Breast-feeding in NICUland
September 15, 2010

NICUland is staffed by some of the warmest, smartest people I’ve ever met. Those NICU nurses fight constantly against death and sickness, and still manage to find various ways for parents to be involved and vital in their child’s care. But, in any hospital department, policies and realities can make individual experiences difficult.
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Teagan was born at 9:14 a.m. At 1:52 p.m., I finally got to hold her and nurse her. She was listless about breast-feeding; she nibbled and licked for a while before she latched on. She stayed on for a few minutes, then fell asleep. The nurse assured me that she was getting everything she needed through her IV line, so there was no need to fuss about my milk coming in.

Down in my room, they brought in The Pump. There were several of these Pumps floating around the NICU for lactating mothers, so that they could pump and spend time with their baby. They even gave you free accessory kits, with the tubes and shields and whatnot, in addition to unlimited sterile bottles to express into. Despite the helpfulness and the fact that I had pumped for ten months with Noah, I found the whole array foreign and intimidating. I had dreamed for months (years?) of this blissful skin-to-skin breast-feeding heaven after her birth, where she’d latch on right after my awesome unmedicated VBAC, room in with me, and snuggle in my arms for days. Instead, I had The Pump, which, on its stainless steel rig, looked like it belonged aboard the Nebuchadnezzar in The Matrix. The top of it looked like the sleep-medicine machine from Inception. It had WHEELS, for crying out loud. Instead of my soft baby in my arms whenever I wanted, I got to hook up to the thing with wheels that the nurse wiped down with sterile wipes beforehand. Yay. (side note: I’m grateful for the breast pump as a tool–and it is a fantastic tool, especially in the NICU, but also for working and studying mothers.)

The second time we went up to see Teagan, the nurse laid down the law. We were allowed to sit with her as much as we liked, as long as we liked, but she was only supposed to nurse every three hours, and only for thirty minutes at a time. I’ve never had a baby not room in with me and I’ve certainly never breast-fed on a schedule (mostly because I’m too disorganized to put *myself* on a schedule) so I was a little taken aback. What if she got hungry in between feeding times? If I was holding her and she started rooting, was I supposed to ignore it? And with such an iffy latch, was I really supposed to pull her off if she was having a great nursing session? Everything about it was antithetical to my mothering instincts. But the nurse was firm: sick babies can’t nurse too much. It wastes their energy. Plus, they’re getting everything they need from the IV. Nursing is really more of a recreational sport at this point.

On the way down to our room, Josh shook his head. “You’d think sick babies would need their mommies more, not less.”

Why didn’t I fight this? After fighting off a c-section for 17 hours, you’d think this would be cake. But I don’t know. I was exhausted from the long labor and no sleep, emotionally numb from my failed VBAC and Teagan’s NICU admission, not to mention fogged out on drugs for pain. My gumption was gone. My energy to advocate was sapped. I just wanted everything to be easy and conflict-free.

Nursing was further derailed by the night nurse. Josh rolled me up to breast-feed, and Teagan was alone in her little booth (this was normal–since she wasn’t all that sick, her nurse usually had one or two other low-priority babies.) Josh, wanting to hold his less-than-a-day-old daughter, scooped her up from the warmer. One of the leads pulled loose. The night nurse, hearing the alarm, came in and literally TOOK TEAGAN OUT OF JOSH’S ARMS, snapping, “You can’t pick her up unless I am here!” With all the noise and jostling, Teagan started crying. The nurse gave Josh a disgusted look. “See? She’s crying now.” That nurse watched us like a hawk. If thirty minutes had passed, even if twenty-seven of those minutes was trying to coax a latch and only three were actual breast-feeding, she took Teagan away and put her back in the warmer.

It was true that it helped to have a nurse around when I tried to breast-feed. All the other nurses were much more lenient and compassionate about us handling Teagan (as in, we were allowed to.) But only the nurses seemed comfortable maneuvering her with the IVs and PIC lines and endless leads. Breast-feeding a newborn is hard enough, trying to find all the right places to support their heads and bodies and your own breasts. Juggling all this while trying not to strain or pull the lines was frustrating. It was easiest when I could sit with my Boppy and have someone hand her to me. One day, I went to hand her back to the nurse and saw blood all over her legs. The PIC line itself snapped, leaving blood to trickle out the ruptured tube.

