Hello, I am an RN from a rural area who does postpartum visits. I've read and learned from you all for awhile. Have always been a breastfeeding supporter and bf my 3 children.
Since taking this job (we just moved here a little over a year ago) I've come to realize how much at a disadvantage rural women are as far as breastfeeding support goes-no
easy access to Lactation Consultants, not even a LLL group within 2 hours of here. So....I've bought books and am learning as I go in my pursuit to help these women. I also
plan to take a Lactation Consultant Training Course this year and IF I can get enough counseling hours(that will be my biggest challenge in this rural setting) , take the exam
in a couple years. I have organized a Breastfeeding Support Coalition and hope to change the environment. I am pleased that I have had great support so far-every one
says "boy is that needed" but no one has done anything about it until now. And you know where I got the idea for the Coalition.......from Lactnet! Thanks to all of you who
have "been there, done that".
Now for a clinical question. Saw a Mother of a healthy fullterm newborn when she came home from the hospital-postpartum day 3. Baby's weight at birth 8#5oz. Day 3-
7#10oz. Breastfeeding was "going fine" according to the mother-Milk was coming in and since the baby looked good and was having appropriate numbers of voids and
BM's I left it at that-I didn't ask to observe a feeding. That was probably mistake #1 I now know. Baby was a little jaundice-Bili level was 13.0 and was going to have it
rechecked the next day.
Anyway, on day 10 the mother called me back to say she thought her milk was going away. I visited on Day 11- Baby's weight was 7#lloz (still about 7.5% below
birthweight). Mom told me the Bilirubin never got any higher than 13.6 and the jaundice was nearly gone. She had seen the Dr on Day 7 and the weight had been 7#13oz.
Difference in scales vs baby losing weight? I observed a feed and heard very little swallowing and the latch looked like she was sucking on her bottom lip and wasn't
getting her tongue forward over the gum line. She was having 6+voids and 4+ yellow/dk green BM's that are very small quantity (less than a tsp). Baby appeared well
hydrated and seemed content with sucking but not getting much. I instructed Mom on getting her supply up with pumping, on getting a better latch and some exercises to get
her to get that tongue out more (from BAB) and breast compression to encourage more milk flow. There was no tongue-tie and palate felt normal to me.
After explaining to the Dr what I thought (baby inefficient at removing milk from the breast and Mother's milk supply down)
he said to have Mom begin supplementing with preferably pumped breastmilk but if there wasn't enough to use formula. I explained to Mom her options for
supplementation (SNS-I highly promoted this, finger feed, cup or bottle). Mom opted to go with bottle.
In one of my references it says a baby needs about 2.5 oz/#/24hrs to gain weight. Should I have instructed Mom to try to feed baby that much formula or just let
baby take what she wants and stop there. What I told Mom was to breastfeed every 2 hours and then follow up with bottle, as much as baby would take. I also told her to
pump after each feeding or every 3 hours. Of course, adding formula to the picture, the baby started to eat less often but still about every 4 hours.
Went back in 2 days and baby gained 3 oz. I instructed her to keep up with the plan and I would call on Monday (4 days later). On Monday I called and Mom said she felt
her milk supply was up and that baby was doing better at getting milk out so she was supplementing less often-"just when baby acted like she hadn't had enough to
eat after a breastfeed". After that conversation I didn't go back until Wed (mistake number 2). Unfortunately, her weight was only up 2 oz, to 8#, in the 6 days since I had been
there. Baby is now 17 days old and 5 oz below birth weight. I again suggested she use an SNS but Mom still didn't want to. Baby still having 6+ voids but only 1-2 "huge"
yellow BM's previous 24 hours. When I observed her feed the latch did look some better and I could hear more swallowing than before but still not as much as desired. I
instructed Mom to go back to supplementing after all feeds and I would call an IBCLC and LLLL who lives 2 hours away to consult. (My confidence was waning). When she
and I visited, 2 days later, the Baby was 21 days old-weight was 8#2oz. She'd gained 2 oz in 2 days. Baby was doing a much better job at removing milk-much more frequent
audible swallow. That was encouraging and we told Mom to just keep breastfeeding as often as possible (just go to bed and stay there as much as possible), supplement
after feedings when Mother feels baby is still hungry and I would be back on day 24. On Day 24 wt was finally 1 oz above birth weight. Baby had gained 4 oz in 3 days with
supplementation only 2 times. Further followup will be at the Dr's office.
Any suggestions on what I should have done differently? Should I have had Mom supplement more than she did and get that weight gain going alittle faster than it did?
Instead of allowing her to decrease supplementing to "when the baby still acted hungry" should I have had her supplement after every feeding as we started out doing
until baby was up to birth weight.
Throughout, baby was alert with good color, muscle tone, lusty cry, elastic skin turgor, etc that told me baby was not in trouble. Dr had wanted to see the baby during
this time but mom waited to make an appt and when she finally did the Dr was off for a few days. They will be going in in a few days. Dr had said, though, when
he saw baby at 1 week of age she looked good. Sorry this got so long
Sally Myer RN, BSN, ICCE
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