Listmates, especially Dr. Hale-I could use some insight and experience on
this one! I have a mom who delivered a 29-30 week preemie on 10/26.
Birthweight 1075gms. Was a c-section for poor BPP. Baby in NICU doing ok,
NPO until 11/1 due to abnormal abdominal x-ray. Eventually had barium enema
and passed meconium plug. Being worked-up for cystic fibrosis although there
is no family history. Mom started pumping one day postpartum and has a good
supply of milk. Mom has a history of seizures and is on 195mg phenobarb
1x/day and dilantin 300mg
1x/day. She is unable to have the regimen changed at this time. Mom and docs
were informed about what the literature says about these drugs. Feeds
started 11/1-something like 2cc every 2 hours via NGT (half breastmilk and
half premie enfamil due to the meds, neonatologist`s idea). The baby has
been on this mixture but the volume has been increased to about 8cc every 2
hours. So the docs order tox levels on the baby and they are: Phenobarbitol
4.6mg (therapeutic range 15-40) and dilantin 5.1mg (range 10-20). The docs
are not too happy with these #`s and when I asked what would be ok I was
told ZERO! So far no changes have been made as the baby is active and very
appropriate.
 My questions:
     1. Is this appropriate for a preemie,ie. to receive EBM with these
drugs, although we give these drugs to preemies? Should decreased metabolism
be considered as to why levels would be up so soon despite receieving
diluted, small amounts of breastmilk? What level is ok?

     2. What have others done in this situation?

 Mom is very involved and informed and dedicated to breastfeeding if it is
appropriate for the baby. So what do all of you think?

 BTW-just saw Jay`s post re: her dream and the NICU. We`re trying hard to do
all that you described! This mom
is to do skin-to skin starting tomorrow, baby eats every two hours instead
of continuous feed and can play at the breast if interested during
skin-skin. Overall the moms are pretty good about pumping too, but need to
be reminded occasionally, especially the long-termers. Our problem is with
introducing bottles more consistently than the breast-but we`re working on
it. Lots of education needed and attitude adjustments to be dealt with!!!


Thanks for your help!
Lisa Logan RNC,IBCLC