well, it’s more of the same today – feeding and sleeping, sleeping and feeding, sleeping, sleeping and feeding. i think we’re going to find him off tube feeding entirely quite soon, as he’s now able to take four or more bottle feeds a day, depending on the nurses discretion as to how tired he’s getting. i think he’s also getting strong enough that soon kris will move from non-nutritive suckling to honest-to-goodness breastfeeding.
for his past couple of feedings, eric had started to increasingly behave in a way that i interpreted to mean that he was getting tired of having a bottle – closing his mouth, pursing his lips, blocking the bottle with his toungue etc. usually when this happens, the nurses are quick to “gavage” him ( feed him via a tube ), with the explanation that it’s best to get his feeding done quick so he has enough time to digest his food.
tonight, when i was feeding him and he hadn’t taken a sip in ten minutes, i started to signal to his nurse that maybe it was time gavage him. i had noticed that nurse marlene had been watching me closely while i was feeding; she walked over and gingerly picked up eric but to my surprise, instead of putting in a tube, she started to whisper to him that she had a lot of faith that he knew exactly what he needed to do to eat. and much to my astonishment, in about five seconds, eric was guzzling away.
nurse marlene is the archetypal nurse caregiver. if you close your eyes and imagine the most grandmotherly of grandmotherly nurses and you’ll likely being envisioning nurse marlene. her white, couffed hair, bifocals and ageing hands betray the fact that she’s been nursing for quite some time and all that experience translates into the thousand little things that she’s doing which result in an easy bottlefeeding.
she very sensitively explained to me all the things i was doing wrong. most obviously, she sits him up, while tilting his head back. i often lay him along my forearm, while holding his head with my hand, which tends to tilt his head foreward making it more difficult for the milk to go down.
she also showed me a great technique for getting the bottle nipple past his tongue. he likes to put his tongue on the roof of his mouth and pretend that he’s sucking, but in reality he’s just playing with the bottle. nurse marlene showed me how put the bottle in his mouth so that the nipple touches the inside of his cheek and then she swoops it past his tongue.
as if that weren’t enough, i’m also being far too timid about putting the nipple all the way in his mouth. apparently, my fears of gagging him are vastly overblown.
nurse marlene continued here tutelage with a lesson on the proper way to burp. his head must be tilted up, not down as i had been doing. and she carefully but very firmly grasps him while keeping his airway open. she swings his head and torso in a full 360 degree circle to show me just how firmly she’s holding him, as his head doesn’t change it’s upward tilt during the arc.
i’m admonished to not rap on his back either, and she rolls her eyes when i tell her that’s what the other nurses do. she’s gently massaging his back and right on cue, eric lets out a little burp.
she clarifies that a properly burbed child never needs their back rapped and i suspect that she might be making a comment about the burping skills of some of the other nurses.
thanks to his low hemoglobin levels and, well, the fact that he is a micropreemie who needs to spend all his energy growing, eric is spending much of his days acting a little listless and sleeping quite a bit. we received the results from his latest blood work and his hemoglobin level is now officially at the same point is was when they gave him his last series of transfusiona. when exactly he’ll get some more blood has become a great conversation topic, and it’s a sneaky way to get a sense for which nurses agree with the neonatologist’s course of action and which don’t. he’s holding out like a champ, although he’s “desatting” more and more, especially when he’s active, which makes feedings an endless series of alarms.
eric is continuing to add weight, thanks in no small part to the fortifier. to put things in perspective, he’s getting about 30 extra calories a day from his fortifier ( about 4 calories per ounce of milk are added ) and that small addition of calories is primarily responsible for his ounce-a-day weight gains. tonight he weighed in at 3 pounds 14.7 ounces or 1777 grams. if he keeps it up, i’ll be much more confident that we’ll be able to celebrate his hitting 4 pounds by his 10 week birthday on sunday.
