tiktok, bfing gurus, bfers, interested parties of all creed and colour... heyulp! bfing a preemie baby... top tips please

[Aitch]

don't know where to start, really...

dd is two weeks old today (blimey) and put on her birthweight on wednesday so that's great. however of course she didn't start putting on weight until her formula top-ups, topping up with ebm didn't do the trick.

her weight gain today was only 30g (last few times has been double that or more) and i do put that down to the fact that i've been pumping more and therefore have been giving her more ebm top-ups than formula.

question is... what's the tipping point? she is gaining, i am producing more milk (not heaps, but volume-wise we are on target for the SCBU calculations). we were told to give dd 280mls per day in top-ups as well as bf, but with the formula it's been more like 350ml.

so do i accept the 'slow' weight gain and think of dd's longer-term benefits having protected my supply, or do i want her on formula but with more energy to feed, iyswim?

midwife has suggested one top-up of formula, and at the next topping-up with ebm, this seems like a reasonable compromise to me, but am i missing something.

Good stuff - hope you get some results now. Did you see the paed consultant when you were in, or more junior staff?

i saw him after i put in a complaint about one of his juniors...

at paeds, they should know better. Good luck with the complaint.

Have just been having a look at the medical literature on preterm breastfeeding to see if there're any pointers. On a quick look (have limited time), this one looks promising.

"Transitioning premature infants from gavage to breast."
Neonatal Netw. 2008 Jan-Feb;27(1):7-13.

"Breast milk provides physiologic and neurodevelopmental protection for premature infants. Most hospitals are breast-milk friendly, but the number of premature infants breastfeeding successfully at discharge is relatively small. There are evidence-based techniques to improve the odds of premature infants breastfeeding at discharge and into the first year of life. Measures that help the infant make the transition to the breast include kangaroo care, nonnutritive sucking, avoidance of bottles, and consistent and supportive staff. A guide to management of the transition process is provided in this article."

That's just the abstract - will see if I can get hold of the full article if you like.

So, kangaroo care and non-nutritive sucking - this seems to suggest lots of skin-to-skin contact and time at the breast even when not actively feeding.

Avoidance of bottles - you're doing that as far as is practical.

Consistent and supportive staff - I guess you're working on that one....

mspotatochip, the annoying thing is that in some ways we're ahead. For some time now, we have had protection in law for public breastfeeding, so ahead of England ( Scotland also give the same protection.) But visit a hospital and they're great for lip-service but shockingly bad for practical help. When I had ds2, I was in a ward with 4 other girls. Four of us were bfing. 2 days later, only 2 of us were still bfing. The other 2 had latch trouble and all the MW's did was hand them bottles of dextrose! I was trying to help the girl beside me but then I got moved to a private room. I heard afterwards that she was very upset because I was the only one helping her.

Hi Aitch congratulations
DS born at 31 weeks as on a drip for a couple of days and I was told just before my milk came in if it did not come in soon they would formula feed him. I did not want this and had given instructions not to formula feed. I pumped like a (can't think of a pumping analogy) good un and it came in.

DS was tube fed and when I was there for one feed I saw the "fortifier" he had already been given it and asked what it was and was told it was extra vitamins for premmies so I agreed to it. I was then transferred to my local hospital and asked about the "fortifier" for my EBM and was told "it is just formula powder" don't know why they do it we just add ready made formula on a 50/50 basis to your EBM. Now I was a wee bit annoyed about this as that is not what I had been told initially.

They also said in new hospital I don't know why you are adding it anyway - we wouldn't bother. So conflicting advice all round. Basically I then did what you are doing pumped/fed pumped/fed ad infinitum. You will get there and so will your DD congratulations.

MY DS was prescribed multi-vitamins/sytron and folic acid though I was not formula feeding.

Hope you are getting some answers from the paed. Agree with everyone else that SCBU just like to see the mls go in and get very twitchy about direct bfing because you "don't know how much they've had" (ds born at 34+3 due to PET). I was really lucky that my hospital had a milk bank, so I had donated bm to top up my initally woeful attempts at expressing. Thanks to the wonderful women who donated, ds didn't need formula top ups - maybe you should take WMMC up on her offer!

