Dear Amy,

I agree that this is an important question.  We need to know the risk
factors for poor feeding on day 2 and 3 as babies are more frequently being
discharged on day 1 and 2.

I have wondered about analgesia as a source of difficulty but feel that
there are too many confounders to answer the question simply.  It may be
that women who have more complicated and longer labours are more likely to
have epidural analgesia or repeated intravenous analgesia.  Poor feeding may
then be the result of the difficult labour rather than an effect of the
analgesia.  One would have to only study infants who were born after
uncomplicated delivery to make a sounder comparison.

My feeling and bias as a neonatologist is that if one requires analgesia
during labour, epidural opiate analgesia is the best for the baby, and may
be preferable for the breastfeeding mother.  If a C-section in indicated
spinal analgesia is preferable.  Women should be given a choice of the full
spectrum of pain control in labour (both conventional and alternative).

On a further point I feel that one of the biggest impediments to
establishing breastfeeding is actually overenthusiastic caregiver support on
the first day.  Policies that recommend frequent nursing on day 1 (eg 3-4
hourly) set the mother up for failure and promote supplementation.  Once an
infant has been put to the breast immediately after birth, both mother and
child should be allowed to rest if they wish.  As long as the child is well
I have no anxieties about the infant not feeding for 8-12 hours.  I believe
that this "down-time" is physiological and that interfering with it is
interfering with a natural process.  I have left one infant 16 hours on the
first day, after which it woke and sucked effectively and consistently.

A second impediment is the false belief that infants should gain weight from
birth.  The mindset should be to encourage normal weight loss in the first
three days of life.  Parents should also be made aware that one wet diaper
on the first day is a common variant of normal and not a sign of dehydration.

A third problem is policies that recommend intervention on a regular basis,
such as "vitals every 4 hours" or "capillary glucose every 3 hours before
feeds".  In the first few days of life infants have no set routine or
timing.  Waking an infant or mother from deep sleep every 3 hours does not
seem rational and will not promote good nursing practice.

Fourthly, mother and baby should be in the same room for the whole hospital
stay so that mom can watch for feeding cues.

I will stop there.  As you can see I am of the opinion that factors in
hospital that impair breastfeeding are too numerous for me to list, thus
making study of one factor, for example, epidural analgesia, very difficult.
Every institution should scrutinize its policies to ensure that they do not
conflict with the principles of breast feeding promotion.

Khalid Aziz
Memorial University of Newfoundland