Prem baby with IUGR - bf or bottle?

[stillfrazzled]

DS2 was born 35+3 weighing 3lbs 5ozs due to IUGR. He spent 3 weeks in SCBU, but with quite a bit of work and support from the staff was discharged EBF and has never had formula.

They were very keen on bf in the unit, at least in the early stages, and I really really wanted to bf.

We're now home and he's gaining between 5-8ozs a week (usually nearer 6) which is OK and follows the line below the 0.4th centile but isn't catching him up at all.

I am getting obsessively worried that I've stunted him for life and he'll never catch up, and that my milk isn't good enough and he'd gain faster and grow bigger on a prem formula. I spend weigh in day at the clinic either nervous or depressed.

Don't know what to do. Really wanted to bf, love the idea of it and the health benefits, but long term would DS2 be better served with something a bit more fortified?

sorry liberty i see what you are saying but why would you express and then offer formula? it doesn't make sense . formula is no more calorific than breastmilk and offering multiple sides - feeding off an 'empty' breast, will encourage more let downs of high fat milk, which is a good thing. it will also up supply so more milk is available.

not criticising your choice. and it is entirely up to the OP. its all good. i just don't get the 'offering formula' while expressing and storing idea .

'If you have BF exclusively for 12 weeks your boy has already had the vast majority of the benefits of BF.' many benefits are ongoing and dose related.

Mine were both full-term and good weights, so I can't help with some of this. But the bit about how he 'shouldn't' be on the 0.4 centile because everyone else is tall - well, my ds weighed 8.5lb at birth, and then dropped through the centiles to the 9th (ebf and I didn't cope well), where he's stayed for five years. Dh is over 6ft and dd has been on the 90th since 12 weeks (born on the 9th...). The most helpful comment I had was from a HV who said that birthweight reflects nutrition in pregnancy and has little to do with eventual height. So don't feel that where he is now is where he'll always be, or that he ought to be on someone else's centile. If you substitute something like 'intelligence' or 'prowess at chess' for weight and height here, you'll see that it's not really how you think of him at all ('he ought to be good at chess because his sister is' 'he ought to be bright because the rest of us are' - no, he ought to be himself. And he is.)

Oh stillfrazzled, I know it's trite but I do know how you feel. 9oz in two weeks is within the normal range; 18oz in a week is either a weighing error or a very, very anomalous case which would have me extremely worried about all sorts of things including water retention attributable to pulmonary dysfunction (although I'm not trying to be all alarmist about your friend's baby, merely saying what would go through my mind for me to rule out with that gain).

Weight gain for weight gain's sake is just that - a figure on the scales. It doesn't predict intellectual or behavioural outcomes, and it doesn't predict later health. If you were happy with his health when you didn't know the number on the scales, are you doubtful about his health now you do? Is there a knowledgable health professional you could talk to about concerns (e.g. I was constantly worried that dd was more vulnerable to illnesses at a low birthweight, but my GP reassured me that there wasn't a relationship there and that the benefits of breastfeeding would still mean that she was better protected than a ff baby who was piling on the pounds).

Incidentally, in relation to the other baby's high weight gain, there is some evidence that premature and/or low birth weight infants are particularly vulnerable to later obesity ( Ong et al 1999 ) and this may be partially attributable to the intensive feeding that such infants frequently receive, leading to internal indicators of satiety being overriden. It may also be due, as Ong et al suggest, to early deposition of central (visceral) fat during the inappropriately fast catch-up growth that is often pushed on small for gestational age babies.

(I didn't research all of this just because I had an IUGR baby, although that motivated my interest as I wanted to be SURE that breastfeeding DD1 was worth all the effort . I was fortunate that my PhD supervisor literally wrote the book on the consequences of IUGR, early growth faltering and postnatal nutrition. He was a very reassuring presence in DD1's early days. I can imagine you're feeling pretty frustrated and isolated (un-Mumsnetty hugs).

PS - to be clear, I was meaning to hypothesise that accelerated catch-up growth is more prevalent in ff infants, partially due to the use of high calorie formula and partially because over time ff infants tend to gain more weight regardless of birthweight - this may be due to generalised over-feeding of formula fed infants or something else entirely (Baker et al 2004 and Dewey et al 2001).

