In the Hospital - a quick look

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For some parents of preemie babies, the neonatal intensive care unit (NICU for short) becomes a home away from home while they wait for their preemie baby to get strong enough to leave.


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The NICU is where your preemie baby will get lots of help.

It can be noisy, confronting, and stressful. Learning a little about the equipment, what health professionals are doing, and some of the medical jargon can help parents of preemie babies feel more confident and less overwhelmed.
Preemie help is here to make sense of it all.

 


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Feeding Preemies

Mothers of full-term babies often take the ability to feed their baby for granted by. The natural satisfaction, pride, and joy of a baby suckling at the breast or the bringing of the bottled formula to a newborn can be a stumbling block for a preemie baby. This section describes the feeding journey for preterm babies.

Introduction to Feeding Premature Babies

Older preemie babies may be able breastfeed or suckle within days, however the younger and sicker the baby the longer it will take. The intestinal tract of preterm infants is not fully matured, and the contractions that propel the food along and important enzymes are not produced until about 28-30 weeks, so it is not nature’s plan for babies to feed by mouth before 32-34 weeks.

Preemies must be able to manage sucking, swallowing, and breathing before feeding, otherwise they may choke on their milk or it may just dribble out of their mouth whilst breathing.

The preemie’s feeding passage usually progresses by;

  • Parenteral Nutrition: This way, premature babies are fed through an intravenous device, such as an IV or other catheter, so the baby receives his nutrition by avoiding the digestive system and instead directly enters the blood stream.
  • Gavage feedings: This way, premature babies receive their breast milk or formula via a tube that enters the nose or mouth and into their stomach
  • Drinking from a nipple: breast feeding and/ or bottle feeding.

Parenteral Nutrition (TPN)

It is normal for all newborn babies not to eat much and to lose some weight after birth. Unfortunately preemie babies have fewer reserves of fat and nutrients, so require nourishment sooner. The first nourishment for many premature babies comes from IV fluids, usually glucose and water. This will then be substituted with a richer solution containing protein, vitamins and other essential nutrients. This can be administered intravenously for several days or weeks, and provides preterm baby with the fluid, calories and nutrition they need.

 

Some complications arising from the administration of TPN are:

 

  • Infection from the IV catheter
  • Skin injury if some of the fluid leaks out of the vein
  • High levels of glucose or fat (this is only a problem when if feedings go on for a long time)
  • Liver Damage ( in most cases the liver heals once the TPN is stopped)

The likelihood of your premature baby developing these problems may not arise; it does however clarify why the little preemies are only given TPN for as long as entirely necessary.

As with many other aspects of preterm infant care, treatment has been historically based on clinical judgement and experience rather than sound scientific research. Therefore there are more and more studies that are researching the best practices for NICU care. It has been suggested by some experts in the field that the publication of new nutritional guidelines for the parenteral nutrition of neonates and preterm infants as well as regular, specific training in the parenteral nutrition of preterm infants are needed. It has also been argued that optimal parenteral intakes of both energy and amino acids are not well established and research in the future may focus more attention on these issues.

(S. Iacobelli, Bonsante, & Gouyon, 2010; Silvia Iacobelli, Bonsante, Vintejoux, & Gouyon, 2010; Lapillonne, Fellous, Mokthari, & Kermorvant-Duchemin, 2009; Sluncheva, 2010; Vlaardingerbroek, van Goudoever, & van den Akker, 2009))

Gavage Feedings of Breast Milk or Formula

It is a huge triumph for a preemie when they have their first gavage feeding. Even though the baby may not be able to suckle, feeding a few drops of breast milk or formula helps the intestinal tract to grow and develop. Your prem baby may also be given these feeds whilst still having TPN. This type of feeding involves a small tube entering your baby’s nose or mouth and going through to his stomach.

These tubes can be referred to as;

  • OG tube or oro-gastric (which goes through the mouth) and is usually preferred so your preterm baby can breathe through their nose
  • NG tube or naso-gastric (goes through the nose) is good for older preemie babies who are have a gag reflex and are already suckling, but need extra calories

The insertion of the tube is painless, and generally does not bother the baby. The nurse will gently glide the tube down the back of your preemie baby’s throat, down the oesophagus and into the stomach. It is secured with tape, either under the nostril or on the cheek. This procedure takes only seconds and can be replaced when needed. Sometimes the baby may gag, or some experience Bradycardia (slow heart rate) while the tube is being inserted.

At mealtime the nurse will connect a plastic syringe to the gavage tube, pours in the correct amount of breast milk/formula, gives a gentle push with the plunger and gravity then allows the fluid to flow down the tube. Sucking on a tiny pacifier/dummy while being fed, can prepare baby for the next step toward nipple feeding.

Another method the nurse may use is connecting the syringe to a pump that will then slowly drip the feed into baby’s stomach. The first feed may only be a few drops of water or diluted milk. If your prem baby does not vomit and the fluid moves well through his bowel, the amount he receives each feed will gradually be increased, until IV TPN is no longer required. The nurse may allow you to hold the baby and syringe during feeds, ask the nurse if this is possible if he/she doesn’t suggest it. This can be a very personal time for you, as your preemie baby will seem peaceful and satisfied as he is fed in your loving arms.

