Does "topping up" give a false impression of weight?

[Amanda3266]

This week I have been seeing a baby newly discharged from the special care baby unit.(I'm a HV for those who don't know) He was there as he had been born at 33 weeks.
The special care staff "topped up" his feeds with formula even though he was breast feeding. I do understand that they have to ensure a certain number of calories but it seemed he was being given lots of formula even though Mum wanted to breastfeed. They apparently even gave a complimentary feed the day he was discharged.
I went in 3 days later. He had been weighed just before discharge and was 4lb 7oz. Mum requested that I weigh him again when I found he had dropped 2oz. I repeated the weight 4 days later as his Mum was anxious and he'd lost a further 0.5oz. It took a great deal of persuading to reassure his Mum that what he was getting from her breastmilk could not be obtained from a bottle. I offered to re-check his weight today and he had regained 1oz. Hooray - so his Mum felt much happier.
I really feel that his weight was influenced by the fact that they had given so many extra formula feeds in hospital that breastfeeding was not established when he went home - hence the weight loss. Is this common practice everywhere?
It seems madness - if a baby is premature surely the breastmilk is more precious than ever. I know they have to give a certain number of calories but even so - surely they could have helped his Mum with expressing milk and given this first. From what she says they rarely offered this option. So he went home with breastfeeding scarcely established - it seems neglectful to me.

Rant over.

don't get me started on this topic!

DS was regularly topped up with 60 mls at a time (he was quite badly jaundiced, under lights etc). I really wish somebody had told me that regular 60 mls formula tops ups meant he was essentially being formula fed. Similarly to your mum, I was discharged with bfing scarcely established, and then DS ended up back in hospital 10 days later as the jaundice had returned and he had become dehydrated. I couldn't agree more re: the formula top ups making bfing go pearshaped.

I was vaguely told to try and express often but not offered any practical support (like bringing me a clean breast pump). I know I sound like a wuss, but I had a tough time after the birth - urinary retention, catheter for 36 hours, and on a gruelling regime of bf/top-up/express 3 hourly so I think I would have benefited from more assistance from HCAs.

Amanda, you are in a good position to have some sort of dialogue with the SCBU about this, in a prof capacity.

Unless this mum has been expressing about 8 times/24 hours since the baby's birth (and I bet she hasn't - so few SCBUs really support this), it is highly unlikely she will now have a good breastmilk supply (I am guessing the baby is now about term?). A 33-weeker is prob not able to take anything like all his nourishment direct from the breast - the co-ordination of sucking and swallowing doesn't take place until later - so the baby would definitely have needed EBM on top of whatever he could have got at the breast.

Yes, knowing the baby has had a certain amount of calories can be important with pre-terms - giving measured EBM would have allowed this. In fact, she would prob have produced more EBM than the baby needed, if she'd been expressing often enough. No matter - it could be frozen, and it can't be emphasised enough, fewer than 6-8 times a day expressing (and the night time expressings are really important) and the breastfeeding may not get established and maintained. The idea is to fool the body into thinking it needs to produce milk for a term baby, so the expressing has to mimic this.

Anyway, if the mother is using the breast direct, then it would not be at all surprising for the baby to lose weight - the milk is just not there, and will not be there unless she starts removing it, one way or the other, effectively, 8 times in 24 hours. I would actually be very concerned about this baby, and the milk supply...the baby should be gaining weight like billy-o now, not losing it (and I would not be overjoyed by the 1 ounce gain - unless it really is the start of a turn round, and you can't tell yet). The baby should be skin to skin with mum 24/7 if poss, and she should be putting the baby to the breast at every possible opportunity - and someone should check the baby is not just at the breast, but is actively transferring milk. Ideally, she needs to see a clinical lactation expert, but there are hardly any of them! The baby should be pooing several yellow poos every day, and weeing plenty.

It's good she has you rooting for her, Amanda

With a bad start, though, and that poor support in the SCBU, and her low confidence, it will take a massive boost for bf to be saved, to be honest. Physically, it is probably possible to save it. Emotionally, it may be more difficult.

Whatever happens, the SCBU need to know how to support pre-term bf, and they seem not to.

All mums whose babies are admitted to our SCBU (preterm and term) are asked whether they wish to express milk for their babies as it is much better for them to receive breastmilk. For mums expressing for preterm babies, they are advised to express at least 3 hourly. Mothers who are unable to produce much milk or whose amounts are dropping are prescribed Domperidone 10mg 3 times a day. The brand name is Motilium and it can be bought over the counter. It's primary use is for bloatedness but a side effect is it increases prolacting levels.
Usually babies would be on all breastfeeds before going home.
When babies are given regular top-ups I would advise expressing to boost milk supply then reducing formula top-ups by an ounce at a time over a few days. The management does seem poor Amanda. Will you raise it with the hospital? Do they have a breastfeeding co-ordinator?

Thanks for the replies. Yes I am going to raise it with the hospital - it is poor management. One of the reasons I felt really happy to advise this mum not to "top up" was that her baby was weeing loads and pooing fairly well. Because of this I felt confident that the weight loss was just a blip which would correct itself once the baby had adjusted to the fact that extra calories were not coming from elsewhere. This Mum says she never breastfeeds for very long, usually 8-10 weeks or so but to lose these precious weeks due to poor management in the hospital seems appalling. I am sure that this baby will now gain weight - Mum is committed to giving the 8-10 weeks she wants to give and I've reassured her that she's giving this baby the best start possible - you really cannot get this from a bottle. (This is not a dig a bottlefeeders as I am a failed breastfeeder who bottlefed). It's just a shame that the SCBU staff didn't seem to realise this.

Keep us posted, Amanda

sorry about my unhelpful rant Amanda. best of luck to the mum and her baby.

Amanda, I know I've said this before, but I wish you were my HV

I found that in hospital, they were very keen to "top up" with EBM even thought it was clear to me that 33 week old ds2 was feeding well at the breast. They would insist on topping up with EBM and he would just throw up. Also they insisted on giving him breast milk fortifier which is derived from cows milk. I didn't know this and if I had, would have been against it as ds1 and ds2 both suffered from allergies to cows milk/cows mild formula.

Yes, yes, yes. Weighed this baby today and he's gained 5lbs and still breastfeeding like a dream.

On a more annoying note I haven't had any response yet to my letter sent to the hospital asking about their breastfeeding policy and pointing out that babies were leaving special care without being allowed to establish breastfeeding.

Will ring them on Tuesday if no response by then.

Good news about the baby, Amanda, but surely you mean 5 ounces and not 5 pounds!!!

Keep on at the hospita!

Yep - meant 5 ounces .

Sorry to butt in on your conversation, but I have to add my 2p worth. I used to work on the post-natal ward of my local hospital doing nights, where it was common practise to give top up feed to term babies! Even when the mothers had specifically said they wanted to b/f the mw would give them a "quick boost" so mum could get some sleep after labour. I thought it was appalling. I didnt let my dd2 leave my sight whilst I was in there and asked to be discharged 8 hours pn (dd1 born somewhere else).
I am in process of trying to get local nct to take this up with midwifery manager, but keep reaching dead ends. No-one seems to have the balls to tackle the problem. Not all of the staff were the same, it's the luck of the draw as to which mw is on duty as to the care you get unfortunately.