Dear Heather and others:

Heather - I have already explained numerous times why ALL measures of intake are 
subject to problems of dependability.  When you say "that's just poor practice" regarding 
examples of people who used a clinical indicator such as observing swallowed I would 
heartily disagree.  Sometimes you see a baby at one moment in time, especially in the 
early days and they ARE doing fine at that moment.  You may see tham a week later and 
that may change entirely.  Ditto if you used a scale.  Many have heartily argued the 
opposite - that the scale is not good because you only get one feeding, but you cannot 
have it both ways.  If one feeding is insufficient to judge a situation, it is insufficient to 
judge a situation no matter what indicator you use.  The POINT is that you really need to 
do follow up and watch mother and baby over time to get a full picture.  

Also, as you mentioned the second study used syringes not bottles.  As has already been 
posted, these are not accurate or precise either.  A 10% range in the measurement of the 
syringes as was previously posted can be quite large depending upon the volume.  I just 
calculated the range of the scale at 0.03%.  That is a 100 fold difference in the precision.  
Calibration is the way one judges the precision and accurancy of a tool and you have 
evidence sent in to Lacnet to show that the precision and accuracy of the scale trumps the 
precision and accuracy of syringes.

I would be happy to take you through the science and epidemiology of this.  The studies 
were poorly designed and do not follow good epidemiologic procedure for comparing 
indicators.  Unfortunately some doctors do not get enough training in epidemiological 
techniques.  One may be quite skilled in neonatology and not have a clue how  to design 
a good study.  These studies would never have made through some of the journals that I 
used to submit papers to, nor would they have even been deemed worthy of our time 
when we were graduate students and THE main thing we were judged upon was how we 
analyzed a study in front of our peers.  The two studies would not be even considered 
worthy of dissecting.  If you have a copy (I'm not spending the money to download these 
articles) I would be happy to privately analyze these for your.

The ISSUE that is the most important is when and how we use our tools.  There are 
plenty of examples of exceedingly poor use of tools.  When one sets up a system where 
the tool becomes primary and clinical acument and individual guidance are discarded, be 
it a nipple shield, an SNS, a scale or even our hands - that tool is more of a detriment.  
When it is used judiciously and in context it can be a benefit.  

So, instead of harping on the accuracy and precision which is irrelevant to the discussion, 
the issue is the utility of our observations of intake.  We need to know their functionality 
to tell us something useful.  What would we change with the piece of information we get 
from watching swallows or using a scale? 

Again, I would argue that THE MOST important use of the scale is to prevent unecessary 
bottle feeding by doctors that do not understand that bottle feeding and pumping tells us 
nothing about how a baby feeds at the breast.

Best, Susan

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