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Feeding Tips for Preemies

I've had a number of parents ask for my advice on feeding premature babies. Extreme preemies, in particular, are notoriously difficult to feed; many doctors give up and surgically insert a G-tube. This can  lead to other feeding problems down the road. (Why learn to eat if a tube automatically brings food to your tummy? Admittedly, this is much more of a problem for infants who never learned to eat anything before they were given a G-tube.)

While a G-tube is sometimes necessary in order to have a healthy baby, it's my opinion that fewer babies would be given G-tubes if their parents had access to good feeding clinics. Without the wonderful folks at our feeding clinic, Anastasia would undoubtedly have a G-tube, too. So if your baby is having trouble eating, I highly recommend asking your pediatrician, neonatologist, or NICU nurses about a feeding clinic. If they have no recommendations, try calling nearby medical universities or children's hospitals, asking for professionals who specialize in eating difficulties.

That said, some parents have found success in copying some of the things we've done to combat Anastasia's eating issues. Although feeding problems should be treated individually, and I am by no means an expert on the subject, it's my hope that here you'll find one or two tips that are useful for your own situation.

For more links related to feeding, please see the Resources section.

To help you navigate to information that will be most useful to you, please choose a topic:

Young Babies (getting most of their calories from breast milk or formula)

Older babies (who should be eating solids)

For Everyone

A Word About Friends & Family


* * *


Young Babies

First, a little background. In the NICU, Anastasia only took some of her feedings with a bottle; her NG (feeding) tube mostly remained in place until the day before she left the hospital. For bottle feedings (breast milk only), we used a Dr. Brown's with a standard Dr. Brown's nipple. When we brought Anastasia home, she cried and cried and cried (which is so not her personality!) and writhed as if she was in pain. We tried giving her over the counter gas drops, but this rarely helped. The medical people we spoke with weren't overly concerned about these symptoms, thinking she "just" had colic.

While Anastasia was in the NICU, she was also overfed - although with good reason. The neonatologists were trying to get her lungs to grow and improve. When she got home and no longer had her NG tube, she starting loosing weight. This freaked out her pediatrician, who began mentioning the possibility of a G-tube. My reply was: "But it seems to me there must be other things we can try before we go to the extreme of surgery!" Finally, she referred us to a feeding clinic.

Here's what worked for us:

* Changing nipples. The feeding clinic gave us a Similac "premature nipple" to use with the Dr. Brown bottle. It requires no real sucking; the milk just drips out. It made a huge difference, and I was shocked the NICU never offered us one. The nipple not only improved Anastasia's calorie intake, but it greatly reduced her stomach cramps. Apparently she was sucking as hard as she could on the regular nipple, but wasn't able to get much milk. This made her stomach cramp up, which made her too uncomfortable to eat. Until 18 months chronological age, Anastasia used the preemie nipple.

I've searched unsuccessfully for a place to buy these nipples, but a feeding clinic or hospital will usually give them away, or sell them for a small fee. I've also seen them new on eBay. Be sure to get a good supply, as they rather quickly become too soft and must be replaced. 

There's also a Dr. Brown's preemie nipple, although we've never tried it. (And the Dr. Brown's bottle is highly recommended for babies with reflux.)

* Cutting fenugreek. I'd been using the herb fenugreek in order to boost my milk supply. On the advice of another mom, I stopped taking it. Within two days, Anastasia's tummy was more comfortable. To be sure the fenugreek was really the problem, I went back on the herb. Sure enough, Anastasia started having bad tummy aches again. I never took fenugreek again.

* Cutting dairy. I stopped eating all dairy and, combined with the two items above, this completely rid Anastasia of her tummy aches.

* Formula. My milk supply could no longer keep up with Anastasia, so I began exploring formulas. On the advice of other preemie parents, I was going to use Neocate, but the feeding clinic folks suggesting trying other, cheaper, formulas first. Since Anastasia apparently had a problem with dairy, I thought about offering her a soy formula - but the possible side effects of soy formulas disturbs me, so I tried Enfamil's Gentlease. This is a dairy product, but with reduced lactose and broken down milk protein. Anastasia did very well on it. (My son, who was born full term but had trouble with tummy aches, also used Gentlease. We also found that Target's version of this formula worked just as well for my son, and at considerable savings.)

A tip from the clinic: If you supplement with formula, be sure every feeding has about the same mix of breast milk and formula. Don't offer breast milk one feeding, formula the next, as this can upset little tummies.

* Hind milk. Beginning when Anastasia was still in the NICU, she was given only hind milk. She put on weight like mad. Hind milk is the latter and fattiest part of breast milk; I got it by pumping for five minutes and then switching bottles. The milk from the second set of bottles was all we used.

