I love Rachel's description "feeding prostheses" to describe shields and
bottles and, for that matter, any type of equipment that is needed in the
early postpartum to ensure adequate intake in the bfg infant and maintenance
of lactation in the mother.

She is absolutely right, and a key point I make in my assessment lectures is
that normal breastfeeding works very robustly.  Any deviation from that
pattern is abnormal.  Generally the period of "abnormal" is brief, and with
careful examination, a reason or reasons for the feeding problem can be
discovered.  Once these are clarified, care givers can give parents
reasonable preditions about how long the dyad will need the help/prosthesis.

The reasons why early breastfeeding may be problematic are getting to be
pretty well defined in the literature.  The Hall study identified vacuum
assisted delivery and PIH.  We know that long or difficult labor,
c-sections, flat nipples, small babies, delayed lactogenesis (reasons
well-described in the lit) etc. are all risk factors.  Hospt. personel
should be trained in the identification of risk factors, and parents can
gently be informed of the issues.  When educated about why the baby can't
suck, and assisted in the 3 rules to protect the outcome (Feed  baby,
Protect milk supply, Keep something happening at breast) the interventions
can do their job without scaring the parents half to death.

 I feel strongly (in response to Jennifer's querry about how to tactfully
alert peds to problems) that hospts can notify the ped of record by fax that
a baby is going home prior to the establishment of effective bfg.  This puts
the responsibility to do early follow-up where it belongs.  Below is the
form we developed here in Austin that does this job.  It is used primarily
at one of our local hospitals, but a pediatrician took it before the
pediatric section (a city-wide meeting) where it was accepted in theory by
all the docs.  I wish it were more widely used, but even getting it going at
one hospt. is a big step.

Date: _______________

From:  Hospital Lactation Dept: _______________________________________

RE:  Baby's name and DOB: __________________________________________

Mother's name/current Ph No: ________________________________________



Dear Doctor __________________:



Since mothers are being discharged before their milk comes in, some common
lactation problems do not present until after discharge.  M. Neifert,
Clinics in Perinatology 1999, 26(2):290.



The hospital lactation consultants have concerns about this nursing couple,
and have identified the following red flags for breastfeeding problems.
This mother and baby may need community-based support to insure that
breastfeeding is well established.



Maternal Risk Factors Noted:

      History of previous breast surgery

         Anatomic breast variations (Large or long nipples/unusual breast
appearance)

         Minimal breast changes during pregnancy/No report of postpartum

         engorgement phase

         Medical illness  (diabetes, hypertension, blood loss)
__________________

         Flat/inverted nipples

          Long/difficult labor - primiparous mother (associated in the
medical lit. with delays in

            onset of copious milk production)

         History of infertility/ovarian cysts/hormonal problems

         Mother younger than 20 years of age:  Age_______________

Infant Risk Factors Noted:

         Prematurity or IUGR

         Twins or higher order multiples

         Jaundice

         Baby with latch-on problem

         Oral cleft and other oral anatomic variations (e.g. tongue
tie)_______ _____________________________

         Medical illness/neuromotor problems
__________________________________

         Loss of >7% of birthweight at discharge birth wt:_________(current
weight)_______________

      Suppl. feed by bottle/cup/SNS/other due to
hypoglycemia/non-alert/separation_________

Notes:______________________________________________________________________
____________________________________________________________________________
________________________________________________________________



Community Resources for Breastfeeding:



Free phone counseling:  La Leche League (accredited volunteers) Hotline #
__________

Income eligible LC services (Mom's Place)
___________________________________

Out-patient LC services at this hospital
_______________________________________

Private Practice Lactation Consultants
:_______________________________________



Developed by:  Bernadette Maloney, RNC, IBCLC, Valerie Mick, RN, IBCLC, B.
Wilson-Clay, IBCLC, 1999; Modified 2003. May be copied freely if
acknowledged

Published in Current Issues in Clinical Lactation 2002, Jones and Bartlett,
Boston,  and in The Breastfeeding Atlas, B.Wilson-Clay, K Hoover, LactNews
Press, Austin, Tx 2002.



Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com
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