feeding problems

Jolie, BSN · Mar 30, 2009

I assume that any possible medical explanation (cardiac, gi, neuro, metabolic disorders) for their lack of interest/stamina has been ruled out.

Has speech therapy or occupational therapy been consulted?

Has a lactation consultant been consulted?

Once in a blue moon, we encounter babies who just aren't ready and willing to nipple all of their feeds. In those cases, if the babies are otherwise ready for DC, we teach the parents to do gavage feedings and send the babies home with home nursing care. Invariably, they wean off their gavage feedings quickly once at home.

It becomes a matter of risk versus benefit of keeping them hospitalized and exposing them to infection, abnormal sleep-wake cycles and separation from their parents versus the risk of complications of short-term gavage feedings at home.

carla.hca · Mar 30, 2009

Medically there is no reason at all. Our speech and language department are involved and have simply advised the use of different bottles?????

They were being gravity fed but ng tubes have since been removed and they are on demand feeds but like I say they are getting nowhere.

You're definately right though, about the risk factors. It's just been said that if we were to send them home anytime soon, thy would end up being re-admitted. But like you say, it may be worth the try , gavage feeds at home, we arent getting them anywhere in our environment so maybe they do just need to get home and into what will be their own routine with mum and dad!!!!!!

RN4Little1s · Apr 1, 2009

If they are losing weight, their nutritional issue must be treated and they will soon have a feeding tube down again. I agree that parent education about enteral feedings should be completed and if the parents and medical team are comfortable with it, the twins could be sent home with PO/gavage feeds.

I wanted to clarify what you said about the feeds taking an hour. Did you mean individually one infant would take an hour to feed by the time you were through? I wasn't sure if you meant for both. My point is that the infant really should not be allowed to attempt the PO longer than 30 minutes; after that, she is burning more calories working hard to eat than she is gaining from the feed.

I'm sure your therapists have tried everything, but my big thing with premies is proper positioning and positive oral stimulation. If they changed to the slow flow nipple, the girls may have outgrown that now and are working hard on the nipple to not be rewarded with enough milk (maybe they couldn't handle it before, but now they could).

There is debate on the developmental appropriateness of waking infants up for feeds. But before we shove the feeding tube back down, we usually put them back on a Q3 hour feeding schedule with a "goal" volume or a daily goal. If they continue not to make it and lose wait, the dreaded tube is placed! Just brainstorming.... HTH!

carla.hca · Apr 1, 2009

Hi there,

The team have now changed their milk to a higher calorie formula in the hope that they will gain weight. They are 3 hourly feeds on a standard teat. As for it taking an hour, that's feeding each baby, waking again when they fall asleep and changing their nappy again in the hope that they will have another !!!!! So in all it takes about an hour atrt to finish!!!!!!!!!!

Nighmare, I tell you........poor little mites, it's such a shame!

dawnebeth · Apr 2, 2009

As another nurse sai--there's no way we would allow a feeding to take an hour. It's exhausting the babies to the point that they may not have the energy to eat again. We only allow preemies to nipple for approximately 20-30 minutes, including taking a break. Maybe give them demand feeding during the day (even every two hours) but only what they can take in twenty to thirty minutes and then gavage them 60 ml an hour, of 24 calorie formula or whatever to help them gain weight between 9pm and 7am.

Dawn

SteveNNP, MSN, NP · Apr 4, 2009

These babies may need even higher calorie formulas, to decrease the volume they need to take while gaining weight. Some babies even need 30 calorie formula.

dawnebeth · Apr 4, 2009

We've had deaths on 30 calorie formula, so we never use that anymore. We only allow up to 27 calorie and even that can cause some digestive problems in many babies, so it's always a last case scenario.

Dawn

carla.hca · Apr 5, 2009

They have been put on a higher calorie feed (higher calorie is all I know at the mo, very new to neonates, having done 10 years in adult medicine). They are still only taking little amounts but no less then previous so they should gain weight!!! Doctors have said if they gain weight tomorrow they can go home! Fingers crossed!!!!!!!

Pediatric Critical Care Columnist · Apr 5, 2009

My experience with prems and feeding is that babies born before 32 weeks have more issues, even when they've reached term and should be doing well. They have problems with getting a good latch, controlling the flow of milk, fatigue of the facial muscles and so on. Sometimes they will need buccal or lingual support or both. It's tricky, but it can be done. When I worked with feeder-growers I learned a method of getting their requirements into them in a reasonable time that worked with almost every otherwise normal baby. I would seat the baby on my lap in an almost upright position, holding their head with fingers and thumb of my nondominant hand on their mastoids and supporting their back with my forearm. My dominant hand little finger and sometimes my ring finger would be tucked under and pressing against the soft area under their chin to support their tongue. My thumb was on one cheek and my index and middle fingers on the other cheek, providing slight pressure to support the cheeks. The bottle rested on the web between my thumb and index finger. I never let the nipple fill completely so that the flow of milk was more controlled. I found that they fed quicker and more completely, with much less dribbling out the corners of their mouths, and they had no more trouble with gas than any other baby. You may not have the opportunity to try this technique with these little girls but you might try it next time you have a difficult feeder.

NicuGal, MSN, RN · Apr 6, 2009

Geez, they are only about what 32 weeks? We never feed over 30 minutes....then you are just fighting to finish. What about that poor mom...has she stayed and fed those kids? We use up to 30 cal, but that is the exception, that is for the severely fluid restricted BPDer. We have sent kids home of 27 cal without problems.

moomoo111 · May 5, 2009

I am an LPN and have a little experience with feeding preemies. I am a mother of 21 year old twin girls who were premature and we had the same problem with them. They did all the tests and nothing with bowel problems or obstructions. The problem was colic. They would only take 1-1/2 oz every 3 hours and if we tried any more, they would do the same as these babies. They would not take it, if it was before the 3 hours and if we got them to , they would projectile vomit the whole amount. We finally had to change formulas and used Isomil. The Enfamil with Iron was making it worse. So we put them both on Isomil, Levsin for the colic and they feedings got better and better and the weight began to increase. They were gassy all the time on the Enfamil and we tried all the formulas. Of course, they have so many more now. We tried Nutramigen, spelling, and we tried powder mixed, we tried Milacon, Mylanta for babies and it just did not work. Until we switched to Isomil and the Levsin for the colic did we see things get better. They are now healthy 21 year old girls. I saved all the notes and had a journal on their feedings. One was only 3 pounds when she was born. We brought her home and she weighed only 4.1. She had more problems than the other but we finally had no choice but to take her off the Iron Enfamil and put her on Isomil and it worked. Just a thought you can consider. I hope these babies get better.