In a message dated 1/13/2004 12:33:50 PM Eastern Standard Time, [log in to unmask] writes:

>  I am currently working with the mother of twin boys who were born 9
> weeks premature. They are currently 14 and 5/7 weeks old.


So their adjusted age is just 5 5/7 (6) weeks...


> Baby A weighed 2 LB 14 oz at birth and
> currently weighs 7 LB 5 4/10 oz. Baby B weighed 3 LB at birth but lost weight
> during a bout of NEC and is now smaller, currently weighs 7 LB 1 7/10 oz.


So, still rather teeny for adjusted age of 6 weeks...


> They came home from the hospital November 7 at 5 weeks old nursing at
> the breast with a nipple shield and being supplemented with breastmilk 2 oz-2
> times/day. They did not grow or gain weight so unlimited breastmilk
> supplements were given and mother began pumping.


Not surprised that with adjusted age of 36 weeks gestation, they had trouble.


> Mother tried cup, spoon, dropper, and
> finger feeding and then resorted to pumping and giving all EBM by bottle. She
> feels the only time they were really content and well fed (judging by diaper
> counts/output) was when they were given all feeds by bottle.


I work mainly with MOT/MOM. Often a mother who has brought home twice, three times or more the usual number of babies may not have the time, physical or mental wherewithall, etc. for a lot of alternative feeding methods. I find stressed out moms in our culture are generally more comfortable with the familiar bottle. However, there is bottle-feeding and then there is bottle-feeding. I'd highly encourage the use of a technique such as that of Dee Kassing as described at: http://www.ilca.org/pubs/jhl/j18h1l10.pdf


> She has supplemented with polyvisol and olive
> oil. There is family history in both families of various allergies and mother
> has asthma. There is also a 7 year autistic older sibling and a 3 and 4 year old
> sibling. The autistic child received formula and the other two children were
> exclusively breastfed.

What has the pedi or allergist had to say about the above? I'm all for fully breastfeeding, followed by EBM but does she have a plan if infants' ineffective breastfeeding and EBM is used up? Is banked milk a realistic possibility (as mentioned later)? If so, she needs to plan how to get it if needed. Sometimes the plan that is great for a singleton is not realistic with two. Time can be the greatest enemy.


>    Baby A - digital suck assessment seemed to suck well and observed feeding
> at the breast showed adequate sucking and swallowing.  I believe he is
> capable of nursing at the breast. However, he frequently gets agitated at the breast
> and will only calm down when given SNS. Mom is now supplementing 1.5 oz --
> 4/day.

What do you mean by "agitated"? Sounds as if he still may have some "effective at breast" issues or production or MER could be an issue? How long does an average feeding take (for each)? Could the simultaneous feedings be an issue for him? (In all honesty I admire this mother's use of the SNS. A lot of MOT find its use several times a day to be overwhelming.)


> Weight changes 1/8 7-1.5    1/9 7-2.9    1/10 7-4.0 (mother counts 17 feeds
> this day and fussiness) 1/11 7-6.3     1/12   7-5.4


Hmm, a 1oz/day gain pattern and then an ounce loss. Was anything different between 1/11 to 1/12 weigh-in?


>       Baby B - missing a muscle on right side of chin, recessed chin,
> doesn't stay latched consistently, falls off frequently, but doesn't get good
> suction at times... I recommended an
> OT which mother is arranging...

The OT is a great idea! But I'm wondering how mother is really accomplishing simultaneous feeding with the baby's inability to maintain latch?


> Weight changes 1/8   6-13.1   1/9 - 6-14.8    1/10   7-1.0   1/11   7-2.4
> 1/12    7-1.7


This baby also went down almost an ounce between 1/11 to 1/12. Bet something different was going on re: feeding, when or how weighed, etc.


> I was there on 1/8 and recommendations included:
> 1 all feeds at breast
> 2 SNS supplementing only
> 3 Each baby gets supplement at a different time so we know who is getting
> what amount
> 4 supplement to remain at prior day's amount of 6 oz total per baby to see if
> it was enough
> 5 weight check each day
> 6 no pacifiers
> pumping 10 minutes after feed during the day as often as possible (Mom has
> managed to pump 2 or 3 times each day and gets from 1 to 2 oz)


This plan is excellent, but I feel tired just reading it. As a (former) breastfeeding MOT, I feel overwhelmed reading it. As a MOT who also had two preschoolers when my twins were infants (much less an autistic third child), I'm feeling over the edge reading it. How long does mother think she can keep this up -- and she may have to do so for a while, at least with little B and his missing muscle? How sane is she feeling? (And I'm not asking that facetiously.) Again, the plan that is feasible for a singleton may be too much for a MOT/MOM.


