Sonya,
 
Thank you for your excellent post.  I wanted to address a couple of them as I am currently working on a talk about this very topic.  I think the literature, particularly the medical literature does a lot to confuse this topic by using the term "neontate" to describe all babies from day of birth to 28 days old.  The two are so very different as to make the term meaningless.  But when you limit your focus to the baby who is less than 24 hours old, you can find some consistent findings.  The ABM has two great protocols that address this.  The first is Protocol #1 on hypoglycemia and the second is Protocol # 16 on the hypotonic infant, another great resource is the APA's protocol for the use of human milk, last published in 2012.  They give pretty clear guidance on this issue.  
 
First, that the first 24 hours is a time of profound sleep for many babies and that even prolonged periods of sleep >8 hours is within normal limits.  I think that we all agree that skin to skin contact will help the health care provider distinguish between a sleepy baby and a sick baby, as will the rest of our assessment (good tone, good temperature, good color, etc...).  I always tell my moms "A hungry baby won't sleep, and a sleepy baby won't eat"  It is just the way of the world.  But I am confident that a healthy sleepy baby will experience gluconeogenesis and make his own fuel to keep the brain happy and healthy.  This is why they lose weight, because they packed a lunch for the trip and lose weight as they eat that lunch.  
 
Second, according to the Compendium for lactation consultants the new mother makes only 37 mL of colostrum on day one and colostrum is only 19.7 kcal/ounce, which means that a baby who takes all mom has to offer is getting less than 30 kcal in the first 24 hours.  Also, Hassitou and Geddes and Hartmann published a great state of the science paper in JHL in 2015 that pointed out that colostrum has 13 Trillion cells per mL and that those cells serve to provide the infant with his mother's immune system, not calories.  So you could say that I don't adhere to the notion that it is important for a newborn to intake calories.  In my book colostrum is an immune system transfer, designed to provide the baby with the stuff he needs to protect him from his mother's environment.  I want him to take it, but I am in no hurry for him to take it.
 
Third, stomach size.  I have seen several estimates of stomach size but I think the most reliable is a systematic review done my Nils Bergman for Acta Paediatrica in 2015.  He reviews six studies (using ultrasound on the term unborn baby, gastric balloons on term newborns before the first feeding, and actual measurements on stillborns) he reports that the stomach size is between 12mL-30mL but that 30 mL of distention caused distress.  In the end he cites 20 mL as the average stomach size for a 3500 g newborn prior to the first first.  Incidentally, he goes on to state that if we expect them to eat 150-180 mL/kg then they have to eat every hour to keep up with that stomach size.  
 
Finally, the ABM in protocol #1 recommends 1-3 mL of supplement / kg (max 5mL/kg) to treat documented hypoglycemic newborns.  That is a maximum of 9-15 mL in the average 3kg newborn.  
 
 
Thank you for this discussion, it is fascinating to me.  
 
Tom Johnston
CNM, IBCLC
Methodist University
 
 

