Dear all:

Kathy had posted quite a while about about test weighing and I've been so busy I haven't 
had a chance to respond.  Any instrument is only as good as the interpretation and 
additional observations and any instrument can be used to empower women or enslave 
them into dependency.  It is a tricky process.  

She posted during a week when three babies showed up in my group that took between 
1.4 and 1.6 oz. I gave each and every one of the mother's different advice.  Why?  
Because of the rest of the picture. 

I have to confess that I am proud of one of my trainees who spotted something I had not 
been as observant about before I did.  One mother had been giving the breast, 
supplementing with formula, and not pumping for quite some time.  We started her 
pumping. The trainee told me afterwards that she suspected marginal insufficient 
glandular tissue.  While I can spot that across the room if a woman in support group is 
openly nursing --- there is a subtlety that is not obvious to marginal glandular tissue even 
when you see women one on one, let alone in the group.  And I do believe the trainee is 
correct.  So after my trainee talked to me and sure enough three days later we saw no 
improvement in expressing milk from any means possible, we sent her to the 
breastfeeding medicine specialist for galactogogues.  At that point she had spent two full 
weeks of espressing milk using every trick I know. 

Another mother had a baby that was six weeks old, barely above birth weight and even 
without the scale you could see the wrinkled skin the avid almost marasmic look that I 
used to see in the malnutrition wards in developing countries and just really fatigued.  
You could spot that without a scale. Yet the pediatrician missed a clue when the baby was 
three weeks old and gaining only a half ounce a day.  A pink flag.  Probably a good LC 
would have spotted that the baby was doing more sucking than swallowing.  And, I'm 
very happy to say that this was picked up by two non IBCLCs who sent this woman over 
to my group.  

Yet another mother had been working her baby off supplementation.  This baby had full 
thighs, happy and smiling, fed sloppily and would just stop feeding.  If you listened 
closely you could her that laryngeomalaceal squeak that was not evident when she was 
younger.  She had gained 11 oz the week before and only 3 ounces this week.  Was I 
worried?  No.  Her baby was much less fussy with her smaller more frequent feeds.  One 
week later she took a full 3 ounces. 

The most important thing it to observe the totality of the picture.  Add up all the clues 
you have from every sense you have and help the mother do the same.  The eyes, ears, 
sensory receptors on the skin, (even smells at times), all tell us something.  The 
connection between all these things must constantly be reinforced when using a scale to 
keep in the background as just the reinforcement of what the mother is really observing 
with other senses.

Unfortunately, when a baby is failing to thrive, the very observation of that can be so 
threatening that a mother cannot allow herself to admit it to herself.  I have had only one 
mother stop me cold so I was speechless and couldn't think of anything positive to say.  
She was highly confrontational with all the group, demanding evidence for everything --- 
and literally hid her baby under a blanket.  We helped a bit with the latch which was hard 
because she kept hiding her baby with the blanket insisting her baby was fine.  Her baby 
was not fine --- yellow, skin in folds and not swallowing.  She did a weight check and the 
intake was not good --- and pronounced it good, then changed a diaper invalidating the 
weight on the other side.  I tried to explain about changing the diaper.  Surprisingly she 
actually weighed the baby again and pronounced the 2 oz weight loss great (even though 
I know that the baby did take a little more --- but probably about 0.1 based on years of 
my observations of swallows pre and post scale use).  This was one where I was hoping 
to get another check in and take her aside for an in-depth conversation.  I think in all my 
years of doing support groups, I've never met a mother who was so confrontational with 
everyone (and probably deeply scared).  After taking a little "bathroom break" to breath 
deeply for a few minutes --- I finally used the indirect approach by talking with another 
mother near her who had a baby who was gaining slowly about stimulation tactics and 
what to watch for in terms of danger signals.  These cases are rare.  This one was the 
hardest one I ever saw.  She never did come back. I've found that the rare times you 
encounter these women, they often do get angry with the first person who does tell them 
that something is truly wrong.  They can then blame it all on that person and eventually 
most of them will go on to find someone else and are more receptive.  Less often they 
will drift from person to person and settle in for someone who will falsely reassure them 
that everything is OK.

One can never rely entirely on one single observation regardless of whether the tool (or 
gadget) is our eyes, our ears, our hands, or a scale. 

Best, Susan

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