Sally,
There is no easy answer to the question of when to bring out the formula.
I'm sure you know that after mother's own expressed milk, that banked donor
milk is the next choice if supplements/complemets are needed. Just wanted to
say that for the record. Often one does not have access to this though. As
you said, mothers should begin expressing right away, and do so very
frequently. Often the pump does not yield much and hand expression may yield
more.
I evaluate every case individually. There are many many variables which need
to be taken into account. For example, the weight and gestational age, risk
for hyperbilirubinemia (bruising, high hematocrit, positive Coombs),
mother's history and anatomy, even availability of followup care.
Let me give an example of a client I saw this week. C/S birth (which at our
facility means delayed initiation and some glucose water). Term baby weighed
6 lbs 6 oz and had positive Coombs. The mother had a history of gastric
bypass surgery for morbid obesity and had lost 150 lbs. Had not bf the
previous baby and did not think she experienced any lactogenesis II with
that birth, but was not sure due to her obesity at that time. Her breasts
were EXTREMELY FLACCID, the most pronounced I have ever palpated. Of course
loose skin and pendulous breasts ares expected after that kind of weight
loss, but really no glandular tissue was felt. Barely a glisten of colostrum
expressed. Also dimpled nipples. Baby latched well, rare swallows. I was
immediately worried and red-flagged this one to coworker who worked with her
next day. The next day baby down to 6 lbs. A little more colostrum, but not
even drops yet. Mother exclusively bf. The baby not fussy seems satisfied.
The 3rd day (day of discharge) baby down to 5 lbs 13 oz (9 percent loss) and
I am back on duty. Encouraging with some glandular tissue felt mostly outer
quadrants and drops of colostrum. Pediatrician not worried will see mom in 1
week. I recommended bf with compression, formula supps (we used lactation
aid) expressing post feed, follow up phone call the next day, and return
for wt check and milk supply check 2nd day. This mom may go home and her
milk may increase quite well. The baby may have lost a bit more weight and
then turned it around. I could have made the wrong decision. It is a tough
call, I don't like to use formula.
Dr. Newman has a decision-tree for supplementing. It should be in our
archives as we have discussed many times. However, in my experience, very
few pediatricians are as familiar with and supportive of breastfeeding and
breastfeeding 'management' as Jack. In reality, most LCs would not be able
to use this decision-tree because the attending pediatrician or nursing
staff or even the mom would use supplementation way before what his plan
would have recommended.
Laurie Wheeler, IBCLC, MN, RN
New Orleans Louisiana, s.e. USA
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