Hello all,
       I am a lactation consultant in the NICU at Brigham and Women's
Hospital.  Our unit has done much work with feeding and we have had Marjorie
Mayer-Palmer come to speak with a team of nurses to discuss her NOMAS scale.
Her work is, admittedly, with bottlefeeding, because it is, according to her,
easier to measure.  Kathy Howard and I have used some of this background,
along with the work of Paula Meier, Nancy Hurst and company, to develop
guidelines for breastfeeding premature infants.  We begin babies in Kangaroo
Care ASAP--and if the baby is awake and alert, mother can put her baby to
breast for a  "a lick and a look", with no attempt to latch baby until baby
tries to root.  The breastfeeding dyad is "congratulated" if the baby even
opens his eyes to look at the breast! and mother is encouraged to do this,
whenever she kangaroos.  This can be started as early as possible.  Babies go
to breast and "latch" if they want to, without any pressure to perform or
take in measureable volumes.  If they do, great, if they don't, no problem.
We use indwelling gavage tubes for feeding and supplementing.  We do not
start bottling until 34 weeks, to avoid issues (like choking) which may lead
to baby protecting airway and, down the road, becoming orally averted.  We do
not introduce nipple shields, if indicated, until 33-34 weeks (33 weeks only
if the baby is aggressively seeking to feed at breast), for the same issues.
We have gotten rid of the infamous red rubber nipples, and "screwing the
feeding in(with a bottle)" is no longer desirable as a nursing skill.  We use
the slowest flow bottles possible for feeding.  After the gavage tubes are
removed in preparation for discharge, the nurses try to avoid supplement
right after breastfeeding, respecting the baby's cues.   The baby's desire to
feed and ability is respected--that's the biggest difference.  Because of all
of these factors, babies go to breast long before bottling is introduced.
And mothers get tons of practice with positioning and assessing latch and
feeding before they go home to be on their own. The biggest complaint we get
is that babies are better at breastfeeding and not good at bottles!  We are
(hopefully) going to be using a lactation flowsheet which reflects these
changes soon.  Just waiting for the hierarchy at the hospital to approve it!
                                                             Maureen Allen
RN, BSN, IBCLC
                                                             Lactation
Consultant--NICU
                                                             Brigham and
Women's Hospital
                                                             Boston, MA

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