Dr Wight wrote, "We have ample evidence that breastmilk alone is
insufficient for optimal (definition here the problem) growth in the tiniest
infants (<1500 gm).  I do not want to see the osteoporosis, rickets poor
weight gain, and slow head growth come back."

I'm not a Neonatologist so it is not my responsibility to set the protocols
for what these tiny pre-term babies should be fed.  But sometimes I am the
LC helping the mother initiate/maintain lactation for some of these tiny
babies, and then to have the pleasure of eventually helping mom and baby
learn to breastfeed.  I sometimes work with babies born at 26 - 28 weeks
gestation, who weigh as little as 600g - 900g.  One of the most challenging
was a baby girl born at 31 weeks who only weighed 800g.

My observation is that the very tiny/sick premies are often on a drip for
the first few days of life, during the time that the mom's milk may have not
yet "come in". This means that they don't receive other milks anyway. Once
the baby is ready for tiny amounts of EBM the mom is producing plenty, and
the paediatrician starts calling for milk - e g 2 ml every 2 hours, then
graduatng to larger quantities, e g 13 ml every two hours (the amounts are
always very specific and individually tailored) - sometimes back-tracking if
it is found that the baby is not digesting all of it, and increasing once
again as the baby's condition improves.  It can be very up-and-down
depending on how the baby is responding.

But eventually the baby stabilizes and the mom continues to provide the EBM
which is fed to the baby by naso-gastric tube in the amounts and at the
times which the paediatrician works out for this particular baby.  Human
milk fortifiers are unknown in Zimbabwe and are simply not available.  So
the baby continues to receive EBM and I have never heard of anyone
suggesting that the mother skim off the cream so that the baby obtains a
high-calorie milk - the milk is expressed and stored in bottles in the
fridge, it's shaken and warmed and the mom measures it out and pours it down
the baby's tube, every 2 hours, or every 3 hours, dependng on the baby's
weight. So the milk is given just as it comes.

The very small babies are given extra Vit D, and later extra iron, but *no*
other supplements are given unless the mom's milk supply dwindles below what
the baby requires (this hasn't happened with the babies I've worked with
from birth but it sometimes happens later, and I get to work with these moms
too sometimes, to increase their supply - which is not difficult actually
but in the meantime they are fed whatever EBM the mom is producing, and
topped up with standard common-or-garden formula).

As to the quantity of milk, the babies start out receiving very individually
tailored quantities of EBM, but eventually the protocol is 150 ml/kg/day,
then 180 ml/kg/day and then working up - to as much as possible I guess.
Depending on the baby's age and weight the mother is encouraged to start
putting baby to the breast at about 31 - 33 weeks corrected gestational age
and around 1300g.  Once this happens there is often a change-over period in
which the baby is having some breastfeeds and some EBM (by naso-gastric tube
at first and later by cup, or cup and spoon) until s/he is breastfeeding
well.  The babies are weighed every other day, and are discharged at 1800g
or 1900g if they are breastfeeding well and otherwise fine.  None of the
babies I have worked with has been older than his/her due date at discharge,
it's generally when they have reached an effective gestational age of around
36 weeks.

Since VLBW and ELBW babies in Zimbabwe are fed unfortified-EBM and the only
supplements are Vit D and iron, with the result that they grow well and are
discharged usually well before due date, I don't think the blanket
conclusion can be drawn that breastmilk alone is insufficient for these
babies.  Sometimes
I work with some prem babies referred for poor weight gain several weeks
after delivery so I know that this is a possibility, but I have never known
of a case of rickets or osteoporosis in one of my baby-clients. Perhaps a
more likely cause of these conditions is poor support for breastmilk-feeding
during the critical first couple of weeks after delivery when it is so easy
to allow the breastmilk supply to dwindle because the baby is taking such
tiny amounts.  Would it not be more likely that poor lactation management,
rather than the breastmilk itself, is the cause of poor growth, rickets,
osteoporosis etc.?

Pamela Morrison IBCLC, Zimbabwe
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