to persist with exclusively bf low weight gain preemie?

[fightingnun]

DP is very keen to canvass the wisdom of Mumsnet and asked me to post this dilemma (nc).

We are very lucky to have a beautiful baby who arrived by unexpected emergency C-section at 31 weeks. The baby has had no significant medical problems - breathing independently from day 1 - but stayed in SCBU for a while due to prematurity.

We were discharged home exclusively breastfeeding after trial rooming in when reasonable weight gain meant the feeding tube was removed.

In the first week home we were visited for weighing and I was told there was a very small gain but 'not enough'. At the SCBU follow up clinic a doctor observed & commented on how well baby is doing, alert, good latching on, tone etc. Then a few days later I had a phonecall from the nurse saying she had miscalculated and there had in fact been a small weight loss not a gain.

At a second visit for re-weighing yesterday there had been a definite gain calculated at 12.5g per day but apparently they want to see 20g per day so I am under a lot of pressure to start supplementing with formula.

The nurse said she would 'allow me' to wait for HV visit on Thursday and not insist on going back to the clinic today which she wanted me to do. I don't know what might happens if the baby fails to put on the desired weight by Thursday (DP is worried about this). Meanwhile I am doing all I can to encourage more and longer feeds and increase my milk production.

Am I being too stubborn or am I right to resist supplementing at this stage?

I'd be very grateful for pointers to any evidence or research as well as anyone's experience or opinion.

I don't want to be dogmatic when my baby's health is at stake but equally I don't want to be pushed into something which isn't really necessary.

The baby weighs approx 2kg and I would be 36 weeks if still pregnant.

I had a similar thing. DD born at 34+4 weighing 5lbs (2.2kg). She was also in SCBU. I EBF for the first two weeks, she went down to 1.9kg and the HV said if she hadn't picked up weight in the next 3 days I'd have to take her back to hospital. In a teary meltdown that night I sent DH out to buy some Aptimel, and she started having about 20ml a day, picked up weight and was absolutely fine! Was lovely as DH could do a night feed, I could rest and DD was getting bigger and stronger.
On an aside, I BF until she was 13 months anyway, do what's right for your baby. That's the most important thing

I had a premmie at 26 weeks & exclusively expressed breast milk for the first 6 weeks & then started to mix with high calorie formula. I wasn't expressing enough to keep up with demand so I was encouraged to supplement with special premature formula. The formula is specially formulated with the right vitamins & minerals needed for catch up growth. You can mix the formula with the breast milk as a booster.

You absolutely 100% are not being unreasonable. You do NOT have to supplement, and it may not be in your baby's interests to do so. Before you do, get an opinion from your baby's consultant - my experience is that nurses and health visitors tend to cry formula at the first hint of a problem, and it isn't necessary.

kellymom and la leche league websites may be helpful to you. There is also an online paper called "just one bottle", which explains the changes that take place in baby's gut when supplementation with formula is introduced.

Also, there are usually breastfeeding focused solutions to any breastfeeding issues. Ask to see the infant feeding co-ordinator, who can check your baby's latch, don't be satisfied with a health visitor checking. before resorting to formula, supplementing with expressed breastmilk, or donor milk if available can (arguably should) be tried.

My experiende, and I'm outing myself completely here to anyone who knows me in real life (namechange after this!) - my third child was born with heart defects and "failed to thrive", i.e. she didn't gain the minimum expected amount according to the chart. She was using more calories as her heart was working harder, and was also not feeding as long as she needed because she didn't have the energy to finish a feed. I had a huge amount of pressure to supplement her with high calorie formula. A GP even told me he'd contact social services if he didn't, and the health visitor kept saying she could count on one hand the number of babies she'd been this concerned about.

Making me sound really irresponsible isn't it? Starving my child because of my own wish to breastfeed exclusively? Well, no. Biecause firstl;y, she's my third child. Neither my first or second child gained "enough" weight according to the charts. they dropped down several centile lines. My ds's weight even dropped below the bottom line. This made me suspect that it was nothing to do with her heart, or very little anyway. My other children's weight dropped, then followed one of the bottom centiles slowly, and this continued long after they were weaned and on solids. They're perfectly healthy. My ds eats like a horse!

