Ann wrote

<Dear Wise Ones:
I know I am not alone with the battles of: "perceptions of low milk
supplies
and infants not getting enough at breast".  Then there are supplements of
large quantities of formula and scheduled feedings.
The approach I have tried to use is to educate the mothers and staff.
But
this is not working.  So I started to watch more of the formula feeding.
Starting right after birth, the assumption is made that the newborn needs
to
eat within 3-6 hours, 30-60 cc.  Then they are feed every 3 hours after
that
with bottles filled with 120 cc (or more) and allowing the babies to
consume
whatever amount drains in.
This feeding schedule is not based on feeding cues: rooting; mouth to
hand,
if these are observed before the scheduled 3 hours, pacifiers are used.
When these babies are being feed, the nipples are sometimes forced into
the
corner of their mouths and the jaw or throat is massaged to encourage
continuous swallowing.  If a set amount is determined to have to be
administered, all means are used to get this in without any observation
of
how the baby is handling this.
I have observed gagging, eyes widening, splayed hands and the formula
pouring
out the sides of the baby's mouth and the nurse continues to push the
feeding.
I asked a nursing instructor if I could observe her teaching her students
how
to bottle feed and she said she really does not teach this.
I am sorry for the length of this post but I am pleading with this group
on
the need to approach this long standing thought process on bottle
feeding.
How did this all start?  Any ideas to best approach this?  PLEASE I need
your
input.
Until bottle feeding mimics breastfeeding, I think we are fighting a
losing
battle.>

Guilty as charged, Ann. I recognize myself in this picture of how I
literally "pushed" formula many times when I was assigned to the nursery
years ago, and also to my own first 3 children, long before I learned
better.

I hope this observation can be broken down into its many component parts,
if for no reason than to have some small amount of mercy on the infants
who are being formula fed. I think it may play a correctible part in
habit formation that leads to our national scourge of obesity, as well as
the diagnoses du jour, gastric reflux.

I sometimes wonder if pediatricians are as aware of this as you have been
in your very astute observations. I hope someone with research
capabilities far beyond yours or mine, decides to expand on Paula Meier's
work with prematures, whom she observed to have episodes of bradycardia
associated with this type of feeding.

I hope thoughtful pediatricians in particular, address this matter in
their literature so that if the hospital nurses do not take the lead in
retraining themselves and the parents under their care, that at least the
pediatric office can emphasize how stressful it is to feed a baby this
way.

A good educational video on common errors would do wonders. I'm sure
there is a part that WIC could also play there, provided with good
research first.

All that aside, I believe there is a portion of this dilemma that LC's
can legitimately focus on. In my population, many parents and their
families are thoroughly familiar with rapid feeding of bottles. When it
is really necessary to supplement, it is much simpler for them to accept
the use of a bottle rather than many of the other possibilities.

Or when they simply just choose to supplement or when mom goes to work or
school and leaves the baby with a sitter or day care, even if the bottle
contains EBM, the baby often gets fed in this way.

Much of this speedfeeding" is attributed to the baby's "greediness". I
try to turn this around and interpret it a sign of struggle with tongue
motion and the baby's stress in attempting to coordinate breathing,
sucking and swallowing without choking. (The same thing applies to the
baby's response to OALD.)

I believe this flow rate and incorrect interpretation of "greediness" is
a very large part of "nipple confusion" or "nipple preference". When I
talk to a mother whose baby I know will be receiving a bottle at times, I
explain that the breast delivers milk in a "pulse/trickle, pulse/trickle"
pattern far different than the continuous "firehose" flow of a rubber
nipple.

I explain that this pulse/trickle flow rate leads to a slower and
possibly smaller total intake more in line with the actual capacity of
the baby's stomach, and gives the required 15-20 minutes for the early
part of the feeding to undergo full digestion, be absorbed into the blood
stream, and reach the message center in the brain that signals satiety,
long before the stomach has a chance to get over-filled. (I heard this
explanation somewhere in the past, and it makes good sense to me
[possibly rephrased it from WeightWatchers?], and to parents. I hope it
is passably accurate.)

It is my impression that if I can get parents to buy my explanation, it
can help "retrain" a nipple confused baby. (I have even demonstrated it
before frightened new parents that were certain their baby was starving.
They were amazed when the frantic baby fell soundly asleep after 3/4 of
an ounce of supplemental formula fed slowly, with frequent pauses.)

In reference to the nursing instructor you spoke to, you might suggest
that this is a sorely needed prime subject for really meaningful academic
research.

Jean
****************
K. Jean Cotterman RNC, IBCLC
Dayton, Ohio USA

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