Read What to Expect the First Year Online
Authors: Heidi Murkoff
What to Expect the First Year (130 page)
IV feeding.
When a very small newborn is rushed to the intensive care nursery, an intravenous solution of water, sugar, and certain electrolytes is often given to prevent dehydration and electrolyte depletion. Very sick or small babies (usually those who arrive before 28 weeks gestation) continue to receive nutrition through their IV. Called total parenteral nutrition (TPN) or parenteral hyperalimentation, this balanced blend of protein, fat, sugar, vitamins, minerals, and IV fluids is given until the baby can tolerate milk feedings. Once your baby is able to begin milk feedings by gavage, TPN will decrease.
Gavage feeding.
Babies who arrive between 28 and 34 weeks gestation and who don't need IV nutrition (or babies who started out on TPN but have progressed to the point where they can tolerate milk feedings) are fed by gavageâa method not dependent on sucking, since babies this young usually have not yet developed this reflex. A small flexible tube (gavage tube; see
illustration
) is placed into the baby's mouth or
nose and passed down to the stomach. Prescribed amounts of pumped breast milk, fortified breast milk, or formula are fed through the tube every few hours. Gavage tubes are either left in place between feedings or removed and reinserted for each feeding. (The tube won't bother your preemie because the gag reflex doesn't develop until about 35 weeks.)
It may be a relatively long time before you'll be able to feed your baby as you'd always imagined you would, through breast or bottle. Until then, you can still take part in feedings by holding the tube and measuring how much your baby takes, cuddling skin-to-skin during tube feedings, or giving your baby your finger to practice sucking on while he or she is being fed (this helps strengthen the sucking reflex and may also help your baby associate sucking with getting a full tummy).
Babies who can't yet feed from a nipple are fed through a small, flexible gavage that is placed through the baby's mouth or nose into the stomach.
Nipple feeding.
One of the most momentous milestones of your preemie's stay in the hospital will be the switch from gavage feeding to nipple feeding. When it comes to readiness for this milestone, there can be some big differences among little babies. Some are ready to tackle the breast or bottle as early as 30 to 32 weeks gestational age. Others won't be ready to take on the nipple until 34 weeks, still others, not until 36 weeks gestational age.
The neonatologist will consider several factors before giving you the green light to begin breastfeeding or bottle-feeding: Is your baby's condition stable? Can he or she handle being fed in your arms? Have all the other physical requirements of readiness been metâfor instance, can baby suck rhythmically on a pacifier or feeding tube and coordinate breathing and sucking? Is baby awake for longer periods? Are there active bowel sounds and no sign of abdominal distension or infection, and has meconium stool been passed?
Since nipple feedings are tiring for a small baby, they'll be started slowlyâone or two a day, alternated with tube feedings. Infants with respiratory problems may have an even harder time, requiring extra oxygen while feeding or experiencing short episodes of apnea (breathing cessation) while sucking (they might concentrate too hard on sucking and forget to breathe). For babies who have trouble mastering the suck, a specially designed pacifier may be used to help them practice and perfect their technique before graduating to breast or bottle.
As parents of a premature or low-birthweight baby, you'll be particularly anxious to start seeing the numbers on the scale creeping up. But don't be discouraged if instead your baby seems to be losing weight at first. It's normal for a premature infant (as it is for a full-term baby) to drop quite a few ouncesâtypically between 5 and 15 percent of his or her birthweightâbefore beginning to gain. As with a full-term baby, much of that weight loss will be water. Premature babies don't usually regain their birthweight before they are 2 or more weeks old, at which point they can begin surpassing it.
What are preemies and low-birthweight babies nourished with? Whether fed through gavage or nipple, your tiny baby will get either breast milk, fortified breast milk, or formula:
⢠Breast milk. Breast is best not only when it comes to full-term infants, but also (or especially) when it comes to preemies, and for a number of reasons: First, it's custom designed for a preemie's special nutritional needs. Milk from moms who deliver early is different from milk from those who deliver at term. It contains more protein, sodium, calcium, and other nutrients than full-term breast milk does. This preemie-perfect balance prevents tiny babies from losing too much fluid, which helps them maintain a stable body temperature. It's also easier to digest and helps babies grow faster.
Second, breast milk has important substances not found in formula. Colostrum (early breast milk) is extremely rich in antibodies and cells that help fight infection. This is especially important when babies are sick or premature and may have a higher chance of developing an infection.
Third, research has shown that breastfed preemies have a lower risk of developing necrotizing enterocolitis, an intestinal infection unique to preemies (
click here
). They also tolerate feedings better, have a lower risk of allergies, and receive all the benefits that a full-term baby gets from breast milk (
click here
). Even if you don't plan to breastfeed long-term or full-time, providing breast milk for your baby while he or she is in the hospitalâeither by nursing or pumping or bothâgives your baby the best possible start at a time when that start has begun too soon. Moms who can't produce milk (or enough milk) can feed their preemies the best, too, since donated milk is often available through the hospital or a recognized and licensed milk bank.
To ensure your baby is still getting enough nutrition in the early stages of breastfeeding (when baby's suck may still be weak or your breasts are not producing sufficient amounts of milk), talk to the doctor about the following supplemental feeding methods that don't interfere with nursing.
If you're nursing, you can:
⢠Nurse with the gavage still in place
⢠Use a supplemental nutrition system (
click here
)
If you're pumping you can:
⢠Bottle-feed with the gavage still in place
⢠Use a feeding system taped to your finger (finger feeding)
⢠Feed the milk through a syringe
⢠Use slower-flow bottle nipples
For more on breastfeeding your premature baby,
click here
.
