Dear Lactnetters:
       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. Their due date was
November 30. They were born October 2.  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.
       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. 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. However, she really
wants to breastfeed and does not want these babies to have any formula if at
all possible and they haven't so far. She also declines human milk fortifier
due to the cow's milk protein. 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.
    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.
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
       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. Also being supplemented 1.5 oz - 4/day via SNS. I recommended an
OT which mother is arranging and demonstrated suck training which mother isn't
doing so far. There is no time.
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
       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)
       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. Most
day feeds are done simultaneously on a nursing pillow with the SNS 4 xs. 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. 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.
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. In the mean time she has to feed the babies if they are
hungry even if it means using all her frozen EBM which will be gone in 3 days.

       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. 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.
I have thought about "lactoengineering", but mom just doesn't milk or time to
pump it to feed only hindmilk.
       I would be grateful for your experienced input into this case.
Judy Gutowski, BA, IBCLC

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