A few days ago I wrote asking how others would advise the management of a sleepy newborn baby 30 hours old.  This is a fairly common situation, and one in which I find conflicting advice is given to mothers in hospital.  The 'Ten steps' apply.
<<      The situation is:
a newborn baby, weighing 2700 g (6lb), at term - looks skinny
an uncomplicated homebirth 
without use of any narcotics
Mother has another child, aged 3, who was breastfed.
Baby breastfed well in the first hour
I encouraged the mother to rest and to feed baby whenever she was interested in the first 24 hours.  Baby was quite sleepy and nursed briefly at about 4 or 5 hourly intervals.
When I saw them at about 30 hours, I considered that
1 Baby was clinically well, not jaundiced, placid
2 was sleepy at the breast,
3 Attachment at the breast was sub-optimal (minimal effort)
4 Feeding was infrequent and for brief periods.
How would you advise this woman, at 30 hours postpartum?  You will be visiting her again the next day, and she can phone you at any time if she is worried.  At what stage would you talk about expressing milk and how would you manage that?>>

Thankyou Jack Newman for responding.  This is what Jack said:
<<Things might turn out just fine, but I would like to prevent a problem here (being a pediatrician, I intervene).  I would get this mother expressing her milk, and if there is only a little, mix it with sugar water and get the baby drinking (I prefer finger feeding because it is an easy way to wake up a sleepy baby, and get him sucking well).  As the baby wakens more and more, he should start taking the breast better.>>
I also chose active management, in that I advised the woman to express her colostrum onto a teaspoon and give it directly to the baby.  We know that wonderful things happen to sleepy babies when they swallow colostrum - tongue starts licking, eyes open, baby starts seeking the breast.  Mother continued this every few hours for about 24 hours.  This usually stimulated baby enough that she nursed, but she remained quiet and sleepy.  Mother had to wake her for feeds, and if she was cuddled without feeding she would go back to sleep.  So I am in full agreement with Jack about getting mother's milk into the baby, and preventing problems down the line.  However I disagree with the use of sugar-water for a baby who is clinically well, and when even small amounts of colostrum are accessible.  I also discourage the use of finger feeding in the early days.  There was nothing to suggest that this baby had sucking impairment, and I have seen babies develop 'nipple confusion' when they are encouraged to finger suck in the early days when they should be learning about breast sucking.  Perhaps a small detail, but I consider it very important.

I can now report to you that:
On the third day we agreed that expressing and stimulating the baby was probably unnecessary, because baby was waking up, her output was excellent, and she was nursing well.  Mother was glad to have developed confidence with (hand) expressing her milk, which she had not felt confident about previously.
On the fourth day baby 'woke up', mother had oodles of milk, and baby was eager to get as much as she could, then settled beautifully.  Mother was thrilled.

One could argue that this might have happened anyway.  I have seen big babies with lots of stored energy take a few days to get started, but I did not feel that we could afford that luxury this time.  The mother understood that there were other options, and she felt that it was not right for her baby to sleep for long periods without feeding - she wanted to see her baby taking lots of her milk and looking keen about it.

I will watch for any more comments on this.  I hope the discussion has been useful.

Joy Johnston, FACM IBCLC
Midwife and Lactation Consultant
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www.webrider.net.au/~aitex/joy.htm