In response to Allison Laverty Montag's post on slow-gaining 35 week preemie:

- preterm infant born at 35 weeks due to slow growth re: head measuring 5 cm smaller than for gestational age

- birth weight of 4 lbs. 9 oz. 

- weight at 19 days = 4 lbs. 12.8 oz., now -4% on preterm growth chart

- baby breastfeeds with nipple shield using L breast only 

- mother pumps right breast 3 to 4 times daily, obtaining 15 ounces each pumping solely from the rt. breast   

- perception that the baby breastfeeds vigorously for up to 20 minutes 

- "if left at breast too long, will spit up"

- baby stooling 8 to 9 x daily, yellow to orange seedy stools, some of which are very large

My response:

1) OH MY re: 15 ounces from the rt. breast, 3 to 4 times a day, which is 45 to 60 ounces of milk production in 24 hours from one breast.  And here's a little preemie trying to handle what may be a similarly high volume on the L, but if mother isn't doing any pumping to address early nipple shield use, perhaps her volume is much less on the L.  Even though mother is only pumping the rt. breast 3 to 4 times a day, her oversupply on the rt. breast is a risk factor for mastitis.  Could she be pumping the rt. breast for 30 minutes at a time, perhaps, in order to feel that she's really emptied her breasts?

2) Color of stools doesn't sound like a foremilk-hindmilk imbalance that could lead to slow weight gain.

3) What have the test weights been during feeding assessments with the IBCLC, especially the most recent test weights at the 19-day mark or when last seen by IBCLC for the feeding assessment?  Some preemies cannot transfer adequate volumes of milk until they've gained more weight, which gives them greater buccal fat pads.  Other preemies transfer milk beautifully, even some 35 weekers.  So test weights are paramount to see exactly where the baby's skill level is for milk transfer, regardless of gestational age.  

4)  Are there at least 8 to 12 feeds in 24 hours?  I'm guessing there are, due to the high stooling output. 

5) Prior to nursing the babe on the left breast, mom could express some milk off the L side to give baby a higher-fat feed.

6) Baby may be refluxing re: "if left at breast too long, will spit up," so adapting feeding position(s) for reflux, holding baby's   head higher than stomach during the feed, may help baby to have a larger meal for better weight gain.  Does baby have any nasal, throat, and/or chest congestion during the feeds?  Has milk ever come out of the baby's nose, even a tiny drop?  These are some of the clinical signs of gastroesophageal reflux or GERD.  

7) If GERD/"reflux" is suspected, has baby been referred to neo or peds to rule out GERD?  Many little NICU preemies are treated pharmacologically for reflux, which decreases the risk of aspiration and supports weight gain.    

8) Holding baby upright for at least 30 minutes after feeding will help baby keep the milk down via gravity.  Since preterm and fullterm newborns sleep between breasts (typically sleeping for 30 seconds to 30 minutes before rousing for another course), this preemie may then have room in his/her stomach for more, which would also enhance weight gain.  I teach parents that this break during eating before finishing the meal is similar to adult behavior, in that we're often not ready for dessert immediately after soup/salad/entree, but in another 30 minutes or so, there may be room for dessert - - and then we're really sated.

9) Since baby hasn't learned how to nurse from the rt. breast yet, returning to the same (L) breast for another course of milk will be a higher fat feeding.  (This is not at all to say that the baby must learn how to nurse from the right breast as well.)  

10) It's time for this baby to have another growth spurt, so would expect baby to cluster-feed, with the above-mentioned little naps in between courses, meals, and snacks.  When mothers are counting number of daily feeds with a cluster-feeding babe in a growth spurt, I advise mothers that any feeding that goes into another hour is counted as another feeding.    

11) Is baby being given a pacifier?  Is baby being given a pacifier after one trip to the breast per feeding?  Sucking on a pacifier does not give the baby any milk for his sucking efforts, and he needs more nourishment to move into optimal weight gain.  The mother's milk supply is so tremendously high on her right breast, so she may be assuming that her baby is getting a tremendous volume during his 20 minutes of nursing on the left breast, and she may not be thinking about the normalcy of cluster-feeding for growth spurts at this age.  Test-weighing is an invaluable and fundamental part of a consult following the onset of Lactogenesis II - - so helpful for giving the mother a full picture of where the baby is in skill level and where her milk supply is as well.  In this dyad's situation with extraordinarily high pumped volume on the rt. breast alone, I'll make an educated guess that the slow weight gain is not related to inadequate milk supply on the L breast, but rather due to one or more of these other possibilities mentioned above and below.      

12) Is baby waking at least every 1 to 3 hours to feed, or being awakened at least every 2 to 3 hours for feeds?  If baby is in a deep sleep cycle for a 4 to 5 hour long sleep stretch daily and is too drowsy to feed in spite of being undressed down to a diaper and placed in skin to skin contact with mom, then compensate for this long stretch of sleep by giving other feedings at least every 2 to 3 hours.  For optimal weight gain, the feeding frequency goal for this young preemie is to get at least 8 to 12 feeds in 24 hours.  

12) For any slow-gaining 35 week preemie at this age, I would recommend another weight check with IBCLC within 2 days rather than in one week.  When average daily weight gain becomes consistent re: two consecutive appropriate weight checks, then weight checks can be spaced out to twice weekly, then weekly, then every 2 weeks, then sole pediatric management with lactation support prn.  

13) How did this preemie score on the Ballard?  Did the initial newborn exam measurement of head circumference also reflect the 5 cm smaller than for gestational age?  A five centimeter discrepancy for GA sounds very significant, but would love to hear from Nancy Wight/other neos/peds/PNPs on this.  Does baby have any other health concerns other than prematurity and slow weight gain?   

Please keep us posted on how this little one is doing!

Debra Swank, RN BSN IBCLC
Ocala FL USA

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