunch).

Jan

Hi, All!

P2P. I saw a premie today who was born at 36+1 at 3lbs 6oz, IUGR noted at 18wk gestation. He is now 3 weeks old, and when he was weighed a week ago, he was 3lb 12 oz. There is much confusion over weights, differing scales at 3 hospitals.

Here's my confusion: He was seen by a local pedi one week ago, and she doesn't want to see him again for yet another week. Parents advised to bottlefeed q3hr during the day and q4hr at night, for which they always have to wake him, for a total of 7, maybe 8 feeds per day. He gets ebm with a "tiny scoop" or 22cal formula as a fortifier. He eats 45-60mL each time.

I was very surprised at how few feeds he gets, and that the pedi was willing to let him go two weeks without checking in, even for a quick weigh. Mom and dad didn't know what to think and were pleased for me to check in with you all.

BTW, mom will continue pumping and trying to nurse, but knows that baby has a bit of growing to do before he will be ready to nurse anywhere near exclusively. Dad is very positive and supportive, and baby is in fabulous health, exceeding everybody's expectations.

Thanks!

Lynn SFO IBCLC

Kirksville, MO

[Guest guest]

Two ways of doing it. For a baby to grow, you take his weight in ounces, multiply by 6 (don't ask me why -- it just works), and divide by the number of feeds/day. Or you can take his weight and multiply by 2.5. As he continues to gain, you continue to figure out how much he needs. If he wants more than that, it's fine, but you use the number you get as your minimum.

Jan

Jan,

How did you determine that amount?

Inquiring mind.

Ellen in Florida

He only needs about 10 to 12 ounces/day to grow --

As long as he is taking between 10 and 16 ounces a day,

Jan

[Guest guest]

Dee,

That's great information. I agree that the babies need to lean back somewhat....but didn't know why - and now I do.

Oh dear. I had another thought to add, but my formula fed brain lost it....

Oh yes -- now I remember. How much is mom doing total skin to skin? Remind her that she can put the baby S2S, put a cami over the two of them, and then a button down blouse or shirt over that -- tie the tails of the shirt in a knot under baby's bottom and button it up. That way she can go for a walk outside or to the park or eat her dinner w/ the baby S2S but without having to be naked in the lazy boy.

Jan

Dee here:

I learned from an OT a number of years ago, that before 38 weeks g.a., the fascia that holds the organs in place is not fully grown in. Therefore, under 38 weeks, there is more risk that in a totally upright position, the organs will "pancake" somewhat (her word), risking more reflux. She advised to have the younger babies leaned back a bit. In cases of IUGR, I also want those babies to be at least 5 lbs before sitting them upright, although that's just my own idea based on what seems sensible to me, rather than anyone else telling me that about the weight.

Dee Kassing

Subject: Re: 3hr feedings for a premie?To: Date: Thursday, May 26, 2011, 1:46 PM

For now, baby is clenching on the bottle nipple for some feeds, leaking out the side of his mouth (yes, I referred for OMM/CST!), but doesn't seem distressed and is eager to eat once wakened.

At what point is it appropriate for a baby like this to begin to feed mostly upright, as in Dee's method? Obviously now it wouldn't be so hot for him to work for his food, but how do you know when it is?

Thanks,

Lynn

obviously on her first premie Couldn't ask for a nicer family to work with!

[Guest guest]

Jan,

How did you determine that amount?

Inquiring mind.

Ellen in Florida

He only needs

about 10 to 12 ounces/day to grow --

As long as he is

taking between 10 and 16 ounces a day,

Jan

[Guest guest]

Not Jan, but I get the same # by using 2.5 oz of formula/milk per pound of baby.  4lb baby gets 10oz formula.Lynn

 

Jan,

 

How did you determine that amount?

Inquiring mind.

 

Ellen in Florida

 

 He only needs

about 10 to 12 ounces/day to grow --

 

As long as he is

taking between 10 and 16 ounces a day,

Jan

 

[Guest guest]

For now, baby is clenching on the bottle nipple for some feeds, leaking out the side of his mouth (yes, I referred for OMM/CST!), but doesn't seem distressed and is eager to eat once wakened.At what point is it appropriate for a baby like this to begin to feed mostly upright, as in Dee's method?  Obviously now it wouldn't be so hot for him to work for his food, but how do you know when it is?

Thanks,Lynnobviously on her first premie  Couldn't ask for a nicer family to work with!

