Transitioning to exclusive breastfeeding (a preemie)

[kathteach]

Anyone have any tips to share? My preemie came home from the NICU last Thursday. I've worked with an LC. Both she and the doctor told me to breast feed him for five to ten minutes, then give a bottle. His suck is really weak--in fact, he needed help to eat from a bottle at first but can now drink on his own, but it takes him about forty minutes to drink his bottle. I am not supposed to tire him out too much with the breastfeeding that he doesn't eat enough. For the most part he gets the breastfeeding. What I don't get is how to move towards just only breastfeeding. He is consuming more expressed bm from the bottle as the days have gone by--but shouldn't he be breastfeeding more and having the bottle stay the same? Or is that unrealistic to expect? I am so afraid of starving him. I would love some advice. I EP'ed for my first and really want breastfeeding to work this time.

[emilysmama]

Congratulations on your new arrival! I think that it's fantastic that you are expressing milk for your baby. I can't think of a more stressful time to pump than when you have a baby in the NICU, so I really admire you.

My daughter had a weak suck. She spent a couple weeks in NICU for jaundice, but she wasn't a premie (just 2 weeks earlier), so what I have to say you may want to take with a grain of salt.

To encourage stronger sucking, LC had us stick adult pinkie finger into baby's mouth, pad side up and nail side down. It soothed baby instead of pacifier and was supposed to strengthen baby's sucking. (It was also much handier than a pacifier because we never lost the finger. Plus, it helped us avoid nipple confusion.)

Also, LC had us use Haberman feeder bottle to develop stronger suck. About half of the premies in the NICU used the Haberman instead of a conventional bottle. Also, it helped us avoid nipple confusion.

As far as how much time on breast, and how much time on bottle, I cannot say because I have no experience with premies. I am sure other mothers will have better advice in that regard.

[Valian]

There are some good threads around about nursing preemies. It really is a differen experience. I knew I've posted about our experiences in the past so I'm pasting parts of old responses I wrote because I figure it may be older but its likely to be more accurate than my memory is now

Quoting myself ...
"Here's a bit of my story. We started with nursing once a day and otherwise EBM in a bottle. After 1-1.5 weeks we upped it to two nursing sessions a day, then in another week to nursing every other feeding and finally the week before he was due we "graduated" to all nursing all the time. Yay! Before that time, I pumped everytime he took a bottle and 3 hours almost around the clock until we went 100% to the breast. Boy, I was glad to finish that!

All of this nursing was done with a nipple shield to make latching easier. Also, we offered a bottle at the end of every nursing session, including the first week we went 100% to the breast, to ensure that nursing sessions weren't ending just because he was too tired to suck anymore rather than because he was full. It sounds like you're doing this too and that your son keeps going until he is full and I think that is a good sign.

We did a few weeks of 100% nursing on the breast with the nipple shield and then worked on ditching the shield. He did fine latching off of the shield but then we ran into some other (non related medical) complications that made our nursing relationship rough again. But I can say that today, at 5.5 mo (4mo adjusted) I have a good supply of milk and he's nursing great."


My Dh was in a rush for us to ditch bottles and get 100% on the breast but honestly, Ds needed time to grow and become strong enough to fill himself by nursing. I felt this slow, comfortable pace for him was an important part of helping him adjust to the world without triggering fear around hunger. In hingsight, my Dh respsects that this is what our Ds needed, even though at the time he felt anxious about getting started with nursing."

And another post I wrote:
"Preemies get really worn out sucking. If babe is nursing too long she's burning as many calories trying to bf as she can take in. I'd suggest limiting nursing sessions to 30min max so babe doesn't wear herself out. Mom should pump to stimulate and baby should be offered ebm by syringe or bottle after every single feeding.