I can only go on what I was told by SCBU, but sounds like the advice you are getting is pretty standard. Ds was "allowed" to be put to the breast every other feed from about 36 weeks (he was poorly and was in SCBU for 7 weeks, despite being a 5lb4 bruiser), ie every 6 hours, was always topped up by NG tube regardless of how well he fed. Because he was in for so long I had plenty of time to build up supply and was fully bfing before he came home, but I would have been terrified bringing him home as early as you have - it sounds like you are both doing amazingly well.

You are probably already doing this, but I managed to up my supply by 1) turning the pump up until it realy hurt (not sure whether to recommend this ), 2) pumping not less than every 2 hours during the day and not less than 4 hours through the night, at least 8-10 times a day. Took about a week of doing this to be able to supply all the feeds myself. Must be bloody hard work with a baby and another child at home though.

Aitch, hope you are doing ok and thanks for filling in some detail on your dd. Fww I believe that the protocol in our hospital was that if babies (both those born under 32 weeks and growth restricted babies) were breastfed then they did not recommend supplements or high calorie formula unless weight gain was consistently poor or there were other challenges (eg needing oxygen or babies with cardiac problems) although they were all prescribed certain vitamin supplements at discharge. I was told by a consultant neonatologist that in the past weight gain to "normal" range was a much bigger focus than it is now - now it's thought that attempting to bulk up low birth weight babies adds to the risk of developing diabetes in later life. DD was on the 9th centile at discharge at 36 weeks gestation, and stayed there until around 4 months past her due date. No one seemed to have a problem as long as she was well in herself and gaining a bit.

I would honestly be surprised if you were prescribed fortifier outside hospital- I suspect due to concerns about correct usage.

Hi Aitch, DS was 6lb 5oz at 35 weeks (huuuge, I know), but wasn't very well at birth and wasn't well enough to be handled for a couple of days, and didn't start going to the breast till 3 days. They didn't say anything about limiting time at the breast, just to feed him as much as possible. Mind, he got no followup care or vitamins, so who knows whether this was a good care example or not

Have you looked into switch nursing ? By swapping breasts several times during a feed they stimulate your breasts more, and take in more as the inital flow is stronger on each swap

i've been switching. dd is feeding much better so have pretty much abandoned the 15 minute rule however... i am fretting that she's looking skinnier about the cheeks. no answer from teh paed but am going to quiz him relentlessly about how quickly dd has to gain weight. i've been switch feeding, as it happens, as much as anything else cos dd often settles better if she has a wee shot on one then a longer, more relaxed on the other. (dd1 thinks that one is hot milk and the other is cold).

Aitch, when I was battling to get bf going with dd1 and she wasn't gaining weight, I did quite a lot of reading around to try and find out if there was some sort of minimum acceptable weight gain.

I found absolutely no helpful info in the form of "a baby must gain X amount of weight per week or they're at risk of harm".

I did find a growing concern in editorials and the like, that fattening babies up to conform to centile charts was possibly messing up their natural weight regulation with possible implications for weight control in adult life.

This was all very speculative for the most part, although one reliable-looking study showed that more rapid weight gain in term babies in the first 2 weeks was associated with increased cardiovascular risk factors as teenagers. So more is not necessarily better.

The current thinking seems to be that on balance a slow weight gain is preferable to an artifically quick weight gain.

This gave me the confidence to ditch the top ups with dd1 even though she looked skinny. In retrospect this was the right decision because dd1 is now 4 and still long and skinny - it's her natural body shape. But at the time it was more of a "lesser of 2 evils" thing and I was aware that I could be wrong so it was nerve wracking.

In shoes I would interrogate the paed about what their absolute baseline criteria would be for worrying about dd2, and ask for justification for each one. For example, if they say "a minimum of X oz per week" ask why. Ask how they arrived at that figure. Ask what dd2 is at risk of if she doesn't put on that amount of weight.

I suspect you'll find that a lot of these criteria are pretty arbitrary tbh.

Aargh at "in shoes" - meant to be "in your shoes" - I don't think it's particularly vital to be wearing shoes while talking to a paediatrician.

i'll try to be in heels, all the better to intimidate.

yup and yup, am going to quiz about this, i got very wound up by the weighing with dd last time (which in a weird way led me to BLW etc so it's not all bad, as i SO rejected the 'get x amount in' thesis).

also wellie, so sorry for not answering your email, thanks so much for sending it... and i'd love to see the full paper if you have it. i like the paed guy, but even my mate who's a paed is not that informed or even enthusiastic when it comes to bfing. and my gp, god love her, is positively negative about it because of the fact that she never got the opportunity to do it with her (oxbridge educated) kids. i think getting an untarnished view of such a sensitive, as well as medically and emotionally complex subject, is a big ask. funnily enough, despite the many complaints i read on here about the oppositional nature of the bfing threads, i have accessed more info here over the years than i'd ever have been able to get in RL.

