Ellen
I read your post to Lactnet with mounting horror. My felicitations that
you manage to work in such a baby-UNfriendly environment!
You are quite right to be concerned. Does this baby need HMF? No. Does
*any* pre-term baby need HMF? No, not IMHO.
Good that you were able to support this mom so well, and obtain more info
first, but there are all sorts of mixed signals in what she seems to
understand from her baby's doctors. This baby was born at a reasonable
weight for 32 weeks, and is now a big newborn, not still a pre-term baby,
so it sounds as if she has done well. If this was my client, I would
suggest face-to-face consult, assess latching, breastfeeding (swallowing)
with and without shield. If you had digital electronic scales that you
would give you an idea of Qx transferred. I don't have them, so never use
them. General care plan would therefore include:
1. Breastfeed first, at least every 3 hours, switching to maximize intake,
using breast compression.
2. Advise mom that a baby weighing 3.8 kg would require ~ 680 ml of milk
(1st choice breastmilk, 2nd choice standard formula, this baby is now an
effective full-term newborn) in each 24 hours, or 85ml every 3 hours - not
quite sure from your post how much breastmilk this baby is already getting....
3. If baby seems hungry after really good breastfeeding (1 above) then she
should offer 85ml after breastfeeding. Very likely that baby will not take
this quantity, she could note what she *does* take.
4. "Settle baby" (baby can go to sleep at breast, full and happy).
5. Asap after breastfeeding she should pump what is left behind, reserve
for part of next top-up.
6. Top-ups after breastfeeding should be given as in (2 above) ie
breastmilk first, formula second - separately - to avoid waste of EBM.
7. Keep chart of breastfeeds, top-ups, urine and stool output for 48
hours, with totals, so you can check that baby is breastfeeding often, and
establish how much supplement (EBM and ABM) baby is taking.
8. Slide this past the paediatrician group. You could probably initiate a
new era in LC/paed co-operation in Tel-Aviv!
9. Request paediatrician to prescribe galactogogue to assist. Here we use
sulpiride 50 mg three times a day for 2 weeks, then twice a day for a week
then once a day for a week.
10. Follow-up after 48 hours to assess (7 above)
11. Follow-up a week later, to see if quantity of ABM needed is reducing.
12. Keep following up until all ABM is eliminated - weekly weight checks
mandatory to ensure baby is gaining 30g/day - if more decrease formula, if
less increase.
Lastly tell mom she's wonderful to have kept going this long in such
hostile conditions, cheer her every inch of the way, but in such a way you
don't imply the paediatricians are uninformed and out of date (very
hard!). Maybe this paediatrician group will learn from you and send you
*more* work in the future!! They certainly need someone to refer to, by
the sound of it!
Good luck. Keep us posted.
Pamela Morrison IBCLC
Zimbabwe
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