Hi again! I need some expert advice once again.
Hx: G1P2, older gravida >40 & a nurse!
Primary C/S Twin gestation 36 1/2 weeks for 1 twin was breech
Twin A girl     5#-3 oz
Twin B boy      4#/3 oz
Plan was to breastfeed.
Day 0=Newborn day
Twin A assessment no problems with heart, lungs,bowel, pees & poo's
Nursing on cue doing well.
3 A's of breastfeeding accomplished
Audible swallow questionable
Temp stable.
Dextrostik with in range for hospital
Twin B was the same assessment No heart murmur heard at this stage
The thought was the babies were nursing too much
Day 1
Twin A doing great minimal weight loss No formula
Twin B wt was 3#14 oz so being he lost it was ordered to give formula
20-30cc every 2 hours per cup or gavage, starter feeding device, must
have or the baby will be transferred to a level 3.
So this mother chose SSNS. She wanted to get the wt on the baby so she
could take  him home.
No heart murmur noted color was pink Temp stable
Baby would still latch & the nurses were happy as the volume was being
ingested. Every 2 hours or so.
I had mentioned that I thought the volume was too much for day 1
so the mother was pumping to encourage her supply so we could feed EBM
to him instead of abm
During this night there was some borderline temp instability had some
bradycardia noted once during the night
(I am not sure if it was feeding related or if the baby was at rest)
Baby was warmed under the lights by night nurse
Twin B was then not responding like he was on day 0
Rooting was less & less
Baby was not awaking for feeds
Sleeping longer intervals & becoming harder to arouse

Day 2 Twin B
Temp was ok
Color was pink
Still having problems with feeding continued with abm & SSNS
Abm was then increased to 24 cal premie formula 25cc as per previous
methods of feeding
No tachypnea
Was regurgitating had an apnea but thought to be related to the emesis
Chest Xray was obtained
Heart looked a little enlarged
but upon auscultation still no murmur heard throught out the course of
the day.
During the night infant condition I believed worsened
the bradycardic episodes were 2-3  but his color was pink from my
understanding - I was not there at this time
The baby was then gavaged as they wanted to conserve the energy of the
baby
Day 3
It was then ordered to get an Echocardiogram
It showed an ASD or VSD
The baby was transferred to a level 3 in Sacramento
The receiving hospital said it was a ASD & VSD
The baby's color was never blue or cyanotic

Now my questions are:
1. If it is both a VSD & ASD could the condition have worsened with
large volume feeds with abm or would it have mattered?
2.If the baby was left to cue could these defects have resolved on their
own if infant not stressed with abm?
3 To the LCs in SACTO is it true that the level 3 on F street(SH)are
unwilling to use alternative methods of feeding as was told to the
mother before her baby left, & they will bottle all their premies as
they don't believe in alternatives not even gavage as it can increase
bradycadia?
Again, I can't account for this, as this was told to me by the nurse
caring for the "threesome." I just want to check it out.
I also don't know alot about pediatric cardiology I could use an
enlightenment.
Sorry for the length
--
MZ