Hi Lisa,
I agree completely that the US health care system sometimes really fails the
bfg dyad by waiting two weeks for the first pediatric check up -- I see that
way too often.  In the case of the 5 lb baby I described recently, however,
the pedi did follow the guidelines that the American Academy of Pediatrics
drafted in 1997.  These require contact and assessment within a day or so of
hospital discharge.  This actually took place with this infant.  When the
pedi saw that the baby had gained back to birthweight.  Again, I suspect
this was because the baby could coast on the mother's bountifully available
milk during engorgement.  The next visit was sched. for two weeks later.  My
suspicion is that it is within this time frame that troubles started.  This
probably was due to the lack of awareness that the baby who is "just a
little early" cannot be trusted to be a robust feeder or a robust stimulator
of milk supply. (Kramer M, Demissie K, Yang H, Platt R, et al:  The
Contribution of Mild and Moderate Preterm Birth to Infant Mortality, JAMA
2000, 284:843-849.)

So the anticipatory guidance that I would have liked to have seen would have
been the following information delivered at the 4-Day check up:

1. Praise for the mother that the baby had gained
2. Information about the fact that AFTER the onset of Lactogenesis II milk
supply is calibrated by breast emptying
3.  Information that the 36-37 weeker often is incapable of good breast
emptying without special management (real kangarooing, and post-feed breast
emptying by hand or pump expression)
4  Information that this is a short term problem likely to vastly improve as
baby approaches the due date
5. Information about diaper counting and perhaps a weekly weight check for a
little while, and some phone follow-up to verify that all is going well
during that interim

Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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