* Peace...Or Distraction? Anastasia is easily distracted while she's eating - a common preemie problem. So when she was little, I took her into the nursery, turned off the light (or used a very dim light), closed the curtains, turned off the radio, made sure the TV wasn't going, and shooed everyone out of the room. Rocking also really helped Anastasia - probably because it made her a little sleepy.

Other parents of preemies say that distraction is the only thing that works. One friend bemoaned that the only way to get her baby to eat was to place him in front of the television. Whatever works!

* Sleepiness.
Like most preemies, originally Anastasia's biggest problem was that she fell asleep before finishing a feed. We implemented all the usual tricks of tickling, changing positions, burping frequently, etc. to keep her awake. However, we found that Anastasia always bottle fed better if she was a little sleepy. That's true to this day. So we always fed her after a nap, instead of before a nap. That way, she went into "auto pilot," and was less likely to get distracted.

* Burping. Once Anastasia got past the stage where burps were hard to get out (about four months, corrected age), I found that I should never interrupt her feedings for a burp. If she really needed one, she'd stop eating on her own, but if I interrupted her, it was always difficult to get her back to eating.

* Start solids early. The clinic encouraged us to begin solids at about four months corrected age (six months chronological). Like most children who are starting solids, Anastasia mostly just tasted, but I'm sure she also got some extra calories. There was some disagreement within the clinic about whether we should start solids this early, but ultimately the doctor said we should use our own judgment. "Don't push, take plenty of time. If she doesn't seem ready, stop and try again a few weeks later. If she takes to it, use the typical precautions of trying one food every three days or so, in case food allergies appear." See more about solids below.

* Don't use baby foods. I was shocked to learn that bottled baby foods (especially veggies) are full of water. Table food is a lot more nutritious, tastes better, and has more calories. You don't have to put table food in the blender, either. Just cook the food thoroughly (steaming veggies helps them retain their nutrients), mash well with a fork, and spoon into ice cube trays. Once the veggies are frozen, transfer them to a freezer bag. When you want to feed the baby, just nuke one of the cubes. (Or feed the baby whatever veggies are on your plate.)

I found that adding formula to everything made Anastasia more accepting of new foods. (But don't make the same mistake I did and add formula to things like peas or corn. This creates a liquid with lumps, which little ones tend to gag on.)

The clinic did not recommend rice cereal, as it's not very tasty or nutritious, and tends to cause constipation (an issue for many preemies). I offered Anastasia baby oatmeal, which she loved, but the clinic has since informed me that adult oatmeal has a lot more fiber in it. (Baby oatmeal has the least amount of fiber, adult "quick cooking" oatmeal is in the middle, and old fashioned oatmeal has the most fiber. If you use the latter, make sure you cook it extremely well. If your baby isn't on formula and doesn't get supplemental iron, use baby oatmeal, anyway, as it contains the iron your baby needs.)

* Reflux medicine. Anastasia was on reflux medication in the NICU, but was taken off the stuff just before coming home because the doctor on call didn't believe in them. It took a while to get her pediatrician to prescribe something - and then several more weeks to find the right medication for Anastasia. She took Zantac in the hospital, through an NG tube, but wouldn't tolerate it directly in her mouth. We ended up using specially flavored Prilosec. Getting Anastasia's reflux under control really helped her eating, too. Later, because it was cheaper (given our perscription insurance), we switched to Prevacid. (For more information about preemie reflux, visit Infant Reflux.)

* Adding calories to formula. I know a lot of parents of preemies add oils and powders to their baby's formula, but the clinic just had us "soup up" Anastasia's formula by adding a little extra formula powder. This is not something you should try on your own, but mention it to your baby's doctor, and see if he or she will approve. (We used 5 oz. of water to 3 scoops of formula to make a 24 calorie drink.)

At one point, we did add Polycose (a powder that's almost all carbohydrates) to Anastasia's formula to increase the calories. Unfortunately, she did what a smallish number of babies do...She started eating less.


* Formula Before Solids. Although many doctors recommend offering solids to the baby before giving her the bottle, for several months, we found the opposite worked best for Anastasia (who was still getting most of her nutrition from formula). We gave her as much formula as she'd take first, and then offer as many solids as she'll take.


* Cup and Dropper. On our very first feeding clinic visit, we were given a dropper and a special cup, which you can see Anastasia using here:

At first, neither were very useful; Anastasia would just spit out whatever we managed to get into her mouth. However, at about 8 months corrected age, I tried the cup again. Anastasia was taking an ounce or two from her bottle, then refusing to suck any more. So, I took her to the high chair and offered her formula from the pink cup. She loved the newness of it, I think, and got quite a lot from the cup. (It is messy and slow going, I must admit. But it gets those extra calories down!)

