Glenda, Becky, and others who've voiced this concern:

I'm an LC in a tertiary care hospital which has about 3800 births a year.
 Our BF initiation rate is slightly above 50% now.  We see a lot of sleepy,
uninterested babies and moms who are going home before the babies have
demonstrated ability to nurse.  We don't have written protocols yet, as I'm
still trying to find some solid science to base them on. The problem there is
that I'm not sure we're dealing with "normal" breastfeeding babies.  A
"normal" baby would not be the product of a medicated labor--most of our kids
are exposed to pitocin, the epidural anesthetic agent, and Stadol, and maybe
Mag sulfate during the labor, and were hydrated (overhydrated?) by mom's IV,
which I suppose could skew the blood sugar responses. A "normal" baby
wouldn't be delivered in the lithotomy position, and mom wouldn't have been
confined to bed during the labor so she could be monitored.  A "normal" baby
wouldn't have had an internal scalp electrod attached, either, or had scalp
pH's drawn. A "normal" baby wouldn't be separated form the mother for an
initial assessment.  (This is much better than it used to be--the initial
assessment is now done in the delivery room instead of the NBN, then the baby
is left with the parents for the rest of the first hour.  But there's still a
separation.  And the baby does eventually go to NBN for a complete check, a
bath, and time under the warmer.)  A "normal" male infant woudn't have been
stressed by an unanesthetized circumcision at 6 hours of age, either.

We don't do routine blood sugars on all babies.  Each doctor has his/her own
preference for this--usually babies over 4000 grams or under 2400 to 2600
gms.  Of course we also do one if the baby is symptomatic.  We were doing
accuchecks in the NBN, but apparently these aren't accurate if the sugars are
very low, so now all blood sugars must be done in the lab, which really
delays getting results. This means babies sometimes get fed on the basis of
symptoms, only to find later that the glucose was ok. (Most of the docs say
"ok" is 40 or above, some say 35.)

We try not to get too pushy with getting the baby on the breast, but the
parents' anxiety level climbs pretty rapidly, and so does mine, knowing the
baby is going home in ~24 hours, so we're probably more aggressive than is
actually necessary.  I seldom initiate use of a pump in the first 24 hours,
as I figure all that manipulation of the nipple as we try to help the baby
attach renders pumping unnecessary.  Besides, as Becky pointed out, there's
not a lot of colostrum to be obtained, and this really makes the moms
anxious--they're sure they "don't have any milk."  I tell them the baby is
much more effective than any pump at extracting colostrum, and that pumps
work much better after their milk is in.  I encourage a lot of skin contact,
discuss hunger cues, and suggest rooming-in.  I emphasize that this
disinterest is a temporary problem, but I've learned never to predict when
the baby will begin to show interest.

If the baby hasn't attached in about 12 hours, we usually start finger
feeding with a syringe--again, it probably isn't necessary, but I don't want
a poor feeder, his reserves already partially depleted, going home with an
inexperienced mom.  We rarely or never use SNS's in the hospital, because, as
Becky pointed out, if the baby isn't attaching, they do no good, and they're
pretty overwhelming for a new mom who feels clumsy anyway.

If the baby isn't attaching at all at time of discharge, we do teach pumping,
recommend a rental Lactina, and instruct the mom to feed every 3 hours,
either at the breast (strong, steady suckling for at least 10 to 15 minutes),
or finger feed with a syringe and pumped milk (plus formula as needed until
the milk is in).  If baby doesn't nurse well, mom is to pump every 3 hours.
 We give written instructions for all this, as well as a handout "How to Know
Your Baby is Getting Enough Milk," and suggest that mom keep a log of feeds,
voids, and stools, so she can monitor intake via output. (The log helps us
assess what's going on, too, when we talk by phone.)  She has a 24 hour help
line phone number to the nursing unit, and she knows the LC's will be calling
her in 3 days.  She's encouraged to get a weight check within the first week,
either at her ped's or in our office. We're developing a for-fee outpatient
clinic, but at present, moms often just come by for a little help at no
charge.  ("A little help" usually takes at least an hour or more.)

I'm not happy with all this intervention, but I don't see how we can safely
send a poor feeder home without it. I've heard a rumor that our hospital,
which does have midwives on the staff,  may be looking at home deliveries.
(This was anathema a few years ago, but now that it may save money, it's
apparently worth talking about.)  This might solve all our initial feeding
problems, at least for the moms who opt for that type of delivery.

Any comments, disagreements, counterpoints to what we're doing?

Judy D in WV