Hi all,
Although I have been woefully behind in reading lactnet posts (family and
work pressures!) and haven't posted for the last 6 mths, or so, a
(reoccuring) discussion thread from a month  ago piqued my interest and has
been rattling around in my head since. There is much discussion about the
preterm discharge formulas and their use in the discharged premie. Because my
work as a VNA nurse requires me to visit breast fed, formula fed and anyone
in between, I have had at least 2 encounters that illustrate the complexity
of the addition of these formulas post discharge as well as illustrating the
complexity of infant feeding in general!
The first involves a pair of premie twins delivered at 32wks and discharged
1wk apart at 3wks and 4 wks of age.  The babies had an unremarkable premie
course, were growing well at approx 1oz/day or greater on D/C. The later D/C
due to an occassional episode of apnea.
They were visited by a non LC RN on day 2 post d/c who referred them to me
for brfdng support. AT the time of my visit, the babies were at 36 wks
gestation, had cont'd to grow at the greater than nl rate on brmilk 24 cal,
enhanced w/ Enfacare. Mom was pumping plenty but was reluctant to try babies
at breast d/t "need" for inc. cals and inability to measure. Consult revealed
diffic. w/ latch and disorganized sucking pattern resulting in
nonnutritive fd. Mom was very reluctant-worried about "stressing" infants
despite reassurances. She had offered "some" k-care during hospit. but little
att at breast.
 Visits were then scheduled at 3-4day intervals, Mom left w/ instr. to
attempt at breast and insructed in use of nipple shield. She was clearly
reluctant-babies were bottling well.
The next few visits were largely the same, Mom tried little at breast,
fearing "stressing" these now term, quickly growing babies (approx.
1.5oz/day) who were still receiving inc. cals. The larger of the 2 was put to
brmilk w/o suppmt shortly thereafter following  1wk of really large gain
(1lb!) but the smaller( who had gained at a very acceptable rate!)  was kept
on the enhanced cals. At that point Mom became very fixated on the wt. gain
for the smaller and became even less interested in putting babies to breast.
We would continue to try as often as possible with visits but the babies
began to resist attempts and I began to wonder if we had missed a critical
window of oppurtunity.
At approx 1mth post D/C, I dc'd visits. Babies were doing well and Mom was
happy with pumping. I left her with instr. to continue att a breast, although
I didn't think she would!
Shortly thereafter and Due to Mom's fixation of volume taken by the smaller,
and also due to her desire to feed  at roughly the same time and on a
schedule, she began to force feed. The smaller baby became more and more
irritable, arching back and pulling away from bottle during feedings. Very
quickly this escalated to almost daily pedi visits whereby the baby was
diagnosed with reflux (back arching!) despite no spitting and no diagnostic
w/u and put on zantac and removed from brmilk entirely (suspect dairy
sensitivity) but left on Enfacare (cows milk based!) Problems persisted
(surprise!), wt gain slowed dramatically, formula changed to soy, then
hypoallergenic. Meanwhile Mom dc'd breast milk entirely as other infant began
to demonstrate same type of feeding aversion and problem was feared to be
"something in her milk".  Weight gain than slowed further w/both and Mom, in
panic mode, introduced solid foods at 4mths of age (2mths corrected!) with
approval by pedi. She insisted that babies were fdng well, despite what she
described as tongue thrusting! When neither gained weight for 2wks, babies
were referred back to me and "feeding team" for eval. (pediat. were at the
end of their rope!)
I then readmitted these babies at 4.5mths of age. Despite instr. by pedi,
feeding team-GI, and occupational therapists, Mom HAS backed off but still
continues to force feed these babies. The smaller will only tolerate a bottle
nipple when she is asleep, despite putting fingers, toys, spoons in w/o
issue. Sadly she has also just started to gag herself with her fingers and
I'm wondering if this is the start of a more "mature" feeding disorder. Mom
adds grape pedialyte as well as karo syrup and prune juice to "flavor" the
expensive (but insurance payed for!) alimentum that the smaller receives.
The larger is back on similac and Mom doesn't grasp the concept that perhaps
she can now use the huge store of  EBM she has in the freezer since the
suspected(!) issue with dairy no longer exists. Nope- she is still afraid to
use her milk.

Lynn Shea Rn,Bsn,Ibclc
Franklin,Massachusetts

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