Obviously feed on demand. Feed until she stops, but IMO, don't try to force her to continue. Rest is really important, just as important as food. Actually, 0.5oz sounds like a good session to me (for a 35 weeker at 37weeks). That tiny tummy might really be filling up on 0.5oz. Think in terms of daily intake, not per session. Assuming the babe is still really sleepy, I would not wake the babe more often than every 3 hours to nurse. This will give her time to re-coup her strength before the next session. "


Just to add a few more details: Our limits were, IIRC, nurse no longer than 20min OR until baby stops the suck-swallow-breathe sequence (meaning the pauses get real long signaling baby stops eating). Always offer a bottle immed. after 20min or when baby seems to have dropped off to sleep. Feed on demand but never wake babe sooner than 3 hours after the start of the last feed (i.e. baby should get 2-2.5 hours of sleep min between nursing sessions to recharge). Ds never would suck on our pinky finger, he thought we were nuts to even offer.

Weaning from the bottle: We recorded the volume of intake by bottle and tracked the volume by the day and looked for increases there rather than session by sesssion. As he neared his due date, Ds was still taking in a lot from the bottle, then spitting most of it back up (i.e. it became clear he was sucking on the bottle because he liked to suck and was becoming overfull because he couldn't stop the flow, kwim?) At that point we slowed down to offering the bottle every other feeding session, then just twice a day, then just afternoon/evening when Ds would be more wornout, then only if he seemed hungry and my breasts were 'empty' (i.e. he wasn't strong enough to extract any more milk). We waited 3-4 days between the different phases. I'm pretty sure we weren't completely weaned off the ebm bottles until right around EDD or even a week or two later.

[Tendaironi]

You didn't say how early your baby was. I don't agree with the five minutes and that isn't what I was told with my preemie. The NEO's told me to feed for 20-30 no more than that and then follow up with a bottle after that. His ped said 5 minutes too too but I disagreed with him and did what I wanted to! It seems wrong to say that breastfeeding tires out all preemies more than the bottle, when not every preemie is the same and not everybodies breastmilk flows slow. Some women are like geysers! Plus following that strategy will not lead to exclusive breastfeeding, the baby gets older and starts like the bottle better rather than the breast.

DS had a weak suck too and was just really sleepy until his due date, which I heard is normally the case with boy preemies from the LC at NICU. She also said when I brought him home I could do bf him whenever I wanted or when he wanted rather. The NICU was fussy about eating every 3 hours only, but when I got him home I fed him whenever he wanted but woke him up after 3 hours. Our biggest turn around was when I started nursing Noah at night rather than making a bottle. We both slept longer and Noah would latch on and sleep for hours, sucking on and off. He gained a lot of weight that way.

How do you feel about the situation? Do you think he is ready to bf full-time? If I were you I would rent a baby scale and go breastfeed full-time for a few days. I would let him stay latched on as long as he wants too but I would watch and listen for the pauses when he swallows and also count how many wet diapers. Check out this site for little videos of the sucking pause and other things http://www.thebirthden.com/Newman.html. With the weighing before and after every feed or just 2x a day if you want and counting diapers you can feel confident that your baby is getting enough food. I was so afraid that Noah wasn't getting enough food and I was totally underestimating my supply. I knew I had supply problems but I had more than I thought. Good luck to you and congratulations on your baby!

www.kellymom.com/bf/preemie/preemie-links.html

www.lalecheleague.org/NB/NBpremature.html

[letniaLynne]

Originally Posted by Valian

Weaning from the bottle: We recorded the volume of intake by bottle and tracked the volume by the day and looked for increases there rather than session by sesssion. As he neared his due date, Ds was still taking in a lot from the bottle, then spitting most of it back up (i.e. it became clear he was sucking on the bottle because he liked to suck and was becoming overfull because he couldn't stop the flow, kwim?) At that point we slowed down to offering the bottle every other feeding session, then just twice a day, then just afternoon/evening when Ds would be more wornout, then only if he seemed hungry and my breasts were 'empty' (i.e. he wasn't strong enough to extract any more milk). We waited 3-4 days between the different phases. I'm pretty sure we weren't completely weaned off the ebm bottles until right around EDD or even a week or two later.

