To the LLL Leader who asked about the premature baby whose mom is being
discouraged from breastfeeding:
I am also an LLL Leader, and an IBCLC for the WIC program. I work with a
lot of preterm babies once they come home. Generally speaking, I find
that the young ones do not usually remove enough milk to totally
breastfeed. Sometimes they look textbook perfect with good sucking but
rarely do they remove milk well enough to totally BF. Often they suck
for a few minutes and go to sleep on the breast. I see a lot of what I
call "self limiting" -- the baby takes 1/2 ounce to 1 ounce only and
quits, when caloric needs appear to be around 1.5 ounces given 8 times a
day. This is a baby that will do some work but tires easily and falls
asleep -- on breast and on the bottle. I do test weights to assess what
baby can remove and in how short of a time. I never let these babies
nurse for 45 minutes because I find they remove all they are going to in
about 10-15 minutes. The rest of the time on the breast is not active
sucking, just hanging out with eyes closed and no milk transfer. We
usually supplement by bottle because we are "topping off" the baby to
make him eat more -- really to eat enough to gain weight and strength
appropriately. Sometimes we supplement at the breast to get better
sucking but when they are self limiting and not participating at
feedings, they remove less from the breast with supplement. Starting at
about 38 weeks adjusted age, they often begin to participate in feedings
and do better -- but still may self limit or tire quickly. This is when
supplementing at the breast often works better. Around 40 weeks, we see
better sucking and more intake. Around 42 weeks adjusted or around two
weeks past the original due date, we usually have a fully breastfeeding
baby. If mom works at it and is patient.
I tell moms to keep pumping 8X in 24 hours. I have them pump after
nursing if baby is self limiting much less than she makes. I have them
pump and bottle feed 4-5 times a day, with breastfeeding 3- 4 times a
day at first. I want moms to use a hospital grade or rental pump (loaned
by our WIC) with big enough flanges. This mom needs to be reminded about
active sucking, rapid jaw movements and liquidy sounding swallows in
long repetitions before short pauses. Breast compression or massage
sometimes helps. The other thing about preterm babies is that you have
to get them to the breast as soon as they indicate hunger because if you
do diapers first, or hugs and kisses first, they shut down and forget to
eat. A full term baby will start crying to be fed but a preterm baby
will often shut down and conserve calories. Diapers and hugs come in
between breasts, say after 10 minutes on the first side. Preterm babies
often shut down quickly and continue to do so until near the original
due date. For preterm babies, we usually have to manage the feedings
until the baby is participating on his own and sucking well enough to
transfer adequate quantities of milk to grow on.
And the weight gain of this baby sounds poor and if mom will be more
patient and concentrate on feeding the baby the most efficient way, she
will get him home quicker. Once she is home, she can have an experienced
IBCLC work with her to assess his BF ability. Mom can rent a Medela baby
weigh scale and do test weights at home. I like to see a milk supply of
at least 2 ounces pumped out (total two breasts) 8X a day, or 16 ounces
total in 24 hours. Too much less and baby doesn't usually work for what
is there. I have seen the kind of treatment you described in hospitals
with moms who are very anti formula and bottles or who assert their
rights as parents of the baby. It makes me sad.
Kathy Eng, BSW, IBCLC
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