while it might be boring for you, poor reader, we aren’t quite bored with the fact that eric is doing such a great job taking his bottles. he’s up to three bottle feeds a day, with the remainder being done via a tube that goes straight to his stomach.
when he’s tired, he’ll often feign like he’s not really interested in eating, but we know it’s all a big act and he inevitably drinks his entire bottle in 20 minutes or less. if all goes well, over the next week or so, we’ll be responsible for giving him all his feeds via a bottle, which will be quite exciting, indeed.
after much nagging from the nicu staff, kris and i selected a pediatrician today! we are notorious for taking months to decide on something as simple as a new toaster, so picking a pediatrician could have been something that threw us into months of “analysis paralysis”. that is, if we actually had months to make the decision. but we didn’t, as the nicu nurses have been making it increasingly clear that they needed to start making arrangements with our pediatrician, like, yesterday. so we created a “short list” by asking all the staff who they would take their kids to and correlating the answers with the list of peds doctors in our insurance plan. we then scheduled “meet and greet” appointments and asked a few pointed questions, which led to a surprisingly quick decision.
for the most part, today was a pleasantly quiet day. eric continued to guzzle his bottle feedings in near record setting time – he cleared away his 40 cc ( 4 more than his feed required ) evening bottle in 15 minutes! the nurses are continually amazed at how well he does with his feedings. currently, he only gets two bottle feedings a day, with the rest being done via a tube. if he keeps up the great work they will gradually increase the number of bottle feeds.
eric put on another ounce and weighed in at 3 pounds 13.2 ounces or 1735 grams. if he keeps gaining an ounce or so a day, he has a pretty good chance of hitting the four pound mark by his ten week birthday!
they also decreased his nasal cannula again to 1.25 liters per minute. he’s started “desatting” ( decreased blood oxygen levels ) a bit more and had a few more “a’s” and “b’s” ( apneas and bradycardias ) around feeding time. this is probably due to the fact that his hemoglobin levels are getting low and has a diminished oxygen carrying capacity; after he gets another another transfusion, which we expect to happen in the coming days, everything should clear up quickly.
i guess there’s no small amount irony in the fact that we haven’t finished getting our registry in order for our baby shower for a baby who is already two months old. our shower was originally going to be on july 31st, but we moved the date to september 19th to give us time to adjust to being in the nicu.
some might remember that there are good reasons why kris trots me out to babies ‘r us in the evening. we had a fun time picking out a bunch of cloths for eric; “grandma pam” accompanied us to the store and spent entirely too much money, but i suspect that grandmas like to do that sort of thing. thanks! grandma pam
today was yet another day tiny little steps of progress. first, eric had the rate of nasal cannula air flow turned down from 2 to 1.5 liters per minute. you might recall that the last time they turned down his flow, he started alarming often that the nicu staff thought he might have an infection. it’s amazing to see how differently he responded after only ten days. it’s even more amazing when you think about how much lower his hemoglobin levels compared to then ( he’s still due for another transfusion ), which means his oxygen carrying capacity should be lower, but his stronger lungs can more than make up the difference.
the fortifier seems to be working, as he put on another ounce and weighed in at 3 pounds 12 ounces or 1700 grams.
eric completed the transition to three hour feeds appears to be tolerating the increase in feeding volume wonderfully. his first “3 hour” bottle feed was an enormous 36 cc meal and the nurses didn’t really expect him to take the whole thing down before getting too tired. but they were pleasantly surprised to be proven wrong. he drank the entire bottle in about 22 minutes!
you’ll notice that we’re very aware of exactly how long it takes eric to eat. that’s because we have exactly 30 minutes to get him to take his food via a bottle. if he doesn’t get everything down in that time, then he’s “gavaged” ( the term for tube feeding ). the strict timing is due to the fact that you want him to have the most amount of time to fully digest his food before the next feeding; and the staff begin to get concerned about how many calories he’s burning while bottle feeding after a half an hour. it’s strange to think that the extra calories burned from being out of the isolette can make a big difference.
