Questions about supplementation/formula

[AppleCrisp]

Hi all,

Introducing myself here....my daughter was born prematurely 2 weeks ago after I had HELLP. She has severe IUGR, and after two horrible weeks she is finally stable. But, she just isn't growing....its so frustrating. She just started nursing but it is such slow going because she is so weak. She also has the NG tube, and is getting HMF. Neonatology keep saying I need to consider adding formula to her breast milk to increase the calories, and that she needs the "extra vitamins" in formula because she is at high risk for poor bone growth among other things. And they keep saying that when she goes home, I should be giving her formula between nursing sessions.

Everything in me says NO!! Don't give such a fragile little system formula. Am I being too strict considering that she really, really needs to grow? They look at me like I have 2 heads when I asked if we could please wait. I have plenty of pumped milk, but they keep harping that it "only has 20 calories" and I feel annoyed that the one thing I can do for her they are saying isn't good enough. *sigh* Its so frustrating.

[irangel]

That is a tough one to accept but the reality is that they are finding babies born especially little and early benefit from the extra minerals in the preemie formulas for bone growth. Little ones like yours are at risk for osteopenia of prematurity that can turn into Rickets. The supplimental formula is aimed at helping to prevent this and also at helping weight gain which is so important for overall health in preemies, especially IUGR ones.

My daughter who was a 25wkr ended up having to be supplimented 50/50 for a short while due to developing osteopenia and eventually rickets when she fractured 7 ribs. It was very very very hard for me to accept but I tried to be comforted by the fact that she was still getting my breastmilk and as soon as we saw her bone labs improving we started to drop formula feeds, and transition back to breastmilk.

That's probably not what you wanted to hear but what you're being told is pretty standard for really little ones.

[Sandstress]

Congratulations on your daughter's birth! I'm sorry you're dealing with pushy neonatologists. I'll tell you what we did. DD had HMF almost from the beginning, as soon as she started taking enteral feeds. A couple weeks later, we started supplementing the pumped milk with Neosure, for the calories and for the calcium. We added it to pumped milk (along with other medications) for about 6 months, and feel that that boost in calories allowed her the "catch up growth" that she really needed. I also pumped hindmilk (the fattier later milk in the pumping session) and gave that almost exclusively. I don't have advice on how to mix supplementation with nursing- I ended up EPing. Can you ask them to see what the calorie count in your pumped hindmilk is?

[jlovesl]

Are you from the States? I'm from Canada and it seems so different here. The only time they ever recommend formula is if Mom is not making enough breast milk. You always here in the NICU the nurses telling some Moms they need to pump more because it's so much better for baby. BM is digested way easier for their under developed systems. They do add HMF to the breast milk. When my little one was in the NICU his tummy refused formula(it took a week for my milk yo come in). Ever time he got formula he would vomit REALLY bad. He couldn't even handle the HMF. So once my supply was able to keep up with his demands, he was strictly breast fed or breast milk through his feeding tube. It was night and day to how fast he started to put the weight on. Once he stopped throwing up the formula.

[AppleCrisp]

Thanks for your replies. I asked them again today and they said I should be giving her formula for at least 8 weeks after discharge because (and I am directly quoting here) "your milk doesn't have what she needs" - namely, phosphorous and calcium. But, I know that over-supplementing those 2 things can lead to poor absorption of other nutrients. Can they check her phosphorous and calcium levels to see if she needs the extra supplementation? Even the lactation consultant said I should give her the formula supplement.

I am pumping off foremilk before I nurse her, but she is just barely getting the hang of nursing. She actually nursed continuously for 40 minutes today and I could see milk at the corners of her mouth and feel letdown, but then when I came back later in the day her nurse said she didn't get enough and she had to give her a bottle while I was away. *sigh* I guess I'm just venting now, its so frustrating watching her weight.

[AppleCrisp]

Originally Posted by Sandstress

A couple weeks later, we started supplementing the pumped milk with Neosure, for the calories and for the calcium. We added it to pumped milk (along with other medications) for about 6 months, and feel that that boost in calories allowed her the "catch up growth" that she really needed.

