I'd like to add some practical suggestions of mine to this thread,
especially in response to Lisa M's comments about the switch from
endocrine to autocrine control possibly being adversely impacted by
parents who adopt a certain schedule.

In my LC practice, I have worked with a number of women whose experience
support's Lisa's observations about how this specific approach to BFing
seems to encourage this kind of problem. These moms have/had embraced
the teachings of a particular highly popular parenting course (Prep for
Parenting) which emphasizes a highly structured approach to early BFing,
but without stressing guidelines (ie, "start using this approach *after*
your baby weighs X pounds; suspend the program if you or your baby have
a medical diagnosis or if you are working on correcting a BFing problem
like tongue-thrusting or inverted nipples; restart the program from the
beginning if your baby has surgery, etc).

Specifically I'd like to offer suggestions I have found helpful for
working with moms who have adopted Prep for Parenting. I first became
aware of these teachings 12 or 13 years ago while being a home health
nurse in the area where the program originated . At first, I could not
figure out how to work with these moms to help them. So I purchased the
tapes and listened to them enough to get an idea of what they were being
taught. Only by adapting my approach, to somehow support their beliefs
and desires to follow the teachings, could I possibly be helpful to
them.

One of the most important things I learned was that the early editions
of the program discouraged using information gained from animal studies
to support human experience. So I quit talking about what I had learned
from animal studies and *only* supported my interactions with examples
from human BFing studies. (This was good; it made me pay closer
attention to the research!) I believe this is not so emphasized in the
current edition (4th ed), but I mention it because there are many 1st
ed, 2nd ed materials floating around out there that keep resurfacing.

Another aspect of the teachings, which I think all of you will agree
with, is that parenting is always "context-specific." In other words, if
the plane is taking off, and BFing will help those tiny ears tolerate
pressure changes, but it is not time for a feeding, the context demands
the specific parenting response of BFing (an actual example from the
classes).

Also, the guidelines and sample routine printed in the materials do not
state specific age or weight criteria for attaining that routine. The
suggestion is made (but not emphasized and thus easily overlooked) that
it is a *goal*; the mother is to gradually move her baby toward that
goal over time (several weeks). It is especially important to discuss
*length of feeding*. The program teaches "no more than 30 minutes." This
is unhelpful for most newborns; however, moms relax when I tell them
that all babies naturally drop duration at the breast when they reach 10
pounds or so and have become expert nursers. (I do suggest they *not* go
longer than 60 minutes. If baby "needs" more than 60 minutes, I consider
that behavior to be a red flag needing expert evaluation and ask the
moms to be sure to call me right away.)

In my own observations, when parents superimpose this program directly
on a newborn one of two scenarios occur. The first is that it is
especially problematic when the birthweight is <7 1/2 pounds. Things do
not go well, supplement begins, and mom completely weans by 3 months.
The second scenario is when the BW is >8 pounds. It may appear at first
that "all is well" until 3 to 4 months, when mom's supply begins to
dwindle, supplementation increases, and before long - weaned, or at best
BF with supplemental formula. Some large babies actually do well on this
program (yes, some do!).

Knowing this, I have developed a consulting approach that seems helpful.
First of all, *if* I mention studies, they are human studies only.
Secondly, using mom's own copies of the materials (so I know which
edition she is using) and the sample feeding schedule chart, I point out
that it is a goal which they *will* be able to attain at some point.
(This encourages her. Many times, these women are under fierce external
presure, subtle though it may be, from their churches to comply with the
program. She will opt to "fit in" with the other church mothers, rather
than "fit in" with my approach. My reassurance that she will "get there"
eventually helps open doors to hear what I have to say.) I show  how
this "goal" schedule fits the baby's current needs with the addition of
some extra feedings interspersed between the printed times. Over time,
these extra feedings will be dropped or consolidated with others to
result in the schedule they see printed. I encourage the parents to
follow Prep suggestions which are not directly related to BFing
(concepts of awake time, routines for diaper changing, interaction
between spouses, etc). Although I never really thought about it until
now, this conveys respect for their choice (another discussion thread of
late).
Thirdly, I emphasize the "context-specific" teachings. I am gentle when
using this but quite "broken-record" in doing so.

