There have been some very interesting threads and concerns lately.  So, to
keep my comments brief...
1.  Regarding LDRP's and effect on breastfeeding.  The hospital
where I work has about 2000 births/year and we've had our new 18-bed LDRP
Childbirth Center for two years now.  I honestly believe (and I think
observations by Celeste Phillips will bear this out) that NOT having a
central nursery anymore, so that babies stay in the room (or even, at times,
the bed) with their mother has done more for breastfeeding than any other
single intervention since I've been an LC there (9 years).
2.  Regarding the mom with PP hemorrhage, hemabate and the
hematocrit of 5.  Hemabate is carboprost, a protaglandin used to stimulate
uterine contractions.  I assume it was used to stop PP bleeding.  But, if
this mom truly had a 'crit of 5, maybe she has Sheehan's syndrome or, at the
very least, such a low level of blood to the pituitary that it has affected
her hormonal production capability.  Lawrence has a good description.
3.  The discussion about solids, "window of opportunity", etc reminds of the
most serious baby complication I've ever seen.  It involved a 7 mo old
breastfed baby who "wouldn't take a bottle" from anyone.  This presented as a
"feeding problem", the assumption being, of course, that a normal 7 month old
is capable of taking a bottle (separate from the issue of whether he or she
SHOULD be getting a bottle...) I was worried and skeptical and worked with
mom, only to find that indeed baby really COULDN"T take a bottle.  Baby was
finally diagnosed with
Gaucher's disease.  BAD NEWS.  The disease is uncommon, but there is an
unusual type, with fatal outcome, seen in infancy.  It's complicated to
explain fully, but dysphagia (difficulty swallowing) is often seen as a
clinical manifestation in pediatric cases.
So, what I'm trying to say is that when a "normal" baby doesn't or can't do
what is usually expected at his or her age, there may well be serious
underlying causes, as yet undetected.  Swallowing, obviously, is a necessary
life skill.  I wonder, at times, how many babies I see with a feeding problem
early in life end up with some type of ongoing developmental problem.
4.  The mom with the severe PP depression/possibly schizophrenia is a case
that I'm not sure we can really comment on without being there.  Serious
mental illness is complicated and uncommon, of course.  I've been involved in
cases where the mom had such an incredible PP illness, mental or physical,
that survival was the most important consideration.  Sometimes having a
loving family member, supported by the LC, bottlefeeding the baby (who is
incredibly vulnerable in all this and sometimes "forgotten", being so small
and easy to pass around from person to person) and trying to provide what the
mother would if she could, is the best short-term solution to a nearly
impossible problem.
5.  The question about milk production and the "critical period" led me to
Lawrence.  She reminds us that Hartman describes the first two phases of milk
production:  Stage I starting 12 weeks before birth; stage II begins ay 2-3
days PP and continues for 10 more days, when "mature milk" is established.
So, at about two weeks PP stage III, the maintaining of established milk
secretion, begins. I remember Neifert, in presenting her work with moms early
PP, mentioning that the first 2 weeks (corresponding to Stages I and II of
lactogenesis) are the most critical in establishing an adequate milk supply.
In my experience, if there has been a situation of inadequate/ineffective
sucking, this leads to decreased or inadquate milk production and this  can
further decrease baby's suck and lead to inadequate milk removal.  If this
goes on much beyond two weeks, it is almost impossible to establish full milk
production.

Sorry to be so long-winded!  Lactnet is such a rich source of
thought-provoking disucssion and questions.

Jeanne M. Brotherton, RNC, IBCLC
Bellingham, Washington

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