This is not really about hypoplasia and when to share information but it arose in this thread so I've kept the subject heading.

To Heather's specific question in her first post in response to the case posted by Maya: "I also want to know why someone in practice thinks it's a good idea to 'instruct' a new mother to bf 3 hourly.  Can this ever be appropriate?"  
Short answer: no, it can't, if the goal is successful breastfeeding.   

In the case in question, this advice borders on malpractice, IMO.  Unless accompanied by clear simple information in writing about how to tell whether the baby is feeding effectively, and what signs in the baby should prompt an immediate visit to the nearest place to get help as well as how to get in touch with that place, it is appallingly inadequate.  Sending a mother out into the world with a baby born at 36 weeks without a solid follow up plan is bad practice, unfriendly to babies, mothers, and breastfeeding.

We weren't there when the mother was instructed.  All we know is what the mother recounted to the next person helping her.  From my own experience I know that maternity ward staff in my unit persist in viewing eight feeds a day as 'very frequent' despite all existing knowledge about how babies actually feed physiologically, and it is routine to tell the mothers of babies who are deemed incapable of self-regulation that the baby should be fed 'at least eight times a day'.  Babies falling into this group are the ones born just before term, or born after about 41 weeks, babies weighing less than 3 or more than 4 kg at birth, or babies who someone thinks are visibly tinged with jaundice on day two, or just any baby who has not fed eight times in the first day, which doesn't leave a lot of babies to self-regulate. Every time I bring this up, which is about 10 times a week, I am ranting about how parents do not hear 'at least', they only hear 'eight' and our orientation to a 24 hour clock is so strong that this is transmuted to three-hourly intervals without consciously thinking about it.   The parents cease observing the baby's cues and start relying on the clock, with results as expected - restless babies and a rising sense of insecurity about their own ability to meet the baby's needs because even though they are following the instructions to the letter (or number!), the baby is obviously not happy.  Gee, this breastfeeding thing is a lot more complicated than I thought!

Naturally this situation rapidly starts including signs of low supply in the mother too, regardless of how normal her breasts may be.

I've wondered at times whether it would be useful to send a note to the facility in question.  Dear colleague, I had occasion to see M and her baby, G, today when they sought our help for a breastfeeding problem. The baby had not begun to gain weight yet and when I saw them she had lost x percent of her birth weight and had not stooled for three days.  M could not recall the details of the plan you and she agreed upon when she was seen by you, and she did not have a written copy of it.  I hope the plan we made when I saw them is not too different from yours. It consists of (some way of ensuring the baby gets fed) and (some way of protecting the milk supply). M and G are coming back here in a couple of days to see how the plan is working, but it is more appropriate for her to continue her care with you since you are in the facility in the community where she gets the rest of her care.  M looks forward to the resolution of the problem and plans to continue breastfeeding for at least six months.'   

That way, they are not cornered into defending some garbled version of a possibly great plan forgotten by the mother, and if there has been no real plan, they will see that I at least (pretended to) respect them so much that I assumed there was a plan but the mother had forgotten what it was and forgotten to bring her copy along to the visit at our clinic.  If they did have a plan, perhaps they will consider the importance of writing it down next time so the mother doesn't have to remember it by heart.

After re-reading Maya's original post I can also say that where I work we would have been happy to watch and wait for at least a day or two following the three day visit, provided all the bad advice had been thoroughly disposed of and the mother had achieved an understanding of what to expect, and how to ensure that her milk supply would have every chance to increase in the next few days.  We would stay in close touch; indeed, we would be extremely unlikely to discharge that baby on day two unless the mother insisted on it, though I hasten to add we would not necessarily handle the situation any better :-(  

I might ask the mother about breast changes in pregnancy if her breasts looked really conspicuously unusual, but I would be most reluctant to make a diagnosis of insufficient glandular tissue before the time when lactogenesis two is expected to occur in a primip, as I understood this mother to be.   Since we also know that supplementation in the first week is strongly associated both with lower likelihood of ever breastfeeding exclusively and a shorter duration of any breastfeeding, we should be cautious.   Without the opportunity for safe, close follow up you will have to weigh the harm to the baby of being fed too little against the harm to the baby and the breastfeeding of supplementing too soon.  If daily visits while you wait are not an option, I would not criticize anyone erring on the side of feeding the baby.

Rachel Myr

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