Wednesday, April 27, 2011

Reply turned post: Bottle feeding, breastfeeding, and the NICU

I vent a lot (maybe too much... trying to stay open to positive possibilities for education and cooperation) about the NICU & breastfeeding.

Because of those challenges, this post on My OB Said What caught my eye today: "You’ll get him home sooner if you just bottle feed," – NICU nurse to breastfeeding mother of a NICU baby. Many commenters chimed in to rightfully assert that the mother's breastmilk is much better than a bottle of formula, especially for a NICU baby, but I think this is not quite what the nurse meant. This was my comment:

"This is sad but true... the requirements for the NICU babies to go home is to take all feeds PO (by mouth), maintain their oxygen sats on room air, and maintain their temp. The PO feeding requirement leads to a lot of bottles because they are the easiest and fastest way to declare the baby capable of all-PO feeding. I have met very few moms able to avoid any bottles in the NICU. It basically means insisting on gavage feeding for every feed at which the mother is not present, and it is hard for the mother to be present 24/7 because the NICU is not set up for that. So it absolutely can mean that the baby stays longer. It is very frustrating because direct breastfeeding is best and least taxing for these babies."

It's a real catch-22. The way to prove the baby can do OK on all PO feeds is for the mother to breastfeed him/her around the clock. But there is often nowhere for the mother to sleep after she's discharged from the hospital herself. So to be with her baby 24 hours a day to breastfeed, she has to agree to bottle feeds to "prove" her baby can effectively take all feeds by mouth. The bottle feeds can and do cause issues with breastfeeding, but even for the most motivated mom, it can be a very difficult choice between agreeing to many bottles, and waiting extra days to take her baby home.

Recently, I saw a baby born at 32 weeks go to the NICU, have nothing but breastmilk and never have a single bottle touch her lips, and eventually go home feeding exclusively at the breast. Her mother was highly educated and motivated, had excellent family and community support, and really advocated for herself and her baby. As LCs, we were all so amazed and impressed by what they did. It was truly an accomplishment in a NICU environment... and it took bucketloads of privilege. Very few people are able to accomplish that without support from the staff, which the nurse quoted above was definitely not providing. Staff support is a huge issue. I have even heard a NICU nurse say "If they don't want to bottle feed, I just tell them 'We can put a tube down your baby's nose instead' [referring to gavage/NG tube feeding] - that changes their mind!'" A really inappropriate thing to say just to scare parents, given that this way of feeding may be necessary for certain babies who aren't able to safely do PO feeds.

In my perfect fantasy world, NICU babies who are ready to do PO feeds are moved to private or semi-private rooms that have a space for mom to sleep, so she can be with the baby 24/7 and breastfeed easily. She can stay there until the baby is ready to go home. Bottles are only given with explanation and consent, used appropriately, and stopped quickly if they begin to cause breastfeeding issues. Is this really such a crazy fantasy?


Susan said...

"It is very frustrating because direct breastfeeding is best and least taxing for these babies."

So my question is this: I've read that for NICU babies, bottle feeds are best because THEY'RE less taxing than direct breastfeeding, since the babies don't have to work as hard to get the milk to flow. I don't have the kind of LC background that you do, though, so I'm really curious to know why you say that direct breastfeeding is less taxing than bottle feeding (definitely don't dispute that either way, breastmilk is best for all babies, but especially NICU babies, whether it's direct from the tap or pumped and fed from a bottle).

Also, just wondering if you were still interested in that Planned Parenthood blog. I've been crazy busy with getting a new job and then I was on vacation, but things are starting to calm down and I'm getting ready to go back to my own blog, as well. Just let me know if you're still interested, and my apologies for not contacting you again sooner.

Anonymous said...

Thank you for this post. When my baby was in the NICU I was the crazy/privileged mama who only went home at night to sleep just long enough that my baby had to have one bottle a night (which she always hated). If they'd had a bed at the hospital I would have slept in it.

Susan, I think it's important to distinguish between reasons for being in the NICU. What one baby can/should do might be different than another baby.

Rebecca said...

Susan, that is a good question. For some NICU babies, bottle feeding may be a fast way to get the milk in, but it is not necessarily for them. This is from the LLL Breastfeeding Answer Book:

"Although it was once thought that breastfeeding takes more energy than
bottlefeeding, research on premature babies (Meier 1988) and babies with congential heart disease (Marino 1995) indicates that the oposite is true: bottle-feeding is more physically stressful than breastfeeding.
Differences between the composition of human mik and formula may also
affect the amount of energy expended. One study of healthy two-day-old babies found that the breastfed newborns had more energy-efficient heart rhythms, lower heart rates, and expended less energy than the artificially fed babies, even though the breastfed babies spent less time sleeping than their bottle-fed counterparts (Zeskind 1992)."

Citations: Marino, B. et al. Oxygen saturations during bresast and bottle feedings in infants with congential heart diesease. J Pediatr
Nurs 1995; 10(6):360-64.

Meier, P. Bottle and breast feeding: effects on transutaneous oxygen pressure and temperature in small preterm infants. Nurs Res 1988; 37:36-41.

Zeskind, P. et al. Rhythmic organization of heart rate in breast-fed and bottle-fed newborn infants. Early Dev Parent 1992; 1(2):79-87.

The way I was taught was that if a baby cannot safely breastfeed, they should not be taking anything PO (unless the issue is aspiration related to the thickness of the milk).

And yes, still interested in the PP blog if you are!

Rebecca said...

@reproductiverites: That is amazing dedication to spend so much time in the NICU (& I'm sure was very stressful). Congratulations on making it out with your breastfeeding goals intact - as an LC we are so inspired by the moms like you, you show that it is possible if we could just change the system to support every family (for example giving them a bed to sleep in!!)