Leslie asks for input about a policy under development in her hospital, on the nutrition of late preterm newborns.   All the questions she raises are familiar to me from my own workplace.  One question is 'When does 'feed the baby' come first in the first few hours?'   Since we are all doing serum blood glucose measurements, it seems logical to me to let that guide the use of breastmilk substitutes.  But I know from my own workplace that babies whose blood glucose is being monitored, are almost automatically regarded as needing supplements, and it makes me crazy.  We have guidelines for acceptable blood glucose levels but babies who have normal levels may be supplemented anyway, particularly if the pediatrician has hinted that the baby has been subjected to more than the usual stress at birth, and such stress is rarely described more specifially than that ('more than usual stress', how informative - NOT).

Unless there are factors leading to very early discharge, i.e. first 24 hours, I don't see why we can't use the same watchful waiting mode we should be using with any baby born in a hospital.  If any baby, regardless of age, isn't actively suckling within 24 hours, I think it borders on negligence not to get mother expressing by hand.  With the late preterm baby we need to be even more watchful because there are some who are just appearing to feed and we need to help them get fed until they can manage on their own.  

The issue of appropriate advice for intervals has been dealt with many times before.  IMO it's never too early to teach the mother to look at the baby and the best way to do that is to model the behavior yourself, pointing out what you are observing so she can learn the earliest signs of appetite and interest.  Please don't let any language into the policy that may end up in practice as three-hourly feeds.  It's not often enough on day three, for one thing, and it misleads parents into trying to feed the baby when it isn't hungry, and even failing to feed it when it is.

All of the things Leslie mentions are things that happen frequently with term babies, and the problems they cause are just as bad in term babies too.  Whatever best practice is in place for the term babies on these issues should be put in place for the late preterm babies as well, possibly with a few words on the heightened vulnerability of the late preterm baby, all the while emphasizing that 'late preterm' applies for a very very short time in the baby's life, and each passing day brings more maturation with it.  The mother needs to be supported to see the baby as *temporarily* being affected by its gestational age at birth, so she knows that all the extra care we are taking in the first few days, will not be necessary once the baby is feeding well.

About the mother's breasts not 'working as well' - I think sometimes the mother compensates for baby's weakness by making copious amounts of milk and ejecting it almost violently from the breasts.   This will subside if the breasts are not drained adequately in the first couple of weeks, but it seems if the baby isn't capable of meeting mother halfway, some mothers (or at least their breasts!) go the extra distance themselves, which is something you can describe for the mother as a sign that her body is adopting the nurturing role full force even if she may be feeling overwhelmed mentally.  Again, there is no need to plan for complications of any kind, as long as you have enough watch-and-wait support.  You can deal with problems as soon as it looks like they are surfacing.

It's a fine line to walk, but worth making the effort to do so.

Rachel Myr
Kristiansand, Norway

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