I'd like to jump in to the discussion about whether or not newborns need to
be woken to feed, or whether they should be trusted to know when they need
to eat. Thanks to all who are sending in such varied views and different
perspectives.  I especially liked Pamela Mazzella Di Bosco's post, alerting
us to all the tiny cues babies might give that mothers need to know about.

Following my submission yesterday suggesting that we might need to
re-examine the assumption that indigenous populations always breastfeed
without difficulty, I would also like to suggest that the other side of this
coin is that we might not automatically need to blame the hospital practices
and policies in the North/West for all that goes wrong with breastfeeding.

Once again, even without the medicated deliveries, the IVs, all the
interventions that many of you see in the US and Europe as so incompatible
with successful breastfeeding, and even with 24 hour rooming in or bedding
in, I can't help noticing that *some* newborns still sleep too much, and
*some* mothers still miss the small cues, even if they've been handling
babies ever since they could first walk.

A large proportion of the babies that I work with, referred by our
baby-friendly paediatricians, are 2 - 6 week olds who are not thriving - eg
they are not gaining sufficient weight on exclusive breastfeeding to
reassure the paediatrician.  When I go through the history, there is nearly
always a situation where the mother has assumed that this baby had taken
enough milk, as demonstrated by the fact that he had slept for long periods.
The small proportion of babies who don't do this usually want to breastfeed
"all day long" and so the mothers again assume that they are "getting
enough".  But the large majority of moms report that in the beginning the
babies sleep, and sleep, and sleep!   Since I do hospital visits too, I
believe them, because I also see some of these newborns sleeping *very* long
periods.  Our hospitals are very relaxed about this.  There is no question
of babies being given *any* formula at all so they are left to their own
devices, right next to their mothers day and night, and everyone trusts to
Nature!

It's so easy to blame birth interventions and hospital practices for poor
breastfeeding. These are the *most* likely causes, I grant you.  But we
might be missing *additional* causes of breastfeeding failure.  I really
think we need to ask ourselves what the infant mortality rate was *before*
we had the nice hospitals, and the medicated deliveries and the formula?
What is the IMR in places where all the babies are breastfed and these
facilities do not exist?  Do we even know what proportion of the IMR is
attributable to breastfeeding failure itself?

The longer I do this work, the less trustful I am of the automatic
assumption that doing as little as possible to disturb the "natural" process
of breastfeeding results in better outcomes.  I don't think breastfeeding
goes well by magic;  there are certain things that have to happen, even if
we don't yet understand exactly how they all work, but if they don't happen,
then the baby is at risk.  From what I can deduce, in an environment where
the hospital breastfeeding practices are pretty good, the overwhelming
majority of breastfeeding problems are attributable to something that the
*baby* is doing, or not doing.  Sometimes I wonder if these babies would
even survive if they were born in a mud hut in the bush.  Sometimes I wonder
how the human race survives!  But then I remember that, in fact, before the
advent of modern medical science the population did *not* increase that
quickly over millions of years, and many babies did die.

Consequently, I tell a mother with a sleepy baby (after the first 24 hours
of life) that breastfeeding on demand is perfect, yes, but only if the baby
is "demanding".  If her baby is sleeping long periods she should take charge
and make sure that her baby eats - at least 8 times in 24 hours, allowing
only *one* 4 - 5 hour gap in 24 hours if the baby is feeding often at other
times.  This means waking the baby to breastfeed, and if he can't/wont, then
she should express her colostrum/breastmilk and feed it to the baby
(preferably on a spoon) *even if the baby is asleep*, and I show her exactly
how to do this.  If the baby is older than 2 - 3 days, I work out how much
EBM he should be having.  There are only two rules: 1) feed the baby and 2)
drain the breasts (preferably by breastfeeding, but if the baby is sleepy,
then she should express).  I give info about expected urine/stool output,
expected weight loss by 3 days of age of 5 - 10%, preferably not more than
7%, and the expected rate of gain of 30g/day thereafter to regain the birth
weight by 10 days, 14 at the most.  I find that when the baby's nutritional
needs are met, he then begins to perk up and *becomes* demanding, the weight
loss is quickly regained, and *then* the mom can start to leave
breastfeeding frequency up to the baby.  I find that the smaller the baby,
or the more pre-term, the more it is necessary for the mom to nudge the baby
to feed.

Tomorrow I see twins born at 36 weeks, weighing 2100g and 2300g, discharged
at 3 days, who have gained 60g and 100g in three weeks, referred by their
paediatrician.  These are two more babies whose mother trusted them to know
what they needed ..... sigh!

Pamela Morrison IBCLC, Zimbabwe

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