First- well done for breastfeeding for so long already! Second- don't feel bad if you do decide to go for formula or mix feeding.
I'm sure your son will grow perfectly well whatever you decide in the end but I understand it is hard when your baby is so small.
Honestly, try not to panic and try not to feel guilty about everything. It isn't your fault that he came early. It isn't your fault that he was small. It's just one of those things.

Have you looked at a breastfeeding growth chart rather than the usual one? That might reassure you somewhat. You are doing so well to get this far.

My DD was 3 pound 6 when born. She didn't put on any weight at all for a few weeks after coming home and I did then mix feed her for a few weeks as I panicked a bit. Then we went back to just BFing again. Take all the help you can find from health professionals and local groups and helplines!
It can help to get different people's advice and opinions.
Good luck!

Updating this thread because didn't want to start a new one.

I read all the advice on here and tried to take it to heart - dropped weigh-ins to three-weekly and tried to relax.

It was working quite nicely; I relaxed loads without the weekly weigh-in spectre, DS2 had started to look quite chubby, developmentally he's doing pretty well.

But. Today was his 3-5 month check. He's put on less than 5ozs per week for the past three weeks. The line he's following is now flatter than the centile line, so he's gaining weight but getting proportionally smaller. His head, in particular, used to be between the 9th and 25th centile corrected for age, and is now in proportion i.e. as weeny as the rest of him.

The HV said she wasn't worried but (a) admits she doesn't know anything much about IUGR or prem stuff and (b) they never do say they're worried, I don't think they're so much bothered that he does well as long as he doesn't actually do badly IYSWIM.

I am totally losing my nerve on bf and any faith in my own judgement - I thought he'd put on loads of weight. Less than 5ozs a week is not loads, not for a baby of 9lbs or more.

Don't know what to do, frustrated as hell that no-one can give me any real answers, and panicking that we seem to be actually going backwards. WHY isn't anyone worried about this?

The only reason I haven't been in tears all afternoon is that I don't want to frighten DS1.

Can you get a referral to a pead who specialises in this area?

The other thing, in the meantime, could you get a fortifier to add to your own expressed milk?

My DS was born at 35 weeks because of IUGR and weighed 4lb 5z but he did catch up pretty fast on my milk. I can relate to feeling guilty for having a crap placenta but it's not like we could help it!

StillFrazzled - I'm not trying to be flippant and believe me I know about obsessive weighing (I had PND-OCD & DD1 had reflux) but may be the reason no one is worried about this, apart from you, is that they see what you don't - a happy baby that they believe is healthy. I really do understand how you can get into such a state, obsessing over one aspect of baby's health to the point you have trouble seeing the big picture of the rest of your baby's health.

If you did swap to formula milk and he didn't take what the packet said he should or he didn't gain the 18oz a week your neighbours baby did, how would you feel? Would it be something you regretted or would you be happy that the worries of bfing were over?

Can you talk this over with a BFC or IBCLC or Infant feeding co-ordinator to get a full picture of your baby's health & the impact of bfing on him? I think having a full and frank discussion with someone who is an expert might help either rest your mind or help make your decision on whether to stop or carry on bfing.

stillfrazzled

Firstly congrats on the birth of DS. Now are you and the HV actually measuring on the right line? This may sound daft but babies born before 37 weeks should be plotted as a corrected age. For example my son was born at 30 weeks so 12 weeks from birth he was infact 2 weeks old. If your son is 14 weeks from birth you should take 5 weeks off so he is actually 9 weeks.

As for growing slowly my ds is still small but he is developing and at the moment we are concentrating on that

BTW He was born on the 75th left hospital on the 9th and is now 19 months later just under the 25th but he stayed on the 9th until he grew to like real food.

Truth, if I switched to formula and he failed to gain any faster, I think I'd feel even more of a failure than I do right now. My worry is that in going for short-term gains with formula, I'd be sacrificing long-term benefits, especially if he's going to start gaining weight naturally, sometime soon. It's a circular argument and it's doing my head in! Idea of talking to someone expert on bf is good, will look into it.

mrsspear, yes, sadly, these are the corrected measurements. I do try to focus on progress, not size, but weigh-in day tends to put paid to it for a while.

