Dear all

I'm assisting a mom in England who has just given birth to triplets 
at just over 31 weeks, and they're a week old tomorrow.  Pretty 
fantastic birth weights, 3 lb 15 oz (1786g), 4 lb 3 oz (1899g) and 
4lb 5 oz (1956g) and they are all well.  Mom and family members are 
providing skin to skin, when possible.  Mom has a history of being 
very dedicated to exclusive breastfeeding previous babies, and is 
very well informed.  But she has IGT and had arranged to have banked 
milk available for the triplets, which is about to run out.  She is 
also, of course, providing her own EBM, to be fed by NGT. Mom is 
happy to take the unprecedented step of paying for more banked milk 
from a registered milk bank (which would usually be available on the 
NHS for babies under 31 weeks and weighing less than 1500g) but the 
milk can only be dispensed if the clinician caring for the babies 
actually orders it, but to date, he wont.  Two of the babies are 
currently 13% under birth weight.  The neonatologist has told her:

1.  That pre-term formula would be better in terms of calories and 
minerals than banked milk.  That the babies are _not_ considered low 
birthweight because they are normal good birthweights for their 
gestation, although they are considered pre-term. If they were low 
birthweight he would be more cautious in recommending formula due to 
associated stresses linked to IUGR, which would make them more 
susceptible to problems like NEC.  But because they are only pre-term 
and very healthy, he wants to maximise early growth, calories etc.

2.  The neonatologist would condone the continued use of banked milk 
if the mom allows the use of Human Milk Fortifier.

3.  Due to the weight loss, staff are wanting the mother (and other 
family members, eg dad and big sister, aged 14, when they are there) 
not to provide kangaroo care for the babies.  The smallest baby had 
actually been breastfeeding well, visible swallowing and sustained 
sucking bursts, and mom is naturally disappointed by this.

4.  The babies will not be discharged from the hospital until 34 
weeks CGA, at which time mom intends to take them home and 
breastfeed, supplementing with informally donated breastmilk as 
necessary - the hospital having indicated that she may not use this 
milk she already has stored at home, for feeding while in their care.

Can anyone help me with more refs, which would hopefully be 
acknowledged by a neonatologist, to help this mother achieve her own 
goals for her babies, which are; human milk feeding (ie banked 
pasteurized milk) while they are in the hospital, in preference to 
pre-term formula.  For babies of this age/weight, is human milk 
fortifier medically indicated? (LN friends will remember that I've 
written about this on LN before, since the pre-term babies I've 
worked with have only had Vit D and calcium - and later, iron - as 
individually prescribed supplements, while receiving more and more 
EBM to pile on the weight....)   And would you agree that S2S and 
KMC, and of course direct breastfeeding according to babies' energy 
levels, can only be of value to the babies' well-being, weight gain, 
oxygen levels etc etc?

I have already sent links to:
    * the protocol from the Great Ormond Street Hospital, 
http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/enteral-nutrition-for-the-preterm-infant/ 

    * The WHO Essential Nutrition Actions guidance, section from p 15 
on feeding pre-term 
infants, 
<http://www.who.int/maternal_child_adolescent/documents/9789241548366.pdf>http://www.who.int/maternal_child_adolescent/documents/9789241548366.pdf 

    * WHO 2011, Guidelines on Optimal feeding of low birthweight 
infants in low-and middle-income countries, 
<http://www.who.int/maternal_child_adolescent/documents/9789241548366.pdf>http://www.who.int/maternal_child_adolescent/documents/9789241548366.pdf 

    * the ABM protocol on feeding late pre-term 
babies, 
http://www.bfmed.org/Media/Files/Protocols/Protocol%2010%20Revised%20English%206.11.pdf 

    * Nils Bergman's Kangaroo Mother Care weblink 
http://www.kangaroomothercare.com/

Anything else that you would recommend for babies of these kinds of 
weights and this gestational age? With links, please, so that my 
client can easily share them with the neonatologist?

Thank you so much.

Pamela Morrison IBCLC
Rustington, England







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