Preemies and hospitals/doctors

[RomanCarmelMom]

Are there federal laws concerning the feeding methods of preemies and parental rights to forbid artificial nipples, or are you completely under the authority of the doctors and hospital? I'm not talking about micro preemies, but babies that are over 5lbs and close to full term.

[MeepyCat]

I very much doubt that there is a law (federal or state) covering this issue, but I wonder why, if you had a baby in the NICU, you would *want* to forbid artificial nipples. If you forbid the use of artificial nipples for a babe in the NICU, you either need to be able to commit to camping out permanently in the NICU yourself once your child is off parenteral nutrition and feedings by gavage tube, or you needlessly prolong the use of the gavage tube. Prolonging use of the gavage tube probably means prolonging your NICU stay.

[Bokonon]

Originally Posted by MeepyCat

I very much doubt that there is a law (federal or state) covering this issue, but I wonder why, if you had a baby in the NICU, you would *want* to forbid artificial nipples. If you forbid the use of artificial nipples for a babe in the NICU, you either need to be able to commit to camping out permanently in the NICU yourself once your child is off parenteral nutrition and feedings by gavage tube, or you needlessly prolong the use of the gavage tube. Prolonging use of the gavage tube probably means prolonging your NICU stay.

I agree with this. Babies need to be taking all of their feedings by mouth to be discharged.

[RomanCarmelMom]

My child never needed to be fed those ways. He had trouble breathing that first day, and no issues after that, but they kept him to give him 3 days of antibiotics even though I had antibiotics during labor. He had no suck/swallow/breathe issues, but they insisted on bottlefeeding because they claimed that babies burned too many calories when they breastfed and he was underweight (but right on target for a 35 weeker). Then, they'd give him a pacifier to suck on. I stayed in the hospital and was pretty much permanently camped out in the NICU except to eat and get a shower. I only left one time when a nurse kicked me out and told me I needed to go sleep. While I was asleep, she gave him his first bath, which we wanted to help with, and she fed him. :-( They wouldn't let me supplement at the breast, even after a day of successful bottle feeds. They also said that nipple confusion doesn't exist and is something some women made up to try to keep other women from giving their children formula. The nurses even tried to give my baby a pacifier while I was there to comfort him! He was only being monitored and wasn't on oxygen or anything and they'd only let me hold him a few minutes at a time. I wanted to do kangaroo care to bond.

[RomanCarmelMom]

Originally Posted by Bokonon

I agree with this. Babies need to be taking all of their feedings by mouth to be discharged.

I guess I'm wondering what my rights are to demand that those feedings occur via a supplementer at the breast rather than through a bottle.

[katelove]

In Australia - your baby, your choice. The hospital staff have an obligation to tell you what course of action they believe is best and why. They must also tell you the potential implications for not choosing to take their advice. But, it is absolutely the parent's decision and the staff must abide by that. As far as I know, the same rules apply in the US.

[MeepyCat]

Originally Posted by RomanCarmelMom

My child never needed to be fed those ways. He had trouble breathing that first day, and no issues after that, but they kept him to give him 3 days of antibiotics even though I had antibiotics during labor. He had no suck/swallow/breathe issues, but they insisted on bottlefeeding because they claimed that babies burned too many calories when they breastfed and he was underweight (but right on target for a 35 weeker). Then, they'd give him a pacifier to suck on. I stayed in the hospital and was pretty much permanently camped out in the NICU except to eat and get a shower. I only left one time when a nurse kicked me out and told me I needed to go sleep. While I was asleep, she gave him his first bath, which we wanted to help with, and she fed him. :-( They wouldn't let me supplement at the breast, even after a day of successful bottle feeds. They also said that nipple confusion doesn't exist and is something some women made up to try to keep other women from giving their children formula. The nurses even tried to give my baby a pacifier while I was there to comfort him! He was only being monitored and wasn't on oxygen or anything and they'd only let me hold him a few minutes at a time. I wanted to do kangaroo care to bond.

