Morning Tricia
Thanks for sending in an excellent question -
wshether it's ever beneficial to limit the number
of minutes at the breast during a
breastfeed.... And for noting the similarity in
behaviour at the breast between a preterm or
late-preterm infant and a newborn with a weak suck.
When I work with premies or low-gain babies
(those who are obviously not transferring enough
milk at breast to achieve a normal weight gain) I
always suggest limiting time at the breast to no
more than 30 minutes, (with breast compression
and switching to keep baby swalllowing), and then
topping up with EBM. Why? Because there's nearly
always a consistent history and current pattern
of behaviour: So much so that I've done a handout noting the following:
At first, the hungry baby shows _prolonged and
frequent crying_, which is often mistaken for
colic, or the baby is pacified/soothed with a
dummy, or with returned to the breast.
During breastfeeding, it may be observed that
there is a _very short period of swallowing_;
thereafter the baby wants to stay attached to the
breast, but _mostly flutter-sucks with closed
eyes_, and he/she wakes again to protest only
when taken off the breast. If put back to the
breast, the same pattern happens again - a short
period of swallowing followed by fluttering and minimal milk transfer.
Later, the hungry baby _may want to feed all day
and sleep all night_; well-meaning friends and
advisors may inappropriately endorse either of
these abnormal situations by urging the mother to
continue breastfeeding "on demand", and by
offering congratulations that the baby is
sleeping through the night; the mother may also
reason that because she is feeding the baby all
day, then s/he must be getting enough as
evidenced by him sleeping well at night; the
truth, however, is that the baby becomes so
exhausted by attempting and failing to obtain
enough nourishment during the day that he is too
exhausted to wake up often enough to breastfeed
adequately at night, and long intervals without
drainage will deplete his mother's breastmilk supply still further.
So yes, these low-gain babies actually conserve
energy (expend so little at the breast) that they
fail to transfer enough. Nature's way - very
clever, but not very effective if the baby is to
thrive.... If the sucking is strong (with good
swallowing) then you'd keep the baby at breast,
but when the baby flutters for more than 5
minutes or so it's really more productive to
stop. So this is why I suggest limiting sucking
at the breast, stopping after giving the baby an
opportunity to "breastfeed" and then topping up
the still-hungry baby with EBM as a first choice,
ABM if there isn't enough (180ml/kg/day or even
more....) and pumping/expressing the breasts to
get the milk that the baby has left behind asap
after the baby is properly fed and settled.
Because the other problem with these babies is
that because they don't drain the breasts
effectively this continues to compromise the
mother's supply which dwindles over time.
Personally, I'm not crazy about the SNS, and I
find that the quickest, easiest way to provide
supplements is by bottle. I've never worked with
a baby being topped up by bottle who has gone on
to refuse the breast....the trick seems to be to
offer the breast first and then offer the
supplements afterwards to fill the baby up and
keep him happy (and fed!) and then pump to the
last drop to optimize breastmilk synthesis.
This protocol really seems to work well - once
the baby has caught up the lost weight and the
mother's milk supply has increased, then you can
start reducing the ABM supplements, then the EBM
supplements and continue breastfeeding as
normal. I do find however, that a previously
low-gaining baby may not breastfeed effectively
until he has regained the lost weight
sufficiently to be a normal weight for age, so
supplements shouldn't be stopped too soon and
these weak babies can slide backwards again very
easily. Now if anyone else can answer why _that_ happens I'd be grateful...
If you'd like my full handout, just let me know
by private email and I'll be happy to send!
Pamela Morrison IBCLC
Rustington, England
------------------------------------------------------------
Hello, Can anyone give me information on whether
or not it's ever beneficial to limit the number
of minutes at the breast of a preterm or late
preterm infant. The ABM Late preterm protocol
seems to recommend it. They state that a late
pre-term should be transferring enough milk
within 20 to 30 minutes by the time they are
discharged from the hospital. But I thought
that they expended less energy at the breast. I
have heard others say that it may be beneficial
if they are sucking weakly and not transferring
milk, but it shouldn't be limited if their suck
is strong. This seems to be a controversial
issue. Is there any reason that you would
recommend the same for a full-term infant with a
weak suck? Even if they are sucking weakly and
using an SNS at the breast, I don't see the point
of taking them off after 30 minutes. If they cry
are we going to just put a pacifier in their
mouth? How does that improve the situation? Any
thoughts or studies would be welcome. Thank you, Tricia Shamblin, RN, IBCLC
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