Amy Mueller asked about a question put to her by the NICU nurse along
the line of expressing the mother's milk, letting the cream rise and
then gavaging it to the baby.  This issue of feeding the "cream"
and/or the separately pumped hindmilk to the NICU baby is of interest
to me.  At the LLL Physician's conference in July I had a chance to ask
my burning question.  I'll have to wait to tell you of whom I asked, he
was one of the speakers and did a wonderful talk, BUT  *I*  am brain
dead on the subject of names.  Back to the ::burning question::.  I
asked if letting the cream rise and skimming it to gain a higher fat
milk had any drawbacks, in other words, would anything be lost in the
process.  The answer was yes, the immunological benefits would be
compromised, that they would remain in the lower (skim?) portion of the
milk.  It had to do with the protein component of the milk also
separating and the one on the bottom retaining the major portion of the
immunological factors.  Not a good idea for any baby but especially bad
for one facing surgery.

Another method to the same end that seems to be less harmful is pumping
off the foremilk in one container, switching containers and continuing
to pump in a second container after the letdown.  When exactly to do
this is based on mother learning signs of letdown and judging by
previous experience how much milk she is likely to obtain and how much
will be needed by the infant and how much will be "surplus".  Surplus
should of course be saved for later use, not discarded.

If further calorie supplementation is needed artificial fortification
of the expressed breastmilk can also be done.  Depending on the needs
of the infant, this may simply be a polycose addition for calories
(this was a 35 weeker) or for the younger premmie one of the more
complex human milk fortifyers may be used to up calories as well as
other protein and minerals.  Since this child is fluid restricted
fortification may be required to get enough calories for growth within
the limits of the fluid allowed.

More on the fluid restriction issue, the infant could of course be test
weighed before and after breastfeeding and the volumes of the other
feedings that day adjusted accordingly.  Volumes are fiqured on a 24
hour basis in my NICU.  If the equipement or the mind set does not
allow for test weighing the mom could pump first and nurse on a
relatively empty breast using a supplementing device as below.

Direct breastfeeding may be too stressful if the infant continues to
arch and cry at the breast.  Cardiac babies are more susceptable to
harm from crying stress.  They also have low energy to start with and
often must be assisted with feeding.  To that end, I would try
assisting at the breast with the large tube of the supplemental feeding
device that comes with 3 tubing sizes.  I'd use this to entice the baby
to the breast as well as to shorten the feeding time.  Since this, if
successful, would reduce mom's stimulation she should plan to continue
pumping until at least several weeks past the surgery.

Best of luck,
Carla