Annoyed

[umcRN, BSN, RN]

So I wanted to get opinions on something that happened while I was at work the other day. I am a former nicu nurse who about a month ago changed to peds cardiac icu. So far I love it, no complaints, I am learning a ton, still getting to take care of lots of babies but a lot has been a big adjustment that I'm still working through. So my situation is the first argument i've gotten in with my preceptor. Got report on a little guy 3 weeks old/3 weeks post open heart surgery. At this point just feeding/growing and weaning off his vapotherm. Night nurse tells us he's been having trouble gaining weight on breast milk fortified to 26cals so they started him on a feeding regimine of 4 hours breastmilk/4hours formula (continuous) and he has started gaining weight. I thought that was a little odd but went with it. Then I went in his room for my first assessment and saw his breastmilk hanging in a kangaroo bag! :smackingf: So I nicely talked to my preceptor about it and about how he was getting no fat/nutrients that way and they were essentially feeding him fortified water, no wonder he wasn't gaining weight

She proceeded to get upset at me that I needed to get out of my "Nicu" mindset and welcome the ways other units do things...which I am totally fine with and understand, but a baby who is being malnourished because of the feeding style i'm not going to just ignore. It is also our hospital, NOT just nicu, but hospital policy that breastmilk be given via syringe if baby is not po feeding, and we have special double syringe tubing that you can use to run two syringes at once if they baby is getting a large volume and you dont want to have to change out the syringe every 2 hours.

Am I wrong for questioning this units practice? Does anyone else use kangaroo bags for breastmilk? Or should I address it with the educator and maybe some more education can be provided to the unit? (Which probably wouldn't be an issue, this unit is HUGE on education)

I also hate to think of the mommies who have nothing else to do for their babies to feel like their milk isn't good enough, especially when its not an issue of tolerance but quality of calories

[NICU_babyRN, BSN, RN]

You are correct in that it should NOT have been given in a K pump. The best would be to find the hospital policies and print them out, gather the available supplies from the NICU, find an article or two on the use of syringes for BM feedings and go to your educator to talk to her about it. Show your educator that you have done your research and that this isn't just a "my way or the highway" type of attitude.

Good luck :)

[Love_2_Learn]

I agree with NICU_babyRN's suggestion. You might also want to consider consulting with the dietitian for your unit since they probably would have some good evidence-based information and articles to share. I believe the American Dietetic Association has lots of guidelines and I'm sure they have some which would apply in this situation; your dietitian might have that information at their fingertips. Good luck, take a deep breath, and as I can see you already know...continue to speak and act as the professional you obviously are when coming up against difficult situations.

[umcRN, BSN, RN]

thank you for both your replies! I think I am going to some research searching and try to find some articles, I have contacted the NICU's lactation consultant to see if she has any goo finds and I may also speak with the nutritionist on our unit, because when it comes down to it, 26cal formula and 26cal breastmilk SHOULD result in the same weight gain, it's obviously the administration that is throwing it off.

[SteveNNP, MSN, NP]

I wasn't aware of nutrition issues giving EBM via a kangaroo pump. I know some of the fats stick to the inside of the bag...is that it?

Here, the nurses only add 4hr worth of EBM at a time, and from my own experience, we haven't had a measurable difference in growth on syringe vs. bag feeds of EBM.

[umcRN, BSN, RN]

I wasn't aware of nutrition issues giving EBM via a kangaroo pump. I know some of the fats stick to the inside of the bag...is that it?

Here, the nurses only add 4hr worth of EBM at a time, and from my own experience, we haven't had a measurable difference in growth on syringe vs. bag feeds of EBM.

from what i've been told the fats can separate and sit on the top and potentially never get to the kid. Sometimes you can see the layer of fat sitting on the top too. I do know that we sometimes send kids home on g-tube EBM feeds, case management has to make sure those families have a specific feeding pump that will ensure the baby gets everything.

[Love_2_Learn]

I'm honestly not familiar with the kangaroo pumps; don't think I've ever seen one but I've never worked in a pediatrics unit. Anyway, just wanted to say that when we put our breast milk on pumps we always make sure the syringe is in a horizontal position so the fats will enter the tubing in a more constant fashion. If the syringe is placed with the plunger on top and the tubing down below, ALL the fat can be seen collecting just under the plunger. When placed horizontally the fats can be seen all along the syringe. It really doesn't take but about an hour to see the separation occur. This is also why we make sure we put exactly the 4-hour amount of feeding in the syringe so we don't waste any of the precious fats.

[littleneoRN]

When we have kids on large volumes, we do transition to kangaroo pumps. But with any type of feeding, breast milk or formula, but especially breast milk I try to mix up the contents about every half hour so that I can't see things starting to separate. I can see formula separating sometimes too, depending on the type of formula. These kids have generally gained weight well on typical fortifications for their condition. We would never switch to formula for poor weight gain unless we could document something wrong with the breast milk. Which is exceedingly rare.

[Coffee Nurse, BSN, RN]

Huh...I learned something new today! I don't think I've ever given a large enough volume of breastmilk to warrant a Kangaroo, but I'll be on the lookout in the future. Thanks everyone!

[RosesrReder, BSN, MSN, RN]

We alternate Q other feeding between fortified EMB and Formula. The formula has extra calcium and phosphorus thus help them in gaining weight. This is for kids that are not gaining weight despite the fortification.

Our hospital policy is all EMB is fed via Syring pump. The pump is propped up so that the fat rises.

It makes sense that if the nurse runs it in a K pump and lets say they add extra for priming and what not that the fat will rise and therefore affecting the nutrition (fat and calories).

I would have questioned it as well.

[umcRN, BSN, RN]

Huh...I learned something new today! I don't think I've ever given a large enough volume of breastmilk to warrant a Kangaroo, but I'll be on the lookout in the future. Thanks everyone!

haha well it's not SUPER huge volumes but say your goal is 20cc/hr, well some nurses don't want to change a syringe q3 hours

I had a primary once who was older (as in a term baby then 4 mos) and her goal was 30cc/hr cont, we have these "bifurcated" syringe tubing's to run two syringes at a time, run each at 15cc/hr (but this was in the nicu where nurses are more strict with the policies), much more than that and you're going to have to change the syringes more frequently no matter what you do. But IMO I would still rather not use a kangaroo pump for a kiddo whose not gaining weight well because I don't want them missing that fat

AND thanks for all the great responses! As much as I am loving learning so much more in the cicu I will continue to keep my nicu brain on, there was a BIG stir up this weekend with a baby who nurses kept asking the drs to check a bili on and the doctors wouldn't order it...by the time they did the kids bili was 22! and THEN the education on the nurses part wasnt there for them to realize how much of an emergency that was, of course then the doctor paid attenction (after they didnt even want to get the level) and freaked out on the nurses! needless to say there will be some more "normal baby" education rolling out

[NeoPediRN]

Why can't they fortify the breastmilk to higher than 26kcal? We usually do corn oil and Enfacare as our emulsifier and they fatten right up. We do use Kangaroos for breast milk if the volume is too big for a syringe pump. Fortified BM always ends up occluding it anyway. We shake the Kangaroo bag during the feed and then flush the bag with sterile water to get the remaining fat off the sides and run the tubing dry. So far so good, our FTT babies fatten up just fine.