I would like to post briefly about a call I got  two nights ago.  A mother
of 5 called me about her newest infant, who was born prematurely at 35 weeks
at around 5 lbs.  MD just saw for 2 mo check and baby (exclusively bfed) is
only 4 oz up from birth weight.  Mother did not want to pay for a consult,
and I am very negative about doing much over the ph. with really compromised
babies, but I felt I had to get involved at least a little as mom was
talking about disobeying MDs suggestion to supplement.  Said she was willing
to cont. to spend hours in the chair nursing.  I finally got blunt and told
her there was NO EVIDENCE that plan was working.  I directed her to the
local WIC Bfg. clinic where the LC reinforced the need to assist the baby
immed. and work out a plan to protect the bfg.  Here is the kicker:  the mom
has been working with someone for all this time and not pumping.  I am not
going to go into that because #1 I can't control it and #2 Mom may have
misunderstood or failed to take advice.

 I do want to make the observation that prematures are, by definition, not
finished cooking.  They are often like a loaf of bread which looks crusty
and brown on the outside, but is squishy on the inside.  Some can do
surprisingly well, but others have stamina issues and can't adequately
access hind milk, and can't adequately trigger a full milk supply.  This may
not become apparant until after the switch from endocrine to autocrine
control.  In otherwords, it may look like mom has an abundant supply -- esp.
a grand multip!  Yet, after the first few weeks, the inadequate breast
emptying begins to take its toll, and suddenly you may wind up with an
acquired undersupply which can't be recovered.  Our job as experts is to
differentiate between normal and not-normal.  We almost NEVER interfer with
the normally breastfeeding infant.  Why would we?  They don't need bottles,
supplements, fancy equipment, or scheduling.  For these babies we maybe
adjust the position a little, offer support and information, but we don't
mess with them.

Now the not-normal baby may be quite different.  This infant may require our
very most honed skills to identify all the areas of compromise so that we
can protect the baby, protect the milk supply, protect all the options to
get to normal feeding when problems resolve.  Frequent weight checks,
intervention sooner rather than later, and post-feed pumping are vital so
that we can use human milk rather than formula to supplement WHILE
PROTECTING PRODUCTION.  These are probably REQUISITES of the management of
the compromised baby.

It is also vital that we communicate honestly with parents. To offer
reassurance which is not based on evidence of baby thriving is ultimately
unkind.

Barbara

Barbara Wilson-Clay, BS, IBCLC
Private Practice, Austin, Texas
Owner, Lactnews On-Line Conference Page
http://moontower.com/bwc/lactnews.html