By the second day, her latch wasn’t improving (although a wandering LC managed to get her on. Murphy’s Law of breast-feeding help: whenever an Lactation Consultant is there, they can get the baby to latch on fine. As soon as they leave, it all goes to pot again.) People started pestering me about my milk coming in. It was a good four or five days with Noah, so I knew it would be a while with Teagan. I also knew that colostrum was plenty for tiny babies. But it became a subject of concern and pity when people would ask and find out that I still didn’t have mature milk in. Still! And it’s day three already! Gasp!

It didn’t help that I wasn’t pumping anything. Even the NASA grade Inception-Matrix-Medela contraption couldn’t coax any colostrum out, which started getting discouraging. I might get one viscous little dribble, which by the time it worked its way down the shield, through the flange and down the side of the bottle, wasn’t even enough to suck up in a syringe. I hated the obligation of pumping, the necessity of stimulating my supply because my baby wasn’t nursing enough because of their stupid schedule. By the time I went up to nurse Teags, got back down, double-pumped for twenty minutes, I had about an hour to sleep before I did it all over again.

Also on the second day, the nurse practitioner raised the possibility that Teagan might be able to go home the following day or, at least, move into the step-down nursery. But in order to do that, she had to keep her temperature without her warmer and produce so many grams of wet diaper without being hooked up to the IV fluids. We had a choice at that point: supplement with formula on the chance that she might be able to leave the NICU and come home with us sooner, thus freeing us from the restraints on nursing and cuddling OR we could leave her hooked up to the line and delay homecoming. We chose formula supplementation. This is something I go back and forth on in retrospect. I wish I would have talked with the neonatologist and maybe a lactation consultant before we agreed, just to make sure that those really were our only two options. At the time, the prospect of bringing her home put stars in our eyes. It was all we saw.

Cups and syringes weren’t allowed feeding methods in the NICU, and I didn’t think to ask about finger feeding, so it was going to have to be the bottle. Teagan’s first bottle experience wasn’t pretty. She turned her head away from the rubber nipple over and over again, making this disgusted face. The nurse grasped her by the neck in one hand and used the other to force the nipple into her mouth. Teagan gagged and sputtered, formula running down her cheeks and chin, fussing and squirming to get away. The nurse just adjusted her grip on Teagan’s neck. “Sometimes they just need to get a taste of it to learn it’s yummy food,” she told us cheerfully.

Unkind words ran through my mind.

After that, I tried to be the one to give her the bottle as much as possible (although, if I liked the nurse on duty, I’d let them do it so I could pump while I watched and potentially get more time to sleep.) There’s no reason that bottle-feeding can’t be a gentle and loving activity, and how much longer would it really take to allow a baby to “latch” onto the bottle themselves and drink at their own pace? Even when Teagan would turn her head away and cry when the bottle was put in her mouth–clearly done eating for the time–some nurses would force her to finish the full two ounces of formula. Why couldn’t they just let her eat to hunger? More things I wish I would have challenged… And, after a full day of bottle-feeding, nipple preference set in.

Hard.

Teagan only had to feel my nipple touch her lips to start shying away. This dead look of existential despair would appear on her face and she’d press her lips shut, as if waiting to die. Death would be better than have that awful fleshy thing that was so much *work* in her mouth. Even the LCs couldn’t work their magic. But as soon as she got that bottle, she’d chug the whole thing in no time. (Also, by this time, it was clear that she was staying the full week, so I didn’t think I had the option of banning the bottle altogether.)

At least my milk came in (four and a half days postpartum), so we could supplement with MamaJuice, but I didn’t want to be doomed to be an exclusive pumper. I wanted to breast-feed her normally! Early on, with her iffy latch, I’d been thinking about a nipple shield to help get her on the breat more. The LC who’d been working with me had been holding back on the shield, treating it like it was a freaking missile code or something. But the other LC gave me one straight away. And guess what? After shooting a little syringe of expressed milk on the silicone, Teagan was able to latch on long enough to get a let-down. With my newly minted supply, the let-down was a like a beer bong. Her eyes widened in surprise, but then she hunkered her body closer to mine, furrowed her brows and got to work.