Do you have to have the weigh in's???

If not i would try and sit back and try to stop comparing, two babies are never the same even siblings let alone one born full term and the other prem.

My HV told me 1lb a month is "good" i.e above OK which equates to 4oz a week plus your HV is happy so try and relax and enjoy. I understand how tough it is; i still get bloody cross for the looks when i say how old ds is!

If you don't mind me asking a few questions?

How do you bf - cue feeding, on schedule, only feed on 1 or 2 sides, limit feed to X mins, feed until suckling stops/baby drops off then switch sides?

How many feeds a day/how long between feeds?

How many wet nappies - clear or dark urine? How many poos - what are they like (nappy fillers/small 'sharts'/something inbetween/green/yellow/liquid/solid)?

What is his demeanor like - happy/content/fractious/sleepy/active/etc?

I'm no expert (only Mother Support & Peer Supporter) but sometimes things like offering side 3/4/5/etc at a feed or doing breast compressions to encourage a reluctant feeder or hand expressing after a feed to stimulate supply (and have a stash of extra fatty milk in case of needed to give a supplementary feed if you go out).

I'm not suggesting to do any of those things right now but they might be something to talk through with someone who has baby, baby's chart and you in front of them. Though offering extra sides never hurt - if baby is full they will just refuse.

stillfrazzled, just adding my support. You are doing an amazing thing .

FWIW, my 4 boys were all slow gainers, not just the 31 week 3lbs10oz DS2 . With (term+15) DS1 I caved at 6 weeks and mix-fed which led to reduced milk supply and spelled the end of BF by 5 months. FF certainly made him fat chubby, but he remained a screamer (now aged 8, still is).
With the others I BF mostly (DS2) and exclusively (DSs3 and 4). DS2 the preemie ended up the fattest of them all and is now built like a rugby prop forward at 7 .

IME, they all really started putting on the beef when they became older than 6 months. But, by jolly, they then really did.

Having always had low confidence in my supply/'quality' of milk I was amazed when I recently stopped BFing DS4 at just over 1 year, changed to 8oz of cow's milk in a bottle at night and his nappies were lighter in the morning than when I fed him! Never thought he got that much from me...

Keep feeding on demand. Offer lots of sides as stated above. Do really look at the baby and not the scales. KEEP GOING. Before you know it he'll have a dimply bum and skinfolds at this thighs .

I hope this post was not too me, me, me, but I recognise myself so much in all the insecurity and the desire to do the best for a precious baby from your post. Hope this helps a little bit.

Just to add my support as well if thats ok? DS2 was born in November at 32+5 weeks as I had PE. He was 3lb 8oz at birth which is still quite small for nearly 33 weeks. I couldn't bf due so he was given high calorie premature formula...he still struggled to gain weight and was discharged after nearly 4 weeks weighing just over 4.5lb.

He is 6 months old on monday and weighs 12lb 10oz. He isn't on the high calorie formula as he wouldn't drink it and he wasn't putting weight on anyway so we took him off it and he is just on normal formula. HV worked out he is averaging 3-4 oz a week but some weeks he's only put on an ounce...and other weeks 7oz (we celebrated those nights lol!).

DS1 was born at 35+6 weighing just under 5lb so still small for that gestation and I later found out that they classed him as IUGR...however by 10 weeks he was 14lb and at 6 years old he's head and shoulders above most of his class.

Im saying this as someone who is ff...it isn't necessarily the magic ingredient that you think it might be. Its taken me 6 months to realise it but nothing I can do will make him put weight on any quicker and trust me Ive done the whole "he's only had 2 oz when he should have drunk 5oz" and it was destroying me. He's little but he's happy and smiley and thats all that matters at the moment.

Also just to agree with pacificdogwood...he's put on 7oz in 4 days (got him weighed at clinic and then at his hospital review) recently and he's now started solids. He's taking them really really well so far and still drinking all his milk so hopefully we're moving in the right direction.

Ive also stopped weighing him...we go every month now and thats it.

Not sure if thats helped at all but just wanted you to know that even ff babies are necessarily giants lol!