(Anderson, 2002; Pinelli & Symington, 2001; Rochat, Goubet, & Shah, 1997; Shulman, Ou, & Smith, 2011; White-Traut, Berbaum, Lessen, McFarlin, & Cardenas, 2005)

Feeding Intolerance and Ways to Overcome It

Some feeding problems can be expected until your premature baby’s digestive system matures, although there may be a couple of set -backs, there is rarely cause for alarm but either way your prem baby will be observed closely.

Some signs to watch for:

Incomplete emptying of the stomach

Before starting a feed the nurse may use a syringe to pull out and assess the contents of your preemie’s stomach. This will be returned to your baby to avoid the loss of valuable nutrients that your prem will need. Depending on the volume and content of the aspirate, i.e. if it is too large or contains bile, the Doctor may suspect the possibility of infection, obstruction of the intestine, or necrotizing enterocolitis (NEC). The risk of NEC is the biggest worry when a preemie starts gavage feeding. Commonly, though more fluid than usual just means the immature intestines are moving slowly and need more digestion time.


Tense or tender abdomen, or blood in the bowel

This can also be a sign of infection or NEC and may be investigated by an abdominal x-ray.


Vomiting

Vomiting can also be an indication of infection or obstruction, but usually signals less serious problems, such as overstimulation or reflux. All babies occasionally vomit, so try not to become too concerned. Your preemie’s doctors will suggest ways to overcome this, which may include slower feeds or placing your baby on their stomach.


Bloated but soft abdomen

This can be a sign of gas, constipation or poor movement of the immature bowel. Full term babies usually have their first bowel action within the first two days, but preemies may take up to a week. A gentle laxative may help with the gas and assist with a bowel action. The doctor may prescribe some medication to aid the intestinal movement.


Diarrhoea

Diarrhoea usually suggests incomplete digestion, as the feed may contain too many calories, or because of lactase deficiency (an enzyme needed to digest milk). This problem can be overcome by briefly changing the make-up of the feedings, i.e. what type of nutrients and amino acids are included. Infection is a possibility but less likely in this situation.


More frequent episodes of apnoea (a temporary pause in breathing) and bradycardia (slowing of the heart beat)

These difficulties may be caused by the gavage tube if it moves from the stomach into the oesophagus. Reflux and infection may also be a cause. Removing the tube between feeds may be recommended.


Excess gas

Sometimes preterm babies having continuous positive airway pressure (CPAP) have feeding problems because their stomach fills with gas. By inserting a second tube and allowing the gas to escape may relieve some of the pressure.


Improving Digestion

To help in the improvement of baby’s digestion, adjustments in his formula may be required. Some changes may include;

  • the amount of milk given
  • an increase in the space between feeds (from 3-4 hrs)
  • the strength of the breast milk or formula - omitting additives or supplements
  • the type of formula (may need a soy or pre-digested formula )
  • placing the gavage tube so feeds enter the intestine rather than the stomach

These small changes are often all that is required to suits your preemie baby’s needs.

(Berseth, Bisquera, & Paje, 2003; Karagianni et al., 2010; Patole, 2005; Sankar, Agarwal, Mishra, Deorari, & Paul, 2008)

Graduating to the Bottle or Breast

When your preemie baby reaches 32 to 34 weeks gestation they are possibly sucking, swallowing, and breathing all at the same time. Encouraged by signs of energetic sucking on a pacifier/dummy, stable vital signs, no longer on the ventilator, and on less than 40% oxygen, along with gaining weight on gavage feedings, the doctors and nurses will decide it’s time to start “suckling’ from the breast or bottle. Breast feeding may be started earlier, however at first your prem baby may not be able to latch onto the breast, or may only be able to swallow very small amounts at a time. Your premature baby may not be able to breast or bottle feed (as they may lack the strength) for every feed and may only feed once or twice a day. This new job can be difficult and tiring, therefore your preemie will continue to need gavage feeds. Your baby’s ability to feed will improve over time, and will steadily be eating well on his own. No doubt the NICU nurses will only be too happy to assist and encourage you in all aspects of your premmie baby’s feeding.

 

Preemies that have been sick for extended periods, can refuse to nipple suck, this can be due to a number of reasons, such as breathing tubes, suction catheters, and tape which give the babies an unpleasant sensation around their mouth. You will sometimes hear these preemie babies referred to as “disorganised feeders.” These can affect the natural connection of mouth, sucking, hunger relief and pleasure. Patience and time by the parents, gradually encourages your preemie baby to feed, only rarely does it not work and requires baby to be fed with a cup and spoon. Your preemie baby has reached the end of their journey when they can complete a meal in 20-30 minutes, gains weight steadily, and no longer requires gavage feedings.

(Pinelli & Symington, 2001; Rochat, et al., 1997; Wechsler Linden, Trenti Paroli, & Wechsler Doron, 2000)

 

Breast Milk Banks

Some mothers have more milk than their babies require and generously donate to Breast Milk Banks. They are non-profit organisations that collect the milk, guarantee its safety, store it and ship it to babies in need. Breast milk is easier to digest than formula, therefore less of a strain on preemie intestines. It also contains substances not found in formula that may improve your preemie baby’s health and development.

