Gosh, I am going to kneel at the feet of our four neonatologists and three
nurse practitioners and do obeisances.

Not only am I not barred from NICU, they are begging me to give up my
nursing shifts and just do lactation - along with the four others who help
me run this program.  We have sleepover rooms for parents (big queen beds)
so they can stay and breast feed at night.  We have rooming-in rooms when
babies are getting ready to go home.  Moms  pump at the bedside of the baby
if they wish.  We do kangaroo care routinely on babies as little as 750 gms
if they are reasonably stable.

The theme of our NICU is "NICU as HOME."  Now that's stretching it a bit
far, admittedly, but that's the goal at least.  We provide lockers for all
parents, and a room where they can rest, read, have a snack (provided by our
parent-to-parent group)  etc.  I could go on, but you wouldn't read it.

We leave  IV's in nearly-term babies and just watch  the IV plus PO totals,
using time suckling as a guideline whenever the mother can be there.  That
is: if the baby nurses more than ten minutes with swallowing, we don't
supplement.  Five to ten minutes, we give half the feeding.  Less than five
minutes we give the whole feeding. However, we give it by gavage which seems
to be one way to keep the insurance company off our backs about getting the
baby out of there ASAP (" If he can take formula out of a bottle, do that,"
they say)

Look at it this way:  If there is still an IV and a gavage tube in place,
the insurance company isn't going to try to push the baby out of the
hospital tomorrow with a bottle in his mouth.  The mom and baby get lots of
practice and support.

If mom can be at the hospital,  and the baby is nursing at all, we don't
supplement at all.   The IV is the backup for poor nursing.  However, the
average number of children per family where we live is 4.9.  That means that
a lot of our mothers are torn between caring for the baby in the hospital,
and those at home.  Babies are transported to our hospital from 19 outlying
hospitals, some a 7 hour drive away.  We do have to figure out some way to
feed these babies until the mother is there with the plumbing.  IV's are
stop-gap measures at best. The problem is to pick something that least
compromises eventual successful breastfeeding.  That ain't easy!  Even WE
(on the list) can't all agree on what is best.

 When the mom CAN be there, we give the baby a chance to experience hunger
and to cluster feed.  Our experience with pre and post weights was a
nightmare with three different scales.  Babies do NOT weigh less after a
good breastfeeding, but that happened a lot no matter what we did.   It was
undermining the whole lactation program so we have gone a different route.

Pacifiers for premies.
We (professionals and LLL leaders)  have taught new mothers so well the
evils of pacifiers that we have them asking us not to give their teeny
premies pacifiers in NICU.  As you can tell from the discussion over this,
it is not a good idea to withhold normal sucking from premature babies who
are going to be weeks and weeks before being able to nurse.  This is true
not only from a behavioral and comfort standpoint, but also because babies
digest gavaged milk much better when they are suckling during the feeding.
We actively encourage hand-to-mouth motions and postures, to encourage
self-regulation and comforting.

Before pacifiers were common in NICU, our followup clinic had lots of babies
who had been home for months, and  still could not suck!  Since our OT
started using little "thumby" pacifiers and graduating them up, we have many
more babies leaving the hospital successfully breastfeeding, and no babies
coming in not suckling at 6 months of age unless there is an underlying
neurologic problem, etc.

Anyway,  another rant, I suppose.  But I am really tired of being the bad
guy when I spend hours and hours helping moms maintain a milk supply and
initiate breastfeeding in the NICU.
 I watched one of our (male) neonatologists sit on the floor with a weeping
mother, let her cry on his shoulder,  and wept with her over her losses
(including the loss of a breastfeeding relationship and the chance to have
any more babies.).   I am tired of having THEM made the bad guys also.
Without them, and the technology we have, we would go back to the statistics
of the 1960's when I first started working in a premie nursery.  Wasn't
pretty!  John and Jacqueline Kennedy's baby, Patrick, is a good example.
Today, that baby would undoubtedly have lived and been normal.

I know we have a long way to go before technological care is as humanized as
everyone would like, but let's get our priorities straight here.  If you
have never spent a night trying to help a mother breastfeed one baby while
you are trying to get a chest tube in to another baby trying to die,  you
need to spend a little time in different shoes.

WHEW!  Okay, I am calmer now.
Deanne Francis, R.N.  NICU     IBCLC

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