33 weeker's weight gain... use formulat for fortification?

[onetrumpeter]

DD2 is our first preemie - DD1 and DS were term, birth center and homebirths.  I developed severe pre-eclampsia w/ this one.  She was born via c section on July 2, *right* at 33 wks.

At birth she was 3.10 (1650 grams).  That was 15th percentile.  My older kids were 80-90th centiles so I was a bit surprised at how small she was.  No one mentioned IUGR, but I wonder of my pre-e caused growth problems for her, or if she's just genetically small?

NICU stay for 25 days. In the NICU she got my milk but they used fortifier to make it 24 cal/oz (20 cal/oz which is average human milk). Then they changed that to 22 cal/oz after a couple of weeks until she was discharged. For her last six or so days I nursed her for 1-3 feedings/day. Our discharge feeding plan was for her to nurse but get at least 2 bottles per day of milk w/ a formula powder added to fortify it to 22 cal/oz. (1/4 tsp powder to 45 mL milk of Enfasure - an Enfamil preemie formula; in the NICU they used a different fortifier but it was not human milk based; it was called "human milk fortifier" but was bovine based)

Discharged July 26.  Next day visit to the pediatrician she was 5lbs 1.2 (every tenth of an ounce counts to me!).  Still 15th percentile.  So she'd stayed at 15th percentile basically her whole NICU stay, getting the fortified milk for most of her feedings.  Ped was OK w/ us doing all nursing (thus no formula).  I said I didn't want to do the formula powder if we didn't need it; she said something to the effect of "nature takes care of its own," meaning I guess my milk has what she needs.  I SO appreciate that but b/c of the below, question it:

Ped wanted a weight check five days later - she was then 5lbs 5.8oz.  Ped said it was satisfactory; do a follow up in one week.  So yesterday she was up to 5lbs 11.2 oz.  Up 5.4 oz in one week.  Ped is OK w/ this and our next appt is in 3 wks for her two month check-up.  Ped printed out a growth chart for me.  It shows that:

1st visit, 36 wks, 5.08 lbs, 15th %tile

2nd visit, 37 wks, 5.36lbs, 11th %tile

yesterday, 38 wks, 5.7lbs, 10th %tile

So she's dropping %tiles and she's busting her butt eating and having lots of wets and poopy dipes.  I think she's consuming as much volume as is nearly possible.  I'm basically nursing her on just one breast to make sure she's getting good amts of hind milk (pumping the other side).  I fear we need to add formula to our feeding plan (which we've not been doing) to increase calories and keep from dropping %tiles further...  Should I just expect that since in the NICU she was getting mostly (all at the beginning; maybe 80% once we started nursing a week before her discharge) 22 cal/oz milk that she'd slow her gaining once home???

Would love thoughts on preemie growth!!

[Adaline'sMama]

I don't have a preemie, but DD was born at 6.8 and dropped to 5.8 before we left the hospital, so we had to monitor her growth super closely. I wouldnt worry too much about the percentiles, as she is growing and having lots of poo and pee dipes. Personally, I know it felt good for me to know that she was gaining .5-1 oz per week, and I know that's not nearly as likely with a babe your age. (DD was born at 37 weeks). If you feel like she is thriving and she is obviously eating a lot, I wouldnt worry too much.

How's nursing going? I would be tempted to use formula to fortify the breastmilk if babe was eating from a bottle, but I wouldnt sacrifice at the boob sessions to bottlefeed to supplement. But, since you have three weeks until your next appointment, you could give it one more week, weigh her, and if you feel like she hasnt gained enough, then make the decision.

Good luck :)

[Phoenix~Mama]

I had a term and a preemie, and my preemie was actually almost as big as my term.  lol

I would not stress over the percentiles, and not look at them at all anyway.  They mean nothing.  Everyone has to fill out a spot on the percentile, because obviously we can't all be at 80%.  ;-)

As long as she keeps gaining, that is the important part.  My DD who was full term has always been petite, and at 3.5, she still is.  She wasn't even on the growth charts percentile for a time, but was still going up on her own little growth curve.

So, really Mama, don't worry about the percentile.  *hugs*  And it's great that you guys can exclusively nurse!!  Awesome!  :-)
 

[SpeechieMama]

Hi onetrumpeter,

I work as part of a team in a medically based feeding clinic so I thought I'd throw my thoughts in. First of all, awesome job keeping track of her weight, and being so vigilant about her progress. It can be hard to figure out, because (term) babies usually lose some weight when they're born, and preemie babes don't necessarily have a "normal" trajectory to follow.

My first recommendation would be to establish care with a feeding clinic in the area. Your PCP can refer you. Make sure it has a team consisting of a feeding specialist (usually an SLP or an OT), developmental pediatrician or nurse practicioner, and a dietician. If you think your babe is working too hard to eat, you're probably right! All that work can burn calories, too, which is no good.

Establishing care with a feeding clinic will be great because they will be able to follow you as you transition to purees aroun 6 months (corrected age) and then eventually solids. They will be able to confirm if the work she has to do to eat is more than normal, and will help you figure out exactly how many calories she needs.

Let me know if you need help looking, and good luck!

[Ratchet]

I agree with SpeechieMama-- get involved with a feeding team-- and I agree with your pedi-- you don't need fortification and a weight check in 3 weeks is fine so long as she has lots of wet and poopie diapers, feeds well, etc.  Dropping from 15th to 10th percentile is not that big of a drop, and it's important to see what happens over the course of time.  She might be finding her own percentile here and won't keep dropping.  So, not something to ignore, and good to be pro-active about it, but not something necessarily wrong at this point.  

[onetrumpeter]

hey!  thanks so much for all the support and thoughts.  I think I should have worded "busting her butt" differently; I mean she was eating all she possibly could, as far as I could tell.  But that wording does make it sound like she was working too hard to eat.  I don't think that's the case...

I've gone back to waking her for feeding every three hours and she's really gaining weight!  We saw and IBCLC last Friday, and she was 6lbs 2.8 oz, and today (5 days later) she is almost 6lbs 9oz!  

My present concern is that on Monday she failed her OAE hearing screening.  Right before she was discharged, she was given the ABR (brainstem) hearing screening and failed it twice in both ears.  So we were referred for follow up.  Well, since she's now failed the follow up we have more testing to do.  The next next is a BAER, which the receptionist said is 2hrs and she's supposed to be asleep. Huh.  Hope I can make that happen!  I'm having quite an emotional roller coaster ride over the idea of her not hearing or not hearing well.  We've been trying to see if she'll react to any loud sounds or any sounds at all, and she isn't.  She does look at our faces, but it doesn't seem to correspond to our speaking; she just seems interested in faces (which seems normal).  

Anyone get to this point in hearing screening/testing?  Feeling rather heartbroken.  I am a musician.  Hard to imagine my daughter not being able to hear.  Wondering if any abx she got in the NICU contributed?  Supposedly the -mycins are ototoxic (toxic to hearing) but I was in SUCH a fog in her early days in the NICU that I don't remember what she got.  I seem to recall something given as prophylaxis but don't think she had an infection.  I think medical records is the only way I'll find that out...  off to post in special needs about this...