The recent inquiries about appropriate fortification for the premature baby
still in the NICU have reminded me of a recent home visit.
Baby was born at 34 weeks 3 days, birth weight 4 lbs. 7 oz. Baby had spent
8 days in the NICU; then was discharged home. I saw the couple on Day 10;
baby was now 4 lbs. 2.9 oz. and adjusted gestation age (AGA) of 35 wks 6
days. Mom sought the consult because the baby tended to fall asleep at
breast (not surprising, given her AGA) ... though baby had a well-organized
suck, and mom had lots of milk. Weight gain had been slow. Using a
combination of feeding-at-breast with breast compressions, and supplementing
by bottle (mom's choice) with expressed breastmilk, baby was able to get
enough. Whoo Hoo!
We had a great consult, and baby continues to do well. Mom told me baby had
received nothing but breastmilk in the NICU -- no fortifier. However, upon
discharge, the NICU nurse sent mom home with a tin of "regular" Similac
powder, and told her she should "fortify" her expressed breastmilk with the
formula. The mom had not done so yet, she rather guiltily admitted, and she
wanted my guidance on how to do all of that.
That was when I commenced with (imaginary, while at the home) forehead
slapping.
I made certain I had it all correct: Nope, no fortifier or even formula was
used in NICU. Breastmilk and nuttin' but breastmilk since the get-go.
Doctors had not ordered fortifier or formula upon discharge. I looked at
the can of powder (CAN!! For a baby less than a month old!!) and confirmed:
this was not fortifier, it was just plain old formula for a newborn.
Offered up with those parting words of wisdom by the RN in the NICU to
"fortify the breastmilk" with it.
Here is my cautionary message. I don't need to tell this list the
physiologic risks of infant formula, especially to a baby born so early and
so little. However, I think we'd all agree that **in the NICU** fortifier is
often used for premature babies, although there continues to be divided
opinion by experts far wiser than me as to how much of what kind of
fortifier each neonate requires.
But think of how powerful that send-off message from the RN was. She
referred to the product as "fortifier," suddenly imbuing it with sanctity.
This mother who was absolutely, positively committed to exclusive
breastfeeding was willing to use it ("if it's what is best for my baby");
she had just delayed because (I think) her Lactation Guardian Angels were
sitting on her shoulder, and told her to hold off.
Whereas our collective advocacy to rid the "regular" maternity floor of
discharge bags and promotional samples of formula are showing gains, the
NICU has been a part of the hospital where infant formula and supplements
and fortifier remain a necessary tool for medically-indicated reasons. And
yet, this mother was being offered this parting gift of powdered, regular
formula with a comment that could be (and was) VERY easily interpreted as
medical advice. Those of us who work with mothers in the community need to
have our radar up about this ... not because it is such a galling violation
of the WHO Code, but because breastfeeding can be negatively impacted with
early, frequent *and unnecessary* supplementation with formula.
--
Liz Brooks JD IBCLC FILCA
Wyndmoor, PA, USA
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