I'm a new IBCLC from Canada. I started to work in a hospital who work slowly toward BHFI designation. The direction is on our side to make the necessary changes but it isn't that easy to change the RNs and pediatricians mind.

The staff receive the training but there is a serious problem managing mother with perception of "only a few drops".
I believe that we have a over the norm cases of "insuffisant milk production" and this result in unnecessary ABM supplementation.

I looked in many books and articles on the web but there is very little about managing those first 3-5 days.
Of course there is a lot of info about sign of milk transfer, infant elimination, how to stimulate milk production but i'm looking for management tool when signs of milk transfer are not there and there is no or just a few drops of colostrum and how to deal when baby is satisfied or not at breast, when to start checking glycemia. I tend to follow Dr Jack Newman's Game Plan but our staff is just scared with these case and will supplement if baby don't feed "enough" every 3-4 hours max.

I come up with plans including skin to skin, frequent BF and/or hand expression and I encourage supplement method that do not put a number on amount of colostrum (drops at breast, spoon), but chances are that there may be ABM-lactation aid-nipple shield combo by the next day. 

I do understand that some infant will need a supplement and that every case is different, but we need some serious guidelines backed with trusted documentation to manage those cases of " only a few drops". (1)

I will present to the BF comity documents that I found about medical reason to supplement, documents to support BF on demand 8 or more time per 24h.

I've work on a table to remind the staff about the different supplement method and their indication, but I wonder if there is some sort of supplement method decision tree available. (2)

I'm also interested to find documentation to support BF management when baby isn't latching at hospital discharge. Unfortunately there seems to be only 4 acceptable methods of feeding at discharge: At breast, Lactation aid at breast, Nipple shield or bottle. I am especially concerned about the last 2 since RNs won't let babies who are cup or finger feeding go home. Instead of trusting the public health RN and community clinics to manage to case, they will offer a nipple shield or a bottle. I would like to find document that support the use of cup or finger feeding beyond 24-48H. (3)

On a positive note, I do really like my job and the staff does a very good job in many situations and did a lot of changes in the last few years, but we still need to work on those topics.

Can you help me find document and evidence about toipic (1), (2) or (3).

Sorry for the mistakes as English isn't my first language.

Emilie Trepanier, RN, IBCLC
Ottawa, Canada

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