[Guest guest]

Dee here:

I learned from an OT a number of years ago, that before 38 weeks g.a., the fascia that holds the organs in place is not fully grown in. Therefore, under 38 weeks, there is more risk that in a totally upright position, the organs will "pancake" somewhat (her word), risking more reflux. She advised to have the younger babies leaned back a bit. In cases of IUGR, I also want those babies to be at least 5 lbs before sitting them upright, although that's just my own idea based on what seems sensible to me, rather than anyone else telling me that about the weight.

Dee Kassing

Subject: Re: 3hr feedings for a premie?To: Date: Thursday, May 26, 2011, 1:46 PM

For now, baby is clenching on the bottle nipple for some feeds, leaking out the side of his mouth (yes, I referred for OMM/CST!), but doesn't seem distressed and is eager to eat once wakened.

At what point is it appropriate for a baby like this to begin to feed mostly upright, as in Dee's method? Obviously now it wouldn't be so hot for him to work for his food, but how do you know when it is?

Thanks,

Lynn

obviously on her first premie Couldn't ask for a nicer family to work with!

[Guest guest]

110-120 kcal/kilo/24 hr

H. Kinne BA IBCLC RLC ICCE CD(DONA)

www.CascadePerinatalServices.com

>

> Jan,

>

>

>

> How did you determine that amount?

>

> Inquiring mind.

>

>

>

> Ellen in Florida

>

>

>

> He only needs about 10 to 12 ounces/day to grow --

>

>

>

> As long as he is taking between 10 and 16 ounces a day,

>

> Jan

>

[Guest guest]

The leaking may not necessarily be out of the ordinary for a preterm infant who

often have low tone.

Also being IUGR, they often lack adequate development of the buccal fat pads,

which interferes with their ability to adequately create the oral pressure

necessary to effectively remove milk, sometimes a shield can help compensate for

this.

>

> For now, baby is clenching on the bottle nipple for some feeds, leaking out

> the side of his mouth (yes, I referred for OMM/CST!), but doesn't seem

> distressed and is eager to eat once wakened.

>

> At what point is it appropriate for a baby like this to begin to feed mostly

> upright, as in Dee's method? Obviously now it wouldn't be so hot for him to

> work for his food, but how do you know when it is?

>

> Thanks,

> Lynn

> obviously on her first premie Couldn't ask for a nicer family to work

> with!

>

[Guest guest]

You all would be amazed to see this kiddo.  He looks just like a ~1 week old should, except hit by a shrink ray :)Thanks for all the input!  it's so very helpful!Lynn

 

The leaking may not necessarily be out of the ordinary for a preterm infant who often have low tone.

Also being IUGR, they often lack adequate development of the buccal fat pads, which interferes with their ability to adequately create the oral pressure necessary to effectively remove milk, sometimes a shield can help compensate for this.

-

[Guest guest]

Why upright at all or on back for feeds? Why not mimic laid back bf with bottle

instead? If bio norm to bf is not laying back why use bottle that way either? I

do not sit baby upright or semi reclined for bottles. I have them in tummy down

or sidelying as in cradle or cross cradle nursing position.

Pam MazzellaDiBosco. IBCLC

Pam MazzellaDiBosco. IBCLC

[Guest guest]

I know how side-lying works with a bottle. In fact, the OTs in the NICU where I used to work had parents give premies their bottle this way so the milk could pool in the baby's cheek if the baby had trouble managing the milk.

But if you lay the baby face down, the milk is in the bottom of the bottle due to gravity. How do you get the milk to the baby when the baby is face down (tummy down) and you're using a bottle? More description please, because I just can't picture this.

Dee Kassing

Subject: Re: 3hr feedings for a premie?To: Date: Thursday, May 26, 2011, 11:23 PM

Why upright at all or on back for feeds? Why not mimic laid back bf with bottle instead? If bio norm to bf is not laying back why use bottle that way either? I do not sit baby upright or semi reclined for bottles. I have them in tummy down or sidelying as in cradle or cross cradle nursing position. Pam MazzellaDiBosco. IBCLCPam MazzellaDiBosco. IBCLC

[Guest guest]

Weighing this baby weekly will make the parents anxious. Baby was IUGR and will probably be failure to thrive for the first month or 2 before playing catch-up. Sounds like he's taking in enough calories for his weight at the moment.

