Barb,
The biggest issue that occurs with breastfeeding complex babies like these
who are receiving milk via a G-tube is related to the lack of an effective
suckling drive related to not being "hungry-enough" to exhibit such a suck.  Most
of the time the volume of milk administered via the G-tube is too much, or at
least on the high-end of normal, because docs are considering the possibility
of malabsorption in the gut, expending more calories for the baby's respiratory
drive since baby is on a trach and ventilator, and then as a result, these
babies don't want to accept the breast because they're stomachs are full!
(Calorie needs are based higher than normal 130-140 kcal/kg/24 hrs. or something
like that? I may not be exactly on target with that number.)

The other issue to contend with which it sounds like the feeding team is
already addressing is the oral aversion due to the prolonged intubation.  And,
everyone's fearful of allowing the mother to breastfeed because they feel the
baby's trach is somehow going to slip out.  I once long ago now,  worked on a
unit for trached vent-dependent babies and it's amazing how fast you get used to
knowing that trachs don't necessarily plop out, and/or if one should "fall
out" or become plugged, you even get used to changing them briskly, and you move
on and the baby's fine!

Congratulations on being permitted to allow this baby to mom's breast!
That's wonderful!

I'd add that it is imperative to do pre/post feeding weights on this infant
with an accurate scale (BabyWeigh Scale).  Be ready to counter the possibility
that if the baby doesn't gain "adequate" weight, whatever that may mean, that
the stress/effort of feeding at the breast may be blamed and the permission to
carry it out may be stopped.  I would imagine this mom would be devastated if
she were allowed to offer breast, and then stopped.  She may appear like she
wants what's best for her baby and be grateful she can provide the baby with
breastmilk, but it would be a real blow to her sense of her ability to nourish
her own baby.  Often times, these moms will never try the route of breast
again.

You ask at what point do you calculate his intake at breast into his 24 hour
caloric need?  Why wait?  Anytime....ie. when he starts to take 10 cc's at
breast, you subtract 10 cc's from the amount he's getting via the G-tube hourly
rate.  And, remember, if concerns come across that he's not gaining adequately,
you should first play around with his breastmilk (have mom pump off initial
(fore)milk, separate it, and then pump off presumably "hindmilk") and provide
this hindmilk via the G-tube before switching off of breastmilk and onto a high
calorie formula.  Unfortunately many doctors switch to formula prior to
working with the breastmilk to optimize growth and calorie needs of baby.

Hope this helps!  This sounds like an exciting challenge!  Wish I were there!
Sincerely,
Carol Chamblin, RN, MS, IBCLC
Breast 'N Baby Lactation Services, Inc.
St. Charles, IL

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