As Jan has expressed her concern that no baby should ever have to be
readmitted for dehydration, I am also wrestling with an aspect of this
question. I just saw a mom yesterday who is now 3 mos postpartum. She
has had very little milk from the start, and in fact this had happened
with her firstborn as well a decade ago. Mom had well-meaning friends
who advised her not to "give in" and allow any bottles or pacifiers.
This is good advice for most situations, but she was at risk and nobody
flagged her. Not only did she not experience a normal lactogenesis II
with her firstborn, but she also had long, tubular breasts with lots of
stretch marks, a history of past obesity and gastric by-pass, plus
secondary infertility. Mom reported that her breasts seemed to have
grown during this pregnancy and she experienced tenderness, but palpable
glandular tissue was scant despite three months of breastfeeding and
galactogogues. During mom's first week, her baby lost weight and was
approaching dehydration before the problem was flagged. After doing a
thorough screening, I shared with the mom my findings and thoughts on
why she didn't have much milk. It all made sense to her when it was
spelled out, and she wanted to know, "why didn't anyone tell me? They
should check for this when you're pregnant!"

She is right, but it isn't happening. Too many caregivers along the line
are not aware of the other side and fail to flag such moms, and when the
mom follows standard advice to just keep trying, nurse more often, and
the milk will come, trouble can result. Without good screening all the
way up the line of mother's caregivers, there is going to continue to be
babies and moms who fall through the cracks with traumatic results. Even
more confounding is the fact that some moms with lots of risk factors do
just fine. I am troubled because we are still having to work so hard to
get caregivers on board with promoting and supporting breastfeeding, and
now there is also a need for them to understand the scenarios where
breastfeeding may not work and mom and baby need special follow-up care.
The solution for preventing breastfeeding-related tragedies is not so
easy.

~Lisa Marasco

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