Dear Wise Ones,
I haven't posted in a long time, but I've been reading intermittently, just
too busy to keep up.  Of course now I'm back because I'm hoping someone will
know more than I do about a particular child.
I have permission to post.  I've mentioned this baby before on Lactnet.  He
will be 1 year old on Oct. 30.  He was born after a serious placental
abruption and has anoxic brain injury.  He has been G-tube fed since 1 month
of age.  His mother has pumped for him this entire year.  Until about 2 mos
ago, breastmilk was almost his exclusive diet.  He has been very slow to
grow.  At almost 1 year, he weighs just 15 lbs, and is also below standard
growth charts 3rd percentile for height and head circumference.  He has been
relatively physically healthy, though.  We have tried repeatedly to increase
the volume that he eats, but have been unable to as he just vomits more if
the volume is increased.  On the advice of a developmental ped, mom tried
adding powdered formula to fortify breastmilk, but he doesn't tolerate this
and just vomits more.
In the last 2 weeks, he has suddenly started to have more intake by mouth. 
He is now taking breastmilk by bottle, about a total of 600-700 ml per day
(21-25 oz) and also some pureed foods, mostly vegetables to which mom adds
some additional coconut oil and infant cereal made with breastmilk.  He is
difficult to feed by any method, and this mom is very dedicated and spends
much of her day pumping, feeding and caring for this little guy.  She has
been on domperidone since baby was about 3 mos old and continues to produce
his current intake, plus a little extra.
Here's the questions after all this background.  Mom recently took him to
the developmental pediatrician and he also had a repeat swallow study.  I
have not seen the report, but mom says they told her he had no aspiration
with any consistencies, but that he had delayed swallowing with thin liquids
and they are worried he may aspirate because of that.  The developmental ped
recommends thickening all thin liquids.  Also, the ped was very unhappy
about his weight, and told mom that she had "long out-lived her usefulness"
pumping milk for this baby and that it was inappropriate for him to still be
getting breastmilk.  She recommended putting the baby on pediasure instead.
This mom is very reluctant to switch to pediasure, especially since this
baby has not tolerated any formula when she's tried it for fortification or
supplementation.  She wants to continue to pump for him through the winter
at least, but she is feeling pretty discouraged after being told she had
"outlived her usefulness."  
Is there any advantage to switching to a formula like pediasure (which is 30
kcal/oz)?  Is there a way perhaps instead to fortify breastmilk to increase
calories since we can't seem to increase his volume?  Now that he is eating
by mouth, is thickening breastmilk vital, knowing that he has never shown
aspiration on a swallow study, just the delayed swallowing?
I have told the mom that I'm out of my league here and that the
developmental ped sees more of these babies than I do, but on the other
hand, breastmilk is an important part of the diet of many healthy children
of this age, so I don't see how it could be bad for this little guy, who
certainly needs the immunologic protection.  I am also friends with this
mom, though, and feel I'm a little too close to the situation sometimes to
be objective.  (The dev. ped. told her "friends make bad doctors")
Thanks for any insight!
Jennifer Tieman
Family Physician
Mom to 4, including my nursling Caroline Rose (now 29 mos!)

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