1. Case Study: Successfully Breastfeeding the Premature Infant Melissa Nash, MPH, RD Washington County Field Team

2. NICU info Bryan is an ex-31 wk premie No major complications in NICU Discharged at 36 wks CA Mom had great milk supply in the NICU: Pumped 6 oz q 3 hrs Discharge meds/vits:  No meds & 0.5 MVI w/ iron Discharge feeding plan:  EMM + EnfaCare to 22 kcal/oz

3. 38 wks GA (RD Home Visit) Feeding history:  Mom has been BF q feeding.  Usually offers fortified bottle before BF  Sometimes pumps after BF Good wt gain since discharge:  ~1 oz/d Bone labs normal in NICU:  Ca 10.6, Phos 6.4, Alk Phos 412 (all normal) Gives 0.5 ml MVI w/ iron

4. 38 weeks GA (RD Home Visit) Nutrition Plan:  Continue to BF q feeding  Offer breast before bottle  Always pump after BF (or every time baby eats)  Continue to fortify all bottles to 22 kcal/oz  Change to 1 ml MVI w/ iron  Order bone labs (to be checked 4-6 wks post- discharge)

5. 40 wks (MD appt) Bone labs drawn  Alk Phos 498 (slightly high)  Ca 9.2  No Phos drawn Nutrition Plan:  Re-ck labs in 1 mo - at next MD appt  Continue w/ same feeding plan

6. 1 wk CA (Home visit by CHN) Weight check:  Excellent wt gain: avg 1.8 oz/d x 3 wks Feeding history:  BF ~10-15 min. q feeding  1-2 oz fort. bottle of EMM to 22 kcal/oz q feed.  Pumping q feeding Nutrition plan:  Night = EBF (no pumping/bottles)  Day = BF + fort. bottles + pumping

7. Growth Grid

8. 1 month CA (WIC appt) Weight check:  Avg 1 oz/d x 3 wks Feeding history:  EBF at night (no pumping/bottle)  EBF 2-3x/day  Offers breast + fort bottle 2-3x/day Nutrition Plan:  Start EBF  Continue w/ 1ml MVI w/ iron

9. 1 ½ months CA (out-pt RD appt) Weight check:  Avg 1 oz/day Feeding history:  EBF Nutrition Plan (no changes):  Continue EBF  Continue 1 ml MVI w/ iron

10. 2 mos CA (MD appt) Bone Labs:  Alk Phos 669 (H), Phos 5.4, no Ca RD Home Visit Plan/Options (MOB chooses): 1. Offer 2 bottles/d of straight EnfaCare (mom to pump & freeze milk) 2. BF + fortified bottle + pumping q feeding 3. Continue to EBF + start Tribasic

11. 2 months CA (RD Home Visit) Start Tribasic (Ca/Phos Suppl.) RD to provide specific instructions to MD:  MD calls Rx into compounding pharmacy  Dosage 1/8 tsp powder BID x 6 wks  Re-check bone labs in 4-6 wks RD to provide specific instructions to family:  Parents to buy Tribasic out-of-pocket, ~$25-30  Parents to buy 1/8 tsp measuring tool  Measure powder & mix w/ ~5ml breastmilk  Give via syringe or infant spoon

12. 3 ½ months CA Bone Labs:  Alk Phos 403, Phos 5.5, Ca 10.2, Hgb 12.2 (all normal) Nutrition plan (no changes):  Continue EBF  Continue w/ Tribasic 1/8 tsp BID  Continue 1 ml MVI w/ iron

13. 4 ½ months CA Bone labs:  Alk Phos 372, Phos 6.0, Ca 10.6 (all normal) Nutrition Plan:  Stop Tribasic  Continue EBF  Continue 1 ml MVI w/ iron  Delay solids until 6 mos CA