Hi, stillfrazzled.

Truthsweet's questions are really important. Before you start looking at other ways to feed your baby, let's stop and take the time to look at what you're doing now.

You sound like you're holding onto a whole lot of guilt about "failing" to grow your baby inside you, and now "failing" to grow him with your milk. What you've actually done is grown two fine and beautiful boys, and although one decided to make a slightly early entrance and give you and your family a terrible fright, you've done the very best thing by continuing to support his little body with your own milk. This has supported his immune system and desperately importantly for a prem, has coated his intestines with components in your milk which are ONLY in breastmilk, which has helped to protect him from necrotising enterocolitis which is a very serious illness (life threatening) that affects prem babies - and those fed formula are 5 times more likely to get it because they don't have the protective effect of breastmilk (hence why I'm passionate about donor milk to prem units).

But he's not a prem baby anymore. He's a small baby who WAS premature, and is now "a baby" effectively at term, and his weight should be tracked by his adjusted age (see where it then falls).

Breastmilk is more calorific than formula. Replacing the same amount of breastmilk with the same amount of formula will mean he gets fewer calories, plus none of the protective effects of breastmilk, or the hundreds of other components that are not in formula and we don't know about. Nothing is more nutritious or more perfect for your baby.

The question may be whether you're giving him enough, which is where Truthsweet's questions come in. Have a look at how often you're feeding, whether you offer both breasts, what his nappy outlook is like and what your baby looks like in himself. But I feel that you may have lost confidence in yourself to judge these things - would this be accurate at all? And because your HV "doesn't know much about prems" then you don't have confidence in her, either.

I would strongly urge you to call the NCT breastfeeding line. Their counsellors are very highly trained specifically in breastfeeding (diploma level) and they will REALLY help you. They will NOT push you to keep breastfeeding if you don't want to. A better name for them would be infant feeding counsellors as they will help you work out the best thing for you and your family. It's free and their number is 0300 330 0771.

Another great website is the Analytical Armadillo. She has written a truly excellent post about exactly what you're talking about - meaning, what "extra" would you get from formula? www.analyticalarmadillo.co.uk/2010/12/infant-formula-what-is-magic-more.html

She is an incredibly highly skilled breastfeeding counsellor - currently sitting exams to obtain her IBCLC which is the highest level of infant feeding training you can get - and she also offers free support by email or telephone. Her website is milkmatters.org.uk/.

Hi stillfrazzled I just wanted to add my experience to all of this. My ds2 was born on 0.4th centile, induced at 37 wks due to IUGR, he weighed 4lbs.

Apart from a tiny amount of formula in his first day or two because his blood sugar was low, he was EBF for about 9m. He has gained weight steadily, meeting developmental milestones, very bright and happy. He is now 16m but still (AFAIK, I haven't weighed him since Jan), around 0.4th centile. He did drop below it at around 4m and gp referred me to a consultant paediatrician because she was being cautious-the consultant was basically not interested, she said it was perfectly normal for babies to drop off a centile at around 16wks and "find a new one" where they continue for a while. She could see he was healthy and happy.

Despite him showing no catch up, at no point did any doctor or hv suggested I ff and now he has been on solids and formula then cows milk for 9m he still hasn't had any spurt, so like iheartttc's DS, it seems that whatever is causing his size, it isn't the lack of formula. I am sure this is also the case for your DS and you would get the same reaction from a paed as I did. As long as he is gaining and is content and developing on track, there should be no reason to give formula rather than breastmilk. Having said all this, it sounds as if you could do with more reassurance so as well as the breastfeeding support recommended you could also get your GP to refer you to a paediatrician?

My brother was born with IUGR. Weighed 4 pounds. This was in 1960s. He was kept in a hospital while my mother was discharged after a week. He stayed in until he hit 5 pounds. My mother expressed and expressed and used to get the bus in in the morning with a kilner jar full of milk.

He then was discharged and she carried on feeding until he was 6 months. He was always on the smaller side, but not stunted in comparison with our brother. They just have naturally adult slight builds and average height.

Wow. I?m really moved that you?ve spent so much time writing out your personal experiences for someone you?ve never met! Thank you so much, it really does help to read it all.

