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From:
Rachel Myr <[log in to unmask]>
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Lactation Information and Discussion <[log in to unmask]>
Date:
Mon, 18 Jun 2007 00:08:46 +0200
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This is likely more than you ever wanted about creamatocrits and my views on
them.

Heather Welford Neil asks about situations in which a creamatocrit might be
of use as part of a clinical assessment of breastfeeding, and what baseline
one would use for comparison.  Maggie Payne provided two examples of using
creamatocrits, though in only one was the information relayed to a health
care professional.  The examples were illustrative for two reasons: they
were both done in uncommon situations, cases many of us would never see in
an entire career of working with breastfeeding, and they were done to
convince skeptics that breastmilk actually was an appropriate food in the
situation.  In both cases it seems the baseline reference was breastmilk
substitutes.  In nearly all situations we see, including those where failure
to thrive is involved, knowing the fat proportion of a sample of the
mother's milk does not add to our ability to solve the problem.

I don't have the possibility of doing creamatocrits and in all the years I
have worked I have never missed it.  I work with mostly term newborns up to
a few weeks of age, but am seeing more and more older breastfed babies who
are having feeding difficulties of one kind or another, many involving
growth patterns that deviate from what is expected.  I can't think of a case
in which having a creamatocrit done might have changed our handling of the
situation.  This is not least due to the fact that we really don't know what
creamatocrit values are normal, nor what influences the value obtained from
a given sample of milk.  

There may have been babies who weren't growing because they were not getting
enough fat.  The basic tools I use in helping breastfeeding mothers include
observing what a baby does at the breast, listening to what the mother tells
me, particulary about what she thinks the problem might be, and taking a
careful history of the whole course of breastfeeding with the child in
question.  Sometimes I find it useful to do pre- and post-feed weight
checks, but not often.  I am more cognizant the longer I practice, of subtle
signs that a child really isn't nursing effectively.  A lot of that
awareness has come from reading Lactnet.  I don't have much direct contact
with other IBCLCs or even other clinicians working with breastfeeding.  In
my own workplace I am the one the others turn to when they are stuck, at
least at the moment.  If I were not aware of clinical signs of ineffective
feeding, I don't think it would help that I knew the creamatocrit value.
One pitfall of relying on a test that spits out a number is that we may
start thinking that the things you can measure with numbers are more
important than the things you have to observer more globally and more
intuitively.  In breastfeeding as in all else, the things you can measure
and quantify simply are a tiny part of the story and in many cases they are
a red herring, making you miss the real story altogether.  I know that I and
my colleagues with more advanced skills in breastfeeding guidance and
support can write a couple of pages of text after observing a feed, to
describe everything we saw, while many of the staff on the post partum ward
would be hard put to write more than a sentence or two.  

With any diagnostic test, no exceptions, it's a good idea to ask yourself
before deciding to do the test, how will the result influence the way I
handle this case?  If you can't think of a single one, or, and some might
find this provocative, if the result might make you change from a treatment
you have every reason to believe in and want to use, to something you really
don't want to use, then you ought to ask yourself why you are doing the test
at all.  At best you are wasting your time and the time of whoever will
analyze the test.  At worst you could be groundlessly sowing doubt about the
normalcy of something that is exactly as it should be.  In Maggie's case,
there was a reason for the test, though it was less a clinical reason than a
judicial one.  Fortunately the test supported doing what Maggie and her
child's health care provider were doing already, in line with their
convictions and their reading of the situation.  But as Heather points out,
it could just as easily have backfired, if the creamatocrit had been lower.

Concerning the mother expecting her 10th child, the case in which
creamatocrits came up, starting this thread, I agree with previous posters,
especially those who describe problems when a baby doesn't manage to
compress anything but nipple shaft because it is lengthened after feeding
numerous older sibs.  I have seen this clearly only once myself, in a mother
whose love for breastfeeding motivated her to help her youngest baby become
a more effective feeder through careful attention to latch.  When we
discovered the problem she was on the verge of giving up, and he was only a
couple of months old.  He learned over several weeks what he really needed
to do to maintain and boost his mother's supply and went on to breastfeed as
long as his older sisters had.  Kathleen Bruce was visiting me when I worked
with this mother, and Cathy Genna helped me via e-mail with her, and I
learned more from their help on that one case than from the last five
conferences I'd attended put together.

Rachel Myr
Who will never forget that mother or her older daughter who wailed in
horror, when her mother tearfully said in despair that she didn't know if
she could manage to continue breastfeeding the youngest, 'Oh, but Mama!!
You MUST breastfeed him!'   She could not bear the thought of her brother
missing out on something so essential :-)

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