I realize the need for such a protocol also, although I'm able to touch
most struggling dyads at our 10 physician office. My pediatrician partners
have a good understanding of breastfeeding, but as you've said, their time
limitations make it hard for them to be as complete as they'd like to be.
I've been working on such a supplementing protocol for general use, but
it's not yet polished. I was a practicing a pediatrician for many years, so
I realize the difference between what they are able to do in their general
practice, vs what I'm now able to do, specializing in lactation as an IBCLC
for the past 13 years.

A basic principle at our office is this: If baby gets "supplied" in any way
other than AT breast, then Mom must be "demanded of" by a pump, to keep
supply and demand in check. If this "triple feeding" regimen doesn't occur,
physiology dictates that supply may not be there when the baby is ready to
exclusively nurse, given that Demand Drives Supply. As we all know, some
breasts need more demanding of than others to get things going. If mom
"triple feeds," it's understood she can't pump EVERY time, but try for most
times. She can then offer the expressed breastmilk (unless formula is used
due to jaundice - which should rarely be necessary).

As time goes on, if baby is gaining around 1oz/day, you can calculate Mom's
supply (within a range). A typical 10ish day old term baby needs about
20-24oz/day of milk to gain ~1oz/day. I usually work with 24oz/day, as it
makes for easy math. SO, if baby has gained ~1oz/day, she likely consumed
about 24oz/day of milk. If 8oz of the milk was formula, then 16oz of the
milk must've been breastmilk (Mom's supply is 2/3 of baby's needs).

Hopefully as issues of low supply or baby's ability to remove milk
improves, baby will get more and more milk directly from breast, such that
less and less supplement will be needed, and thus less pumping will be
needed. SO, as this happens and baby still gains ~1oz/day, ideally none of
the presumed 24oz/day will have been formula.

You can also figure out baby's milk removal ability. If gaining ~1oz/day
with NO formula, then Mom's supply must be ~24oz/day. If baby has been
hungry after nursing and takes a total of 8oz/day of expressed breastmilk
after nursing, then baby has removed 16oz/day directly from breast.

Understand that some babies require less than 24oz/day for good gain, and
some need around ~32oz/day, or more. So the math above simply gives a
general idea of where you're at. It's also understood that the pump may not
remove milk completely and thus supply might be underestimated.

In your office, perhaps if the check in nurse can gather the "data" ahead
of time, and the doctor can quickly figure this out. Or get the baby to YOU
sooner than later to get the details.

If triple feeding is not done, a common hiccup is when the supplementation
is removed but the Mom's supply simply isn't adequate, perhaps due to
insufficient Demand Driving the Supply, or some other risk factor for low
milk supply (which was hopefully inquired about in the beginning).

Sorry this got so long! Hope it helps a bit!



On Wed, May 9, 2018 at 11:48 AM, Susan Lawrence <[log in to unmask]>
wrote:

> I work in an outpatient pediatric clinic. We are working to get our
> exclusive bf rates up after hospital discharge.
> One big issue is that frequently in the hospital or first week or two,
> babies are started on formula supplementation for a number of reasons, from
> jaundice, wt loss, etc.
> Most of our pediatricians look at the baby's weight as gaining enough or
> not, and don't actively "manage" or advise parents on if the baby can now
> decrease supplementation, even when the baby is gaining at excessive weight
> velocity and/or conditions such as jaundice have resolved.
>
> So we are trying to come up with some sort of guidelines on how a provider
> can recommend decreasing "x" amount of  supplementation on "y" amount of wt
> gain, especially in the first month.
>
> While I do this supplementation management with each baby I see, there are
> many more infants in the clinic than I have time to see. (yes, more LC
> staffing would be better, but this is where we're at...)   My
> recommendations on how much and how often to give in addition to
> breastfeeding are based not only on wt gain but also observing feed
> efficacy, etc.  So I'm finding it challenging to tease out how to make
> these recommendations for MDs who only have 15 minute appointments and no
> training in bf assessment. Academy of BF Medicine's supplementation
> protocol is good, but doesn't address decreasing of supplemental feeds.
>
> Anyone already have this sort of guideline or protocol? Or have
> suggestions?
>
> Thanks for the wise hive mind ideas-
> Susan Lawrence, RN, IBCLC
>
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-- 
Kay Anderson MD, IBCLC
The Lincoln Pediatric Group
[log in to unmask]
LincolnPedsGroup.com

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