The decision to breastfeed a preterm baby is not always an easy one, even if you always had your heart set on nursing your newborn. After all, the major bonus of breastfeeding, that close mom-baby contact, is usually missing, at least at first. Instead, an impersonal pump stands in the way of that intimate experience until nipple feeding can begin. But though almost all women find pumping milk for their preemie exhausting and time-consuming, most who commit to it find it well worth the effort, knowing that this is one wayâand one of the best waysâthey can contribute to the health and well-being of their tiny baby.
Here's how you can make the most out of pumping for your preterm baby:
⢠Figure out the logistics. Most hospitals have a special room (with comfortable chairs and an electric double breast pump) set aside for moms of preemies to use throughout their baby's stay in the neonatal intensive care unit (NICUâpronounced niku). But first things firstâmake sure you're familiar with the mechanics of pumping (
click here
). Rent a hospital-grade pump or buy a high-quality double pump so you can pump at home, too, and bring milk to the NICU. Read more about safely storing and transporting breast milk
here
.
⢠Begin expressing milk as soon after delivery as possible, even if your baby isn't ready to take it. Pump every 2 to 3 hours (about as often as a newborn nurses) if your baby is going to use the milk immediately, every 4 hours or so if the milk is going to be frozen for later use. You may find getting up to pump once in the middle of the night helps build up your milk supply. On the other hand, you may value a full night's sleep more. Whatever works for you is best.
⢠It's likely you will eventually be able to express more milk than your tiny baby can use. Don't cut back, however, figuring you're wasting too much. Regular pumping now will help to establish a plentiful milk supply for the time when your baby takes over where the machine leaves offâso it's never a waste. In the meantime, the excess milk can be dated and frozen for later use.
⢠Don't be discouraged by day-to-day or hour-to-hour variations in supply. That's completely normalâand something you wouldn't be aware of if you were nursing your little one directly. It's also normal to have a drop in milk production after several weeks. Baby will ultimately be a much more efficient stimulator of your milk supply than even the most efficient pump. When actual suckling begins, your supply is almost certain to increase quickly.
⢠When baby is ready for feeding by mouth, try offering the breast first, instead of a bottle of pumped milk (even if you're planning to do both). Studies show that low-birthweight babies take to the breast more easily than to the bottle. But don't worry if yours does better on the bottleâuse it while your baby gets the hang of breastfeeding, or use a supplemental nursing system (
click here
). And remember, how you ultimately end up feeding your baby is less important than the side of nurturing attention you serve nourishment up with.
⢠Fortified breast milk. Sometimes, even the milk of a preemie's mother isn't enough for a preemie. Since some babies, particularly very tiny ones, need even more concentrated nutritionâincluding more fat, proteins, sugars, calcium, and phosphorus, and possibly, more of such other nutrients as zinc, magnesium, copper, and vitamin B
6
âthe breast milk being fed through a tube or a bottle may be fortified with human milk fortifier (HMF) as needed. HMF comes in a powdered form that can be blended with breast milk, or in a liquid form for use when adequate amounts of breast milk are not available.
⢠Formula. Babies can do well, too, when they're fed formula specially designed for preemies. Even if you are breastfeeding, your baby may get additional feedings with a bottle or supplemental nursing system. Preemies are fed using small plastic bottles marked in cubic centimeters (cc) or milliliters (ml). The nipples are specially designed and require less sucking strength from your baby. Ask a nurse to show you the correct position for bottle-feeding your preemieâit may differ slightly from that for a full-term infant.
Feeding a newborn often comes with challenges. Feeding a preemie or low-birthweight baby multiplies those challenges:
Sleepiness.
Many preemies get tired easilyâand sometimes sleeping can win out over eating. But frequent feeds are needed so a small baby can start catching up on growthâand it's up to you to make sure your extra-little one doesn't sleep through the feeds he or she needs. For tips on how to wake a sleepy baby,
click here
.
Breath holding.
Some preemies, especially those who were born without good sucking-breathing coordination, will forget to breathe when feeding. This can be tiring for baby and anxiety producing for you. If you notice your baby hasn't taken a breath after a number of sucks or looks pale while feeding, remove the nipple from baby's mouth and let him or her take a breath. If your baby seems to be holding his or her breath all the time during feedings, regularly remove the nipple after every three to four sucks.
Oral aversion.
Babies who have spent a lot of time in the NICU may come to associate their mouths with feeding tubes, ventilator tubes, suctioning, and other unpleasant sensations and experiences. As a result, some preemies develop a strong aversion to having anything in or around their mouths. To combat this, try to replace the unpleasant oral associations with more pleasant ones. Gently stroke your baby around the mouth, give your baby a pacifier or your finger to suck, or encourage your baby to touch his or her own mouth or suck on his or her thumb or fist.
Reflux.
Many preemies are prone to gastroesophageal reflux disease (GERD) because of their immature digestive systems. Click for tips on coping with
spitting up
and
GERD
.
If by the time you get home together you're breastfeeding your preemie exclusively, you'll be all setâyour breast milk supply will continue to grow with your baby. If you're formula
feeding (or doing a combo), you may or may not need to continue using formula specifically designed for preemies once you're home with your little one. It'll depend on your baby's progress, and your doctor will be able to steer you to the right formula. You might decide to continue to use the same small bottles that were used in the hospital, especially because preemies need to be fed smaller amounts and need to be fed more often than full-termers. But keep in mind that what worked in the hospital might not work as well once you're home and your baby continues to grow in both size and maturity.