When they say "underweight" about preemies, they aren't talking about weight for gestational age. Even an on-target 35 weeker is really small to be in the outside world and is likely to have problems with getting enough calories and maintaining body temperature. (My daughter was born at 32 weeks gestation, and was huge for her gestational age, but was clearly deeply exhausted by nursing well past 35 weeks and 5 pounds. I sincerely doubt that she was capable of getting enough calories from breast alone at that point.)

The paci is also pretty standard NICU procedure. I don't have a study to cite because Harvey Karp failed to give me one, but he claims in "The Happiest Baby on the Block" that studies have shown that pacifier use helps pre-term babies grow faster and lowers the incidence of SIDS in full-term infants. A little googling suggests that this ain't necessarily so, but NICU nurses don't like letting babies cry any more than anyone else does, and sucking can be pretty deeply comforting. So some NICU nurses believe that pacifiers are helpful, and all are fans of the paci. Nurses who were really interested in working with you would do things like give you the binkie to give to your babe.

The kangaroo care issues would make me crazy. Do you have a pediatrician? Is there a neonatal specialist assigned to your case? In the NICU we were in, neonatologists made policy and recommendations, and decisions about what actually happened were left to be made, cribside, by the nurses on duty. I understand why they did it that way, but it was sometimes maddening. We made a fair bit of progress by discussing things directly with the neonate, and the way to get to that was to say things like "I'm concerned that the way we're doing things is causing my baby to miss out on the benefits of kangaroo care. I would like to discuss it with her doctor - please page him for me."

Whatever you want to do, emphasize the benefits to the baby. When you talk about kangaroo care, it's about breathing, heartrates, improved weight gain, and positive effects on cognitive development. Bonding is all very nice, but not medically quantifiable. It's too easy for them to write off.

The not letting you supplement at the breast is just weird - I'd hit the neonate about that one too.

[CallMeMommy]

My preemie never received a feed by artificial nipple, either, he weaned straight from tube to breast.

I think it's all going to depend on your neonatologist. If you're not liking the policies the nurses are trying to push then talk directly to the doctor and get orders written specifically for your baby. You'll have a lot more weight behind your requests with a written order.

We also have a preemie/nicu forum here, I think you'd get better "been-there-done-that" support and suggestions over there.

[annekh23]

It doesn't need specific laws, you are the parent, you have right over absolutely everything, other than something that is clearly illegal. If they considered you negligent, it would depend on the exact local laws as to the timeframe any action was taken in. In theory you could refuse to even allow your child to be taken into the NICU, though again, local laws may allow them to give lifesaving treatment whilst a court order was obtained.

Less than 6 months ago, we had a baby briefly in the NICU, she was technically 37 weeks, but I didn't have an early scan and we think she was closer to 36 weeks, she was with us for 24hours, then developed symptoms of low blood sugar and on testing it was VERY low, so they rushed her straight there. She was refusing all attempts to breastfeed, so we'd already initiated feeding of pumped colostrum via a syringe and tube on my husbands finger, we were pretty clear that we didn't want any artifical nipples and the wrote a notice on the board that was pretty comprehensive, covering feeding, pacifiers and no formula.

I don't think the syringe feeding took any longer than giving her a bottle, but they called my room everytime she needed feeding in the daytime, I'm pretty sure that was because she wasn't being bottlefed, but I may have misunderstood that. So my husband would go and feed her and I would pump, the first day I couldn't make it down there (c-section), but the 2nd day I'd go and try and breastfeed her, but she wasn't interested.

She was discharged never having breastfed and only consuming half the volume of milk they wanted her to, which is pretty unusual, but it was unofficially what they recommended to us, officially they said that in theory they should keep her, they just didn't try very hard to do so, not sure whether we'd have agreed or not if they had wanted to keep her!

She ended up being at least partially tube fed for 2months, but more due to her tongue tie than her slight prematurity. Having compared notes with other mums of tongue tied babies and slightly premature babies I'm exceedingly glad that we insisted on no artifical nipples and also that we kept that up even when at about 6 weeks the lactation consultants were saying we really should move to supplementing with bottles.

