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LACTNET  August 2005, Week 3

LACTNET August 2005, Week 3

Subject:

How would YOU counsel this mother

From:

Pamela Morrison <[log in to unmask]>

Reply-To:

Lactation Information and Discussion <[log in to unmask]>

Date:

Tue, 16 Aug 2005 23:38:14 +0100

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (192 lines)

Oh Amy - a cry from the heart!!

Firstly, it sounds like you really did everything you could to persuade 
this mother to breastfeed, starting with her prenatal consult/private 
breastfeeding class, monitoring her progress in the hospital, including 
helping her latch her baby, listening to her concerns, doing test-weighs 
and reassuring her that 45 - 50 ml intake was OK, checking baby's rate of 
gain (surely if baby regained birth weight by 10 days this was enough?), 
setting her up with a lactaid so she didn't need to use bottles, praising 
her, encouraging her giving handouts in two languages, etc etc etc

On the other hand, what has the mother done to show that she really wants 
to breastfeed her baby?  Allowed the baby to stay in the nursery, told the 
nurse to give the baby a bottle so she could have a shower, consulted 
another doctor in her country of origin - clearly out of date and behind 
the times if he condones the use of half-strength formula and orange juice 
- supplemented with huge quantities of formula on the advice of family and 
friends, and by bottle, and then, to top it all, accuses *you* of  making 
her feel she's doing everything wrong.  Actually she is!  But, amazingly, 
you're not!  On the contrary, you're believing her when she says she really 
wants to breastfeed (against all the evidence) and then beating yourself 
over the head because you think it might be your fault!

I'm going to go out on a limb here to suggest that it's *not* your 
counselling skills or lack of understanding that's at fault here.  My 
experience working in an extremely breastfeeding-friendly society is that 
when there is a strong recommendation to breastfeed, the mothers who really 
don't want to (and there *are* such mothers around) will *say* that they 
want to, rather than just coming right out with it to say they'd rather 
bottle feed.  In fact the very words, "I really want to breastfeed" are 
something of a red flag in themselves. I can't tell you how familiar your 
scenario sounded - nor the number of times I've attempted to assist a 
mother in the first few days to her refrain of "I really want to 
breastfeed", when she does everything possible to make it *not* 
happen.  I've worked with mothers who would literally starve their babies 
for three days in the hospital (formula was not available for healthy 
full-term babies) rather than put them to the breast.  One of the 
paediatricians only half-jokingly said he knew they had bottles waiting in 
the car to give on the way home. Then later the ones who wanted to quit at 
about 4 or 5 or 6 weeks would say, "I know it's best for my baby, but 
...."  At first I couldn't believe it, but another of the paediatricians 
once said to me, "In the REAL world, you can't win 'em all".   Sad, but true.

You did all the right things Amy.   Most importantly, you kept using all 
the tricks in your little black bag to let this marginally motivated mom 
know that you - the doctor - really *recommend* breastfeeding and were 
doing everything to help make it possible.  You sent the right 
message.  It's not your fault if she wasn't willing to be honest with 
you.  This was ambition without effort - the one that got away.  Over time, 
you'll have fewer and fewer mothers like this.  Another of the doctors I 
knew used to "bargain" with her patients by asking those who wanted to give 
up to just make it to the six-week mark to get their babies off to a good 
start.  Often, of course, by that time, they would be over the initial 
difficulties and would have fallen in love with the whole thing.  Slowly 
there was a ripple effect and even the most reluctant mothers were easier 
to persuade since word gets around on the coffee-morning circuit and one 
mother will influence another to just go that little bit longer.  We always 
agonize over the ones we lose, but when a mom is saying one thing and doing 
another, I've learned to do my absolute best, write "?marginally 
motivated?" in my notes, and to try and let go of the outcome.  The really 
interesting thing is that as hospitals and societies become more 
"baby-friendly" we will probably feel more of this frustration for a while 
because it is very hard to distinguish the really motivated mothers who 
have genuine breastfeeding difficulties from the unmotivated mothers who 
simply have - well - little desire to breastfeed.

Better luck next time!

