<< For example, a baby comes in with a significant
weight loss: first we have the mom pump, but rule # 1 is "Feed the
baby" and this baby desparately needs to be fed, so if mom is not
able to pump a significant quantity at that moment, we will use AIM
via whatever method seems to be called for-usually supplementing at
breast if baby will latch. >>
I want to add to the supplementing issue with this story: New mom, infant born 11/28 normal vaginal delivery, no meds for mom. Good BF in the hospital evaluated by the LC. Seen by me on 11/30 with a 10% wt loss, jaundice, good suck. Mom's milk coming in. Told to BF every 2 hours at least. Infant was sleepy and not waking to feed. Seen on 12/1 with a 12% wt loss, sleepy, increased jaundice even with a biliblanket. No stools for 48 hours and only 2 wet diapers in 24 hours!
Here's the problem: This infant is now significantly dehydrated. Ideally, you would have the infant latch first BUT: What if the infant is too sleepy/too dehydrated to latch? What if the at-the-breast feeding is taking 45 minutes out of the 2 hour interval and the mother is exhausted?
My first point is that what is possible in the HCP's or lactation consultant's office may not always be possible for the mother in the middle of the night. When I called this mother at 10pm, she asked me desperately if she could supplement the infant first rather than put him to breast because he was at the breast latching ineffectively for 45 minutes and she was not getting any rest at all. At this point, this infant was very close to hospitalization for dehydration and jaundice. What do you say to this mother?
The following morning after 1-2oz of EBM (or whatever artificial stuff I had around) every 2 hours by fingerfeeding with a syringe PLUS trying to BF, the infant was up to a mere 10% wt loss again. Off they went to the LC's office for assessment- good latch, sleepy baby, mom doing all the right things, milk in. After supplementing wiht BF for about 12 more hours, the infant WOKE UP and started to respond to feeding cues. At this time, the mother started offering the breast to all cues, supplementing only if the infant seemed still hungry, and 24 hours later, is breastfeeding exclusively with the infant up to 8% wt loss, alert, normal cues and 7 days old!
In this case, this infant was too dehydrated/jaundiced to breastfeed well and the normal cues were lost. I realize that I am going out on a limb but in this case requiring this mom to BF first was actually causing her to fall apart at night with no support and the infant was too dehydrated to do so. 24 hours of supplementing with BF afterward resulted in a turnaround which was dramatic. I realized as I was doing this that I might well have to cope with nipple confusion but to me this is one of those cases where the infant needs the EAT and mom's self-confidence needs to be preserved first for breastfeeding to be successful. In this case, supplementing first worked well in a LIMITED situation with about 15 phone calls between me and the mother in a 72 hour period. Perhaps the most significant thing is that neither I nor the mom ever lost exclusive breastfeeding as the ultimate goal- thus we minimized the "negative" and she never felt that she "couldn't" breastfeed.
My second point is that there comes a point where the situation shifts from the positive as breastfeeding and the negative as bottlefeeding to the positive being a hydrated infant and the negative being a hypernatremic dehydrated infant who is at risk of seizing or worse. I realize that usually infants are taken off the breast for no good reason but there are good reasons got supplementing too and that is what we are talking about here since all of us occasionally are going to see these infants.
IN this case, it worked and was worth the time and effort. I am fortunate to be able to be able to do this- many physicians are not so lucky.
Kate
Kate McIntosh MD FAAP
Benzonia, MI
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