I've been thinking a lot about your experience, Jean, and trying to find a moment to write you. You've experienced a loss. I'm guessing that you may have expected that somehow it would all work out, that your knowledge and skill (and that of those who were enlisted to help, too) would be enough to help your granddaughter through in spite of the many, many barriers she faced that were entirely outside of your and her control. That your granddaughter would somehow hang in there. That she would get to experience substantial breastfeeding. That her baby would get to experience substantial breastfeeding. When our expectations are not met, we can feel sad, angry, confused, frustrated, ....and we can grieve their loss. You, even more than your granddaughter probably understands right now, are keenly aware of what has been lost. If this rings true, I just want to be sure that you know that it's all right to be grieving. It doesn't mean you don't recognize all the positives that are also going on. It doesn't mean that you can't or won't participate in celebrating all the wonderful developments and growth that your granddaughter and great grandchild have, are, and will be making. It just means you experienced a loss and are healthily, humanly, and normally grieving.

When we have strong emotions, we often need to vent them--and vent them well--before we try to invite others (like a health care provider who dropped the ball) to enact change. For more ideas, my article "Helping Mothers Create Breastfeeding Allies" is about steps we can take to more successfully encourage others to make changes that increase support of breastfeeding: http://www.lalecheleague.org/llleaderweb/LV/LVDecJan02p123.html. I hope something in it might be helpful.  

A big hug to you,

Cynthia

--
Cynthia Good Mojab, MS clinical psychology, IBCLC, RLC, CATSM 
Ammawell 
Website: http://home.comcast.net/~ammawell 
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To all my Lactnet friends: My granddaughter Jenni has given me permission to post. It is so easy to get one's feelings "enmeshed" in the breastfeeding experience of a loved one, and so hard to separate them again! One month of partial breastfeeding is good. Much better than no breastfeeding at all. My head knows that. I trust my heart will one day get the message. It is 4 times more than any one of my first three children received, and I told her so when I was "giving her (my) permission" to stop her efforts. (She reminded me that none of her girlfriends had ever even tried, and that unless she had accompanied me to the ILCA convention in D.C. at age 16, and heard so much breast feeding talk among my friends, she never would have thought to try breastfeeding either! (And she says "Besides, the fee for her base nursery covers the cost of formula!" Argh-h-h! Even the mention of antibodies, exposure to illness from other children at the nursery, more time off for doctor's visits, more rest at night when she is the sole caregiver, and the prospect of her first Montana winter, didn't make a dent!) A cascade of events eventually overwhelmed the support of the milk supply, till the experience was so far "down the tubes" that both she and the baby were obviously dreading/fighting each nursing.


I realize that a grandchild's purpose in life is not to fulfill the expectations and dreams of their grandparents and parents. So I take responsibility for my feelings, and reflect on how to continue to be supportive as she learns motherhood, and where to divert my energies to help improve the healthcare system so that others might have a better experience. (That's why I'm ventilating here.) My original motivation, left over from my own experiences as a mother, is that far too many mothers are saddled with unnecessary feelings of inadequacy, when it is our health care system that is often inadequate!


She is in the US Air Force, stationed in Great Falls, Montana, and her husband, (Daddy Reuben) stationed in Korea, had exactly 28 days to travel home and be with her, to help her finish "feathering their nest" and to experience the birth of their son. I arrived there a week after he did, squeezed in a little vacation sightseeing to let them have their privacy before the due date and did "doula" duty. I was privileged to support them both and help out grocery shopping, cooking, washing dishes, sewing curtains (my outlet for "perfectionism"), etc., wherever I saw a need as they transitioned to their new roles as parents. So many adjustments for them to make, in such a short time! 



I was never able to persuade her to go to a LLL meeting prenatally, and I think seeing how casually other women could nurse would have helped her form her feeding ideas in a more relaxed way, instead of making it "a project" every time she put him to breast, and breaking suction and declaring "He's done!" every time suckling effort tired him momentarily. I did take her to a weekend childbirth class when she was home on leave about mid-pregnancy, and all along, I had provided some of my favorite parenting books, (alas, I saw them gathering dust on her shelf) and several of Diane's sheets, including "He Can't be Hungry, He Just Ate", but they went mostly unread because of her resistance to "TMI" (too much information). She was also curiously resistant to learning to nurse lying down, stating she just couldn't relax that way. (This has been reinforced, I believe, by the recent newspaper articles on AAP recommendations on how to avoid SIDS!) 


