Tuesday, January 19, 2016

Calorie Packing 101 - Part 1 - Babies

R only needed fortified feeding for the first 6-7 months of her life while C has been classified as FTT for most of his life.  He didn't learn what hunger felt like as a child, he doesn't have a good relationship with his body, and he doesn't acknowledge his own hunger cues without meds. We've tried a lot of calorie packing strategies.  I won't say we've tried them all, but we've tried a lot.  I'm going to try and summarize what I've learned in terms of Calorie Packing, Medical support for eating, Delayed Gastric Emptying (DGE) and reflux.

This is part 1 of a 3 part series on calorie packing.

Please note, I am not a doctor, these are my personal experiences.  Please speak with your baby's medical team about your baby's particular condition as all children have unique circumstances that must be taken into account.

Calorie Packing For Babies 

When your has a genetic or physical condition that causes them to use extra calories, is starting from a low or extremely low birth weight or simply doesn't gain weight, the medical community jumps feet first into fortification.  If you are breast feeding, some doctors will tell you to immediately quit breast feeding and begin feeding formula.  Generally speaking, that is a big, drastic step to take initially (if you are in a drastic situation, then drastic steps are generally warranted, otherwise, it is worth some quick investigation).  

The first thing you should know about infant weight gain is that your fastest weight gain occurs in the first 4 months and you should be averaging at least 20-30 grams per day.  If that isn't happening, there are steps you can take.  If your baby is close to that goal, say they are only gaining 15 grams per day in the first few weeks and you are breastfeeding, you should get a good lactation consultant and troubleshoot your breast feeding situation.  Make sure you've got good transfer, that baby doesn't have a tongue tie and that you are feeding on demand.  There are times, early on in breastfeeding, where it seems like baby will never stop eating... keep feeding them.  

For those babies with medical conditions, you may be told not to let baby eat more than 30 minutes because it burns too many calories.  While this may be true if the choice is between eating and sleeping, it is not true when the choice is between eating and screaming.  If baby is going to scream when you are not feeding them, keep the boob in their mouth (or a bottle, or a pacifier, whatever). you'll be at a net gain overall because eating requires less energy than screaming.  

Standard formula by default, is 20 calories per ounce, breast milk is generally expected to average about that per ounce as well.  Though that isn't always true.  My breast milk tends to run about 22-23 calories per ounce (I know this because I'm a milk donor and they check the calories when processing the milk).  If you've determined your baby is not gaining weight on breast milk or formula, the doctor may start talking about calorie packing.  First, if you are breastfeeding, it might be worth asking for a creamocrit to determine the total calorie content of your milk.  If not, you can assume the typical 20 calories per ounce and fortify from there.  You may want to make sure your doctor is consulting with a nutritionist when formulating your baby's caloric needs.  If breastfeeding, try to ensure they allow you to continue to put baby to breast at least once or twice a day for a full feeding, plus comfort feedings as long as they don't interfere with your daily intake goals.  Note: Keeping your breast emptier will generally increase the fattiness of your milk, so pumping more often is recommended when you are worried about nutrition.

For both formula and breast milk, fortification entails adding additional formula to the measured total.  So, if you are at 20 calories per ounce with breast milk or formula, you could add a teaspoon of formula to 6 ounces of milk increasing the calories to 22 cal/oz.  There are recipes for increasing calories up to around 30 calories per ounce.  Caloric adjustments to formula or fortification of breast milk should only be done under the supervision of a medical professional as adding and modifying calories also modifies other nutrients received by the baby and the balance should be carefully maintained by a trained professional (preferably a pediatric nutritionist).

If you are totally and completely set against formula in any form, there are other, older methods of fortification that you can turn to.  For example, coconut oil can be used to fortify breast milk to add calories.  However, please note that formula was created for a reason and it is a safer method of fortifying.  If a baby aspirates formula or breast milk with formula into their lungs, they will have fewer issues (genearlly speaking) than if a baby were to aspirate breast milk mixed with oil.

When you are fortifying breast milk or adjusting formula, you may end up increasing the richness of the food beyond the baby's tolerance.  If this is the case, the baby may vomit after feeding.  Sometimes this can be confused with Reflux, Delayed Gastric Emptying or other issues.  Ask if you can trial lower caloric fortification (or if fortifying breast milk and you haven't had one, ask for a creamocrit) it is possible that you are just exceeding baby's tolerance for rich foods.

Sometimes preemie fortification is less for weight gain and more for the trace minerals and nutrients in Neosure or other specialty preemie formulas.  Be sure you understand the reasons for fortification and if it is causing difficulty, ask what alternatives there are.  My daughter had a really hard time with constipation when we fortified her bottles.  We ran a nutrition panel to check how her bones were growing, what her blood iron levels were and a host of other numbers to see how she was doing and if we could wean down off of fortified bottles.  In the end, we were able to wean off a few months before we started solids.  Once you are on solids, you can get those nutrients through other means and wouldn't need to fortify if the reason for fortification is to provide trace nutrients.

In general, I've found adding a probiotic with approval from a physician is a great way to help improve all aspects of the GI tract.  I'm personally partial to the Jarrow powdered probiotic for babies.  My pediatrician also asked me to give my children both a D vitamin supplement since they are breastfed.  There is a study that shows if mom takes about 6000 iui per day then baby will get the Vitamin D they need from the breast milk, but it is only one study, so I do take 6000 iui and I also give my children 400 iui of Carlson D Drops.

When I fortified breast milk for my daughter after she came home from the hospital, I had to use Human Milk Fortifier from Enfamil.  I found if I called them and asked, they'd at least give me a small coupon toward the purchase.  They also sent me some coupons for Poly-Vi-Sol with Iron which we were giving as well as the fortified bottles.  It is totally worth giving them a call at 1-800-BABY123 or checking them out on the web at www.enfamil.com.
With my son, his heart condition led to delayed gastric emptying and reflux that led to some other medical interventions in addition to fortification.  I'll address that in part 2 of this series.  

Overall, The most important thing here is your baby's health and growth.  Any combination of formula, breast milk, either or both are OK, the goal is happy, healthy baby and happy, healthy mommy.

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