Breastmilk, formula and mother guilt

I keep seeing this issue come up for premmie mums. You’ve expressed for your baby while they are in the NICU (and often longer) as much as you could, you’ve given breastfeeding your best shot, but at some point despite all your best efforts it just doesn’t work out, you can’t keep your milk flowing and it feels like the end of the world.

You are not alone in feeling this way.

First, if you’ve expressed milk for your child while they were in hospital, woken up in the middle of the night at home to attach yourself to a breastpump far away from the child you want to be holding, and endured all the dairy cow comparisons, you are a legend. You have given your child the most amazing gift, one which has made the awful hospital journey that much easier for them to negotiate. You’ve dealt with stress, grief, fear and everything else on the emotional roller coaster and still delivered the elixir of life. As time passes, I hope you will look back on this achievement, as I do, with considerable pride.

If you’ve managed to establish breastfeeding, you are a champion - and so is your prem! It’s not easy trying to suck when you’re on CPAP or have an NG tube in the way. You might have had a prem with a weak suck, or who needed the help of a nipple shield, or other assistance. It may have been a battle getting nurses to stop tube feeding or topping up while you’re trying to move to all suck feeds. It’s nothing like the pictures in the hospital of chubby full term babies instinctively suckling within hours of their birth. Yet your persistence has been rewarded by the amazing feeling of your child connecting with you in one of the most powerful maternal bonding experiences around. This moment may be fleeting but it is definitely one to treasure.

Then things go pear-shaped. Your baby isn’t gaining weight, the stresses and strains of the whole prem experience lead to supply issues, you just can’t bear to keep expressing after everything you’ve been through. Or maybe you expressed or breastfed for months and months after coming home - but you wanted to keep going for longer, and it just isn’t working out. You’ve searched the internet for every possible means to increase your milk supply, you’ve been on prescription drugs but even they don’t help, and despite everything the pro breastfeeding lobby says (and you consider yourself a pro breastfeeding mother) sometimes mothers don’t produce enough milk to keep both baby AND mother healthy. Because ultimately your mental health is just as important as your baby’s physical health - and sometimes this gets overlooked. I was on the verge of serious postnatal depression because I was so worried about Talia’s lack of growth and my inability to produce more milk for her, when I desperately wanted to keep breastfeeding.

Then comes the awful moment, the time you had always thought you could avoid - when you have to go and buy a tin of formula. For me this came when Talia was about 6 months old, 3 months corrected. Personally I found this step so horrible that I looked at tins many times, picked them up and read them but couldn’t put them in my trolley. My mother (who was hugely supportive of my breastfeeding goals, and very impressed with the resources available to help me, such as the Breastfeeding Centre etc) reminded me gently that I had gone onto formula at 6 weeks of age during the 1970s when breastfeeding levels were at an all time low and support for mothers to breastfeed was minimal - and I’d turned out OK, and no-one could tell whether I’d been breastfed or not.

Eventually it was my sensible GP (who is a mother herself and had done all she could to help me by giving me a 6 month prescription of motilium) who asked me to consider making the move, because she could see I was digging a big hole for myself psychologically, and didn’t think depression would benefit either Talia or me. She also reassured me that I had done an amazing job to breastfeed under the circumstances - and eventually I believed her. Still, the first day I offered formula I was still a mess of tears and disappointment. I hadn’t cared about getting a big pregnant belly, I didn’t feel guilt about her early arrival, but not being able to continue breastfeeding felt so much like failure.

I continued to breastfeed as well as formula feed for several months, but Talia found the bottle so much easier and eventually my supply which had never been plentiful dwindled beyond redemption. However, I gradually relaxed and was able to enjoy it without worrying so much about her weight gain.

Now I look back and things are much more in perspective - the joy of 20:20 hindsight. It’s true that no-one can tell which babies were breast fed and which were formula fed. It’s true that giving my daughter breastmilk while she was in hospital was the most critical thing, and that anything beyond that was a bonus. It’s true that I fed for longer than some mothers did, and for a shorter time than others, that I produced more milk than some but less than others - but it’s not about comparing yourself to other mothers. I know I did my best under the circumstances I faced, which is as much I could realistically ask of myself, and that’s all that matters now. The guilt has gone the way of my breastfeeding cleavage, and it is not missed at all - unlike the cleavage.

