Dear all:

I know I have used mixed examples for weighing for growth and intake.  I have done so 
deliberately because while the specifics of how you interpret the date for each are different the 
problem solving skills are not.  Of course, teh specifics of each are different.  

Here's the deal on socialized medicine which may get me in trouble because I know for a fact that 
there is active interference right now in allowing the public access to research findings that are at 
variance with current social policy. I know this because have a relative who worked for the 
Department of Health and Human Services who is not allowed to publish or expose the public to 
his "politically incorrect" data that children of divorced parents actually often do better with a 
single parent than a parent that remarries.  Can't have the public thinking single parents actually 
do a better job than parents that remarry now can we?  And the relative says this type of 
suppression is currently very common in DHHS.

So I will tell you about a piece of research on socialized medicine is highly unlikely to reach the 
general public in the United States.  One of my fellow students at Cornell did an indepth study on 
socialized medicine in developing countries versus nonsocialized medcine and it clearly showed a 
high cost-benefit ratio to the socialized medicine.  The reason was the preventive services 
reduced costs and this included breastfeeding promotion.  Whether or not one can achieve the 
same degree of breastfeeding success in a nonsocialized medicine situation remains to be seen - 
but those of us who work in a nonsocialized medicine situation are certainly have our work cut out 
for us right now.

Here's how I think this applies to our respective situations and use of the scale in countries that 
are more supportive of breastfeeding and other countries or areas of the world or risk groups that 
are more likely to have problems.  In a high risk situation I think it is much more imperative that 
lactation consultants use test weighing.  We are more likely to encounter the situations that 
warrant interventions to return women to a more normal breastfeeding relationship.  On a public 
health scale, the triage systems for when to use a scale for test weighing may be entirely different 
in a country that supports breastfeeding rigorously than one that does not because the former will 
have far fewer cases that don't need it.

However, I still think that there is a use for the scale for high risk situations in any country 
regardless of how supportive they are of breastfeeding.  First, I know from my experience in Niger 
and the Democratic Republic of Congo that there are real problems with low supply that go 
completely undetected because the infant mortality rates are so high, no one even notices those 
babies that slip away and die.  Yes, most mothers in these countries produce plenty of milk just 
despite harsh conditions and poor maternal nutritions.  Each of those countries, however, has 
pockets of iodine deficiency with resulting hypothyroidism.  I am sure there is low supply in a 
proportion of mothers who are suffering from hypothyroidism that have problems with supply in 
these countries.

Ditto developed countries.  Sweden is not Norway but it is still better than the US.  I had a good 
friend who did everything right with her baby --- she is a researcher in maternal and child 
nutrition herself.  Nevertheless, at six weeks her baby was faltering beyond the point where it was 
acceptable.  She never did have anyone do the proper diagnostic follow up to figure out what 
happened with her supply.  Was her baby simply not driving it?  Did she have some problem that 
impeded her milk production?  No one investigated and explored in depth what was going on.  
And in her circumstance I think the data from a few test weighings would have been helpful.  So, 
because she is in a country that is highly supportive of breastfeeding, I think the psychological 
impact of having a baby that is failing to thrive is much worse in her circumstance because she is 
surrounded by women who "successfully breastfeed" and she is a "failure" with no explanation of 
why.  Moms in Manhattan are surrounded by friends who couldn't do it and feel good if they can 
do improve what they are able to do.  It seems to me that my friend would have benefitted 
enormously from a second tier intervention where an expert LC stepped in to help her investigate 
what was going on, help her improve her supply, or if it was a situation where the supply didn't 
improve give her the concrete reason why it didn't so she could come to terms with it.  And I think 
judicious use of the scale would have been useful in detecting what was wrong.

I just saw an 8 day old baby yesterday that had lost 13% body weight.  Both parents were 
physicians and neither noticed.  Two days before the visit, the pediatrician scheduled a check up 
for a week later after two bili tests and weights that were declining and getting close to the 10% 
mark.  The baby had great skin color, slightly low skin turgor, had a period of quiet alert, and I 
defy anyone to have been able to tell that baby had lost that much weight just by looking at her.  
The baby took 0.4 oz from the breast & 0.4 oz EBM from the bottle (which looked like 1.0 oz in 
the bottle --- so much for eyeballing bottles).  Parents reported that this was a MORE VIGOROUS 
feeding for this baby.  The baby came off and did not ask for more and looked around.  That to 
me is a baby that is underfeeding and has a slowed metabolism that needs more gentle active 
feeding to nudge up the intake.  If the baby had taken a good feeding, I would not have 
recommended supplementing.  If the parents had said this was a poor feeding, I would have 
watched closely.

I'm still thinking about the anger of the mother of the four month old premie who developed 
developmental delays because everyone was ignoring her and telling her the baby was just fine 
when she knew differently.  Again, I defy anyone looking at that baby to tell me they could have 
spotted the failure to thrive by looking at the baby alone.  The baby looked fine.  The test 
weighing over a number of support groups helped clarify what was going on.  Her baby did not 
deserve to have been compromised because everyone was ignoring his mother's very valid 
concerns.

Finally, I find the scale to be a useful tool to hone my observational skills.  My colleague Ayelet 
called last night and we both do this guessing game.  We watch the baby and "guess" how much 
the baby takes.  Most of the time we are pretty close.  Sometimes - perhaps 1 in 10 - we are really 
off.  

We have talked about nipple shields, supplementing devices, bottles, and all sorts of other tools 
that are sometimes overused, sometimes misused and sometimes not used when they should be 
used.  The scale is but one of these tools that has a useful place in our aresenal when used 
appropriately.

Best regards, Susan Burger

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