I saw the infant feeding co-ordinator, who developed a plan - several steps that should be tried before formula - including lending me a hospital grade pump to feed her expressed milk using a supplemental feeding device (google it - it hangs round your neck so baby suckles your boob at the same time as receiving the expressed milk, so stimulating your milk supply, avoiding the problems with reduced supply that are associated with supplementation). next step - expressed milk through a feeding tube if she really didn't have the energy to breastfeed. etc etc. waved this in the face of anyone who mentioned the "f-word", and they did, often.

The cardiac consultant was pretty horrified that the local paeds, health visitors and nurses had put me under so much pressure. He was very supportive of my decision to breastfeed, and said that in his experience, artificially increasing the weight of a heart baby tends to make the heart problem worse, in that it increases the demands on the heart, and babies often go into heart failure when supplementation is started - it should be avoided if baby is otherwise well. Two cardiology consultants from leading hospitals in the UK have said that breastfeeding is probably a huge part of the reason she has not had a single infection, and has avoided major surgery. She is nearly 2, never had a drop of formula, and continues to breastfeed.

If your baby is otherwise well, showing all the signs of getting enough milk (6-8 wet nappies in a 24 hour period, poo should be mustardy yellow and seedy, 2-5 bowel movements in 24 hours. baby should seem satisfied after feeeding, feeding 8-12 X in 24 hours and feeds lasting roughly 20-40 mins)...also, feeding shouldn't be painful for you (if it is, or you have nipple damage, that suggests that baby's latch might need a bit of help which could lead to inadequate milk being taken in...so, if all these other signs are met, and you want to exclusively breastfeed, I wouldn't supplement in your shoes.

I hope some of that long ramble is helpful, but don't let anybody tell you that you have to supplement, because there are other ways.

Ask for nutriprem, your gp will subscribe it. Aptimel & mainstream formula milk causes constipation & isnt easily digested by a premmie baby. Ask for it in ready made in cartons as the powder causes constipation in some babies.

The maximum she ever gained in a week was 2oz.

Thank you all for massively helpful advice, sharing experience and the notes of caution too.

I will be going to a breastfeeding clinic tomorrow (well today now) and getting a lactation consultant to check baby's latch, I'll also ask about the supplementer device.

DP is also very grateful & feels more positive about all the various paths we might find ourselves on in the next few days.

The bf clinic was really helpful, several very good bits of advice to improve milk flow and production, lots of reassurance and encouragement and the lactation consultant made me a written plan. She took the nurses concerns about weight gain seriously and was very 'medically' aware as well as very pro bf which gave me a lot of confidence.

I am hopeful that when the HV comes later today we'll be able to have a good conversation about it and of course I hope baby has managed to put on enough weight in the last 3 days to prevent too much stress!

Thank you all again

I am glad you are getting help and feeling more positive.

I remember when my twins were in SCBU. I nearly changed to formula because the babies on bottles seemed to progress so much more quickly, and I was so desperate to get them home. The older nurse who I talked to said that breast milk was much more easily digested by their immature intestines, so I carried on. They were tube-fed until about 37 weeks, and were fast and efficient feeders within a couple of weeks (thankfully).

Good luck with it all

That's good news, I hope things go smoothly now

Jack Newman is a really good place to look.

Breast and Bottle Feeding is a better area to post in than this one.

The things that will help:

• make sure the latch is as good as you can get it
• skin to skin
• feed often
• breast compression can be a big help with tinies
• expressing, if you can face it

Congratulations, fightingnun, and so pleased to hear that you are feeling positive about things.

May I humbly suggest that if you need further expertise you try pming tiktok? She is a breastfeeding counsellor, often to be found on the breast and bottle feeding boards, where she is incredibly generous with her time and wisdom.