so there’s a bit of strategy involved to get him to take all the food in the proper amount of time. one tactic is to switch his bottle nipple during his feeding to make it more or less difficult to get the milk. you can differentiate the nipple by the color of the plastic ring surrounding the nipple. a white ring indicates the most difficult and a red ring is the easiest, while peach is a medium difficulty nipple. we found that we had to use all three nipples during his feeding to make it easier for him to get milk as he got increasingly tired. why not just start with the “red” nipple? because if he’s not tired, he’ll get too much milk at once and gag.
who knew that feeding could be so complicated? that said, he’s doing fantastic and word spread quickly through the nicu that he was able to take his first “3 hour feed” bottle in the proper amount of time.
in my continuing efforts to provide evidence that i am not one to shirk my fatherly duties, i’m happy to present photographic evidence that i am capable of feeding my son without drowning him or otherwise causing any grievous bodily harm. woohoo! perhaps due to my superior bottle feeding skills, he managed to make small work of the whopping 29
ounce cc ( d’oh! there’s a big difference between ounces and cc’s! ) feeding in about 12 minutes, with nary a burp or sign of reflux!
he’s looking right at the camera and it’s fun to imagine that he might be waving to his fans all over the world.
we’re in much more cramped quarters these days since the move to the isolette and it’s rude to turn the overhead lights on when a baby might be sleeping just a few feet away. so kris, relents and decides to use the evil flash.
i like this picture because it shows that even though he’s getting big, he’s still quite small and it’s easy to hold him in one hand while i feed him with the other.
eric has been getting fed every two hours, but today they decided that it was time to move to three hour feeds, as he’s been doing so well eating over the past few days.
when micropreemies are very small their stomachs can’t handle very much milk during feedings, so they feed them less milk more often. but as they get bigger, they can feed them larger volumes less frequently; so it’s a great sign that he’s transitioning into three hour feeds, and it’s yet another little, tiny step towards getting out of the nicu.
in another bit of progress, micropreemie style, eric’s had his isolette temperature turned down from 30 degrees C to 29.3 degrees C which means he’s rapidly getting even better at holding keeping his body temrerature stable all by himself. when the isolette tempterature reaches room temperature ( about 26 degrees C ) and he approaches 1800 grams, then he’ll probably be ready to move to an open bed. tonight, eric gained an ounce and weighed in at 3 pounds 11.1 ounces or about 1675 grams, so it’s possible that he could hit the 1800 gram mark before the end of the week.
odin celebrated his second gregorian birthday today! even though you’ll likely be reading this a day after the fact, you can feel free to hum him a few bars of the birthday song, since tomorrow will be his nine week birthday. we like to find any ol’ reason to celebrate. we weighed in at 3 pounds 9.7 ounces or about 1636 grams. it’s fun to look back at his first gregorian birthday and see that he’s gained almost exactly a pound and a half.
eric got cleaned-up with a a birthday bath. while he’s tolerated his other baths quite well, for whatever reason, he decided that he was not impressed at all with this one and he squirmed and kicked and generally gave kris and nurse jan a run for their money.
but rather than posting a dozen pictures of him kicking and grimacing, i’ll commemorate the event with the one picture of him looking relatively calm.
you might notice in the bath pictures that he doesn’t even have his nasal cannula in his nose! the plastic tube is gently blowing oxygen in his face to help him breath, but i don’t think he really needed to it, since it was often pointed away from his face at odd angles. nurse jan commented at one point that perhaps he didn’t need to be on supplemental oxygen at all, so maybe sooner rather than later he’ll be rid of the nasal cannula completely.
eric proved that taking the bottle yesterday wasn’t a fluke; after the bath he finished off his second bottle in short order.
he drank the first 16 cc’s quite quickly ( i.e. in under 10 minutes ). he then drank about 4 more cc’s over 10 minutes before deciding that he didn’t want the last couple of cc’s as he was getting very, very sleepy.
