Thank you Pamela for your informative response. It makes absolute sense! 
If you wouldn't mind sending me on your handout when you get an opportunity, I would greatly appreciate it. 
Kind regards
Amanda Devane Glynn
LLL Leader 
Ireland
(And sitting the IBCLC exam for the first time this year)

> On 10 Jan 2015, at 08:16, Pamela Morrison <[log in to unmask]> wrote:
> 
> Morning Tricia
> 
> Thanks for sending in an excellent question - wshether it's ever beneficial to limit the number of minutes at the breast during a breastfeed....  And for noting the similarity in behaviour at the breast between a preterm or late-preterm infant and a newborn with a weak suck.
> 
> When I work with premies or low-gain babies (those who are obviously not transferring enough milk at breast to achieve a normal weight gain) I always suggest limiting time at the breast to no more than 30 minutes, (with breast compression and switching to keep baby swalllowing), and then topping up with EBM. Why?  Because there's nearly always a consistent history and current pattern of behaviour:  So much so that I've done a handout noting the following:
> 
> At first, the hungry baby shows _prolonged and frequent crying_, which is often mistaken for colic, or the baby is pacified/soothed with a dummy, or with returned to the breast.
> 
> During breastfeeding, it may be observed that there is a _very short period of swallowing_; thereafter the baby wants to stay attached to the breast, but _mostly flutter-sucks with closed eyes_, and he/she wakes again to protest only when taken off  the breast.  If put back to the breast, the same pattern happens again - a short period of swallowing followed by fluttering and minimal milk transfer.
> 
> Later, the hungry baby _may want to feed all day and sleep all night_;  well-meaning friends and advisors may inappropriately endorse either of these abnormal situations by urging the mother to continue breastfeeding "on demand", and by offering congratulations that the baby is sleeping through the night;  the mother may also reason that because she is feeding the baby all day, then s/he must be getting enough as evidenced by him sleeping well at night;  the truth, however, is that the baby becomes so exhausted by attempting and failing to obtain enough nourishment during the day that he is too exhausted to wake up often enough to breastfeed adequately at night, and long intervals without drainage will deplete his mother's breastmilk supply still further.
> 
> So yes, these low-gain babies actually conserve energy (expend so little at the breast) that they fail to transfer enough.  Nature's way - very clever, but not very effective if the baby is to thrive.... If the sucking is strong (with good swallowing) then you'd keep the baby at breast, but when the baby flutters for more than 5 minutes or so it's really more productive to stop.  So this is why I suggest limiting sucking at the breast, stopping after giving the baby an opportunity to "breastfeed" and then topping up the still-hungry baby with EBM as a first choice, ABM if there isn't enough (180ml/kg/day or even more....) and pumping/expressing the breasts to get the milk that the baby has left behind asap after the baby is properly fed and settled.
> 
> Because the other problem with these babies is that because they don't drain the breasts effectively this continues to compromise the mother's supply which dwindles over time. Personally, I'm not crazy about the SNS, and I find that the quickest, easiest way to provide supplements is by bottle.  I've never worked with a baby being topped up by bottle who has gone on to refuse the breast....the trick seems to be to offer the breast first and then offer the supplements afterwards to fill the baby up and keep him happy (and fed!) and then pump to the last drop to optimize breastmilk synthesis.
> 
> This protocol really seems to work well - once the baby has caught up the lost weight and the mother's milk supply has increased, then you can start reducing the ABM supplements, then the EBM supplements and continue breastfeeding as normal.  I do find however, that a previously low-gaining baby may not breastfeed effectively until he has regained the lost weight sufficiently to be a normal weight for age, so supplements shouldn't be stopped too soon and these weak babies can slide backwards again very easily. Now if anyone else can answer why _that_ happens I'd be grateful...
> 
> If you'd like my full handout, just let me know by private email and I'll be happy to send!
> 
> Pamela Morrison IBCLC
> Rustington, England
> ------------------------------------------------------------
> Hello, Can anyone give me information on whether or not it's ever beneficial to limit the number of minutes at the breast of a preterm or late preterm infant. The ABM Late preterm protocol seems to recommend it. They state that a late pre-term should be transferring enough milk within 20 to 30 minutes by the time they are discharged from the hospital. But I thought that they expended less energy at the breast. I have heard others say that it may be beneficial if they are sucking weakly and not transferring milk, but it shouldn't be limited if their suck is strong. This seems to be a controversial issue. Is there any reason that you would recommend the same for a full-term infant with a weak suck? Even if they are sucking weakly and using an SNS at the breast, I don't see the point of taking them off after 30 minutes. If they cry are we going to just put a pacifier in their mouth? How does that improve the situation? Any thoughts or studies would be welcome. Thank you, Tricia Shamblin, RN, IBCLC
> 
> 
> ---
> This email has been checked for viruses by Avast antivirus software.
> http://www.avast.com
> 
>            ***********************************************
> 
> Archives: http://community.lsoft.com/archives/LACTNET.html
> To reach list owners: [log in to unmask]
> Mail all list management commands to: [log in to unmask]
> COMMANDS:
> 1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
> 2. To start it again: set lactnet mail
> 3. To unsubscribe: unsubscribe lactnet
> 4. To get a comprehensive list of rules and directions: get lactnet welcome

             ***********************************************

Archives: http://community.lsoft.com/archives/LACTNET.html
To reach list owners: [log in to unmask]
Mail all list management commands to: [log in to unmask]
COMMANDS:
1. To temporarily stop your subscription write in the body of an email: set lactnet nomail
2. To start it again: set lactnet mail
3. To unsubscribe: unsubscribe lactnet
4. To get a comprehensive list of rules and directions: get lactnet welcome