Nevertheless, I started with "where she was at" and my goal was to be the "wind beneath her wings" to help her. She had to overcome numerous hurdles, including an elective CS for breech presentation and a 41-week g.a. 5# 7 oz. baby with IUGR (intrauterine growth restriction from a small placenta. Fortunately, the IV fluids did not overhydrate her, and RPS was unnecessary.) Even though I have been a maternal-child nurse with experience in every phase, from infertility clinic on, through years in every area of hospital maternity care, plus public health, and now WIC, this is the first time in 24 years (since my daughter came to stay with me for a week after her first child), that I have spent virtually 24 hours a day with a new mother, and did so for over 2 weeks! I stayed all night after her CS, and even though it was 2 1/2 hours after surgery when Baby R. came out to her to begin skin to skin contact, I sat and listened in awe as she cooed and talked to him off and on for hours while they literally fell in love with each other that night. That just wasn't done back in my days in the hospital, and I encourage everyone to put it into practice!


The IUGR resulted in Baby Reuben having very unstable blood sugars, and I must compliment the hospital staff (especially the four dedicated CLC's, two about to sit the exam in 2006) on their efforts. They were in no hurry re: the first day's feedings, very sparing on early blood sugars, and no "threats". Despite the eventual need for IV's to maintain his lab-confirmed blood sugars, they fingerfed him formula when absolutely necessary, and faithfully returned him to her room, IV and all, to let her have as many hours of time to learn nursing, and skin to skin contact as she and Daddy desired. Baby R. had to stay after she went home, for an extra 36 hours of IV's and a bili lamp for a bili of 16. They supplied the pump in her home till he was discharged.  



One thing was definitely not so fortunate. As ably as the pediatrician managed the blood sugar issues, she was definitely not informed on the latest professional literature on tongue-tie, and unwilling to entertain the idea of newborn frenectomy, stating unequivocally (in front of the medical student accompanying her on rounds) that it might even cause complications and could be addressed IF AND WHEN there were ever any speech impediments!  (Not shouting-just emphasizing! But I did really feel like shouting!!) I had been determined from early pregnancy that Jenni's somewhat unusual nipples would not be turned into hamburger. But with this extra complication, I had to turn to a nipple shield, a long pacifier for "tug of war", football hold, breast compression, some pumping and some supplemental EBM and/or formula bottle feeding as per Dee Kassing's article, to get us through till we could get home for a frenectomy at 17 days. (I think finger-feeding, at that moment in time, might well have caused her to "throw in the towel" right then and there! In retrospect, since tongue-tie interferes with efficient milk transfer, if I could do just one thing over, I would have insisted they start her on the pumping earlier, paid the rental fee for her and would definitely have had her "insurance pumping" till we flew home, in order to build an oversupply early on, instead of fearing the problems of oversupply. Handpumping just didn't fill the bill. One of several definite learning experiences for me.) 



Five days after Daddy Reuben's return to Korea, she (at 16 days post-op, but in excellent physical condition from her Air Force experiences) and I flew home to Dayton, Ohio, so she could spend the last 4 weeks of her maternity leave with her parents. (I will never forget her valiant efforts, wearing a sling, nursing exclusively, with shield, on the plane, and even in the middle of the main lobby of Minneapolis-St. Paul airport! She really gave it the "college try"!) Back home in Dayton, we immediately had the tongue clipped by my friend Greg Notestine DDS (Ankyloglossia, JHL 1990). Sadly, even at 6.5 #, the baby still has a tiny mouth and had developed habits that were hard to break [humping, clamping, etc.] and at one month, is still slow to form boluses even with carefully paced bottle-feeding. 


Even though the shield seemed to transfer milk nicely, as in Meier's premi research, eventually, after the first few (still painful) nursings after the clipping, she was just too overwhelmed with all of new motherhood, unrealistic expectations of herself, especially the effects of sleep deprivation and how often newborns wake in the night, and the fear of still-acute nipple pain, to put the baby to breast, even with the shield. Since she will always mainly see me in my grandmother hat, I fed info to my daughter (G2,L1), to ration out as she saw fit after we returned to Dayton, in order not to overstep my bounds and crush her ego with my approach. I enlisted other relatives to buoy up her ego, re-emphasize the importance of turning off the TV and sleeping when the baby sleeps, to help her be more patient with herself learning Motherhood 101. And just as important, perhaps moreso, I asked my good friend Geneva to step into the LC role, and I withdrew to my own home to tackle the stack of mail. Via phone contact, I continued to dole out praise and support, but waited to be asked for further help.