I had two prem babies - the last one, my DD didn't come home as quickly as she was being fed my expressed milk and they needed her to show a certain amount of weight gain before she could leave SCBU.
In the end I just didn't have enough time (another young child at home, hospital was an hour away) to express enough milk for her night feeds. She then had formula, gained weight quickly and was home.
I've always combined fed and am happy with that but it's really down to you. Don't give yourself a hard time over formula though - its absolutely fine.

Have only read op, so sorry if I've missed something. It sounds to me that you and your baby are doing a great job. Babies rarely follow the 'perfect centile line', breast milk has more calories in it than formula anyway. Lots of skin on skin and allow baby to feed whenever baby wants. Try and go to a breastfeeding support group if you can, or ask your Hv to refer you to a bfing counsellor. No one can make you give your baby formula. My prem dd lost 24% of her body weight. It took a while, but she finally started gaining. At almost 4 years she's one of the biggest amongst her friends. Try not to concentrate to much on weight, is baby alert when awake, good skin tone, plenty of wet and dirty nappies? These things sometimes mean more than weight.

When they talked tho me about introducing formula a different nurse showed me how to syringe feed with expressed milk, I just had to feed every 2 hours if she was not interested in boob then syringe it was.

It worked and they stopped pressuring me,

However, talk this through with a HCP whose qualified to formally advise you.

Sorry, I haven't read all the replies, but of those I have non mention your diet. Having a pre term baby is massively stressful and your body wasn't actually quite ready for all this.

I'm a midwife and when (a long time ago), I was a student, my mentor midwife had an expression that was so very true:

Eat well, drink well, rest well.

Diet very rich in carbs, lots of fluids, not much else, just baby and rest.

Tiny babies expend a lot of energy just sucking so don't gain as fast as full term babes. Mum needs to be alert to the difference between a baby who feeds all the time because unsatisfied and baby who is having a growth spurt.

So do the above. Eat those carbs: rice, pasta, cereal, bread. Then apply judgement, if your baby is still struggling a little there is no shame in adding a formula feed. This is not giving in, it's saying, thankyou god for medical science.

Best wishes.

Matilda - are you saying eating carbs has an impact on milk production?

My 29 weeker is ebf coming up to 6 months actual.
He was discharged at 35 weeks but there was a wobble around his due date as he hadn't doubled his birth weight he was gaining 200g a week but immunisations knocked him of killtere for a couple if weeks.
Our outreach nurse had concerned and we had to give one top up of nutriprem a day. He hated it and refused the bottle after a couple of weeks. It also really affected his bowels so we decided to stop. When we saw his consultant she was happy with his weight so no more nutriprem.
I tried lactation cookies, fennel, constant feeding and was really stressed. He started gaining more weight as soon as I relaxed after seeing the consultant. I think our too up was about measuring input and covering all bases.
Hope your plan is working. If you do have to top up don't push it, I also breast fed after he had it.

Good luck OP.

OP, having had a prem who took many months to get onto the very bottom of the growth chart I know how stressy this can be. I did mixed feeding with my own bf and Infatrini. I was initially reluctant as I felt that I was being told that it was something else that my body was rubbish at - but I had faith in my hospital nurse - and it did work.
In my personal experience HV know practically nothing about prems and I would disregard all their advice - what they said completely went against advice from the SCBU staff. And yes, they are obsessed with numbers and scales can be highly inaccurate.

Good luck.

The HV had a very supportive and constructive attitude and fortunately baby had gained since Monday so she felt happy to write in the red book that I would be following the lactation consultant's plan and she (HV) would review in a week. She is also, she says, 'not a fan of very frequent weighing'.

This involves a lot of the suggestions made here, better latch/position, more effective breast compression, expressing etc and seems to be helping to prolong feeds and improve milk flow already.

This thread has been of immense help to both DP and I, every single comment has been helpful. It's led me to loads of useful information and encouraging experiences including why weight gain can be a key indicator of problems. If we do need to supplement we will be ok with that, for now there are still more things to try so I can continue ebf.