Why a preemie can’t eat on demand in the NICU

Feeding on demand is normal for term babies. A baby cries and shows other signs of hunger, is fed, eats his fill, is satisfied, and the crying stops. As the baby grows, he learns to feed himself based on his own hunger cues. And hopefully, as an adult he learns to listen to these hunger cues (unfortunately, obesity is a consequence of disregarding hunger cues, as many people can no longer tell if they are hungry, or not. Different story for a different blog).

But preemies, of course, are different. Many moms and dads wonder why, once a preemie is capable of breastfeeding or taking a bottle, that they have to stick with the strict every 3-4 hour feedings (depending on the NICU recommendations)? It is easy to feel frustrated when your baby only takes 2 ml a feed instead of the recommended 15 ml, and many start to wonder if their baby isn’t really hungry, so why push them? Why not let them eat on demand?

The reason preemies can’t feed on demand is that hunger cues are not well developed before 37 weeks and quite simply, many babies will not eat enough calories. Crying with preemies is actually a very late sign of hunger, so if you wait until they start to cry, they may not get enough food.  Many normal processes are affected when the nervous system is exposed to our environment too soon. Altered hunger cues are only one consequence.

Getting enough nutrition is vital. During pregnancy, a baby gets a free flow of nutrients 24/7 with no energy expenditure. Every single calorie received is turned into building blocks. In the 3rd trimester, a lack of nutrition has the biggest effect on both overall growth (size) and brain growth. Take a baby born at 33 weeks – he still has 4 weeks of serious growing inside the uterus, both body and brain, but if he is premature he is now not getting a steady stream of nutrition. In addition, he has to expend calories to breathe, move, keep warm, and of course eat. More so if he has any health challenges. So once born, a preemie needs more calories/body weight than a term baby.  To top it off, his hunger cues are not developed. So, left to their own internal cues many preemies will just not eat sufficient amounts, and any nutritional deficits in these precious first few months can have consequences on long term growth and brain development. So if that 33 weeker will only take 2 ml of their 15 feed, they really need the remaining 13 ml. They would be getting those calories if they were still in the uterus.

For some babies this is a temporary interruption, and many preemies as they get older are able to eat on demand. Others, are not and just never develop these important cues. My son Oliver is one of them.

Left to his own devices, Oliver does not consume enough calories. He doesn’t feel hungry most of the time and unlike his brother, there is no temper tantrum that in retrospect was due to eating dinner an hour late. In fact, I can never tell if Oliver is hungry and I think he can’t tell either. I can tell when he is tired long before he knows, but no idea about the hunger. The result: he is now back down to less than the 3rd percentile for weight.

The additional problem is his caloric needs. Like many preemies with lung damage he needs additional calories (lung repair is a protein hog!). His heart problems also require more calories. He needs to eat about 2,500 calories a day (more than me), but when left to his own devices eats about 1,000.

At home he knows he has to eat in front of me, but sometimes there is crying, “I don’t want to eat.” Although afterwards he always has more energy.  With much effort managed to get his weight into the 7th percentile, only to have it plummet back down below the 3rd at the last check. After some investigations, it seems he just doesn’t eat at school. “Forgets” his snack, ” and “forgets” his lunch. Even “forgets” the dessert.

“But if you are all sitting at a table and the other kids are eating, how can you forget? Aren’t you hungry” I ask?

“I don’t know,” he says.

And that of course, says it all.

So we have talked about drinking Pediasure at school. His teachers are going to administer it just like medication, every 3 hours. He loves the stuff and can down 8 ounces in a minute and then still has time for recess. It’s just he forgets.

I know if I look upset or worried when I see the still full lunch box at the end of the day or the scale stuck at the same low number for 3 months, it just makes it worse and he eats less. I don’t want him to feel bad. He is the love of my life, and when he is sad it is like a knife in my heart. I also don’t want to further warp any connection he has with food. I know he is trying, it’s just normal instincts have deserted him. It’s not his fault. It’s just the way it is.

So the most important lesson I have learned from this is to control my reaction to his not eating. Because honestly, that is about the only thing I can control.

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2 Responses to Why a preemie can’t eat on demand in the NICU

  1. Melissa says:

    My Daphne is the same way. She is only 21 months, but if we follow her cues, she would drink an ounce here, an ounce there, eat a couple Cheerios, and call it a day. Her heart defect was patched at 6 months, and doctors promised us amazing growth. It didn’t happen. First it was reflux, then food aversions… She has improved, but she’s not even close to the curve – even for her adjusted age. I often wondered what makes preemies “learn” their hunger cues, when they get fed by ng tube when they don’t finish a bottle. I completely understand it HAS to be that way, but so often there are long-term repercussions. In our case, she will eat much better for others than for me or my husband – the people who stress the most and are most invested in her growth and weight gain. We are trying to modify our reactions too, in addition to making meals positive and fun and maximizing every calorie. Hard work.

  2. Jennifer Gunter says:

    I think it is doubly hard for the cardiac kids. Our cardiologist said it might improve after the second repair, but it didn’t.

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