great discussion regarding the fortification of breast milk for premies!
Thank-you so much Sharon for sharing your EXTENSIVE review of the research
and info on lactoengineering, applied specifically to the case of Alicia's
poorly gaining, former 29 wkr.
I wholeheartedly agree with your suggestion to   FIRST "manage" the pumped
milk into a pool that is likely higher in fat.
And, as she suggests, If the weight gain remains low, try the crematocrit.
Although the teeny premies seem to need more than mother's milk alone
provides, how wonderful it would be if every NICU/nsy had protocols
instituting the above measures BEFORE   embarking on the infinitely more
risky road of breast milk "fortification", if even for the "older" premies
only!   Unfortunatley the factual pix is quite different. Since the advent of
*premie D/C formulas* and the research data supporting its use, even the
older premies are dc'd breast feeding very little and suppmt'd with every
feed, at a rate much higher than in the past.   My most recent VNA admission
was for a 2wk old former 34 wk premie, dc'd nursing 2xday only, and suppmt'd
at each feed with formula enhanced MM 24cal.
Upon my eval the baby had little experience at the breast and all attempts up
til that point were largely nonnutritive.
Further assist revealed that the baby was very capable and my D/C instr. were
to "try" to br fd only during the day, pump after each fd and suppmt with
pumped milk after nursing at night. Phone call to Mom revealed that Pedi
disputed this on visit the next day, insisting that Mom continue suppmts each
fd. Visit 3 days later revealed that Mom had done little suppmtng/ less than
5oz day because baby refused and or spit up when forced.   Lengthy disc
around huge wt gain, s/s of satiety etc. reassured Mom to continue to follow
her instinct and not suppmt if feeding appeared adequate. Visit to pedi 4
days later revealed cont'd huge wt gain and pedi's recommendation to D/C
suppmt (he was surprised to hear that Mom already had ;)). My visit 1 wk
later revealed 17oz wt gain in 7 days , exclusively brfed.
Of course in this instance all was well in the end BUT if this Mom did not
have the benefit of a home visit by an RN/LC, as most do not, we know from
the research that the most likely scenario is abandonment of the br fdng.
And, as Valerie suggests, the message that Mom's milk alone isn't good enough
is a very powerful one.
Lynn Shea Rn,Bsn,Ibclc
Franklin,Massachusetts

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