After reading some of the other posts on this, I decided to post a portion
of my response to Amy to this list for discussion.

...... And to answer your other
question from Lactnet, I use a surprised and curious tone of voice and say
"oh my! The chart says baby got two bottles overnight? What happened?".  Use
the same tone of voice that you'd use if your friend came into work with a
cast on his arm. That way you can find out what you need to know without
sounding accusatory (sore nipples, change of heart about bf, nurse said it
didn't matter, etc) So then when mom says "The nurse said it was ok"  you
can use the same tone of voice and question with the nurse only to be told
"Mom requested it".  It happens all the time..... hang in there.  As the
nurses begin to know you and trust you they'll be more likely to see that
your bf friendly practices are carried out.  I've found that the "I'm sad
for the mom and baby" approach works better than the "Dammit, my orders
weren't carried out!" approach, but that's a personal thing.  As in
residency, it's better not to be one of the residents who has their eyes
poked out with a pen (on the composite picture behind the nurses station -
that's how you could tell who the nurses really didn't like)........

I find it interesting, the variety of responses on this.  I really feel it
all depends on tone of voice. "What happened?" is a legitimate question for
the physician to ask. Certainly not in an accusatory tone, but in a
concerned, answer seeking tone. When the doctor left the room, the
expectation was that the baby was not going to get formula. This changed and
it's important for the doctor to know why. It will allow the doctor to avoid
having the situation happen again. As someone mentioned, physicians have a
lot of power and people will agree to things just to make the docs happy.
[Think of the last time your doc asked you to get more exercise or watch
your diet - what did you say - did you follow through to the letter?] If it
was a case of the patient trying to please the doctor, the doctor is better
to realize this at the onset and find out where the patient really is in
terms if her breastfeeding desires so that mom can be supported the best she
can be at the level that's right for her. My experience with these patients
is that many of them stop breastfeeding pretty early on if you don't find
out what they really want to do [give an occasional bottle, only partially
breastfeed, are they worried that baby won't take a bottle when they go back
to work?].

In fact NOT asking almost smacks of "not making mom feel guilty" type
behavior.  If she made the decision to supplement as an informed decision -
that's her choice to make, but the doc should know this so the doc can give
mom the proper input. When I see a baby sleeping on it's belly in the
bassinet in mom's hospital room, I say something to the mom about sleeping
position. I can't control what she does with the baby, but it's my job to
let her know the risks of the situation and possible alternatives [if baby
is fussy you can hold him or swaddle him...].

Mom might not even know the baby was supplemented. The night nurses may have
just fed the baby in the nursery to "top him off" after  breastfeeding. Or
the night nurses might have said to the mom " It's not going to matter or
baby will sleep better or baby will be less jaundiced, etc., etc. if we give
him a little formula after he nurses. I can't do this on my own, but you can
request it if you like." And they get their "request".  This type of
supplementation requires a different response from the doctor, even if it's
just to warn all the moms ahead of time "that the night nurses may tell you
that .....about supplementing, but you should know.....". This is no
different than when we give pre-teens anticipatory guidance about smoking or
drug use "your friends might tell you to try..... but you should
know.......".

I still maintain that the best way to fight this phenomenon is to first get
the facts in a non threatening manner, and second, to win the nurses over to
your way if thinking. This is why the formula companies give so many goodies
to the nurses [even bags to "give away" to parents -  talk about making
someone feel good]. And why the formula companies balk at having the bags
given out at a different part of the hospital, by people not in a position
to promote their product. Again, this game is about persuasion.

Comments?
Gail S. Hertz, MD, IBCLC
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