When your baby graduates the NICU – by Amanda Rusch Ferreira

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When your baby graduates NICU, it is an exciting time but can also be nerve wracking. What can you expect in terms of nutrition and feeding?

Preemie growth after discharge

In terms of growth, you should use baby’s corrected age for 2-3 years for assessing weight. After this, you can use actual age. Prem babies will most likely be small for age, even after correcting for gestational age, and it is not unusual for baby to be discharged while on the (-3) or (-2) line on the growth chart. This is fine. Remember to take it low and slow with your preemies growth. While we do want to provide loads of nutrients for brain and organ development, and we do want them to eventually catch up on growth to above the (-2) line, it can take up to 3 years for this to happen in a healthy way. Remember growth will slow after discharge. At a month after going home, we want baby to be gaining about 25-30g per day, while at 1 year corrected age, we want baby to be gaining about 10g per day.

What milk to feed?

Choosing the right milk to feed your baby is a big decision. Allow your doctor or dietitian to guide you in this. If you are formula feeding, they will help you choose between a preterm formula (such as the ones you were using in the NICU) and a standard infant formula. Most infants will be discharged on a normal formula, as the high energy preterm formulas will cause baby to grow too fast. Your dietitian will try to choose one with slightly higher protein – this will help your baby grow a healthy brain and more muscle, whilst not becoming too large.

If you are breastfeeding, you will probably be able to go home on breastfeeding alone. Your doctor and dietitian may decide that you still need to slightly fortify your breast milk for a short while; if this happens, you will need to express a bit before the feed, add the fortifier, and top up feeds with this bit of fortified milk. Remember, adding fortifier to your breast milk does not mean there is anything wrong with your milk – it only means that baby needs a bit extra for a while because she has more special requirements than the average term baby, and soon your breast milk will be all she needs.

We want your breastmilk to be nice and high in protein and fat, so make sure you eat a super healthy diet. Fill up with protein (meat, eggs, chicken, fish, cheese, full cream plain yoghurt) and fats (seeds, nuts, avo, olive oil, cream cheese). Cut out as many refined carbohydrates as you can, as these will reduce the protein and fat in your breastmilk. This means anything sugary, like fruit juices, flavoured yoghurts and sweet treats, as well as any refined starches, like white bread and breakfast cereals. Don’t forget loads of fruits and vegetables, and keep taking your pregnancy multivitamin and a good omega 3 supplement.

Feeding volume

After days or weeks or months in the NICU with a medical team determining your milk volume, it can feel a bit daunting to have to choose the milk volume for your little bundle. There are some general guidelines: Feed baby every 3 hours, even during the night, especially in the first week after discharge. You can start to drop feeds in the night after a few weeks, but baby must never go more than 5 hours without feeding. Start by using the volumes your doctor or dietitian prescribed when you go home, but you can start to slowly increase as baby tolerates after a few days.

If you are breastfeeding, the issue of volume is not something that you can really choose, but make sure that at least one breast is emptied per feed. It is better to empty one breast than feed from both breasts, as the last bit of milk is always the highest in energy. If baby struggles to completely empty the breast, you should finish each feed by pumping the remaining milk and topping up. Continue to feed or express 6-8 times a day to maintain milk supply.

The good news is that preemies tend to moderate their own volume intake based on how many calories they are getting, so you can let baba guide you on volumes, provided he is growing well according to the growth chart. If baby still struggles to feed from the breast or bottle after discharge, consult your doctor, dietitian or speech therapist as soon as possible. A good speech therapist will be able to assess and intervene to teach baby to feed better.

Supplements

Don’t forget to keep supplementing baby with iron and a multivitamin – your doctor or dietitian will guide you on which products and dosages to use. This should be used for at least 1 year, or as long as your medical team decides.

Introducing solids – the food adventure begins!

A few months down the line, you will want to start introducing solids. The timing of this can also be a bit confusing – do you use corrected age or actual age? A good guide is to use the midpoint between 16 weeks adjusted age and 16 weeks actual age. Remember, however, that baby needs to meet all milestones to be able to eat safely – he especially needs to be able to hold up his neck and head without support, and to sit with some support. You want to keep her as healthy as possible, so start with fresh, healthful, natural foods, loads of fruits, veggies, meats, fish, chicken, eggs. Don’t skimp on fat – avo, nut butters, cream cheeses – and avoid sugary infant cereals like the plague.

After weeks or months in ICU, being fed with tubes, syringes and bottles, some preemies develop a bit of an aversion to food. If this happens, try some baby led weaning instead of spoon feeding. Keep meal times light and fun and make sure to share meals with baba – if you both nibble off the same plate, food becomes exciting and social, and not something stressful to create issues for years to come.

Have fun and ask for help

Have fun in this precious period! Don’t stress too much, you’re not alone, keep in contact with your doctor and dietitian and keep up to date on all your clinic visits.

Amanda Rusch Ferreira

Clinical Dietician (Specialising in Paediatrics)

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