Well, as I read  posts about getting babies to breast in the NICU, I guess I
will quit being depressed, thinking we are moving along too slowly.  Maybe
we're further ahead in our unit than I thought.

If a mother has chosen to breastfeed (and most of our mothers do choose this
after a little education) we watch the baby for feeding readiness as well as
health status.  Now, let's be realistic.  Just because a baby can be held,
doesn't mean he is ready to breastFEED.   A 700 gm premie on a ventilator
MAY be stable enough for the mother to hold skin to skin at the breast,  but
even if the endotracheal tube did not prevent breastfeeding, the baby does
not have the maturity or stamina to coordinate suck, swallow, breathe.  At
that point, most babies are being given total parenteral nutrition
(intravenous)  and graduate from that to gavage feedings accompanied by
"thumbie" pacifiers to stimulate their suck reflex.  That's if the baby is
lucky enough not to need vasopressors, chest tubes, a high frequency
oscillating ventilator, paralyzing drugs, insulin drips, surgery, etc. etc.

As the baby improves and matures, we  progress to non-nutritive
breastfeeding, based on a protocol, and from there to nutritive
breastfeeding. No bottles are introduced for at least one week following the
initiation of nutritive breastfeeding: ---bottles are NEVER offerred before
breastfeeding and attempted breastfeeding is NEVER followed by a bottle.
Thereafter breastfeeding progression is dependent upon the infant's illness,
gestational age, post conceptual age, readiness to nurse, mother's
preference and availability.  This is based on a protocol which can be
overridden by a consult by our OT or a lactation consultant.  Nowhere in our
protocol does it state that a doctor's order must be obtained, yet it was
approved by four neonatologists and three neonatal nurse practitioners.

We sometimes put breastmilk on a 4X4 by the baby's nose so the baby gets
used to the smell of his own mother's milk.  If the baby shows no
willingness to root or suck, oral stimulation is done with the mother's
finger  if the baby is to breastfeed.  It is done with a pacifier if the
mother has chosen to bottle feed (preferably EBM)

EBM is the preferred milk for supplementation by gavage, sometimes
fortified, and if a mother and baby are able to breastfeed well enough NOT
to need gavage supplements,   yet some fortified human milk is necessary, we
offer the mother the opportunity to choose an SNS if she would like, rather
than adding bottles.  A written discharge plan is worked out with each
mother and we make  a followup call the first week.  A referral to the
outpatient lactation clinic is made if the dyad is discharged before total
breastfeeding is achieved.

By the way, Danny, I just realized that the quick reference I sent you to
our protocol, is the old one and doesn't agree fully with the algorithm.
(dumb me!)  I could tell you briefly the changes if you want.

This is a simplified version of a very complex process.  I think that any
mother who chooses to cuddle up to an electric pump for months to maintain a
milk supply for a  sick baby,  hoping the baby MIGHT eventually be induced
to breastfeed after a whole lot of negative oral stimulation,  needs our
congratulations and a major pat on the back.   Having a baby who needs the
intensive care unit is certainly is not the ideal way to begin a successful
breastfeeding relationship.  The very equipment which has the potential to
save the baby's life, interferes badly with the initiation of breastfeeding.
Even if the baby were 100% healthy,   immaturity and fragility alone make
initiation and eventual success of breastfeeding a real challenge.
Sometimes the residual problems left by prematurity makes breastfeeding
difficult.

At any rate, I have to stand up and defend those of us who kill ourselves
trying to help moms preserve breast milk volume and the breastfeeding
relationship for those babies in danger of losing their lives without modern
technology.

Climbing down off my soapbox.
Deanne

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