This seems really smart! If the amount taken by bottle throughout the day increases then I would reduce the number of bottles offered and continue that pattern until you are fully BFing.

On a side note I would not be using a bottle at all, I would be really scaird of nipple confusion. I have had it due to bottles and that is one of the main reason why I am EPing currently. I would try another method such as a syringe, something that has nothing to suck on to deliver the milk.

Also what about an SNS when your babe gets a bit bigger but is not totally ready to EBF, just to get rid of those last few bottles. You could insert the tube when his suck, swallow pattern is no longer removing much milk after you do some breast compressions to empty your breast as much as possible.

Hugs I am really pulling for you, you need to succeed for all EPers who never want to EPump with the next babe.

[MamaSS]

Congrats on having your baby home!

I had twin boys at 26 weeks & 6 days. They spent 86 & 99 days in the NICU. When Seth came home I continued to pump & made a few attempts to nurse him when I could. I had very little help in actually nursing them from the NICU staff (a few were good, but they really just wanted them eating orally period) and I probably saw the hospital LC less than a handful of times during the entire 3 months. However, I was determined that when I had them both home I was putting the pump away & letting it collect dust. No way did I want to continue to pump & bottle feed 2 babies...especially considering I was going to be home alone with them 95% of the time.

So, when Sean came home I had an LC come in. She was AMAZING! And I never gave either of them a bottle from that point on, never pumped again either (til I went back to work at a year). It was tough. There were days that I felt like I did nothing except nurse them and go to the bathroom. I used nipple shields with them both for a while. Seth was pretty efficient at nursing but Sean was awful. He was constantly falling asleep, sometimes after 5 minutes, and most times during those first couple weeks I would spend 45 minutes trying to get him to nurse. I know people say they get more tired out by nursing, however, in the 2 weeks that I had Seth home and was still pumping & bottle feeding him EBM, I realized he had more "spells" with the bottle (they both came home on apnea monitors). so that was another contributing factor to wanting to exclusively nurse. If there is one thing I can say, it's to just keep nursing. The more the baby nurses the better it will get at it.

So, I had this notebook that I wrote down every single feeding, the duration, which breast he started on, etc. I wrote this down for each child, every feeding for at least 2 months consistently. This really helped me keep an eye on how often they were nursing, and see how the slowly became efficient at it. I also had a baby scale that I would use at least twice a day to ensure they were getting something. Sean was a slow gainer, but he did gain and at 3 years old, they are both just above 30 lbs. and completely healthy. I exclusively nursed them from the time they came out of the NICU (October) til about February (they were born in July) and then started introducing rice cereal, etc. And I nursed them til they were 26 months old. And I had one nurse tell me (while still in the NICU) that they would "probably never exclusively nurse" and that I would "most likely always have to supplement with something". And I NEVER ONCE gave them formula.

[GooeyRN]

Hi there! I haven't seen you on lately and I was worried about your and Desmond. I am so glad he is home from the NICU. How long was his stay? He was born at 34 weeks if I remember, right? I am glad he is accepting the breast some! Can you try an SNS or lactaid? Maybe use a Haberman a few times a day to get a stronger suck? I would try to avoid bottles. I learned the hard way with my dd, and thats why I wound up EPing. I really hope things turn out well for you guys this time. How are you doing? Are you feeling ok physically and emotionally? How is Desmond?

[kathteach]

Thanks all for the support and advice. To give you a little background, Desmond was born at 33 weeks. He was deprived of oxygen and his organs took a hit. Even babies born much younger than him fed better in the NICU, and I don't know why that is. When we brought him home we basically had to use our fingers on his chin /jaw and cheeks to support him to drink from the bottle. He couldn't suck on his own.