OK, some questions to answer.

Truth, DS2 feeds approx every 2.5-3 hours during the day. I normally wait for his cues but will offer early if we?re going out, or are out and have stopped, or something. At night I feed him at 11 or so (inc several ounces of expressed milk), then he wakes up at 3-ish for another feed.

I always offer both sides, he generally seems quite content after two. I don?t know if I?m doing proper breast compression, but have noticed that squeezing the breast while he?s feeding will encourage him to start if he?s stopped.

Nappies are always wet, not esp dark. He poos once a day or so, generally bright yellow nappy (and occasionally vest) fillers.

He?s very lively and cheerful but pretty placid ? will amuse himself for fairly long periods. Does have a little double chin and some folds of fat on his legs, so def storing a bit extra.

Two things I have been wondering about:

1. At night I have been feeding him on my side, and we both fall asleep pretty quickly. Is it possible that he?s only been having a little snack and missing out on the richest milk? I forced myself to sit up and feed last night, and he took both sides and slept far longer afterwards.

2. He?s quite a sicky baby. Often wet burps, frequently throws up a few mouthfuls after a feed. What I wear is generally sicked on at least once a day. Had wondered about reflux (he was colicky though it seems to be passing now) but it doesn?t seem to bother him at all.

Pacific Really glad to hear that the solids helped. Can I ask you what your top tip weaning foods were? I like the idea of BLW but can?t think of much high-calorie finger food.

iheartttc Oh poor you, having to do this twice. Much sympathy. And thank you for the reminder that formula isn?t a magic solution and will bring its own things to obsess over...

organiccarrotcake Thank you for the lovely words of encouragement, and for the v practical advice re the Analytical Armadillo ? my next stop, I think.

Sleepwhenidie V interesting point about the 16 weeks, which is exactly when DS2 started to slow down. Did the consultant say why? Glad your DS is doing well, and sounds like you did amazingly with him.

pooka Your mum sounds like an incredible woman. And thanks for mentioning the average height (I keep getting upset because I think DS2 will be about four foot tall and left out of everything at school. Irrational and there are far worse things, but it still gets to me).

stillfrazzled All sounds good really. Charlotte (Analytical Armadillo) will make sure that everything is fine, though, and give the support you need :)

stillfrazzled, how old is your DS? Sorry, I am incapable figuring it out myself.

In Germany folk-wisdom will have it that 'Sick babies are thrive babies' - not sure at the truth of this. My preemie DS2 had dreadful reflux, used to regularly chuck the precious, hard won, expressed BM across the room. He was always wet down his front, alwasy smelt of cheese , had a rash on his chest. All this no matter whatever meds we tried and no matter how obsessively often I changed his clothes.
It all just Stopped. At 6 months. Just lilke that. As he had been 10 weeks prem, I did not wean him until he was over 7 months and yes, solids also helped. But clearly there was some kind of maturation process that helped his stomach sphincter to keep things down that happened before solids. As he also had his barium swallow X-ray test around 6 months, it seemed like the test cured him . Which of course it didn't - time did.

Re weaning: I like the idea of BLW. I had never heard of it until I was expecting DS3. And I like making purees - fruit purees are still known as 'baby slop' in this house and the big boys (aged 8 and 7) also love it. It is a great way of getting about 3 of their 5-a-day into them without them moaning. I started with carrot or sweet potato purees, or carrot and apple, or carrot and butternut squash, or carrot and... You get the picture. Cream or Philadelphia into everything.
You don't need to worry about calorie content when you do BLW because you will just continue milk feeds as before and baby will reduce them as he takes more solids. It is entirely baby led.
I have always done a mixture of spoon feeding (yoghurts are just irreplacable as food on the go IMO) and finger foods. The first 3 are great eaters who will at least try almost anything (they refused snails at a recent trip to France - fair 'nuff!). DS4 seems to regard vegetable intake as against his Human Rights or something

BTW, my biggest newborn (DS1, 42 weeks, 7lbs12oz) is the skinniest 8 year old, eats like the proverbial horse, but fidgets every waking second.

You'll get there, you will, and so will he and be absolutely fine.
We only know a fraction of how much good you are doing him with BFing, particularly because he was early and small.