Example, I am working presently on a consult starting a week ago for a
Prep mom: baby 4 weeks old, attempted nursing at birth without success,
was receiving EBM with no direct nursing, following the Prep program as
much as possible (not much!). Baby was (early) discharged home as a
"BFer" (!) having never BF with a hospital-documented feeding problem.
The hospital nurses noted tongue-thrusting (bad enought to interfere
with bottle-feeding!) and inverted nipples (I think they were "just"
flat). The hospital LC taught finger-feeding (but not tongue-training),
dispensed syringes, nipple shields, an SNS, and a Pump-in-Style
double-kit with instructions to "call if you have questions."
(Hopefully, there is more to this story than I got from mom; otherwise
this LC isn't improving PR for the profession!!)  Mom called LLL and got
some helpful advice. However, infant dropped weight from 6-3 BW, down to
5-6, supplemented ABM along with EBM until plateaued at 6-7, at 4 wks
weighed just at 7-3. She was pumping 21 ounces daily; baby was taking 27
ounces daily. Mom wanted to BF but didn't like her pump/refeed routine -
was ready to quit everything. I got lucky on this one. Baby still had a
sloppy suck (thick tongue) which corrected nicely with palate
stimulation, mom had a decent supply and great nipples (thanks to 4
weeks of pumping). Baby nursed 45 minutes when I was there, and is now
nursing every other feeding quite well (current weight 7-13). (I taught
mom how to help baby "remember" the BF suck following a bottle-feed. She
is not experiencing nipple "confusion.")

Along the way, I talked about how Prep emphasizes context-specific. "For
you," I said, "this means that while your baby is demonstrating *by her
weight* that she needs to eat more, the context requires that you feed
her. Because she is working so hard to get the milk, because of her
immature suck, the context suggests she may need extra time at the
breast - perhaps 45 minutes or so. Also, because of her smaller size for
now, the context implies she'll need to nurse more often to get those
extra calories to catch up to her birthweight and regain her growth
curve (I make a growth chart and give it to her). It is easier for baby
at this weight to get extra calories by nursing more often, rather than
trying to get those calories by nursing longer at any feeding. As she
grows bigger, her face will get bigger, her muscles will become more
efficient, and she will become an "expert nurser." At that time, in that
context, you can *start* guiding her gradually into the program's
guidelines. Until then, the context requires you to adapt your parenting
to help her learn how to suck and to continue to gain weight well."

Basically, I teach "baby-watching" and interpretation. This mom told me
yesterday that she realizes she should have watched her baby more, and
looked at the book less. She can see now that she will be able to follow
the program soon enough, but after her baby is bio-physically capable of
doing - maybe by 3 months. Interestingly enough, she probably will
succeed, because she'll have laid a good foundation for a successful
change over to autocrine control of supply. At that point, her baby
probably *will* be able to follow the Prep guidelines very well. In the
meantime, some great attachment parenting will have been established.
Looks like a win-win situation to me.

I know *none* of what I actually said to her is anything new to the
readers of LactNet. I only include it as an example of how I bring Prep
concepts into the support of establishing BFing adequately. May I state
for the record that I am *not* a paid employee of this organization, but
I have learned how to work with parents who choose to follow it. As a
result, on occasion (once a year or less), my opinion is asked for by
this organization. If I can help in this way, I gladly offer my services
for as long as they are accepted. Likewise, if I can share my experience
and understanding of how to work with these parents with LactNetters, I
am glad to do so.

Classes have started for me now, so I will be lurking more and
contributing less. If you pvt email me, it may take a few days until I
can respond, so please be patient.

Katharine West, BSN, MPH, IBCLC(exp)
Family Nurse Practitioner in-training
Sherman Oaks, CA