Farewell to the breastpump

Yesterday I sold my breast pump. It was only a little one, not like the double-pumper I hired from KEMH while Talia was in the nursery, but it kept me company on many an evening in front of the TV when I was trying to increase my supply. In tribute to those days, here’s an old post I wrote in March 2008 for the L’il Aussie Prems blog.

Good to the last drop

The bottom drawer of our freezer (we have an “upside-down” fridge) belongs to Talia. It’s full of plastic tubs containing ice-cube-sized portions of stewed fruit, mashed veg, pulverised chicken, flakes of fish in cheese sauce etc. Wedged in the middle of this oyster of solids was a little pearl - the last remaining bottle of my frozen expressed breast milk (EBM).

I’ve rambled at length about the ups and downs of milk production. It wasn’t easy, but it was worth it. I wanted to do more, but now I’m happy that I did as much as I could. If I had to do it all over again, I would. So what’s the story with this bottle of EBM? Talia stopped breastfeeding exclusively last October, and ceased completely at the end of January. It’s now the end of March. This bottle of liquid gold was dated 21/6/07 - the day before Talia came home from hospital. This bottle of milk has reigned, happy and glorious, over the bottom drawer of the freezer for NINE months, as one by one all the other bottles (older) and baggies (younger) of EBM were defrosted and used up. (Don’t worry, my freezer is cold enough that it was safe to keep it longer than the usually recommended three months). This bottle was a testament to my hours of expressing but also a life-line which I had clung to for months in case of emergency, but which was no longer needed now that Talia is healthy and happy with formula and solids.

So last Thursday, a week after Talia’s first birthday, I liberated this vintage bottle from its cryogenic home and defrosted it. On Saturday, Talia’s bottles were half formula and half EBM, the final instalment of my first gift to her. It doesn’t usually happen, but she completely finished every bottle. That night we both went to sleep satisfied.

The joy of glop

About a year ago I started trying to give Talia “solids” - which is a crazy name for baby mush which is anything but solid! We called any mixed food that was more or less a puree “glop”. (Glop is the sort of sound it makes as it comes off a spoon and lands on a plate, or the floor. )

A year ago Talia was rejecting farex (and who can blame her?) We bought her a snazzy new high chair at the start of last November which was so big that we couldn’t use the tray because she just disappeared behind it. Here she is in early January 2008.

It took a while before her tongue reflex subsided and she started to enjoy a variety of home-made glop. I cooked up a storm, mixing veges with chicken, beef, fish or lentils. Talia grew steadily and I was so happy to have a baby who ate well.

Then just after her birthday, Talia decided she no longer wanted to be fed - the great spoon strike had begun. At first I worried a lot that she would starve, but thanks to some rapid improvement in her hand-eye co-ordination (one pea or corn kernel at a time), she was able to feed herself finger food and carried on growing.

Occasionally I would try to offer Talia food off a spoon, but my success rate was so low I didn’t do it as often as I probably should.

So today I decided to let her play with a bowl of custard and some spoons and see what happened. (She was driving me crazy anyway, so at least this gave me time to cook dinner!) At first she wouldn’t eat the custard, but enjoyed painting the tray of the high chair. Then she decided the custard wasn’t so bad after all, and fed herself as best she could - using the wrong end of several spoons, and then just trying to pick it up by hand. An entertaining half hour later, with custard spread liberally over just about everything, I decided enough glop had been consumed to call it a successful exercise in self feeding. And modern art.

Necrotising enterocolitis (NEC)

What is it?

Necrotising enterocolitis (NEC) is a condition where the bowels (intestines) become infected and inflamed. “Necrotizing” means the death of tissue, “entero” refers to the small intestine, “colo” to the large intestine, and “itis” means inflammation.

Why does it occur?

Most cases of NEC occur in premature babies, typically within the first 2-3 weeks of life and usually after the baby starts receiving milk feeds. The exact cause is not clear, but it seems to occur when a baby’s immune and digestive systems have not yet properly developed. An immature gut may have difficulty absorbing milk. If a baby’s intestines are weak due to low oxygen (due to the body prioritising oxygen to other parts of the body) or poor blood flow, then the stress of food moving through it may result in bacteria that would normally not cause any problems invading and damaging the walls of the intestine. In addition, a premature baby’s immune system may not be able to deal with the resulting infection.