Here's a link to the exact cup Anastasia uses: http://www.equipmentshop.com/ProductDetail.asp?ProductID=19

If you can't buy this cup, you could use a small paper cup, and cut an indention in it, like Anastasia's pink cup. This allows you to easily see how much milk the baby is getting in his or her mouth. A small clear cup might work, too.

The feeding clinic suggested I put the cup to her lips and let her lap up milk, but I've found it works best if I get a little milk in her mouth and then take the cup away and allow her to swallow.



Older Babies

* Encourage fattening foods. Once Anastasia was eating oatmeal well, we began offering fattening foods like avocado and cottage cheese. Don't give up after one or two tries. If your baby doesn't like the food right away, offer it at least once every two weeks, and chances are, she'll eventually take to it. (A trick: In the early days, I could slip almost anything into Anastasia's oatmeal, and she'd tolerate it so much better than if I offered it to her by itself. So take a food your baby loves and mix in just a little of something she doesn't. Gradually add more and more of the new food.)

Other great fattening foods: Toby's Tofu Pate (not the "lite" version); bean dip; hummus; cream cheese (kids especially like the flavored berry or salmon types); almond or cashew butter or tahini; guacamole (mashed avocado and mayo); dips (without chunks); pudding; yogurt (especially whole milk varieties); Laughing Cow cheese (soft Swiss cheese); jams or preserves; scrambled eggs with grated cheese and cream cheese; refried beans with cheese, cream cheese, sour cream; chicken, tuna, or egg salad with lots of mayo; shakes made from whipping cream, milk, and ice cream; ice cream; custard; egg nog; oatmeal made with milk, margarine or butter, and brown sugar; cottage cheese (not the low fat or fat free varieties); cheesecake; macaroni and cheese (preferably home made or Velveta brand). And if you're cooking your child things that include milk, definitely use whole milk...or, better yet, cream.

Oh, and something new I've tried: YoBaby. This is a yogurt made of whole milk. It's the highest calorie yogurt I've ever seen, and Anastasia adored it! She would eat it when she'd eat nothing else.


* Adding butter or vegetable oil.  Just a little bit added to Anastasia's solids adds precious calories. We also sometimes add ground flax seed to her foods (which has the added benefit of keeping her regular). Some parents prefer flax seed oil. Please talk to your doctor before adding any oils to your baby's diet, however. If your baby ever aspirates, oils can cause serious breathing issues.

* Variety. Anastasia likes variety, so I always offered at least three different solids per meal. I might start out with avocado, for example, and feed her that until she eats it all or doesn't want any more, and then move on to YoBaby. I always ended each meal with something she could easily feed herself, like Ritz crackers or Cheetos.

Any time I get stuck in a rut with regard to what foods I offer Anastasia, she begins eating less.

Be sure to read the information on baby foods, too.


* Sometimes Bottle, Sometimes Solids. When Anastasia was about 9 months corrected age, we completely changed her feedings. (When the feeding clinic suggested this plan, I was skeptical...but it really worked.) They wanted me to give Anastasia three bottles a day and three solid-food meals a day, alternating. (Example: First meal, bottle; second meal, solids; third meal, bottle; fourth meal, solids.) Because I knew Anastasia took much more from her bottle when she's sleepy, I changed this a bit and started giving her a bottle in the morning, solids for her next three meals, and a bottle in the evening, and another in the middle of the night. Within a few days, Anastasia was eating considerably more in the way of solids. At 10 1/2 months corrected age, Anastasia was eating 4-5 tablespoons of solids per meal. That was an incredible improvement. (Please note that it's important to offer something to drink after each solids meal.)


* Self Feeding.  If your baby shows an interest in feeding herself, it's important to let her. I can't count the number of times Anastasia wanted to feed herself, I didn't allow it, and she promptly refused to eat anything more.

When you're worried about calories, it's tough to see food all over the floor...This is why self feeding at the end of the meal is nice. Also, try to offer at least one food that will tend to stay on the spoon. For example, avocado sticks to the spoon, even when a baby turns that spoon upside down and waves it through the air. Things that stick on fork prongs (like chicken or peaches) are also good choices. (Be sure to use blunt edged baby forks.)

Sometimes, when I really needed to get food down her and Anastasia wanted to self feed, but would just end up playing with her food, I held her hand while I fed her. Other times, offering her an empty spoon to play with distracted her enough that I could get food into her.


