This is to Jennifer Tieman's post.  In all the flurry of posts here I must
have missed the part that explained why the pediatrician expects this baby
to gain faster than term babies of the same size.

An ounce a day is considered adequate gain.  What is the problem?

Given this week's publicity about how using growth curves based on the
growth patterns of largely artificially fed childrens may have contributed
to the obesity epidemic, and recent research showing impaired insulin
sensitivity in adolescence in children who started out as premature,
partially breastfed babies who were supplemented to accelerate growth, maybe
this advice isn't even as up to date as it ought to be.

According to the document Nancy refers to at the ABM website,
supplementation/fortification is indicated when the infant is suffering from
sub-optimal nutrition, defined as the presence of any one or more of the
following:
Total intake under 160 cc/kg/day, with rare exceptions
Infant can not take all feedings by mouth
Growth less than adequate, i.e. < 20 grams/day of weight gain (which is
approximately 5/7, that is five sevenths, of an ounce per day) and/or < 0.5
cm/week in length, which is approximately one fifth of an inch/week 
Abnormal, and non-improving biochemical indices (which are not readily
available in all settings)

It is not clear from Jennifer's post whether the pediatrician wants her to
mix enriched formula with her milk, or to feed it supplementally after
breastfeeding.  The Academy of Breastfeeding Medicine warns about mixing
formula into breastmilk: "Many neonatologists and institutions add powdered
discharge premature formula to expressed breastmilk to provide enriched
feeds while still providing the
advantages of breastmilk. There is no evidence to recommend for or against
this practice.  This use of powdered premature formula is off-label and the
potential for error is great, so be advised to be extremely cautious if
using this approach."

We do not supplement premature babies here after discharge, with the
exception of multivitamins, folic acid and iron, which are in themselves
controversial in some circles.  Once baby is deemed ready for discharge, if
mother's milk supply is adequate, that's what they get.  We discharge babies
well under 5 pounds, fully breastfed, and we routinely have babies in our
hospital with birthweights well under 1 kg (2.2 lb).  They get fortifier
added to the breastmilk in hospital, but not afterwards.

Rachel Myr
Kristiansand, Norway

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