> Hello, I have a problem that I would love some help with. A mom, who has  
> done a fantastic job making a nice milk supply for her now full term baby girl,  
> is now home from the NICU. She is struggling to get her baby to  take  milk 
> from her breasts, and is still continuing to pump and feed the baby with  slow 
> flow bottles. Mom is getting very exhausted with the full time job of pumping 
> as she has a 3 1/2 year old at home. She is starting to use formula when she 
> is overwhelmed.  She has done a fantastic job keeping the baby happy to latch 
> on and even suck a little, but the baby screams at breast when she is really 
> hungry, demanding the bottle. The baby will nurse for about an hour then 
> still take 2 ounces of milk from the bottle. Mom uses breast compression while 
> baby is nursing. She has tried but didn't have much success with the SNS, or 
> nipple shields. She does lots of skin to skin time. Her baby has a nice suck 
> on exam. She is now 7 lbs 4 oz and is 3 weeks past her due date. she was born 
> at 28 weeks 2 lbs 7 oz. and had no complications. She is hoping that someone 
> else has had some experience that might shed some light on how to get this 
> transiton to happen. any ideas? 

At only 43 weeks and after all the invasive procedures/experiences (including oral ones) even a healthy premie with no complications is subjected to, I'd still call this a premie issue. That this baby will latch on and suckle even a while seems very positive. I hope mom and everyone else has taken a moment to stop, smell the roses and celebrate the progress this baby has made re: direct BF! (Too often moms/we forget to do that and just focus on the next issue or problem!) I know lots of moms of premie twins who found it took significantly longer for babies to "get" direct BF -- but they get there with patience and persistence. The following ideas assume that the infant's oral spece has been inspected for tongue tie, high arched palate, etc.

Is the direct skin-on-skin/kangaroo mother care (KMC) contact has been going on preceding BF -- allowing baby to hang out at and enjoy the scents and ambience of the restaurant at a time when getting hungry but truly without pressure to perform? (Have you seen her do KMC? I've found some moms think they're doing it when they're doing a lot of holding but it's not truly skin on skin. If she is and she keeps this up, this is often the best tool to transition baby to breast when baby/baby's mouth is ready!)  

How long ago did mom try a correctly fitted/sized nipple shield? Ditto for SNS? Some devices work great at one point and not so great at others. Something that didn't work yesterday may be very helpful today or vice versa. May be time to try either/both again?

Has anyone done any test weighing re: pre- and post-BF weights using a precise electronic scale?  (Ideally, can be taken for several BF in 24 hours initially since variation could be within normal.) With one-hour feedings and a baby who does not appear satiated, it sounds as if baby is not yet able to effectively transfer milk. If test-weighing, it may be useful to do a post-weight after 15-20 minutes, BF some more, and then do another post-feeding weight in another 15-20 minutes to see if much more was transferred. 

Since a baby tends to be most orally organized earlier in a feeding, I find moms wear out with long BF that aren't really accomplishing much/anything in terms of milk transfer. Hour-long BF for a baby that ineffectively transfers milk is not "teaching" that baby how to BF, plus moms then don't have as much time for the pumping needed to maintain adequate milk production. A plan that includes 10-20 min BF (preceded by KMC when possible) and is followed by the supplement (if SNS or Lact-Aid is not used) and pumping. When possible mom could let a helper handle the bottle-feeding while she pumps. (Helpers can be taught the more physiological/paced bottle-feeding technique.) Actually, a lot of moms decrease the number of direct BF/24 hours and BF as able in order to protect adequate milk production.

You didn't mention which slow-flow teat is being used, but packaging isn't always truthful as we found out with our flow rate trial with about a dozen of "alleged" stage/level 1, newborn, slow-flow teats. Premies have often received teats with too fast flow rate while in the hospital. Subtle maladaptive behaviors that allow them to cope with the bolus but conflict with oral behaviors for BF include excessive drooling and clenching/biting. 

Other ideas that have helped moms save time when they've brought premies who need more time to transition to BF once home may include:
- Using something as per the Precious Image Creations Miracle Cami for KMC
- Using hands-free pumping -- special bra, putting holes in supportive sports bra or the rubber band types (just Google "hands-free breast pumping" or search this term at www.kellymom.com or scroll down Links at www.karengromada.com) -- also some use WhisperWear pump to get in extra/cluster pumping -- to get something done during at least some pumping sessions.
-- Getting physical household/older child HELP!

Moms of premies are also more at risk for PPD, so that is something to be aware of too...

Hope some of this helps. I think there is much to think very positively about if she hangs in and maintains adequate pumping for good production. Please convey my congratulations on the homecoming of her baby and the fantastic job she's doing!

Karen G

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