The syringe of milk onto the nipple shield was Nurse Awesome’s idea. Just like Molly the LC was the reason I kept breast-feeding Noah, L the Awesome Nurse was the reason Teagan and I could shed so much NICU baggage. She was the first nurse to actually read the doctor’s orders regarding Teagan’s feeding. I was putting Teagan back in her warmer and telling L that I’d be back in three hours, when she bit her lip and started rifling through papers. “Dr. S wrote on here that you could breast-feed ad lib,” she said. I stared at her. She explained, “That means you can feed her whenever you want, as often as you want.”

Oh.

“And,” she continued, looking through the nurses’ notes, “I can see that you’ve been able to pump several ounces after each feeding? There’s no need to keep supplementing. Even if you weren’t pumping a lot, I’d still say let’s stop supplementing and see how her wet diapers are now that your milk is in.”

She peeked in the trash and shook her head at all the used bottles of expressed milk and formula. In the NICU, they had two kinds of nipples that were both technically newborn nipples, but were from different manufacturers. L always gives her breast babies the one with a single small hole, so that they have to work at the nipple like they do at the breast. The other nurses had been giving Teagan the other nipple–one with two larger holes. “The milk just pours out of those nipples,” L said. “No wonder she got nipple confusion.”

L was only Teagan’s nurse for twelve hours. In those twelve hours I got Teagan back on the breast, stopped supplementing and discovered the cause of her intense nipple confusion. Another bonus? After five days of scheduled feedings and aggressive formula supplementation, Teagan weighed one ounce under birth weight. After twelve hours of unrestricted, on-demand breast-feeding with no supplementation? She had gained four ounces. The nurse on the shift after L’s couldn’t believe it. He weighed Teagan three times to make sure the scale wasn’t malfunctioning.

Things were much better after that. It took about a week after we got home to wean off the nipple shield, but we took it slowly, and I let Teagan dictate the pace. I did get some plugged ducts and mastitis, probably because of the shield use in addition to my tendency toward oversupply, but we got over that too. She wisely rejected a pacifier, and decided that first week home would be all about building my supply. I sat in my glider for hours at a time. We had bottles and bottles of milk pumped in the NICU–Josh would have to cup feed her expressed milk just so I could take a shower. She ate constantly.

And here we are, two months later, no worse for the wear. Even though everything is fine now, looking back, there are a few things that I wish I would have done differently.

1) Most importantly, I wish I would have asked more questions about the mandated schedule. I knew Teagan wasn’t very sick, and I also knew that it was my right as a parent to question anything that felt wrong to me. It turns out that I could have breast-fed on demand her entire NICU stay, and those five days of scheduled feedings and headaches are days I’ll never get back. That she’ll never get back.

2) I wish I would have made sure there was no other options than formula or more NICU time (she ended up having to stay longer anyway…bad gamble on our part.) I also wish I would have remembered to ask about finger-feeding. I would have been willing to take the time to do it, and it might have prevented the nipple confusion and thus the shield and thus the mastitis later on.

3) I wish I would have spoken up about some of the more aggressive bottle-feedings. One nurse tried to get Teagan to eat four ounces in a setting so that she’d go FOUR hours in between feedings instead of three. I was so unhappy about it–why didn’t I speak up?

Teagan was only in the NICU for a week. I can’t imagine all those brave mamas who struggle through all the necessary and unnecessary concessions to NICUland for weeks or even months to continue nursing. Of course, we all know it’s more than worth it; breastmilk is even more vital to vulnerable preemies. But sometimes that fact is cold comfort when you’re pumping alone at three in the morning, staring blearily at your baby in her web of leads and tubes. All nursing mothers should be celebrated, but NICU mothers deserve something more. Praise. Limitless admiration. A nap, perhaps.

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