NEC is less common in babies who are fed expressed breast milk rather than formula, possibly due to the anti-bacterial and anti-inflammatory properties of human breast milk.

Why is it a problem?

If a NEC infection becomes severe, it can cause serious damage to or holes in the intestines, and/or infection of the blood or the membrane lining the abdomen. This can be life-threatening in a tiny baby with an immature immune sytem. Even when a case of NEC is mild, doctors must stop milk feeds until the infection clears up, resulting in a baby failing to gain weight at a critical time in its life.

The lower the birth weight and earlier the gestational age of a premature baby, the more likely they are to develop NEC, and the higher their chances of dying from it.

How is it treated?
For babies who have mild to moderate NEC, treatment usually consists of
- “nil by mouth” - stopping milk feeds and using intravenous feeds (ie through a vein) while the bowel recovers
- a course of antibiotics, and
- removing extra fluids and gas from the intestine via a naso- or orogastric tube.
This treatment usually lasts between 3 and 10 days.

If the baby’s abdomen is so swollen that it interferes with breathing, extra oxygen or a ventilator may be used to help the baby breathe. If the baby does not improve with treatment, or if he or she gets a hole in their intestines, it may be necessary to use surgery to remove damaged parts of the intestines.

Unfortunately NEC is difficult to diagnose quickly, as the earliest symptoms can be quite general (eg apnoea and bradycardia, temperature instability) and vary depending on how severe the condition is. Later symptoms include a swollen belly. A diagnosis of NEC is usually confirmed via x-ray (showing air bubbles in the intestines) and blood tests.

Hospital staff try to minimise the risk of a baby contracting NEC by carefully regulating the amount of milk a baby receives, increasing the volume of milk slowly, encouraging mothers to express milk for their baby, and maintaining strict hygiene standards in the NICU.

Are there ongoing complications?

Most babies who develop NEC recover fully and do not have further feeding problems, but in some cases, scarring of the bowel may occur, particularly if surgery was required. This can lead to future problems such as malabsorption (the inability of the bowel to absorb nutrients normally).

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This is one of a series of articles I’ve written for the L’il Aussie Prems newsletter under the heading of Premmie Health. Read my disclaimer here.

Talia at 18 months

Doesn’t time fly? It’s hard to imagine that a year ago this gorgeous almost-toddler was borderline failing to thrive, and I was struggling with post-natal depression as a result.

Talia at 18 months

Now she’s a little above the 10th percentile at 9.33kg and 74cm long, and has made the move into size 0 and size 1 clothing. I pulled out her summer clothing from last year and marvelled how 000 could look so small, when at first we could hardly imagine she would ever be big enough to wear it. We’ve come through winter with only two minor colds, which is fantastic given that she left hospital with chronic lung disease.

Developmentally speaking, Talia still exhibits global delays, but they do not stop her enjoying life immensely. She is nearly walking, having taken her first few steps, but is happier crawling at the moment - including some new crab walking with her bottom in the air. She recently started baby swimming classes (known here as “synchronised splashing”) and hopefully that will help her core body strength as well as giving her confidence around water.

Her favourite activities at the moment are going on the swing in the park, reading books, playing with balls, pegs and balloons, popping bubbles, starting games of peek-a-boo and hanging out with her bath toys. She has recently grasped the concept of putting pieces into a simple jigsaw (no interlocking pieces) but doesn’t have the dexterity to complete it by herself just yet.

Talia at 6 months (3 corrected) - one year ago.

Eating is still patchy, with the same problems of “loved it yesterday, hate it today, don’t even bother tomorrow”, but she’s continuing to gain weight (and grow out of things) despite the fact that she’s almost 100% self fed on finger food and I’m no closer to getting her to eat off a spoon, regardless of whether I’m holding it or she is. On the positive side, we can feed her a little bit of whatever we are having and no longer have to rely on food organised specifically for her (although we still do to some extent), and we’ve moved from formula to cow’s milk in the last month without any problems - in fact she clearly prefers it.

She will sometimes allow us to brush her teeth but it does take quite a bit of persistence. She sleeps well overnight and has one nap in the middle of the day, usually 1-1.5 hours long. I wish she’d sleep longer during the day but no luck so far - her room is probably not dark enough.

All in all, a wonderful, easy-care baby, even if she came without a manual! We feel very fortunate, and very proud.