Becky,

There's big difference between <37 wks and babies who are usually 34wks on
up. And a 34 weeker who is iugr could potentially benefit from extra calories
and minerals, depending on just how severe that is. And i say that presuming
that this is a baby not nursing as you mentioned. Stephanie Atkinson's work
was used by our fellows and nutritionists to make a guideline based on well
vs ill pretermers and on their weight at birth.  Her findings suggest that
well babies born above 1500 grams do not need fortified milk when they reach
full feeds, nor no they at discharge if they are taking in the equivelent of
180cc/kg/day. Babies who have had an ill course, or not aga may require
fortifying during the stay but not at discharge if they are taking in
sufficient quantities.  As to when to supplement, if a baby isn't nursing. If
you are waiting 24 hrs on a preterm baby i am assuming that you are checking
the blood sugar, since preterm babies have been found to be more vulnerable
to low sugars (brain-wise) than full term babies according to the WHO
recommendations on hypoglycemia ( a 57 page document available on the net).
I wonder about the appropriateness of supplementing with d5w between 24 and
48 hrs, since this has been documented to increase the risk of
hyperbilirubinemia. Nutramagin sounds like a viable alternative according to
the most preferred to least preferred order that Marsha Walker has presented
when she talks about the hazards of formula usage, that is when mom's milk or
pasturized donor milk is not available.  It also wasn't clear to me if your
mothers stay with their babies until the babies are discharged. If they do,
they can nurse during gavage feedings. Gavage is preferred over bottle, and
there was an article this past yr in JOGNN i believe that looked at the
superiority of transitioning a baby to breast by gavage instead of bottle.
If the mom isn't available, I have mixed thoughts about the pacifier, since
most of the data addresses full term babies whose moms are with them. Lastly,
from Meier's data on nipple shields, you may find that after being offered
the direct breast without success, a nipple shield may prove useful and not
detrimental.    Hope that helps. Email me privately if you want more info.

Chris in cincinnati

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