[Bluegoat]

Originally Posted by MeepyCat

I very much doubt that there is a law (federal or state) covering this issue, but I wonder why, if you had a baby in the NICU, you would *want* to forbid artificial nipples. If you forbid the use of artificial nipples for a babe in the NICU, you either need to be able to commit to camping out permanently in the NICU yourself once your child is off parenteral nutrition and feedings by gavage tube, or you needlessly prolong the use of the gavage tube. Prolonging use of the gavage tube probably means prolonging your NICU stay.

Um, because in many cases there is no need, and a lot of problems, caused by giving artificial nipples. The idea that it is "too hard" for premature babies to breastfeed is bogus, this issue has been studied and it is easier for babies to breastfeed than to use a bottle. If the baby can drink from an artificial nipple, than the baby can breastfeed. And there are other methods of supplementing if required. As well, if mom is pumping for baby, she might as well come and breastfeed.

[Bokonon]

Originally Posted by Bluegoat

Um, because in many cases there is no need, and a lot of problems, caused by giving artificial nipples. The idea that it is "too hard" for premature babies to breastfeed is bogus, this issue has been studied and it is easier for babies to breastfeed than to use a bottle. If the baby can drink from an artificial nipple, than the baby can breastfeed. And there are other methods of supplementing if required. As well, if mom is pumping for baby, she might as well come and breastfeed.

Some moms can't always be in the NICU for every feeding, 24 hours a day.

[MeepyCat]

Originally Posted by Bluegoat

Um, because in many cases there is no need, and a lot of problems, caused by giving artificial nipples. The idea that it is "too hard" for premature babies to breastfeed is bogus, this issue has been studied and it is easier for babies to breastfeed than to use a bottle. If the baby can drink from an artificial nipple, than the baby can breastfeed. And there are other methods of supplementing if required. As well, if mom is pumping for baby, she might as well come and breastfeed.

I'd love to see the research on that.

Your statements do not match at all with my experience nursing (and pumping for and bottle feeding) a premature infant. And the whole "if mom is pumping for baby, she might as well come and breastfeed," thing - again, not matching with my reality. I could pump at home, and when I slept there I had a place to lie down.

I don't think that the idea that breastfeeding is a challenge for some premature infants is bogus at all. It was very clear to me from observation while we were still in the NICU that nursing exhausted my daughter and she wasn't able to do it long enough or consistently enough to get as much milk as she needed, and that, by contrast, bottle feedings did not wear her out as badly. She wasn't confused - she has a great latch and a strong suck, and she always has. She got tired. Sucking directly from the breast takes more effort than sucking even from a very slow flow nipple. Yes, now that she's home, she is somewhat resistant to the breast because the bottle is easier. I'd rather have this minor battle of wills than worry about slow weight gain, or still be stuck in the NICU.

We are working on nursing more, but DD receives calorie-fortified breast milk and vitamin supplements from bottles - 6-8 of them every day. It's easier for me to offer bottles than it is to cope with an SNS. That's entirely my call, and one that I think everyone gets to make for themselves, however, I will submit that I think the very LAST thing the mother of a premature infant needs is to take on stuff that makes daily life any harder than it already is.

[KJoslyn78]

Originally Posted by Bluegoat

Um, because in many cases there is no need, and a lot of problems, caused by giving artificial nipples. The idea that it is "too hard" for premature babies to breastfeed is bogus, this issue has been studied and it is easier for babies to breastfeed than to use a bottle. If the baby can drink from an artificial nipple, than the baby can breastfeed. And there are other methods of supplementing if required. As well, if mom is pumping for baby, she might as well come and breastfeed.

While i don't have experience with a NICU, i did have a preemie (34w5d) (yeah - long story as to why we didn't need to transfer to the hospital with NICU, short version - she was fine and didn't need it)

She could not nurse... could not. She didn't have the muscle strength to latch and suck from me. even her bottle feeding to start were small (6cc of expressed milk), and even those would take nearly 1/2 hour. We spent her first 8 days at the hospital, from 7am till midnight so i could do as many feedings as possible.

So please tell me how my baby should have been able to breastfeed - cause i dont see, in my personal experience, how it could have been possible.