> Mother is practically living in the bedroom with the babies only
> leaves to eat at the table, maybe only 1 time a day. She has her mother,
> mother-in-law, and sister-in-law to help but everything seems to be chaotic. She sleeps
> with the babies and nurses them one at a time at night without the SNS.


Again, how long can this mother keep this up? I can only imagine how torn this mother may feel between her babies' needs and her other children's need for her at least on occasion.


> Most
> day feeds are done simultaneously on a nursing pillow with the SNS 4 xs.


How long does a typcial breastfeeding take per each baby? Although simultaneous feeding may seem a time saver, it can actually complicate current breastfeeding issues and moving toward effective breastfeeding when learning to do it with two babies. Many mothers find they cannot easily keep track of what both babies are doing, and little B has that difficulty sustaining latch.


> Mother
> called at midnight last night in a fluster because they were fussing and she
> has given them all the supplement already.  Diapers seem sufficiently wet, but
> stools are scant.

Rule #1: Feed the babies... I don't feel I have enough info yet, but sometimes it helps to take a breastfeeding "time out" of a day or two and work on production via an effective method of milk expression and letting others help out with alternative infant feedings, e.g. Kassing's bottle-feed method. Mother can put each baby to breast as possible or desired and kangaroo more and spend some time with older children. If mother really wants babies to get only her milk, this may be helpful. It may seem like a step backward, but I've usually not found it so and the improved milk production often helps a mother's immediate spirits.

> Earlier in the evening she called to say they were fussy,
> had lost weight and they weren't getting enough. I told her to FEED the babies
> more supplement if needed. She doesn't want to use the supplement any more
> than necessary because she is running out of her frozen milk and doesn't want
> formula. We talked about banked milk which she says she will buy if she has to.


Rule #1... She may run out of options; she needs a plan in case she runs out of EBM and/or can't get other moms' milk when needed.


> We talked about reglan and fenugreek during my visit and yesterday. I am having
> a hard time figuring out if the problem is inadequate milk intake or
> inadequate milk supply. I am thinking that if we get the reglan (she leans toward that
> because of one mention of it's aggravating asthma in a mother) and get the
> supply up we will know.


How often is each baby effectively breastfeeding in 24 hours? To me it sounds as if this still is an issue for both A and B. How often is she pumping and what is she using? (Has she tried pumping on one side while breastfeeding on the other? That may work better than simultaneous feedings.) Keep in mind that postpartum depression is about 25% in MOT and Reglan can be associated with depressive s/s.

> What am I missing here? Does anyone have a strategy that will be
> helpful in this situation? I have not worked with this kind of problem before and
> all of the information I have regarding premature infants seems to end at the
> time they come home from the hospital.


Part of this is that you are working with a mother who has twice as many preterms as the usual mother. She needs higher milk production due to twice as many babies, yet preterms are more likely to have to transition to effective from ineffective breastfeeding and that takes more mompower, and she has less time to work on it due to having twice as many babies. Add to that her responsibility to her three older children and she's doing magnificently!

> Also, the pediatrician wants them to
> gain 1 oz per day. Is it acceptable, since they are past their due date, to gain
> the usual 4-8 oz per week? They are still so tiny and their growth was stunted
> for a period of time when they first came home.

The docs online will probably have better answers, but since their feeding is still not "stable," that may be playing a part in this recommendation.


> I have thought about "lactoengineering", but mom just doesn't milk or time to
> pump it to feed only hindmilk.
>

I think you are most likely correct!

Don't know if the above is helpful or clear. Hope something rings a bell...

Karen Gromada

             ***********************************************

To temporarily stop your subscription: set lactnet nomail
To start it again: set lactnet mail (or digest)
To unsubscribe: unsubscribe lactnet
All commands go to [log in to unmask]

The LACTNET mailing list is powered by L-Soft's renowned
LISTSERV(R) list management software together with L-Soft's LSMTP(R)
mailer for lightning fast mail delivery. For more information, go to:
http://www.lsoft.com/LISTSERV-powered.html