Gail Neuman RNC BSN CPHW Notary Public

certified in high risk OB/Nurse Educator

childbirth/lactation educator & student nurse practitioner

AHA BLS for Healthcare & Heartsaver Family/Friends instructor

Perinatal Nurse Associates

Baby Your Way Midwifery Associates

801 N. Tustin Ave., Suite 305

Santa Ana, CA 92705

[Guest guest]

I'm so glad you asked this Dee. I've been sitting here at the computer trying to picture giving a baby a bottle when he is tummy down and it just wasn't coming together in my mind. Sidelying yes -- no problem. Prone? Problem.

Jan

But if you lay the baby face down, the milk is in the bottom of the bottle due to gravity. How do you get the milk to the baby when the baby is face down (tummy down) and you're using a bottle? More description please, because I just can't picture this.

[Guest guest]

That should read <37 weeks

>

> At 36 weeks that baby is most certainly late preterm (in our SCN we call

anything >37 weeks preterm).

>

erm, however they are not.

>

> H. Kinne BA IBCLC RLC ICCE CD(DONA)

> www.CascadePerinatalServices.com

>

> >

>

[Guest guest]

This little guy is in no danger of having his risk overlooked.  His dad is really, really concerned that they get the right support bc of his size.  So he may not focus on GA, but he's really paying attention.  Dad's concern was that intervention for IUGR may be very different than what would be appropriate for a premie, so he didn't want me to treat him as just early when size is the bigger concern.  It seems to me that we're looking at six of one and half a dozen of the other in this case

[Guest guest]

Ah, I had forgotten that they make bent bottles. That certainly changes the picture. Thank you for the extra information.

Dee

I will have to get permission for a picture next time. I use Playtex Vent Air standard bottles. They are bent. Mom leans back and places bottle as close to where nipple on her breast is as possible. I also do skin to skin. And encourage baby to search and go through all the steps of self attachment. If not doing it on his own I still have mom guide accordingly. If baby is 35 weeks (most babes here are not discharged sooner than that) I may do more modified because they can't get milk from the vent air yet. They need an easier flow so the angle may need to change. What I find is it changes the way they eat. Their whole body relaxes. It makes me think babies were not meant to eat reclined and upright. I can do the same with finger feeding of course even easier.. I have used the more sidelying but still in position for nursing when they don't have a bottle that does what I want and for moms with breasts so large it is really awkward for them

otherwise.I also discourage others from helping with feedings. I have my own reasons for that but I have found moms are relieved to hear they feed others do other stuff. Dee, it was your article that started my search for a way to transition to breast or to use bottle when needed without causing breast refusal. I also took info I learned years ago from Ruthie about back to breast. And over the years have added and subtracted depending on the situation and new things that clicked for me. . Right now what I do seems to work and mom and baby seem so much more relaxed during a feeding. And I don't have moms dealing with "nipple confusion" or breast refusal even if mom uses bottle for a week or more. I also help moms get babies back to breast by first having mom change bottle and bottle feeding method. And then add everything else we know about encouraging back to breast. Pam MazzellaDiBosco IBCLC

[Guest guest]

Years ago, I learned at a conference that SGA babies require twice as many calories to gain an ounce as normal-for-gestational-age babies. (I assumed they meant until the baby gets caught up to normal.) Anyone here know if that information is still considered to be true?

Dee Kassing

That should read <37 weeks

> > At 36 weeks that baby is most certainly late preterm (in our SCN we call anything >37 weeks preterm).>

erm, however they are not.> >

[Guest guest]

Dee, that's fascinating info -- I've never heard it before (doesn't mean much), but I'm not sure why, physiologically, that should be true. I don't think they gain weight as fast -- but is it because they need twice as many calories or ????

I think one concern I have is that in our zeal to have small (IUGR or SGA or late preterm or preterm babies) gain weight quickly is that we overfeed and end up with a risk of having an obese child later on....

This is especially problematic when we *assume* all mother's milk is 20 cal/ounce and supplement it to bring it up to X cal/ounce (Similac is now making a 30 cal/ounce formula -- or will be shortly)..... So if a mom has milk that runs around 24 cal/ounce, what are we doing to that baby?

Jan

Years ago, I learned at a conference that SGA babies require twice as many calories to gain an ounce as normal-for-gestational-age babies. (I assumed they meant until the baby gets caught up to normal.) Anyone here know if that information is still considered to be true?