[Sandstress]

Originally Posted by Bluegoat

Um, because in many cases there is no need, and a lot of problems, caused by giving artificial nipples. The idea that it is "too hard" for premature babies to breastfeed is bogus, this issue has been studied and it is easier for babies to breastfeed than to use a bottle. If the baby can drink from an artificial nipple, than the baby can breastfeed. And there are other methods of supplementing if required. As well, if mom is pumping for baby, she might as well come and breastfeed.

It's dangerous to be so dogmatic about something so variable as a NICU stay. This issue has been studied. In many babies, expending the energy to nurse is too much of a workout, for preemies and other situations like congenital heart defects. In other babies, the difference isn't that big of a deal.

In our case, there is a HUGE difference between nursing successfully (which is what I wanted my 28 week dd to do) and using a "preemie" nipple (already small and fast flow) with the holes widened to drink calorie-supplemented EBM. Yes, you take a chance with nipple preference (as we did, and lost- ended up EPing), but then again, you get to take your baby home sooner. I wanted her out of that place as soon as possible, and I took her home with an NG tube in combo with bottles. To others, refusing artifical nipples was more important than having the privacy of your own home, and I don't judge them- just didn't want to be them.

[BugMacGee]

In my 9 years of NICU nursing experience, I can pretty confidently say that if you refuse all artificial nipples, you are committing your baby to a longer NICU stay. I, personally, believe it is more important to have your baby home with you.

[spughy]

It's illogical to state that nipple confusion is a major issue AND that preemies can breastfeed as easily as they can bottlefeed. As someone (Dr. Newman?) said, it's not nipple "confusion" - it's nipple preference. Bottles ARE easier for babies to drink from. And preemies ARE smaller, weaker, tire more easily and need every speck of nutrition they can take in.

I just did an observation yesterday on the NICU ward at my local hospital, for a breastfeeding educator course I'm doing. Mamas are strongly encouraged to try breastfeeding their babies at every feed whenever possible, but the majority of the babies' calories are from bottles or, in the more intensive care sections, gavage tubes. However, MOST of the babies, even the really tiny, really sick ones, are getting the majority, if not all, of their calories from breastmilk. (Donor milk is now being used for the most sick babies.) All the nurses I talked to said it's very, very rare for a mama not to pump. The only babies that were getting formula were one whose mama had serious drug-addiction issues () and one who had been in the NICU for months and the mama's milk dried up because she didn't respond well to the pump. Even the baby whose mama was positive for H1N1 was getting her breastmilk! But most of it was via bottles & gavage.

So even in a VERY pro-breastfeeding hospital they still use bottles, because the #1 rule is "Feed the Baby" and the #2 rule is "Get the baby home ASAP." Mamas certainly CAN supplement at the breast if they wish, but SNS systems or LactAids typically don't work all that well if the baby has a weak or ineffective suck, as many preemies do. That's just an unfortunate reality, and yes, they probably could suggest mamas use an SNS more often - but I've seen babies with poor latches try to nurse with an SNS and they don't get much more than from the breast alone. And trying to work on latching with a baby who is weak, and possibly sick, is very hard on the already-stressed mama and possibly dangerous for the baby.

There ARE babies in the NICU who are exclusively fed at the breast, but they're rare. It's unfortunate, but it's the way it is - and while nipple preference certainly IS a risk of a NICU stay, I'd say it's more of an unavoidable risk in most cases. Most mamas would probably rather risk nipple preference and get their babies home sooner, and work on the nipple preference when the baby is bigger and strong enough to cope with some struggle for a feed.

That having been said, OP - it sounds like the care at the hospital you were at was very different, and they could stand to take a step back and look at the guidelines they have and ask WHY they have those guidelines, and if it wouldn't make sense occasionally to let the available, willing mama and the available, willing breasts do some of their work for them! I understand you're angry, and rightly so... but it might help you to be more at peace with your experience if you understand the rationale behind the regulations. By all means, ASK them about the parts that didn't make sense to you, and if their answers are contradicted by good current research, let them know.

