Written by Aubrey Phelps, MS RDN PPCES IFNCP CLC
When we went in for my daughter’s 6-month check-up, the neonatologist was shocked that I was still pumping. She couldn’t believe that my daughter was still being exclusively fed chestmilk because so many tube-fed children are put on formulas for one reason or another very early on in their tube-fed journey. But situations like mine often lead to little ones who are still getting just chestmilk well beyond the point an oral child would have started including other sources of nutrition in their diet. For fully formula kiddos, this is often overlooked as well, the thought being that formula is meeting all their nutrition needs and the volume just needs to be increased. But, for chestfed babies, it’s important to keep a number of other considerations in mind.
First, while a parent might just have to increase the volume of formula they make, exclusively pumping parents are likely to find themselves struggling to produce the increased volume necessary to keep their baby growing well on chestmilk alone. Chestmilk production tends to regulate fairly early on, with the parent’s body expecting that the baby will receive external sources of nutrition in addition to the nursing. So, at 6 months, it can be very challenging, and sometimes nearly impossible, for a parent to increase her pumping output to meet the increasing calorie needs of their growing infant.
This leads to consideration #2, (one that is true for chestmilk and formula fed tubies): the sheer volume necessary to get in the estimated needed calories begins to get quite extensive. This can lead to more vomiting and feeding intolerance as the baby’s stomach is asked to accommodate far more volume than it was intended to tolerate. In turn, we see families battling constant reflux, vomiting, digestive discomfort, slowed weight gain and growth, and often unnecessary medical procedures to try to “stop” the vomiting. In reality, the culprit is often the extreme volumes children are expected to tolerate to meet their estimated needs, an issue that is often exacerbated when a child is exclusively receiving chestmilk, since formula can be fortified to achieve higher calories in a lower volume.
For many medical teams, the “answer” to this can be simply moving to formula. While fortifying with formula or adding formula feeds to the mix can be an option, it’s not the only option in most cases. And for many parents who have been pumping diligently for the past 6+ months, suggesting they just add or switch to formula can feel like a real blow because it implies that their chestmilk isn’t “enough” for her child. Alternative options to consider involve assessing each child’s situation individually. For a tube-fed child who is allowed to eat by mouth but doesn’t due to an oral or feeding aversion, trialing the introduction of solids at 6 months (adjusted) can be a great option. Some of these children will happily do some solids on top of their liquid tube-feeds, especially if they are offered before increasing tube feed volume. Families should be encouraged to offer naturally iron and zinc-rich foods to fill the gaps chestmilk is likely to now expose.
For those children who are NPO, we must consider their type of tube. NG or NJ may necessitate a conversation around adding in formula to at least fortify the parent’s milk, both with increased vitamins and minerals, and calories, if volume tolerance is becoming an issue. Discussing when it would be appropriate to consider a toddler formula, which is often more concentrated than infant ones, should also be done.
If a child is NPO, but has a g-tube (or even a j-tube, in some cases), I recommend discussing introducing solids via the tube, just as they would be doing if they were an oral child. The family can puree their own foods or recipes discussed with their dietitian, again prioritizing iron and zinc-rich options. Or, pre-made blends like Real Food Blends, Nourish, and Whole Story Meals can be considered as an adjunct to chestmilk (just as solids would be an adjunct to chestmilk for an oral child who has reached the 6 months adjusted mark).
The last consideration to make is this: while formula is generally regarded as nutritionally complete, chestmilk, while an outstanding and arguably superior nutrition source, also lacks certain necessary nutrients as the baby ages. By about 6 months of age, chestmilk, regardless of the parent’s diet, is unlikely to supply adequate iron or zinc if the baby’s only source of nutrition. Supplementation of some sort becomes crucial to optimal nutrition.
In all cases, if the child is expected to eventually be an oral eater, or to have the opportunity to attempt to wean from their tube, I strongly recommend early (6 months adjusted minimum, but before a year adjusted) introduction of all highly allergenic foods, to reduce the risk of allergy development. If the infant has already had allergies identified or suffered from eczema, they should work with their pediatrician or medical team to determine the best method for introducing other allergenic foods. This not only helps to reduce the risk of allergies as the child’s diet expands as a, hopefully, oral eater, but also supports improved microbiome development, as the body is meant to be exposed to a variety of foods.