Once again, I need some advice. I don't know what I would do without your
collective wisdom and experience. I have permission to ask these questions.

I am working with a mom who delivered twins at 35 4/7 weeks gestation. The
baby who is causing concern is a little girl--her brother, the bigger twin
is doing quite well. His feedings are not of much concern---he
is "practicing" at breast and learning well. The babies are a week old now.

The little girl had some temperature instability at first, but that has
resolved.There are no apparent physical or neurological abnormalities. Now,
we are having a real struggle getting her to nurse. Mom is pumping and now
providing plenty of milk which is being fortified. She did skin-to-skin
with the babies right from the start  and continues to do so. The little
girl, who weighs about 1820 gms now ( gaining)had made some good attempts
at breast, but tired easily as was to be expected.Right after birth the
pediatrician ordered supplements after nursing attempts, which were done
with a cup. That didn't go too well. The mother, about two days later and
after discussion, decided to offer the supplements with a bottle--and had
much better success. The pediatrician wasn't quite satisfied with the
baby's intake and we placed an NG tube too. The order now is to feed her 1
ounce ( 30 cc) every two hours.( either 22Kcal formula or fortified
breastmilk). More and more is being fed through the tube as her interest
in "eating" wanes.
In the past day or two, she has shown less and less interest in the breast--
and even the bottle. She rouses briefly, sucks a few times and falls asleep
again. The mom has tried directly at breast and with a nipple shield. The
baby has a good suck--just cannot sustain it and seems to lose interest
more and more quickly. Attempts are breast are limited to about 5-10
minutes.

And now my question. How do those of you working in NICUs handle this kind
of situation? This baby never has the chance to wake up "hungry". I realize
that she needs the calories, and is a premie with somewhat limited stamina,
etc. but her very best feeding at breast happened when the "schedule" got
out of whack, and she was alert and an eager participant.

The mom is patient but getting frustrated. This afternoon she said that she
didn't even offer her the breast "because she won't do anything anyway".
The mom is an RN and understands that her baby has a lot of catching up to
do, but she is feeling so sad.

Is this a case of wait and be be patient, or is there a better feeding
plan? The doctor won't let her go home until she is eating well. The twin
brother is doing OK and taking all his feedings at breast with top-offs by
bottle as needed.

Thanks for your ideas.

Kirsten, IBCLC

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