Amy Mueller asked about a question put to her by the NICU nurse along the line of expressing the mother's milk, letting the cream rise and then gavaging it to the baby. This issue of feeding the "cream" and/or the separately pumped hindmilk to the NICU baby is of interest to me. At the LLL Physician's conference in July I had a chance to ask my burning question. I'll have to wait to tell you of whom I asked, he was one of the speakers and did a wonderful talk, BUT *I* am brain dead on the subject of names. Back to the ::burning question::. I asked if letting the cream rise and skimming it to gain a higher fat milk had any drawbacks, in other words, would anything be lost in the process. The answer was yes, the immunological benefits would be compromised, that they would remain in the lower (skim?) portion of the milk. It had to do with the protein component of the milk also separating and the one on the bottom retaining the major portion of the immunological factors. Not a good idea for any baby but especially bad for one facing surgery. Another method to the same end that seems to be less harmful is pumping off the foremilk in one container, switching containers and continuing to pump in a second container after the letdown. When exactly to do this is based on mother learning signs of letdown and judging by previous experience how much milk she is likely to obtain and how much will be needed by the infant and how much will be "surplus". Surplus should of course be saved for later use, not discarded. If further calorie supplementation is needed artificial fortification of the expressed breastmilk can also be done. Depending on the needs of the infant, this may simply be a polycose addition for calories (this was a 35 weeker) or for the younger premmie one of the more complex human milk fortifyers may be used to up calories as well as other protein and minerals. Since this child is fluid restricted fortification may be required to get enough calories for growth within the limits of the fluid allowed. More on the fluid restriction issue, the infant could of course be test weighed before and after breastfeeding and the volumes of the other feedings that day adjusted accordingly. Volumes are fiqured on a 24 hour basis in my NICU. If the equipement or the mind set does not allow for test weighing the mom could pump first and nurse on a relatively empty breast using a supplementing device as below. Direct breastfeeding may be too stressful if the infant continues to arch and cry at the breast. Cardiac babies are more susceptable to harm from crying stress. They also have low energy to start with and often must be assisted with feeding. To that end, I would try assisting at the breast with the large tube of the supplemental feeding device that comes with 3 tubing sizes. I'd use this to entice the baby to the breast as well as to shorten the feeding time. Since this, if successful, would reduce mom's stimulation she should plan to continue pumping until at least several weeks past the surgery. Best of luck, Carla