Tricia,

Great case history.  This is going to be based on my own experience working
with IUGR babies and babies who gain inadequate weight, FTT etc. and
working closely with the paeds of these babies.

Firstly, you've done well.  Very well.  We used to feed these very
underweight babies up to 280ml/kg/day, ie breastfeed first if they could,
then top up with any EBM if available by bottle.  Yes, wake the baby every
3 hours (maybe one longer period at night if everyone is sleeping) and you
can bottle-feed a baby in his sleep (they will suck and swallow without
waking up...)  but the most important thing is to get the milk in at least
8 times in 24 hours and as much as he will take!
There IS some concern about an underwieght baby getting too "fat" and
suffering obesity later, but all the studies I've tried to find on this
have not been clear about what the baby has been fed, and I strongly
suspect that when it's breastmilk, or even breastmilk with formula- top-ups
then it's different.  I've managed to follow some of these babies up for
several years and they did not turn out to be obese children.
Some of the babies I worked with gained as much as 76g/day (as do prem
babies when you feed them enough) and what you're aiming for is to have the
baby achieve catch-up growth - to reach the weight he should have been if
he hadn't basically been starved - asap.  So you could check on the WHO
growth charts to find out what would be "normal" (say the 50th percentile)
for that corrected age for that baby and aim for that.  Also my experience
is that the baby will not breastfeeding effectively (sometimes he will, but
not consistently, as you describe) until he HAS achieved that catch-up
growth - it's the weirdest thing - but IME it's consistent.  At the same
time, when they start getting enough food, they become impossibly greedy,
and should be responded to.  You will find that the appetite will calm down
when he nears the catch-up weight.   I don't think the paed you describe
has a lot of experience with this!

Sorry so rushed, wanted to get this off to you!

Best wishes

Pamela Morrison IBCLC

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