The donor is screened in the same way as blood donors; they are checked for infections, illness, ingestion of dangerous substances and risky behaviour. The donor and her baby’s doctors are also questioned. When the breast milk is collected it is pasteurised, and screened for bacterial infection, guaranteeing its safety. Although the pasteurising process wipes out some of the infection-fighting antibodies, some remain.

If you are not going to breast feed your preemie baby but would like to give him donor milk ask your doctor. Sometimes the stores run low and it is then rationed to preemies that need it the most. Most banks will provide milk to preemie babies whilst they are in hospital, but often preemie parents need a doctor’s prescription for when they take baby home. Also donor breast milk can be expensive, and you may need a certificate of need to claim from your health care provider, or health insurance plan.

(Arslanoglu, Ziegler, Moro, & World Association of Perinatal Medicine Working Group On, 2010; Quigley, Henderson, Anthony, & McGuire, 2007)

 

 


Technical Reference List

Anderson, D. M. (2002). Feeding the ill or preterm infant. Neonatal Netw, 21(7), 7-14.
Arslanoglu, S., Ziegler, E. E., Moro, G. E., & World Association of Perinatal Medicine Working Group On, N. (2010). Donor human milk in preterm infant feeding: evidence and recommendations. J Perinat Med, 38(4), 347-351.
Forsythe, P. (1998). New practices in the transitional care center improve outcomes for babies and their families. J Perinatol, 18(6 Pt 2 Su), S13-17.
Berseth, C. L., Bisquera, J. A., & Paje, V. U. (2003). Prolonging small feeding volumes early in life decreases the incidence of necrotizing enterocolitis in very low birth weight infants. Pediatrics, 111(3), 529-534.
Iacobelli, S., Bonsante, F., & Gouyon, J. B. (2010). Fluid and electrolyte intake during the first week of life in preterm infants receiving parenteral nutrition according current guidelines. Minerva Pediatr, 62(3 Suppl 1), 203-204.
Iacobelli, S., Bonsante, F., Vintejoux, A., & Gouyon, J.-B. (2010). Standardized parenteral nutrition in preterm infants: early impact on fluid and electrolyte balance. Neonatology, 98(1), 84-90.
Karagianni, P., Briana, D. D., Mitsiakos, G., Elias, A., Theodoridis, T., Chatziioannidis, E., et al. (2010). Early versus delayed minimal enteral feeding and risk for necrotizing enterocolitis in preterm growth-restricted infants with abnormal antenatal Doppler results. Am J Perinatol, 27(5), 367-373.
Lapillonne, A., Fellous, L., Mokthari, M., & Kermorvant-Duchemin, E. (2009). Parenteral nutrition objectives for very low birth weight infants: results of a national survey. J Pediatr Gastroenterol Nutr, 48(5), 618-626.
Patole, S. (2005). Strategies for prevention of feed intolerance in preterm neonates: a systematic review. J Matern Fetal Neonatal Med, 18(1), 67-76.
Pinelli, J., & Symington, A. (2001). Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev(3), CD001071.
Quigley, M. A., Henderson, G., Anthony, M. Y., & McGuire, W. (2007). Formula milk versus donor breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev(4), CD002971.
Rochat, P., Goubet, N., & Shah, B. L. (1997). Enhanced sucking engagement by preterm infants during intermittent gavage feedings. J Dev Behav Pediatr, 18(1), 22-26.
Sankar, M. J., Agarwal, R., Mishra, S., Deorari, A. K., & Paul, V. K. (2008). Feeding of low birth weight infants. Indian J Pediatr, 75(5), 459-469.
Shulman, R. J., Ou, C.-N., & Smith, E. O. B. (2011). Evaluation of potential factors predicting attainment of full gavage feedings in preterm infants. Neonatology, 99(1), 38-44.
Sluncheva, B. (2010). Strategies for nutrition of the preterm infant with low and very low birth weight. Akush Ginekol (Sofiia), 49(2), 33-39.
Vlaardingerbroek, H., van Goudoever, J. B., & van den Akker, C. H. P. (2009). Initial nutritional management of the preterm infant. Early Hum Dev, 85(11), 691-695.
Wechsler Linden, D., Trenti Paroli, E., & Wechsler Doron, M. (2000). Preemies: The essential guide for parents of premature babies. New York: Pocket Book
White-Traut, R. C., Berbaum, M. L., Lessen, B., McFarlin, B., & Cardenas, L. (2005). Feeding readiness in preterm infants: the relationship between preterm behavioral state and feeding readiness behaviors and efficiency during transition from gavage to oral feeding. MCN Am J Matern Child Nurs, 30(1), 52-59.

 

 



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Preemie, Premmie, or Prem?

Most babies spend between 38 and 42 weeks in their mother’s uterus. So, technically a preterm birth, preemie, premmie, or prem, is an infant who is born less than 37 completed gestational weeks. 


Read More: Defining Preterm birth


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