High calorie finger food - cheese cut into sticks or melted on toast fingers or nut butters on toast or rice cakes. In my experience though,they lose concentration before they get full so would recommend starting a meal with finger food then topping up with purees.

DS was also v possetty. Their sphincter muscle between gullet and stomach isn't as strong as a full termer's. He grew out of it around 7 or 8 months.

Thanks - my mum is brill. She's always said that db, being her first, meant that she had no benchmark, and what she did and how he was seemed normal to her at the time. She was completely confident (she has said she doesn't know why) that she was doing the right thing by him and that he'd be fine. Has explained it as like a zen thing. She was exceptionally well cared for by the NHS - loved her hospital stay, well supported at hospital and at home. And my great Aunt, her Aunt, was an amazing midwife then health visitor who was incredibly useful to mum and then to me (when she was in her 80s) as a fountain of knowledge, support and advice, particularly wrt breastfeeding.

My mum wrote an article for mother and baby or similar magazine. Wish I could find the clipping - think my brother might have it actually. Was all about his first year, baggy knees and dolls' clothes!

I think that until he was about a year he was always slightly skinny, but not like the skinned rabbit mum says he looked like at birth. Then from about 1 year old he actually looks positively chubby in baby photos.

Height-wise, he is maybe 1 inch shorter than my middle brother who was born at 8 pounds a week late. I would say that he has a slightly stockier build though - which all comes down to genes rather than how he fed or how much he weighed at birth. He is the average height of a british man, and was always going to be that since my father, and maternal and paternal grandfathers were not especially tall. His is entirely as he should be heightwise and IMO what he would have been even if he had beena 10 pounder at birth. :)

Re: the sickiness, ds2 (my third) was spectacularly sicky until he was just shy of his first birthday. He is now nearly 2 and I can count on one hand how many times he's thrown up since then. He has a slighter build than my older two, but is longer so perhaps just looks thinner. Has nver really had creases, even though he weighed 7 pounds when he was born.

I suppose what I'm saying is that what you've described doesn't alarm me. He sounds very content and happy, and the peeing and pooing sounds textbook too. When you introduce solids you can try and maintain the high fat content of breastmilk by adding fat to foods. I used to, with ds2, make stews into creamy stews by adding a dollop of creme fraiche and his favourite food ever is pasta with cheesy creamy sauce.

StillFrazzled - Thanks for your answers. It doesn't sound like anything is glaringly wrong (e.g. if you were only bfing for 10mins each sides every 5 hours) and you do sound like a responsive, in tune with your baby, mum.

If your DS is feeding every 2.5-3 hours (which sounds fine TBH) what happens if you offer earlier, say after 1.5 hours, does he take a feed (small/usual size/bigger than normal) or does he refuse?

If he does take a feed, does he then go his usual 2.5-3 hours before requesting the next one or does he feed as though the offered feed didn't happen (i.e. 1-1.5 hours after the offered feed)?

What are his cues for feeding? Licking lips, mouthing, wriggling, crying, arm waving, sucking fingers, 'milky' noise, or something else?

On the weaning front, DD3 was very under weight due to bronchiolitis multiple times in her first year (born on 91st and down to 2nd%ile). I answered a post in Weaning on what we started her on (was mixture of BLW/what we ate/most calorific food ever) that might give you some ideas for when the time comes. She now back up to around 25th%ile at 19m though she is still only 9.8kg up from 3.9kg at birth.

Also, totally recommend Charlotte/Analytical Armadillo - she is a fantastic BFC and really knowledgeable - one day I hope to be half as good as her

Thanks for the vote of confidence and excellent weaning tips, everyone

Truth not sure about the answers to some of these, but have noticed that when DS2 is offered the breast soon after a feed (like a day or so ago, when he was whinging and I wasn't sure what was wrong) he'll feed a bit, but in a fairly desultory fashion. And the next feed will be a max of a couple of hours later. So we might get an afternoon of snacking rather than proper feeds.

Cues start with looking a bit anxious and the 'chat' getting very intense, progresses to finger chewing, and literally two minutes after that will be full-on yelling. He doesn't have a lot of patience!