[Little Bear's Mama]

Originally Posted by RomanCarmelMom

Are there federal laws concerning the feeding methods of preemies and parental rights to forbid artificial nipples, or are you completely under the authority of the doctors and hospital? I'm not talking about micro preemies, but babies that are over 5lbs and close to full term.

In any hospital, you're pretty much under the rules set by administration, but that doesn't mean you're helpless. Patients can have a say in their own care. Furthermore, patients are consumers and have a level of power in that role.

Originally Posted by RomanCarmelMom

My child never needed to be fed those ways. He had trouble breathing that first day, and no issues after that, but they kept him to give him 3 days of antibiotics even though I had antibiotics during labor. He had no suck/swallow/breathe issues, but they insisted on bottlefeeding because they claimed that babies burned too many calories when they breastfed and he was underweight (but right on target for a 35 weeker). Then, they'd give him a pacifier to suck on. I stayed in the hospital and was pretty much permanently camped out in the NICU except to eat and get a shower. I only left one time when a nurse kicked me out and told me I needed to go sleep.

That notion that bottle feeding burns less calories and is better (generalized) for preterm babies is not evidence-based.

Here is a little bit of information:

As feedings advance, discussions related to evidence-based oral motor mechanics and the objective measurement and facilitation of milk transfer are incorporated into the plan of care. Early studies by Meier19,20 and others21–23 reveal more optimal physiologic variables (ie, oxygen saturation, respiration, heart rate, and body temperature) during breast-feeding than during bottle-feeding. In several observational studies by Nyqvist et al,24,25 preterm infants as early as 28 weeks demonstrated rooting, areolar grasp, latching on, nutritive sucking from 30.6 weeks, and repeated swallowing at 31 weeks. The compilation of these studies demonstrates the physiologic stability of the preterm infant during breast-feeding, and thus shatters the myth of the necessity to delay breast-feeding until the infant has demonstrated the ability to bottle-feed successfully.The 3 M's of Breast-feeding the Preterm Infant

(The article goes on to discuss ways to assure a preterm baby gets enough milk while breastfeeding directly, and urges NICU staff to preserve the breastfeeding relationship.)

More information in this article:
BREASTFEEDING IN THE SPECIAL CARE NURSERY: Prematures and Infants with Medical Problems

Originally Posted by RomanCarmelMom

While I was asleep, she gave him his first bath, which we wanted to help with, and she fed him. :-(

I'm so sorry. : It hurt not to be there for that special moment, especially since the nurse knew you were coming back.

Sometimes nurses overstep their roles, seeming to forget that the mother is who the baby belongs to. Sometimes nurses misunderstand (or simply don't try to understand) a mother's intent, or feelings about a particular issue. Here is a great study that deals with the relationships between nurses and mothers in the NICU that you might want to look over and share:
Vigilant Watching Over: Mothers' Actions to Safeguard Their Premature Babies in the Newborn Intensive Care Nursery

Originally Posted by RomanCarmelMom

They also said that nipple confusion doesn't exist and is something some women made up to try to keep other women from giving their children formula.

That isn't an uncommon opinion. I don't think you will change anyone's mind about nipple confusion, but I believe you can make a difference when it comes to nurses over stepping their roles in the NICU where your baby stayed (is staying?). More hospitals are moving towards "family centered care", as research proves it is not only cost effective but promotes better care for babies in the hospital and beyond.

Originally Posted by RomanCarmelMom

The nurses even tried to give my baby a pacifier while I was there to comfort him! He was only being monitored and wasn't on oxygen or anything and they'd only let me hold him a few minutes at a time. I wanted to do kangaroo care to bond.

From what you're telling us, that doesn't make any kind of logical sense. Did you ask for the rationale behind the refusal to allow you to hold your baby? If the nurse couldn't provide satisfactory answers, I would then suggest contacting your baby's doctor and talking to him/her directly.

Here is some information on KMC to share:
Kangaroo Mother Care: Research
Table of KMC studies/outcomes
A Randomized, Controlled Trial of Kangaroo Mother Care: Results of Follow-Up at 1 Year of Corrected Age
Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns.
KMC: Holden NICU

Originally Posted by RomanCarmelMom

I guess I'm wondering what my rights are to demand that those feedings occur via a supplementer at the breast rather than through a bottle.