Heels are good.

Sorry, I know all of my post is stuff that you already know perfectly well. I suppose what I was really saying was, don't lose heart. Which I think can happen when you're all upside down from having just had a baby, and other people are trying to scare you into doing something that doesn't feel right to you.

Will see if I can get that paper for you - might take a couple of days though - it doesn't seem to be available online.

On no account are you to reply to emails - dog knows you have enough to do right now.

Agree with you about MN - I've learned a huge amount here and I think the depth of discussion here beats other sites hands down. Not naming names or mentioning ticker tapes....

Cross posted.

If it were completely up to you, what would you do? ie, just looking at dd2, what seems right to you?

Good luck with the weigh-in, boy do I remember that dread.

heard back from the paed.

"Thanks for your Email
Im not against this per se however we normally give this on the unit to babies who are getting enough breast milk but have a greater need for these supplements due to prematurity under 34 weeks. It would also need to be prescribed for you.
We should discuss whether you need this with your midwife as it would be unusual not to have enough breast milk to allow babies to grow but still have enough to fortify, if you see what I mean. As you say, it is not really any different from giving formula in this instance and formula would overall give dd2 more calories, which is really what she needs at present as well as the overall fluid volume which is also important (the extra phosphate and calcium is not the main issue here).
I will have a chat with your midwife this week and contact you before I am due to see you next week in my clinic (wednesday afternoon).
Sounds like you are both doing well however, if she has regained her birth weight and that is good news.
kind regards"

any thoughts? am bricking it about dd being weighed today... hate this feeling.

LOLOL i reported my previous post cos i'd left the names in, then reposted without and MNHQ has deleted the wrong ones. hungover again, i'll be bound...

i don't know, wellie, that's the pisser about all this. she is feeding better, longer etc but WHAT IF SHE'S NOT PUTTING ON WEIGHT? and what does that even mean, what's the minimum that they want? what actually constitutes slow growth (particularly bearing in mind that even on formula top-ups my previous dd didn't make up her birth weight until she was five weeks old).

If DD1 was a slow grower, then it would make sense that DD2 could quite possibly be like that too ? As long as she's putting on weight, then that would seem to be the main thing. I have a friend whose DT2 is tiny, and always has grown very slowly, even though she was fully formula fed from birth and was on high calorie milk - its just the way she is, and at 2 is very delicate.

I've just been looking at pictures of DS in his first two weeks, and I think his cheeks look thinner at 2/3 weeks - my theory is that all the exercise in feeding brought them in.

By switch nursing I mean 2,3 or more goes on each boob per feed - if you know she normally feeds for 20 mins, take her off the first after 5, then the second after 5 etc. Or you can just swap after her initial fast sucking slows down each time.

right, will do, i think i was just offering both breasts a couple of times. anyhoo, what do you think i should do? sounds like he's going to say 'it's a bad idea because' to the midwife.

I would just stop and look at dd2 for a bit. Is she alert, active, responsive? If she is, that would reassure me a lot.

The fact that she's progressing with feeding sounds great to me. If she was running out of energy, she wouldn't be feeding well. And if the milk's going in, she will grow.

She's had an excellent weight gain so far and I think that's a good bargaining chip for you. If her weight does a bit of a wobble now, you have a bit of time on hand before you need to take action.

Remember also, weighing is such a random activity in a little baby because one good feed will give them a fantastic weight gain, and one good poo will set them back weeks. And remember what St Tiktok always says about differences between scales. I would be really, really reluctant to make big decisions based just on a weigh-in.

I think that I'd just ask what the parameters are: what is the minimum weight gain she needs to be healthy. What is the target weight gain for her percentile, and what is the general plan (ie, tailing off top ups, going to a less frequent weighing which will be more accurate - 30g is 30ml of wee after all).

If she's gaining, weeing, pooing, alert etc, then theres no immediate issue is there, so perhaps taking a deep breath, asking to weigh less, and maybe doing a bit of hand expressing after pumping to get that milk thats hardest to pump out as its the thickest and giving that first as top up, could be a plan ?