I did try an SNS. It broke the suction when I put it inside my nipple shield though. It is a huge pain in the @$$ but I think I will try it again but with the tube in the corner of his mouth like GooeyRN said. I don't know what a Haberman feeder is. I saw it in the Medela catalogue but I don't know how it works, I'll ask the LC about it. I might rent the scale, that's a good idea.

I am getting more comfortable with positioning, that's a plus. (I'm definitely looking for pluses here.) He seems to like breastfeeding, that makes me feel good.

I just want to be done with the whole nursing/bottle/pumping routine. I want to not worry about if we'll succeed. I want this to be over with us already having come out on the good side. The bad side is ep'ing and possibly formula and that's something I have to realize may happen because there are no guarantees and hard work doesn't always get you what you want and it is dragging me down. I need your support here guys.

[GooeyRN]

Originally Posted by kathteach

I just want to be done with the whole nursing/bottle/pumping routine. I want to not worry about if we'll succeed. I want this to be over with us already having come out on the good side. The bad side is ep'ing and possibly formula and that's something I have to realize may happen because there are no guarantees and hard work doesn't always get you what you want and it is dragging me down. I need your support here guys.

Yuo have my support! I completely understand you wanting to be done with the whole nursing/bottle/pumping routine! It is more than exhausting, ESPECIALLY when you have another little one at home to care for.

I think its wonderful that he seems to like breastfeeding. Hopefully, he stays interested so that he can bf full-time once he gets strong enough. It sucks that it isn't coming easy for you guys. But you are putting so much effort into it, you deserve to have a long, easy bfing relationship! Hopefully you won't have to EP again, but if it comes down to that and/or formula feeding, it doesn't change the fact that you are an AMAZING mother! I am really pulling for this to work out for you. Hang in there, and keep us posted!!!

[veganone]

i absolutely support you! dd is 7 weeks and we were triple feeding for at about four weeks... it's so hard, but it gets better! i never did get the hang of the sns and was also on a nipple shield... we are now nursing without the ns all the time (almost two weeks now) and are down to one bottle in the evenings,mostly because i have raynaud's and give up when she marathon-nurses... we used formula on and off for her supplements.

you'll get there and it's worth it...

for me, letting myself back off on the pumping and allowing some formula probably saved our bf'ing because i emotionally couldn't take it anymore... all those bottles and the ns made for a tricky latch, but dd loves nursing and prefers it to the bottle... i am just now starting to feel "normal", but it's wonderful.

DD went up and down on how much she was getting from the bottle. I bf'ed before EVERY bottle and she just got it if she was still hungry. After some trial and error I figured out that I can't let her nurse as long as she wants to because she'll never stop on her own and does end up getting even more hungry from all of the nursing... We do up to 20 minutes per side if she's actively eating. When she starts just flutter sucking I pop her off... I think that the bottles went up during growth spurts...

Keep it up, momma!!! You're doing so great.

[kathteach]

Thanks so much for the support. I am so down right now. Nothing seems to be improving. Sometimes he just struggles so much at the breast that he is mostly getting everything via bottle. Exclusive pumping is looking pretty attractive right now, especially when all this feeding cr@p is taking so much time away from my toddler. I have another LC app't today but I can't keep going to her forever at seventy bucks a pop. I am hating my boobs right now and mad at everything. :

[GooeyRN]

If your other post you stated you have flat nipples. Have you tried nipple shells? Not the shields you wear during nursing, but you wear them between nursing/pumping and they pull your nipple out. I am going to start wearing mine soon, even though still pregnant. I know how hard it is to get a baby to latch with flat nipples, unfortunatley. :

[veganone]

I have flat nipples too. I think it's worth it to keep nursing, if you can, even for short periods... I think keeping up the nursing at all is what got DD imprinted on the boob and why we were able to transition to nursing more. I pump maybe twice a day to try to have enough for her one bottle at night, when she's tanking up.

I'm so sorry it's so hard - I can't tell you how many times I almost gave up completely and went to ff'ing. I can't imagine doing it with a toddler too.

Hugs, and do what you need to for both of your little ones and yourself!