Pamela Morrison IBCLC
Rustington, UK (13 years in private practice in Zimbabwe)

At 14:42 16/08/2005, you wrote:
>Date:    Mon, 15 Aug 2005 23:26:32 -0500
>From:    Amy <[log in to unmask]>
>Subject: How would YOU counsel this mother
>
>Feeling frustrated
>
>Young mother, I did a prenatal consult/ private breastfeeding class with her.
>Wound up with long labor, multiple interventions, and then C/S for failure to
>progress
>
>First 2 days in the hospital mother only gave about 1/2 oz of formula twice/
>day, I kept commending her, I helped her with latch, which looked good, 
>also by
>IBCLC (latch looked good) and baby had nice jaw excursions
>
>by second hospital day night shift nurse told her baby lost some weight 
>and she
>better give formula, this probably ruined her confidence, but I think there is
>some cultural influence also by friends and family saying its okay and
>desirable to give formula
>
>by day of discharge, mom's complaining that he wants to nurse "all the 
>time", I
>notice multiple formula/ bottle feedings in the chart and as I am examining
>baby in nursery (which I usually don't do, but thats where he was) baby is
>crying and I tell nurse to bring him to mom, nurse reports back that mom said
>to give a bottle she wanted to take a shower.  So, maybe motivation is not
>really there.  BUT to ME mom keeps saying that she WANTS to breastfeed.  And
>I've multiple times discussed normal feeding patterns etc...
>
>At 1 wk old visit pre and post BF feeds weights (on my new "baby weigh") 
>infant
>gained 50g from the breast.  So I encouraged exclusive breastfeeding and gave
>them handouts (in English and Spanish for the mother-in-law) about how
>"Breastfed babies don't need formula" (coutesy of LA WIC and SanDiego BF
>coalition website) and LLL when to start solids in Spanish (this will be
>relevant later on)
>
>next visit at 10 days baby was at or slightly above birth wt, and had gained
>close to 1oz /day from the previous visit.  Mom said she hadn't given any
>formula since the previous visit and infant wasn't stooling.  (small amount
>every 2-3 days) Also mom never got engorged.
>
>Its hard for me to say that she definitely doesn't have a supply problem, SHE
>feels she does.  The lack of stool still could be "constipation" or normal
>pattern from the formula he had before. His wt gain really was 
>normal  BUT, mom
>says she can't take it anymore (his "constant nursing and her lack of sleep)
>She also says that she gets very little out (less than 1oz) when she pumps, so
>she was definitely going to start giving him formula again
>
>so...
>I set mom up with a lactaid (Jack Newman style, we did it in the office and it
>worked)  I would rather her "supplement" that way than with a bottle, I also
>suggested a change in formula to Alimentum and a glycerine suppository for the
>"constipation", and for her to take fenugreek and mother's milk tea
>
>Today in follow up, mom is giving about 12 oz of formula/ day.  3-4 times 
>in the
>bottle and only 2 times by lactaid.  Infant gained >8 oz in 4 days!!!  pre and
>post feed weight showed 1 1/2 oz gain from the breast, and infant still
>rooting. Mom reports she did notice increase in her breast size.
>
>Mom says that glycerin supp didn't work SO... over the weekend she called a
>doctor from Colombia (the country not the university)  Parents are latino and
>what they decided to do is reccomended by all their friends etc...
>
>Here's what she's doing....
>
>1. Watering down the formula (still regular similac b/c alimentum was too
>expensive)
>2. planning to buy the low iron formula since that is what worked with her
>friends
>3. Gave infant ORANGE JUICE as recommended by this Columbian doctor and IT
>WORKED!!! for the constipation
>
>When I gave her the standard lines against these practices, she is giving me
>that look "I don't believe you"  "I'm going to do this because it is
>reccomended to me by people I know and trust and it works for them"  She also
>said, which is true, that I'm making her feel that she's doing everything
>wrong.
>
>I really spent a long time with her, I said that I am against these practices
>but that I acknowledge she is working hard to breastfeed her baby.  I
>reiterated to them about long term increased illnesses in nonbreastfed babies
>and again encouraged her to see an IBCLC (last week there were 2 LLL meetings
>in the area that I encouraged her to go to "free" but she said that she coukd
>not get there b/c of scheduling times etc...)
>
>
>I feel so ineffective, its not a language barrier- they speak perfect English
>and we speak perfect Spanish in our office, its a cultural barrier, not just
>her particular social group but the massive formula is "good" and "free" from
>WIC (she has already been and gotten some and wants a prescription to change
>brands) She could ask ten other doctors and a hundred Friends and consult 20
>magazines and books and they will all tell her that what she is doing is just
>fine and that Dr Kotler is just a fanatic so don't listen to her
>
>What would YOU have done and said????
>
>Amy M. Kotler, MD FAAP
>Dover Pediatrics
>LLLI Breastfeeding Resource Center
>Doctors Park 369 W. Blackwell St
>Dover NJ 07801
>ph 973 328 8300
>fx 973 328 8315

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December 2005, Week 5
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