Dee Kassing

That should read <37 weeks

> > At 36 weeks that baby is most certainly late preterm (in our SCN we call anything >37 weeks preterm).>

erm, however they are not.> >

[Guest guest]

I have a visual of this thanks to the Museum of Natural History which does talks

for kids. One was on predators and they had a bear cub (orphaned). He had to

take a bottle during the talk and they feed him prone, back legs against the

crook of the forearm, belly along the length of the forearm, chin cradled in the

palm of the hand, bottle horizontal in his mouth. I have never tried it myself,

but i can see using this in the same way that one would use a lying DOWN

position for mom with the baby prone on top (as opposed to leaning back

position).

Best regards,

E. Burger, MHS, PhD, IBCLC

[Guest guest]

I have done it laying down too. but it works if she just leans back far

enough too. I love how those working with mammals know so much and work so hard

to protect their natural needs. I wish humans respected our mothers and babies

as much. How we can get it for puppies and giraffes and be clueless about our

own is frustrating.

Pam MazzellaDiBosco

Pam MazzellaDiBosco. IBCLC

[Guest guest]

I don't understand that, twice the number of calories as what, an avg. weight

newborn? That confuses me, why would it take twice the calories for them to

gain? IUGR or SGA is in utero, after birth we are dealing with the deficiencies

that were related to the their lack of prenatal growth.

Jan's point is why using a creamatocrit is helpful.

>

> Dee, that's fascinating info -- I've never heard it before (doesn't mean

> much), but I'm not sure why, physiologically, that should be true. I don't

> think they gain weight as fast -- but is it because they need twice as many

> calories or ????

[Guest guest]

Obesity is not the only physiologic concern I have with overfeeding preemies or

IUGR or SGA babies. I am just as concerned about diabetes and other chronic

conditions related to the epigenetic response to a starvation/feast shift. In

general, American mothers are overfed and undernourished. This means their

babies are genetically selected to survive starvation. When they are overfed

instead, the most obvious risk is diabetes. I believe a good number of babies

born prematurely are responding to gestational stress in arriving early (and

then there are the multitudes being forced into early arrivals whose adrenals

are unprepared) and who are even more likely to be subjected to premature cord

clamping and we have chronic disease every which way we turn. The more I

understand epigenetics, the more worried I am.

Tow, IBCLC, France

>

>

>

>

> Subject: Re: Re: 3hr feedings for a premie?

> To:

> Date: Friday, May 27, 2011, 11:55 AM

>

>

>

> This little guy is in no danger of having his risk overlooked. His dad is

> really, really concerned that they get the right support bc of his size.

> So he may not focus on GA, but he's really paying attention. Dad's concern

> was that intervention for IUGR may be very different than what would be

> appropriate for a premie, so he didn't want me to treat him as just early

when

> size is the bigger concern. It seems to me that we're looking at six of

> one and half a dozen of the other in this case.

>

>

[Guest guest]

One thing I recall from a Nils Bergman's workshop day was how differently babies are fed when skin to skin and kangaroo care is incorporated.  There is a sleep/wake cycle and babies are fed during the wake cycle, even though it only lasts about 5 minutes...babies are at breast....and get the milk from a single letdown. There is no 'three hour' rule, or any rule, it is more about mom and baby together all the time and mom watching baby.  I am sure he discussed amounts too, need to go pull out CD and see if it is there.  The thing is, here, we are not about baby and mother and kangaroo.  We are about technology, control, and schedules. And yes, babies need to sleep and grow, but I also know sometimes babies are hungry sooner and not getting fed because it is not time yet. Translated to not enough nurses to care for the babies if we just allowed babies to be fed on cue, or smaller volumes but more often, etc.  Now, it's not that we are wrong and he is right, more that somewhere in between is likely a better option than ignoring the baby's hunger and feeding volumes based on time and calories and not on cues and digestion times.  I think we do not know as much as we think we know, and much of what we do know is not based on understanding of breastfeeding or breastmilk, but on technology and science of improved milks. Perhaps we do need to 'add' whatever fortifiers, but how will we ever even know since we are not feeding the baby to match the behavior or needs of baby, but to match the schedule and staff.  What I usually tell moms, is just deal with it, don't argue too much, and get out as fast as you can.  Because in my experience, when a mom argues, social services is called in and mom is considered a problem.  Nurses do not respond well to be questioned any more than the neonatologists do. Ah, the stories I hear just make me nuts! And I am oh so glad i never had to deal with any of it personally.  And, I am not a NICU nurse dealing with that reality either.  I think what Nils Bergman said was " it would require a paradigm shift " and I don't see that happening anytime soon.

-- Pam MazzellaDiBosco, IBCLC, RLCBirthing & Beyond, Inc.Labor Support and Lactation Consultant Services