* Sippy Cup? Although our pediatrician recommended Anastasia start practicing with a sippy cup at about 6 months corrected, Anastasia simply didn't have the sucking ability to use any standard sippy cup. (And I think we tried them all!) So the feeding clinic gave us an old fashioned baby cup. It has an indented lid with a hole in it. It isn't spill proof, but it's not as messy as an adult cup, either. Try it with water (or something else that's easy to clean up) first. Here's the exact, two handled cup we use:


(If you want to buy a feeding cup and a baby cup in the same spot, this company also has cups similar to Anastasia's pink cup: http://www.kcup.com/nosey.htm )

Some babies do really well with a cup and straw, too. To help them learn to suck fluid through the straw, try a cup with soft sides; squeeze it to push a little bit of fluid into the straw. Chances are, the baby will understand how to use the straw pretty quickly.


For Everyone

* Relax. When I was uptight about Anastasia's eating, she didn't eat well. When I learned to relax, enjoy the process, and stop worrying when she ate less, she started eating a lot more. (Yes, not stressing out is easier said than done!) Although it's important to track how many ccs or ounces the baby is eating, try not to obsess like I used to. Look at the bigger picture: How has she done overall this week? Is she staying in her growth curve? (Because Anastasia was "overfed" in the NICU, it took her a little while to find her natural weight and settle into a growth curve.)


* Humor. Retaining your sense of humor during feedings will not only help you not be so stressed and frustrated, but it may help your child eat more. As soon as Anastasia used to start turning away from her bottle or spoon, I'd find that if I reacted in a silly fashion (making funny noises, silly faces, singing high notes, etc.) she'll smile or laugh and then eat a little more. Perhaps this worked because it kept feedings from becoming a power struggle. Or perhaps it worked because everyone was more relaxed and eating becomes less stressful. Or maybe it just distracted the babe.


* Don't push your baby. There are plenty of times I got extremely frustrated because Anastasia wouldn't eat. At those times, it's tempting to force the bottle or spoon in the baby's mouth and somehow make her eat. But not only is it almost impossible to make a baby eat if she doesn't want to, trying to force food down her will likely lead to oral aversions. In other words, pushing your baby will only exacerbate your child's eating problems and lead to long-term difficulties.

This doesn't mean that when Anastasia turned away from the nipple that I automatically gave up. Instead, I made sure she didn't need a burp or a diaper change, then offered her the nipple again. If she still refused, then we ended the feeding. Patience - lots of it - is necessary when feeding babies with eating issues.


UPDATE 9/28/09:

Parents magazine has an interesting article on teaching "Healthy Eating at Home." Despite the fact this article is geared toward kids who eat normally, it includes many scientifically backed-up ideas that can be used for kids who don't eat enough:

* In a study of grown women, those who ate off pretty plates ate more food. Why not try using plates your kids love (Elmo or Winnie the Pooh, anyone?) and see if it induces them to eat more, too?

* If your child indicates she's thirsty, don't ask what she wants to drink. Simply bring her a beverage of your choice and place it in a very large container. Study after study shows the more food or drink people are offered, the more they consume. If you give your child a 20 oz. container, studies indicate she'll drink more than if you give her a 6 oz. container. (Though, of course, you shouldn't expect her to drink the full 20 oz!.

* When it comes to foods you really want your child to eat, pile them on the plate. Don't simply given him the portion you expect him to eat. By giving your child more than you expect him to eat, he's more likely to eat more.

* Don't insist your child use utensils. Some experts believe children get more enjoyment from food if they use their hands to eat. And for kids with eating issues, more enjoyment usually means more calories.

* Make up fun names for ordinary foods. In the Parents article, Dr. Brian Wansink, Ph.D., says "In one experiment I did, preschoolers ate twice as many vegetables when we called them things like X-Ray Vision Carrots, Power Peas, Tomato Bursts, and, yes, Dinosaur Trees." In your household you can do this not just with vegetables, but with fattening foods, too.

* Dr. Wansink also says he puts two different types of vegetables on his children's plates. "They seem to respond better when they feel like they're part of the decision-making process," his wife says. In your household, try putting at least two types of fattening foods on your child's plate.


A Word About Friends & Family

Most are undoubtedly well-meant, but when your child has feeding issues, you're going to get some interesting comments. Some people think you must be a bad (or stupid) parent, because the idea that "babies will eat what they need" has been pounded into people's brains by baby magazines and books. Others say, "Oh, but she looks great!" As if to say you shouldn't worry, even though myriad of doctors say you should. Still others will be shocked that you aren't feeding your baby only "good foods" like fruits and vegetables; they simply can't imagine the situation could be serious enough that your primary concern is calories - no matter where they come from. Some people will balk that you let your infant watch TV (for example) while he's eating. "The American Academy of Pediatrics says children under 2 shouldn't watch TV at all!" they say. True, you reply. But that's the only way you seem to be able to get those calories down ...

Hang in there and try to find other parents who have children with eating issues. Only they can fully understand how difficult the situation is on you and your child. Here are two good forums made up of parents who know what you're going through: