Laurie and Ann
This is becoming really interesting.
Laurie wrote, "in the usa, most premies are not given the large volume
feeds that Pam in Africa is used to. i think the feeling is that it would
compromise the cardio/pulmonary status due to fluid overload. but maybe
that could be tried and then hmf would not be needed"
And Ann wrote, ". I just received a call from my charge nurse asking for
information on "Hindmilk" feedings for premature infants in place of the
current Human Milk Fortifier
currently used in the NICU."
Ann, this is great - it sounds like a real breakthrough. But to bring in
Laurie's related comment, another question I should have asked in my
previous post was - How many oz/ml per lb/kg are the very low birthweight
babies usually fed, and at what age, ie what protocol is used? I
understand the concern about compromising the cardio/pulmonary status due
to fluid overload, There is concern about patent ductus arteriosus,
right? I'm wondering if this concern is really justified once these tiny
babies have been stabilized and are out of danger? Our paediatricians
monitor these babies very closely, and individualize their care, and the
quantities fed, as I'm sure yours do, and start them off on very tiny
amounts of EBM at first. It often happens that EBM may be started,
increased, or even withheld completely several times, depending on the
baby's condition, so everything goes backwards and forwards several times
in the first week, or two, or three. But, when things start to go well,
the most commonly used protocol is 60ml/kg/day, then 90, 120, 150,
180. Another paed (a paediatric cardiologist) uses a more conservative
protocol, 60ml/kg/day, then 80, 100, 120, etc with two-day intervals
between increases (I observe that his babies gain weight more slowly). The
large volumes I described (up to 280 ml/kg/day) are certainly not given in
the beginning - in fact often not for several weeks - only when the baby is
obviously out of danger, and now just needs to *grow*. Does that reassure
everyone?
Interestingly enough, it seems, too, that once these babies (many weeks
down the line) are gaining well, then they become more and more competent
at *breastfeeding*, and if they are not, then they remain sleepy and
sluggish and very difficult to breastfeed. So the rationale
for protecting the nutrition of these small pre-terms is well-established,
and I'm not trying to imply that it's not absolutely critical.
But, in the firm belief that if we all talk long enough and share enough
info, we will all arrive at similar conclusions, I guess I'm now wondering
- for those tiny babies who are out of danger, stable, and have turned the
corner, and are *subsequently* thought to "need" HMF, or even
lacto-engineered EBM for that matter - could they not be fed larger
quanties of straight, as-it-comes, breastmilk instead?? Is it the
*volume*, rather than the *calorie-content*, which could be adjusted -
obviously with extremely close medical supervision??? Isn't the protein in
breastmilk contained in the aqueous portion? If so, adding extra hindmilk
to as-it-comes EBM would increase the fat, but might mean that the baby
receives an inadequate proportion of *protein*? (for which HMF would
presumably rectify the deficiency??)
When the baby is stable and now needs to *grow*, why not just increase the
breastmilk? Is this idea totally off the wall?? If so, can someone
explain why??
Meanwhile, Ann, congratulations on what seems like a major step
forward. Hindmilk instead of HMF is certainly a move away from mixed
feeding and a move towards exclusive breastmilk-feeding for your
especially-vulnerable babies.
Pamela Morrison IBCLC, Zimbabwe
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