The best thing I could suggest is to talk to your baby's doctor. Ask questions. Talk about what you want and why. Ask him/her to advocate for you with the nurses.

Here's a great article about how to talk to your doctor:
Coaching for More Effective Communication with Your Doctor

Here is a well-known and well-regarded resource that you can share with your baby's doctor. It discusses, in detail, the scenerio you described and what the best practice is for that situation.
Care and Management of the Late Preterm Infant Toolkit (Click the first PDF link)

Another resource to read and share:
Humane Neonatal Care Initiative (long list of resources at end of article especially helpful)

Does your hospital have an IBCLC on staff? If so, you might wish to get her involved in the conversation (and if you haven't already done so, ask for her support in establishing your breastfeeding relationship).

Good luck and please let us know how things are going!

[Siera]

Originally Posted by Bluegoat

Um, because in many cases there is no need, and a lot of problems, caused by giving artificial nipples. The idea that it is "too hard" for premature babies to breastfeed is bogus, this issue has been studied and it is easier for babies to breastfeed than to use a bottle. If the baby can drink from an artificial nipple, than the baby can breastfeed. And there are other methods of supplementing if required. As well, if mom is pumping for baby, she might as well come and breastfeed.

This was definitely my experience. My DD was born at 31 weeks. We received the same crap about how bottles are less stressful than breastfeeding, etc, etc. Really??? I mean, my DD was SOOOO attached to the breast (or at least wanted to be even at that little age, and could transfer a lot!) but the NICU would not allow it. I put my foot down once and said no more bottles and they called the "bottle feeding police" on me aka the occupational therapists. They pulled what I call the "sick baby card" on me. In other words, if I chose to cut out all bottles, then DD could be in the NICU for WEEKS extra. I backed down. Now, if I had to do it all over again, I would not have backed down. I would have stood my ground regarding breast or nothing!!! I lived at the NICU, so that was not a problem. I was willing to sit in that recliner for 24 hours if need be to feed my child at the breast. And, remember that YOU know your child best! I knew that DD preferred the breast. In fact, she hated the bottles so much. I could easily argue with a doctor that we stayed in the NICU longer because of the bottles. And by the way, she was not micro. She was almost 5 pounds at 31 weeks, so she was a big girl and she had her preferences set already. Ultimately, these babies are OUR babies. Not theirs. Just because you do not have MD or RN after your name does not mean you do not count! I'm sure you've done plenty of research and know your stuff. You also have mothers intuition. I think if more moms put their foot down and communicate with their doctors (but don't just roll over and let them take our kids) then doctors and nurses would be forced to deal with us differently. Just my two cents worth. This subject makes me very angry.

[CallMeMommy]

Originally Posted by BugMacGee

In my 9 years of NICU nursing experience, I can pretty confidently say that if you refuse all artificial nipples, you are committing your baby to a longer NICU stay. I, personally, believe it is more important to have your baby home with you.

See, and that's exactly the opposite of what all of our NICU nurses said during our son's stay. I never saw a baby fed via bottle unless it was full of formula (and I was one of the moms lucky enough to say there almost around the clock). If your baby was breast-fed, if you couldn't nurse them they received the milk via tube.

[Bokonon]

Originally Posted by CallMeMommy

See, and that's exactly the opposite of what all of our NICU nurses said during our son's stay. I never saw a baby fed via bottle unless it was full of formula (and I was one of the moms lucky enough to say there almost around the clock). If your baby was breast-fed, if you couldn't nurse them they received the milk via tube.

That's awful - so if mom was unable to spend 24/7 in the NICU, her baby would inevitably end up staying there until mom could be there 24/7? What if she wasn't producing enough milk? Because a baby can't be discharged with a feeding tube unless they absolutely need it to be fed. I would be livid if my NICU had tube-fed my baby when I wasn't there for feedings, when it was capable of taking a bottle, especially because it would have further delayed discharge.