What is Neosure?

[liberal_chick]

Neosure is a formula developed especially for premature babies with a bunch of extra minerals in it.

OP, could they use the neosure to up your breastmilk's calories? Or is that what they're doing with the HMF? The NICU where my ds1 was would add X number of tablespoons to the breastmilk to make it 24 calories an ounce, but the base was breastmilk so I felt ok with it.

[irangel]

Originally Posted by AppleCrisp

Thanks for your replies. I asked them again today and they said I should be giving her formula for at least 8 weeks after discharge because (and I am directly quoting here) "your milk doesn't have what she needs" - namely, phosphorous and calcium. But, I know that over-supplementing those 2 things can lead to poor absorption of other nutrients. Can they check her phosphorous and calcium levels to see if she needs the extra supplementation? Even the lactation consultant said I should give her the formula supplement.

They likely have already checked her levels. I know at our hospital they don't recommend supplimenting unless the alk/phos is elevated which is a sign of poor bone health and the need for additional minerals. I am not a fan of supplimenting preemies routinely, or necessarily for weight gain because there are things like, pumping of fore milk, etc you can do to increase weight gain without supplimenting but there really are benefits to supplimenting for bone health.

[AppleCrisp]

They are supplementing with HMF right now to go from 20 calories to 22, but as you said, formula would be more calories. I'll ask if they've tested her levels yet. I just hate the fact that formula is corn syrup solids and cow's milk.

Thanks so much for all your advice.

[sbrinton]

We were in a similar situation with our son Zephan last fall. I was pumping, he was getting my milk by gavage, and once he was about 33 weeks we were beginning to breastfeed. He did not have IUGR, but he was a little guy as he was born at 31 weeks.

I understood the doctors reasons for adding HMF to my milk - and later adding neosure formula to 2-3 of his feedings each day - but I wish I had said no. We have a lot of milk allergies in our family and I was worried that giving him formula based on cow's milk would cause problems. But I decided not to fight with the doctors too hard as long as they were letting me breastfeed. Sure enough, Zephan now has a milk allergy. I have to completely avoid dairy as long as I'm breastfeeding. And all of that for a few calories...

There are some good reasons to fortify breastmilk (especially extra minerals), but there are SO MANY MORE reasons that breastmilk is the best food for preemies that I would fight hard to be able to breastfeed as much as possible. There are ways you can try to increase the calories in your breastmilk, either what he gets by gavage or later when you are breastfeeding. I would talk to your docs about the goal of breastfeeding 5-6 times a day and using expressed milk mixed with formula for 2-3 bottles a day until your pediatrician at home says you can go to just breastfeeding. That was our goal...and we went to just breastfeeding as soon as we were home.

You might also try using a nipple shield to see if that helps your baby get more breastmilk when he does try to breastfeed. Zephan got so much more milk when we were just beginning to breastfeed with the nipple shield. If you can get your volumes up, the docs may relax about supplimenting too. For example, if your baby needs to eat 1 1/2 ounces, they assume that much breastmilk has 30 ounces, so they want to fortify it to 33...but if you can get him to breastfeed more than his "full feeds" the docs will probably back off. We were able to get Zephan to have between 40-60 cc most feedings when his "full feeds" were maybe 36-40 cc.

When I was pumping for Zephan, to increase the calories in the milk, I would pump the foremilk (first 2-3 minutes) in one container and the hindmilk (the next 5-8 minutes) in a second container. I kept the thick creamy hindmilk at the hospital to to in his gavage tube and fed the thinner milk to his 2 year old brother mixed with his usual rice milk. Once Zephan was breastfeeding most of the time, I would still pump for 2-3 minutes before feeding him so he got more hindmilk. We have continued to suppliment with an infant multivitamin and extra iron (floradix) instead of the poly-vi-sol the hospital used.

He has grown really, really well - he was 3 pounds 9 ounces the day after he was born and he's almost quadrupled in size now at 5 1/2 months.

