Breastfeeding premies is tricky. Babies all develop at different rates, and
development is rarely always in a straight line going up. I tell parents, and
nurses, and residents, that just as 12 months is considered the 'norm' for
walking, but that some infants walk at 9 or 10 months and others not until 15
or 18 months and all are within normal range, so there is a 34 week 'norm'
for adequate oral feeding. Yet not all babies are ready to feed at 34
weeks.Just like in walking, you have to look at the WHOLE child. There are as
many variations on feeding readiness as there can be differences with
premies. Basically, I like to put a baby to breast as soon as their medical
status, temp and HR/RR is stable, whether they can take nutrition from the
breast or not. It is good for the babies, and good for the moms ( increases
prolactin levels and volume of pumped milk) I heard Paula Mier speak last
year and she called this recreational breastfeeding- a term I like to use,
and the Mom's and staff seem to understand and like it also. I also explain
to mom (and staff) that to breastfeed well an infant must have adequate
behavioral states( alert and awake long enough), strength and endurance, and
organized sucking and swallowing skills. Most premies do not have all these
skills at 32-34 weeks, but some do. Some babies don't click until 36 or more
weeks. But I tell the parents that until these all come together, the baby
must practice on the breast. I don't know if the analogy is totally correct,
but I emphasize that for premies, breastfeeding is a skill as well as a
reflexive motor response, and that skill must be rehearsed as much as
possible, just like learning to swim or to play an instrument. Of course, if
the infant looses weight, the medical staff immediately blames it on too much
breastfeeding and restricts the moms to once a day- grrrrrr (when I do a lot
of teeth gritting  to remain calm). The only thing I would disagree with is
about not to gavage past 32 weeks. I don't think you can put an arbitrary
date on when a baby should not be gavaged. If a baby is 33 or 35 weeks but is
unable to stay awake long enough or at all to breastfeed, why bottle feed?
Just gavage the poor child. Uses less calories and avoids the artificial
nipple. Of course there are many babies who don't get to breastfeed or whose
mothers are rarely present, so they get bottles of ABM, unfortunately for
them. My biggest beef and frustration is with moms who are present and giving
a wide awake baby a bottle of expressed breastmilk- because they are under
the misconception that it is "easier for him and I know how much he is
getting." It is really hard to talk them into putting the baby to the breast.
I am getting to them too late in their stay. Sorry to go on for so long, but
this is a topic I feel very strongly about.

Just a note on circumcision- For Jews, circumcision is prescribed  in the
bible. The Hebrew word for circucision is "brit" which means covenant. This
refers to the agreement between God and the Jewish people,  " And ye shall be
circumcised in the flesh of your forskin, and that will serve as a sign of
the covenant between Me and you" (Genesis 17:11). My own son's Brit Milah
(circumcision ceremony) was much much more than a whacking off of body parts,
but was a reaffirmation of our heritage and faith, a continuation from one
generation to another of the passing of our beliefs to the next generation. I
think most Jews will acknowledge this for their sons, also. Throughout the
ages, circumcision was practiced only by Jews (do muslims circumcise their
sons?) and men who were circumcised were identified as Jews and persecuted
becuase of their faith, from the time of the ancient greeks through the
second world war and the communists regime. But enough. Why non- Jews are
circumcised I don't know, but I do know that it takes 10-15 times longer (and
looks 10-15x more painful,) in a hospital than it does  in a Jewish ceremony.
 I don't really think this is the proper forum for a discussion on
circumcision, I just wanted to clarify this is terms of perspective.

Debbie Rabin, OTR, CLC
Los Angeles ( where Lactnet was the only thing I dragged myself out of bed
for every day during six days of the flu and 102 temp this past week).