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Big questions and no real answers. It's frustrating, because if we don't really know, we can't make informed choices and we can't help parents make informed choices.
A few thoughts on the topics. The first thought is that every baby and every dyad is different, and therefore requires critical thinking skills in their HCP's to ensure best course of action.
A baby with hypoglycaemia risks will need more attention to feeding, a baby with higher jaundice risks will need more attention, a term baby who is happy, healthy, and well, will not need extra focus on feeding. We need to assess every dyad individually and plan best course of treatment with informed consent on an individual basis.
Is there harm in teaching early hand expression and spoon/cup feeding to all mothers? I don't know, but I do know that every time the medical community feels there is no harm being done in a course of action, turns out that better knowledge makes us cringe. Perhaps asking mothers to do all this extra work creates a situation where she is overwhelmed, goes home and starts formula feeding, because it is easier? Perhaps a baby who has spoon/cup fed for a bit in the first few days will have a harder time latching? Perhaps a mother will love the idea of seeing what her baby is taking and then offer a cup/spoon feed in place of a breastfeed, even in a baby who is latching and nursing well? We have a lot of unanswered questions on this approach to care, and I think we also don't have all the questions figured out yet, let alone the answers.
Another thought that comes to mind is that the babies born today are very different from the babies born 200 years ago. At least where I work they are. We have an almost 99% epidural rate, typically the only mothers who don't get an epidural are the ones that birth in the parking lot... So the babies we see are a little drugged up, they are sleepier, and have more disorganized sucks. I find that with good support, they tend to start figuring things out after 24 hours, but often are on their way out the door after a 24 hour stay. Babies born to mothers who birth naturally (and by this I mean no epidural, no surgery, no forceps, no vacuum, birthed the way nature intended us to birth) behave very differently than babies born to mothers who have had interventions. Are those babies more typical of what human babies usually do after birth? 
Talking about birth, a mother who can move through labour - are there different pressures at play on baby and baby's head so that breastfeeding is easier than a baby whose mother has been static through the labour? Remember when we used to think bed rest was the cure for disc lesions, and now we know it's actually movement? The human body was designed to be in motion, what happens to it when it is static?
Skin to skin may not cure all things, but boy, it certainly does cure a lot of things. It's so simple, and so important, and babies who are skin to skin tend to give feeding cues sooner and more frequently than babies who are not skin to skin. They also transition to life outside of utero better. I think this is pretty well known, I also think we don't advocate for it enough. I know I talk about skin to skin with my postpartum mothers and sure as nuts, visitors come and pass the baby becomes the game of the day >.< 
Babies who aren't latching seem to do better after a feed of colostrum, it is as if a light bulb goes off, and they suddenly realize that they need to do some work here, so often just one session of hand expression is enough on day of birth to get on the right path. 
So here is what I counsel mothers to do. In the case of a healthy term baby with no concerns at all: feed baby on demand, at least 8 times per day (minimum is 8, maximum is 24 ;) ), according to baby and not the clock, offer both sides, but baby can refuse the second side. Do lots of skin to skin and watch the baby. Baby communicates with non verbal behaviour and crying, so watch your baby and learn their language. If your baby has slept 7 hours, and you cannot feed this baby, even when you try and wake baby up, your baby needs medical attention, head to the nearest ED or Dr. 
(Note: yes, 7 hours is very long, it hardly ever happens, and when it does happen and baby is still not eating, there is often a very real medical reason for it. It typically only happens if there is a medical reason for it. It also means those mothers seek help sooner than a mother who has woken a baby up, baby had a poor feed, but did latch and suck for 3 minutes, and mom stays home thinking all is well, when it is not)
For every other scenario, I individualize my plan according to how baby and mom present. I like mom to know how to hand express, I don't necessarily teach them to do this right away. If her baby is latching and nursing frequently, all is good, and hand expression gets taught on discharge. If however baby is not feeding well, hand expression gets taught earlier on. While it would be nice to have a standard formula to use for every dyad, in my opinion, it just isn't possible. People are too varied to be treated all the same. 
I agree with Tricia who has noticed that colostrum amounts decrease with hand expression on day 2. I blame the oxytocin surge after birth and the stress of a non latching baby on day 2 for this. However, just because I can't express as much on day 2, that doesn't mean baby can't nurse well and obtain larger amounts. The truth is, that again, we just don't know enough, and we can't assume. 
I also want to challenge the idea of "First, do no harm". I think that every time a HCP does something or suggests a course of action, there will be fall out. The trick is to chose the course of action that has the best outcome with the least fall out. I think we should all be taught to "First, do the least amount of harm possible". Yes we save lives every day, yes fewer mothers and babies are dying in 2017 than died in 1017, but that doesn't mean we don't mess up something else, cause some other health issue, or cause psychological harm as we work. I would place a bet on the fact that in 20/30/40 years time we will look back on what we do today and cringe, because we will know better then. Why will we know better? Because we keep asking the questions that lead to more knowledge.
So fellow Lactnetters, keep asking questions, keep challenging the system, and keep "talking" to the rest of us, Lactnet is often a highlight in the day for me, even if it is just because it made me think about something in a different way.
 
 
Tom Johnston CNM, IBCLC
Assistant Professor of Nursing
Methodist University
910-480-8423

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