[OGirlieMama]

Originally Posted by irangel

They likely have already checked her levels. I know at our hospital they don't recommend supplimenting unless the alk/phos is elevated which is a sign of poor bone health and the need for additional minerals. I am not a fan of supplimenting preemies routinely, or necessarily for weight gain because there are things like, pumping of fore milk, etc you can do to increase weight gain without supplimenting but there really are benefits to supplimenting for bone health.

You may be right, but I wouldn't say it unequivocally. My 29-weekers had HMF for about half their NICU stay, and then were on straight BM when they came home. At their 1-month high-risk clinic follow-up, the neo told me I had to supplement once a day with Neosure to prevent osteopenia/rickets. I questioned this, and he went and discussed with one of the other neos (the one who was on service when they were admitted, as it turns out). When he came back in the room, he said we could have their alka/phos levels tested and then decide based on that whether they needed the supplement. I think he was actually surprised I took him up on bringing my babies back to the hospital for heel sticks, but we did it and their levels came back fine. They made me repeat the test a couple of months later and that was fine, too.

Anyway, in case I've obscured my point too much, supplementation was recommended for my girls on an entirely routine basis, with no testing to back it up.

[AppleCrisp]

They do the labs once a week I found out, and hers do show she is supposedly at risk. I had a talk with the NICU dietitian, and she said its just a tablespoon or so in a bottle of breastmilk a few times a day, it isn't like a whole bottle of formula at a time. I asked her about the corn syrup, and she said that they use that because preemies don't digest other sugars very well (whether that's accurate or not I have no idea).

At any rate, now I have other problems, the kid won't even breastfeed now, she's so sleepy all the time. They were allowing her just to breastfeed, but she's so slow with it they went back to supplementing with EBM in the NG tube.

[sbrinton]

Sometimes everyone is tired and needs a break. I remember being really frustrated when Zephan would have a day where he was not getting the volumes I was hoping for by breast. I sometimes felt like a failure, even though how much he ate wasn't really up to me. I had to get used to the idea that he would learn some things slowly. He wasn't even supposed to be born for another 6 weeks when we were beginning to breastfeed almost around the clock. After a week or so, however, he got stronger and became more consistent. It wasn't until after his due date that I stopped worrying, however!

[waldenmommy]

(Zephan's mom- we're supposed to stop worrying? ;P Missed that memo!)

To the OP:
Think of it this way... your little girl is an athelete and she is training HARD for a big event- going home and living LIFE. Now your average athelete (baby) would do fine on water (breastmilk). After all, water is perfect for hydration and replaces fluids lost during exercise (in your baby's case, exercise is feeding, growing, etc in the NICU). However, for super atheletes, like your baby, they need water with a kick- gateraide! Think about it- swimmers, football players, etc all need to replace fluids, electrolytes, etc they loose while doing their super intense workouts. She's in the middle of a super intense workout so, right now, she needs a little kick- some formula in her bm. When she's done with the super intense workout and goes not to be an average athelete, water (your milk) will do her just fine.

Every single drop of BM you are giving her is good. It is awesome, wonderful and nourshing- just like her mama.

You are not a failure and your baby is strong!

[~bookcase~]

what was her weight and gestation ?

[~bookcase~]

linky on hmf:

http://www.babymilkaction.org/update/update20.html#11

[AppleCrisp]

Hi - just wanted to say thanks for all your input. She came home last week after 4 weeks, and I did decide to go ahead and supplement her. It turns out it was only 3 teaspoons in 24 hours mixed with breastmilk, not entire bottles, so I thought that was a reasonable amount (Whether its effective or not against rickets, I have no clue....I have my doubts but I don't think its going to hurt her). They explained it to me and I read as much as I could...her labs did show she has rickets, and just the circumstances of her birth indicate that she needed more than I could give. So, I feel ok with it, and hopefully she will only be supplemented for about 8 weeks and then transition to breastfeeding exclusively.

Thanks again everyone