I've been out for 3 days for the Jewish New Year- there were some discussions
that I want to add to.

I got Diane Weisenger's (?) article about her history with teaching the latch in
my BRC packet- it was very helpful to me in helping some moms lately (the
sandwhich hamburger anology) so recently I was visiting a friend (so not a full
consult- and she is going to go to a "real" IBCLC) in the hospital with her 3
day old twins boy and girl- she said she was having some nipple pain so I asked
her if she would like my assistance- yes- so we did the girl who was the second
smaller twin (~5# 8oz) also 37 wks and low apgar- I thought I was teaching her
the sandwich technique but come to  think of it I guess thats also the
"folding" technique- but this time we REALLY folded it in- other moms I had
tickle philtrum and nose with nipple and when baby opened big mom brought right
onto nipple- but I have them cross cradel in the office "so that they can tilt
the head back" I explain that its only for the first few wks while the infant
doesn't have head control- anyway- back to my friend- her nipple was pretty big
IMHO it was about a nickel ~1.5 - 2 cm (wide- diameter) and the baby did not
have a very big mouth for a 5 1/2 pounder so it looked more like we were
folding (actually shoving) the NIPPLE into her mouth- I was not happy with this
as I know there needs to be compression BEHIND the nipple to extract milk- well
mom said that it felt much better (not painful like before) and we heard
swallowing! (she has 3 singletons already who she breastfed for close to a year
each) unfortunately, this particular twin had already been exposed to artificial
nipples-

Is this oroboobular disproportion? what can be done for it?

There's more to this story- I was there when the service pediatrician who she
was using came to give the discharge instructions- "feed every 2-4 hrs, give
formula if you feel you don't have enough, feed about 15- 20 min per side"

after he left, I told her that I have been getting some extra training in
breastfeeding and that it wasn't the best advice and here's why...

sadly, he also stated that the girl twin had to stay over night even though mom
and boy twin had to be released- because she wasn't maintaing her temperature
in the nursery even with extra blankets and the warmer! (that gets me mad! I
told mom about skin to skin being better- but didn't argue with the other MD's
decision) If she had only 1 she could at least sleep on a couch and breastfeed
the one who was still in the hospital- now she has to be home with the other!
But at least my being there helped her negotiate that she could stay until 11
pm with both babies!

I conferenced on BFmed how I should approach (reproach) this physician - since I
am only 4 yrs out of residency and only 4 months on temporary privileges at this
hospital- with HIM being one of my "supervisors"!
Anyway, I did go up to him later on and said that I would like to talk to him
about the breastfeeding advice he gave my friend- I said it like I was asking
him to teach me- "what were the sources for the evidence behind these
practices?" He said "years of experience" I said that I have been doing a lot
of extra CME's on breastfeeding and have been comming across quite a different
approach... and that sadly ~80% of moms wean by 2 wks- he was very aggreable
and in the end we had a pleasant conversation- he works for the "clinic" which
in this area is mainly hispanic- they have a pretty good initiation rate and
continue about 2-4 months (probably NOT because of his advice however) I also
get some of these mothers as transfers and they really wanted to breastfeed for
longer but the baby just suddenly refused the breast- or they for some reason
suddenly had no more milk! Anyway, he made a comment that he only gives ranges
(which in his defense was true) but that "many mothers/ parents need to 'limit'
the intervals and duration of breastfeeding to 'make it more bearable' and if he
doesn't give this advice early on then he gets a lot of phone calls of
complaints" one of the reasons I really felt compelled to talk to him was that
he does a lot of the teaching to the residents- I actually got to give the
residents a 1 hour lecture- but he works with them every day in the clinic-
anyway- I'm rambling and if I don't send this now it'll get lost-

Amy M. Kotler, MD FAAP
Dover Pediatrics
LLLI Breastfeeding Resource Center
Doctors Park 369 W. Blackwell St
Dover NJ 07801
ph 973 328 8300
fx 973 328 8315

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