Hi Sally,
Since I am currently providing home VNA visits to new Moms and have done so
for a large number of the 20 or so years that I have been an RN and 8 that I
have been an LC, I wanted to respond to your great questions regarding your
slow gaining newborn.
First of all, I think you did a great job!
The ultimate decider of that is the fact that on last visit the baby was
gaining well on largely brmilk!  There are a few things I might consider
*tweaking* along the way. If it is a first nursing experience or if the Mom
had any issues nursing previous children or if you are questioning the
adequacy of intake up until the time of the visit eg. excessive wt. loss or
hyperbili,  I always, always, always observe the baby at the breast. This is
an absolute expectation at the agency where I work, no excuses, as it is
considered a huge part of what we do. When I hear of visists where this is
not done, I am left wondering *how* since with 99% of the newborns I see,
once you finish their exam, they are actively rooting and looking to feed!
This leads me to the assessment tool that I have often complained about and
that is using output, as relayed to you by the parents, as an accurate
indicator of feeding effectiveness. It is far too subjective and in so many
instances, as in the case described by you, is irrelevant.
On the first visit, all of the instructions you gave to Mom were great. I
liked your emphasis on compression during feeds and pumping after to allow
for q2hr. fds. What caused a problem was the suppmt amt. If the baby was
waking only every 4hrs, the breast wasn't getting optimal stimulation. I
would have instructed to offer suppmt but adjust amt accordingly, thus only
give enough to allow for q2-3hr. fds. during day, less frequent at night if
needed. Also, depending on the baby's capability once corrections of the
problems at breast were made, I might not have used formula suppmts at all at
this point but simply saved EBM til enough to offer. Sometimes I have the Mom
save it and offer as suppmt at night only, to promote longer sleep periods
and thus allow for more frequent daytime feeds. If the baby is deemed to be
capable, this approach is preferable as it enables him to get more milk from
and more practice at the breast but is a little more risky in terms of
guaranteed wt. gain and thus requires close f/u. As time went on and Mom
decreased the suppmt amts I think your concordance with this was fine if the
supply was aligned well enough with the babie's ability to transfer milk.
Obviously one, the other or both was still off at this point and one wonders
if he had more practice at the breast, if this could have been avoided.
Hope this helps!
Lynn Shea Rn,Bsn,Ibclc
Franklin,Massachusetts

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