Please search the archives.  We have been round and round about this issue
before.  As a lactation consultant I would hesitate to instruct the mother
differently from what the Peds has directed.  As a neonatologist with an
interest in nutrition, I understand the physician's concerns - which are
nutritional, not maintaining or increasing Mom's milk supply (which we should
all be concerned about as well).

In the NICU we take appropriately grown babies and turn many of them into SGA
(small for gestational age) babies because we cannot, given diseases and
fluid restrictions, give them as good a nutrition as they were getting in
utero.  Preterm infants are born with nutritional deficits which increase for
the first few days-weeks-months depending on their gestational age and weight
at birth.

Although mothers who deliver preterm have milk that is different at first, it
changes over time (2-3 weeks) just as all milk does.  The milk is not
"designed" for the preterm infant - preterm infants used to die!  It is a
function of the architecture and physiology of the breast tissue at 26 - 28 -
30 etc weeks vs at term.  There is not enough protein, calcium and phosphorus
in even preterm milk to optimize a very low birth weight infant's growth
without clinically impossible volumes of human milk.  That is why we use
fortifiers in the NICU.

There is now a growing body of evidence that preterm infants may need
additional nutrients post-discharge as they are doing an amazing amount of
"catch-up" growth and are usually discharged home several weeks before they
were supposed to be born.  If you do the math, you can get more protein into
an infant by having him/her breastfeed for most feeds, then take a follow-up
artificial milk for 2-4 feeds per day, rather than have Mom pump and
bottle-feed fortified EBM for every feed.  It is also more supportive of
breastfeeding.  A 34-36 week infant (which is what most are at discharge) is
usually not capable of getting enough milk or maintaining Mom's milk supply
by him/herself.

I realize that if you wait long enough (5-8 years) the growth and bone
mineralization  of exclusively breastfed infants will catch up.  I also note
Dr. Lucas's research that says mild undernutrition may be good for your blood
pressure when you are an adult.  I don't think the final answer is available
as to what is BEST for these premies yet. We certainly do not know how LONG
additional nutrition is necessary - but 4-12 months is not an unusual
recommendation.
Nancy

Nancy E. Wight MD, FAAP, IBCLC
Neonatologist, Children's Hospital, and Sharp Mary Birch Hospital for Women
Medical Director, Lactation Services, Sharp HealthCare
San Diego, CA, USA

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