after the bath and the feeding, eric barely has any energy left to celebrate and he falls fast asleep on kris’ chest while clutching his balloon.
woohoo! we received a phone call from the nicu to not be freaked out when we arrived and found an empty radiant warming bed, since eric had been moved to an isolette! it’s a big step up, as the isolette is the step before an open, unheated bed, which is the step before going home.
after the move to the isolette, they removed eric’s temperature sensor that constantly monitored his body temp. this means that they are increasingly confident in his ability to regulate his own body temperature, which is one of the “exit criteria” for leaving the nicu. the isolette is still heated to keep a thermoneutral environment, which is the temperature that is needed to prevent him from burning any calories on keeping warm, as they’d like every bit of evergy to go towards growing and staying healthy. that said, they will slowly ween his off the thermoneutral settings, at which point he’ll get transferred to an open bed.
eric also took his first bottle today! i think it might be impossible to convey to non-nicu parents what a big step it was for him to guzzle down a bottle on the first try. it can sometimes take weeks for a micropreemie to get the suck-swallow-breath sequence down for an entire 20 cc bottle.
nurse nancy got the process started because she wanted to make sure he didn’t drown, but he did so well that she quickly transferred him over to kris so she could enjoy the moment.
gulp. gulp. even more amazingly – nurse nancy used a newborn nipple and not a preemie nipple, which makes it that much more difficult to get the milk. that means he’s got a pretty strong suck reflex.
maybe he’s looking for a “high five”?
it’s time for a burb. as always, things are more complicated with a micropreemie, so it takes a bit to figure out how to burp him without accidentally stopping his breathing.
nurse nancy shows kris how to stimulate eric’s suck reflex.
who knew feeding could take so much effort. after the bottle is finished, eric falls fast asleep.
kris watches his monitor after the feeding. all the food in his belly can stimulate his vagus nerve which affects his heartrate and can lead to a “brady” ( bradycardia – a dangerous slowing of his heartreate ).
after nurse nancy saw how well eric was doing with the bottle, she casually asked us how the nursery looked. we looked at her blankly.
“uh. the nursery is still an office.”
she looked shocked and then said something that neither one of us could possibly have expected. “well, what are you going to do if everything “clicks” and he’s released in two weeks! get your butts in gear! have you taken the infant cpr class? have you watched the “shaken baby syndrome” video? there’s lots to do and he’ll be leaving quite literally before you know it.”
kris responded with exactly what i was thinking as my mouth went dry, “nancy. your lips are moving but there’s no sound coming out.”
before today i had been trying to manage my expectations and thought that if we were lucky, eric might be home by the last week of october or the first week of november. this hadn’t seemed an unreasonably assumption since the the neonatologist told us when we arrived that eric would most likely be in the nicu until his original due date ( around actober 17th ) plus ” a few weeks”. so it’s no small shock to find out that it’s not outside the realm of possibility that he could be home soon. she did say that it probably wouldn’t be exactly two weeks, but my guess is that they are likely looking at 2 weeks to a month. it’s odd to think that if he were released even in a month, he’d be coming home a full three weeks before his original due date.
i guess it’s time to get cracking at turning the home office into a nursery.
even though the isolette is considered a big move, is still takes a bit of adjustment to get used to the new environment. after two months of having unobstructed access to eric, it’s hard to get used to having to reach into a “box” to say “goodnight”.
there’s also a lot less space around the isolette, since it’s less likely that a large number of personnel will need to gather around eric for an emergency intervention. and we’ve moved from a a quiet, corner on the far end of the room ( the room is a rectangle with the sickest babies at the far end of the rectangle and the healthiest babies at the near end close to the entrance ) to right next to the nurses station and the entry door, so it’s a lot more noisy.
i guess any change, no matter how positive, takes some adjustment.