Fortunately, prenatally, I had been able to get her to accept a limited amount of vital info, including Rule 1, 2 and 3. Rule 1 has never been broken (thanks to the formula company and the diaper bag stash of formula. Galls me to admit it, but I am glad it was there when I thought it was needed. Of course, I suppose I could have gone out and bought it when it was needed.) We worked (mimimally, per her efforts) on Rule 2 with a Lactina back home in Dayton, but I don't think she ever got past the idea that pumping was mainly for obtaining milk, and the reverse logic kept taking over, so that she only pumped "when she felt full enough" despite numerous simple explanations that "you must keep removing the milk to maintain your supply, and to re-build your supply higher, short, frequent pumpings are more important now, even if you don't get much out at a time". 


She confided to her mom that she felt like "she was disappointing me". I tried not to let that show, for I knew, of course, that was my own problem. I tried to keep "accentuating all the positives" of her accomplishments, help facilitate any (possible) grieving on her part and manage and reframe my goals and expectations as needed. I would be glad to give her two purple hearts, one for each nipple, if I could!  I zealously helped her avoid skin breakage, but some pictures show much peaking, slight bruising, and the pain eventually became excruciating. But amazingly, about 6 days after the clipping, when all internal bruising had resolved, her mom walked in one morning and found her nursing, without shield. She asked Jenni "Does it still hurt?" "No, it just feels a little bit funny. Is it supposed to feel that way??" After her mom's assurance that that was exactly the way it was supposed to feel now that the tongue was no longer tied down, she smiled and said "I can do this!" But the pumping became even less after that.


I think the final crack in the dike came the day she went to see the pediatrician at our local air base. (We had kept the weight gain adequate, by following Rule # 1, with EBM, and with formula, but just when necessary.) He did tell her that they clip frenulums all the time here in Dayton, but when he found out the amount she was getting per pumping, he of course, took that to be indicative of the amount Baby R. was obtaining at breast, and told her to supplement with formula after each feeding.  (She had not informed me that her own base had called her and told her to go to our local base for a check-up, or I certainly would have accompanied her to the visit and added my $.02 about the pumping at that time. Of course, maybe she didn't want me along, or felt that getting a base pass for me was too much hassle.) Supplementation after absolutely every feeding made him sleep longer, which pleased her. And you know the rest of the story. This became a self-fulfilling prophecy. She felt confirmed in her fears/discouraged about the amount being pumped, and soon there was no more pumping, less and less milk, slower and slower MER and less and less immediate reward from the breast. He began to clamp, struggle and cry at the breast, and of course, she refused to be "clamped on", and I could see impatience mounting so that between the two of them, the breast was turning into a battleground. 

And I saw great relief on her face when I acknowledged that it didn't look like either one of them was enjoying nursing the least bit, and how would she rather proceed from here on? "Permission" had been granted-to me to cease and desist all but appreciation of her efforts and how fortunate her baby was to get such a good start. And permission for her, to return the pump, buy more bottles and more formula and "get on with her life".   She declares "It seems so much easier."

I am trying to maintain professionality by supplying the name and address of the Great Falls pediatrician to Dr. Notestine so that he can send pictures and a report on the frenectomy, but I can't decide whether to chance sending along anything myself as far as events after the baby left the hospital. I don't want to go overboard, but I can't help feeling that if that large stumbling block had been taken care of in the beginning, things would have been different from there on out, and her motivation, tenuous as it may have been to start, would subsequently have been rewarded and strengthened, rather than spiraling downward to complete weanng at one month. I am particularly interested in suggestions from physicians on the list as to how best to handle this. My main goal is to improve the healthcare system, not ventilate my own strong feelings that remain. And what about the physican at the local base who recommended formula after every feeding, based on Jenni's report of the amount she had been getting at pumping? Since I did not meet him, any professional way for me to improve his information?

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

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