Thanks to everyone who has been sharing in this discussion.  It is very
helpful to me!

I'm wondering if part of the problem with the question of when to intervene
for ineffective breastfeeding is that we may not always know *why* babies are
not feeding well.  Thanks for the reference Barb from JHL 11:2 p 127.  This
reference lists the need to assess for factors that may inhibit the baby's
willingness/ability to feed effectively.

If we see a healthy full term infant of a mother who has no lactation related
risk factors and whose mother did not receive medication in labor, most would
agree that given mother and baby contact and breastfeeding assistance and
support that baby will not need supplementation.  When I do have the *rare*
chance to assist with such a mom and baby, I find that the consult takes
little time and that the baby is indeed waking appropriately to feed and
doing well--- even if I happened to see her due to difficulty with an
inverted nipple.

So much so that wouldn't we be a bit worried if this baby had not had an
effective breastfeeding by 12 hours postpartum?  Do we wait to intervene
until the baby's problem is diagnosed?  Or do we begin nutrition support of
expressed breastmilk (formula if none available) while the medical staff
keeps a close watch over baby?  At minimum, when should we be concerned about
beginning support of mother's milk supply?  12<24 hours postpartum seems to
be the time stated in the LC literature for the maximum time to wait for
intervention.

In the The Breastfeeding Answer Book, revised edition, page 283ff,,, there is
a list of the risk factors in mother and/or baby that can predispose a baby
to hypoglycemia.  The babies that need regular frequent feeding from birth.
In the hospital setting where I work we see many many of these babies.  My
need for references has been that the newer medical staff has expected the
LCs to intervene at the same low level for these high risk situations as in
the no evidence of risk factors situation.

How many attempted feedings should go by before intervention begins in these
high risk cases?  Or, should we begin intervention as soon as we determine
baby's feeding pattern is ineffective despite good breastfeeding assistance?

For the pre-term infant, should we be doing more pre and post test-weighs as
a way to document need for intervention when supplemental feedings of
expressed breastmilk (augmented with formula as needed) are determined
medically necessary?  Would this make our assessments more accurate and less
likely to just follow a protocol?  At our hospital we do the test-weighs in
the NICU but in the well post partum unit we only do them if the LC asks for
it.

I would like to begin intervention sooner (yes, even before 12 hours) for
these high risk nursing couples so that mother's milk production can be
optimized and thus reduce the amount of formula needed for these babies.  For
these at risk babies and those others who for some unknown reason are not
eating, early frequent feeding of expressed milk even in small amounts can
hopefully prevent or minimize the need for exposure to formula proteins.

I believe it will also optimize mother's milk production so that the overall
time needed for intervention is shorter.  I believe a baby and mom who have
had early such intervention in the hospital are more likely to be discharged
breastfeeding effectively than the baby whose problems have now compounded to
include >8% weight loss and jaundice which is causing more lethargy and
possible need for intervention--- not to mention the risk of delayed or
compromised onset of milk and more engorgement with its subsequent problems.

And if intervention must continue post-discharge, early intervention allows
mother to practice the feeding plan and she goes home confident that she can
manage.  The baby doctors are happy because the baby's are getting fed well
and are ready to listen when we need their help (i.e. with a short frenulum
situation)

We offer all these moms follow-up visits within a few days so that
intervention can be discontinued as soon as possible.  I find these moms are
coping so much better than the moms I've worked with in private practice
before I was in the hospital.  Why?  They have not had the emotional stress
of feeling guilty because they didn't feed their baby enough.  They have had
more sleep and less frustration with trying to breastfeed a baby that needs
more support than just positioning and latch on help.  For the few moms that
have insufficient milk supply, I have found that they are more willing and
able to persist in breastfeeding to provide the milk they have since they
were supported from the very beginning.  We didn't let their baby get in
trouble and have gained more trust. This emotional stress vs. support factor
is one I'd also like to see investigated further.

Actually, having to think through this to advocate for our current practice
in our LC program has been good for me.  Discussions like this and the
Journal Club on Lactnet will help us all to continue to keep statistics,
research, and keep up with the literature so that our profession can be
respected and moms and babies can succeed in providing their milk for their
babies and move from intervention to exclusive direct breastfeeding quicker
and with confidence.

Natalie Shenk, BS, IBCLC
Findlay Ohio USA

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