To the LLL Leader who asked about the premature baby whose mom is being 
discouraged from breastfeeding:

I am also an LLL Leader, and an IBCLC for the WIC program. I work with a 
lot of preterm babies once they come home. Generally speaking, I find 
that the young ones do not usually remove enough milk to totally 
breastfeed. Sometimes they look textbook perfect with good sucking but 
rarely do they remove milk well enough to totally BF. Often they suck 
for a few minutes and go to sleep on the breast. I see a lot of what I 
call "self limiting" -- the baby takes 1/2 ounce to 1 ounce only and 
quits, when caloric needs appear to be around 1.5 ounces given 8 times a 
day. This is a baby that will do some work but tires easily and falls 
asleep -- on breast and on the bottle. I do test weights to assess what 
baby can remove and in how short of a time. I never let these babies 
nurse for 45 minutes because I find they remove all they are going to in 
about 10-15 minutes. The rest of the time on the breast is not active 
sucking, just hanging out with eyes closed and no milk transfer. We 
usually supplement by bottle because we are "topping off" the baby to 
make him eat more -- really to eat enough to gain weight and strength 
appropriately. Sometimes we supplement at the breast to get better 
sucking but when they are self limiting and not participating at 
feedings, they remove less from the breast with supplement. Starting at 
about 38 weeks adjusted age, they often begin to participate in feedings 
and do better -- but still may self limit or tire quickly. This is when 
supplementing at the breast often works better. Around 40 weeks, we see 
better sucking and more intake. Around 42 weeks adjusted or around two 
weeks past the original due date, we usually have a fully breastfeeding 
baby. If mom works at it and is patient.

I tell moms to keep pumping 8X in 24 hours. I have them pump after 
nursing if baby is self limiting much less than she makes. I have them 
pump and bottle feed 4-5 times a day, with breastfeeding 3- 4 times a 
day at first. I want moms to use a hospital grade or rental pump (loaned 
by our WIC) with big enough flanges. This mom needs to be reminded about 
active sucking, rapid jaw movements and liquidy sounding swallows in 
long repetitions before short pauses. Breast compression or massage 
sometimes helps. The other thing about preterm babies is that you have 
to get them to the breast as soon as they indicate hunger because if you 
do diapers first, or hugs and kisses first, they shut down and forget to 
eat. A full term baby will start crying to be fed but a preterm baby 
will often shut down and conserve calories. Diapers and hugs come in 
between breasts, say after 10 minutes on the first side. Preterm babies 
often shut down quickly and continue to do so until near the original 
due date. For preterm babies, we usually have to manage the feedings 
until the baby is participating on his own and sucking well enough to 
transfer adequate quantities of milk to grow on.

And the weight gain of this baby sounds poor and if mom will be more 
patient and concentrate on feeding the baby the most efficient way, she 
will get him home quicker. Once she is home, she can have an experienced 
IBCLC work with her to assess his BF ability. Mom can rent a Medela baby 
weigh scale and do test weights at home. I like to see a milk supply of 
at least 2 ounces pumped out (total two breasts) 8X a day, or 16 ounces 
total in 24 hours. Too much less and baby doesn't usually work for what 
is there. I have seen the kind of treatment you described in hospitals 
with moms who are very anti formula and bottles or who assert their 
rights as parents of the baby. It makes me sad.

Kathy Eng, BSW, IBCLC

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