[kathteach]

Thanks Veganone and Crystal for checking in and responding. It is keeping me going.
I went back to the LC. Basically she told me my expectations were too high, that he was doing well for his gestational age and like you said Veganone do what I need to do for my family. She told me he's drinking way too much from the bottle and that he's doing so because he likes to suck. Why not from my boob as much as the bottle I don't know, but she recommended a pacifier. She said no more than 3 oz from the bottle and she based it on his weight. She also said I don't have to follow up with a bottle every single feeding. I haven't been brave enough to do that but I think I will. He weighs seven pounds now. She said to not expect much until Thanksgiving (his EDD was Nov. 12.)
All I can do is try. That's all I can do.

(Crystal, about the breast shell things, I did some research on the internet that said they weren't effective so I never got any. Are you finding that they work?)


Keep cheering me on, I need it so bad! I am so grateful for all the cheerleading!!!

[GooeyRN]

Originally Posted by kathteach

(Crystal, about the breast shell things, I did some research on the internet that said they weren't effective so I never got any. Are you finding that they work?)


Keep cheering me on, I need it so bad! I am so grateful for all the cheerleading!!!

I haven't yet used the nipple shells. I used the breast shells in the past for extrememly sore nipples (I had some nipple necrosis from an infection from pumping, OUCH!) and they did draw my nipples out some. But, by that time, dd wouldn't even look at a boob without screaming in protest. The nipple shells are made by medela, and I think they were somewhere around $15. I don't plan on using them for another week or two.

Your son was born quite early. I wouldn't give up hope of bfing yet. I think your LC is right, that you need to give him a little more time. Its probably a lot of work for him bf. Can you offer the bottle after every other feed? Or if you aren't comfortable with that, maybe reduce the amount of milk in the bottle? I would expect him to be a bit fussy at first, but I think he would learn he has to take more from the breast if he wants more. 3 oz per feeding does seem like a lot for a baby his age. My dd didn't take 3 oz at a time from a bottle until she was several months old. You would obviously have to feed him more often, which means more work, but cutting back on the amount given from the bottle may give him incentive to bf longer. Its great that he is already 7 lbs! It sounds like he is getting more than enough to eat. Maybe your LC is right, that he is just enjoying the sucking? I don't know if I would go with a pacifier though. Maybe your finger? Or try the breast again after he finishes a very small bottle?

I have been thinking of you so much lately. I know what you went through to EP the first time, and I would really hate to see you have to do that long term with a baby AND a toddler to care for. I am really pulling for you guys! Don't give up hope!!!

[kathteach]

Just a little update here. I have been able to have three feedings so far (not in the same day though) where I didn't have to top off with the bottle. I am going to try doing that at least once a day and then work up from there going to two exclusive feedings per day, three, etc. Does that sound like a good plan? Desmond is gaining weight like a champ and is 7lb 14oz so I think we can afford to experiment a little. His due date is coming soon, too. What do you think?

[GooeyRN]

As long as he is still very interested in the breast, I think its a great idea. I would just watch for him loosing interest in the breast or difficulty latching.

[veganone]

That's awesome!!! I remember (vaguely, through my sleep deprived haze) those first feedings where she WASN'T starving after a feeding. That's awesome. Keep up the bf'ing and he'll learn to enjoy that. DD really does love to nurse and we did give in (after she was mostly exclusively bfing) and got a pacifier for when she's just too upset. It's helping some.

I'm to the point now that I get excited for a bottle free day, not feeding... You'll get there!

[Valian]

Yay! That is wonderful news and it sounds like a great plan to me. IIRC, our LC said that full bfing by the EDD may be a good goal, but in reality that many (if not most) preemies will still be tapering off of supplement at that point. I'm so glad to hear you're making it!

[veganone]

Yeah, we started tapering off around her EDD and are just now down to no supplement some days and only one on days she does get one. Her EDD was a month ago... It takes time and more patience than I knew I had.